Indian Journal of Dental ResearchIndian Journal of Dental ResearchIndian Journal of Dental Research
Indian Journal of Dental Research   Login   |  Users online:

Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size         


Table of Contents   
Year : 2022  |  Volume : 33  |  Issue : 2  |  Page : 223-226
Novel management of internal root resorption with vertical root fracture using mineral trioxide aggregate - A case report

Department of Conservative Dentistry and Endodontics, Ragas Dental College and Hospital, (Affiliated to The Tamil Nadu Dr. MGR Medical University), Chennai, Tamil Nadu, India

Click here for correspondence address and email

Date of Submission22-Apr-2021
Date of Decision21-Feb-2022
Date of Acceptance02-Aug-2022
Date of Web Publication13-Oct-2022


Introduction: This case report presents the diagnosis and management of extensive internal root resorption (IRR) in a 17-year-old male patient, with a 9-year-old history of trauma. Method: The affected tooth 21 was associated with vertical root fracture (VRF) and incomplete apex closure with a substantial loss of tooth structure, including dentin and cementum. Encouraged by a healthy periodontal condition, the choice was made to use mineral trioxide aggregate (MTA) to reconstruct and reinforce the resorptive defect and the fractured segment. A composite veneer was placed to enhance the aesthetics. Result: A follow-up of the patient after 2 years revealed healing with a resolution of the lesion. Conclusion: This case report highlights the use of MTA as a lone-standing filling material for the treatment of IRR with VRF in a non-vital immature tooth.

Keywords: Immature apex closure, internal root resorption, mineral trioxide aggregate, vertical root fracture

How to cite this article:
Karumaran CS, Ramachandran AK, Chandrasekaran N, Manuel CE, Kattula D. Novel management of internal root resorption with vertical root fracture using mineral trioxide aggregate - A case report. Indian J Dent Res 2022;33:223-6

How to cite this URL:
Karumaran CS, Ramachandran AK, Chandrasekaran N, Manuel CE, Kattula D. Novel management of internal root resorption with vertical root fracture using mineral trioxide aggregate - A case report. Indian J Dent Res [serial online] 2022 [cited 2022 Nov 29];33:223-6. Available from:

   Introduction Top

Internal root resorption (IRR) is a rare, insidious, resorptive pathological process, beginning in the pulpal space and extending into the surrounding dentin. Its diagnosis and management have been a perplexity to dental clinicians. The incidence of internal root resorption has been estimated to vary between 0.01% and 1%, depending on the inflammatory status of the pulp.[1] Internal inflammatory resorption begins after a stimulus (inflammation), causing the loss or alteration of the protective pre-dentin layer, followed by pulpal invasion by multinuclear giant cells, odontoclasts and dentinoclasts.

It is often asymptomatic, although when a tooth is partially vital, symptoms of typical pulpitis are reported.[1] If there is complete perforation of the crown, the pain would be the main presenting symptom. IRR is usually present in the mid and apical regions of the tooth. A pinkish colour in the cervical area of the crown is a hallmark feature when resorption has extended to the cervical region, hence it is also known as 'pink tooth'. When the pulp has been completely necrosed, the tooth appears grey.[1]

The radiographic appearance of IRR is 'a well-defined symmetrical radiolucency of uniform density, continuous with the root canal'. However, it is difficult to give a diagnosis in the early stage of IRR by examination of conventional X-rays. Therefore, cone beam computed tomography (CBCT) can be used to evaluate the true nature and severity of resorptive lesions.[2]

The extent of the lesion determines the approach of management. In a non-perforated lesion, the management of choice is root canal treatment.[2] In most cases, the apex is sealed using mineral trioxide aggregate (MTA), and the canal is obturated with thermoplasticised gutta-percha.[2] In cases of extensive resorption with an open apex, MTA is considered a potential option for an obturating material because of its unique physiochemical and bioactive properties. This report presents a complex case of IRR superimposed with vertical root fracture (VRF) and highlights its successful management with MTA as stand-alone material.

   Case Report Top

A 17-year-old male patient came to the Department of Conservative Dentistry and Endodontics with a chief complaint of a discoloured broken tooth in the upper front tooth region. The patient gave a history of trauma to the upper front tooth about 9 years ago.

