Diagnosis and treatment of accidental root perforations

Endodontic Topics 2006, 13, 95–107
All rights reserved
Copyright r Blackwell Munksgaard
ENDODONTIC TOPICS 2006
1601-1538
Diagnosis and treatment of
accidental root perforations
IGOR TSESIS & ZVI FUSS
A review of endodontic and periodontal aspects on the prognosis, diagnosis, prevention, and treatment of
accidental root perforations is presented. Successful treatment depends mainly on proper diagnosis and immediate
sealing of the perforation to eliminate risk of infection. A classification of root perforations is presented in the review
to assist the clinician in making a proper choice of treatment protocol.
Introduction
Root perforation is an artificial communication between the root canal system to the supporting tissues of
teeth or to the oral cavity (1). Often, the cause is
iatrogenic as a result of misaligned use of rotary burs
during endodontic access preparation and search for
root canal orifices (2–4). Accidental root perforation
may also complicate the endodontic treatment per se,
for example, during efforts to negotiate calcified and
curved canals as well as following lateral extension of
the canal preparation to a so-called strip-perforation
(5). Inappropriate post space preparation for permanent restoration of endodontically treated teeth is yet
another common iatrogenic cause of root perforation
(3). Non-iatrogenic causes, including root resorption
and caries (4, 6–9), will not be addressed in this review.
Accidental root perforations, which may have serious
implications, occur in approximately 2–12% of endodontically treated teeth (4, 10–14). Bacterial infection
emanating either from the root canal or the periodontal tissues, or both, prevents healing and brings
about inflammatory sequels where exposure of the
supporting tissues is inflicted. Thus, painful conditions,
suppurations resulting in tender teeth, abscesses, and
fistulae including bone resorptive processes may follow.
Down-growth of gingival epithelium to the perforation site can emerge, especially when accidental
perforations occur in the crestal area by lateral
perforation or perforation in furcations of two- and
multi-rooted teeth.
Once an infectious process has established itself at the
perforation site, prognosis for treatment is precarious
and the complication may prompt extraction of the
affected tooth (10, 15). Yet, if discovered early and
properly managed, prolonged survival of the tooth is
possible. This review relates specifically to the diagnosis
and the impact of various factors on the prognosis, as
well as the principles for treatment of root perforations.
It also discusses measures for prevention.
Factors of significance to prognosis
for treatment
Whether or not a root perforation can be successfully
treated depends on whether the perforation can be
repaired such that bacterial infection of the perforation
site can either be prevented or eliminated (16). A
number of factors including time from the perforation
to detection, size, and shape of the perforation as well
as its location impact the potentials to control infection
at the perforation site.
Time
Indeed, numerous experimental studies have demonstrated that time is a most critical factor determining
outcome of treatment, with immediate closure carrying the best prognosis. Lantz & Persson (17–19)
produced root perforations in dogs that were treated
either immediately or after some delay. The most
95
Tsesis & Fuss
favorable healing response was evidenced when perforations were sealed immediately. Seltzer et al. (20)
treated 22 perforations in monkeys at intervals from
immediately to 10 months post-perforation. While the
periodontium was damaged in all teeth, the most severe
tissue destruction was in the untreated perforations and
in teeth where treatment was delayed. Beavers et al.
(16) observed consistent periodontal healing following
treatment of experimentally produced root perforations in a monkey model. The high success rate was
attributed to the immediate obturation of the perforations and the aseptic technique used. Others supporting these results found that delay in repair of
perforations decreased the prognosis for healing (21,
22). However, Benenati et al. (23) observed that a
delay in repairing perforations with amalgam did not
influence the prognosis, if the perforation site had been
kept aseptic in the time interval from its inception.
Consequently, to minimize the potential for emergence of infection of the perforation site, these studies
infer that the best time to repair root perforations is
immediately after occurrence. Proper treatment of the
perforation may not always be possible, due to lack of
time, lack of experience of the operator, and proper
equipment. The perforation is then best maintained by
an adequate, bacterially tight temporary seal, and referral
to a specialist for as rapid a treatment as possible.
Size
Large-sized perforations may not respond to repair as
well as smaller ones (24). Himel et al. (25) evaluated the
effect of three materials on healing of perforations of the
pulp chamber floor of mandibular molars in dogs, and
found that the larger teeth with proportionally smaller
perforations showed a better healing response. Large
perforations are more likely to occur during operative
procedures, when aggressive burs are used, causing more
traumatic injuries to the surrounding tissues. Furthermore, large perforations can cause the problem of an
incomplete seal of the defect, thus allowing continuous
bacterial irritation of the perforation area (26). Small
perforations clearly are easier to repair and therefore
provide potential for predictable healing.
Location
The most important parameter affecting treatment
prognosis is the location along the root surface. A
96
perforation occurring relatively close to the crestal bone
and the epithelial attachment is critical as it may lead to
bacterial contamination from the oral environment along
the gingival sulcus. Furthermore, apical migration of the
epithelium to the perforation site can be expected,
creating a periodontal defect (3, 17–20, 26–30). Once
the periodontal pocket is formed, persistent inflammation
of the perforation site is most likely maintained by
continuous ingress of irritants from the pocket (26, 27).
These perforations have a poor treatment prognosis from
a periodontal aspect, and treatment from the inside of the
root canal, even if adequately performed, cannot normally
improve the condition.
Perforations of the furcation areas of multi-rooted
teeth are similarly critical (3, 7, 17–19, 27, 31, 32) (Fig.
