Internal Root Resorption: A Review

Shanon Patel, BDS, MSc, MClinDent

,
Domenico Ricucci, MD, DDS
, ,
,
Conor Durak, BDSc, MFDS RCS (Eng)

,
Franklin Tay, BDSc (Hons), PhD

Endodontic Postgraduate Unit, King's College, London Dental Institute, London, United Kingdom

Private practice, Rome, Italy

Department of Endodontics, School of Dentistry, Medical College of Georgia, Augusta, Georgia

http://dx.doi.org/10.1016/j.joen.2010.03.014, How to Cite or Link Using DOI
Permissions & Reprints
View full text

Purchase


Abstract
Introduction
Internal root resorption is the progressive destruction of intraradicular dentin and dentinal tubules
along the middle and apical thirds of the canal walls as a result of clastic activities.
Methods
The prevalence, etiology, pathogenesis, histologic manifestations, differential diagnosis with cone
beam computed tomography, and treatment perspectives involved in internal root resorption are
reviewed.
Results
The majority of the documentation that exists in the literature is in the form of case reports, and there
are only a limited number of studies that attempted to examine the histologic manifestations and
biologic aspects of the disease. This might be due, in part, to the relatively rare occurrence of this type
of resorption and the lack of an in vivo model, apart from the previous attempt on the use of diathermy,
to predictably reproduce the condition for study. From a histologic perspective, internal root resorption
is manifested in one form that is purely destructive, internal (root canal) inflammatory resorption, and
another that is accompanied by repair, internal (root canal) replacement resorption that is featured by
the deposition of metaplastic bone/cementum-like tissues adjacent to the sites of resorption.
Conclusions
From a differential diagnosis perspective, the advent of cone beam computed tomography has
considerably enhanced the clinician's capability of diagnosing internal root resorption. Nevertheless,
root canal treatment remains the treatment of choice for this pathologic condition to date.
Key Words
Bone metaplasia;
cone beam computed tomography;
internal root resorption;
pulp histology;
pulp inflammation

Figures and tables from this article:

Figure 1. Light microscopy images of a case with early internal (root canal) inflammatory resorption. (a)
Maxillary canine with caries penetrating the pulp. The tooth was tender to percussion. There was no response
to sensitivity tests. (b) Sections were taken along the buccolingual plane. Overview image shows carious
perforation and necrotic tissue in the root canal (Taylor's modified Brown & Brenn [TBB]; original magnification,
2). (c) Coronal third of the root canal shown in (b). Dense bacterial biofilm was present on the canal walls.
Necrotic tissue can be identified in the canal lumen (TBB; original magnification, 16). (d) High magnification of
the area indicated by the arrow in (c). Dense aggregation of bacteria can be seen along the canal wall (TBB;
original magnification, 400. Inset; original magnification, 1000). (e) Apical third of the root. Contrary to the
histologic condition present in the coronal two thirds, the tissue was vital (hematoxylin-eosin [H&E]; original
magnification, 25). (f) Magnification of the left root canal wall. The odontoblast layer was absent, with only
some remaining predentin. Resorption lacunae can be observed along the canal wall (H&E; original
magnification, 100). (g) Higher magnification of the upper lacuna in (f). Large multinucleated resorbing cell
(odontoclast) and granulation tissue consisting of fibroblasts and chronic inflammatory cells can be seen (H&E;
original magnification, 400). (h) High magnification view of the odontoclast showing multiple nuclei. The empty
space is a shrinkage artifact (H&E; original magnification, 1000).
Figure options

