Delayed management of re-implanted maxillary central incisor with pulp canal obliteration and root dilaceration: A case report of labial access

Abstract Traumatic dental injuries in children commonly involve avulsion of immature permanent maxillary incisors, often leading to pulp necrosis, pulp canal obliteration, and developmental anomalies such as root dilaceration. This case report describes the endodontic management of a 30-year-old female who presented with a 10-day history of dull, nonspontaneous pain in the maxillary anterior region. The patient had a history of avulsion of the maxillary left central incisor (#21) at age 7 due to trauma, which was replanted within 2 h and remained asymptomatic for over two decades. Clinical examination revealed normal soft tissues with no swelling or sinus tract, mild discoloration of tooth #21, tenderness to vertical percussion, and no response to cold sensibility testing. Radiographic evaluation demonstrated a calcified pulp chamber, near-complete obliteration of the radicular canal space, and atypical anatomy consistent with severe palatal root dilaceration. Based on the combined clinical and radiographic findings, a provisional diagnosis of pulp canal obliteration with symptomatic apical periodontitis was established for tooth #21. Cone-beam computed tomography (CBCT) and a patient-specific three-dimensional-printed model enabled precise visualization of the aberrant morphology. Given the deep canal entry and curvature, a labial access approach was planned instead of the conventional palatal route, providing a more conservative and direct path to the patent canal. Careful negotiation, rotary instrumentation, and thorough irrigation were followed by calcium hydroxide dressing and obturation. The treatment resulted in successful canal negotiation and healing, with the periapical lesion showing uneventful resolution and the patient remaining asymptomatic at 6 months. This case highlights the importance of CBCT-guided planning and customized access design in managing complex post-traumatic root morphologies.