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Azerbaycan Saytlari

 »  Home  »  Endodontic Articles 5  »  External cervical resorption associated with localized gingival overgrowth
External cervical resorption associated with localized gingival overgrowth
Case report.



K. Patel, U. R. Darbar & K. Gulabivala
Division of Restorative Dental Sciences, Eastman Dental Institute and Hospital for Oral Health Care Sciences, London, UK.

Introduction.
External cervical resorption is a relatively distinct clinical entity, although its wide spectrum of clinical presentations has resulted in its designation by different names such as progressive intradental resorption (Lepp 1969, Barclay 1993) and invasive resorption (Bakland 1992). It is defined as a localized resorptive process that commences on the surface of the root below the epithelial attachment and the coronal aspect of the supporting alveolar process, namely the zone of the connective tissue attachment (Tronstad 1988). The clinical presentation is determined by the rate and the direction of the spread of the resorptive front. The lesions are rarely symptomatic but may be associated with bleeding from the hyperaemic and often proliferative tissue which occupies the resorption defect. Coronal advance of the resorptive process may undermine the enamel giving it a pink hue. Sometimes, it is possible to probe the resorptive defect through the gingival margin, and under such circumstances the dentine is found to be firm (Southam 1967).
The radiographic appearance of the cervical resorption is characteristic and often the presenting feature (Gartner et al. 1976, Gulabivala&Searson 1995). Relatively uniform progress of the resorption over the entire front results in a macroscopically concave cavity with a radiographic appearance of uniform radiolucency and a smooth, regular outline. However, a nonuniform preferential spread is also possible and may result in ‘fingers’ of resorptive tissue extending in different directions, often with little lateral spread at the site of initiation. This is observed radiographically as an irregular, diffuse radiolucency of nonuniform radiodensity (Makkes & van Velzen 1975). Consistent with other types of external resorption, the outline of the root canal remains continuous and is evident through the radiolucent lesion. This is owing to the presence of undefined inhibitors which prevent advance of the lesion beyond the unmineralized predentine (Wedenberg 1987). The resorption may also involve adjacent alveolar bone, giving the appearance of an intrabony defect (Tronstad 1988).
Although the precise pathogenic mechanisms and the natural history of external cervical resorption are only loosely identified, a number of possible contributory factors have been implicated. These include trauma, orthodontic tooth movement, dentoalveolar surgery and periodontal disease and its treatment (Tronstad 1988, Bakland 1992). In the endodontic literature, intracoronal bleaching is the most commonly cited aetiological factor (Goon et al. 1986, MacIsaac & Hoen 1994). The proposed theory of pathogenesis involves predisposing root conditions and perpetuating bacterial factors. It is hypothesized that an initial physical injury to the root surface (Tronstad 1988) or the presence of natural cementum defects (Rotstein et al. 1991) may predispose of resorption by altered host tissue modified by a bacterially driven stimulus. The micro-organisms tip the balance from a potentially reversible physiological resorptive process to a progressive pathological one (Kerr 1961, Dragoo & Sullivan 1973, Tronstad 1988).
The present case report describes an unusual presentation of external cervical resorption. The salient features presented were the localized gingival overgrowth and associated resorption located almost wholly on the labial aspect of the maxillary incisor crown involving the enamel. The management and possible aetiology of the resorptive lesion are discussed.

Report.
A 29-year-old Caucasian male patient with localized gingival overgrowth associated with a maxillary central incisor was referred by his general dental practitioner to the Periodontology Department of the Eastman Dental Institute and Hospital. The presented complaint was swollen and bleeding gums which had particularly worsened over the past 2 years. He was also aware that his gums were especially swollen around one of his upper front teeth. Although the patient had first noticed this 6–7 years earlier, he felt that the lesion had increased in size over the years and was now an aesthetic concern.
The medical history was unremarkable and the patient had been a regular dental attendee with half-yearly visits to the hygienist over the past 2 years. On extra-oral examination, the lips were found to be incompetent with a high smile line exposing the uneven gingival contour. Intraorally, the oral hygiene was poor with generalized inflammation of the gingival tissues and immediate bleeding on probing. Probing depths of 5 mm were noted in the maxillary anterior region, especially around tooth 21 and the molar segments. Tooth 21 had an irregular band of gingival fibrous overgrowth (8 mm _ 3 mm) covering approximately one-third of the labial surface and involving the gingival margin (Fig. 1). This tissue coronally appeared to be located within a mid-labial cavity in the crown. The coronal aspect of the cavity could just be probed. The irregularity of the gingival margin between teeth 11, 21 and 22 gave a poor appearance. It was noted that the anterior mandibular gingivae were enlarged and inflamed (Fig. 1). This was exacerbated by occlusal trauma from the maxillary central incisors. Tooth 21 also had a mesial restoration. The remaining dentition was minimally restored. All of the maxillary incisors gave positive responses to vitality testing with electric pulp test and ethyl chloride. Periapical radiographs revealed an irregular but well-demarcated area of radiolucency at the cemento–enamel junction extending coronally (Fig. 2).

