ROOT RESORPTION

MAR JOVANI

1. EXTERNAL ROOT RESORPTION

1. External root resorption caused by an injury restricted to the external root surface.
2. External root resorption caused by an injury to the external root surface with an inflammatory component.

1. External root resorption caused by an injury restricted to the external root surface
An injury causes loss of the protective layer and serves as an inflammatory stimulus.

Types
Localized injury: Healing with cementum. Diffuse injury: Healing by osseous replacement.

Localized injury: Healing with cementum

Causes A localized injury (eg, after concussion or subluxation injury). Mechanical damage to the cementum occurs resulting in a local inflammatory response and a localized area of root resorption. Signs and symptoms It is free of symptoms and in most cases undetectable radiographically. In a minority of cases, small radiolucencies can be seen on the root surface if the radiograph is taken at a specific angle. Positive sensitivity test Treatment is not required Periodontal healing and root surface repair will occur within 14 days

Treatment

Localized area of root resorption The initial damage was caused by a mild localized luxation injury. It has healed with new cementum and periodontal ligament (PDL).

Diffuse injury: Healing by osseous replacement

Causes A severe traumatic injury (eg, intrusive luxation or avulsion with extended dry time). Dentoalveolar ankylosis: Bone comes into direct contact with the root, without the intermediate cementum . Osseous replacement: The root is resorbed by the osteoclasts and is slowly replaced with bone. Avoiding or minimizing the initial inflammatory response.

Signs and symptoms

Treatment

Severe traumatic injury

Initial inflammatory response

A diffuse area of root surface will be devoid of cementum

Cells in the vicinity of the denuded root compete to repopulate it

Bone comes into direct contact with the root

dentoalveolar ankylosis

The root is resorbed by the osteoclasts

Bone instead of dentin is laid down

osseous replacement

Osseous replacement

2. External root resorption caused by an injury to the external root surface with an inflammatory component

Types of inflammatory stimuli

Pressure Pulp space infection Sulcular infection

Pressure
Causes Excessive forces of orthodontic tooth movement. Impacted teeth and tumors. Pressure both damages the cementum and provides a continuous stimulus for the resorbing cells.

Active transient external inflammatory root resorption

Pulp space infection

Causes Signs and symptoms Pulpal necrosis (caries). The radiographic appearance is not detectable in most cases, but when apparent, the radiolucencies are evident at the root tip and adjacent bone. Irregular shortening or thinning of the root tip is sometimes seen. There are no clinical manifestations because apical root resorption is asymptomatic. Symptoms that might lead to its diagnosis are associated with periapical inflammation and not root resorption per se. To remove the stimulus for the underlying inflammatory process (the bacteria in the root canal system).

Treatment

Tooth with external apical resorption

Sulcular inflammation (cervical root resorption) external subepithelial root resorption

Causes Damage immediately below the epithelial attachment of the root (orthodontic tooth movement, trauma) The pulp plays no role and is usually normal. It occurs usually but not exclusively at the cervical area. Asymptomatic and usually detected only through routine radiographs. Occasionally, symptoms of pulpitis will develop if the resorption is extensive. When the resorption is long-standing, granulation tissue may be seen to undermine the enamel of the crown of the tooth, resulting in a pinkish appearance. The radiographic appearance can be quite variable. If the resorptive process occurs mesially or distally on the root surface, small radiolucent openings into the root are common. The radiolucency expands coronally and apically in the dentin and reaches, but usually does not perforate,the root canal.

Signs and symptoms

A "pink spot" of external inflammatory resorption. The granulomatous tissue has spread coronally and undermined the enamel, causing the pink color in the crown.

Careful removal of the granulomatous tissue shows the canal to be almost entirely encircled but not penetrated by the resorptive defect.

Radiographic appearance of external subepithelial root resorption.

The resorptive defect on the mesial side of the molar shows a small opening into the root.

The apical and coronal expansion reaches but usually does not penetrate the pulp canal.

Note the adjacent bone resorption.

Because the pulp is not involved, its outline can usually be distinguished through the resorptive defect

2. INTERNAL ROOT RESORPTION

Internal root resorption is rare in permanent teeth. When it does occur, it is characterized by an ovalshaped enlargement of the root canal space .

