Multidisciplinary conservative management of invasive cervical resorption in an adolescent patient: a 2-year follow-up case report

Case Presentation

A 17-year-old male patient in good overall health presented for a routine dental examination, reporting a pink discoloration of tooth 3.2 (mandibular left lateral incisor).

Clinical Examination

• Absence of mobility
• Absence of carious lesions
• Negative percussion test
• Physiological periodontal probing depths
• Positive pulp vitality response

Radiographic Assessment

Periapical radiography identified a radiolucent lesion situated at the cemento-enamel junction extending apically, characterized by an irregular radiolucent pattern and lacking evident pulpal involvement (Fig.1).

It is essential to acknowledge that two-dimensional imaging may underestimate the actual extent of resorptive lesions [5]. Although CBCT imaging could potentially provide a more precise assessment of the lesion’s extent, it was not undertaken owing to the patient’s young age and the anticipation that it would not influence the treatment plan derived from two-dimensional imaging and clinical examination.

Diagnosis

A clinical examination of the crown utilizing a periodontal probe revealed communication of the resorptive defect on both the buccal and lingual aspects (Fig. 2–3).

In conjunction with the clinical and radiographic findings, this led to the diagnosis of invasive cervical resorption, classified as Class III according to Heithersay (Fig. 3) [7].

Surgical Phase

Due to the location of the residual sound tooth structure at the crestal bone level, surgical exposure of healthy margins was performed to allow proper restorative management and endodontic rubber dam isolation (Fig. 4) [8].

Local anesthesia was achieved using one cartridge of 4% articaine with 1:100,000 epinephrine administered in both buccal and lingual aspects. A full-thickness flap was then elevated using a #15C surgical blade, allowing adequate exposure of the remaining sound tooth structure.

Endodontic Treatment

During rubber dam placement, a complete crown fracture occurred, likely due to structural weakening from the resorptive process. Although pulp vitality tests were initially positive, endodontic treatment became necessary following an intraoperative crown fracture, which resulted in pulpal compromise. Root canal therapy was therefore performed to allow proper reconstruction of the tooth and to enable subsequent multidisciplinary procedures.

A pre-endodontic build-up using a liquid dam material was performed to ensure adequate isolation (Fig. 5a).

Endodontic treatment included manual glide path establishment followed by canal shaping with martensitic nickel–titanium instruments. The canal system exhibited apical confluence.

Irrigation was performed using sodium hypochlorite and EDTA, with both ultrasonic and intracanal heating activation to enhance debridement efficacy [9].

Root canal obturation was carried out using a calcium silicate–based sealer in combination with a single-cone technique (Fig.5b–5c) [10].

Restorative Phase

Preliminary reconstruction was performed utilizing a fiber-reinforced post to facilitate subsequent orthodontic procedures and traction [11].

The coronal reconstruction was accomplished employing a flow-injection technique with a transparent silicone index, fabricated prior to treatment due to the high risk of crown fracture (Fig. 6) [12].

a) Silicone index positioned for the injectable composite technique; (b) radiograph of the reconstruction; (c) polishing of the restoration.

Orthodontic Extrusion

Orthodontic extrusion was performed to improve the ferrule effect and enhance the long-term prognosis of the tooth [13]. A rectangular Ni–Ti archwire (0.017 × 0.025-inch) was engaged between two brackets with a 0.018-inch slot positioned on the adjacent teeth (3.3 and 3.4), incorporating a spring loop to generate extrusive forces. Fibrotomy and scaling were performed at regular 5-day intervals.

Approximately 2 mm of coronal displacement was achieved after one month. The tooth was subsequently stabilized with a stainless-steel splint for 4 months to allow periodontal reorganization (Fig. 7) [13].

Prosthetic Rehabilitation

Following the retention phase, a new fiber post reconstruction was performed [11]. A vertical tooth preparation was then carried out to enhance the ferrule effect and allow placement of the future crown on sound margins [14–15].

A provisional crown was used for soft-tissue conditioning over 30 days [14]. Subsequently, a definitive analogic impression was taken using a polyether material with a one-stage (double-mix) technique, following the placement of two retraction cords (sizes 000 and 0).

After two weeks, a zirconia crown was delivered and adhesively cemented using a dual-cure resin cement (Fig.8) [16].