Case Report

Treatment of Severe Pre-eruptive Intracoronal Resorption

of a Permanent Second Molar
Esti Davidovich, DMD, MSC Bruno Kreiner, DMD Benjamin Peretz, DMD

Dr. Davidovich is a postgraduate student, Department of Pediatric Dentistry, Dr. Kreiner is staff member, Department of Oral and Maxillofacial Surgery, and
Dr. Peretz is clinical associate professor, Department of Pediatric Dentistry, The Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel.
Correspond with Dr. Peretz at Benny@cc.huji.ac.il

Abstract
Pre-eruptive intracoronal resorption is a lesion often located within the dentin, adjacent
to the dentin-enamel junction, in the occlusal aspect of the crown. As the lesions resemble
caries, they are often referred as “pre-eruptive caries.” The purpose of this case report
was to describe the diagnosis and treatment of a permanent molar with pre-eruptive
intracoronal resorption and to elaborate on possible associated clinical problems. After
surgical exposure of the unerupted tooth, the tooth structure in the resorbed area was
removed and the tooth was restored with glass-ionomer material. Three months after
the treatment, partial pulpotomy had been performed and the restoration was replaced
by amalgam. Elaboration on possible associated clinical problems is provided. (Pediatr
Dent. 2005;27:74-77)
KEYWORDS: TOOTH DEVELOPMENT, INTRACORONAL RESORATION, DENTAL CARIES
Received April 16, 2004 Revision Accepted September 10, 2004

T
he prevalence and etiology of pre-eruptive The prevalence of pre-eruptive intracoronal resorption
intracoronal resorption has been recently reported is 2% to 6%, depending on the tooth and radiographic
in several studies.1-7 These lesions are often located technique. When bite-wings are used, the prevalence is 4%
within the dentin, adjacent to the dentin-enamel junction, for the permanent mandibular first molar, 2% for the
in the occlusal aspect of the crown. As the lesions resemble mandibular first premolar, and 1% for the permanent
caries, they are often referred as “pre-eruptive caries.”8 maxillary first molar, maxillary first premolar, and man-
The pathogenesis of pre-eruptive intracoronal resorp- dibular second molar.1
tion is unclear, since the developing tooth is encased in its In contrast, when panoramic radiographs are available,
crypt and is not likely to be infected with cariogenic mi- pre-eruptive intracoronal resorption has been found in 4%
croorganisms.1 It has been suggested that local factors play of permanent maxillary first molars and in 3% of perma-
an important role in the etiology. Ectopic positioning of nent mandibular first molars. Usually, a single tooth is
affected teeth or the adjacent abutting teeth can cause lo- affected in an individual.3 Nearly half of the lesions extend
cal pressure that may be an inciting factor for resorptive to more than two thirds of the dentin’s width.6 No asso-
cells to invade the dentin through enamel fissures or via ciation was found between pre-eruptive intracoronal
the cementoenamel junction.1,5,6 Histological examination resorption and gender, race, medical conditions, systemic
of the lesion’s soft tissue revealed signs of resorption, in- factors, or fluoride supplementation.1,5,6
cluding resorptive cells (osteoclasts and macrophages) and The purpose of this case study was to describe the diag-
scalloped lesion borders.3-6,9,10 nosis and treatment of a permanent molar with pre-eruptive
It has been suggested that this lesion might have origi- intracoronal resorption and to elaborate on possible asso-
nated as a developmental anomaly in which sections of the ciated clinical problems.
tooth failed to mineralize properly. This theory, however,
has been subsequently disproved lately.3 The retentive na- Case report
ture of the cavitated lesion favors caries development, and An 11-year-old-girl was referred by her dentist to the depart-
the lesion becomes distinguishable as a carious lesion once ment of pediatric dentistry at the Hebrew University-Hadassah
it is exposed to the oral cavity.1 School of Dental Medicine in Jerusalem. The referring dentist

