NZEJ Vol 58

New Zealand

Endodontic

Journal

Vol 57 November 2021

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Published by the New Zealand Society of Endodontics (Inc)

New Zealand

Endodontic

Journal

Vol 58 NOVEMBER 2021 ISSN 0114-7722

New Zealand Society

of Endodontics (Inc)

President

Joanna Lowe

161 High Street

Dunedin 9016

president@nzse.co.nz

Secretary

Nick Tramoundanas

Unit 5, 47 Miramar Avenue

Wellington 6022

secretary@nzse.co.nz

Treasurer

Theodore Kay

Unit GD, 164 The Terrace

Wellington 6011

treasurer@nzse.co.nz

Journal Editor

Dikesh Parmar

Unit GD, 164 The Terrace

Wellington 6011

journal@nzse.co.nz

Co-Editor

Rajneesh Roy

Suite 3, 1 Thackeray Street

Hamilton 3204

Contents

2 Editorial Notices

3 Editorial Dikesh Parmar

4 President’s Report Joanna Lowe

5 Surgical Decoronation: Management of a

Severe Intrusion Injury

David Parkins

15 Root Reporption: Dikesh Parmar

A Review – Part 2

and Rajneesh Roy

31 Financial Statements for the Year Ended 31 March 2021

42 News from the Dental School

43 Continuing Professional Development Questionnaire

Front Cover:

Collage of photos of the management of an Intrusion injury:

from repositioning the tooth, treating it with root canal treatment

and internal bleaching. Once submergence started, the crown

was decoronated and the space maintained with a bonded

prosthesis for future rehabilitation.

New Zealand Endodontic Journal Vol 58 November 2021 Page 1

Editorial Notices

The New Zealand Endodontic Journal is

published twice yearly and sent free to

members of the New Zealand Society of

Endodontics (Inc). The subscription rates for

membership of the Society are $75 per annum

in New Zealand or $100 for overseas members.

Graduates of the University of Otago School of

Dentistry enjoy complimentary membership

for the first year after graduation. Subscription

inquiries should be sent to the Secretary, Nick

Tramoundanas, secretary@nzse.org.nz.

Contributions for inclusion in the Journal

should be sent to the Editor, Dikesh Parmar,

journal@nzse.org.nz. Deadline for inclusion

in the May or November issue is the first day

of the preceding month.

All expressions of opinion and statements

of fact are published on the authority of the

writer under whose name they appear and

are not necessarily those of the New Zealand

Society of Endodontics, the Editor or any of

the Scientific Advisers.

Information for Authors

The Editor welcomes original articles, review

articles, case reports, views and comments,

correspondence, announcements and news

items. The Editor reserves the right to edit

contributions to ensure conciseness, clarity

and consistency to the style of the Journal.

Contributions will normally be subjected to

peer review.

It is the wish of the Editor to encourage

practitioners and others to submit material for

publication. Assistance with word processing

and photographic and graphic art production

will be available to authors.

Manuscripts should be emailed at journal@

nzse.org.nz as Word (.doc) or Rich Text

Format (.rft) files (not write-protected) plus

separate figure and illustration files. Figures

and illustrations need to be in and GIF or JPEG

format with a minimum of 200dpi resolution.

The text file must contain the abstract,

main text, references, tables, and figure and

illustration legends, but no embedded figures

and illustrations. In the main text, please

reference figures as for instance ‘Figure 1’,

‘Figure 2’ etc to match the separate tag name

you choose for the individual figure files.

References

References cited in the text should be placed

in parenthesis stating the authors’ names and

date, eg (Sundqvist & Reuterving 1980). At the

end of the article references should be listed

alphabetically giving surnames and initials of

all authors, the year, the full title of the article,

name of periodical, volume number and page

numbers.

The form of reference to a journal article is:

Sundqvist G, Reuterving C-O (1980) Isolation of

Actinomyces israelii from periapical lesion. Journal

of Endodontics 6, 602-606.

The form of reference to a book is:

Trowbridge HO, Emling RC (1993) Inflammation,

4th edn, pp 51-57. Chicago, USA: Quintessence

Publishing Company Inc.

Arrangement

Page 2 New Zealand Endodontic Journal Vol 58 November 2021

Editorial

The prevalence of dental trauma in the New Zealand population aged between 18-94 is

around 23%, and of these, only 2.3% are either avulsion or luxation injury. In the age

group of 7-17, the prevalence is around 16%, however there is no data available on the

type of injury sustained (Ministry of Health 2010; Scott et al. 2020). Treatment of avulsion

and luxation injuries are complicated and challenging. If managed correctly, it leads to an

excellent long-term outcome for the patient. The first article in this edition is by Dr David

Parkins. He manages an intrusive luxation injury of tooth 11 using a multidisciplinary

approach to obtain an excellent long term outcome prospect.

The second article is on root resorption. Root resorption is a topic that usually presents a

challenge to the dental practitioner at the best of times. Different types of resorptions require

knowledge and understanding of its aetiology, which then influences its management. This

article comprises of cases of root resorption and its management. These being, internal

inflammatory (IIR), external inflammatory (EIR), external cervical (ECR), external

replacement (ERR) and external surface (ESR) resorptions.

At our last annual general meeting, it was decided that the printed journals were no longer

viable due to the substantial print and postage costs. Therefore, this edition will also be the

first edition that will be circulated to all members as an e-Journal.

This edition is also verified for 1 hour of CPD to all New Zealand Dental Association

(NZDA) members. Simply answer the 6 questions pertaining to the three articles, and use

the number obtained as your 6-digit NZDA verifiable code.

Dikesh Parmar

Editor

References:

Ministry of Health (2010) Our Oral Health: Key findings of the 2009 New Zealand Oral Health Survey pp. 1-356.

Wellington, New Zealand: Ministry of Health.

Scott N, Thomson WM, Cathro PR (2020) Traumatic dental injuries among New Zealanders: Findings from a

national oral health survey. Dental Traumatology 36(1), 25-32.


President’s Report

One of the main purposes of the New Zealand Society of Endodontics is to support education

and research. Stephen Crisp who was awarded the 2020 undergraduate New Society of

Endodontics Prize, our webinars have been enormously popular, and our biannual journal

under the stewardship of Dikesh Parmar continues to thrive. In addition, we continue to

provide all members with free access to the Dental Trauma Guide, an invaluable online

resource for all practitioners and their patients.

I’d like to thank our specialist endodontists who generously give their time to produce

educational resources, we are extremely grateful to this group of members.

Mike Jameson, one of the founding members of the NZSE, is stepping down following his

retirement from practice. Mike has served in every role of the committee at some point,

from president to journal editor and his enormous contribution has been invaluable. Mike’s

generous support of colleagues and commitment to improving endodontics care in NZ, in

many ways reflects the ethos of our society; practitioners supporting each other, to improve

care for our patients.

Finally, a reminder that we’re working with our Australian colleagues to produce another

trans tasman endodontic conference next year, and if borders allow, we hope to see you in

Sydney.

Joanna Lowe

President


Surgical Decoronation:

Management of a Severe Intrusion Injury

David Parkins

Introduction

Intrusive luxation is the displacement of a tooth

into the alveolar bone, resulting in fracture of

the socket. This can occur in an axial direction,

but also with a lateral component, particularly to

the buccal, mesial and distal with an associated

soft tissue laceration or tear. The signs are, a

high metallic percussion sound, loss of mobility,

a negative response to sensitivity testing, and

submergence of the tooth relative to surrounding

teeth. Radiographically, the tooth can be seen to

be out of position, with loss of the periodontal

ligament space. The injury causes disruption of the

neurovascular supply to the pulp and periodontal

ligament, contusion of the periodontal ligament

and alveolar bone, laceration of the PDL, and

disruption of the marginal gingival tissues. As a

general rule, intrusion of 3 mm or less in a tooth

with immature roots, or, a mature tooth (with a

closed apex), can be left to spontaneously erupt

over 4-6 weeks. For a mature tooth intruded up to

6-7 mm, orthodontic extrusion and repositioning

are generally preferred. In all cases orthodontic

fixtures are useful for stabilisation and accurate

repositioning. Intrusions greater than 6-7 mm

usually require immediate surgical repositioning

and stabilising with a flexible splint for 4-6

weeks (Kenny et al. 2003; Chaushu et al. 2004;

Andreasen et al. 2006). These guidelines,

however, are subject to several other important

factors, such as the time between the injury and

repositioning, patient compliance, and available

resources. Local anaesthesia can be difficult to

achieve in a distressed patient, who may be facing

their first dental procedure. If the time between the

trauma and treatment is greater than 24 hours, an

established blood clot in the spaces around the root

can make repositioning difficult, making gentle

orthodontic forces the favoured option (Fields

& Christensen 2013). If general anaesthesia is

required for treatment of other aspects of the

trauma, then management may change.

