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Case Reports in Dentistry

Volume 2022, Article ID 9620629, 7 pages
https://doi.org/10.1155/2022/9620629

Case Report
Conservative Therapy of External Invasive Cervical
Resorption with Adhesive Systems: A 6-Year Follow-Up Case
Report and Literature Review

Riccardo Aiuto ,1 Gianluca Fumei ,2 Erica Lipani ,3 Daniele Garcovich ,3

Mario Dioguardi ,4 and Dino Re 1
1
Department of Biomedical, Surgical and Dental Sciences, Istituto Stomatologico Italiano, University of Milan, Milan, Italy
2
Department of Restorative Dentistry and Endodontics, University of Insubria, Varese, Italy
3
Department of Dentistry, Universidad Europea de Valencia, Valencia, Spain
4
Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy

Correspondence should be addressed to Erica Lipani; erica.lipani@outlook.it

Received 11 March 2022; Accepted 7 October 2022; Published 28 October 2022

Academic Editor: Hamdi Cem Gungor

Copyright © 2022 Riccardo Aiuto et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

The diagnosis and treatment of external invasive cervical resorption (EICR) could be a challenging clinical situation even for the
most experienced dentists. It is a fairly rare lesion and a poorly understood phenomenon, and its insidious and aggressive nature
can lead to tooth loss. Even in the era of dental implants, trying to save a compromised tooth is imperative for any clinician. This
report presents a case of an upper central incisor with a class II Heithersay EICR in which treatment was performed using a
multidisciplinary approach and the defect was restored with resin composite. The surgery in which the defect was exposed and
repaired was followed by an endodontic treatment and the placement of a fiber-reinforced post. In this case, the use of modern
materials, such as resin composites, allowed not only the avoidance of tooth extraction but also the achievement of satisfactory
aesthetic results. The 6-year follow-up demonstrated the success of therapy and the resolution of clinical symptoms. This case
report highlights the importance of early detection of EICR and how composite resins could provide an effective and aesthetic
restauration of the defect, which favors the health of the surrounding gingival tissue.

1. Introduction EICR is a clinical term used to describe a rare condition

whose prevalence ranges from 0.02 to 2.3% [3] but often
Root resorption is characterized by the loss of tooth hard tis- leads to tooth loss as a result of its insidious and asymptom-
sues; this process can be physiological if it occurs during atic nature [4]; the lesion may become symptomatic in
teething, but it is a pathological if it occurs in the permanent advanced cases when pulp tissue is involved [5].
dentition, producing irreversible damage and/or potential The lesion is characterized by a cervical location and an
tooth loss [1]. Root resorption may be classified, according invasive nature. The resorptive process begins on the surface
to the location on the root surface, into external resorption of the root below the epithelial attachment, namely, the con-
(if it starts from the periodontal tissue) and internal resorp- nective tissue attachment zone [6]. Several clinical classifica-
tion (if it starts from the pulp tissue). Furthermore, external tions were introduced to assist the clinician in treatment
root resorption can also be divided into superficial resorp- planning. The Heithersay classification [7] was the first to
tion, external inflammatory resorption, external invasive be developed, but despite its great usefulness, it relied on a
cervical resorption (EICR), external replacement resorption, two-dimensional radiograph that cannot guarantee a detailed
and transient apical breakdown [2]. assessment of a three-dimensional lesion. Patel et al. has
2 Case Reports in Dentistry

Figure 1: Preoperative clinical condition.

Figure 2: Bleeding on probing exam.

