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Case Report/Clinical Techniques

Management of Inflammatory External Root Resorption by

Using Calcium-enriched Mixture Cement: A Case Report
Saeed Asgary, DDS, MS,* Ali Nosrat, DDS, MS, and Amir Seifi, DDS, PhD

Introduction: Inflammatory external root resorption is
one of the major complications after replantation of
avulsed teeth. Here we report a case of inflammatory
D ental traumas are more common in young adults and more prevalently occur in the
anterior region of the mouth. One of the consequences of these traumas is tooth
avulsion, which leads to cementum detachment and pulpal necrosis (1). If excessive
external root resorption in a maxillary left central incisor drying of the root surface takes place before replantation, the damaged periodontal liga-
in an 11-year old male patient that was managed and ment cells will initiate a severe inflammatory response over a diffuse area on the root
treated by using calcium enriched mixture (CEM) surface. This inflammatory response can exacerbate in the presence of bacteria and
cement. Methods: The patients chief complaint was their by-products inside the root canal system and dentinal tubules after pulp necrosis
mobility of avulsed and replanted maxillary left central and in the absence of protection of cementum barrier. This situation is called inflam-
incisor and pain in chewing on left central and lateral matory external root resorption (IERR), which can cause serious complications and
incisors. Radiographic examination showed progressive lead to rapid tooth loss (2, 3). Following the progression of this process, the tooth
inflammatory external root resorption of the left central might become symptomatic and mobile, and periradicular abscess might develop.
incisor with an inadequately obturated root canal treat- Radiographically, radiolucencies can be observed in the external root surface and
ment. Both teeth were immature and had periapical adjacent to the bone (4). Because the dentinal tubules are wider and allow easier trans-
radiolucencies. Both teeth were irrigated copiously mission of the irritants to the external surface of the root, IERR can occur faster in
with 2.5% NaOCl and obturated with CEM cement. younger teeth (5). The treatment strategies in IERR should tip the healing procedure
However, the central incisor was treated with calcium toward the cemental healing (favorable response), which allows the formation of peri-
hydroxide 6 weeks before CEM cement obturation. odontal ligament (PDL) and re-establishment of the normal attachment apparatus (2).
Results: The clinical and radiographic examinations at The conventional and preferred treatment protocol for a progressive IERR
3-, 6-, 12-, 24-, and 40-month follow-up showed that consists of chemomechanical preparation of the root canal system including a short-
treated teeth were functional with normal mobility, term (1 month) dressing of creamy paste of calcium hydroxide (CH) for bacterial disin-
the progression of the inflammatory external root fection of the root canal space. The process is followed by a long-term dressing of
resorption ceased, the resorptive lacunae were filled densely packed CH to provide an alkaline pH inside the dentinal tubules to kill the
with newly formed bone, and periapical radiolucencies bacteria and neutralize the endotoxins, which are potent inflammatory stimulators
healed. Conclusions: Considering the biological proper- (4, 6). Also, this treatment stimulates formation of hard tissue barrier at the root
ties of CEM cement, especially its alkalinity and sus- apex of immature teeth with IERR induced by trauma (7).
tained calcium hydroxide release, using this novel Although this treatment protocol has a high success rate (1), the long-term use of
cement for treatment of inflammatory external root CH has some disadvantages. Because the treatment includes repeated clinical sessions to
resorption and obturation of immature necrotic teeth replace the CH, it demands high cooperation and motivation from the patient. In addi-
might be an applicable choice. (J Endod 2011;37:411413) tion, long-term presence of CH in root canal space can increase the brittleness of the root
dentin and the risk of future cervical root fractures especially in immature teeth (8, 9).
Key Words There are studies that discuss the contraindication of CH use in teeth with damaged
Apexification, avulsion, calcium enriched mixture, CEM cementum because of the necrotizing effects of CH on PDL cells that repopulate on
cement, dental trauma, open apex, root resorption the root surface. This necrotizing effect can prevent formation of a normal
attachment apparatus and result in replacement resorption and ankylosis (10).
Recently a new water-based and tooth-colored endodontic biomaterial, calcium
enriched mixture (CEM) cement, has been introduced (11). The major components
From the *Iranian Center for Endodontic Research, Dental of the CEM cement powder are CaO, SO3, P2O5, and SiO2, and the minor components
Research Center, Dental School, Shahid Beheshti University of
Medical Sciences, Tehran, Iran; Department of Endodontics, are Al2O3, Na2O, MgO, and Cl. This cement is alkaline (pH >10.5) and releases CH
Dental School, Rafsanjan University of Medical Sciences, Raf- during and after setting (11,12). An in vitro study revealed that because of its
sanjan, Kerman, Iran; and Department of Oral Biology, School continuous CH release, antibacterial properties of CEM cement are the same as CH
of Dentistry, University of Washington, Seattle, Washington. (13); however, unlike CH, CEM cement is a nontoxic material (14). In comparison
Address requests for reprints to Dr Ali Nosrat, Department
of Endodontics, Dental School, Rafsanjan University of Medical
with CH, CEM cement has shown more favorable biocompatibility and the potential
Sciences, Aliebneabitaleb Blvd, Rafsanjan, Kerman, Iran. E-mail to induce hard tissue formation in vital pulp therapies (1517). Animal studies
address: ansrt2@yahoo.com show that regeneration of PDL and cementogenesis can occur adjacent to CEM
0099-2399/$ - see front matter cement (18,19). Also, the sealing ability of CEM cement as a retrograde filling
Copyright 2011 American Association of Endodontists. material is comparable with mineral trioxide aggregate (MTA) (20) and improves by
storage of the cement in phosphate-buffered saline solution (21).
The following case report discusses successful management of IERR by using CEM
cement in an avulsed tooth in a young male patient.