Periapical radiographs should be taken from

two vertical and horizontal angles to assess the

position of the tooth, or a conebeam computer

tomograph (CBCT) taken to identify the exact

position of the tooth, and the extent of alveolar

bone fracture. This can be very useful in planning

treatment to accurately reposition the tooth, and

any displaced bone fragments. Once the tooth

is back in position, endodontic treatment can be

started.

It is important to realise that a time limit exists

before root canal treatment must be undertaken.

The crown must be accessible within 2-3 weeks,

to remove necrotic pulpal tissue to reduce the

chance of infection, and subsequent inflammatory

root resorption, and development of painful

symptoms (Kenny et al. 2003). It is indicated to

start root canal treatment within 2-3 weeks in a

tooth with mature apex (closed), but the treatment

may be delayed in an immature tooth (open apex),

if intruded no more than 3 mm (Kenny et al.

2003). The immature tooth should be followed

up over the next 3 months (2-3 weekly) to check

its pulp vitality. If pulp necrosis occurs, then root

canal treatment should be initiated immediately to

reduce the risk of inflammatory root resorption of

its thin dentinal root walls (Andersson et al. 1989).

Intruded teeth have a poor long-term prognosis.

Extensive damage to the root surface and

the subsequent inflammatory process in the

periodontal tissues results in re-organisation of

the new attachment apparatus (Fuss et al. 2003).

Osteoclasts move into the damaged area, and with

time, progressive replacement resorption and

ankylosis occur. In a growing patient, the eruption

process is delayed, inducing infrapositioning of

the tooth, and disturbance in the growth of the

alveolar bone. The process is progressive and there

is no way of arresting the resorption (Malmgren et

al. 1994).


Surgical Decoronation

Removal of the ankylosed tooth will cause further

damage to the alveolar bone, but leaving the tooth

in situ will also contribute to future aesthetic and

prosthetic problems (Cohenca & Stabholz 2007;

Sapir & Shapira 2008). Therefore it is best to

consider decoronation of the tooth (Malmgren et

al. 1984).

When the pulp is removed, the canal is debrided

and filled with an intracanal medicament, usually

calcium hydroxide. The access can be temporized

with a double seal to prevent infection establishing

in the root canal system. The double seal consists

of white cavit, placed from the canal orifice to

within 3 mm of the cavo-surface margin of the

access cavity, and then glass ionomer cement, as

the final layer (Jensen et al. 2007). This will allow

time to plan for definitive long-term management

and treatment. The tooth maybe retained for

several years until infraposition becomes

noticeable. This can go a long way towards

maintaining co-operation and compliance with a

young patient, and their family at the start of an

often-long journey to ultimate replacement of the

tooth.

Case Report

This case report follows an 11-year-old girl from

the time of injury, through her teenage years and

orthodontic treatment for her malocclusion, to the

point where she is ready to proceed with definitive

rehabilitation with an implant-supported crown in

the site of her decoronated tooth.

An 11-year-old girl fell face first onto the floor

while roller blading in her home around 6 pm.

Tooth 11 was intruded axially, buccally and distally.

She was taken to a local Accident and Emergency

Medical Clinic where she was assessed for head

injury and given diazepam to manage distress,

antibiotics (amoxycillin) to prevent infection, and

analgesics (Panadol and codeine) to manage pain

and instructed to see a dentist to have the tooth

repositioned. She was seen by her dentist the

following day, approximately 18 hours after the

injury. Clinical examination revealed that tooth

11 was intruded half the length of the adjacent

tooth (21) in a buccal direction, with laceration of

the gingiva mesial to the 11, lateral to the midline

frenum. This is the most common lateral luxation

due to the often-thin buccal cortical plate over

maxillary central incisors. The radiograph showed

that the apex was several millimetres higher than

the 21, with the tooth tilted distally, and showing

loss of the periodontal ligament space. The tooth

had a high percussion tone and no mobility (Figs

1, 2 and 3).

1

2

3

Figures 1, 2, 3 (above): Initial presentation of tooth 11, clinical

photographs and radiograph.



Under local anaesthetic the tooth was repositioned

with forceps and held in position with a wire splint

bonded to teeth 13, 12, 21 and 22 with composite

resin. The gingival laceration was approximated

with a single absorbable suture. The patient

and her mother were informed that root canal

treatment would be required within 2 weeks.

Sixteen days later the patient attended to start root

canal treatment. The crown was discoloured, the

marginal gingiva inflamed and tender to palpation,

the tooth was slightly tender to percussion, and to

buccal pressure to the crown. However, treatment

could not be started due to the patient being very

apprehensive and upset about the procedure. The

possibility of providing sedation for treatment

was discussed. A referral was arranged to see a

paedodontist for assessment and treatment.

Twenty-seven days after the accident the

paedodontist saw the patient, but the patient was

still very anxious about having local anaesthetic,

and sedation was requested. Clinical examination

revealed a convex facial profile, incompetent lips

with the lower lip tucked behind the maxillary

incisors. Teeth 12 and 11 tested negative to ethyl

chloride, teeth 21 and 22 tested positive. Tooth

11 had become a red/brown colour. The patient

was referred to an endodontist to have the splint

removed and root canal treatment carried out

under intravenous sedation with an anaesthetist or

under general anaesthetic (GA).

The patient was seen in my practice 5 weeks

after injury. The splint was removed without

local anaesthetic, using a high-speed diamond

bur, ultrasonic scaler and flexi-discs. The teeth

were cleaned and polished with a rubber cup

and prophy paste (Figs 4, 5, 6, and 7). Teeth

4 5

Figures 4, 5, 6: Pre-operative presentation 5 weeks after the

injury.

6

7

Figure 7: Discolouration of tooth 11, splint removed.

12, 21 and 22 tested positive to cold challenge,

exhibited normal mobility and percussion sounds,

while tooth 11 had no mobility and had a highpitched

percussion tone, indicative of ankylosis

(replacement resorption). The preoperative radiograph

showed a diffuse apical radiolucency with

some blunting of the apex of 11 compared to the

apex of the 21. The patient tolerated the procedure

very well with no discomfort, and was prepared

to attend for pulp removal at another appointment

without sedation.

Forty-seven days after the trauma, the gingival

tissues were healthier due to improved access

for cleaning after removal of the splint. Topical

anaesthetic (Hurricane 20 % benzocaine, Beutlich

Pharmaceuticals, LLC, Florida, USA) was

applied to the mucosa for one minute prior to a

slow injection of local anaesthetic (0.9 ml of 4

% Articaine 1:200,00 adrenaline) in the buccal

sulcus over the apex of 11, and a mid-palatal

block (0.6 ml of solution).

Access was made through the palatal surface

of the tooth into an empty pulp chamber. The

remaining necrotic pulp tissue was removed from

the canal intact with a rotary ProGlider (Dentsply

Sirona, Ballaigues, Switzerland) file. The canal



was prepared using a Protaper Next® (Dentsply

Sirona) X5 rotary file to a working length of 24

mm, verified with an apex locator. The canal was

irrigated with 4 % sodium hypochlorite during the

preparation then agitated with an Endo Activator

(Dentsply Sirona) for 30 seconds at completion.

This was followed by a 17% ethylenediamine

tetra acetic acid (EDTA) solution and a final flush

with sodium hypochlorite, with both irrigants

again activated for 30 seconds. The canal was

dried with an irrigation tip attached to the suction

prior to injecting calcium hydroxide to the crestal

bone level. A barrier of white cavit was placed in

the canal orifice before injecting a mix of sodium

perborate and water to internally bleach the

discoloured crown. The access cavity was closed

with another layer of cavit and sealed with glass

ionomer cement.

9

10

The tooth was obturated 4 weeks later with

an apical plug of white mineral trioxide

aggregate (MTA) (Dentsply Sirona) followed

by thermoplastic injectable gutta percha and

Roth 801 zinc-oxide eugenol sealer (Roth

International, Chicago, USA). The canal orifice

was sealed with Fuji 1 (GC Corporation, Tokyo,

Japan), and the access closed with composite

8

Figure 10: 9 months recall radiograph showing replacement

resorption.

(Fig. 8). It was decided to obturate the tooth as

an interim measure to ensure the canal system

was sealed to reduce the possibility of infection.

