Decisions…decisions. A very young looking 10 year old girl presented after an avulsion of tooth number 9 with a very short extra-oral dry time, immediately replanted and subsequently splinted. The decision of whether to initiate endo on the central is dictated by the time out of the mouth and the development of the tooth. I made the call that the apex looked wide open and the tooth hadn’t completely developed. So we decided to wait and see if the tooth would revascularize. My first follow-up time of trauma is typically 3 weeks. I saw her inside of 4 and resorption was already full on; progressive and aggressive. Classification wise this would be external axial resorption. We initiated endo immediately, but the damage was done. Additionally, the concussed lateral wasn’t responding to cold, so we started endo on that one as well.
We kept the tooth in medication for 5 months changing it out monthly. Over that period of time there was ankylotic tone and no mobility under the scope using 2 mirror handles to evaluate. Ugh. We placed Vitapex in the canal which lasts longer than many other CaOH preparations, and restored. Over time, washing out of the medication could be observed; a common finding in a resorbing root. We waited until we measured 3mm infra-occlusion and set her up for a flapless decoronation like my buddy Buck came up with circa 2008.
If you can, preserve the pulp. If you can’t; save the root and tooth. If you can’t do that, at least save the bone. That’s where decoronation comes in.
We clamped the other central and split dam to the distal of the lateral and used a rubber dam triangle to wedge the dam distally. Then we cut the crown off using a an 014 tapered diamond. Then a surgical length 556 on end, we cut the tooth flat to 1-2mm below the bone. It’s critical to remove all the enamel as it won’t resorb. We observed granulomatous soft tissue extending from the canal space. A good clot was evident before dismissing the patient.
Hindsight being 20/20 I woulda medicated the tooth at a week. Similar patient representing the same way? That’s tougher. I’m thinking if the tooth looks most of the way developed, regardless of the apex developement, I might jump in. It’s a tough call.