recently introduced a three-dimensional classification [8]. sidering the clinical and radiological findings, the resorptive
This new classification aims to provide a more accurate esti- defect was classified as a Heithersay class II.
mate of the preoperative EICR condition using cone beam Due to the importance of saving a natural tooth and the
computed tomography (CBCT) imaging. aesthetic value of a central incisor, all treatment options
The etiology of EICR is complex and unclear; several fac- were discussed with the patient, and finally, the external
tors are potentially involved, such as a history of trauma, approach was chosen. That included a surgical phase, end-
intracoronal bleaching, orthodontic treatment, and peri- odontic treatment, and finally replacement of the previous
odontal root planning or scaling [3]. restoration. The informed consent form was obtained from
A correct diagnosis of EICR, based on a clinical and the patient prior to the beginning of treatment.
radiological examination, is an essential prerequisite for its The main phases of the clinical procedure are reported as
successful treatment. Several materials have been proposed follows.
in the literature to restore the defect. In the past, in these
cases, amalgam [9] and glass ionomer [7] were widely used. 2.1. First Session: Surgical Step. The complexity of this
Currently, an approach based on biocompatible materials is pathology requires the use of an operating microscope and
preferred, such as MTA (Dentsply-Tulsa Dental, Johnson the exposition of the defect by a surgical flap. After adminis-
City, TN, USA) [10] or Biodentine (Septodont, Saint- tering local anesthesia (articaine 4% with epinephrine
Maur-des-Fossés, France) [11], and materials with high aes- 1 : 100,000, Pierrel, Capua, Italy), a full thickness flap was
thetic properties, such as composite resins [12]. In the last performed (Figure 4(a)). Once the defect was exposed, the
few years, there has been a growing interest in the treatment resorptive granulation tissue was accurately removed, and
of EICR, perhaps due to the increased use of CBCT in end- the site was debrided and cleaned with surgical straight
odontics or also due to the aggressive and invasive nature of handpieces (Ultimate Power+, B.A. International, Fiumana,
this type of lesion. This case report aims to illustrate the Italy) and with a round tungsten carbide ball bur. Once
effects of a multidisciplinary approach and the use of com- hemostasis was managed, isolation with a liquid rubber
posite resin as a restorative material in EICR. dam was obtained (Figure 4(b))), and common steps were
followed for composite restoration.
2. Case Report First, a dentin etching was performed for 15 seconds
with 37% phosphoric acid, and a two-step bonding system
A 38-year-old male who attended the University Depart- (Scotchbond Universal Adhesive, 3M Company, St. Paul,
ment of the Istituto Stomatologico Italiano (ISI) referred a MN, USA) was applied and light cured for 40 seconds. Sub-
slight pain during brushing of the upper left central incisor sequently, the defect was filled and restored with flowable
(1.1). The patient reported a good level of general health, composite (Filtek™ Universal Restorative, 3M Company,
and a detailed anamnesis did not report a history of trauma St. Paul, MN, USA), and the restoration was accurately fin-
or other relevant problems. During clinical examination, a ished and polished (Figure 4(c))). Finally, the flap was repo-
class V composite restoration was observed in the cervical sitioned with interrupted 4\0 silk suture (Perma-Hand™,
third of 1.1. In the same area, the presence of bleeding on Ethicon Inc., Johnson & Johnson Company, Somerville,
probing (Figures 1 and 2) indicated a relevant gingival NJ, USA; Figure 4(d)). Ice application was recommended,
inflammation. The tooth was negative to the pulp sensitivity and a twice-daily oral rinse with 0.20% chlorhexidine was
thermal test. prescribed during the 7 days after surgery.
To confirm suspicion of EICR, a radiographic examina-
tion was also realized; first of all, a periapical radiograph 2.2. Second Session: Endodontic Step. Due to the negative
was performed and showed the presence of a radiolucent pulp response, endodontic treatment was required. In this
lesion in the coronal third of the root of 1.1, in its distal por- appointment, soft tissue healing was checked, sutures were
tion (Figure 3(a)). However, in this case, CBCT imaging was removed, and root canal therapy was performed.
essential to assess the stage of the lesion and which struc- First, local anesthesia (articaine 4% with epinephrine
tures were compromised (Figure 3(b)). 3D images revealed 1 : 100,000, Pierrel) was administered, and a rubber dam
that the lesion had already penetrated close to the coronal (Nic Tone, Manufacturera Dental Continental S.A. De
pulp, but it appears that there was no communication. Con- C.V., Zapopan, Mexico) isolation was placed (Figure 5(b))
Case Reports in Dentistry 3

(a) (b)

Figure 3: (a) Preoperative periapical X-ray and (b) preoperative CBCT.

(a) (b)

(c) (d)

Figure 4: Phases of surgery: (a) defect exposition by surgical flap, (b) isolation by liquid rubber dam, (c) composite restoration of the defect,
and (d) repositioning and suture of the flap.