The appearance of the tooth was improved with

the bleach having removed the discolouration

(Fig. 9). This was 78 days after trauma and the

tooth showed no obvious signs of submergence.

At 9 months after obturation (Fig. 10) the apical

radiolucency had resolved, but there were signs

of replacement resorption around the root with

changes more evident on the distal cervical 1/3 of

the root. The tooth had a high-pitched percussion

tone and no mobility.

Figures 8, 9: Post-operative radiograph and photograph –

completion of root canal treatment and internal bleaching.

Prior to the accident the patient was scheduled for

orthodontic assessment for her malocclusion. She



had a convex facial profile and a moderate skeletal

class 2 facial pattern. There was a class 2 division

1 incisor relationship with a large overjet and

deep overbite with the lower incisors occluding

on the palatal mucosa. The molar relationship was

class 2 on the left and ¾ class 2 on the right. The

decision was made to wait 12 months for further

facial growth and assessment of the prognosis of

tooth 11 before considering orthodontic treatment.

A study (Forsberg & Tedestam 1993) reporting

on etiological and other predisposing factors

related to traumatic injuries showed that class 2

malocclusion with an overjet exceeding 4 mm,

a short upper lip and incompetent lips were all

factors that increased susceptibility to traumatic

dental injury.

15 months after obturation and a year and seven

months since the trauma, the tooth was now in

infraposition (Figs. 11 and 12). It was decided to

decoronate the tooth in order to maintain normal

development of her maxilla. Prior approval

was obtained from Accident Compensation

Corporation (ACC) and the patient seen again

5 months later to plan the decoronation. A

conebeam computer tomograph scan was taken to

fully assess the treatment site (Fig. 13). Contact

was made with the orthodontist to co-ordinate

11

the decoronation with the start of her orthodontic

treatment so that the original crown could be

maintained in the site for aesthetic and confidence

reasons.

Two options were presented to the patient and her

mother:

1. Extraction of teeth 14, 24 and the decoronation

of 11 combined with fixed appliances to

maintain the root to preserve the native bone

for a future implant. Other goals included

improving her facial balance, reduction of the

dental protrusion, overjet and deep overbite.

During treatment the patient would have either

the original tooth or a false tooth attached to

her orthodontic wire to replace the 11. At the

end of treatment, the tooth would be added

to the retainer to hold the space until she was

ready for the implant.

2. Extraction of teeth 11 and 24 combined with

orthodontic treatment. This involved moving

the 12 into the 11 position, and 13 to the 12

position. This would eliminate the need for

an implant in the future, but restorative dental

work would be needed to reshape the crowns.

The family chose the first option. The orthodontist

requested that the 11 crown be retained after

decoronation to use as a pontic in the braces until

12

13

Figures 11, 12, 13: Tooth 11 shows submergence and extent

of resorption is evaluated using CBCT.



a plastic tooth could be substituted. A week before

fitting the appliances the patient would have tooth

11 decoronated and the 14 and 24 removed at the

same visit.

Two years after trauma, tooth 11 was decoronated

(age 13 years). Treatment was carried out under

oral sedation (0.185mg of Triazolam) and local

anaesthetic (all buccal and palatal infiltrations

used 2% Xylocaine 1:50,000 Adrenaline, 0.6

ml over the buccal of 14,24,11 and 21, 0.5

ml in the nasopalatine foramen. Bilateral mid

palatal blocks were administered with 0.6ml of

Articaine 1:200,000 Adrenaline). Teeth 14 and

24 were removed first. Then a full thickness

buccal muco-periosteal flap was laid and the

crestal bone exposed. The crown was sectioned

and removed, with the remaining tooth structure

reduced to 1.5 mm below the crestal bone level

(Figs. 14, 15 and 16). The gutta percha root filling

was removed with rotary files, the MTA plug was

removed with a long fine ultrasonic tip. The canal

was irrigated with saline and instrumented to a

level just beyond the apical foramen to stimulate

bleeding. A blood clot was allowed to form in the

canal prior to the socket being partially closed

with 5-0 plain gut sutures. The sectioned crown

14

15

Figures 14, 15, 16: The crown of tooth 11 decoronated, and

the root canal contents removed.

16

was trimmed and polished before being attached

to the 12 and 21 with a palatally placed strip

of Ribbond and composite resin (Figs. 17, 18

and 19). Pain management was achieved with 2

Maxigesic® (AFT Pharmaceuticals, Auckland,

NZ) preoperatively, followed by the same dose

every 4-5 hours, as required. Post-operative

oral hygiene included a 1-minute Chlorhexidine

mouthwash soak daily, along with warm saline

mouth rinses after meals.

The patient tolerated the procedure very well,

and was discharged with the original crown at

the same incisal level as tooth 21. At the 1-week

post-operative check the tissues around the

decoronation site were healing normally with the

patient feeling comfortable and happy with her

front teeth. Orthodontic treatment started in the

following week.

A review at 9 months after decoronation revealed

bone growing over the root face (Figs. 20 and 21).

Further reviews continued to show bone apposition

over and around the retained root along with

improved definition of the interproximal crestal

bone on the mesial of 12 and distal of 21. The

root was progressively resorbing. Further reviews



17 18

19 20 21 22

23 24 24

26 27 28 29

Figures 17, 18, 19: 11 crown attached to adjacent teeth using Ribbond.

Figures 20, 21: 9 months review post decoronation.

Figures 22, 23, 24, 25, 26: 15, 21, 27 and 33 months post-decoronation reviews respectively.

Figure 27: Bonded bridge made to replace tooth 11.

Figures 28, 29, 30, 31: 5 years 9 months review.



Figure 30 Figure 31

were done at 15 (Fig. 22), 21 (Fig. 23), 27 (Fig.

24) months and at the completion of orthodontic

treatment, 33 months after decoronation with the

crown of 11 now bonded to the 12 and 21 (Figs.

25 and 26). The original tooth was discoloured

and the composite splint was too bulky, making

it difficult to clean interproximally. The patient

was referred back to her dentist to have a bonded

bridge made.

At 4 years and 9 months the patient was happy

with the appearance of the new bridge and found

it much easier to maintain the gingival health. The

root was continuing to resorb but crestal bone on

the mesial of 12 and 21 was at a normal level (Fig.

27).

At 5 years and 9 months (19 years of age) the

bonded bridge was stable and gingiva healthy.

The crown length was shorter than the 21 due to a

lower gingival contour. That may be an advantage

in the future when implant placement is planned

(Figs. 28, 29, 30 and 31).

Discussion

Complex dental trauma cases generally

require multiple procedures with some form of

anaesthesia administered by injection. These

procedures include rubber dam application, pulp

removal, root canal debridement, root filling,

coronal restoration or surgical decoronation. It is

important to spend time educating and informing

the patient and parents about the treatment to

alleviate fears and anxiety (Sghaireen 2020). In

most cases, a minimum of 2 appointments are

required to complete treatment, so it is important

to get through the first visit without traumatising

the patient (mental and physical), otherwise it

becomes difficult to get them back for subsequent

appointment/s. Hence, allowing for ample time,

profound local anaesthetic and frequent positive

reinforcement helps build patient confidence.

Deep sedation with an anaesthetist in a private

setting or GA in a hospital environment is a

great strategy in managing patients with severe

dental anxiety or dental phobia (Appukuttan

2016). However, it should be the last resort

in management of these patients because of

additional risks and complications related to deep

sedation and GA (Tiret et al. 1988). It is also an

expensive procedure with ACC partly contributing

to the cost but leaving a substantial co-payment

for the patient.

Decoronation is a common treatment of ankylosed

teeth in infraposition. It has been clinically shown

that the procedure preserves the alveolar width

and rebuilds lost vertical bone of the alveolar ridge

in growing individuals (Malmgren et al. 1984).

The decoronated root serves as a matrix for new

bone development during resorption of the root.

The troughing of 1.5 - 2 mm of the root below the

alveolar crest allows new periosteum to form over

it. The interdental fibres that are severed by the

decoronation procedure are reorganized between

adjacent teeth. The continued eruption of these

teeth mediates marginal bone apposition via the

dental-periosteal fibre complex. The erupting

teeth are linked with the periosteum covering

the top of the alveolar socket and indirectly via

the alveolar gingival fibres, which are inserted

in the alveolar crest and in the lamina propria of

the interdental papilla. Both structures generate

traction, resulting in bone apposition on top of the

alveolar crest (Malmgren et al. 2006).