JOE Volume 37, Number 3, March 2011 Management of Inflammatory External Root Resorption by Using CEM Cement 411
Case Report/Clinical Techniques
Case Report the working length. During the same clinical session, CEM cement
An 11-year-old male patient presented with a history of impact powder and liquid (BioniqueDent, Tehran, Iran) were mixed according
trauma to the anterior maxilla and avulsion and replantation of tooth to the manufacturers instructions, and the root canal of lateral incisor
#9 three months before the initial visit. The extraoral dry time was was filled by vertical compaction of CEM cement by using paper cones
approximately 1 1/2 hours. The patients records showed that the size #70; then the access cavity was filled with normal saline. A radio-
avulsed tooth was replanted without using any soaking medium, and graph was taken to evaluate the quality of CEM cement obturation
the root surface was cleaned by saline-moistened gauze before replan- (Fig. 1 B). Both teeth were restored temporarily with Cavite (Ariadent;
tation. After replantation the tooth was splinted to the right central Asia Chemi Teb Co). On the following day after confirming the CEM
incisor with glass ionomer for 1 week, followed by root canal therapy. cement setting, tooth #10 was restored with acid-etch light-cured
Three months after the initial treatment, the patient developed a notice- composite technique (3M ESPE, St Paul, MN). The patient was sched-
able mobility on tooth #9 associated with pain in chewing on teeth #9 uled for return after 4 weeks, but he returned 6 weeks after first visit
and #10. Our clinical examinations showed that upper left central (Fig. 1 C). Under rubber dam isolation, the temporary restoration of
incisor had grade 3 mobility (ie, horizontal tooth movement greater tooth #9 was removed, and the CH paste was eliminated by using passive
than 1 mm and visible vertical depressability (22)), with a faulty resto- irrigation with normal saline and passive filing with a K-file size #60. The
ration in the access cavity. Both central and lateral incisors were tender root canal was filled with CEM cement (Fig. 1 D), and the tooth was
to percussion and palpation. The results of periodontal probing of both temporarily restored by using the same technique as described for tooth
teeth were within normal limits (<3 mm). Cold test with Endo-Frost #10. A day later after CEM cement setting, the tooth was restored by
cold spray (Roeko; Coltene Whaledent, Langenau, Germany) elicited using acid-etch composite technique.
no response on tooth #10, whereas teeth #7, #8, and #11 responded Patient was recalled in 3, 6, 12, 24, and 40 months after operation
to cold without lingering. In radiographic examination, tooth #9 had for clinical/radiographic follow-up. In clinical examinations, both teeth
extensive external root resorption, teeth #9 and #10 were immature were functional without sensitivity to palpation and percussion; tooth #9
with periapical radiolucencies, and the root canal space of tooth #9 showed a normal physiologic mobility and normal probing depths (<3
was inadequately obturated (Fig. 1 A). The concluding diagnosis for mm). Periapical lesions of both teeth healed, external root resorption of
tooth #9 was symptomatic apical periodontitis with inflammatory tooth #9 ceased, and the resorption lacunae were filled with newly
external root resorption, and for tooth #10 diagnosis was pulp necrosis formed bone without radiographic signs of replacement resorption at
with symptomatic apical periodontitis. Because of extent and severity of any of the follow-up sessions (Fig. 1 E, F).