On clinical examination, greyish discolouration of tooth number 21 (upper left central incisor) [Figure 1]a with mild pain on percussion was elicited, VRF extending to the crown involving the enamel, dentin and pulp was noted, and the fractured segment revealed slight mobility in the labio-palatal direction. Heat and cold pulp vitality tests indicated non-responsive pulp.
Figure 1: (a) Preoperative image revealing the discoloured 21 with coronal facture. (b) Labial image after composite veneer placement

Click here to view

Intraoral periapical radiographs were taken in three angulations. Radiographic examination of 21 revealed a large radiolucency of the pulp chamber and an oval-shaped radiolucency in the middle-third segment of the root, giving evidence of IRR [Figure 2]a. A wide radiolucency in the apical region continuous with the root canal was indicative of an immature apical closure. A vertical fracture line from the coronal portion of the tooth up to the middle third was noted. The diagnosis of IRR with VRF and an open apex was confirmed. Though CBCT was suggested, the patient did not comply due to financial constraints.
Figure 2: (a) Preoperative radiovisiography image revealing large oval-shaped radiolucency in the middle-third of the canal with an incomplete apical closure. (b) Working length determination of the tooth with a size 40-k file. (c) Custom-made obturator by fusing 3 size-80 gutta-percha cones with xylene. (d and e) Stepwise incremental obturation of the root canal with MTA. (f) Obturated root canal sealed with type II glass ionomer cement. (g): Radiovisiography image of 21 after placement of the composite veneer. (h) Radiovisiography image of 21 after 2-year follow-up

Click here to view

The possibility of conserving tooth 21 was considered through a combination of root canal treatment by obturating the canal with MTA, sealing with glass ionomer cement and placing a composite veneer. Informed consent was obtained from the patient after explaining the procedure and possible complications. Root canal treatment was performed by established methods. After coronal access preparation, the remnant necrotic pulp tissue was removed using K and H files, and a working length of 24 mm was determined using an 80-size K file [Figure 2]b. The biomechanical preparation of the canal was performed by gentle circumferential filing with K files to size 80. It was accompanied by copious passive irrigation with 2.5% sodium hypochlorite to prevent seepage beyond the open apex. Calcium hydroxide paste dressing was placed as an intracanal medicament to provide an alkaline environment. The patient was recalled after 7 days; the dressing was removed and irrigated with 2.5% sodium hypochlorite. This procedure was done once a week for 2 weeks until the tooth was asymptomatic. Final irrigation was done and three 80-size gutta-percha cones were fused with xylene and measured to the working length, and 2 mm was cut from this tip of the custom-made obturator [Figure 2]c. Because this was a case of an open apex with VRF, root canal space beginning with the apical portion was filled incrementally with white MTA. Each increment was inserted using the custom-made gutta-percha obturator and condensed with the plastic instrument. After each increment, radiographs were taken to ensure adequate compaction of the material and confirm the absence of voids in the canal space. Care was taken to make sure MTA did not extrude beyond the apex [Figure 2]d and [Figure 2]e. All excess filling material was removed from the coronal pulp chamber to prevent discolouration and was promptly sealed with glass ionomer cement. An immediate postoperative radiograph was taken to ensure satisfactory filling of the root canal and resorptive defect [Figure 2]f. Finally, a composite resin veneer was placed as interim restoration to enhance aesthetics [Figure 1]b and [Figure 2]g. The patient was asymptomatic and was content with the treatment after 2 years of follow-up [Figure 2]h and was unwilling to the ceramic crown.

   Discussion Top

IRR is a pathologic process that affects the dentin walls of the pulp cavity causing the loss of intra-radicular dentin. This affects both primary and permanent teeth with a higher frequency in permanent maxillary incisors.[3] Caliskan et al. attributed trauma as the most frequent etiological factor accounting for 43% of the internal resorption cases, with 18–20% of cases of crown fracture involving the pulp of young permanent teeth.[3],[4]

Interestingly, even in this case report, the affected tooth had extensive oval-shaped resorption within the canal space after 9 years of trauma and was asymptomatic, although it was associated with VRF with the facture line extending until the cementoenamel junction. This is unusual, as most often VRF is observed in a post-endodontically treated tooth and clinically presents with mild-to-moderate pain, swelling of soft tissue and tenderness on palpation or with sinus tracts.[5],[6] None of these signs were present in this case except for mild mobility in the labio-palatal direction with mild pain on percussion and discolouration of the tooth.