This report highlights the multidisciplinary

approach and careful planning required to treat



such a complex case, from a terrible injury to a

successful outcome. It is important to look at all

treatment options and opinions from colleagues

prior to starting, while also considering aesthetics

and self-image of the young patient. Treating the

malocclusion was enough of a challenge, but,

having a traumatised front tooth, which eventually

would need to be removed just made it more

difficult. Commencing endodontic treatment,

even if the long-term prognosis is poor, should

always be considered. It reduces the likelihood

of infection complicating healing, and retains the

tooth in position while treatment planning options

can be explored.

Starting with trauma at 11 years of age,

endodontic treatment and surgical intervention

before superimposition became a problem worked

well for this teenager. Retaining the resorbing

ankylosed root to conserve alveolar bone and

allow for normal eruption of the adjacent teeth

along with orthodontic treatment for a significant

malocclusion without resorting to a partial

denture. A lot of credit also goes to the patient,

because without their courage, cooperation and

commitment to the process the outcome would

not be as good.

My thanks to:

Dr David Westcott and Donna Lim, Orthodontists

Dr Nina Vasan, Paedodontist

Dr James Stone, General Dentist for the initial

emergency treatment

Dr Tim Little, General Dentist for ongoing

restorative care

Dr David Parkins graduated with a BDS in 1980

from the University of Otago, and completed his

post graduate studies in Endodontics in 1986 at

the Baylor College of Dentistry, Dallas, Texas,

USA. There David trained with two of the world’s

leading authorities on Endodontics at a pivotal

time in the development of this specialist field.

Returning in 1986, David established New

Zealand’s first private specialist Endodontic

Practice, in Auckland where he continues to

practice today. He is a past president of the NZ

Society of Endodontics, The Auckland Dental

Association, and the Australian and New Zealand

Academy of Endodontics.

David is an active member of the New Zealand

Dental Association, Fellow of the New Zealand

Dental Association, New Zealand Society of

Endodontics, Australian Society of Endodontology,

Australian and New Zealand Academy of

Endodontics, International Association of Dental

Traumatology and the American Association of

Endodontics. He has presented numerous lectures

and hands-on training courses in endodontics

and remains active in the area of continuing

professional development throughout New

Zealand and overseas.



References

Andersson L, Bodin I, Sörensen S (1989) Progression of

root resorption following replantation of human teeth

after extended extraoral storage. Endodontics and Dental

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Root Resorption:

A Review – Part 2

Dikesh Parmar and Rajneesh Roy

Introduction

Root resorption is characterized by the loss of cementum and dentine through the pathological

activation of odontoclast/osteoclast cells (Tronstad 1988; Lin et al. 2013; Patel & Saberi 2018).

Deciduous teeth routinely undergo physiological resorption due to eruption of the permanent

successor, however, it is relatively uncommon for a permanent root to resorb. We have covered this

topic over two articles. The first, published in the previous volume, presented dental practitioners

with some tools to characterize the kind of resorption they are dealing with. These being, internal

inflammatory (IIR), external inflammatory (EIR), external cervical (ECR), external replacement

(ERR) and external surface (ESR) resorptions. A guide was also presented to help determine the

course of treatment and the prognosis.

This present article showcases clinical cases of the different resorption types, and their management.

Case 1 – ECR Class 1

A 37-year-old female was referred by her general

practitioner for evaluation of teeth 21 and 22. The

concern was that tooth 22 had undergone root

canal sclerosis (in this article, the management

of tooth 22 will not be discussed), and that tooth

21 appeared to have a radiolucent shadow at the

cervical area. When she was 10 years old, she was

involved in a motor vehicle accident, in which she

traumatised a few teeth in the anterior maxilla.

She had lost tooth 11, which was replaced with an

implant-supported crown. Her medical history was

unremarkable, as was the extraoral examination.

Intraoral examination revealed a well-maintained

dentition with excellent oral hygiene and small

restorations.

Tooth 21 was asymptomatic. It was not tender

to percussion or palpation, had no significant

discolouration, normal surrounding gingival

appearance, with normal periodontal probing,

and it responded positively to cold test. However,

when probed using an explorer, a defect was

identified on the disto-palatal cervical surface.

Radiographic examination showed a subtle

radiolucent area on the cervical third of tooth 21.

When another periapical radiograph was taken

at a different angle, the radiolucent area became

clearer. The lamina dura around the root appeared

to be intact. A conebeam computer tomograph

(CBCT) was taken as well, however, due to the

proximity of the 11 implant-supported crown,

there was a lot of radiation scatter that limited the

diagnostic value of the scans (Figs. 1A-C).

A diagnosis of external cervical resorption (ECR)

Class 1 was made.

Two treatment options were discussed, i.e., to

monitor the area until further changes were seen;

or, to intervene and restore the cervical resorption

with composite.

It was decided that the best option was to

proceed with early intervention and eliminate

the resorption and restore the cavity. The surgical

procedure was carried out under local anaesthesia.

A sulcular flap (envelope design) was used and

the incision was made from mesiopalatal of 21 to

distopalatal of 22, without any relieving incisions.

The flap was elevated and the resorption site was

exposed.

It was noted that there was soft tissue infiltration

into the tooth. The periphery of the resorptive

cavity was bordered by enamel coronally,

extending past the cemento-enamel junction

into root dentine apically. Once the soft tissue


Root Resorption: A Review – Part 2

was curetted, bone infiltration was seen into the

cavity. Using a surgical round bur, the infiltrated

bone was removed carefully until the apical

boarder of the root was seen. The dentine was also

carefully cleaned to remove the dentine infiltrated

by soft tissue. The dentine surface was treated

with trichloroacetic acid (TCA) to ensure all of

the invaginated soft tissue was removed. Using

sectional matrix stabilised with block-out resin

as well as polytetrafluoroethylene (PTFE) tape, a

subgingival border was created. The cavity was

etched with 37% phosphoric acid for 20 seconds,

and the bond was applied according to the

manufacturer’s instructions. Flowable composite

was placed into the cavity in increments, light

cured and polished to a high gloss finish. The flap

was repositioned and sutured. The sutures were

removed after 1 week and healing was uneventful

(Figs. 1D-H).

Summary of Tooth: 21

Chief Complaint: None

Colour:

Normal

Palpation:

Within Normal limits

(WNL)

Percussion:

WNL

Mobility:

WNL

Cold Test:

Yes

Sinus Tract:

None

Pulpal Diagnosis: Normal Pulp

Periapical Diagnosis: Normal Apical

Periodontium, ECR –

Class 1

Treatment:

Surgical intervention to

restore the resorption

Figure 1. ECR class 1 of tooth 21

A. Pre-operative radiograph

B. Pre-clinical photograph - labial view

C. Palatal view, exploring the resorption defect

D. Flap elevation exposing the resorption defect

E. Black arrows showing bone infiltration into the resorption crypt

F. Black arrows showing Invasive invagination of soft tissue

G. Excavated crypt treated with TCA

H. Post-operative radiograph



Case 2 - ECR Class 2

A 62-year-old male was referred by his general

practitioner for assessment and management of

suspected external cervical resorption of tooth 13.

During a routine examination a large subgingival

cervical lesion was detected. The tooth was

asymptomatic without any signs of periodontal

disease, caries or restorations. His medical

history was unremarkable, as was the extraoral

examination.

Intraoral examination revealed a well-maintained

dentition with excellent oral hygiene and minimal

restorations. Tooth 13 was asymptomatic. It was

not tender to percussion or palpation, had pink

discolouration palatally at the cervical third of the

crown. The surrounding gingival appearance was

normal, with normal periodontal probing and it

responded positively to cold test.

Radiographic examination showed a welldemarcated

radiolucent area on the cervical third

of tooth 13. The lamina dura around the root

appeared to be intact. A CBCT scan was taken

and a radiolucent area found on the palatal surface

in the cervical third. The radiolucency was well

circumscribed and adjacent to the pulp tissue.

It was uncertain whether a communication was

present. The apical extent of the radiolucent area

did not extend below the alveolar crest (Figs. 2A,

B and I, J).

A diagnosis of ECR Class 2 was made.

The best treatment option was surgical exposure

of the lesion, and restoration with composite. The

risk outline was the possibility of the pulp necrosis

after the treatment, which would then require a

root canal procedure.

The surgical procedure was carried out under

local anaesthesia. A palatal sulcular flap (envelope

design) was laid. The incision extended from the

distal of 12 to distal of 14, without any relieving

incisions. The flap was reflected and the resorption

site exposed.

The soft tissue was curetted out from the defect.

