Selective preservation of the apical pulp vitality during surgical management of perforating root resorption: a case report with 1-year CBCT follow-up

Perforating internal root resorption (IRR) is conventionally managed by complete pulpectomy and root canal treatment. Preservation of the remaining apical pulp tissue has not, to the best of our knowledge, been previously reported as part of the surgical management of a perforating resorptive lesion in a pulp-sensible tooth. A healthy 27-year-old woman presented with a pulp-sensible maxillary left central incisor with an asymptomatic pulp-sensible tooth exhibiting a perforating root resorptive lesion that was radiographically interpreted as being most consistent with IRR. The tooth responded positively to cold and electric pulp sensibility tests. Cone-beam computed tomography (CBCT) demonstrated a perforating resorptive defect involving the buccal and distal root surfaces while demonstrating preservation of the apical root canal space beyond the resorptive defect. Although the imaging findings favored IRR, a combined internal-external resorptive process could not be completely excluded. After declining conventional root canal treatment, the patient consented to an alternative one-step surgical procedure. The coronal root canal and internal resorptive cavity were retrogradely prepared, after which the coronal root canal was sealed with calcium-enriched mixture cement. The remaining apical pulp tissue was preserved by shallow pulpotomy and direct pulp capping with the same biomaterial. At the 1-year follow-up, the tooth remained asymptomatic. Periapical radiography and CBCT demonstrated complete mineralized tissue fill of the resorptive cavity and formation of a cortical bony bridge across the buccal perforation, findings consistent with advanced hard tissue repair. This single case suggests that selective preservation of healthy apical pulp tissue may be biologically feasible in carefully selected cases of perforating pulp-sensible root resorptive lesions. However, this report should be considered hypothesis-generating, and conventional root canal treatment remains the current standard of care. Further clinical studies with longer follow-up are needed to determine the predictability and broader clinical applicability of this approach.