INTERNAL ROOT RESORPTION
PRESENTED BY: DR SHERAZ M KHAN
PGR OPERATIVE & ENDODONTICS
CONTENT:
• Introduction
• Classification of IRR.
• Etiology
• Pathogenesis
• Clinical and radiographic features
• Management
INTRODUCTION:
DEFINITION: Internal root resorption can
be defined as: “the loss or damage to
pre-dentin, lining the pulp chamber or
root canal spaces combined with
inflammation and activating
odontoclasts.” (Tronstad)
IRR is usually asymptomatic, associated
with pulpal necrosis coronal to the
resorptive lesion and vital or partially vital
pulps where active.
CLASSIFICATION:
1. Internal inflammatory resorption.
2. Internal replacement resorption.
The replacement type is associated with the deposition of
mineralized tissue in the root canal space after the initial
loss of dentin.
ETIOLOGY:
• Trauma 45%
• Inflammation as a result of carious lesions
(25%)
• Carious/periodontal lesions (14%).
• Excessive heat generated during
restorative procedures on vital teeth
• Calcium hydroxide procedures
• Anachoresis
• Orthodontic treatment
• Cracked teeth
PATHOGENESIS OF INTERNAL
ROOT RESORPTION:
• Damage to the outermost protective odontoblast layer and
the predentin of the canal wall results in exposure of the
underlying mineralized dentin to odontoclasts, which
subsequently leads to IRR
• progression of IRR depends on bacterial stimulation of the
clastic cells involved in hard tissue resorption. Without this
stimulation, the resorption is self-limiting.
• For IRR to continue, the pulp tissue apical to the resorptive
lesion must
• have a viable blood supply; this provides clastic cells and
their nutrients, and the infected necrotic coronal pulp tissue
provides stimulation for those clastic cells
HISTOLOGIC APPEARANCE:
• The pulpal tissue is populated with an
inflammatory infiltrate composed
predominantly of lymphocytes and
macrophages, with some neutrophils
• The odontoblast layer and predentin are
absent from the affected dentinal
walls,which are populated by large,
multinucleated odontoclasts occupying
resorption lacunae.
CLINICAL FEATURES:
Clinical features of Internal Root Resorption (IRR) vary based
on:
• Histologic status of affected pulp.
• Extent of hard tissue destruction in the root canal.
• Position of the resorptive cavity within the root canal space.
Pulpal necrosis and bacterial colonization can cause:
• Symptoms of acute or chronic apical periodontitis.
• Development of sinus tract(s) and suppuration in periapical tissues.
• Possible perforation of the root canal wall.
Extensive coronal pulp resorption may result in:
• - Pink or red discoloration visible through the tooth crown due to
RADIOGRAPHIC FEATURES:
• IRR can occur at any location in the root canal system and
may manifest radiographically as a radiolucency with variable
shape, radiodensity, outline, and symmetry in relation to the
root canal.
• Internal inflammatory root resorption lesions are more likely
be uniformly radiolucent, whereas in internal replacement
(metaplastic) root resorption, the defect has a somewhat
mottled or clouded appearance as a result of the radiopaque
nature of the calcified material occupying the lesion
HOW TO DIFFERENTIATE IRR
FROM ECR:
Two radiographs are needed:
• A paralleled periapical radiograph.
• Another radiograph with a horizontal angulation shift between the
x-ray tube and the image receptor.
In Internal Root Resorption (IRR), lesions maintain their position
concerning the root canal system on the angled view.
External Cervical Resorption (ECR) lesions exhibit movement:
• Lingually/palatally positioned ECR lesions move in the same
direction as the x-ray tube shift.
• - Buccally located ECR lesions move in the opposite direction of
the x-ray tube shift.
ROLE OF CBCT IN CASES OF
INTERNAL ROOT RESORPTION:
• In a study by Estrela et al PA radiographs and CBCT scans were
exposed on 40 individuals. IRR was detected in 68.8% of PA
radiographs, whereas CBCT scans showed 100% of the lesions.
CBCT in IRR Management:
• Diagnostic and Treatment Planning Tool
• Provides details on position, extent, and dimensions of IRR
lesions.
• Identifies associated perforations.
• Distinguishing between ECR and IRR:
• Offers clarity in diagnosis compared to conventional
radiographs.
• Helps differentiate between External Cervical Resorption
(ECR) and Internal Root Resorption (IRR).
MANAGEMENT:
Management of IRR requires assessing hard tissue destruction and
determining tooth prognosis.
• Salvageable teeth with reasonable prognosis necessitate root canal
treatment.
• Main goal: Removal of intra-radicular bacteria and disinfection of
root canal space.
• Active resorption demands additional focus on eliminating vital
apical tissue stimulating resorption.
Challenges in IRR Treatment
• Active resorption causes profuse bleeding from granulomatous,
inflamed pulpal tissues.
• Bleeding affects visibility during initial treatment stages and
persists during canal drying.
• Irregularly concave resorption defects pose challenges for direct
mechanical debridement.
CHEMOMECHANICAL DEBRIDEMENT OF
THE ROOT CANAL
Internal root resorption (IRR) defects are
difficult to access using standard instruments
and passive rinsing techniques.
Ultrasonic activation of irrigants becomes
essential for effective treatment in such
cases.
This method helps in reaching and treating
areas that are otherwise inaccessible with
conventional tools and techniques.
Ultrasonic activation aids in improving the
penetration of irrigants into these hard-to-
reach areas, enhancing treatment efficacy.
CONTINUE…
• - Despite …
using additional methods, microbes might
remain in restricted areas after cleaning the root
canal.
• - To further decrease the microbial presence and
enhance disinfection, an intracanal antibacterial
medicament is recommended.
• - Calcium hydroxide, an antibacterial medication
used between appointments, effectively eliminates
lingering bacteria in the root canal after treatment.
• - Its application significantly improves the
sterilization process, ensuring a more thorough
eradication of bacteria within the root canal space.
OBTURATION:
• Effective obturation of resorptive defects in endodontic
treatment is crucial for successful outcomes.
• Resorptive defects pose challenges in achieving adequate
filling during endodontic treatment.
• Thermoplastic GP systems like Obtura II and Microseal show
superior efficacy in filling these defects compared to
traditional techniques like CLC and Thermafill.
• Attaining higher GP/sealer ratios is vital to minimize voids and
prevent contaminants' ingress, thereby enhancing treatment
success.
IN CASES OF PERFORATION:
• The presence of a perforating resorptive defect is certainly
not an indication for extraction.
• If the resorptive process has caused sufficient tissue
destruction to render the tooth unrestorable, extraction is
the most appropriate treatment option.
• If perforation has occurred, mineral trioxide aggregate
(MTA) should be considered the material of choice to repair
the root wall.
• MTA is biocompatible, has superior sealing properties when
used as a retrograde filling material’ it supports almost
complete regeneration of the adjacent periodontium.