The periphery of the resorptive cavity was boarded

by enamel coronally, extending past the cemento-



B. Pre-clinical photograph –

palatal view

C, D. Flap elevation exposing the

resorption defect

E. Removal of the soft tissue

revealing the resorption crypt



Figure 2 (continued)

F. Black arrow showing pulp chamber outline

G. Pulp lined with Vitrebond


I and J. Pre-operative CBCT sagittal and axial view

enamel junction into the root dentine apically.

The outline of the pulp was identified due to the

colour difference between the different regions of

dentine. No obvious pulp exposure was sighted.

Using a surgical round bur, the peripheral dentine

was also carefully drilled to remove remnants

of the dentine made porous by invaginated soft

tissue. The dentine surface was treated with TCA

to ensure complete removal of all invaginated

tissue.

Using

sectional matrix stabilised with block-out resin,

as well as PTFE tape, a subgingival border was

created. The predentine, the resistant layer to

resorption, was cleaned with dentine conditioner

and then lined with Vitrebond (3M ESPE

Dental Products, St. Paul, Minneapolis, USA)

first. The cavity was etched with 37% phosphoric

acid for 20 seconds, and the bond was applied

according to the manufacturer’s instructions.

Flowable composite was placed into the cavity

in increments, light-cured, and polished to a

high gloss finish. The flap was repositioned and

sutured. The sutures were removed after 1 week

and healing was uneventful. At the 6 months

review, the tooth remained asymptomatic and

tested positive to cold test (Figs. 2C-H)



Colour:

Pink discolouration

palatally at the cervical

third of the crown

Palpation:

WNL

Percussion:

WNL

Mobility:

WNL

Cold Test:

Yes

Sinus Tract: None


Periapical Diagnosis: Normal Apical

Periodontium, ECR –

Class 2

Treatment:

Surgical intervention to

restore the resorption





practitioner for evaluation of tooth 11 for a

suspected root fracture. Six years ago, she was

involved in an accident and the tooth was rootfilled

in the hospital. The tooth had remained

asymptomatic, but recently she had noticed

discolouration of the tooth. She visited her dentist

with the intention to get her tooth whitened. Upon

examination, the tooth was noted to have pink

discolouration at the buccal cervical area, a sinus

tract, as well as deep periodontal pocketing on the

buccal aspect of 11.

Her medical history was unremarkable, as was

the extraoral examination. Intraoral examination

revealed a well-maintained dentition with fair oral

hygiene and minimal restorations. Tooth 11 was

asymptomatic. It was slightly tender to percussion

but not on palpation and had significant pink

discolouration in the buccal cervical third of

the crown. The surrounding gingiva appeared

inflamed with a buccal draining sinus. There was

buccal periodontal probing of 6mm.

Radiographic examination showed a radiolucent

area in the middle third of tooth 11. The lamina

dura apically appeared diffuse as well. A CBCT

scan found a large resorptive defect extending

from the cervical third of the crown to the middle

third of the root. The defect had perforated into

the pulp space. The buccal cortical plate around

the defect had dehisced (Figs. 3A-E).

A diagnosis of ECR Class 3 with chronic apical

periodontitis was made.

Due to the patient’s age, it was considered

important to treat the tooth and maintain it in

occlusion. Treatment was planned over 2 phases.

Phase one was to perform root canal retreatment

and the second was to surgically expose and

restore the resorbed area with composite.

Tooth 11 was anaesthetised using Ubistesin

Forte (3M ESPE, Neuss, Germany) and isolated

using a dental dam. A palatal access cavity was

created and using an iso size 20 hedstrom file,

the existing gutta percha root filling was removed

entirely. The root canal system was carefully

instrumented making sure that the buccal wall

was not entirely perforated, irrigated with sodium

hypochlorite and then dressed with calcium

hydroxide. After 6 weeks intra-canal dressing,

the root canal was obturated with gutta percha,

AH Plus sealer® (Dentsply DeTrey, Konstanz,

Germany) and restored with a stainless-steel post

with LuxaCore Z Dual (DMG America, New

Jersey, USA).

At a subsequent appointment, surgery was

performed. A buccal sulcular flap was laid and the

incision was made from distal of 21 to distal of

12, with a relieving incision at the 12 end. The flap

was elevated and the resorption site exposed. The

soft tissue infiltration was curetted and then using

a surgical round bur, the peripheral dentine was

also carefully cleaned to remove remnants of the

soft tissue invaginated dentine. The post within the

root canal was exposed. The dentine surface was

treated with TCA to ensure all invaginated soft

tissue was removed. The root dentine was cleaned

with dentine conditioner and then restored using

RetroMTA® (BioMTA, Seoul, The Republic of

Korea).

The cervical third of the crown was etched with

37% phosphoric acid for 20 seconds, and the

bond was applied according to the manufacturer’s

instructions. Flowable composite was placed into

the cavity in increments, light cured and polished

to a high gloss finish. The flap was repositioned

and sutured. The sutures were removed after 1

week and healing was uneventful. At the 6 months

review, the tooth was asymptomatic. The buccal

periodontal probing had reduced to 2mm and the

periapical radiolucency had healed (Figs. 3F-Q).



Colour:

Pink discolouration

buccally at the cervical

third of the crown

Palpation:

WNL

Percussion:

Positive

Mobility:

WNL

Cold Test:

Negative

Sinus Tract:

Yes

Pulpal Diagnosis: Root filled

Periapical Diagnosis: Chronic Apical Periodontitis,

ECR – Class 3

Treatment:

Root canal retreatment

and surgical intervention

to restore the resorption





B and C. Pre-clinical photograph – labial view and probing of

resorption defect

D and E. Pre-operative CBCT sagittal and axial view

F. Radiograph check of intra-canal dressing of calcium hydroxide

G. Radiograph check of obturation of the root canal

H. Radiograph check after placement of a stainless-steel post

I and J. Flap elevation exposing the resorption defect

K and L. The resorption was excavated and the root surface

etched

M. The coronal portion of the root was restored with retroMTA

N. The cervical portion of the crown was restored with composite

O. The flap was reapproximated and sutured

P. Post-operative radiograph

Q and R. Clinical photo and radiograph at 6 months recall





practitioner for evaluation of tooth 36 as the tooth

had developed root resorption. He could not

recollect any history of trauma, vital bleaching

or orthodontic treatment and was unaware that

there was a problem until his dentist mentioned

it. The clinical exam revealed that the tooth was

not tender on percussion or palpation with no

periodontal pockets of note. The clinical crown

was intact, but had a small subgingival defect

around the distobuccal cervical area.

Radiographic examination showed the lamina

dura around the roots to be intact. There was a

‘moth-eaten’ radiolucent appearance over the

distal pulp horn that extended to the middle of the

distal root. A CBCT scan found this ‘moth-eaten’

pattern of radiolucency to be extensively spread

in the distal half of the crown and extending as far

apically as the pical third of the distal root. There

were multiple areas of radiolucency bordering the

edge of the root (Figs. 4A-D).

Treatment options were discussed and it was

decided that the tooth would be left untreated

until it became troublesome. However, in the

meantime, he would consult an oral surgeon for

an implant-supported crown in preparation for

when the tooth is extracted.



Colour:

Pink discolouration

distobuccally at the

cervical third of the

crown

Palpation:

WNL

Percussion:

WNL

Mobility:

WNL

Cold Test:

Positive

Sinus Tract:

None


Periapical Diagnosis: Normal Apical Periodontium,

ECR – Class 4

Treatment:

No treatment

Diagnosis: ECR Class 4, normal apical

periodontum.


A. Pre-clinical photograph – lingual view

B. Pre-operative radiograph

C and D. CBCT screenshot and axial view with red arrows showing extension of the resorption



Case 5 EIR


practitioner for evaluation and treatment of tooth

26. He had been experiencing pain in the area

for over 6 months before seeing his dentist. When

he presented there was swelling of his gums both

palatally and buccally.

He was taking Quinapril and Felodipine to

control his hypertension, but otherwise was fine.

His extraoral examination was unremarkable.

Intraoral examination revealed a reasonablymaintained,

but heavily restored dentition with

good oral hygiene. Tooth 26 appeared normal in

colour and had an mesio-occlusal-distal amalgam

restoration. The tooth was tender to percussion

and palpation. The gingiva surrounding the tooth

was swollen with a buccal and 2 palatal draining

sinuses and palatal periodontal probing of 10mm.

Radiographic examination showed the lamina

dura around all the roots were diffuse and a

large periapical radiolucency associated with the

palatal root. The palatal root outline was unclear

and could not be distinguished as an intact root.

