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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
Discussion - References.



Discussion.
The present case describes an unusual presentation of external cervical resorption, bordered at the surface by enamel and associated with localized gingival overgrowth. The localized gingival overgrowth, of which fibrous epulis is the most common example, has been well documented (Macleod & Soames 1987). However, none have been reported in association with external cervical resorption. More typically, the fibrous epulis is seen mainly in the anterior maxilla and usually presents interdentally localized to 1 or 2 teeth (Soames & Southam 1993). The most common cause of these lesions is chronic irritation of the gingival tissue caused by subgingival plaque, calculus or restoration margins.
In the present case, the aetiological origin was not proven, but it is highly likely that the inflammatory changes in the periodontium induced by the inadequate plaque control played a role in the initiation of the resorption. The enlarging resorption cavity and associated advancing inflamed gingival tissue probably contributed to the exacerbation of the poor oral hygiene resulting in a vicious cycle perpetuating the gingival overgrowth and labial resorption. The presence of natural cementum defects (Rotstein et al. 1991) or physical injuries to the root surface (Tronstad 1988) have been quoted as predisposing factors in the pathogenesis of root resorption. However, Heithersay (1999) reported that 16.4% of the 257 teeth analyzed did not have a history of predisposing factors. He suggested that some of these cases may have had undetectable developmental defects, such as hypoplasia or hypomineralization of cementum. In this case, it is possible that a predisposing defect may have been caused by regular periodontal debridement provided by the hygienist in the dental practice.
The unusual presentation of the resorption cavity bordered at the surface by enamel and involving loss of enamel may be explained by the close proximity of periodontal connective tissues to the resorption site. Nyman et al. (1980) demonstrated in their study that the close relationship of periodontal connective tissues to a root surface deprived of cementum, and periodontal ligament cells resulted in several of the specimens demonstrating significant root resorption. In this case, the periodontal connective tissues were in close proximity to the denuded root surface and enamel because the alveolar crest was at the level of the cemento–enamel junction. Thus, the periodontal connective tissues from the gingivae cannot run horizontally and attach into the enamel. Instead, the fibres run apically parallel to the angular crest allowing for insertion of the connective tissue fibres just apical to the cemento–enamel junction. This relationship has been described by Garbar & Salama (1996) as type 1-B. One may hypothesize that the resorption began on the denuded root surface (close to the cemento–enamel junction) and progressed to involve mainly enamel because of the proximity of the periodontal connective tissue fibres. The minimal localized bone loss seen at tooth 21 (Fig. 3) may have occurred because of the persistent localized inflammatory changes in the periodontium.
In this case, clinical and radiographic examination indicated that the pulp on tooth 21 was vital and long-term follow-up has confirmed this. Occasionally, pulpal exposure may be found during removal of inflamed tissue from the resorption cavity. The exposure rarely results from direct communication of the inflamed tissue (Makkes & van Velzen 1975, Wedenberg & Zetterqvist 1987) in the resorption cavity with the pulp, because of intervening predentine (Wedenberg 1987). The presence of a communication is difficult to ascertain pre-surgery. More commonly, pulp exposure occurs owing to the accidental mechanical removal of the thin predentine separating the inflamed tissue from the pulp. When the pulp is exposed, options for treatment are direct pulp-capping or root-canal treatment (Gulabivala & Searson 1995). When root-canal treatment is necessary, it is best performed as a single-visit procedure during surgery, so that a permanent restoration may engage the resorption cavity and the root canal for sufficient retention. This also avoids the risk of accidental displacement of a restoration during a second visit for root-canal obturation. The combined endodontic/surgical approach is also helpful in preventing the complication of persistent bleeding into the root-canal system during treatment.
The aims of the treatment in the present case were to prevent further resorption, and to improve gingival aesthetics. The former aim could not be guaranteed as no specific aetiology had been identified. However, by eliminating probable aetiological factors, e.g. inflamed and overgrown soft tissue (Kerr 1961, Dragoo & Sullivan 1973, Tronstad 1988), the resorption process was arrested. Access to the resorption cavity was obtained surgically. Additionally, surgery facilitated improvement in gingival aesthetics by apical repositioning of the flap. At the 3-year recall, no recurrence of the lesion was noted.

References.

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