with a 9 clamp (Ivory®, Kulzer Nordic AB, Helsingborg, condensation technique. Once the canal was definitely filled,
Sweden) fixed on tooth 1.1. The cleaning and shaping of the post space was realized, and a fiber-reinforced post was
the root canal were carried out with a rotary file (ProTaper subsequently inserted. Postoperative X-ray was performed
Gold, Dentsply Maillefer, Ballaigues, Switzerland), 5% (Figure 6).
NaOCl irrigation (NICLOR 5, OGNA, Muggiò, Milan,
Italy), and 17% EDTA (OGNA, Muggiò).
In Figure 5(a), it is possible to appreciate the characteris- 2.3. Third Session: Restorative Step. The patient was recalled
tic grey color of a necrotic pulp tissue. After drying the canal after 3 months. On clinical examination, the periodontal
with paper points, the root canal was filled with a 40# Pro- probing revealed healthy periodontal tissues, without bleed-
Taper Gold master cone and cement (AH Plus®, Dentsply ing and a probing depth of less than 3 mm. The class V res-
Sirona, Lancaster, A, USA) using the continuous wave of toration was replaced, on the patient’s request. Rubber dam
4 Case Reports in Dentistry

(a) (b)

Figure 5: (a) Necrotic pulp tissue and (b) rubber dam isolation.

radiolucent image on the X-ray could be misdiagnosed as a

subgingival caries. However, there are some distinctive
features that allow the clinician to establish a differential
diagnosis: a carious lesion in a healthy periodontium does
not usually present bleeding on probing, which is usually
observed instead in the case of EICR due to the high vascu-
larization of the granulation tissue [6]; moreover, there is a
typical pinkish discoloration (pathognomonic clinical
sign) of the crown in the cervical region of the affected
tooth, and in addition, the resorbed area produces a scrap-
ing sound on probing giving the feeling of hard tissue,
quite different from the one that characterizes the softened
dentine [7].
The introduction of CBCT imaging in dentistry, espe-
cially in endodontics, plays an important role in the diagno-
sis and management of pathologies, such as EICR; however,
considering that the patient’s radiation exposure should be
kept “as low as reasonably achievable,” the use of CBCT
Figure 6: Postoperative X-ray of root canal treatment. imaging should be limited to the cases in which the informa-
tion gathered by conventional imaging systems is not
enough.
isolation was placed with No. 9 clamp on tooth 1.1 and No. 0 At present, CBCT imaging has been recommended for
clamp on tooth 2.5 (Figure 7(a)). the planning of endodontic surgery treatment [13–15];
The old resin restoration was removed, and total acid etching indeed only with a 3D imaging, the clinician can assess the
was performed for 20 seconds (Figure 7(b)). Then, a two-step exact location and extension of the lesion, and therefore its
bonding system (Scotchbond Universal Adhesive, 3M Company) real restorability. Furthermore, the increased precision of
was applied to the cavity (Figure 7(c)). The cavity was filled with the CBCT imaging can also result in early detection of EICR
resin composite (Filtek Z500, 3M Company), and finally, the res- and, in these cases, is of great importance [16, 17].
toration was polished and finished (Figure 7(d)). As previously reported, in the present case report, the
Subsequently, the patient received monitoring visits during treatment of a Heithersay class II lesion was performed.
which clinical examination, and radiographs were performed; The Heithersay classification was the first developed, in
follow-up has been carried out, respectively, after 1, 2, and 3 which EICR lesions were classified into four classes accord-
year, and at each appointment, a periapical radiograph was ing to the size and extension of the defect into dentine: from
taken (Figure 8). a small resorptive lesion in the cervical area (Class I) to an
Six years later, the patient was checked again, and the 6- extensive resorptive defect beyond the coronal third of the
year follow-up confirmed the treatment success; indeed, as is root (Class IV) [3].
apparent in Figure 9, it showed that the absence of sign of gin- Depending on the severity and type of injury, the treat-
gival inflammation, no bleeding on probing, the absence of ment plan will radically change from an external approach
periodontal pocket, complete remission of symptoms, and to an internal approach, up to orthodontic extrusion or, in
the X-ray examination indicated that no bone loss occurred. some cases, even tooth extraction. Today, there are no clear
treatment guidelines for EICR, and for this reason, clinical
3. Discussion classifications, such as the Heithersay class I, are so useful.
However, this classification was developed on two-
Diagnosis is a key step when facing an insidious lesion, such dimensional images, which could offer an underestimated
as EICR; clinician may initially be disorientated, since a representation of the real situation. To overcome this
Case Reports in Dentistry 5

(a) (b)

(c) (d)

Figure 7: Phases of class V restoration: (a) rubber dam isolation, (b) enamel total acid etching, (c) bonding agent application, and (d) final
restoration results.