1A). At times, they are especially troublesome as the
inflammatory process may cause rapid and extensive
destruction of the periodontal tissues that ultimately
leads to a permanent communication with the oral
cavity and a persistently suppurating lesion (20, 24).
Nevertheless, a high healing rate was attained in the
treatment of experimental furcation perforations in
monkeys (16). In 24 teeth of two monkeys, furcation
perforations were sealed with either hard-setting
calcium hydroxide or Teflon disks. All procedures were
performed under strict aseptic conditions after extirpating the pulps, and the access cavities were sealed
with hand-mixed zinc oxide eugenol cement and
amalgam. Furcation perforations showed evidence of
histologic healing after various time periods with no
epithelial migration to the wound site (Fig. 1B, C). An
additional set of lateral perforations exhibited similar
evidence of periodontal tissue healing following treatment. According to the graphic illustrations given, the
furcation perforations were produced in the middle of
the pulpal floor and directly into the crestal bone. The
fact that the epithelial attachment was not compromised may explain the high success rate, as well as the
strict asepsis and the atraumatic preparation of the
experimental perforations. The long-term healing
response was not studied in this report.
Hartwell & England (30) had a high clinical success
rate following repair of furcation perforations in
monkeys using freeze-dried bone. However, histologically, a layer of epithelium was found immediately
beneath the perforation with no bone healing in any of
the samples. From the radiographs presented in the
study, the perforation defects were located at the crestal
bone level and thus susceptible to epithelial migration.
Accidental root perforations
Fig. 1. A histologic section is seen in (A) of a tooth with an old (infected) furcation perforation that resulted in
inflammation, bone resorption, and proliferation of the epithelium in the perforation area. Microphotographs of tissue
sections in (B) and (C) are from the study of Beavers et al. (16). (B) Tissue defect immediately after bur penetration of the
furcation in a mandibular molar. Forty-two days following immediate seal of the perforation in (C) with a teflon disk and
zinc oxide eugenol cement resulted in a healing response. Note emerging bone fill of the perforation along with cellular
cementum formation on the canal walls and absence of epithelial proliferation (microphotographs in (B) and (C) kindly
provided by Dr G. Bergenholtz).
Perforations, coronal to the crestal bone, are easy to
access and seal, and teeth may be restored without
periodontal involvement. For a good prognosis, there
should be sufficient sound tooth structure for an
adequate restoration.
Perforations, apical to the crestal bone and epithelial
attachment, are considered to have a good treatment
prognosis when adequate endodontic treatment is
rendered and the main canal is accessible. In these
cases, the risk of periodontal involvement is reduced,
making the prognosis good (16, 20).
Classification of root perforations
Based on the factors impacting the outcome of
treatment considered above, the following classification of root perforations, proposed by Fuss & Trope
(1), may assist the clinician to select a treatment
strategy:
Fresh perforation – treated immediately or shortly
after occurrence under aseptic conditions, Good Prognosis.
Old perforation – previously not treated with likely
bacterial infection, Questionable Prognosis.
Small perforation (smaller than #20 endodontic
instrument) – mechanical damage to tissue is minimal
with easy sealing opportunity, Good Prognosis.
Large perforation – done during post preparation,
with significant tissue damage and obvious difficulty in
providing an adequate seal, salivary contamination, or
coronal leakage along temporary restoration, Questionable Prognosis.
Coronal perforation – coronal to the level of crestal
bone and epithelial attachment with minimal damage
to the supporting tissues and easy access, Good
Prognosis.
Crestal perforation – at the level of the epithelial
attachment into the crestal bone, Questionable Prognosis.
Apical perforation – apical to the crestal bone and the
epithelial attachment, Good Prognosis.
In multi-rooted teeth where the furcation is perforated, the prognosis differs according to the factors
described for single-rooted teeth.
Determination of the presence and
location of root perforation
As accurate detection of root perforations and determination of location are crucial to the treatment
outcome, certain signs, and tools must be recognized
in making the diagnosis. Sudden bleeding and pain
during instrumentation of root canals or post preparations in teeth are warning signals of a potential root
perforation. The appearance of blood on paper points
97
Tsesis & Fuss
may also be indicative, but unreliable as bleeding may
originate from the apical foramen or from residues of
vital pulp tissue. To enhance radiographic detection, it
has been proposed to place a highly radiopaque
calcium-hydroxide paste, by inclusion of barium
sulfate, in the root canal (33). However, caution should
be exercised in crestal perforations as this measure can
result in extrusion of the material into the periodontal
tissues and cause unnecessary mechanical and chemical
irritation impairing the treatment prognosis (Fig. 2).
Radiographs taken at different angles with radiopaque
instruments in the root canal are a better option and
may confirm the presence of a root perforation (Fig. 3).
However, when the perforation is located at the buccal
Fig. 2. Case demonstrates a treatment attempt of an old large crestal perforation that resulted in root resorption (A).
Calcium hydroxide placed in the root canal was extruded into the resorption cavity (B). One week post-treatment,
necrosis of the mucosa adjacent to the perforation area is obvious (C).
Fig. 3. Radiograph of a maxillary right incisor with a post in the root canal and a radiolucent area in the coronal third of
the root (A). In an angulated view, penetration of the post to the periodontal tissue can be seen (B).
98
Accidental root perforations
Fig. 4. Radiograph showing a maxillary first molar with a large post in the palatal root. Radiolucencies affect the palatal
root and the furcation area (A). Furcal perforation is to be suspected but cannot be confirmed because of superimposition
of root structures on the post in the palatal canal. Studying the extracted tooth, a large furcation perforation became
evident at the buccal aspect of the palatal root (B).
or palatal aspects of the root, the diagnostic value
of radiographs is limited (Fig. 4). Anatomical structures, as well as radiopaque materials superimposing on
the image of the root, may also obscure the perforation
site.
