Management of Invasive Cervical Resorption with Heithersay approach: a case report.
Invasive Cervical Resorption (ICR) is a relatively uncommon clinical finding, characterized by invasion of cervical region of the root by fibro-vascular tissue derived from periodontal ligament. In this case report, a 45 year old female patient came with dislodged restoration in maxillary left lateral incisor. She revealed history of trauma she had undergone ten years back with blow from utensil. Her history also stated that she had developed decay in distal aspect of the same tooth for which she had got filling done 4 years back. Here, trauma and intra coronal restoration might be the predisposing factors for ICR. Since this case of ICR was class 3 defect, the Heithersay approach was treatment of choice.
Key words: Invasive Cervical Resorption, Heithersay approach, non surgical, trauma, Intra coronal restoration.
Invasive Cervical Resorption (ICR) is a relatively uncommon clinical finding. This may occur in any tooth in the permanent dentition at the cervical location and invasive in nature and leads to progressive loss of tooth structure1. This pathological process is characterized by invasion of cervical region of the root by fibro-vascular tissue derived from periodontal ligament. There is progressive resorption of cementum, enamel and dentine to eventually involve pulp in the later stages2.
The exact etiology of ICR is poorly understood but several predisposing factors have been identified. These were documented following first report by Harrington and Natkin in 19793. Orthodontics was the most common sole factor (21.2%) followed by trauma (14%); intracoronal bleaching was sole predisposing factor for lesser extent and to a greater extent it was in combination with trauma and/ or orthodontic treatment. Surgery involving cemento enamel junction (5.9%), periodontal therapy (4%), bruxism (2%), and intra coronal restorations (15.3%) were less common as predisposing factors. 15% of the patients showed no definite potential predisposing factor2.
A clinical classification has been developed by Heithersay not just as research tool but allows for complete assessment of results of cases of ICR by non-surgical or surgical regimen. Treatment of ICR should aim at the inactivation of all the resorptive tissue and the restoration of resorptive defect. For the small, localized lesions (class 1 or 2), he reported that successful treatment was close to 100%. For the moderate-size lesions (class 3), he reported a 77.8% success rate. For the extensive, class 4 lesions, his success rate was only 12.5%2.
Part of the confusion about ICR is that it is identified in the literature by at least nine different names. Heithersay1 coined the name invasive cervical resorption used in this article. It is sometimes referred to as extracanal invasive resorption based on an article by Frank and Backland in 1987 4 and was recently labeled as external cervical resorption (ECR) by Patel et al in 20095.
The case we are presenting falls under class 3 category of classification based on clinical and radiological findings.
A 45 year old female patient reported to Department of Conservative Dentistry & Endodontics with dislodged restoration in relation to upper left lateral incisor. Her history also revealed trauma she had undergone ten years back with blow from utensil. Her history stated that she had developed decay in distal aspect of the same tooth for which she had got filling done from local dentist 4 years back, which is dislodged now. On examination of 22, there was class III arrested caries and dislodged restoration on distal aspect. In the cervical area of the tooth, red coloured defect was noted (figure 1). On probing this resorptive cavity wall, hard mineralized tissue was felt accompanied by sharp scraping sound. The tooth was asymptomatic. Electric pulp test was negative. No periodontal pockets on probing. Radiograph revealed an irregular ‘moth eaten’ appearance in the cervical area and there were no periapical changes seen(figure2).
Since this case of ICR was class 3 defect, the Heithersay approach was treatment of choice.
The maxillary left lateral incisor is treated under rubber dam isolation. Trichloroacetic acid (TCA) 90% is applied on small cotton pellet to resorptive tissue on the palatal aspesct of the tooth for 3-4 minutes (figure 3). The TCA is replenished atleast twice till resorptive tissue undergoes coagulative necrosis (figure 4). The resorptive tissue is removed by curettage. Root canal treatment is carried out with hand instruments.(ICR 10) K-files (Mani, Inc. Japan). Sodium hypochlorite 2.5% (Prevest Denpro Limited Jammu, India), Normal saline (Preet International Pvt.ltd. New Delhi, India) and EDTA (Dentsply Maillefer, Switzerland) are used as irrigants during root canal treatment. The canal is obturated with zinc oxide eugenol cement (Vishal Dentocare, Ahmedabad, Gujarat, India) and gutta-percha (Dentsply). Now the resorptive defect is restored with glass ionomer cement (figure 5). A post operative radiograph revealed satisfactory filling of resorptive defect. (figure 6)
At a follow-up period of one year, radiograph showed satisfactory treatment outcome and no signs of further resorption.
Whatever be the treatment modality of treating ICR, ultimate goal should be removal of resorptive tissue and restoration of the defect1. The chosen material which should be esthetic, biologically acceptable and the one that provides strength to already weakened tooth structure 6. Here, trauma and intra coronal restoration might be the predisposing factors for ICR. Since this case of ICR was class 3 defect, the Heithersay approach was treatment of choice.
The topical application of trichloracetic acid as an adjunctive measure in the removal or inactivation of active resorptive tissue in cases of invasive cervical resorption provides an alternative approach to other methods that have been reported 7-11.
Since 1977, Heithersay wrote a classic series of articles in which he describes the predisposing factors, features and recommended treatment regimen for treating ICR. He describes class 3 defect can be best treated by Heithersay approach 2. The clinical advantages of this approach are: better patient comfort, avoidance of flap procedure, avoidance of bone removal while gaining access to the defect, control of hemorrhage and inactivation of small, fibro-vascular tissue 6. This treatment regimen is well accepted by patients as it is least traumatic and cost effective and carries good prognosis.
Trichloroacetic acid 90% causes coagulation necrosis of resorptive tissues. The additional advantage of TCA is its effect on periodontal ligament tissue adjacent to resorptive site where it is able to destroy actively resorptive cells by same mechanism of coagulation necrosis while expecting uncomplicated repair of the tissues 6.
The insertion of suitable restorative material is facilitated by moisture control of both blood and tissue fluids following application of TCA. Thus a moisture-free field was created for placement of glass ionomer cement. Glass inomer cement(GIC) provides some reinforcement to weakened tooth structure 12. While many of the restorations need to be placed subgingivally, the glass ionomer cement used was well tolerated owing to its fluoride release and subsequent antimicrobial effect 13.Conditioning prior to insertion of GIC is not necessary as TCA has been shown to condition enamel and dentine 14.
Early and accurate diagnosis of ICR along with well planned treatment regimen can lead to successful treatment outcome and long-term retention of the affected teeth