|Year : 2023 | Volume
| Issue : 1 | Page : 88-93
Preeruptive intracoronal resorption: A cone-beam computed tomography study
Kendra Clark1, Mehrnaz Tahmasbi2, Robert A Augsburger1, Poorya Jalali1
1 Department of Endodontics, Texas A and M College of Dentistry, Dallas, Texas, USA
2 Department of Diagnostic Sciences, Texas A and M College of Dentistry, Dallas, Texas, USA
|Date of Submission||02-Aug-2022|
|Date of Decision||06-Sep-2022|
|Date of Acceptance||09-Sep-2022|
|Date of Web Publication||11-Jan-2023|
Dr. Poorya Jalali
Department of Endodontics, Texas A and M College of Dentistry, 3302 Gaston Ave, Dallas, Texas 75246
Source of Support: None, Conflict of Interest: None
Introduction: Preeruptive intracoronal resorption (PEIR) is described as the cavitation of intracoronal dentin just below the dentinoenamel junction in the coronal portion of an unerupted tooth. The aim of this study was to analyze cone-beam computed tomography (CBCT) scans of teeth affected by PEIR and report the radiographic findings.
Materials and Methods: In this retrospective study, a total of 26 CBCT scans including 33 PEIR-affected teeth were evaluated. The following data were documented: age, sex, affected tooth, presence and location of enamel/cementum disruption, lesion extension, radiographic distance of lesion to the pulp, pericoronal radiolucency, and periapical radiolucency.
Results: Third molars were the primary teeth affected (88%). A radiographic disruption of the external surface of the tooth was noted in all cases. Disruption of the enamel only was observed in 29 cases, followed by disruption of enamel and cementum in two cases, and disruption of the cementum only in two cases. Twenty-one cases (64%) showed lesions extending to or above the cementoenamel junction (CEJ), and 12 cases (36%) displayed lesions extending below the CEJ. In 21 cases, the lesion progressed close to the root canal system, leaving <1 mm of dentin. However, due to the limitations of CBCT imaging, resorptive pulpal exposure could not be accurately determined. One case exhibited a pericoronal radiolucency, whereas none of the 33 cases displayed signs of a periapical radiolucency.
Conclusion: These data suggest that PEIR is a form of external resorption. CBCT is a viable tool for the identification of cases with PEIR, and for determining the extent of the resorptive defect.
Keywords: Endodontics, radiolucent lesion, resorption, unerupted tooth
|How to cite this article:|
Clark K, Tahmasbi M, Augsburger RA, Jalali P. Preeruptive intracoronal resorption: A cone-beam computed tomography study. Saudi Endod J 2023;13:88-93
| Introduction|| |
Preeruptive intracoronal resorption (PEIR) is described as the cavitation of the intracoronal dentin just below the dentinoenamel junction in the coronal portion of the unerupted tooth. It is often discovered during routine radiographic examinations. Resorption occurs in the dentin of primary or permanent teeth only after crown development is complete. Although this type of resorption was first reported in 1941, the etiology of PEIR remains uncertain. Although little is known about PEIR, Seow et al. suggested that pressure from adjacent teeth, or an ectopic position of the tooth bud, with prolonged disruption of tooth formation, may be a causative agent. The literature supports an association between PEIR and both ectopic eruption and dental impaction.,
Histological analysis of PEIR from an unerupted tooth reveals classical signs of resorption, including the presence of osteoclasts and the scalloping of the dentin margins. A thin layer of dentin (odontoblast layer) separates the resorptive defect and the pulp.,,, This thin layer has been described in the literature as a pericanalar resorption-resistant sheet (PRRS) that prevents pulp space penetration and is present in all stages of external cervical resorption (ECR) cases. When the tooth erupts, the pulp usually becomes infected and the resorptive lesion resembles a large carious lesion. In some affected teeth, the pulp is encroached soon after the eruption and a dental abscess develops, leading to swelling and pain. The expeditious and efficient treatment of these lesions is imperative as complete resorption of the crown may occur within 1–2 years. The prognosis of these cases is dependent on early detection.