Electronic apex locators (EALs) can accurately
determine the location of root perforations, making
them significantly more reliable than radiographs (34).
After root instrumentation, it is recommended that the
working length be verified with EALs. Readings, that
are significantly shorter than the original length can be
an indication of perforation (34).
A dental operating microscope is another helpful
tool (35, 36) effective in detecting root perforations
during orthograde root canal therapy and in surgical
endodontic treatments. High magnification with coaxial illumination allows precise detection and visualization of perforations along straight non-curved root
canals.
A narrow isolated periodontal defect is a possible sign
of periodontal breakthrough due to root perforation.
Probing the gingival sulcus to reveal possible communication with the oral cavity is recommended in such
teeth. To determine locally isolated vertical bone losses,
periodontal probing should be carried out by walking
the probe around the tooth while pressing gently on
the floor of the sulcus (37). In the presence of narrow
isolated periodontal defects, differential diagnosis from
vertical root fracture should be made with explorative
surgery (38, 39).
Treatment aspects
Measures for prevention
Care should always be excerised during endodontic and
operative procedures to prevent the complication of a
root perforation. The following precautions may serve
as general guidelines.
Before accessing root canals
The crown-root alignment should always be evaluated
and bony eminences noticed. Often, palpation is useful
to detect the direction of the root relative to the crown.
Careful examination of radiographs is important to
evaluate the shape and depth of the pulp chamber and
width of the furcation floor. Indeed, adequate knowledge is needed of the location and dimensions of the
pulp chamber (40). Attention should also be given to
root inclination, the long tooth axis, the shape, number
and degree of canal curvatures, presence of calcifications, and type of previous restorations. Additional
radiographs of good diagnostic quality should be taken
from other angles if needed (41).
During access preparation
The use of magnification is advantageous to observe
canal orifices and the coronal alignment of the root
canal. A rubber dam should not be placed before access
99
Tsesis & Fuss
preparations in teeth with narrow or calcified pulp
chambers (41, 42), in re-treatments, and when accessing crowned teeth. In such cases, the pulp chamber
may not readily be seen, as calcification processes
induced by the previous treatment may have altered its
normal anatomy. Krasner & Rankow (43) studied 500
extracted, permanent human teeth and found that the
pulp chamber was always centrally located at the level of
the cemento-enamel junction (CEJ). The CEJ was the
most consistent anatomic landmark observed. They
proposed to ignore the clinical crown contour as a
guide in directing the access preparation and instead
use the CEJ. Radiographs taken during the access
preparation with a bur in place may be helpful.
Kvinnsland et al. (3) found that in maxillary anterior
teeth, all perforations were located at the labial root
aspect due to the operator’s underestimation of the
palatal root inclination in the upper jaw.
During root canal preparation
Overzealous use of rotary instrumentation can cause
apical or crestal perforations of the root canal wall, also
called ‘strip perforation’ (5). Hence, large tapered
instruments and Gates–Glidden (GG) burs should
therefore be used with caution (44). Modern flexible
nickel titanium instruments along with copious irrigation and lubrication were proposed for curved canals to
prevent apical perforations (45, 46).
During post preparation
Utmost care should always be exercised during post
preparations so that root canals are not overextended.
Generally speaking, a safe preparation is best attained
with the surgical microscope immediately after completion of a root canal filling. Kuttler et al. (47)
examined the effects of post space preparation with GG
drills on residual dentin thickness in distal roots of
mandibular molars in vitro and found that such post
space preparation carries a significant risk of perforation
(7.3% with GG #4). Kvinnsland et al. (3) observed that
more than half of the perforations in their cases of root
perforation occurred during post-preparation procedures.
Treatment by an orthograde approach
As early as 1903, Peeso (48) stated that successful
management of root perforations is dependent on early
100
diagnosis of the defect, choice of treatment, materials
used, host response, and the experience of the
practitioner. These factors are also valid today. No
doubt, the rationale for orthograde treatment of root
perforations is the same as that of conservative
endodontic therapy, i.e. prevention and treatment of
periradicular inflammation. This may be achieved by
measures aimed to control infection of the perforation
site, or if already infected, by using procedures that can
disinfect the site and provide the best possible seal
against penetration of bacterial elements.
Fresh perforations that occur during either operative
or endodontic procedures are followed by hemorrhage.
The first step then is to control the hemorrhage by
pressure or irrigation (49). Subsequently, the perforation should be adequately sealed. The efficacy of a
sealing material depends primarily on sealability and
biocompatibility and thus ability to support osteogenesis and cementogenesis. It may also be advantageous
that the material is relatively inexpensive, radiopaque,
and bacteriostatic (50). In certain instances, it could
also be beneficial to use a resorbable matrix in which a
sealing material can be condensed (25, 51).
