Management of External Inflammatory Root Resorption following Tooth Autotransplantation Using a Modified Combination of Triple Antibiotics

Abstract

External inflammatory root resorption (EIRR) is one of the most undesirable potential repercussions of various types of trauma and traumatic injuries to the tooth and its structure. This detrimental phenomenon may lead to severe complications, the consequent destruction of dental tissues, and eventual tooth loss. In the presented case, following the autogenous transplantation of tooth #17 as the host-tissue replacement for tooth #18, signs of EIRR were radiographically detected after 6 months. However, the thorough preparation of root canals, which involves complete cleaning and shaping, in addition to the application of a modified combination of triple antibiotics, consisting of penicillin G, metronidazole, and ciprofloxacin (PMC), managed to arrest EIRR. Moreover, the obturation of root canals using calcium-enriched mixture (CEM) cement as the endodontic biomaterial as well as the proper management of EIRR resulted in the healing of periradicular pathosis, abatement of clinical symptoms, and finally refunctionalisation of the tooth during a follow-up period of 2 years. It seems that the appropriate disinfection of the root canal system using PMC next to the prevention of microbial recontamination using CEM cement can perfectly manage EIRR.

Figure 1

Mandibular left second molar with large periapical radiolucency: (a) mandibular left second molar with inappropriate previous root canal therapy, intracanal broken instruments, large periapical radiolucency, and furcation involvement; (b) former mandibular second molar was diagnosed hopeless and thus was removed whereas the mandibular left third molar was soundly extracted, and root-end cavities were cautiously prepared, carefully sealed using calcium enriched mixture (CEM) cement, and transplanted as a replacement for the mandibular left second molar; (c) in the 3-month follow-up, relative healing of periradicular bone was evident; however, radiolucencies in the mesial periapical region and furcation persisted, and signs of external inflammatory root resorption (EIRR) appeared on the distal root; (d) after the 6-month follow-up from the first treatment session and persistence of EIRR signs, the coronal restoration was removed, root canals were prepared, canals were medicated with a new combination of triple antibiotics (PMC), and the coronal cavity was sealed with Zonalin™; (e) after 3 weeks from the previous appointment, relative bone healing and complete arrest in EIRR progression were seen. Root canals were then filled with CEM cement, and the coronal cavity was restored using amalgam; (f) in the 2-year follow-up, thorough bone healing, disappearance of periapical and furcation radiolucency, and arrest/treatment of IERR were observed.

Figure 2

Cone-beam computed tomography (CBCT) showed large periradicular radiolucency around the mesial root in tooth #18, with sizable bone loss/resorption and the furcation involvement.