74 Davidovich et al. Pre-eruptive intracoronal resorption Pediatric Dentistry – 27:1, 2005

noticed a large radiolucent area underneath the occlusal
dentoenamel junction of the unerupted permanent mandibu-
lar left second molar on a panoramic radiograph, which was
taken for orthodontic reasons (Figure 1). Medical history re-
vealed no systemic disease or allergies. Clinical examination
revealed the alveolar mucosa distal to the first molar with nor-
mal color, texture, and contour. A periapical radiograph
demonstrated the unerupted mandibular second molar with a
clear radiolucent area in the crown extending from the occlusal
surface into the dentin (Figure 2). No periapical pathology had
been observed. Pre-eruptive intracoronal resorption was diag-
nosed, and the decision was made to remove the defective tooth
structure in the resorbed area and restore the tooth. Figure 1. A large radiolucent area underneath the occlusal
dentoenamel junction of the mandibular left second molar on a
After administration of local anesthesia (1.8% lignocaine panoramic radiograph taken for orthodontic reasons.
with 1:100,000 adrenaline), the gingival tissue above the
unerupted molar was surgically retracted, revealing the oc-
clusal surface of the second molar (Figure 3). A probe was
inserted through the occlusal fissures into the resorbed area,
and caries–like soft tooth structure was detected. While re-
tracting the gingival tissue from the tooth, an opening to the
cavity was made with a high-speed bur and the caries-like
tissue was removed with a low-speed round bur. The remain-
ing tooth material appeared white and hard.
The cavity floor was lined with glass inomer (Vitrebond, 3M,
ESPE, St. Paul, Minn) and glass inomer (GC Fuji IX–GP, GC,
Tokyo, Japan) was used to restore the tooth (Figure 4). The
gingival tissue was replaced and sutured with a resorbable su-
ture, exposing some of the buccal aspect of the tooth.
In a follow-up examination 1 week later, emergence of Figure 2. A periapical radiograph demonstrating the unerupted
mandibular second molar, with a clear radiolucent area in the crown,
the buccal cusps of the tooth and fibrin healing tissue were extending from the occlusal surface into the dentin.
detected. Three months later, as the tooth erupted (though
not fully exposed), dental plaque was evident around the
tooth. The gingiva was red and swollen and bleeding oc-
curred when plaque was removed. The patient complained
of sensitivity to cold in the treated tooth. Clinical exami-
nation revealed intact margins of the restoration. A
periapical radiograph showed a radiolucent area underneath
the restoration (Figure 5).
Local anesthesia was administered, and a rubber dam was
placed using a 14A clamp, which helped retract the gingiva.
Nevertheless, a completely dry area could not be achieved. The
restoration was removed, and the cavity floor was carefully
cleaned with a round low-speed bur. Pulp exposure had been
noticed on the mesiobuccal area. Partial pulpotomy with cal-
Figure 3. The gingival tissue above the unerupted molar surgically
cium-hydroxide was performed, followed by placement of retracted, revealing the occlusal surface of the second molar.
reinforced zinc-oxide eugenol dressing (IRM–LD Caulk,
Dentsply Milford, Del) and an amalgam restoration. Six-
month follow-up revealed no clinical symptoms and normal Pre-eruptive intracoronal resorption has been previously
appearance of the tooth and restoration. A radiograph dem- described as located adjacent to the dentin-enamel junc-
onstrated continued root development (Figure 6). tion, and extending into various depths of the dentin. 5,6
The dental literature generally recommends surgical expo-
Discussion sure of the unerupted tooth—as soon as the lesion has been
The present case demonstrated an accidentally diagnosed, diagnosed radiographically—to arrest the progression of the
asymptomatic, pre-eruptive, intracoronal resorption of a resorptive process and prevent its penetration into the den-
mandibular second molar on a panoramic radiograph taken tal pulp.2,3,5,6,11 In this case study, the extensive radiolucent
for orthodontic reasons. area under the enamel on the unerupted tooth required an

Pediatric Dentistry – 27:1, 2005 Pre-eruptive intracoronal resorption Davidovich et al. 75

 immediate intervention due to a concern of pulp involve-
ment.
Glass-ionomer was chosen as the restoration material for
the tooth after its surgical exposure due to its benefits:
1. less sensitivity to moisture (because of the wet work-
ing field);
2. minimal tooth preparation;
3. fast setting;
4. high viscosity, which allowed for easy handling and
packing as well as stronger bonding to enamel and
dentin, without etching, via photochemical reaction;
5. fluoride release into the cavity.12,13
The gap between the tooth and restoration (Figure 4)
may be attributed to shrinkage of the restoration material
or lack of its proper condensation.
A possible explanation for the sensitivity, which was re-
ported 3 months later, is that the removal of the caries-like
Figure 4. Cavity restoration with glass-inomer, (GC Fuji IX–GP, material was incomplete, and bacteria may still have re-
GC, Tokyo, Japan).
mained in the dentinal tubules on the cavity floor despite
its sound appearance.
Due to their proximity to the pulp and the tooth’s im-
maturity, the dentinal tubules may have been more
permeable than in mature dentin. Thus, remaining bacteria
could have easily progressed into or close to the pulp, thereby
irritating it. Partial pulpotomy was performed, as this pro-
cedure appeared successful in treating a carious exposure in
permanent molars.14 Amalgam was chosen as the restorative
material following the partial pulpotomy, due to its handling
characteristics, good performance in preventing marginal
leakage, and decreased sensitivity to moisture.15

Conclusions
1. Early diagnosis and treatment of pre-eruptive
intracoronal resorption are essential to avoid pulp in-
volvement after tooth eruption.
2. Immature dentin of young teeth must be considered
Figure 5. A periapical radiograph showing a radiolucent area a potential source for pulp inflammation even though
underneath the restoration and on its mesial aspect.
it appears sound after caries removal.