No material offers all of these properties. In search for
the ideal material, numerous sealing materials and
techniques have been tested over the years with varying
success, including amalgam (17, 18, 23, 26, 28, 52–
54), phosphate cement (17, 18), gutta-percha (3, 17,
18, 23, 27, 31), zinc oxide eugenol (4, 20, 56),
SuperEBA (55), dentin chips (27), AH-26 (27),
various formulations of calcium hydroxide (26–28,
56), Cavit (7, 12, 17, 18, 22, 28, 29), tricalcium
phosphate (13, 25, 26), hydroxylapatite (26, 54, 57),
glass ionomer cement (53, 58), resin-ionomer (59),
mineral trioxide aggregate (MTA) (60, 61), tin foil
(62), and indium foil (63, 64). Yet, the material factor
must be regarded as only one of several critical factors
(discussed above) that is significant to the outcome of
treatment (54). Clearly, the selection of material must
be related to the type of perforation. Consequently, an
apical perforation should be treated according to
routine endodontic principles and sealed with root
canal filling materials. Infected apical perforations may
be medicated with an antibacterial intracanal dressing
before obturation. It has been suggested that large
apical perforations should be treated similar to teeth
with immature apices, i.e. with long-term calcium
hydroxide treatment to achieve a hard tissue barrier (1,
7, 8). When the original canal is not accessible and
Accidental root perforations
apical periodontitis has emerged, root end resection
may be the treatment of choice.
Management of crestal root perforations
Treatment of crestal perforations carries a guarded
prognosis because of their proximity to the epithelial
attachment. For sealing, any biocompatible material
with a short setting time and good sealability should be
selected (1). Orthodontic extrusion has been recommended for single-rooted teeth to bring the perforation to a coronal position, where it can be sealed
externally without surgical intervention.
Perforations in the furcal region of molars are
particularly challenging. Large furcation perforations
make the control of sealing material hazardous, and risk
of extrusion of the filling material into periodontal
tissues is common (1), an additional complication that
significantly impairs the chances for a desirable periodontal healing (23, 27, 54).
For large perforations, an internal matrix technique
has been suggested (24, 30, 53–55). The defect
(perforations in the furcation area and in straight
canals) should then be directly accessible and visualized
for the successful use of this technique (Fig. 5). The
internal matrix must, of course, be sterile, possible to
manipulate, and should not produce inflammation
(24). Materials suggested in the literature are hydroxylapatite (24), decalcified freeze-dried bone (30),
plaster of Paris (calcium sulfate) (53), hydroxyapatite1calcium sulfate (54), and resorbable collagen with
MTA (65). Petersson et al. (27) and Bogaerts (55) have
stated that materials based on calcium hydroxide as a
main ingredient are not suitable for crestal and
furcation perforations because of the initial inflammatory response to these materials, which could lead to
breakdown of the supporting tissues and subsequent
pocket formation (25, 28).
Resin-modified flowable glass ionomer cement can
be used as an artificial floor barrier without risk of
pushing the material into the supporting tissues (Figs 6
and 7). Furthermore, other materials can be added and
condensed to improve sealability with minimal inflammatory response (identical healing for glass ionomer
cements when used alone or over calcium sulfate or
hydroxyapatite barrier) (66).
MTA has recently been proposed for repair of root
perforations (67) (Fig. 8). Several in vitro studies on
MTA have demonstrated its sealing ability (67–69).
When used to repair perforations in animal models,
Fig. 5. Case of a maxillary left second molar serving as a distal abutment in a bridge. Root canal treatment was initiated
because of pulp necrosis (A) in which a large furcation perforation occurred during access cavity preparation through the
crown (B). Treatment attempt of the perforation included closure with calcium sulfate (C), covered by a resin-composite
(D) before completion of root canal treatment (E).
101
Tsesis & Fuss
Fig. 6. Case of a mandibular first molar with an old furcation perforation (A). In spite of the poor prognosis, treatment
was initiated by post removal, gentle saline irrigation, and sealing the defect with a glass ionomer cement (Chelon Silve,
3M-Espe, Seefeld, Germany). The cement, with a setting time of 5 min, served as a barrier to avoid contamination during
retreatment of the root canals. Radiograph in B is 3 years post-treatment and demonstrates resolution of both the apical
and furcation lesions. A piece of the post displaced into the periodontal tissues during treatment remains (from Fuss &
Trope (1)).
Fig. 7. Radiograph of a mandibular molar with an old large furcation perforation. It was deemed possible to resolve the
lesion as there was no pocket probing depth to the furcation (A). The amalgam was gently removed through the root
canal and the large perforation was sealed with glass ionomer cement. Thirty months following treatment, repair in the
furcation is evident (B). Note that the material was not pushed into the periodontal tissues in spite of the large
perforation defect (from Fuss & Trope (1)).
minimal or no inflammation was presented and, in
addition, cementum repair occurred at the material
interface (60, 61). It is reasonable to assume that the
high surface pH of MTA supports repair and hard tissue
formation in a similar fashion as calcium hydroxide.
Thus, Holland et al. (70) have proposed that calcium
oxide in MTA reacts with tissue fluids to form calcium
102
hydroxide, which in turn may encourage hard tissue
deposition.
It should be noted that there are no comparative
human studies to demonstrate the superiority of MTA
to other materials. Yet, numerous case reports exist in
the literature showing excellent healing results with
MTA when used as a vehicle for repair of root
Accidental root perforations
Fig. 8. Radiograph of a mandibular second molar with an
old furcation perforation (A). The perforation was sealed
with mineral trioxide aggregate (MTA) (B). Twelve months
following treatment, the lesion in the furcation resolved (C).
perforations (71, 72). A disadvantage is the prolonged
setting time that requires two appointments to
complete root canal therapy with permanent sealing.
The cost of this material is substantial.
Several studies have shown that MTA is microscopically identical and chemically similar to Portland
cement (73–75). Both materials show comparable
biocompatibility and histologic tissue responses (76–
78). Thus, Portland cement should be considered in
future research.
Treatment by a surgical approach
Indications for surgical intervention are large perforations, perforations as a result of resorption, failure of
healing after non-surgical repair (4), non-surgically
inaccessible perforations, extensive coronal restorations
(7), when concomitant management of the periodontium is indicated (8), and large overfilling of the
defect (31). The purpose of surgical treatment is to
achieve a tight and permanent seal that will prevent
bacteria and their byproducts in the root canal from
entering the surrounding periodontal tissues (79–81).