ETIOLOGY

Infected coronal pulp tissue Traumatic episodes Extreme heat produced by cutting on dentin without an adequate water spray

CLINICAL MANIFESTATIONS

Usually asymptomatic It is first recognized clinically through routine radiographs. Pain may be a presenting symptom if perforation of the crown occurs and the granulation tissue is exposed to oral fluids. A positive response to pulp sensitivity testing is possible. Pink tooth, due to the granulation tissue in the coronal dentin undermining the crown enamel.

Pink spot on a mandibular central incisor indicating internal root resorption. Because the pink spot is so far from the periodontal attachment level, this example is unlikely to be external in nature.

RADIOGRAPHIC APPEARANCE

A fairly uniform radiolucent enlargement of the pulp canal. The original outline of the root canal is distorted. Unlike external root resorption, the adjacent bone is not affected by internal root resorption.

TREATMENT

Because the resorptive defect is the result of the inflamed pulp, endodontic treatment is the treatment approach

Uniform enlargement of the pulp space is apparent.

Adjacent bone is intact.

Outline of the canal cannot be seen in the resorptive defect.

Radiograph of an incisor with internal root resorption.

DIAGNOSTIC FEATURES OF EXTERNAL VS INTERNAL ROOT RESORPTION

Pink spot: pink spot caused by granulation tissue

undermining enamel is a possible sign of both subepithelial external and internal root resorption

Radiographic features: A change of X-ray angle should

give a fairly good indication of whether a resorptive defect is internal or external.

 When the defect is external, the root canal outline appears normal and can usually be seen "running through" the radiolucent defect. External inflammatory root resorption is always accompanied by resorption of the bone in addition to the root.

A defect on the external aspect of the root moves away from the canal as the angle changes

 In internal resorption, the outline of the root canal is usually distorted and the root canal and the radiolucent resorptive defect appear contiguous Internal root resorption does not involve the bone; as a rule, the radiolucency is confined to the root. On rare occasions, if the internal defect perforates the root, the adjacent bone is resorbed and appears radiolucent on the radiograph.

A lesion of internal origin appears close to the canal whatever the angle of the X ray

Internal resorption. Radiographs from two different horizontal projections depict the lesion within the confines of the root canal in both views

External resorption. Radiographs from two different horizontal projections depict movement of the lesion to outside the confines of the root canal.

Vitality testing:
External inflammatory resorption on the apical and lateral region

Subepithelial external root resorption normal response to sensitivity testing.

Internal root resorption Usually occurs in teeth with vital pulps and elicits a positive response to sensitivity testing.

negative response to sensitivity tests

Common misdiagnoses:
Apparent internal root resorption

Root canal therapy

Bleeding within the canal should cease quickly after pulp extirpation

If bleeding continues during treatment, particularly if it is still present at the second visit

Internal resorption

External resorption

CLINICAL CASE 1
Woman, 60 years old She came to an annual check-up visit

 Asymptomatic Dental history 2.6: Direct

pulp capping with calcium hydroxide, glass ionomer and composite, two years ago. Soft tissue: Percusion and palpation:Periodontal examination: Positive pulp sensitivity test

Radiographic examination

Internal root resorption

History of trauma, crown preparation or pulpotomy

Positive pulp sensitivity likely

May occur at any location along the root canal (not only at attachment level)

Lesion stays associated with the root canal on angled X rays

Radiolucency contained in the root without an adjacent bony defect Pink spot possible

What will we do?

1 YEAR LATER

CLINICAL CASE 2

 Asymptomatic Dental history: 4.6, restoration with composite

1 week ago

Soft tissue: Percusion and palpation: Periodontal examination: 5mm mesial Positive pulp sensitivity test

Subepithelial external inflammatory

History of trauma

Positive pulp sensitivity test

Lesion located at the attachment level of the tooth Lesion moves on angled X rays

Root canal outline is undistorsed and can be visualized radiographically Crestal bony defect associated with the lesion.
Pink spot possible

CLINICAL CASE 3
Chief complaint: I have a toothache in 2.1

 Deep restoration 2.1

Soft tissue: Percusion: +

Palpation: Periodontal examination: Negative pulp sensitivity

test Rx

Chronic Apical periodontitis

External inflammatory root resorption due to pulp infection

With or without a history of trauma Negative pulp sensitivity test Apical external root resorption

CLINICAL CASE 4

CLINICAL CASE 5

Common misdiagnoses:
Apparent internal root resorption

Root canal therapy

Bleeding within the canal should cease quickly after pulp extirpation

If bleeding continues during treatment, particularly if it is still present at the second visit

Internal resorption

External resorption