the resorption, we decided to do CEM cement obturation of the canal
space of tooth #9 to arrest the inflammatory root resorption. The Discussion
patients medical history was noncontributory. We obtained informed Treatment of IERR is based on eliminating bacteria and their by-
consent from the patients legal guardians after a complete explanation products from the root canal system and dentinal tubules to stop the
of the possible risks of the treatment. inflammatory processes involving the root surface to allow the regener-
After local anesthesia with 2% lidocaine and 1:80,000 epinephrine ation of periodontium (24). Although current data show that long-term
(Daroupakhsh, Tehran, Iran) and rubber dam isolation, access cavities CH therapy has a high success rate in treatment of IERR (25), the long-
were prepared in both teeth with a diamond fissure bur (Diatech, Heer- term nature of treatment, necrotizing effects of CH, and weakening the
brugg, Switzerland) and high-speed handpiece with copious water root structure are some complicating disadvantages (10). A recent
spray. The gutta-percha in tooth #9 was removed by using H-files size study showed that intracanal corticosteroids as well as Ledermix (a
#30 and #35 (MANI; Mani Inc, Tochigi, Japan). Because irrigation is paste containing triamcinolone and demeclocycline) are useful in pre-
central to the debridement of immature teeth (23), both teeth were irri- venting IERR in an emergency visit, but in case of progressive IERR, it is
gated with 2.5% NaOCl copiously for 20 minutes without any instrumen- necessary to eliminate intracanal and intratubular infection with an anti-
tation. CH powder (Ariadent; Asia Chemi Teb Co, Tehran, Iran) and bacterial agent before using intracanal corticosteroids (26).
sterile normal saline were mixed to achieve aqueous consistency. The Recently, a few studies reported successful use of MTA as root
root canals were dried with paper cones size #70 (Ariadent; Asia Chemi canal filling material in immature traumatized teeth with IERR after
Teb Co), and the CH paste was placed inside the central incisor canal by long-term CH therapy (27) or after a short-term (10 days) antibiotic
using counterclockwise rotation of a K-file size #60 (MANI; Mani Inc) to dressing (ciprofloxacin and metronidazole) (28); however, the latter

Figure 1. (A) Preoperative radiograph of teeth #9 and #10. Tooth #9 showed progressive inflammatory root resorption with poor canal/coronal filling. Tooth #10
was immature with visible periapical radiolucency. (B) Postoperative radiograph after obturation of tooth #10 with CEM and placement of CH in tooth #9. (C) Six
weeks after operation. (D) Immediately after obturation of tooth #9 with CEM cement. (E) Twenty-fourmonth follow-up. (F) Forty-month follow-up; tooth #9
regained its normal mobility, the inflammatory root resorption stopped, and the resorptive lacunae were filled with newly formed bone. There was no sign of
replacement resorption at any of the follow-up sessions.

412 Asgary et al. JOE Volume 37, Number 3, March 2011

Case Report/Clinical Techniques
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30. Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature
The authors deny any conflicts of interest related to this study. reviewpart II: leakage and biocompatibility investigations. J Endod 2010;36:
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JOE Volume 37, Number 3, March 2011 Management of Inflammatory External Root Resorption by Using CEM Cement 413