Before corrective surgery, root canals must be properly
treated and permanently filled, if possible (8, 82, 83).
When surgical intervention is needed in an apical
perforation, resection of the apical root to sound root
structure with an adequate filling is recommended (8,
82, 84). While Oswald (82) has stated that for crestal
perforations surgical repair will almost certainly result
in a loss of the epithelial attachment and pocket
formation, Rud et al. (80) found that after sealing root
perforation elsewhere with dentin-bonded resin-composite (Retroplast), bone regenerated and a periodontal ligament space was partly formed with a lamina
dura against the material.
Before surgical intervention, the following parameters should be considered (8):
amount of remaining bone,
extent of osseous destruction,
duration of the defect,
periodontal disease status,
soft tissue attachment level,
patient’s oral hygiene, and
surgeon’s expertise in tissue management.
Rud et al. (80) suggested that even if a small bridge of
crestal bone remains, it should be preserved by all
means. Accessibility to the perforation is a definitive
factor to be decided upon before a surgical repair
attempt. Buccal perforations are easy to repair, whereas
lateral and lingual/palatal perforations especially offer
substantial technical difficulties, which may make the
operator abstain.
During surgical procedures, hemostasis is critical and
may be achieved by various methods like profound
anesthesia with a vasoconstriction agent (infiltration of
2% Lidocaine with 1 : 50 000 epinephrine), (8, 85)
cotton pellets soaked in epinephrine, Gelfoam (86),
calcium sulfate (53, 87), and CollaCote collagen
sponges saturated with 2.25% racemic epinephrine
(88). A Class I cavity is prepared and the preferred
filling material is placed (8, 83).
Guided tissue regeneration has been attempted to
manage perforations and offer the possibility of
successful repair in surgical treatments by serving as a
103
Tsesis & Fuss
barrier for apical migration of epithelium (89, 90). The
technique is, however, both costly and technically
demanding (89) and has only gained support by case
reports (89–92), which calls for additional clinical
studies before this technique can be advocated.
Intentional replantation
Intentional replantation may be considered when
orthograde and surgical treatments are not possible,
undesirable, or have already failed (93, 94). This
procedure can be recommended as a substitute for
surgical treatment when the perforation defect is too
large for repair and when the perforation is inaccessible
without excessive bone removal (24, 95).
Generally, intentional replantation is not recommended for teeth with periodontal disease, furcation
involvement, or gingival inflammation (95, 96). However, recently, it was evaluated for treatment of periodontally involved teeth, with good results (97).
The procedure involves atraumatic tooth extraction to
avoid excessive damage to the cementum and periodontal ligamentum. Replantation should be completed
quickly to reduce the extra alveolar time and risk for
external root resorption. After removal, the tooth should
be kept in forceps and bathed gently in a balanced saltsolution. The dental operating microscope has the
advantage of careful inspection of the root surface and
perforation site. Modest or no post-operative pain can be
expected following the procedure (96, 98) (Fig. 9).
Teeth with divergent or long and curved roots are not
suitable for intentional replantation because of the risk
of fracture during extraction. The advantages of this
procedure are the short time involved and easy
manipulation. It allows thorough examination of the
root surface and adequate seal of the perforation defect.
The success rate reported in clinical follow-ups ranges
from 80% to 90% for carefully performed procedures
with proper case selection (93, 96, 98, 99). Several case
reports present successful treatment (100–103), but no
Fig. 9. Case of a mandibular first molar with an apical perforation of the mesial root subjected to intentional replantation
(A). After careful luxation and extraction by forceps (B), the apical 3 mm were resected and prepared for retrograde
fillings with IRM (C, D). The radiograph in E shows the reimplanted tooth. Twelve months post-operatively, periapical
healing is evident (F).
104
Accidental root perforations
studies have evaluated the long-term success of
intentional tooth replantation with root perforations.
Inflammatory root resorption and ankylosis due to
trauma to the periodontal ligament are complications
that may occur after intentional replantation (96).
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Fuss Z, Trope M. Root perforations: classification and
treatment choices based on prognostic factors. Endod
Dent Traumatol 1996: 12: 255–264.
American Association of Endodontists. Glossary of
endodontic terms, 7th edn. Chicago: American Association of Endodontists, 2003.
Kvinnsland I, Oswald RJ, Halse A, Gronningsaeter
AG. A clinical and roentgenological study of 55 cases
of root perforation. Int Endod J 1989: 22: 75–84.
Nicholls E. Treatment of traumatic perforations of the
pulp cavity. Oral Surg Oral Med Oral Pathol 1962: 15:
603–612.
Abou-Rass M, Frank AL, Glick DH. The anticurvature
filing method to prepare the curved root canal. J Am
Dent Assoc 1980: 101: 792–794.
Eleftheriadis GI, Lambrianidis TP. Technical quality of
root canal treatment and detection of iatrogenic errors
in an undergraduate dental clinic. Int Endod J 2005:
38: 725–734.
Sinai IH. Endodontic perforations: their prognosis
and treatment. J Am Dent Assoc 1977: 95: 90–95.
Gutmann JL, Harrison JW. Surgical Endodontics.
Boston, MA: Blackwell Scientific Publications, 1991,
p. 409.
Fuss Z, Tsesis I, Lin S. Root resorption – diagnosis,
classification and treatment choices based on stimulation factors. Dent Traumatol 2003: 19: 175–182.