Figure 2. Light microscopy images of a case with early internal (root canal) inflammatory resorption followed by
necrosis and infection. (a) Periapical radiograph shows a mandibular second premolar with gross caries and
enlargement of the periodontal ligament. There was no response to sensitivity tests, and the tooth was
extremely sensitive to percussion. The buccal gingival tissues were swollen and fluctuant. The diagnosis was
pulpal necrosis with acute apical abscess. After discussing the various treatment options, the patient opted for
extraction. (b) Sections were taken along the mesiodistal plane. Overview image shows that the distal caries
had penetrated the pulp space. Pulp tissue was necrotic (TBB; original magnification, 2). (c) Apical third. Main
canal and ramifications were filled with a bacterial biofilm (TBB; original magnification, 16). (d) Higher
magnification of the main canal in (c). Numerous resorptive defects were present on the right root canal walls
and filled with bacteria (TBB; original magnification, 100). (e) High magnification of the upper lacuna in (d).
Predentin was absent, and the cavity was occupied by a bacterial biofilm. Some polymorphonuclear leukocytes
can be observed (TBB; original magnification, 400). (f) Resorption lacuna apical to that shown in (e) (TBB;
original magnification, 400). (g) High magnification taken from the left canal wall of the apical canal. Despite
the presence of necrotic pulp tissue along the root canal wall, predentin was intact at this level, and no
resorption can be seen (H&E; original magnification, 400).
Figure options

Figure 3. Light microscopy images of a case with internal (root canal) inflammatory resorption. (a) Radiograph
of a nonrestorable grossly carious mandibular molar. A radiolucent area can be seen in the distal root at the
transition between the middle and the apical thirds of the root canal. (b) Longitudinal section of the distal root,
taken from a mesiodistal plane. The defect appears empty, except for some debris present in its apical
extension (H&E; original magnification, 16). (c) High magnification of the area from the right wall indicated by
the arrow in (b). Resorption lacunae appear empty; no multinucleated cells are visible (H&E; original
magnification, 400). (d) Section taken approximately 60 sections after that shown in (b). Necrotic tissues can
be seen at the transition between the resorption area and the apical canal followed by a concentration of cells
(TBB; original magnification, 50). (e) High magnification of the area demarcated by the rectangle in (d),
showing the transition between necrotic tissue with bacterial colonies and an area of acute inflammation (TBB;
original magnification, 400). (f) High magnification of the area indicated by the arrow at the center of the
cellular accumulation in (d). Dense aggregation of polymorphonuclear leukocytes can be identified (TBB;
original magnification, 400). (Reprinted with permission from Ricucci D. Patologia e Clinica Endodontica.
Edizioni Martina, Bologna, Italy, 2009).
Figure options


Figure 4. Light microscopy images of a case with internal (root canal) replacement resorption. The tooth was
derived from a 44-year-old male patient who was referred to the first author for management of a perforated
root. The tooth was asymptomatic on examination, but there was a history of previous trauma. (a) Radiograph
of a maxillary central incisor with a radiolucent lesion in the mid-third of the root canal. The radiolucent lesion
appears to be mottled, which is suggestive of internal root resorption with metaplasia. (b) Radiograph of the
tooth after extraction taken at 90-degree angle to the clinical radiograph showing the continuity of the
resorptive lesion with the canal space. (c) Cross section taken approximately at the level of line 1 in (b). Low
magnification overview shows that the dentin around the root canal had been replaced by an ingrowth of bone
tissue, and the root appears to have been perforated on the distopalatal aspect (H&E; original magnification,
8). (d) Higher magnification of (c) (H&E; original magnification, 16). (e) High magnification of the area
demarcated by the rectangle in (d). The intraradicular dentin has been resorbed (H&E; original magnification,
100). (f) High magnification taken from the right part of (c) showing that the resorbed dentin has been
substituted by lamellar bone. Osteocytes are present in lacunae between the lamellae. A characteristic cross
section of an osteon can be seen on the right (open arrows), with concentric lamellae surrounding a vascular
structure (H&E; original magnification, 100). (g) High magnification of the area indicated by the left open
arrow in (e). A multinucleated resorbing cell (odontoclast) can be seen in a dentinal lacuna, indicating active
resorption of the dentinal wall (H&E; original magnification, 1000). (h) High magnification view of the bone
surface indicated by the right arrow in (e). The large cells are osteoblast-like cells. Once they produced
mineralized tissue, they were embedded in the bone lacunae, assuming the characteristics of osteocytes
(H&E; original magnification, 1000). (i) Cross section taken approximately at the level of line 2 in (b). The root
canal was still large at this level and surrounded by a relatively thin layer of newly formed bone (H&E; original
magnification, 16). (j) Cross section taken approximately at the level of line 3 in (b). At this level the root canal
appears consistently narrowed by a dense layer of newly formed bone (H&E; original magnification, 16).
Figure options

