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CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 3  |  Page : 405-411

Management of external root resorption with Biodentine and platelet-rich fibrin matrix: A case report with 3 year follow up


1 Department of Conservative Dentistry and Endodontics, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India
2 Department of Prosthodontics and Implantology, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India

Date of Submission08-Jun-2020
Date of Decision03-Jul-2020
Date of Acceptance14-Sep-2020
Date of Web Publication3-Sep-2021

Correspondence Address:
Dr. Sindhu Ramesh
Department of Conservative Dentistry and Endodontics, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, 162, Poonamallee High Road, Chennai - 600 077, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_143_20

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  Abstract 

A male patient aged 28 years presented with a chief complaint of discolored left central incisor and missing tooth, due to road traffic accident 15 years ago with no associated symptoms. Clinical and radiographic examination revealed no pulp to response to vitality test, large periapical radiolucency, and root resorption of the middle third of the root. A definite diagnosis of pulpal necrosis with asymptomatic apical periodontitis and external resorption was made. Root canal treatment was done, and the extent of the lesion was analyzed and planned for surgical management. The periapical lesion was curetted, and the external resorption site was sealed with a matrix of Biodentine and platelet-rich fibrin. The case has shown successful healing after 3-year follow-up.

Keywords: Biodentine, external root resorption, platelet-rich fibrin, root canal, tissue engineering


How to cite this article:
Teja KV, Sujith Kumar IL, Ramesh S, Vasundhara KA. Management of external root resorption with Biodentine and platelet-rich fibrin matrix: A case report with 3 year follow up. Saudi Endod J 2021;11:405-11

How to cite this URL:
Teja KV, Sujith Kumar IL, Ramesh S, Vasundhara KA. Management of external root resorption with Biodentine and platelet-rich fibrin matrix: A case report with 3 year follow up. Saudi Endod J [serial online] 2021 [cited 2021 Dec 4];11:405-11. Available from: https://www.saudiendodj.com/text.asp?2021/11/3/405/325387


  Introduction Top


Resorption is a condition, characterized by loss of dentin, cementum, or bone, which is a consequence of either physiological or pathological processes.[1] It occurs in many circumstances other than the normal process associated with the shedding of deciduous teeth, and the conditions that lead to resorption of roots seem to be related to a complex combination of mechanical factors. These biological factors encompass the role of immunologic structures, including specialized cells.[2] In some instances of clinically asymptomatic pathologic resorption, where the condition is undiagnosed and left untreated, the outcome is the premature loss of tooth or teeth in those cases.[1]

Tooth resorption in a majority of cases is asymptomatic and diagnosed by radiographs during a routine dental checkup; it can be associated with both vital and nonvital teeth.[3] The consequences of this resorption can range from slight mobility to the complete loss of tooth structure, due to excessive amounts of resorption.[4] Although various materials such as hydroxyapatite, mineral trioxide aggregate (MTA), Biodentine, and EndoSequence are used for root repair,[5] case reports have been widely published on using MTA or Biodentine as a matrix for repairing the resorptive site.[6],[7]

Platelet-rich fibrin (PRF) is widely named as Choukroun's PRF after its inventor.[8] It is a resultant of centrifugation of the collected blood.[9] PRF serves not only as an ideal scaffold in revascularization of immature necrotic teeth by enhancing the cellular proliferation and differentiation but also acts as a matrix for tissue ingrowth.[10]

PRF and collagen were reported as being the best scaffolds for revascularization procedure in the immature necrotic permanent teeth.[11] A successful healing on the combined use of PRF as an internal matrix and MTA as an apical barrier in apexification was reported by Rudagi and Rudagi[12] as well as for iatrogenic furcal perforation by Bains et al.[13] This was attributed to the autologous and biocompatible nature of the PRF and MTA. Previous reports have shown an increased regenerative effect on using PRF along with other biomaterials, such as hydroxyapatite and beta-tricalcium phosphate, with a predictable clinical and radiographic results.[14],[15],[16]

The present report aimed to prospectively observe and analyze the 3-year healing outcomes of surgically managed external root resorption using autologous PRF membrane alone without any bone graft as a scaffold along with the Biodentine as a matrix.