A CBCT scan found that the buccal and palatal

cortical plates were perforated with radiolucencies

surrounding all three roots. The distobuccal root

was found to have an irregular root shape apically,

while the palatal root was entirely irregular. The

external surfaces of these roots appeared to be

resorbed. The distobuccal root canal was intact,

however, the palatal root canal was open due to

the resorption (Figs. 5A-F).

Diagnosis: Chronic apical abscess with external

inflammatory resorption.

Treatment options of extraction and root canal

treatment were discussed, the latter being

the preferred option. He understood that the

prognosis of the treatment was guarded due to the

extensive resorption of the palatal root surface but

opted to get the tooth investigated. An occlusal

access cavity was created and 4 canals located.

These were chemomechanically instrumented

and dressed with calcium hydroxide for 12

weeks. After 12 weeks, the tooth was reviewed.

The tooth was asymptomatic, the swelling and

draining sinuses had resolved and the palatal

probing depth reduced to 4mm. The tooth was reaccessed,

irrigated with sodium hypochlorite and

dressed with calcium hydroxide. The treatment

was completed after another 12 weeks. The

mesiobuccal (MB), MB2 and the distobuccal

canals were obturated with gutta percha and

AH Plus sealer® (Dentsply DeTrey, Konstanz,

Germany) while the palatal canal was filled with

RetroMTA® (BioMTA, Seoul, The Republic of

Korea). The access was filled with everX Flow

(GC Dental Products Corp., Kasugai, Aichi,

Japan) and the tooth restored with composite

(Figs . 5G and H).


Chief Complaint: Pain and swelling

Colour:

Normal

Palpation:

Tender

Percussion:

Positive

Mobility: Grade 1

Cold Test:

Negative

Sinus Tract:

Yes, multiple

Pulpal Diagnosis: Pulpless

Periapical Diagnosis: Chronic apical abscess

Overall Impression: External inflammatory

resorption

Treatment:

Root canal treatment

At his 6 months recall visit, the tooth was healing

unremarkably, asymptomatic and functioning

well. The soft tissues around the tooth were firm,

not inflamed and the palatal pocketing remained at

4mm. The periapical radiograph showed that the

radiolucency had reduced in size suggesting the

infection site was healing. The CBCT found that

the buccal cortical plate was no longer perforated

while that of the palate was smaller. There was

bone growth on the buccal surface of the palatal

root. The patient was scheduled for another review

in 1 year.

Opposite Page –

Figure 5. Radiographs and photographs of tooth 26 treatment

of EIR.

A and B. Pre-clinical photographs buccal and palatal view

C. Pre-clinical photograph of periodontal pocketing of 10mm

D. Pre-operative radiograph

E and F. CBCT coronal and axial view with red arrows showing

extent of the resorption

G. Radiograph check of intra-canal dressing of calcium

hydroxide





I. 6 months recall radiograph. J. Clinical photograph, palatal gingiva.

K. & L. CBCT coronal and axial view – 6 months recall.



Case 6 IIR


practitioner for treatment of tooth 36 which

was diagnosed with internal inflammatory root

resorption. Her chief complaint was a dull ache

in her jaw and inability to chew on the tooth. Her

medical history and extraoral examination were

unremarkable. Intraoral examination revealed

a well-maintained dentition with very good

oral hygiene and a few large restorations. Tooth

36 appeared normal in colour and had a buccoocclusal

composite restoration. The tooth was

tender to percussion but not on palpation. The

periodontal probing depths around the tooth were

normal and the tooth did not respond positively to

cold test.

Radiographic examination showed a diffuse

radiolucent area around the mesial root while

the distal root had widened periodontal ligament

space. There was a radiolucent area under the

mesial pulp horn within the crown. It also showed

that the composite restoration was deep and

encroaching on the pulp chamber. A CBCT scan

found that the composite was very deep and on

the mesio-buccal roof of the pulp chamber. The

radiolucent area under the mesial pulp horn was

well-circumscribed, with regular, smooth edges,

and had a diameter of 2mm (Figs. 6A, D and E).

Diagnosis: Chronic apical periodontitis with

internal inflammatory resorption.

Non-surgical root canal treatment was performed.

An occlusal access cavity was created and four

canals located, two in each root. These were

chemomechanically instrumented and calcium

hydroxide used as intracanal medication. The

canals were filled with gutta percha and AH Plus

sealer® (Dentsply DeTrey, Konstanz, Germany).

The access cavity and the internal resorption

defect was filled with everX Flow (GC Dental

Products Corp., Kasugai, Aichi, Japan) with final

composite seal. At the 6-month follow-up, the

periapical radiolucency had healed and there were

no signs of continuing resorption (Figs. 6B and

C).


Chief Complaint: Dull ache, Pain on chewing

Colour:

Normal

Palpation:

Normal

Percussion:

Positive

Mobility:

Normal

Cold Test:

Negative

Sinus Tract:

None

Pulpal Diagnosis: Pulpless

Periapical Diagnosis: Chronic apical periodontitis,

Internal inflammatory

resorption

Treatment:

Root canal treatment

Figure 6. Radiographs and photographs of tooth 36 treatment

of IIR.


B. Post-operative radiograph

C. 6 months recall radiograph

D and E. CBCT axial and sagittal view with red arrows

showing extent of the resorption



Case 7 ERR

A 12-year-old female was referred for

management of her anterior teeth especially teeth

12, 11 and 21. She sustained trauma to these teeth

when she ‘blacked out’, while brushing her teeth

one morning in October 2017. As she fell to the

floor, she knocked her face on the porcelain sink.

She presented to the Hospital Dental Department,

where initial care was provided. Teeth 12 and

11 were avulsed, while tooth 21 had suffered a

complicated crown root fracture. The avulsed

teeth were out of the mouth for 3 hours but were

stored in milk. Tooth 11 was replanted without

much difficulty, but tooth 12 was unable to be

seated into the correct position due to the distal

curvature in the apical one third of the root. It was

manipulated several times, but to no avail. It was

left within 2.5mm of its intended depth. In tooth

21, the exposed pulp was covered with setting

calcium hydroxide and glass ionomer cement as

a temporary restoration. A flexible wire splint was

placed from 14-22 for 4 weeks (Note that the 2020

Trauma Guidelines recommend splinting teeth for

up to two weeks (Fouad et al. 2020)).

At her consultation appointment, 4 days after the

accident, her medical history as well as her extraoral

examination were unremarkable. Intraorally, the

wire and composite splint was firmly in place.

The palatal view showed the cervical gingiva

to be lacerated. Teeth 12 and 11 were tender on

palpation and percussion, while tooth 21 was not.

Teeth 12 and 11 tested negative to cold test, while

tooth 21 was positive (Figs. 7A-D).

Diagnosis:

Tooth 12 Avulsion (3hrs dry time), non-vital pulp

Tooth 11 Avulsion (3hrs dry time), non-vital pulp

Tooth 21 Complicated crown root fracture, vital

pulp

Non-surgical root canal treatment was performed

on teeth 12 and 11. The canals were accessed

palatally, and chemomechanically debrided, with

calcium hydroxide used as intracanal medication

for 6 weeks. After 4 weeks, the splint was

removed and Cvek pulpotomy done on tooth 21.

The pulp was sealed with bioceramic putty and

glass ionomer, and the incisal fracture restored

with composite.

The root canals of teeth 12 and 11 were filled

with gutta percha and AH Plus sealer® (Dentsply

DeTrey, Konstanz, Germany), and restored

with composite. The 6-month follow-up was

unremarkable, however, at 18 months, tooth 12

had extensive resorption and replacement of the

root. Tooth 11 showed a small area of external

replacement resorption. Tooth 12 was ankylosed

totally and had poor prognosis while tooth 11 was

starting to ankylose. At the 2-years follow-up, the

resorption had worsened. The root filling in tooth

11 was removed and replaced with Vitapex (Neo

Dental International Inc., Washington, USA). The

external replacement resorption in tooth 12 had

progressed further, and there was no root left on

the buccal cervical surface. Both teeth appeared to

be submerging (Figs. 7E-Q).

Tooth 12 is planned to be extracted and replaced

with a plastic partial denture. Tooth 11 will be

monitored for the rate at which it submerges. If it

happens rapidly then the plan is to decoronate the

crown and add to the plastic partial denture.

Summary of Tooth: 12 11 21

Chief Complaint: Avulsion Avulsion Complicated fracture

Colour: Normal Normal Normal

Palpation: Positive Positive Normal

Percussion: Positive Positive Normal

Mobility: Grade 1 Grade 1 Normal

Cold Test: Negative Negative Positive

Sinus Tract: None None None

Pulpal Diagnosis: Non-vital Non-vital Vital

Periapical Diagnosis: Acute apical Acute apical Normal apical

inflammation inflammation periodontium

Treatment: Root canal Treatment Root canal treatment Cvek Pulpotomy



Figure 7. Radiographs and

photographs of teeth 11

and 12 treatment of ERR.