Ingle JL. A standardized endodontic technique utilizing newly designed instruments and filling materials.
Oral Surg Oral Med Oral Pathol 1961: 14: 83–91.
Seltzer S, Bender IB, Smith J, Freedman I, Nazimov
H. Endodontic failures – an analysis based on clinical,
roentgenographic, and histologic findings. Oral Surg
Oral Med Oral Pathol 1967: 23: 500–530.
Kerekes K, Tronstad L. Long-term results of endodontic treatment performed with a standardized
technique. J Endod 1979: 5: 83–90.
Sinai IH, Romea DJ, Glassman G, Morse DR, Fantasia
J, Furst ML. An evaluation of tricalcium phosphate as a
treatment for endodontic perforations. J Endod 1989:
15: 399–403.
Farzaneh M, Abitbol S, Friedman S. Treatment
outcome in endodontics: the Toronto study. Phases
I and II: Orthograde retreatment. J Endod 2004: 30:
627–633.
Gorni FG, Gagliani MM. The outcome of endodontic
retreatment: a 2-yr follow-up. J Endod 2004: 30: 1–4.
Beavers RA, Bergenholtz G, Cox CF. Periodontal
wound healing following intentional root perforations
in permanent teeth of Macaca mulatta. Int Endod J
1986: 19: 36–44.
17. Lantz B, Persson PA. Experimental root perforation in
dogs’ teeth. A roentgen study. Odontol Revy 1965: 16:
238–257.
18. Lantz B, Persson PA. Periodontal tissue reactions after
root perforations in dogs’ teeth. A histologic study.
Odontol Tidskr 1967: 75: 209–237.
19. Lantz B, Persson PA. Periodontal tissue reactions after
surgical treatment of root perforations in dogs’ teeth.
A histologic study. Odontol Revy 1970: 21: 51–62.
20. Seltzer S, Sinai I, August D. Periodontal effects of root
perforations before and during endodontic procedures. J Dent Res 1970: 49: 332–339.
21. Bhaskar SN, Rappaport HM. Histologic evaluation of
endodontic procedures in dogs. Oral Surg Oral Med
Oral Pathol 1971: 31: 526–535.
22. Harris WE. A simplified method of treatment for
endodontic perforations. J Endod 1976: 2: 126–134.
23. Benenati FW, Roane JB, Biggs JT, Simon JH. Recall
evaluation of iatrogenic root perforations repaired
with amalgam and gutta-percha. J Endod 1986: 12:
161–166.
24. Lemon RR. Nonsurgical repair of perforation defects.
Internal matrix concept. Dent Clin North Am 1992:
36: 439–457.
25. Himel VT, Brady J Jr, Weir J Jr. Evaluation of repair of
mechanical perforations of the pulp chamber floor
using biodegradable tricalcium phosphate or calcium
hydroxide. J Endod 1985: 11: 161–165.
26. Balla R, LoMonaco CJ, Skribner J, Lin LM. Histological study of furcation perforations treated with
tricalcium phosphate, hydroxylapatite, amalgam, and
Life. J Endod 1991: 17: 234–238.
27. Petersson K, Hasselgren G, Tronstad L. Endodontic
treatment of experimental root perforations in dog
teeth. Endo Dent Traumatol 1985: 1: 22–28.
28. El Deeb ME, El Deeb M, Tabibi A, Jensen JR. An
evaluation of the use of amalgam, Cavit, and calcium
hydroxide in the repair of furcation perforations. J
Endod 1982: 8: 459–466.
29. Jew RC, Weine FS, Keene JJ Jr, Smulson MH. A
histologic evaluation of periodontal tissues adjacent to
root perforations filled with Cavit. Oral Surg Oral Med
Oral Pathol 1982: 54: 124–135.
30. Hartwell GR, England MC. Healing of furcation
perforations in primate teeth after repair with decalcified freeze-dried bone: a longitudinal study. J
Endod 1993: 19: 357–361.
31. Strömberg T, Hasselgren G, Bergstedt H. Endodontic
treatment of traumatic root perforations in man. A
clinical and roentgenological follow-up study. Sven
Tandlak Tidskr (Swed Dent J) 1972: 65: 457–466.
32. Frank AL. Resorption, perforations, and fractures.
Dent Clin North Am 1974: 18: 465–487.
33. Hovland EJ, Dumsha TC. Problems in the management of tooth resorption. In: Gutmann JL, Dumsha
TC, Lovdahl PE, Hovland EJ, eds. Problem Solving in
Endodontics, 3rd edn. St Louis: CV Mosby Company,
1997: 253–276.
34. Fuss Z, Assooline LS, Kaufman AY. Determination of
location of root perforations by electronic apex
105
Tsesis & Fuss
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
106
locators. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 1996: 82: 324–329.
Wong R, Cho F. Microscopic management of procedural errors. Dent Clin North Am 1997: 41: 455–479.
Daoudi MF, Saunders WP. In vitro evaluation of furcal
perforation repair using mineral trioxide aggregate or
resin modified glass ionomer cement with and without
the use of the operating microscope. J Endod 2002: 28:
512–515.
Cohen S, Liewehr F. Diagnostic procedures. In:
Cohen S, Burns RC, eds. Pathways of the Pulp, 8th
edn. St Louis, MO: CV Mosby, 2002: 12.
Fuss Z, Lustig J, Katz A, Tamse A. An evaluation of
endodontically treated vertical root fractured teeth:
impact of operative procedures. J Endod 2001: 27: 46–
48.
Tamse A. Vertical root fractures in endodontically
treated teeth: diagnostic signs and clinical management. Endod Topics 2006: 13: 84–94.