Figure 1. Labial view of anterior gingivae on initial presentation. Note, the enlarged anterior mandibular gingivae associated with occlusal trauma from the maxillary incisors.

Labial view of anterior gingivae on initial presentation. Note, the enlarged anterior mandibular gingivae associated with occlusal trauma from the maxillary incisors

Figure 2. Long cone periapical radiograph of tooth 21 at initial presentation.

Long cone periapical radiograph of tooth 21 at initial presentation

A provisional diagnosis of the external cervical resorption associated with tooth 21 and mild adult periodontitis was made. Further questioning revealed no history of trauma or vital bleaching to the maxillary incisors.

The management of the present case was carried out in two phases:
1) The first phase of treatment was aimed at controlling gingival inflammation. This was achieved by oral hygiene instruction, supra- and subgingival debridement. At the end of this phase, the response to the treatment was evaluated. The response was good with a significant improvement in the oral hygiene and overall periodontal health. However, the gingival overgrowth associated with tooth 21 persisted with a 5 mm probing depth labially.
2) The second (corrective) phase of the treatment was aimed at improving the appearance at tooth 21 by surgical removal of the band of gingival overgrowth and to investigate the residual resorption cavity. As the main concern was the aesthetic contour of the gingivae, the outline of the adjacent gingival margins at teeth 11 and 22 were noted prior to surgery. The surgical procedure was carried out under local anaesthesia by raising a full thickness inverse bevel flap followed by excision of the band of overgrown gingival tissue, simultaneously re-contouring the tissues. The flap was extended to the adjacent incisors to maintain an even gingival contour. The excised tissue was submitted for histopathological examination. The excised gingival tissue was housed within the labial cavity and appeared to have contributed to its coronal mid-labial extension. The surface periphery of the resorptive cavity was bordered almost completely by enamel and extended into the mesial and distal embrasures. Apically, the cemento–enamel junction was marginally involved and the rest of the root appeared intact (Fig. 3). There was mild localized bone loss associated with tooth 21 compared with the alveolar crest level of the adjacent teeth which was in line with the cemento–enamel junction. The granulation tissue and debris were removed from the cavity. No soft dentine was present. The resorptive defect was examined, and the bone was smoothed and re-shaped at tooth 11 to obtain an even contour. The cavity was temporarily restored with conventional glass ionomer cement (Ketac Fil Aplicap, ESPE, Seefeld, Germany) using rubber-dam isolation. The flap was repositioned apically and sutured. At suture removal 1 week later, healing had been uneventful and the desired gingival contour achieved. The patient was satisfied with the improved appearance, despite a slight ‘yellowing’ of the restoration (Fig. 4).

Figure 3. Extent of resorption lesion after removal of granulation tissue.

Extent of resorption lesion after removal of granulation tissue

Figure 4. Labial view demonstrating restoration of resorption defect associated with maxillary left central incisor with conventional glass ionomer cement restoration.

Labial view demonstrating restoration of resorption defect associated with maxillary left central incisor with conventional glass ionomer cement restoration

Figure 5. Labial view of gingivae and replacement restoration relating to maxillary left central incisor at 6 months postsurgery.

Labial view of gingivae and replacement restoration relating to maxillary left central incisor at 6 months postsurgery

Figure 6. Long cone periapical radiograph of tooth 21 at 36 months.

Long cone periapical radiograph of tooth 21 at 36 months

Histological evaluation of the excised tissues confirmed the presence of relatively acellular fibrous connective tissue and isolated foci of inflammation, one of which was particularly dense in the corium. The glass ionomer cement restoration was subsequently replaced with a composite resin restoration (Herculite XRV, Kerr, Orange, CA, USA) in order to improve the appearance (Fig. 5). Additionally, the mesial restoration on the tooth was polished.
The patient was recalled at 6, 12, 24 and 36 months (Fig. 6). At 36 months, the patient remained happy with the aesthetic outcome, with no recurrence of the lesion. The patient continues to maintain a high standard of oral hygiene and will be kept under long-term review.