Inflammatory root resorption after trauma
Jon Richards DDS MS
This patient is a 14 year old male. Tooth #7 was avulsed (fell and hit his face on some cement steps…. ouch) and was not reimplanted until he could get to a dentist approximately 40 minutes later. It was preserved in water.
The dentist splinted the tooth and correctly recommended root canal therapy be performed. Unfortunately, the patient then saw another dentist who removed the splint, but the patient never followed through on the RCT. Ideally, the endodontic treatment should have been initiated 7-10 days after the traumatic episode and include the use of intracanal Ca(OH)2.
Trauma to the teeth results in 2 primary concerns:
- Damage to the periodontal ligament, and
- Disruption of the pulpal blood supply and pulpal necrosis.
Preserving #7 for as long as possible is advised. The likelihood of external inflammatory root resorption is increased in such a scenario. If left unchecked, this can be a rapidly progressing destructive process and lead to premature loss of the tooth. In this case, the radiographic signs of this are easily visible already.
The improper transport medium (hypotonic tap water vs. a more physiologic solution like skim milk) and delayed reimplantation will likely result in very negative long term survival of tooth #7 due to changes in the periradicular tissues. Taking into account the patient’s age, the treatment options are somewhat limited. Extraction would leave him without the function and estetics of an anterior tooth at a critical time in the patient’s life. Replacement with an implant is not recommended until a later time when facial/skeletal development is closer to complete. If #7 is lost, so will be the alveolar ridge, later complicating the implant therapy.
The purpose of prompt RCT on avulsed teeth is to remove the pulpal tissues from the canal system and reduce the inflammatory effect on the exterior root surface. The goals here was to slow down the resorption and try to preserve #7 as long as possible.
Endodontic access on anterior teeth should be placed to minimally affect the structural integrity of the tooth. A small (1.5mm wide) and incisally placed access preparation was completed. Traditional access is a large triangular-shaped opening placed much more cervically, nearly involving the cingulum. Such a size and placement should have been removed from the textbooks 20 years ago. While it might be argued that such an approach improves visibility, the use of the improved illumination and visibility with the microscope overcomes this and makes working through a smaller hole possible. Preserving the cingulum dentin increases the fracture resistance for the 80 years this tooth will need to be present.
Minimal lateral canal wall preparation was also planned, as the “thinness” of these structures are already a concern. Hand files only with apical gauging, followed by sonically activated irrigant, and 3 months of Ca(OH)2 was used. After 3 months of medicament (2 changes), radiographic signs of healing were favorable and the canal was obturated with warm gutta percha. The access was restored with composite.
In at least the short term, this treatment appears to have favorably extended the life of tooth #7. Will the resoprion continue? Time will tell… The next follow up visit is scheduled for 6 months from now. These recall visits are critical to assess the condition over time.