Management of severe external cervical resorption: the multidisciplinary approach to grade 3

La résorption cervicale externe (RCE) représente un défi thérapeutique majeur, particulièrement lorsque les lésions atteignent des stades avancés menaçant la pérennité de l'organe dentaire. Ce rapport de cas documente la prise en charge complexe d'une patiente de 32 ans présentant une RCE sévère sur l'incisive centrale supérieure (#11). Le tableau clinique initial associait une mobilité modérée, une extrusion, des saignements récurrents et une suppuration, avec une profondeur de sondage critique de 10 mm et une récession gingivale associée de 1 mm. Le diagnostic, affiné par tomographie volumique à faisceau conique (CBCT), a classé la lésion en grade 3 selon Heithersay et 3Dp selon Patel, confirmant une atteinte radiculaire étendue.

The objective of this clinical presentation is to detail a multidisciplinary rescue protocol aimed at preserving this anterior tooth despite an initially guarded prognosis. The study is based on the hypothesis that a synergy between rigorous surgical debridement, biological obturation using bioceramic (Biodentine®), and periodontology optimization via a buried connective tissue graft (15x4 mm) allows for long-term clinical and aesthetic stability. The validation of this approach was evaluated over a 24-month follow-up, measuring the reduction in probing depth, the healing of peri-radicular tissues, and the restoration of function without residual symptomatology.

Therapeutic protocol and study design

Ce rapport de cas clinique détaille la prise en charge multidisciplinaire d'une résorption cervicale externe (RCE) sévère chez une patiente de 32 ans, sans altération systémique, sur l'incisive centrale supérieure droite (#11). La méthodologie repose sur une approche combinée endodontique, chirurgicale et parodontale, structurée comme suit :

• Three-dimensional diagnosis: Use of cone beam computed tomography (CBCT) to characterize the lesion, classified as Heithersay grade 3 and Patel 3Dp. The initial examination revealed a probing depth of 10 mm and a gingival recession of 1 mm.
• Surgical procedure: Direct access to the lesion for rigorous debridement of root resorption tissues.
• Tissue repair: Use of Biodentine® (bioactive bioceramic material) for filling the resorption cavity and restoring root integrity.
• Periodontal plastic surgery: Palatal harvesting of a 15 x 4 mm subepithelial connective tissue graft, positioned at the defect site to strengthen the gingival attachment and correct the recession.
• Post-operative follow-up: Evaluation of clinical stability, absence of symptoms and probing depth (reduced to 4 mm) over a 24-month period.

Clinical results and 24-month follow-up

L'issue de cette intervention multidisciplinaire montre une résolution complète des signes inflammatoires et une stabilisation structurelle de la dent #11. Le suivi à long terme (24 mois) confirme l'efficacité de l'approche combinant biocéramique et chirurgie plastique parodontale pour traiter une lésion de résorption cervicale externe (RCE) sévère.

The main clinical parameters recorded during the final follow-up are as follows:

From a qualitative and radiographic perspective, the following observations were noted:

• Biological integration: The use of Biodentine® allowed for a fluid-tight repair of the resorption lacuna, without signs of lesion recurrence or secondary endodontic complication.
• Periodontal health: The subepithelial connective tissue graft allowed for the restoration of the integrity of the mucogingival complex, compensating for the tissue loss induced by the surgical debridement of the Heithersay grade 3 lesion.
• Patient satisfaction: The patient, a practitioner herself, reported a high level of satisfaction, both functionally and aesthetically, with long-term preservation of the dental unit on the arch.

Control imaging confirms the stability of the bioceramic repair and the absence of resorption progression, validating the initial three-dimensional diagnosis (Patel 3Dp) as an essential planning tool for this type of complex cases.

Analysis of results and clinical relevance

Ce rapport de cas démontre l'efficacité d'une approche combinée pour traiter une résorption cervicale externe (RCE) de stade avancé (Heithersay grade 3 / Patel 3Dp). Le passage d'une profondeur de sondage de 10 mm à 4 mm à 24 mois illustre la capacité de ce protocole à restaurer l'attache parodontale, même face à une lésion complexe sur une dent antéro-supérieure.

The use of Biodentine® as a filling material is decisive here. Its bioactivity and sealing properties allow for a stable repair of the root substance loss, while the subepithelial connective tissue graft (15x4 mm) compensates for the initial recession and stabilizes the gingival interface. For the practitioner, this result highlights that the prognosis of grade 3 lesions, once considered poor, can be re-evaluated thanks to the synergy between bioceramics and periodontology plastic surgery.

Limits and perspective

Although the 24-month follow-up shows satisfactory clinical and radiological stability, this is a single case report (n=1). The reproducibility of this success depends heavily on surgical expertise and the precision of granulation tissue debridement. Patel's classification (3Dp) proved to be more accurate here than Heithersay's for anticipating the three-dimensional extent of the lesion and guiding the therapeutic choice.

Implications for practice

Ce cas confirme que le diagnostic par CBCT est indispensable pour cartographier l'extension de la RCE avant toute intervention. La réussite repose sur une séquence précise : élimination rigoureuse du tissu résorptif, scellement biocéramique et renforcement parodontal par greffe conjonctive. Cette stratégie multidisciplinaire offre une alternative viable à l'extraction, préservant ainsi l'esthétique et la fonction dans le secteur antérieur.

Summary of results

This clinical case illustrates the rescue of an incisor condemned by severe external cervical resorption (Heithersay grade 3). The combination of oral surgery debridement, Biodentine® filling, and a connective tissue graft (15x4 mm) transformed a poor prognosis into clinical success: periodontology probing decreased from 10 mm to 4 mm, with tissue stability and absence of symptoms maintained at 24 months.

In concrete terms, for the practitioner:

• CBCT is non-negotiable: For a lesion classified as Patel 3Dp, only 3D imaging allows for the assessment of the actual circumferential extension and validation of the feasibility of root preservation.
• Secure the biological seal: Opt for a bioceramic such as Biodentine® for its setting capacity in a moist environment and its biocompatibility, which are essential for achieving tissue integration without residual inflammation.
• Think "plastic surgery": Do not limit yourself to filling the gap; the systematic addition of a subepithelial connective tissue graft is the key to restoring gingival volume and providing long-term protection for the tooth-restoration interface.

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