A and B. Pre-clinical photographs – labial and palatal view

C and D. Pre-operative radiographs

E. Radiograph check of intra-canal dressing of calcium hydroxide

F. Post-operative radiograph

G and H. Post-clinical photographs

I. 6 months review radiograph

J, K and L. 18 months review radiograph and photographs

M and N. 2-years review radiograph and CBCT scan

O. Root filling removed from tooth 11

P. Root canal filled with Vitapex

Q. Resorption in tooth 11 worsens



Case 8 ESR

A 10-year-old male was referred to an orthodontist

for correction of his occlusion. His chief complaint

was pain and discomfort on eating certain foods.

The initial clinical exam revealed gingival trauma

to the upper palate and incisal wear of the lower

anterior teeth. He had a Skeletal Class 1 occlusion

with a 100% overbite to the palate (Fig. 8A). The

treatment to correct the deep bite was planned in

two phases. First, an anterior bite plane appliance

was used to correct the deep bite. The bite

plane was worn for approximately 18 months,

monitored every 3 monthly. At age 12, the second

phase was implemented (Figs. 8B-G). Full fixed

appliances were bonded on all permanent teeth

except the second molars. Teeth positions were

reviewed every 6 weeks, and the o-rings/wires

were changed when necessary. Oral hygiene was

unsatisfactory initially but improved after positive

reinforcements. The fixed appliances were

debonded 30 months later, at age 14. At the end of

the treatment, the results were excellent however

the orthopantomagram (OPG) radiograph showed

blunting of root apices of several teeth (Figs. 8H-

M).

Diagnosis: ESR 12, 21 and distal roots of 36 and

46

Dr Dikesh Parmar obtained his BDS and then

his Doctorate in Clinical Dentistry (Endodontics)

from the University of Otago, in 2007. He is

currently practicing in Wellington, maintaining a

specialist endodontic practice.

Dr Rajneesh Roy spent 20 years in general dental

practice before training as an endodontist. In

2007 he graduated from Otago University with

a Doctorate of Clinical Dentistry (Endodontics)

and currently maintains a specialist practice in

Hamilton. He is also a Fellow of the Royal Australasian

College of Dental Surgeons (FRACDS).

References

Fouad AF, Abbott PV, Tsilingaridis G et al. (2020) International

Association of Dental Traumatology guidelines for the

management of traumatic dental injuries: 2. Avulsion of

permanent teeth. Dental Traumatology 36(4), 331-342.

Lin YP, Love RM, Friedlander LT, Shang HF, Pai MH (2013)

Expression of Toll-like receptors 2 and 4 and the OPG-

RANKL-RANK system in inflammatory external root

resorption and external cervical resorption. International

Endodontic Journal 46(10), 971-981.

Patel S, Saberi N (2018) The ins and outs of root resorption.

British Dental Journal 224(9), 691-699.

Tronstad L (1988) Root resorption-etiology, terminology

and clinical manifestations. Endodontics and Dental

Traumatology 4(6), 241-252.

Root canal treatment were not required for these

teeth.

Summary of Teeth: 12, 21, 36 and 46


Colour:

Normal

Palpation:

WNL

Percussion:

WNL

Mobility:

WNL

Cold Test:

Positive

Sinus Tract:

None


Periapical Diagnosis: Normal Apical Periodontium,

ESR on

multiple teeth

Treatment:

No treatment



A

B

G

D

C

E

F

Figure 8. Pre and post orthodontic treatment

radiographs and photographs – Courtesy of

Dr Nitin Raniga, Specialist Orthodontist,

Auckland.

A and B. OPG at age 10 and 12 respectively

C to G. Clinical photographs before fixed

appliance are bonded at age 12.


H

M

J

I

K

L

Figure 8 (continued):

H. OPG at age 14, prior to debonding the fixed appliance

I to M. Clinical photographs after debonding of the fixed appliance at age 14.


NZ SOCIETY OF ENDODONTICS

FINANCIAL STATEMENTS

FOR THE YEAR ENDED 31 MARCH 2021



Contents of Financial Statements

For the Year Ended 31 March 2021

Contents of Financial Statements 1

Compilation Report 2

Directory 3

Statement of Profit or Loss 4

Statement of Changes in Equity 5

Balance Sheet 6

Notes to and forming part of the Financial Statements 7 - 9

Depreciation Schedule 10

BDO Auckland

Page 32 New Zealand Endodontic Journal Vol 58 November Page 12021


Report on the Engagement to Compile Financial Statements


COMPILATION REPORT AND DISCLAIMER OF LIABILITY TO THE TRUSTEES

Reporting Scope

On the basis of information that you provided we have compiled, in accordance with "Service Engagement Standard Number 2:

Compilation of Financial Information", the Financial Statements of NZ Society of Endodontics for the year ended 31 March 2021 as set

out on the following pages.

These statements have been prepared on the basis disclosed in note 1 to the financial statements.

Responsibilities

You are solely responsible for the information contained in the financial statements and have determined that the basis of accounting

used is appropriate to meet your needs and for the purpose that the financial statements were prepared. The financial statements were

prepared exclusively for your benefit. We do not accept responsibility to any other person for the contents of the financial statements.

No Audit or Review Engagement Undertaken

Our procedures use accounting expertise to undertake the compilation of the financial statements from information that you provided.

Our procedures do not include verification or validation procedures. No audit or review engagement has been performed and

accordingly no assurance is expressed.

Disclaimer of Liability

Neither we nor any of our employees accept any responsibility for the reliability, accuracy or completeness of the compiled financial

information nor do we accept any liability of any kind whatsoever, including liability by reason of negligence, to any person for losses

incurred as a result of placing reliance on the compiled financial information.

BDO Auckland

BDO Centre

Level 4

4 Graham Street

Auckland

27 July 2021

Date

BDO New Zealand Ltd, a New Zealand limited liability company, is a member of BDO International Limited, a UK company limited by guarantee, and forms part of the

international BDO network of independent member firms. BDO New Zealand is a national association of independent member firms which operate as separate legal

entities. For more info visit www.bdo.co.nz BDO is the brand name for the BDO network and for each of the BDO Member Firms.

New BDO Zealand Auckland Endodontic Journal Vol 58 November 2021 Page 33

Page 2


Directory

As at 31 March 2021

Nature of Business

To promote and advance the study and practice of Endodontics

Incorporation Number

Date of Formation

Officers

Registered Office

New Zealand Business Number

683589

19 July 1995

Dr Jo Lowe (President)

Dr Mike Jameson (Secretary)

Dr Dikesh Palmer (Journal Editor)

Dr Theo Kay (Treasurer)

Dr Melissa Naik (Committee Member)

Dr Payman Hamadani (Committee Member)

Prof Nick Chandler (Committee Member)

402/11 Fenton Street

Mt Eden

Auckland 1024

9429042688808

Accountants

BDO Auckland

Chartered Accountants

BDO Centre

Level 4

4 Graham Street

Auckland

Bankers

ANZ Bank

IRD Number 025-832-718

Page 34 New Zealand Endodontic Journal Vol 58 November BDO Auckland 2021

Page 3


Statement of Profit or Loss


Revenue

Note 2021 2020

$ $

Interest Received 2,409 3,940

Subscriptions 5,681 3,957

Total Revenue 8,090 7,896

Less Expenses

Accountancy Fees 2,325 830

Audit Review 1,500 1,500

Bank Fees & Charges 57 57

Computer Expenses 636 636

Depreciation - 65

Licensing Fees 56 192

Loss on Disposal of Fixed Assets 235 -

Magazines, Journals & Periodicals 4,890 5,997

Printing & Stationery - 57

Subscriptions - Overseas 2,617 2,670

Total Expenses 12,316 12,004

Loss before Income Tax (4,226) (4,108)

Income Tax Expense 2 520 318

Net Loss (4,747) (4,426)

Allocated pursuant to Deed of Trust as follows:

Transfer to Trust Capital (4,747) (4,426)

(4,747) (4,426)

This statement should be read in conjunction with the notes to the financial statements.