References
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5. Seow WK, Wan A, Mcallan LH. The prevalence of
pre-eruptive dentin radiolucencies in the permanent
dentition. Pediatr Dent 1999;21:26-33.
Figure 6. A periapical radiograph taken 6 months after the partial
pulpotomy. Continued root development is evident.

76 Davidovich et al. Pre-eruptive intracoronal resorption Pediatric Dentistry – 27:1, 2005

 6. Seow WK, Lu PC, Mcallan LH. Prevalence of pre- 11. Skaff DM, Dilzell WW. Lesions resembling caries in
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7. Kupietzky A. Treatment of preeruptive intracoronal 12. Donly KJ, Segura A. Fluoride release and caries inhi-
radiolucency. Pediatr Dent 1999;21:369-372. bition associated with a resin-modified glass-ionomer
8. Guinta JL, Kaplan MA. “Caries-like” dentin radiolu- cement at varying fluoride loading doses. Am J Dent
cency of unerupted permanent tooth from 2002;15:8-10.
developmental defects: Case report. J Pedod 13. Croll TP, Bar-Zion Y, Segura A, Donly KJ. Clinical
1981;5:249-255. performance of resin-modified glass ionomer cement
9. Taylor NG, Gravely JF, Hume WJ. Resorption of the restorations in primary teeth. A retrospective evalua-
crown of an unerupted permanent molar. Int J tion. J Am Dent Assoc 2001;132:1110-1116.
Paediatr Dent 1991;1:89-92. 14. Mass E, Zilberman U, Fuks AB. Partial pulpotomy:
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Pediatr Dent 2002;24:448-455.

ABSTRACT OF THE SCIENTIFIC LITERATURE

EFFECTS OF SALIVA ON MARGINAL INTEGRITY OF PIT AND FISSURE SEALANTS
Pit and fissure sealants have been widely used since the 1970s, with continuous advances made in: (1)
materials; (2) ease of placement; and (3) rate of retention. Salivary contamination can adversely affect the
sealant bond integrity. Therefore, many experts suggest that an adjunct adhesive or glass ionomer cement
be used to try and decrease, if not eliminate, sealant failure. The purpose of this study was to assess the
marginal microleakage of glass ionomer cement and a resin-based sealant associated or not with an adhesive
system, under salivary contamination.
Forty-eight human third molars were divided into 3 groups, according to sealant material: (1) Fluroshield;
(2) Single Bond and Fluroshield; and (3) Ketac-fil. Each group was then subdivided in half, with 8 speci-
mens serving as a control and the other 8 being exposed to salivary contamination. For the control group,
the sealant material was applied to the occlusal surface after being etched and air dried. For the subgroup
with saliva contamination, the occlusal surface was exposed to fresh human saliva for 20 seconds after etch-
ing. The surface was then air dried, and sealant placement occurred. Materials were placed according to
manufacturers instructions. Samples were: (1) stored in distilled water for 24 hours; (2) subjected to
thermocycling; (3) treated with a dye solution; and (4) sectioned for observation under a microscope. The
results showed that the salivary contamination subgroups had a higher percentage of marginal leakage than
the control. Within the saliva contamination subgroups, only the Single Bond plus Fluroshield provided
complete marginal sealing. Furthermore, the glass-ionomer cement yielded the best result when compared
to the sealant material alone.
Comments: Although the sample size was rather small, this study’s results substantiate the deleterious
effect of salivary contamination during sealant placement, particularly when a resin-based sealant is used
alone. The addition of an adhesive agent improved the marginal seal, but has the drawback of added steps
and time. In cases involving an active child or copious salivary flow, or when lack of time is a problem, the
glass ionomer material seems to be well suited for the job and should be considered as an alternative mate-
rial. As practitioners constantly strive to reduce sealant failure, this study could provide added
insight—ultimately benefiting both patient and practitioner. GM
Address correspondence to Dr. Maria Cristina Borsatto, Faculdade de Odontologia de Ribeirao Preto/USP,
Departamento de Clinica Infantil, Odontologogia Preventiva e Social, Av. do Café, S/N Monte Alegre, CEP:
14040-904 Ribeirao Preto- SP, Brazil.
Borsatto MC, Corona SAM, Alves AG, Chimello DT, Catirse ABE, Palma-Dibb RG. Influence of
salivary contamination on marginal microleakage of pit and fissure sealants. Am J Dent 2004;17:365-
367.
25 references

Pediatric Dentistry – 27:1, 2005 Pre-eruptive intracoronal resorption Davidovich et al. 77