A 23 years old female complained of pain and bad odour related to upper right premolar. There was previous endo ttt and crown from 2 years ago. From an x ray, I found internal resorption for more than half of the root and radiolucent area. There is no looseness in the tooth. So what do u think is the reason of the resorption and what is the right time for implant? Discuss with me the ideal treatment plan.
As seen in the X-ray film, the extraction of the tooth will be the only suitable choice. There is no way for any other conservative treatment.
I agree, in this case, there is extensive resorption, most likely mobility, poor crown to root ratio and extraction is the only option. It is hard to make a diagnosis a this point whether the resorption started as internal or external. If caught at an early stage there is conservative treatment which will depend on diagnosis (ext x int).
I think the treatment plan is obvious and according to the X-ray the extraction of the tooth is inevitable.
But about the cause of the resorption, there are some points:
1. I am not completely sure about the radiolucent area that you mentioned. I can see it only on the distal part of the root filling and in my opinion the border is so smooth, which is somewhat unusual. Anyway, I recommend you taking more radiographs with different angles to see this area better.
2. Why do you think that the internal resorption has been occurred? Personally, I do not agree with and there is not any clear evidence for this phenomenon. As I can see, except the 1/3 coronal portion of the root the whole root structure has been resorpted. I cannot distinguish periodontal ligament space as well as laminadura in apical portion of the root filling. In this phase we cannot surely say that the origin of the resorption is internal or external. I can mention the possibility of 2 kinds of resorptions: Inflammatory Root Resorption or Replacement Root Resorption.
3. As you know the cause of the Inflammatory Resorption is inflammatory irritation of microorganisms and in this case according to previous root canal treatment the presence of such an irritation is possible; but why the resorption process did not stop after RCT? Maybe for inappropriate treatment or maybe for the fact that the resorption was not inflammatory. On the other hand the replacement resorption is a progressive condition in which the whole root structure (dentine) can be replaced by bone. Since in this case the tooth was not mobile, the chance of replacement resorption is higher. Did you ask about the history of trauma or replantation? They can prone the tooth to replacement resorption. Also how does the tooth sound on percussion?
4. As you mentioned the patients chief complaint is pain and bad odor. What was the characteristic of the pain? Spontaneous? Throbbing? Dull? On mastication? With cold or warm stimulation? Answering to all these questions is helpful for finding the source of pain. Did you notice any discharge of pus? Please pay attention to the proximal bone loss. Maybe the cause of bad odor is periodontal problem.
There are quite a number of possible causes for the resorption. Without any radiographs taken in the past and also clinical data and anamnestic information we won't be able to determine the etiology.
Just some thoughts, some already mentioned by Kaveh Oloomi: internal resorption or external? Originally a cervical resorption - maybe idiopathic, due to trauma, caused by bleaching? Or was it originally located more apically? Was it initially a resorption-free replacement resorption (RR) until the resorption lacunae reached areas which were contaminated by microorganisms, and therefore it turned into an infection related resorption (IR, formerly named inflammatory root resorption)? Or was it an IR from the very beginning? Why should a premolar undergo RR or IR, resorptions which are related to a severe damage to the PDL like after avulsion (and inadequate extraoral storage) or intrusion? I have seen canines with this trauma type, but not premolars. Was the premolar transplanted? Maybe the resorption is caused by a tumor or a cyst, i.e. keratocystic odontogenic tumor? Is the endo the cause or the consequence of the resorption?
Many possible reasons and many unknown details.
"There is no looseness in the tooth" means what? "no mobility" according to periodontal classfication (0=physiologic mobility) or to trauma classification (completely immobile=ankylotic=typical percussion sound)?
Not an easy going with the treatment. I guess you will face a bone deficit, caused by the infection. And you still have to remove the (possibly ankylotic) premolar. I think you would need an augmentation of bone, probably also of soft tissue.
Hi ... Thanks everyone for your answers... We extracted the tooth .these are x-rays images.
photo 1.
the patient shifted to implantologist. the photo after extraction and immediate implant.
photo 2.
Hellas its already taken out . Do you familiar with abfraction? Next time check it out maybe that is the caused. Than you just proceed with treatment.
No problem at all .. can u discuss more your point of view in this case ?
Here You can find treatment protocol of internal resorption: Article CLINICAL CASE OF A RARELY DIAGNOSED TOOTH ROOT INTERNAL RESORPTION
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