Invasive cervical root resorption: Engineering the lost tissue by regeneration
A 35-year-old non-smoking male patient presented for consultation at the Endodontic Department with a chief complaint of swelling and pus discharge in the upper left canine [Figures and ]. Patient's medical history was non-contributory. Patient reported trauma to his upper teeth when he was about 20 years old. After performing sensitivity tests, tooth #11 was diagnosed as having pulpal necrosis. Clinical examination revealed localized gingival recession and gingival enlargement in relation to tooth #11. Probing pocket depth on the mesial surface of the tooth #11 was 10 mm with a high bleeding score. Radiographic examination showed two bowl shaped radiolucency at mesial aspect of the root. Based on the clinical and radiological finding, we came to the diagnosis of localized chronic periodontitis and pulpal necrosis with external inflammatory root resorption. The treatment plan was informed to the patient, which included patient motivation, oral hygiene reinforcement, scaling and root planning, endodontic procedure and lastly surgical intervention. Patient and his parents were informed of possible discomforts and potential risks concerning the planned treatment procedure and prognosis.\nIn phase one therapy oral prophylaxis was performed. Endodontic access cavity was prepared after placing a rubber dam and disinfecting the area with 2% of chlorhexidine digluconate (Calypso, Septodont, India). Working length was determined by using the electronic apex locator Root ZX (J. Morita MFG. Corporation, Kyoto, Japan) and file in-radiograph with 15 number K-files. The root canal was cleaned and shaped by Rotary Ni-Ti Protaper System along with GLYDE (Dentsply Maillefer Company, USA) using the crown down technique. The root canal was copiously irrigated with 2.5% sodium hypochlorite (Novo Dental Product, India). Access cavity was temporized with calcium hydroxide and temporary endodontic restorative material (TERM). Patient was recalled after 1 week; the tooth was asymptomatic. Root canal was irrigated again with normal saline and dried using paper points. Before obturation, master points were seated to test their suitability to canals and radiograph was taken. The canals were obturated with selected master gutta-percha cone (variable taper) and AH-Plus sealer (Dentsply Maillefer Company, USA). The coronal gutta-percha cones were sheared off using heated instrument and vertical compaction was done using the heated pluggers at the canal orifices. The access cavity was restored with a composite (Clearfil Majesty; Kuraray, Osaka, Japan).\nThe surgical procedure was performed under local infiltration anesthesia (2% of lidocaine with 1:100,000 adrenaline) on vestibular mucosa. An intrasulcular incision was made from the distal surface of the maxillary left central incisor to the distal surface of the maxillary left canine and full-thickness mucoperiosteal flap was elevated. Surgical exploration revealed that two lesions were present on the mesial surface of upper left canine and there was no palatal intercommunication []. Granulomatous tissue within the defect area was removed and 90% of trichloroacetic acid was applied to the resorptive defect for coagulation necrosis. The resorptive defects were restored with microfilled composite (Durafill VS; Heraeus Kulzer GmbH, Dormagen, Germany) to a thickness of about 1 mm and light cured for 20 s. The rest of the defects were restored with Resin modified glass ionomer cement (RMGIC) (Fuji II LC; GC Corporation, Tokyo, Japan) to a smooth finish with a cervical matrix and light cured for 20 s [].\nA 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 in consistency. PRF clot started to release its serum (PRF-clot exudates) and was ready for compression into the membrane. The bony defect was filled with freeze-dried bone allograft (LifeNet, Virginia Beach, VA) and PRF []. Without delay autologous PRF membrane was placed [] and the flaps were secured with 4-0 polyglactin 910 sutures (Vicryl, Ethicon, Inc., Piscataway, NJ). After the surgery, the patient was prescribed amoxicillin 1 g twice a day for 1 week and 0.2% of chlorhexidine mouthwash 15 ml twice a day for 2 weeks. The desired gingival contour was achieved; the patient was asymptomatic 1 week after the surgery and the sutures were removed. Patient was followed-up for 6 months, [] 1 year [] and 2 year. At 2-year follow-up period, periodontal status of related tooth demonstrated mild mobility with normal probing depth, no gingival recession and no loss of clinical attachment [Figures and ].