Definitive treatment options for PEIR include extraction, restoration of the crown, or endodontic treatment along with the restoration of the coronal tooth structure.,, Le et al. found in their systematic review that surgical opening and restoration treatment of PEIR before tooth eruption was a high priority for treatment options. The decision of the most effective treatment depends on the status of the lesion, whether the lesion is static or progressive, and the extent of the resorptive lesion. The status of the PEIR can only be determined by comparing successive radiographs. The extent of the lesion has predominantly been assessed with panoramic, periapical, or bitewing radiography. However, assessment with these types of radiography does not allow high-resolution and a three-dimensional view of the PEIR without superimposition.
Cone-beam computed tomography (CBCT) is a more sensitive method in detecting PEIR. CBCT analysis may also provide more information in determining lesion progression and extension. Therefore, the purpose of this retrospective study was to analyze the CBCT scans of teeth affected by PEIR and report the radiographic findings.
| Materials and Methods|| |
In this retrospective study, a total of 26 CBCT scans of patients who had at least one tooth with a PEIR lesion were evaluated (a total of 33 teeth). All the scans included in this study had been anonymized previously; therefore, the project protocol was exempted by the Institutional Review Board of the Texas A and M College of Dentistry, Dallas, TX (#IRB2020-0447). The CBCTs used were obtained from the database of an oral and maxillofacial radiology private practice and included images with a medium field of view (12 cm × 10 cm). The images had been taken as a part of the routine examination and preoperative assessment for various dental treatments (e.g. implant and third molar surgery) during July 2017–December 2019, and the identification of intracoronal resorption was an incidental finding. Only the scans that were diagnostic and had an acceptable quality for evaluation of the pattern of resorptive defects were included in the study. Radiographically, PEIR was defined as a radiolucency in the coronal portion of an unerupted tooth. An unerupted tooth was defined as one that was covered by bone and/or mucosa and under the occlusal plane.
The CBCT scans were analyzed using InvivoMac Application version 6.0.5 (Anatomage, San Jose, CA, USA) on a 13.3-inch MacBook Pro with a retina display and a resolution of 2560 × 1600 pixels (Apple Inc, Cupertino, CA, USA) in a dark room dim light. Two observers, a board-certified endodontist and a board-certified oral and maxillofacial radiologist, simultaneously evaluated the multiplanar images to conclude the CBCT findings. During the analysis of the CBCT scans, the following data of each case were documented: age, sex, affected tooth, presence and location of enamel/cementum disruption, lesion extension, radiographic distance of lesion to the pulp, pericoronal radiolucency, and periapical radiolucency.
The presence of enamel/cementum disruption was classified by radiographic evidence of the lesion in the enamel or cementum. In addition, the disruption point was categorized as originating in the occlusal/incisal, mesial/distal, or buccal (facial)/lingual (palatal) of the tooth. Lesion extension was grouped as being located or extending above or below the cementoenamel junction (CEJ). Furthermore, lesion extension was reported relative to the coronal-apical extension in thirds. Due to the limitations of CBCT imaging, resorptive pulpal exposure could not be accurately determined. Therefore, teeth were organized as to whether there was less or more than 1 mm of tooth structure separating the resorptive defect from the pulp chamber.
| Results|| |
Demographic data of the 26 patients included 10 females and 16 males [Table 1]. The ages of the patients ranged from 39 to 89 with an average age of 64. Of the 33 teeth included in the study, 21 patients had one tooth with resorption, three patients had two teeth with resorption, and two patients had three teeth with resorption. Of these 33 teeth included, 17 teeth were upper third molars, 12 teeth were lower third molars, 2 were anterior supernumerary teeth, 1 tooth was an upper second molar, and 1 was an upper incisor.