It could be speculated that this VRF could have occurred at the time of trauma predisposing the IRR or could have resulted because of the extensive internal resorption. Radiographically, VRF showed a diffuse widening of the periodontal ligament, separating the root fragment; however, there was no displacement of apical portions of the root. Although CBCT is a much sensitive diagnostic tool to provide information with respect to the extent and severity of resorption and fracture, it was not done due to the financial constraint of the patient.

In addition, the radiograph revealed incomplete apical closure indicating the cessation of root formation. This could be due to the necrosis of the pulp due to inflammation caused by trauma, which happened when the patient was young.[7] According to Cvek's classification of root development, the tooth in this report is categorised as type IV with wide open apical foramen and nearly complete root length.[7]

For a case with an extensive IRR along with VRF and open apex and questionable prognosis, there is always a dilemma whether to conserve the tooth by doing root canal treatment or opt for an implant after extraction of the tooth. Owing to the favourable periodontal condition, conservation of 21 was considered through a combination of root canal treatment and internal MTA repair using the technique by Bramented, George Bogen and Sergio Kuttler in which the entire canal was filled with MTA.[8]

Though calcium hydroxide and composites can be used as obturating material, the main drawback of calcium hydroxide is that being proteolytic in nature, it weakens the dentin and composites with a high configuration factor of 100:1 in the root canal that is highly unfavourable with the risk of debonding, making them less popular.[9],[10] Superior clinical properties of MTA, such as biocompatibility, applicability in wet environments, prevention of bacterial microleakage, alkalinising medium, bioactive property and mechanical strength make it a material of choice in repair and reinforcement in our case management.[11] Due to the predominance of calcium oxide in the MTA formula, its biological properties show similarity to those of calcium hydroxide, making it useful for tissue healing.[11] In addition, MTA has a profound advantage as canal obturating material because of its superior physiochemical and bioactive properties, initiating the process of forming hydroxyapatite precipitates between MTA and dentin, causing the bonding with dentin that was initially mechanical, with time, to become chemical. MTA promotes cementum coverage directly upon the MTA surface creating a double seal of the root canal.[12],[13] Therefore, a more complete peri-radicular architecture and a high degree of structural integrity can be produced, whereas histologically, reparative periodontal tissue formation is stimulated.[14]

Several case reports have shown MTA as an effective root reinforcement material,[15] because of the added advantage of higher fracture resistance and compressive strength. The compressive strength of MTA increases from 40 MPa after 24 h to 67.3 MPa after 3 weeks.[16] Hence, roots reinforced with MTA had fracture strengths almost four times higher than those of the empty root canals and twice that of the roots with an apical MTA plug and a backfill of gutta-percha.[17] According to Parashos et al.,[18] manual compaction of MTA resulted in denser root filling than those filled with ultrasonic activation.

The patient followed for 2 years and demonstrated uneventful healing with no post-operative complications accentuating the evidence from the other studies of healing rates ranging from 81–100% in open apex teeth when treated with MTA.[14],[19] Therefore MTA as lone-standing filling material of the entire root canal system is the evolutionary application for the management of non-vital immature teeth.

   Conclusion Top

Early diagnosis, removal of the causative factor and appropriate treatment of the resorbed root is mandatory for successful treatment outcome. It is easy to control the process of IRR via severing the blood supply to the resorbing tissues with conventional root canal therapy. Using MTA, a severely weakened, internally resorbed tooth can be restored. The purpose of the present report was to provide an alternative treatment for IRR with VRF using MTA to fill the canal aiming to reinforce and fortify the tooth.

