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Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 40-45

Management of invasive cervical resorption in maxillary incisors with cone-beam computed tomography: A case series

Department of Conservative Dentistry and Endodontics, CSI College of Dental Sciences, Madurai, Tamil Nadu, India

Date of Submission10-Jul-2020
Date of Decision24-Jul-2020
Date of Acceptance27-Jul-2021
Date of Web Publication25-Feb-2021

Correspondence Address:
I Anand Sherwood
Department of Conservative Dentistry and Endodontics, CSI College of Dental Sciences, 129, East Veli Street, Madurai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_83_20

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The purpose of this case report is to highlight the importance of cone-beam computed tomography, magnification, thermoplastic gutta-percha obturation, trichloroacetic acid, and bioactive endodontic cement usage in diagnosis and efficient management of invasive cervical resorption (ICR). Patients with predisposing factors associated with ICR, especially trauma of maxillary incisors, need close periodic monitoring to prevent the progression of the resorptive activity and initiate early management.

Keywords: Biodentine, cone-beam computed tomography, invasive cervical resorption, trichloroacetic acid

How to cite this article:
Vaanjay M, Prince E, Sherwood I A, Nivedha V, Evangelin J. Management of invasive cervical resorption in maxillary incisors with cone-beam computed tomography: A case series. J Dent Res Rev 2021;8:40-5

How to cite this URL:
Vaanjay M, Prince E, Sherwood I A, Nivedha V, Evangelin J. Management of invasive cervical resorption in maxillary incisors with cone-beam computed tomography: A case series. J Dent Res Rev [serial online] 2021 [cited 2023 Jan 30];8:40-5. Available from: https://www.jdrr.org/text.asp?2021/8/1/40/310195

  Introduction Top

Dental clinicians can often face the challenging situation of managing resorption in injured maxillary incisors. In 1994, Heithersay[1] introduced the term invasive cervical resorption (ICR) to define type on resorption progressing from the external cervical region of the tooth. ICR can many times be misdiagnosed as internal resorption or caries which leads to inappropriate treatment and even unnecessary tooth loss.[2] New findings about nature of osteoclasts responsible for resorption and how they behave in the oral environment have provided valuable insights for the diagnosis and treatment of this entity.[3] ICR occurs below the epithelial attachment of tooth in the cervical region.[2] Damage to cementum in that region exposes dentin to osteoclasts which starts the resorption process, creating space filled with invasive tissue.[4] The exact cause of ICR remains unknown with potential predisposing factors associated with it such as trauma, orthodontic tooth movement, and intracoronal bleaching which can be alone or in combination.[5]

Clinical presentation of ICR varies from one case to another; it is painless unless there is a superimposed secondary pulpal or periodontal infection.[2] ICR can have a clinical presentation of cervical cavitation, irregularity in the gingival contour, and/or pinkish discoloration of the overlying enamel.[6] Radiographic features vary from well-delineated lesion to irregularly mottled radiolucency which can be confused with caries.[2] Periapical radiographs in assessing the ICR are limited because of their two-dimensional nature, geometric distortion, and anatomic noise.[6] Radiograph interpretation of ICR has been reported to contribute to misdiagnosis, inadequate assessment, and management.[6] Cone-beam computed tomography (CBCT) is increasingly used for diagnosis and treatment planning in complex endodontic problems. This is endorsed with statements issued by the European Society of Endodontology and the joint statement by the American Association of Endodontists (2014) and the American Academy of Oral and Maxillofacial Radiology (2015).[7],[8] Many clinical studies have reported about the significant advantages with limited field of vision (FOV) CBCT scans for management of ICR.[6]

This case series aims to portray about the importance of CBCT scans in management of ICR and its potential limitations. Informed consent was obtained from all the patients in the present report before initiation of the treatment.