Figure 5. Light microscopy images of a variant of internal (root canal) replacement resorption with tunneling
resorption. Lower right lateral incisor was derived from a 39-year-old former boxer who suffered from jaw
fracture during a boxing match in his early twenties and was placed in intermaxillary fixation. The patient
developed symptoms 20 years later and complained of pain associated with his lower incisors. (a) Radiograph
of the mandibular right incisors. Lower right central incisor had asymptomatic apical periodontitis associated
with a necrotic and infected pulp. Lower right lateral incisor showed a large area of internal root resorption. The
tooth did not respond to sensitivity tests. (b) Sagittal CBCT slice shows some calcified tissue in the resorptive
defect. (c) Cross section taken at the level of line 1 in (a, b). Overview shows that the canal was apparently
empty at this level (H&E; original magnification, 6). (d) High magnification of the area indicated by the arrow in
(c). Lamellar bone fills an area of previous resorption. Note the osteon structure (arrow) (H&E; original
magnification, 100). (e) Cross section taken at the level of line 2 in (a, b). Overview shows that the canal
lumen was partly occupied by necrotic remnants, partly by bone-like tissue (H&E; original magnification, 8). (f)
High magnification of the lower part in (e) (H&E; original magnification, 50). (g) Higher magnification of (f).
Bone trabeculae surrounded by necrotic debris (H&E; original magnification, 100). (h) Cross section taken
from the same area as that in (e) (TBB; original magnification, 16). (i) High magnification of the area indicated
by the arrow in (h). Fragment of bone-like tissue can be seen surrounded by bacteria-colonized necrotic
tissues (TBB; original magnification, 100. Inset; original magnification, 1000). (j) Longitudinal section passing
approximately through the center of the root apex. Dentin walls had been resorbed and substituted by a bone-
like tissue (H&E; original magnification, 16).
Figure options

Figure 6. (a) Clinical examination reveals that the mandibular left central incisor tooth was discolored and
nonresponsive to sensitivity testing. (b) Two periapical radiographs taken at different horizontal angles confirm
the resorptive lesion is labially positioned by using the parallax principle; the root canal outline is still visible
through the lesion, indicating that the lesion is ECR. (c, d) Sagittal and axial CBCT slices show that the lesion
is actually internal root resorption, which is located at the periphery of the root canal. True nature of the
resorptive lesion could only be assessed with CBCT.
Reprinted with permission from Patel S. New dimensions in endodontic imaging: part 2cone beam computed
tomography. Int Endod J 2009;42:46375.
Figure options

Figure 7. (a, b) Parallax views of the maxillary left lateral incisor showing internal (root canal) resorption. A
gutta-percha point has been used to track the sinus. The reconstructed sagittal (c) and axial (d) slices from
CBCT reveal that the lesion has extensively resorbed the palatal aspect of the root (arrows) and has nearly
perforated the root wall. (e) The tooth has been obturated with gutta-percha by using a thermoplasticized
technique.
Figure options

Figure 8. (a, b) Radiographs reveal internal (root canal) replacement resorption of maxillary left central incisor;
note the lesion remains centered with second parallax view. (c) CBCT-reconstructed coronal (left) and axial
(right) views of the tooth indicate that calcified tissue was present in the coronal part of the defect. (d) The
tooth was obturated with gutta-percha by using a thermoplasticized technique; note the irregular borders and
varying radiodensity of the root filling associated within the internal root resorption lesion. (e) 2-year review
radiograph.
Fig