Deutsch AS, Musikant BL. Morphological measurements of anatomic landmarks in human maxillary and
mandibular molar pulp chambers. J Endod 2004: 30:
388–390.
Moreinis SA. Avoiding perforation during endodontic
access. J Am Dent Assoc 1979: 98: 707–712.
Torabinejad M, Lemon RR. Procedural accidents. In:
Walton RE, Torabinejad M, eds. Principles and
Practice of Endodontics, 3rd edn. Philadelphia: WB
Saunders, 2002: 312–331.
Krasner P, Rankow HJ. Anatomy of the pulp-chamber
floor. J Endod 2004: 30: 5–16.
Wu MK, van der Sluis LW, Wesselink PR. The risk of
furcal perforation in mandibular molars using GatesGlidden drills with anticurvature pressure. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2005: 99:
378–382.
Hülsmann M, Herbst U, Schafers F. Comparative
study of root-canal preparation using lightspeed and
quantec SC rotary NiTi instruments. Int Endod J 2003:
36: 748–756.
Schafer E, Schulz-Bongert U, Tulus G. Comparison of
hand stainless steel and nickel titanium rotary instrumentation: a clinical study. J Endod 2004: 30: 432–
435.
Kuttler S, McLean A, Dorn S, Fischzang A. The
impact of post space preparation with Gates–Glidden
drills on residual dentin thickness in distal roots of
mandibular molars. J Am Dent Assoc 2004: 135: 903–
909.
Peeso FA. The ‘‘ABC’’ of crown and bridge work.
Dent Cosmos 1903: 45: 274–279.
Grossman LI. Endodontic Practice, 8th edn. Philadelphia: Lea & Febiger, 1974, p. 205.
Alhadainy HA. Root perforations. A review of
literature. Oral Surg Oral Med Oral Pathol 1994: 78:
368–374.
Levin MP, Getter L, Cutright DE, Bhaskar SN.
Biodegradable ceramic in periodontal defects. Oral
Surg Oral Med Oral Pathol 1974: 38: 344–351.
52. Weisman MI. Treatment of an unusual perforation of
an anterior tooth; report of a case. Oral Surg Oral Med
Oral Pathol 1959: 12: 732–735.
53. Alhadainy HA, Himel VT. An in vitro evaluation of
plaster of Paris barriers used under amalgam and glass
ionomer to repair furcation perforations. J Endod
1994: 20: 449–452.
54. Rafter M, Baker M, Alves M, Daniel J, Remeikis N.
Evaluation of healing with use of an internal matrix to
repair furcation perforations. Int Endod J 2002: 35:
775–783.
55. Bogaerts P. Treatment of root perforations with
calcium hydroxide and SuperEBA cement: a clinical
report. Int Endod J 1997: 30: 210–219.
56. Bramante CM, Berbert A. Root perforations dressed
with calcium hydroxide or zinc oxide and eugenol.
J Endod 1987: 13: 392–395.
57. Roane JB, Benenati FW. Successful management of a
perforated molar using amalgam and hydroxylapatite.
J Endod 1987: 13: 400–404.
58. Fuss Z, Abramovitz I, Metzger Z. Sealing furcation
perforations with silver glass ionomer cement: an in
vitro evaluation. J Endod 2000: 26: 466–468.
59. Resillez-Urioste F, Sanandajt K, Davidson RM. Use of
a resin-ionomer in the treatment of mechanical root
perforation: report of a case. Quintessence Int 1998:
29: 115–118.
60. Ford TR, Torabinejad M, McKendry DJ, Hong CU,
Kariyawasam SP. Use of mineral trioxide aggregate for
repair of furcal perforations. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1995: 79: 756–763.
61. Holland R, Filho JA, de Souza V, Nery MJ,
Bernabe PF, Junior ED. Mineral trioxide aggregate
repair of lateral root perforations. J Endod 2001: 27:
281–284.
62. Parreidt R. Root perforation and its treatment. Dent
Cosmos 1903: 45: 580.
63. Auslander WP, Weinberg G. Anatomic repair of
internal perforations with indium foil and silver
amalgam: outline of a method. NY J Dent 1969: 39:
454–457.
64. Aguirre R, ElDeeb ME, ElDeeb M. Evaluation of the
repair of mechanical furcation perforations using
amalgam, gutta-percha, or indium foil. J Endod 1986:
12: 249–256.
65. Bargholz C. Perforation repair with mineral trioxide
aggregate: a modified matrix concept. Int Endod J
2005: 38: 59–69.
66. Alhadainy HA, Himel VT, Lee WB, Elbaghdady YM.
Use of a hydroxylapatite-based material and calcium
sulfate as artificial floors to repair furcal perforations.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1998: 86: 723–729.
67. Lee SJ, Monsef M, Torabinejad M. Sealing ability of a
mineral trioxide aggregate for repair of lateral root
perforations. J Endod 1993: 19: 541–544.
68. Ferris DM, Baumgartner JC. Perforation repair
comparing two types of mineral trioxide aggregate. J
Endod 2004: 30: 422–424.
Accidental root perforations
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
Weldon JK Jr, Pashley DH, Loushine RJ, Weller RN,
Kimbrough WF. Sealing ability of mineral trioxide
aggregate and super-EBA when used as furcation
repair materials: a longitudinal study. J Endod 2002:
28: 467–470.
Holland R, de Souza V, Nery MJ, Otoboni Filho JA,
Bernabe PF, Dezan Junior E. Reaction of dogs’ teeth
to root canal filling with mineral trioxide aggregate or
a glass ionomer sealer. J Endod 1999: 25: 728–730.