  Case Report Top


A male patient aged 28 years has reported to the department of conservative dentistry and endodontics, with a chief complaint of discolored front tooth for the past 3 years with a history of a road traffic accident 15 years back. On eliciting history, the patient presented with a discolored left central incisor [Figure 1]a, with no associated symptoms. There was no relevant medical or dental history. A preoperative radiograph revealed external communicating resorption and widening of the apical periodontal ligament (PDL) [Figure 1]b. On cone-beam computed tomography (CBCT) evaluation, there was a resorptive site on the distobuccal aspect of the root at middle and apical one-third which was communicating externally and the apical root end was resorbed completely with ill-defined radiolucency which was measuring around 2 mm × 3 mm from the largest diameter at the middle third of the root [Figure 2].
Figure 1: Clinical photograph depicting the discolored left central incisor (a). Preoperative radiograph depicting the periapical and the resorptive area (arrow) (b)

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Figure 2: Preoperative cone-beam computed tomography axial (a-c), tangential (d-f), and cross-sectional view (g-i) at different levels showing the resorptive area (arrow)

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The tooth was not responsive to heat, cold, and electric pulp testing. No pain on percussion or palpation was noted. A definite diagnosis of pulpal necrosis with asymptomatic apical periodontitis was made in relation to the left central incisor. The treatment plan was advised for orthograde root canal treatment followed by curettage and surgical repair of the external resorptive defect using Biodentine and PRF as a matrix. The prognosis of the present treatment was considered to be poor, and the informed consent was obtained from the patient, before the intervention.

The patient also presented with a root canal-treated right lateral incisor, for which the obturation was done by a previous operator 1 year back. On clinical examination, permanent restoration was seen in the right lateral incisor, with no tenderness on percussion or palpation. However, the right central incisor showed a mild enamel fracture, which was asymptomatic, with no pain on percussion or palpation. Pulp sensibility testing showed no response for heat, cold, and electric pulp tests. Radiographic examination revealed an intact crown, with an ill-defined radiolucency involving the root apex with loss of lamina dura and widening of PDL space in the right central incisor. Hence, a definitive diagnosis was made as pulpal necrosis and asymptomatic apical periodontitis in the right central incisor. Accordingly, the root canal treatment was also planned in the right central incisor.

In the first visit, the access cavity was prepared, and initial negotiation was done with No. 15 stainless steel hand K-file (M-access; Dentsply Maillefer, Ballaigues, Switzerland) under strict rubber dam isolation. There was serous exudate drainage along with pus. Working length was determined, and shaping and cleaning was done using the step-back technique. Apical enlargement was done up to No. 50 K-files, followed by sequential step back until 80 K-file. During instrumentation, 30-gauge side vented needle irrigation was carried out with 1.5% sodium hypochlorite (NaOCl); intermittent irrigation was done with 17% ethylenediaminetetraacetic acid (EDTA) liquid and a final flush of 2% chlorhexidine and saline. Calcium hydroxide medicament (RC Cal; PRIME Dental Products Pvt. Ltd., Maharashtra, India) was applied into the canals and was replaced twice.

In the third visit, the tooth was re-accessed under rubber dam isolation; final irrigation protocol was carried out as it was done in the previous visits. The canals were dried with paper points. There was no pus drainage from the canal and was absolutely clean and dry. The canals were coated with BioRoot RCS sealer cement (SEPTODONT; Saint-Maur-des-Fosses, France) using lentulo-spirals. The master cone was verified, obturation was carried out by cold lateral compaction technique, and the access cavity was filled with double seal of resin-modified glass ionomer liner (Vitrebond Light Cure Glass Ionomer Liner/Base, 3M ESPE, St. Paul, MN, USA) and composite restoration (3M™ Filtek™ Z250XT Nano Hybrid Universal Restorative A3, Syringe, 3M ESPE, St. Paul, MN, USA) [Figure 3]. The right central incisor was treated similar to the left central incisor.
Figure 3: Immediate postobturation radiograph

