Patient: 75-year-old patient in excellent health

Chief Complaint: Soreness of the gums

Dental History: The patient reported a history of root resorption associated with the mandibular left central incisor (#24), which had been surgically repaired by a periodontist 3 months prior to the examination. No root canal treatment had been performed.

Significant Findings: Labial gingival inflammation, moderate percussion sensitivity, necrotic pulp, and Class 2 mobility. There were 3 mm pocket depths on the labial with bleeding and gingival recession

Diagnosis: Necrotic pulp with acute periradicular periodontitis and extracanal invasive resorption previously repaired

Prognosis: Fair

Treatment Plan: Combined Nonsurgical Endodontic Therapy and Surgical Root Resorption Repair

Treatment Description with Special Considerations: The #24 tooth was accessed and calcium hydroxide was placed. The calcium hydroxide was noted to leak through the "repaired" resorption defect. The initial CBCT mapping was helpful for an accurate prognosis assessment. If the surgical resorption repair is performed before the nonsurgical phase then the repair material may be pushed out later when NSRCT is performed thus requiring that the surgical phase be repeated. In retreatment of this case, nonsurgical endodontic treatment was begun with internal TCA treatment and placement of calcium hydroxide. On the second visit, one month later, the root canal system was obturated and the canals backfilled with MTA. Throughout the cleaning and shaping procedure sodium hypochlorite was used without creating positive pressure with the syringe so that a bleach accident would not occur. There was adequate confinement of the irrigants due to tissue resistance with the labial wall existing from the previous repair material. It is generally rare to have a problem with sodium hypochlorite unless there is a grossly open defect and positive pressure is employed when injecting irrigant. It the irrigation needle tip is not bound in the canal an accident will not occur. It is advised to place the irrigant passively in a canal shaped with adequate taper then let the files work irrigant into the space as the irrigant is constantly turned over and refreshed.

As mentioned in other cases, Geristore provides a surface with excellent fibroblast adhesion. This property does not seem to be as predictable with other hybrid glass ionomer materials (Dragoo, 1997). CBCT scan mapping showed a shallow and surgically accessible resorption defect with a favorable prognosis. The case was a bit more challenging to treat due to the periodontal pocket, gingival recession and some likely epithelialization of the inflamed pocket which otherwise would have had junctional epithelial attachment if Geristore had been used as the original resorption repair material. A deep Cavit temporary filling was placed with no sponge apical to the level of the repaired defect after placing the CH. A month later the endodontic treatment was completed with gutta percha apical root canal filling and an MTA backpack. The case was followed up to judge improvement and pocket reduction. Gingival recession had already begun to occur since the first resorption repair.

UPDATE: The 2014 recall visit demonstrated continued labial inflammation but normal periodontal pocketing. Once a resorption defect is treated with a non-ideal repair material predictable fibroblast adhesion is lost due to the downward growth of epithelium. Initial management with the proper resorption treatment protocol and the proper materials is a predictor of success.

Key Learning Points:

1. When combination nonsurgical/surgical resorption management is planned, it is advised to perform the nonsurgical phase first in order to prevent later Loosening and disruption of the surgical repair material which would lead to the surgical procedure having to be performed twice.

2. CBCT mapping allows the surgical planning of access approach to the resorption defect

3. Geristore is arguably the evidence-based material of choice for surgical repair of root resorption defects

4. Sodium chlorite should be used carefully avoiding positive pressure injection when irrigating during the nonsurgical phase of treatment

5. MTA is an excellent backfilling material to be used when filling in the root canal space communicating or adjacent to the resorption defect (new alternative materials like Biodentine and Bioceramics show promise)

6. Proper initial tissue management and planning of resorption prevents later complications of gingival recession and the need for advanced periodontal surgical procedures like free-gingival grafting

7. As suspected when retreated in 2012, reducing the the labial gingival inflammation and regaining normal periodontal attachment was a challenge and continuing management issue