Numerous predisposing factors correlated with the occurrence of ICR. In both cases, trauma triggered the ICR commencement. Our cases showed advanced resorptive process with invasion of the root canal and severe bone loss was also observed in case 2. The surgical approach was planned, because it was not possible to control the chemomechanical and obturation procedures adjacent to resorptive cavity through an orthograde route. Once the resorptive cavity was exposed, the topical application of TCA was done to inactivate all resorptive tissue. It made the area avascular, aiding in the treatment of ICR. The application of escharotic solutions such as TCA has the advantage of deeper penetration into the resorptive tissues where complete mechanical removal of granulation tissues is not possible. Soft tissue diode laser was used as an adjuvant to chemical and mechanical debridement of granulation tissue. They are used in soft tissue surgeries such as removal of pyogenic granuloma, periodontal pocket irradiation, flap reflection and treatment of soft tissue pigmentation therapy. Laser irradiation can severe small blood vessels, eliminate the tissue of the resorptive cavity and maintain a hemostatic field. Antimicrobial efficacy is also an added advantage of soft tissue diode lasers.
Restorative material for restoring the ICR should be biocompatibile, moisture insensitive, have good sealing ability, induce periodontium regeneration along with cementum and bone repair. Literature suggests that MTA possess these qualities hence was our material of choice for restoring ICR lesions.
MTA favours the release of calcium ions and calcium hydroxide formation that warrants an antimicrobial activity and generates a conducive environment for cell division. Several authors have demonstrated that both grey and white MTA formulations induce metabolic activity on the PDL cells, encouraging its adhesion and modulating an osteogenic phenotype on the fibroblasts of the PDL. Studies have confirmed cementoconductivity, cementoinductivity, and osteoconductivity of WMTA. In case 2, bone defect received a bone graft because HA graft has shown successful periodontal regeneration in periapical defects and greater pocket depth reduction. HA is an osteoconductive material and induces bone regeneration.
Even though the failure rate is high for class 4 ICR lesion, patient’s parents rejected the option of extraction and wanted to save the tooth, so surgical endodontic management with MTA may be justified, as reported here. Extension of the lesion can be clearly visualised and demarcated using CBCT, and hence it is a valuable tool in the diagnosis of ICR in both the cases. In the follow-up period, the successful healing was observed with clinical and radiographic evaluation in both the cases. The clinical periodontal conditions also led us to hypothesize that this case was an example of a periodontal healing with a long periodontal junction over the remaining MTA.
The reported surgical endodontic management of a class 3 ICR lesion with MTA and a class 4 ICR lesion with MTA and HA bone graft, combined with laser irradiation and Heithersay’s approach promotes healing and survival of a compromised tooth. Randomized control trials and studies with longer follow-up periods are further required to support its use in these type of cases