  Case Reports Top

ICR clinical and anatomic extension can differ extensively in each case. This is evidenced by a 29-year-old male patient who came with a complaint of pain in relation to his traumatized mandibular incisors and canine upon radiograph observation. It was concluded that multiple mandibular anterior teeth displayed evidence of ICR. CBCT scan ([Kodak CS 8100 3D, Carestream Dental, Atlanta, USA] with a FOV to a maximum of 8 teeth with an exposure of 80 KV, 5 mA, 19.96 s, and a voxel size of 90 μm) was advised, and it showed several areas of ICR in mandibular incisors and canine with periapical radiolucency [Figure 1]a and [Figure 1]b. A proper evaluation and interpretation of CBCT scan is essential in devising the management strategy for ICR. This is highlighted when a 21-year-old male patient was referred to clinic with restoration for root canal-treated maxillary right central incisor and CBCT scan report taken before root canal treatment. His pretreatment radiograph observation showed resorptive cavity overlapping with root canal space, and CBCT scan ([NewTom VGi evo, CEFLA s.c, Imola, Italy] with an exposure of 90 KV, 5 mA, 5.6 s, and a voxel size of 150 μm) observation was ICR in relation to maxillary right central incisor [Figure 2]a and [Figure 2]b. However, his dental clinician made a diagnosis of internal resorption and proceeded with root canal treatment, and eventually, postobturation radiograph showed that resorptive cavity was not managed [Figure 2]c.
Figure 1: Cone-beam computed tomography scan showing (arrows) pointing to resorption in mandibular incisor (a) and canine (b)

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Figure 2: (a) Pretreatment radiograph with radiograph denoting the resorptive defect in right maxillary central incisor. (b) Cone-beam computed tomography images describing the invasive cervical resorption (arrows) in the same tooth. (c) Postobturation radiograph showing the resorptive defect (arrow) not managed

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Case 1

In 2017, a 56-year-old female patient with complaints of pain and discolored in traumatized maxillary left central incisor reported to department. On clinical and radiograph examination, ICR was confirmed in maxillary left central incisor which was confirmed with CBCT ([Kodak CS 8100 3D, Carestream Dental, Atlanta, USA] with a FOV to a maximum of 8 teeth with an exposure of 80 KV, 5 mA, 19.96 s and a voxel size of 90 μm) [Figure 3]a, [Figure 3]b, [Figure 3]c. CBCT scan detected Heithersay Class III ICR,[5] and according to Patel et al. three-dimensional (3D) classification, it was 2Bd[6] with periapical radiolucency. The root canal was obturated with Biodentine® (Septodont Healthcare Pvt. Ltd., Raigad, India) as a sealer and thermoplasticized gutta-percha (B&L Biotech Inc., Gyeonggido, Korea) [Figure 3]c. Since the resorptive defect was coronal to alveolar crestal bone level with loss of crestal bone, the lesion was accessed by external access method from the labial aspect.[2] The resorptive defect was cleaned with 90% trichloroacetic acid (NICE Chemicals Pvt. Ltd., Kochi, India) following curettage with hand curettes and ultrasonic curettes and restored following a full-thickness mucoperiosteal flap reflection with resin-modified glass-ionomer cement and using Biodentine® as a base under magnification (Labomed Prima, Labomed Inc., CA, USA) [Figure 3]d and [Figure 3]e. Access preparation was sealed with composite.
Figure 3: (a) Traumatized left maxillary central incisor. (b) Preoperative radiograph showing resorptive defect (arrow) and periapical lesion (arrow). (c) Cone-beam computed tomography image depicting the resorptive defect (arrow) and periapical lesion (arrow). (d) Labial mucoperiosteal flap reflection showing resorptive defect (arrow). (e) Postobturation and after restoration of defect radiograph