BDO New Auckland Zealand Endodontic Journal Vol 58 November 2021 Page 35

Page 4


Statement of Changes in Equity


Revenues and Expenses

2021 2020

$ $

Net Loss (4,747) (4,426)

Total Recognised Revenues and Expenses (4,747) (4,426)

Contributions and Distributions

Members' Funds at the Beginning of the Year 165,024 169,450

Members' Funds at the End of the Year 160,277 165,024


Page 36 New Zealand Endodontic Journal Vol 58 November BDO Auckland 2021

Page 5



Notes to and forming part of the Financial Statements


1 Statement of Accounting Policies

Reporting Entity

The financial statements presented here are for the entity The New Zealand Society of Endodontics, incorporated under the

Incorporated Societies Act 1908.

Historical Cost

These financial statements have been prepared on a historical cost basis.

Statement of Compliance and Basis of Preparation

These special purpose financial statements have been prepared in accordance with the requirements outlined under the Tax

Administration (Financial Statements) Order 2014.

The accounting principles recognised as appropriate for the measurement and reporting of the Statement of Profit or Loss and

Balance Sheet on a historical cost basis are followed by the trust, unless otherwise stated in the Specific Accounting Policies.

These financial statements are presented in New Zealand dollars and all values are rounded to the nearest dollar, except where

otherwise indicated.

Specific Accounting Policies

The following specific accounting policies which materially affect the measurement of the Statement of Profit or Loss and Balance

Sheet have been applied:

(a) Revenue Recognition

Revenue is measured at the fair value of the consideration received or receivable for the sale of goods and services, to the extent it

is probable that the economic benefits will flow to the trust and revenue can be reliably measured.

(b) Property, Plant & Equipment and Investment Property

Property, Plant & Equipment is recognised at cost less aggregate depreciation. Historical cost includes expenditure directly

attributable to the acquisition of assets, and includes the cost of replacements that are eligible for capitalisation when these are

incurred.

All other repairs and maintenance are recognised as expenses in the Statement of Profit or Loss in the financial period in which

they are incurred.

Depreciation has been calculated using the maximum rates permitted by the Income Tax Act 2007.

The following estimated depreciation rates/useful lives have been used:

Computer Equipment

Plant & Equipment

48.0% P

21.6% DV

Gains and losses on disposal of fixed assets are taken into account in determining the net result for the year.

Page 38 New Zealand Endodontic Journal Vol 58 BDO November Auckland 2021

Page 7


Notes to and forming part of the Financial Statements (continued)


(c) Income Tax

Income tax is accounted for using the taxes payable method. The income tax expense recognised in the Statement of Profit or Loss

is the estimated income tax payable in the current year, adjusted for any differences between the estimated and actual income tax

payable in prior years.

(d) Goods and Services Taxation (GST)

Revenue and expenses have been recognised in the financial statements exclusive of GST.

(e) Comparative Figures

The comparative figures shown are for a twelve month period

(f) Changes in Accounting Policies

There have been no changes in accounting policies. All policies have been applied on a bases consistent with those used in

previous years.

2 Tax Reconciliation 2021 2020

$ $

Loss before Income Tax (4,226) (4,108)

Permanent Differences

Non Assessable Income (5,681) (3,957)

Tax Exemption (1,000) (1,000)

Non Deductible Expenses 9,390 10,200

Total Permanent Differences 2,709 5,243

Timing Differences

Timing Differences 3,375 -

Taxable Income 1,858 1,135

Tax Expense at 28% 520 318

Tax Expense 520 318

3 Income Tax 2021 2020

$ $

Opening Balance (1,110) (688)

Plus:

Provision for Taxation 520 318

Less:

Terminal Tax Paid - 30

RWT Paid 511 709

511 739

Income Tax (Receivable) (1,100) (1,110)

BDO

New

Auckland

Zealand Endodontic Journal Vol 58 November 2021 Page 39

Page 8


Notes to and forming part of the Financial Statements (continued)


4 Property, Plant & Equipment

Cost Depreciation Accumulated Closing Book

Charged Depreciation Value

Property, Plant & Equipment 2021 $ $ $ $

Total Property, Plant & Equipment - - - -

Cost Depreciation Accumulated Closing Book

Charged Depreciation Value

Property, Plant & Equipment 2020 $ $ $ $

Computer Equipment 1,058 - 1,058 -

Plant & Equipment 21,516 65 21,281 235

Total Property, Plant & Equipment 22,574 65 22,339 235

5 Related Parties

There were no significant transactions or transactions that were on terms and conditions that are likely to be different from the terms

and conditions of transactions in similar circumstances, involving related parties during the financial year. (Last year - Nil)

Page 40 New Zealand Endodontic Journal Vol 58 BDO November Auckland 2021

Page 9


Depreciation Schedule


RATE & % PVT Cost OPENING ADDITIONS DATE of SALE PARTSALE PROFIT DISPOSAL Cost CAPITAL DEPN ACC PRIVATE ACCUM CLOSING

TYPE USE on HAND WDV ADDITION PRICE PRICE (LOSS) DATE GAIN/LOSS DEPN DEPN PRIVATE WDV

Computer Equipment

Computer 48.00P - - - 01/04/00 - - - 01/04/20 1,058 - - - - - -

- - - - - - 1,058 - - - - - -

Plant & Equipment

Microscope 21.60D - 235 - 01/09/01 - - (235) 01/04/20 21,516 - - - - - -

- 235 - - - (235) 21,516 - - - - - -

TOTAL - 235 - - - (235) 22,574 - - - - - -



BDO Auckland

Page 10

News from the Dental School

Welcome to the two new endodontic postgraduates who commenced their three-year

clinical doctorate (endodontics) programme in January 2021.

Howard Chao graduated in 2013 and his BDS Honours research was supervised by Nick Chandler

and Jonathan Broadbent. Since graduation, he has worked in Auckland and has been lucky to have

talented colleagues who taught and mentored him from the very first day of his career. This has

allowed him to explore many facets of dentistry and to discover what he loves. He was always

fascinated by Endodontics for its complexities and its exciting technologies and techniques. He looks

forward to learning more about it and considers himself very fortunate to have the selfless support of

his wife while they embark on this journey. He feels very privileged to be back at the University of

Otago to commence his DClinDent programme.

Shraddha Patel graduated from the University of Otago in 2007 with Credit. Her first job was as a

dental house officer at Middlemore, Greenlane and Auckland City Hospitals. She then went to work

in private practice in Auckland and then undertook a mini-OE to Australia. Subsequently she worked

privately on the Gold Coast, then in Melbourne both in private and at the Royal Melbourne Dental

Hospital, and later in Adelaide in private. She returned home in late 2019 and worked in private practice

in central Auckland. Shraddha completed her primary exams with multiple commendations and later

completed her fellowship in GDP through the RACDS. Shraddha loves to travel, read, and paint.


Continuing Professional Development

Questionnaire

After reading the 2 articles in this edition of the journal, members can verify their participation in this continuing

education activity by completing the following assessment. One hour verifiable CPD is available to NZDA

members who correctly complete the 6 questions by selecting the number which best matches the answer. This

resulting 6 numbers are the NZDA CPD code.

A. What is the first choice of treatment for

mature teeth that have intruded greater than

6-7 mm?

3. Extraction of the tooth

9. Orthodontic extrusion of the tooth

2. Monitor the tooth

5. Immediate surgical repositioning of the

tooth

1. Decoronation of the tooth

B. What is a double seal?

1. Consists of Cavit and Glass ionomer

restoration

3. A way to temporize the access cavity

4. Two layers of material to seal the access

cavity

7. Prevents infection setting in the root

canal system

2. All of the above

C. Which statement correctly describes

Decoronation procedure?

4. Is a common treatment of ankylosed

teeth in infraposition

2. The procedure preserves the alveolar

width

3. The troughing of 1.5 - 2 mm of the root

below the alveolar crest is required

4. The procedure allows for the rebuilding

of lost vertical bone of the alveolar ridge

0. All of the above

D. Why is trichloroacetic acid (TCA) used in

external cervical resorption?

1. It etches the surface

0. It removes invaginated soft tissue from

dentine.

5. It smooths the surface

5. It roughens the surface

6. All of the above

E. What protects the pulp from being invaded

by external cervical resorption?

7. Enamel

8. Dentine

0. Pre-dentine

5. Cementum

6. All of the above

F. How many weeks should an avulsed

permanent tooth with a closed apex be

splinted for?

7. indefinitely

8. 1 week

2. Up to 2 weeks

1. Up Enter to 4 weeks your 6-digit CPD code here:

9. Up to 8 weeks

7. No.10 K file

3. Canal Pathfinder

1. C-pilot

Enter your 6-digit CPD code here:



year/cycle during which it’

has been printed.



year/cycle during which it

has been printed.


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