Declaration of patient consent

The authors certify that they have obtained consent form from patient's caregiver and assent from the patient. In the form, the consent for images and other clinical information to be reported in the journal has been taken. The patient and the caregiver understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Haapasalo M, Endal U. Internal inflammatory root resorption: The unknown resorption of the tooth. Endod Topics 2006;14:60-79.  Back to cited text no. 1
Nilsson E, Bonte E, Bayet F, Lasfargues J. Management of internal root resorption on permanent teeth. Int J Dent 2013;2013;1-7.doi: 10.1155/2013/929486.  Back to cited text no. 2
Caliskan MK, Turkun M. Prognosis of permanent teeth with internal resorption: A clinical review. Dent Traumatol 1997;13:75-81.  Back to cited text no. 3
De Blanco LP. Treatment of crown fractures with pulp exposure. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:564-8.  Back to cited text no. 4
Ojeda-Gutierrez F, Martinez-Marquez B, Arteaga-Larios S, Ruiz-Rodriguez MS, Pozos-Guillen A. Management and followup of complicated crown fractures in young patients treated with partial pulpotomy. Case Rep Dent 2013;2013:1-5. doi: 10.1155/2013/597563.  Back to cited text no. 5
Yu C, Abbott P. Responses of the pulp, periradicular and soft tissues following trauma to the permanent teeth. Aust Dent J 2016;61:39-58.  Back to cited text no. 6
Plascencia H, Díaz M, Gascón G, Garduño S, Guerrero-Bobadilla C, Márquez-De Alba S, et al. Management of permanent teeth with necrotic pulps and open apices according to the stage of root development. J Clin Exp Dent 2017;9:e1329-39.  Back to cited text no. 7
Bogen G, Kuttler S. Mineral trioxide aggregate obturation: A review and case series. J Endod 2009;35:777-90.  Back to cited text no. 8
Carvalho RM, Pereira JC, Yoshiyama M, Pashley DH. A review of polymerization contraction: The influence of stress development versus stress relief. Oper Dent 1996;21:17-24.  Back to cited text no. 9
Tay F, Loushine R, Weller R, Kimbrough W, Pashley D, Mak Y, et al. Ultrastructuralevaluation of the apical seal in roots filled with a polycaprolactone-based root canal filling material. J Endod 2005;31:514-9.  Back to cited text no. 10
Camilleri J, Pitt Ford TR. Mineral trioxide aggregate: A review of the constituents and biological properties of the material. Int Endod J 2006;39:747-54.  Back to cited text no. 11
Andreasen JO, Munksgaard EC, Bakland LK. Comparison of fracture resistance in root canals of immature sheep teeth after filling with calcium hydroxide or MTA. Dent Traumatol 2006;22:154-6.  Back to cited text no. 12
Felippe WT, Felippe MCS, Rocha MJC. The effect of mineral trioxide aggregate on the apexification and periapical healing of teeth with incomplete root formation. Int Endod J2006;39;2-9.  Back to cited text no. 13
El-Meligy OA, Avery DR. Comparison of apexification with mineral trioxide aggregate and calcium hydroxide. Pediatr Dent 2006;28:248-53.  Back to cited text no. 14
Cauwels RGEC, Pieters IY, Martens LC, Verbeeck RMH. Fracture resistance and reinforcement of immature roots with gutta percha, mineral trioxide aggregate and calcium phosphate bone cement: A standardizedinvitromodel. Dent Traumatol 2010;26:137-42.  Back to cited text no. 15
Torabinejad M, Hong C, Mcdonald F, Pittford T.physical and chemical properties of a new root-end filling material. J Endod 1995;21:349-53.  Back to cited text no. 16
Bortoluzzi EA, Souza EM, Reis JMSN, Esberard RM, Tanomaru-Filho M. Fracture strength of bovine incisors after intra-radicular treatment with MTA in an experimental immature tooth model. Int Endod J 2007;40:684-91.  Back to cited text no. 17
Parashos P, Phoon A, Sathorn C. Effect of ultrasonication on physical properties of mineral trioxide aggregate. Bio Med Res Int 2014;2014:1-4. doi: 10.1155/2014/191984.  Back to cited text no. 18
Pace R, Giuliani V, Pini Prato L, Baccetti T, Pagavino G. Apical plug technique using mineral trioxide aggregate: Results from a case series. Int Endod J 2007;40:478-84.  Back to cited text no. 19

Correspondence Address:
Dr. Deepthi Kattula
Department of Conservative Dentistry and Endodontics, Ragas Dental College, Uthandi, Chennai 600 119, Tamil Nadu
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.ijdr_350_21

Rights and Permissions


  [Figure 1], [Figure 2]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  

   Case Report
    Article Figures

 Article Access Statistics
    PDF Downloaded24    
    Comments [Add]    

Recommend this journal