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Case 2

In 2018, a 45-year-old male patient came with a complaint of pain in traumatized maxillary right central incisor; a periapical radiograph showed a resorptive defect suggestive of internal resorption with periapical lesion [Figure 4]a. CBCT scan ([Kodak CS 8100 3D, Carestream Dental, Atlanta, USA] with a FOV to a maximum of 8 teeth with an exposure of 80 KV, 5 mA, 19.96 s, and a voxel size of 90 μm]) detected ICR Heithersay[5] Class IV, and according to Patel et al.[6] 3D classification, it was 4Bp [Figure 4]b with root canal communication and periapical lesion. The apical one-third of root canal below the resorptive defect was obturated with thermoplasticized gutta-percha, using Biodentine® as root canal sealer. Since resorptive defect was confined to palatal aspect and apical to alveolar bone crest level, a full-thickness mucoperiosteal flap reflection was done from palatal aspect [Figure 4]c. Resorptive defect and access preparation management was done as in earlier case [Figure 4]d.
Figure 4: (a) Preoperative radiograph of right maxillary central incisor resorptive defect (arrow) mimicking an internal resorption with periapical radiolucency (arrow). (b) Cone-beam computed tomography image showing invasive cervical resorption defect (arrow). (c) Palatal mucoperiosteal flap reflection to access the resorptive defect (arrow). (d) Postobturation and resorptive defect closure radiograph

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Case 3

In 2020, a 28-year-old female patient reported with pinkish discolored and painful maxillary left central incisor with no history of trauma [Figure 5]a. Upon close examination of periapical radiograph, the tooth showed pulp canal obliteration [Figure 5]b. CBCT scan ([Kodak CS 8100 3D, Carestream Dental, Atlanta, USA] with a FOV to a maximum of 8 teeth with an exposure of 80 KV, 5 mA, 19.96 s, and a voxel size of 90 μm) indicated the presence of pulp canal obliteration with periapical pathology and Heithersay[5] Class I and Patel et al.[6] 3D classification 1Ad ICR on the labial aspect of the tooth with associated crestal bone loss which was not detected in the conventional radiograph [Figure 5]c. Clinical probing detected a small resorptive defect with subgingival extension. SICAT Endo™ software (SICAT GmbH and Co., Bonn, Germany) was used for marking the point of entry for the access preparation to minimize the loss of tooth structure [Figure 5]d. Root canal treatment was done with Biodentine sealer and thermoplastic gutta-percha obturation [Figure 5]e. Labial resorptive defect was restored as in previous cases after a full-thickness labial mucoperiosteal flap reflection [Figure 5]f.
Figure 5: (a) Pretreatment photograph of slightly pink discolored traumatized left maxillary central incisor. (b) Pretreatment radiograph of the tooth showing evidence of pulp canal obliteration (arrow). (c) Cone-beam computed tomography scan showing resorptive defect (arrow), pulp canal narrowing (arrow), and periapical lesion (arrow). (d) SICAT Endo software analysis depicting the location of required access preparation location. (e) Postobturation radiograph. (f) Labial mucoperiosteal flap reflection with resorptive defect (arrow) cleaned with trichloroacetic acid

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In the above three cases managed for ICR, the pulpal diagnosis was necrotic pulp with nonresponsive thermal pulp test and associated with acute apical periodontitis [Figure 3], [Figure 4], [Figure 5].

Case 4

A female patient aged 10 years reported to corresponding author's clinic with avulsion of four maxillary incisors due to trauma in 2018, the teeth were replanted after more than 2 h, fiber splinted (Interlig, Angelus Indústria de Produtos Odontológicos S/A, Londrina PR, Brazil) followed up with root canal treatment for all the avulsed maxillary incisors [Figure 6]a.
Figure 6: (a) Preoperative radiograph of avulsed four maxillary incisors replanted and stabilized with fiber splint. (b) One-year postroot canal-treated maxillary incisors following replantation with arrow depicting invasive cervical resorption in left maxillary central incisor. (c) Two-year posttreatment radiograph with extensive invasive cervical resorption (arrow) with clinical signs of mobility in left maxillary central incisor and left maxillary lateral incisor with resorptive defects (arrow). (d) Root submergence procedure adopted for left maxillary central incisor (arrow). (e and f) Pre- and postroot submergence photographs of left maxillary central incisor (arrow)