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Under local anesthesia, a full-thickness trapezoidal flap was reflected with vertical releasing incisions from the distal aspect of right lateral incisor to the distal aspect of the left central incisor. A test dose of 12 ml sample of whole blood was drawn intravenously from the patient's right antecubital vein and centrifuged (REMI Model R-8c with 12 ml × 15 ml swing out head) under 3000 rpm for 10 min to obtain the PRF, which was jelly-like consistency. Curettage of the surgical site was done, and the surgical site was flushed with saline. The perforation site was sealed with Biodentine (SEPTODONT; Saint-Maur-des-Fosses, France) without any delay; the autologous PRF membrane was placed as a matrix on the sealed perforation site and in the curetted surgical socket [Figure 4]a, [Figure 4]b, [Figure 4]c, [Figure 4]d, [Figure 4]e. The curetted lesion was not sent for the histological examination because small amount of tissue obtained was insufficient. Flaps were secured with 4-0 polyglactin 910 sutures (Vicryl, Ethicon, Inc., Piscataway, NJ, USA) [Figure 4]f. The patient was prescribed with an antibiotic regimen of 625 mg of amoxicillin and clavulanic acid three times daily for 3 days, and the analgesic regimen was diclofenac 50 mg for every 8 h. The patient was followed up for 3 years. Follow-up radiographs were adequately depicted [Figure 5]. At 3-year follow-up, postoperative CBCT revealed satisfactory healing with an evident reduction in lesion size and a thick radiopaque seal at the middle third, suggestive of repaired of the resorptive site [Figure 6].
Figure 4: The surgical procedure. Resorptive site after flap exposure (a), placed Biodentine as matrix in the resorptive site (b), completely set Biodentine sealing the resorption (c), obtaining the platelet-rich fibrin (d), platelet-rich fibrin placed at the defective site (e), and suturing (f)

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Figure 5: Immediate postsurgical radiograph (a). Follow-up, 3 months (b), 1 year, (c) 2 years (d), and 3 years (e)

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Figure 6: Postoperative cone-beam computed tomography axial (a-c), and cross-sectional view (d) at different levels after 3 years showing good healing of the defective area (arrow). Postoperative clinical picture (e)

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  Discussion Top


The successful management of a pathological condition is associated with the appropriate understanding of the etiological factor that has caused it.[17] In the present case, the traumatic injury was the major contributing factor for the resorption. Since the affected tooth remained untreated for a long duration, the ultimate result of the chronic low-grade infection has led to the resorptive defects. The lesions were initiated by the damage that was caused from the trauma and inflammation of the dental pulp and periodontium.[18] Once the infection is established in the root canal space, the by-products from the bacteria and tissue breakdown can stimulate inflammation in the adjacent periodontal tissue, leading to progressive, inflammatory resorption of the root.[19]

Two major factors are involved in the initiation of root resorption, which includes the loss or alteration of the protective layer over the root surface (precementum or predentin) and then the inflammation that occurs around the root surface.[20] Damage to the protective layer may occur either directly due to trauma of dental injury or indirectly when the inflammatory response occurs as a result of dental injury.[20] Physical damage to the cemental layer will only occur at the specific points where the force of the trauma pushed the tooth into the socket.[21],[22] Hence, in the present case, the external resorption was also concentrated in the distobuccal aspect in the middle one-third and apical region. The probable reason might be the traumatic forces that led to the direct or indirect injury initiating the resorptive process.

The inflammatory response from the dental injury can be divided into two critical phases: the destructive phase and the healing phase.[20] In destructive phase, the active resorptive process gets initiated, and the destruction gets initiated and continues as long as there is an inflammatory stimulus is persisting.[20] The outcome of healing after a traumatic dental injury depends on the cells that populate over the root surface.[20] If cementoblasts cover the root surface, a favorable healing (cemental or surface resorption) occurs.[23],[24] In case of osseous repopulation, an unfavorable direct contact of bone and root occurs leading to replacement resorption or osseous replacement.[23],[24] Usually, the external inflammatory resorption can begin after 2 weeks of the sustained injury and tends to progress.[20]

The uniqueness of the present case was the extensive involvement of the resorption in the middle one-third and apical region communicating externally. It was a challenging task even with the routine root canal therapy and surgical repair of the resorptive site.

The ultimate goal of treating such teeth is to primarily arrest the active resorption process, with restoring defect and maintaining the functionality.[25] Proper treatment planning is essential for each and every case. However, in certain conditions, diagnosis becomes challenging and needs an accurate assessment before obtaining an appropriate treatment plan. Studies have shown the accuracy of CBCT in assessing the external and internal resorption.[26],[27] The use of CBCT, in the present case, was to evaluate the three-dimensional location, size, and accessibility of the resorptive defect. It has provided a vital information for planning the treatment.[26]

As the communication between the root canal system and the resorptive defect was more significant in size, the defect was treated surgically. Complete debridement of the resorptive tissue is an essential part of treating external root resorption. In the present case, instrumentation and irrigation were done with utmost care to prevent the extrusion and caustic reactions caused by chemical agents used in debriding the root canal space. Thirty-gauge side vented needle irrigation was carried out slowly using 1.5% NaOCl, intermittent irrigation with 17% EDTA liquid, and a final flush of 2% chlorhexidine and saline. A significant challenge in the present case was to maintain the dry field in the root canal space before obturation.

