PMC10329763_01
A) The initial clinical appearance of tooth #21 demonstrating cervical resorption and crown discoloration; B) Initial periapical radiographic image of tooth #21 indicating the presence of a large radiolucent area in the cervical region
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F1
In the clinical examination, the presence of cervical cavitation, irregularity in the gingival contour and discoloration of tooth #21 were observed (Figure 1A). The periapical radiographic examination (Figure 1B) showed an extensive radiolucency in the cervical region of tooth #21.
A) Axial section in the cervical region showing circumferential extension between 90o and 180o of the resorption area; B) Coronal section of tooth #21 demonstrating an extensive hypodense supracrestal image; C) Sagittal section, visualizing the portal of entry (red arrow)
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F2
Cone-beam computed tomography (CBCT) was performed to assist in the clinical diagnosis and selection of the most appropriate treatment (Figure 2). Thus, from the axial, coronal and sagittal sections (Figures 2A, 2B, 2C), it was possible to visualize the presence of extensive ICR in tooth #21.
A) Intrasulcular incision to visualize the granulation tissue in the resorption area; B) Removal of the granulation tissue from the coronal region with a spherical bur; C and D) Insertion of a gutta-percha cone inside the root canal to avoid obliteration by the restorative material; E) Sealing the external cervical resorption area of tooth #21 using light-curing glass ionomer; F) Filling the entire resorption area with glass ionomer and finishing with a conical diamond bur, with a suspensory suture at the end of the surgical procedure
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F3
Then, the surgical periosteal flap was raised (Figure 3A), and the removal of granulation tissue was performed using a #1014 HL spherical diamond bur (KG Sorensen, Cotia-SP, Brazil) in a high-speed handpiece (Gnatus, Sao Paulo-SP, Brazil) followed by a #3072 conical bur (KG Sorensen, Cotia- SP, Brazil) under irrigation with sterile saline solution (Jp Farma, Ribeirao Preto-SP, Brazil) to perform the refinement of cervical region (Figure 3B). To avoid any obliteration of the root canal by the restorative material, a gutta-percha cone was inserted inside the canal for future access opening (Figures 3C and 3D).  The sealing of resorption area was achieved with light-curing glass ionomer (Ionofast-Biodina, Ibipora-PR, Brazil) (Figure 3E). At the end of the surgical procedure, a suspensory suture was performed (Figures 3F).
A) Complete isolation of the operative field, preserving the periodontium, with the coronal access via the palatal surface; B) Periapical radiograph showing the intracanal medication, i.e. calcium hydroxide
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F4
In the first consultation after the surgery, absolute isolation of the operative field was performed at a distance to avoid dislodging any sutures (Figure 4A). Then, the access opening through the palatal surface was performed (Figure 4A). A calcium hydroxide-based medication (Ultracal XS, Joinville-SC, Brazil) remained in the canal for 15 days (Figure 4B).
A) Clinical aspect of tooth #21 after removing the suture (15-day follow-up); B and C) Periapical radiograph immediately after the endodontic treatment of tooth #21; D) Clinical appearance after 30 days of treatment and restoration with resin-based dental composite restorative material; E) CBCT sagittal section showing the proper sealing of the portal of entry, and endodontic treatment after 2 years; F) Coronal section showing the tomographic appearance of tooth #21 demonstrating good sealing of the resorption area after 2 years of follow-up
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F5
In the second session (Figure 5B), the intracanal medication was removed after irrigation with 2.5% sodium hypochlorite (Brilux, Paulista - PE, Brazil), and the canal was prepared with a #60 K file (Maillefer, Ballaigues- Switzerland, Switzerland). Paulo-SP, Brazil) and FF accessory cones (Tanari, Manaus-AM, Brazil). Sealer Plus (MK Life, Sao Paulo-SP, Brazil) was used as resinous cement, and crown sealing was achieved with Z350/A3B resin (3M ESPE, Sat. Paul, MN, USA) on the palatal surface (Figure 5B and 5C). Paul, MN, USA), (Figure 5D). 