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Obturations for the incisors were completed with lateral gutta-percha compaction and zinc oxide-eugenol sealer (Dental Products of India Pvt. Ltd., Mumbai, India). One-year review radiograph showed evidence of ICR (Heithersay[5] Class II) in left maxillary central incisor apical to crestal alveolar bone, and the patient did not opt for CBCT scan or further management [Figure 6]b. Two-year follow-up demonstrated mobility of left maxillary central incisor associated with a significant increase in ICR (Heithersay[5] Class III) both in the mesial and distal aspect of the root [Figure 6]c, and the patient was suggested for root submergence with careful removal of tooth structure coronal to the resorptive defect[9],[10],[11] procedure considering the patients' age [Figure 6]d, [Figure 6]e, [Figure 6]f. Following removal of the tooth structure, the submerged root portion was carefully cleaned with trichloroacetic acid. Root submergence or root banking is a procedure advocated to preserve the alveolar crestal bone height and maintain the gingival harmony with those of adjacent teeth.[9],[10],[11] Left maxillary lateral incisor also had ICR (Heithersay[5] Class III) without mobility and was opted to be managed by surgical flap reflection with trichloroacetic acid cleaning and resorptive defect restored with resin-modified glass-ionomer cement. Crown portion of left central incisor was replaced with fiber-splinted crown restoration.

  Discussion Top

The three cases of resorption management and root canal treatment with CBCT in this report sought treatment only after development of symptoms. This is contrary to report by Espona et al.[2] This is due to the trend that most of the patients in our institution report for dental services only after occurrence of pain. Therefore, all the cases required root canal treatment for management of the infected canal and associated apical periodontitis. The three cases with CBCT in this presentation were above the age of 25 years and had a long-standing trauma history which has made the root canals narrowed making cleaning and shaping of canals difficult. External access method suggested by previous authors[2] was an effective method to gain access to the resorptive defect for effective management. Small FOV CBCT imaging significantly contributed to choosing the appropriate surgical flap entry, especially when the resorptive process overlaps the labial or palatal surfaces. Patel et al.[6] have suggested that the CBCT may be considered only if the resorption is clinically amenable to treatment following clinical and conventional radiograph examination. An extensive ICR (>2/3rd of cervical root structure is resorbed) apical to alveolar crestal bone was evident and nonrestorable, as depicted in [Figure 6] and [Figure 7]. This did not warrant the use of CBCT. Furthermore, in case 4, the resorptive defect management in left maxillary lateral incisor was accomplished after removal of coronal portion of adjacent left maxillary central incisor approximating the resorptive lesion which provided better access, and also, root canal treatment for this tooth has been completed earlier. Requirement of root canal treatment in traumatized maxillary incisors with ICR further complicates the management of ICR. ICR has been mostly associated as a painless process until late in its course.[4] Contrary to this finding, case # 3 had a mild ICR which was associated with painful necrotic pulp and apical periodontitis, but in this case, it would be difficult to ascertain which process started first whether it was the necrotic pulp tooth which later on had ICR or vice versa. Shemesh et al.[12] concluded that ICR in traumatized teeth had a higher prevalence for necrotic pulp as evidenced in this case report. Trauma as one of the associated factors with an increased incidence of ICR has been acknowledged in a recent report.[13] All the teeth in the present report exhibited no/minimal loss of crown structure and also had alveolar crestal bone loss surrounding the resorptive defect. Hence, these teeth would have suffered trauma in the form of concussion injury which could have led to cemental tear and resorptive activity initiation.[14] Crestal bone loss in ICR is observed to be associated only with superimposed periodontal infection, and the patients with CBCT scans in this report sort treatment long time after trauma which could be the reason for alveolar crestal bone loss or secondary periodontal infection.[4] Traumatic injuries to teeth have been reported to be the fifth most prevalent disease/injury; therefore, patients should be made aware of long-term complications arising out of these injuries even if the tooth does not exhibit any fracture and need for regular follow-up of these teeth for every 1 year if necessary with radiograph.[15],[16] One-year periodic follow-up is being recommended as all the teeth in the present report had trauma history many years back which patient could not recollect. Biodentine and glass-ionomer cement are better restoring the resorptive cavity which may help in the formation of long epithelial attachment.[17] Trichloroacetic acid application to the resorptive cavity promotes the coagulation of the invasive tissue by penetrating smaller, more inaccessible recesses and resorptive channels.[18] This helps in preventing any further progress of the resorptive lesion.
Figure 7: (a) Preoperative photograph of traumatized right maxillary central incisor with discoloration (arrow) evident in cervical aspect. (b) Preoperative radiograph depicting the extensive resorptive defect (>2/3rd of cervical root structure involvement) (arrow)