In all the cases, a radiographic disruption of the external surface of the tooth was noted. Twenty-nine of the cases showed enamel disruption only, 2 cases showed enamel and cementum disruptions, and 2 cases showed cementum disruption only [Figure 1]. Therefore, only two cases exhibited radiographic disruptions below the CEJ, not involving the enamel. Of the 31 cases with evidence of enamel disruption, the radiographic disruption was noted in the occlusal/incisal portion of the crown in 22 cases, the buccal/lingual faces of the tooth in 5 cases, and the mesial/distal surfaces of the tooth in 4 cases.
|Figure 1: CBCT images showing radiographic evidence of (a) enamel disruption and (b) cementum disruption. CBCT: Cone-beam computed tomography|
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Regarding lesion extension, 21 cases (64%) showed lesions extending to or above the CEJ. Of those 21 cases, 4 lesions extended one-third the length of the crown, 7 lesions extended two-thirds the length of the crown, and 10 lesions extended the full length of the crown. The remaining 12 cases (36%) had lesions extending below the CEJ. Of those 12 cases, 11 lesions extended into the root coronal third and 1 lesion extended into the root middle third [Figure 2]. Evaluation of the CBCT images did not allow a clear determination of pulpal involvement. In 21 cases, the lesion progressed very close to the root canal system leaving <1 mm dentin thickness remaining [Figure 3]. In the remaining 12 cases, the distance between the root canal system and the resorptive defect was equal to or more than 1 mm, suggesting no radiographic evidence of pulpal exposure.
|Figure 2: Coronal and sagittal views of five cases with PEIR extended to (a) coronal 1/3, (b) coronal 2/3, (c) coronal 3/3, (d) root 1/3, and (e) root 2/3. PEIR: Preeruptive intracoronal resorption|
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|Figure 3: (a and b) Two cases in which the lesion progressed very close to the root canal system leaving <1 mm dentin thickness remaining. However, CBCT imaging, due to its limitations, cannot provide strong evidence of a direct communication of the resorptive defect and the pulp chamber. CBCT: Cone-beam computed tomography|
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One case exhibited a pericoronal radiolucency, whereas none of the 33 cases reported displayed signs of a periapical radiolucency.
| Discussion|| |
A role for local etiologic factors is considered when subjects have only one affected tooth with PEIR.,, However, our study contains patients that have more than one affected tooth suggesting the difference may be related to unknown etiologic factors, multiple local factors, systemic factors, or radiologic techniques.,,, Furthermore, the prevalence of PEIR has been reported to be 2%–8% by subject and 0.6%–2% by tooth, primarily affecting the mandibular first premolar and second and third molars. In this study, third molars were affected in 29 of the 33 cases. Consistent with our research, a retrospective CBCT study with a similarly aged population found that third molars followed by supernumerary teeth were the most affected tooth type.
Most studies have not reported evidence of pulp degeneration, dental caries, or microbial invasion before tooth eruption. The hypothesis that resorption is the underlying mechanism in PEIR is now commonly accepted. The resorptive process in PEIR defects has been suggested to stem from undifferentiated cells of the developing dental follicle or osteoclast-like giant cells on the pulpal surface of the dentin. Approximately 36% of the cases reported in this study had >1 mm of tooth structure separating the radiolucency from the pulp chamber, whereas 100% of the cases showed radiographic evidence of external tooth surface disruption. This suggests that PEIR is a form of external resorption. In accordance with our findings, other researchers have stated the resorptive process is likely to be initiated externally rather than internally.,
Of the 31 cases with evidence of enamel disruption, the radiographic disruption was noted in the occlusal/incisal portion of the crown in 22 cases, the buccal/lingual faces of the tooth in 5 cases, and the mesial/distal surfaces of the tooth in 4 cases. Studies report PIER lesions are located on the central aspects of the crown, with smaller percentages in mesial or distal aspects of the occlusal. However, these studies utilized 2D radiography that was not able to distinguish whether a lesion initiated from the occlusal/incisal, buccal, or lingual surfaces., As most cases showed disruption of the enamel only, four cases exhibited disruption of the cementum. This cementum disruption and resorption pattern resemble ECR. All ECR cases examined by CBCT, nano-CT, histology, and scanning electron microscope share common characteristics. These include a portal of entry located in the cementum below the gingival epithelial attachment, 3D resorption progression (circumferentially and/or coronal-apical), and the structure of the PRRS tissue and pulp reaction. Like PEIR, the etiology of ECR remains unknown. Similar relevant predisposing factors are delayed eruption, developmental defects, and impacted teeth., If PEIR cases only exhibit enamel disruption, the disruption of the cementum may be ECR occurring before the eruption. Furthermore, these two resorptive entities may occur simultaneously as seen in the two cases showing concomitant, but isolated disruption of the enamel and cementum.