(a) (b) (c)

Figure 8: X-ray at (a) 1-year, (b) 2-year, and (c) 3-year follow-ups.

limitation, Patel et al. introduced a three-dimensional classi- thus improving communication between colleagues, prog-
fication based on CBCT findings [8]. Three parameters were nostic, and treatment outcomes.
considered in this new classification: lesion height (1: at CEJ A careful removal of the resorptive tissue and thorough
level or coronal to the bone crest (supracrestal), 2: extends root canal cleaning [18] are absolutely necessary to guarantee
into the coronal third of the root and apical to the bone crest a successful treatment outcome; regarding the restoration of
(subcrestal), 3: extends into the middle third of the root, and the defect, as previously discussed, several materials have been
4: extends into the apical third of the root), circumferential proposed. Several studies have been conducted in recent years
spread (A: ≤90°, B: ≤180°, C: ≤270°, and D: >270°), and prox- on the qualities and clinical performance of mineral trioxide
imity to the root canal (d: lesion confined to dentine and p: aggregate “MTA” (Dentsply-Tulsa Dental); many favorable
probable pulpal involvement) [8]. Following these parame- properties were described, among the most important being
ters, it is possible to classify EICR defects in three dimensions, biocompatibility and optimal tissue response [10, 19].
6 Case Reports in Dentistry

(a) (b)

Figure 9: (a) Probing and postoperative clinical condition and (b) X-ray at the 6-year follow-up.

Although several articles reported that Biodentine (Sep- response. More research is needed to confirm the long-term
todont), a calcium silicate-based product, has better physical outcome of this treatment modality.
properties (resistance and compressive strength) and han-
dling properties than MTA, in fact, Biodentine was devel-
oped from MTA technology in order to improve some Conflicts of Interest
characteristics of these types of materials [11, 20].
The authors declare that they have no conflicts of interest.
Even if the efficacy of Biodentine and MTA is widely
demonstrated, in this case report, composite resin (Filtek™
Universal Restorative, 3M Company) was preferred. Both References
the “white” and “pink” aesthetics of a smile are complex to
imitate, especially if there is an impairment of the dental [1] G. S. Heithersay, “External root resorption,” Annals of the Royal
and periodontal tissues that entail the risk of losing a tooth Australasian College of Dental Surgeons, vol. 12, pp. 46–59, 1994.
in the aesthetic area [21]. However, modern composite [2] S. Patel, S. Kanagasingam, and F. T. Pitt, “External cervical
resins offer a very satisfactory degree of integration when it resorption: a review,” Journal of Endodontia, vol. 35, no. 5,
is possible to restore the natural tooth. Adequate adhesive pp. 616–625, 2009.
bond strength is ensured in root dentine by employing a [3] G. Heithersay, “Invasive cervical resorption: an analysis of
proper self-etch adhesive system [12]. potential predisposing factors,” Quintessence International,
Additionally, composite resin has a faster setting time vol. 30, no. 2, pp. 83–95, 1999.
(20 seconds light-curing time) compared to the long setting [4] O. Rotondi, P. K. S. Waldon, and S. G. Kim, “The disease pro-
time of the MTA. Moreover, the polishing of the restoration cess, diagnosis and treatment of invasive cervical resorption: a
provides a smooth surface that prevents the accumulation of review,” Dental Journal, vol. 8, no. 3, p. 64, 2020.
subgingival plaque, unlike the rough surface MTA. Although [5] H. M. Goldman, “Spontaneous intermittent resorption of
composite resins are not fully biologically acceptable for teeth,” Journal of the American Dental Association, vol. 49,
no. 5, pp. 522–532, 1954.
periodontal tissues, the “creeping attachment” described by
Goldman and Cohen [22] develops, and coronal migration [6] S. D. Kandalgaonkar, L. A. Gharat, S. D. Tupsakhare, and M. H.
Gabhane, “Invasive cervical resorption: a review,” Journal of
of gingival marginal tissue occurs [23]. In this case, the
International Oral Health, vol. 5, no. 6, pp. 124–130, 2013.
absence of gingival inflammation and the complete resolu-
[7] G. Heithersay, “Invasive cervical resorption,” Endodontic
tion of the symptoms support the clinical assessment of a Topics, vol. 7, no. 1, pp. 73–92, 2004.
new and healthy epithelial tissue gingival attachment.
[8] S. Patel, F. Foschi, F. Mannocci, and K. Patel, “External cervical
resorption: a three-dimensional classification,” International
Endodontic Journal, vol. 51, no. 2, pp. 206–214, 2018.
4. Conclusions [9] G. Rabie, M. Trope, and L. Tronstad, “Treatment of a maxil-
lary canine with external inflammatory root resorption,” Jour-
Early detection of EICR lesion and an accurate endodontic nal of Endodontia, vol. 14, no. 2, pp. 101–105, 1988.
and restorative treatment planning are paramount to achieve [10] C. J. White and N. Bryant, “Combined therapy of mineral triox-
a favorable clinical outcome. This case report shows how ide aggregate and guided tissue regeneration in the treatment of
accurate removal of resorption tissue followed by defect res- external root resorption and an associated osseous defect,” Jour-
toration with composite resins could be a good choice for nal of Periodontology, vol. 73, no. 12, pp. 1517–1521, 2002.
EICR treatment in aesthetic zones. As reported, this treat- [11] Ö. Malkondu, M. K. Kazandaǧ, and E. Kazazoǧlu, “A review
ment approach could result in a favorable periodontal tissue on Biodentine, a contemporary dentine replacement and
Case Reports in Dentistry 7