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Resorptive defects extending beyond the middle third of the root with pulp canal involvement poses a high technical difficulty in obturating the root canal space apical to the resorptive defect as in case 2. This is because we do not want any gutta-percha material in the resorptive defect which could interfere with removing the granulation tissue or bonding of the restorative material. Previous long-term follow-up reports have mentioned about successful management of ICR with external access method.[2],[18] All the four cases in the present report and future ICR management requiring root canal treatment are planned for 4-year follow-up to evaluate the clinical success of the treatment procedure.

ICR has been shown to be easily misdiagnosed by general practitioners as presented in this report [Figure 2] also, so clinicians should be made aware of early detection of these lesions to manage it efficiently.[10] Modern magnification and CBCT/radiograph imaging has enhanced the detection of resorptive defects. It would be impossible to manage ICR in a minimalistic manner without the aid of 3D imaging, especially when the teeth require root canal treatment. Furthermore, the use of thermoplastic obturation is recommended when the circumferential spread of the resorptive defect is >90°. This report highlights the wide variation in clinical presentation and anatomy of the ICR. Maxillary central incisor had a higher prevalence for ICR in this report, and this is similar to earlier review report.[19] The overriding objective in management of ICR should be continuousmonitoring of teeth with exposure to predisposing causative factors for ICR and sealing it at the earliest stage of detection than allow it to progress and combine with root canal treatment procedure. As and when ICR occurs in traumatized root canal-treated teeth, options of root submergence and other conservative options should be explored, especially in young age patients.

  Conclusion Top

Continuous regular monitoring traumatized maxillary incisor with periodic radiograph observation and thermal testing is mandatory for early detection of ICR and halting the resorption procedure at early stages. This is especially important for maxillary incisors with no/minimal crown structure loss even when they have undergone root canal treatment. Resorptive defect in maxillary incisors associated with requirement for root canal treatment should be managed with CBCT imaging to precisely locate the surgical entry under magnification. Most of the time, teeth with ICR and requiring root canal treatment, the resorptive defect could be close to or encroaching the pulp canal space which can only be accurately detected in CBCT imaging for proper management. Root submergence option should be explored for maxillary associated with nonrestorable resorptive defects.

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.


The authors would like to thank Winthrop Professor Dr. Paul V Abbott BDSc, MDS, FRACDS (Endo), Winthrop Professor of Clinical Dentistry, Endodontist, Program Co-ordinator (Endodontics), UWA Dental School, University of Western Australia, Australia, for his valuable scientific inputs for improving quality of the manuscript.