Examination of the 3D progression of these lesions exhibited two distinct patterns. One pattern initiated in the enamel, extended into the crown and was typically limited to the crown only. This pattern is suspected to be the PEIR lesions as reports state these lesions are often located within the dentin, adjacent to the dentin–enamel junction, in the occlusal aspect of the crown, and are found as single or multiple lesions in both maxillary and mandibular arches.,,, The other pattern started in the CEJ and extended toward the root. This pattern suggests ECR as it is described to invade the tooth structure by resorbing cementum, dentin, and enamel. Although one pattern progressed more coronally and the other more apically, both progressed circumferentially toward the pulp, but not into the pulp chamber [Figure 4]. It is also important to note that there was not strong evidence of a direct communication of the resorptive defect and the pulp chamber in most of the cases reported. This resorptive pattern is likely due to PRRS, which is composed of a 210 μm sheet of predentin, dentin, and reparative tissue apposition that aids in preventing pulp space penetration.
|Figure 4: (a and b) Sagittal and axial views of two cases with PEIR with the resorptive defects extended very close to the root canal system but leaving an intact thin shelf of dentin surrounding the pulp. This feature resembles that of external cervical resorption. PEIR: Preeruptive intracoronal resorption|
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PEIR is also similar to the process of occult caries but differs from the latter because the tooth has no communication with the oral cavity., Hence, a developing tooth which is completely encased in its crypt is not likely to be infected with cariogenic microorganisms. CBCT analysis is limited in its ability to determine pulpal involvement and traditional methods of sensibility testing could not be employed. However, if bacteria are involved in the progression of PEIR with the involvement of the pulp, a radiographic periapical radiolucency may arise. CBCT examination did not reveal a periapical radiolucency in any of the cases reported. Patients do not typically become symptomatic until the affected tooth erupts into the oral cavity. Ultimately, this evidence suggests the pulps in these teeth are vital.
Due to the low prevalence of PEIR, this study has a small sample size. Because this was a retrospective study, the CBCT protocol used to acquire the scans was unknown. There may also be a bias in case selection as the pediatric population is less likely to have a CBCT performed for a tooth exhibiting PEIR. Bitewing and panoramic radiographs do not clearly evaluate the coronal details and defects in these teeth may be missed., While bitewing and panoramic radiographs are recommended to detect the presence of PEIR, CBCT examination is recommended to determine the extent of the resorptive lesion and subsequently the appropriate treatment.,, If treatment of a PEIR lesion is necessary and pulp exposure occurs during treatment, vital pulp therapy and restoration of the coronal tooth structure will likely be adequate. This study displayed the similarities and dissimilarities of PEIR and ECR lesion progression. However, further studies are needed to ascertain the prevalence and etiology of PEIR. In addition, the management of these resorptive lesions after the eruption and possible preventive measures will need to be further investigated.
The authors would like to thank Drs. Kendra Clark and Mehrnaz Tahmasbi for contributing equally to this work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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