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28 GENERAL DENTISTRY Dental Tribune Middle East & Africa Edition | 3/2018 Clition and Irreversible Inflammatornical Management of a First Upper Molar with Invasive Cervical Resorpy Pulpitis By Prof. Dr. Leandro A. P. Pereira External cervical tooth resorption is characterized by an irreversible loss of dentin tissue due to the action of odontoclasts (Patel et al 2007). It may also be called invasive cervi- cal resorption (ICR). It is an inflam- mation of the tissues supporting the tooth. Initially, there is no pulp involvement (Mavridou AM, Pyka G, Kerckhofs G, et al 2016). Gener- ally, this type of resorption begins immediately below the union epi- thelium in the cervical region of the tooth. While there is no bacte- rial invasion in the pulp cavity, the pulp's vitality is maintained. Thus, the pre-dentin layer will be present. The ICR does not progresses into the pulp cavity possibly due to the presence of inhibitory factors in this pre-dentin layer (Wedenberg 1987, Mavridou et al. 2016, Mavri- dou AM, Pyka G, Kerckhofs G, et al 2016). Its diagnosis and treatment are not always easy and the progno- sis depends on the location and de- gree of severity of the lesion when diagnosed. Several etiological factors may be involved in ICR. These include the following: - Physical: dental trauma, surgical procedures, orthodontic move- ments, periodontal scaling and bruxism (Heithersay 1999). - Chemical: internal bleaching agents, especially in cases of heat- ing and high concentrations of hydrogen peroxide (Harrington & Natkin 1979, Cvek & Lindvall 1985, Schroeder & Scherle 1988, Gold & Hasselgren 1992, Neuvald and Con- solaro 2000). - Anatomical variation: the type of cementoenamel junction seems to play a key role in external cervical resorption. In 10% of teeth, there is no juxtaposition of the sealing to the enamel (Schroeder & Scherle 1988). Thus, an area of the dentin has no sealing or enamel (Cvek & Lindvall 1985, Neuvald and Conso- laro 2000). This dentin exposure is a risk factor for the development of ICR (Neuvald and Consolaro 2000). In cases where the cementoenamel junction is not continuous, physi- cal and/or chemical irritants can cause damage to the bone and dentin. This aggression may lead to biochemical changes in the af- fected tissues, leading to the forma- tion of multinucleated giant cells. These cells are clastic cells. In these clinical situations, they may act by reabsorbing the dentin. In the re- sorption process, monocytes and macrogens are present, as well as complex enzymatic and hormonal events. Cervical reabsorption begins on the outer surface of the root and pro- gresses toward the pulp. However, when it still presents vitality, the pre-dentin layer is maintained and the ICR does not invade the pulp cavity. Predentin, which is a non- mineralized tissue, changes the di- rection of resorption progression by making it settle circumferential- ly to the pulp cavity (Fig. 4-7). The diagnosis of ICR can be per- formed by clinical examination when it is in a more advanced stage, allowing its direct visualiza- tion. Clinically, at the beginning of the process, the tooth condition is asymptomatic since no pulp patho- physiological changes are involved. In these cases, diagnosis by image is the most effective method. For this reason, direct visual clinical diagno- sis is not possible in the early stages. Imaging examinations such as peri- apical radiographs and/or CT scans are efficient methods of diagnosis. Among these, the conical beam to- mography is more accurate than the periapical radiography (Patel et al 2016, Vaz de Souza D et al 2017). The treatment of ICRs aims to pro- tect the affected dentin from expo- sure to the patient's immune sys- tem. For this, cleaning the affected area and restoring the cavity with biocompatible material is the indi- cated treatment. As these areas are in direct contact with tissue and sal- ivary fluids, they are wet and irreg- ular due to the destructive aspect of the resorption process. Therefore, the material of choice for the clo- sure of this cavity, besides being biocompatible, must be able to fill irregular cavities and have good physicochemical behavior in a wet environment. purpose. However, none of these presented desirable characteristics and results. Only bioceramic mate- rials have the desirable characteris- tics for this purpose. Among bioce- ramic materials, MTA is the most used material and has the highest scientific evidence of its results (Pitt Ford et al 1996, Torabinejad & Pari- rokh M 2010, Parirokh M & Torabi- nejad 2010). Clinical Case A 52-year-old female patient, ASA I, came to the clinic with complaints of spontaneous pain exacerbated by hot and cold foods in the right maxilla. On clinical examination, tooth 16 responded to thermal tests with high-intensity, pulsating pain and taking long to cease. She did not present positive responses to lateral and vertical percussion tests, nor to apical palpation. The clinical diagnosis was symptomatic irreversible pulpitis with normal periapex. In addition, a radiolucent image was visualized on the radio- graphic examination involving the cervical and coronary region of tooth 16, leading to the suspicion of a Cervical Invasive Resorption (Fig. 1-3). In order to have a confirma- tion of the diagnosis and assess the extent of the lesion, a concomitant computed tomography scan was performed. Throughout the history of den- tistry, several materials such as res- ins, amalgam, resin-modified glass ionomer, hydroxyapatite and en- dodontic sealers were used for this In the tomography, we could ob- serve the three-dimensional ex- tension of the ICR around the pulp cavity. As previously described, the ICR does not invade the pulp cavity when the pulp is alive due to the presence of the pre-dentin layer. This imaging characteristic is present in cases of external dental resorption where the pulp is still alive with consequent preservation of the pre-dentin non-mineralized layer (Fig. 4-7). The endodontic treatment was performed according to the pulpal diagnosis. However, a complemen- tary approach was required in the resorption area (FIGURE 8). The marked curvature of the mesial root led to the selection of a recipro- cating nickel - titanium instrument with shape memory control (Re- ciproc Blue - VDW) for mechanical preparation. After accessing the pulp chamber, 5 ml of sodium hypochlorite were used for initial irrigation (FIGURE 9). Afterwards, a Reciproc Blue 25 instrument was progressively in- troduced into each of the canals, in cycles of 3 slight incoming and outgoing movements in the ca- nals followed by irrigation of 3 ml Hypochlorite between each cycle, until they reached 2/3 of the radio- graphic length of the tooth. At this time, the actual working length was established using an electronic fo- raminal locator. Subsequently, the Reciproc Blue 25 instrument was taken to the working length. With a Reciproc Blue 40 instrument, the diameter of the apical preparations was increased (FIGURE 10, FIG- ÿPage 26 Fig. 1: Initial periapical radiograph Fig. 2: Initial periapical radiograph at dif- ferent horizontal angulation Fig. 3: Interproximal radiograph Fig. 4: Computed tomography showing the shape of the resorption around the pulp chamber Fig. 5: Computed tomography showing the Invasive Cervical Resorption Fig. 6: Invasive Cervical Resorption around the pulp chamber Fig. 7: ICR Area and Location Fig. 8: Live pulp Fig. 9: Connective tissue filling the area of resorption Fig. 10: Location of mesiobuccal canal 2 Fig. 11: Root channels prepared with Reciproc Blue 40 Fig. 12: Final radiograph Fig. 13: Clinical aspect 8 months later - color preservation Fig. 14: Control periapical radiograph (8 months later) Fig. 15: Horizontal angulation variation of the periapical control radiography (8 months later)