The authors would also like to thank Dr. Lucila Piasecki MS, PhD, Clinical assistant Professor, Department of Periodontics and Endodontics, School of Dental Medicine, University at Buffalo, New York, US, for her help with SICAT Endo™ software (SICAT GmbH and Co., Bonn, Germany).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Heithersay GS. External root resorption. Ann R Australas Coll Dent Surg 1994;12:46-59.  Back to cited text no. 1
Espona J, Roig E, Durán-Sindreu F, Abella F, Machado M, Roig M. Invasive cervical resorption: Clinical management in the anterior zone. J Endod 2018;44:1749-54.  Back to cited text no. 2
Andreasen JO, Heithersay GS, Bakland BF. Pathologic tooth resorption. In: Ingle's Endodontics. Rotstein I, Ingle JI, editors. NC, USA: PMPH USA; 2019. p. 421-438.  Back to cited text no. 3
Heithersay GS. Clinical, radiologic, and histopathologic features of invasive cervical resorption. Quintessence Int 1999;30:27-37.  Back to cited text no. 4
Heithersay GS. Invasive cervical resorption: An analysis of potential predisposing factors. Quintessence Int 1999;30:83-95.  Back to cited text no. 5
Patel S, Foschi F, Mannocci F, Patel K. External cervical resorption: A three-dimensional classification. Int Endod J 2018;51:206-14.  Back to cited text no. 6
European Society of Endodontology, Patel S, Durack C, Abella F, Roig M, Shemesh H, et al. European Society of Endodontology position statement: The use of CBCT in endodontics. Int Endod J 2014;47:502-4.  Back to cited text no. 7
Special Committee to Revise the Joint AAE/AAOMR Position Statement on use of CBCT in Endodontics. AAE and AAOMR Joint Position Statement: Use of cone beam computed tomography in endodontics 2015 update. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;120:508-12.  Back to cited text no. 8
Delivanis P, Day O, Esposito C, Bickley R. Clinical considerations for root-submergence procedures. J Prosthet Dent 1980;43:487-90.  Back to cited text no. 9
Dugan DJ, Getz JB, Epker BN. Root banking to preserve alveolar bone: A review and clinical recommendation. J Am Dent Assoc 1981;103:737-43.  Back to cited text no. 10
Choi S, Yeo IS, Kim SH, Lee JB, Cheong CW, Han JS. A root submergence technique for pontic site development in fixed dental prostheses in the maxillary anterior esthetic zone. J Periodontal Implant Sci 2015;45:152-5.  Back to cited text no. 11
Shemesh A, Levin A, Ben Itzhak J, Brosh Y, Braverman E, Batashvili G, et al. External invasive resorption: Possible coexisting factors and demographic and clinical characteristics. Aust Endod J 2019;45:141-5.  Back to cited text no. 12
Irinakis E, Aleksejuniene J, Shen Y, Haapasalo M. External cervical resorption: A retrospective case-control study. J Endod 2020;S0099-2399:30384-8.  Back to cited text no. 13
Heithersay GS. Invasive cervical resorption. Endod Topics 2004;7:73-92.  Back to cited text no. 14
Petti S, Glendor U, Andersson L. World traumatic dental injury prevalence and incidence, a meta-analysis-One billion living people have had traumatic dental injuries. Dent Traumatol 2018;34:71-86.  Back to cited text no. 15
Abbott P. Traumatic dental injuries are now the 5th most prevalent disease/injury in the world-But they are being neglected!! Dent Traumatol 2018;34:383.  Back to cited text no. 16
Martins TM, Bosco AF, Nóbrega FJ, Nagata MJ, Garcia VG, Fucini SE. Periodontal tissue response to coverage of root cavities restored with resin materials: A histomorphometric study in dogs. J Periodontol 2007;78:1075-82.  Back to cited text no. 17
Heithersay GS. Treatment of invasive cervical resorption: An analysis of results using topical application of trichloracetic acid, curettage, and restoration. Quintessence Int 1999;30:96-110.  Back to cited text no. 18
Patel S, Mavridou AM, Lambrechts P, Saberi N. External cervical resorption-part 1: Histopathology, distribution and presentation. Int Endod J 2018;51:1205-23.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

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