Fifteen-year Clinical Follow-up of Restoration of Extensive Cervical Resorption in a Maxillary Central Incisor
Internal bleaching in endodontically treated teeth requires care and protection to prevent harm to the periodontal ligament due to peroxide and may result in external root resorption. There is a myriad of treatment options when this occurs, such as monitoring, extraction, and subsequent rehabilitation with implants or fixed prosthodontics. In some cases, such as the one described here, a conservative attempt to maintain the tooth as a single structure can be made by sealing the resorptive defect. In the present case, we show a multidisciplinary approach where orthodontics, periodontics, and restorative dentistry were involved in treating the maxillary right central incisor (#8) of a 65-year-old patient with extensive cervical resorption, whose chief complaint was esthetics. The proposed treatment was extrusion of the tooth followed by curettage and restoration of the defect with glass ionomer cement. The patient has been followed for 15 years with no signs of recurrence, maintenance of periodontal health, and patient satisfaction with the esthetic outcome.SUMMARY
DESCRIPTION OF THE TECHNIQUE
A 65-year-old patient sought dental treatment mainly due to esthetic concerns, and the initial periodontal evaluation indicated the presence of a subgingival cavity in the root surface of tooth #8 (maxillary right central incisor). The patient's medical history revealed internal bleaching of tooth #8 six years before. A periapical radiograph showed extensive structural loss directly related to external cervical resorption (Figures 1 and 2). Conventional treatment would involve tooth extraction and placement of an osseointegrated implant. However, at that time, implants did not have the esthetic features and dimensions that they do today.1 Moreover, the technique should be mastered, and gingival recontouring would be required in tooth #9 (the maxillary left central incisor). Fixed prosthodontics was discarded by the patient due to the risk of damage to adjacent tooth structures. The gingival smile line and maintenance of the existing harmony were considered compromising factors.
Citation: Operative Dentistry 42, 2; 10.2341/15-131-S
A multidisciplinary approach to the case allowed us to offer the patient an alternative treatment. The patient was aware of the risk of possible failure and, consequently, of the need to return to one of the options initially considered in case of failure. Professionals from the fields of orthodontics, periodontics, and restorative dentistry were involved. The procedures are described below in chronological order.
Tooth Traction/Extrusion
The lesion was located approximately 3 mm below the crestal bone, and tooth extrusion was therefore proposed with the use of orthodontic traction. Using the straight wire technique, 0.022-inch slot brackets (Ormco, BR Amersfoort, The Netherlands) were bonded to the six maxillary anterior teeth. The adjacent central incisor served as anchorage, and a sequence of nickel-titanium (NiTi) and stainless steel wires was used for traction. Within 80 days, an extrusion of 3 mm was achieved (Figure 3). The device was kept passive for 3 months until complete tissue reorganization and periodontal bone healing2-5 (Figure 4).
Citation: Operative Dentistry 42, 2; 10.2341/15-131-S
Surgical Access
The periodontal access technique was selected, aiming to preserve the alveolar crest and gingival tissue as much as possible. The gingiva was detached, and a small portion of the crestal bone was removed near the cavity, exposing its margins.5-7
Restoration of the Resorptive Defect
The cavity was restored trans-surgically. After visual access to the area, the affected portion was excavated and cleaned with periodontal curettes. Moisture control is a challenge in trans-surgical restoration, and based on the literature, a light-cured glass ionomer cement (Vitremer, 3M ESPE, St Paul, MN, USA) was selected and injected into the cavity with a Centrix syringe.6,8-15 After the initial setting, the finishing process of the glass ionomer cement was performed and the area was then sutured.
To improve esthetics, a direct composite veneer was placed. The use of ceramic restoration was not considered because of the overall condition of the tooth, including a weakened structure and uncertain prognosis. The composite restoration met the patient's esthetic needs at the time and has been maintained since placement.
The patient returned for evaluation and suture removal seven days after the procedure.
Since then, the patient has been followed radiographically every six months with no evidence of recurrence of resorption thus far (Figures 5 and 6).
Citation: Operative Dentistry 42, 2; 10.2341/15-131-S
POTENTIAL PROBLEMS
During the course of treatment, unpredictable outcomes may occur. Orthodontic tooth extrusion may result in crown-root fracture, as well as in the inability to expose the resorbed area. The necessary exposure may result in excessive bone removal during surgical access, compromising the final esthetic result. In addition, the filling of the cavity may be incomplete and fail to prevent disease progression.16
A prefabricated post was placed eight months after the defect was sealed. Although it does not reinforce the structure, it could possibly increase retention. The authors understand that the post placed was short, and could be longer, but not wider, to enhance retention without transferring stresses to the weakened walls which were reinforced by glass ionomer cement as a dentin replacement.
ADVANTAGES AND DISADVANTAGES
Maintenance of tooth structure, along with its psychological aspect, and stabilization of bone height can be considered the main advantages of the presented technique. Furthermore, there was no impairment of the already established esthetics, which could occur in case of tooth extraction, the healing process, and implant placement.
The main concern is the unpredictable longitudinal behavior and therefore inability to ensure the longevity of the procedure to the patient. The technique may appear to be more complex than implant placement, but when performed by trained professionals, the success rate can be improved. Additionally, at the time this case was treated, the knowledge of dental implants was not as developed as it is today.
Regulatory Statement
This study was conducted in accordance with all the provisions of the local human subjects oversight committee guidelines and policies of the Lutheran University of Brazil.
Conflict of Interest
The authors of this manuscript certify that they have no proprietary, financial, or other personal interest of any nature or kind in any product, service, and/or company that is presented in this article.
Initial periapical radiograph.
Figure 2. Initial clinical aspect.
Orthodontic extrusion and GIC restoration.
Figure 4. Fixation after extrusion.
Fifteen-year follow-up radiograph.
Figure 6. Fifteen-year follow-up clinical aspect, after esthetic direct resin veneer.
Contributor Notes
Jeniffer Zettermann, DDS, MSD, PhD, School of Dentistry, Universidade Luterana do Brasil (ULBRA), Canoas, Brazil