repair material,” BioMed Research International, vol. 2014,

p. 10, 2014.
[12] P. R. Pleffken, A. P. de Almeida Lourenço, C. R. Torres, and
B. A. Bühler, “Influence of application methods of self-
etching adhesive systems on adhesive bond strength to dentin,”
The Journal of Adhesive Dentistry, vol. 13, no. 6, pp. 517–525,
2011.
[13] S. Patel, A. Dawood, T. P. Ford, and E. Whaites, “The potential
applications of cone beam computed tomography in the man-
agement of endodontic problems,” International Endodontic
Journal, vol. 40, no. 10, pp. 818–830, 2007.
[14] S. Patel, “New dimensions in endodontic imaging: part 2. Cone
beam computed tomography,” International Endodontic Jour-
nal, vol. 42, no. 6, pp. 463–475, 2009.
[15] D. Vaz de Souza, E. Schirru, F. Mannocci, F. Foschi, and
S. Patel, “External cervical resorption: a comparison of the
diagnostic efficacy using 2 different cone-beam computed
tomographic units and periapical radiographs,” Journal of
Endodontia, vol. 43, no. 1, pp. 121–125, 2017.
[16] T. Venskutonis, G. Plotino, G. Juodzbalys, and L. Mickevičiene,
“The importance of cone-beam computed tomography in the
management of endodontic problems: a review of the litera-
ture,” Journal of Endodontia, vol. 40, no. 12, pp. 1895–1901,
2014.
[17] H. Ren, J. Chen, F. Deng, L. Zheng, X. Liu, and Y. Dong,
“Comparison of cone-beam computed tomography and peria-
pical radiography for detecting simulated apical root resorp-
tion,” The Angle Orthodontist, vol. 83, no. 2, pp. 189–195,
2013.
[18] M. Dioguardi, V. Crincoli, D. Sovereto et al., “Effectiveness of
vapor lock effect removal in endo training blocks: manual
dynamic agitation versus passive ultrasonic irrigation,”
Applied Sciences, vol. 9, no. 24, p. 5411, 2019.
[19] M. Kuratate, K. Yoshiba, Y. Shigetani, N. Yoshiba,
H. Ohshima, and T. Okiji, “Immunohistochemical analysis of
nestin, osteopontin, and proliferating cells in the reparative
process of exposed dental pulp capped with mineral trioxide
aggregate,” Journal of Endodontia, vol. 34, no. 8, pp. 970–
974, 2008.
[20] L. Grech, B. Mallia, and J. Camilleri, “Investigation of the phys-
ical properties of tricalcium silicate cement-based root-end fill-
ing materials,” Dental Materials, vol. 29, no. 2, pp. e20–e28,
2013.
[21] R. Crippa, R. Aiuto, M. Dioguardi, M. Peñarrocha-Diago,
M. Peñarrocha-Diago, and F. Angiero, “Laser therapy for
infected sites and immediate dental implants in the esthetic
zone: a case report and review of literature,” Case Reports in
Dentistry, vol. 2020, 2020.
[22] H. M. Goldman and D. W. Cohen, Periodontal Therapy,
Mosby, St. Louis, Mo, USA, 5th edition, 1973.
[23] L. A. Bell, T. A. Valluzzo, J. J. Garnick, and B. M. Pennel, “The
presence of “creeping attachment” in human gingiva,” Journal
of Periodontology, vol. 49, no. 10, pp. 513–517, 1978.