Although complete removal of bacteria and its contents from the root canal is never achievable, emphasis should be made on optimal disinfection.[28] The preferred antibiotic protocol for treating external resorption includes the complete chemomechanical preparation, followed by long-term dressing with densely packed calcium hydroxide.[29] Several theories have been postulated to explain their biological activity.[30] One theory discusses the high alkaline pH, which neutralizes the resorptive cells by creating an unfavorable environment for them,[21],[31] kills the bacteria, and neutralizes endotoxin, arresting the favorable environment for resorption.[20]

Newer calcium silicate-based materials have been aimed at improving the drawbacks of MTA, such as handling property and longer setting time.[6],[32] Biodentine is one of the calcium silicate-based materials introduced and has claimed to have better properties than other bioactive materials. The interesting note is that the Biodentine has a capacity to form tight fluid interfaces, both with the dental structures and with several adhesive systems.[7] The sealing ability is a factor, which mainly guards the microleakage of the blood and other periradicular tissue fluids to leak into the root canal space, which ultimately leads to the failure of the treatment performed. Hence, in the present case report, the Biodentine was used as a sealing material for the perforate site. A bioactive sealer BioRoot RCS proved to yield successful outcomes even after 3-year follow-ups.

In the present case, lateral condensation was the technique used as the thermoplastic techniques cause uncontrolled forces laterally and apically, leading to extrusion of root canal sealer and gutta-percha.[33] Case reports have analyzed the successful outcomes of various bioactive endodontic cements when used as a matrix for sealing the perforations.[34] The healing rates in the present case can be attributed to the bioactive sealer. Previous report proved the enhanced healing rates on using BioRoot RCS in chronic apical periodontitis cases.[35] Although reports of low-level evidence exist on the usage of bioactive endodontic cements for the treatment of teeth with resorption, showing favorable outcomes, clinical investigations with a high level of evidence are necessary.[34]

In the present case report, PRF was used as a matrix over Biodentine as it has several advantages, including ease of preparation and lack of biochemical handling of blood, which makes this preparation strictly autologous.[36] Recently, studies have demonstrated that PRF has a very significant slow sustained release of many key growth factors such as platelet-derived growth factor and transforming growth factor β for at least 1 week and up to 28 days.[37] Moreover, it does not dissolve quickly after application; instead, the strong fibrin matrix is slowly remodeled.[38] PRF can upregulate phosphorylated extracellular signal-regulated protein kinase expression. In addition, it suppress osteoclastogenesis by promoting the secretion of osteoprotegerin in the osteoblast cultures and allows cellular infiltration and subsequent integration of the newly formed tissue.[8] Even though the prognosis of the present case report was thought to be poor, the PRF has shortened the healing time without using bone graft as a substitute and the outcome correlated with the previous case report by Shivashankar et al.[38]

Although reports state the superiority of bioactive materials for various nonsurgical and surgical endodontic management,[39] the evidence level is low to come to a generalized conclusion. The CARE guidelines were used for reporting the present case report as they help to reduce the bias, increase transparency, provide evidence documenting the effect of interventions, and provide feedback on clinical practice guidelines.[40]

As there was an extensive communicating externally in this case, it was difficult to manage surgically. The tooth should also serve as an abutment for the fixed prosthesis, and the estimated survival rate of the tooth was also questionable. Hence, the prognosis of the present case was considered as poor. The alternative treatment options for the present case would be the extraction of involved tooth followed by prosthetic rehabilitation or implant prosthesis, or the alternative endodontic management would be the sealing of the perforation site before the obturation. This approach leads to enhanced disinfection of the canal three-dimensionally.

The limitation of the present report is the lack of long-term evaluation to come to a generalized conclusion. The other limitation would be the approach as such. Especially in cases with external communications, it is questionable whether the disinfection of the canal was optimal to achieve the adequate bacterial reduction and eradication of biofilm. It was suspected that the frequent intracanal canal medication using calcium hydroxide would have caused the optimal disinfection and the surgical approach following the replacement of lost tissue with bioceramic would have led to the therapeutic success of the present protocol.

Although endodontic treatment outcomes aim at complete regeneration of the tissues, it is always a matter of discussion which can only be justified by histological assessments. In the present case, it is difficult to assess whether it is a repair or regeneration.


  Conclusion Top


Although tissue engineering concept and usage of bioceramic were favorable in the management of external root resorption, future studies with a high level of evidence and long-term follow-ups are still encouraged to assess the outcomes of the currently proposed treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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