Arens DE, Torabinejad M. Repair of furcal perforations with mineral trioxide aggregate: two case
reports. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 1996: 82: 84–88.
Main C, Mirzayan N, Shabahang S, Torabinejad M.
Repair of root perforations using mineral trioxide
aggregate: a long-term study. J Endod 2004: 30: 80–83.
Estrela C, Bammann LL, Estrela CR, Silva RS, Pecora
JD. Antimicrobial and chemical study of MTA, Portland cement, calcium hydroxide paste, Sealapex and
Dycal. Braz Dent J 2000: 11: 3–9.
Asgary S, Parirokh M, Eghbal MJ, Brink F. Chemical
differences between white and gray mineral trioxide
aggregate. J Endod 2005: 31: 101–103.
Ribeiro DA, Duarte MA, Matsumoto MA, Marques
ME, Salvadori DM. Biocompatibility in vitro tests of
mineral trioxide aggregate and regular and white
Portland cements. J Endod 2005: 31: 605–607.
Ribeiro DA, Sugui MM, Matsumoto MA, Duarte MA,
Marques ME, Salvadori DM. Genotoxicity and
cytotoxicity of mineral trioxide aggregate and regular
and white Portland cements on Chinese hamster ovary
(CHO) cells in vitro. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2006: 101: 258–261.
Saidon J, He J, Zhu Q, Safavi K, Spangberg LS. Cell
and tissue reactions to mineral trioxide aggregate and
Portland cement. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2003: 95: 483–489.
Menezes R, Bramante CM, Letra A, Carvalho VG,
Garcia RB. Histologic evaluation of pulpotomies in
dog using two types of mineral trioxide aggregate and
regular and white Portland cements as wound dressings. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2004: 98: 376–379.
Rud J, Andreasen JO, Jensen JF. A multivariate analysis
of the influence of various factors upon healing after
endodontic surgery. Int J Oral Surg 1972: 1: 258–271.
Rud J, Rud V, Munksgaard EC. Retrograde sealing of
accidental root perforations with dentin-bonded
composite resin. J Endod 1998: 24: 671–677.
Tsesis I, Rosen E, Schwartz-Arad D, Fuss Z. Retrospective evaluation of surgical endodontic treatment:
traditional vs. modern technique. J Endod, (in press).
Oswald RJ. Procedural accidents and their repair. Dent
Clin North Am 1979: 23: 593–616.
Arens D. Practical Lessons in Endodontic Surgery. Carol
Stream, IL: Quintessence Books, 1998: 187–190.
Luebke RG, Dow PR. Correction of an endodontic
root perforation. Oral Surg Oral Med Oral Pathol
1964: 17: 98–101.
85. Witherspoon DE, Gutmann JL. Haemostasis in
periradicular surgery. Int Endod J 1996: 29:
135–149.
86. Walia H, Streiff J, Gerstein H. Use of a hemostatic
agent in the repair of procedural errors. J Endod 1988:
14: 465–468.
87. Kim S, Rethnam S. Hemostasis in endodontic
microsurgery. Dent Clin North Am 1997: 41: 499–
511.
88. Vy CH, Baumgartner JC, Marshall JG. Cardiovascular
effects and efficacy of a hemostatic agent in periradicular surgery. J Endod 2004: 30: 379–383.
89. Goon WW, Lundergan WP. Redemption of a perforated furcation with a multidisciplinary treatment
approach. J Endod 1995: 21: 576–579.
90. Barkhordar RA, Javid B. Treatment of endodontic
perforations by guided tissue regeneration. Gen Dent
2000: 48: 422–426.
91. Duggins LD, Clay JR, Himel VT, Dean JW. A
combined endodontic retrofill and periodontal guided
tissue regeneration technique for the repair of molar
endodontic furcation perforations: report of a case.
Quintessence Int 1994: 25: 109–114.
92. Dean JW, Lenox RA, Lucas FL, Culley WL, Himel VT.
Evaluation of a combined surgical repair and guided
tissue regeneration technique to treat recent root canal
perforations. J Endod 1997: 23: 525–532.
93. Grossman LI. Intentional replantation of teeth. J Am
Dent Assoc 1966: 72: 1111–1118.
94. Weine FS. The case against intentional replantation. J
Am Dent Assoc 1980: 100: 664–668.
95. Kratchman S. Intentional replantation. Dent Clin
North Am 1997: 41: 603–617.
96. Bender IB, Rossman LE. Intentional replantation of
endodontically treated teeth. Oral Surg Oral Med Oral
Pathol 1993: 76: 623–630.
97. Demiralp B, Nohutcu RM, Tepe DI, Eratalay K.
Intentional replantation for periodontally involved
hopeless teeth. Dent Traumatol 2003: 19: 45–51.
98. Raghoebar GM, Vissink A. Results of intentional
replantation of molars. J Oral Maxillofac Surg 1999:
57: 240–244.
99. Koenig KH, Nguyen NT, Barkhordar RA. Intentional
replantation: a report of 192 cases. Gen Dent 1988: 36:
327–331.
100. Barnett RJ, Burton WE, Nuckles DB. Intentional
replantation: report of a successful case. Quintessence
Int 1992: 23: 755–757.
101. Tang PM, Chan CP, Huang SK, Huang CC. Intentional replantation for iatrogenic perforation of the
furcation: a case report. Quintessence Int 1996: 27:
691–696.
102. Poi WR, Sonoda CK, Salineiro SL, Martin SC.
Treatment of root perforation by intentional reimplantation: a case report. Endod Dent Traumatol 1999:
15: 132–134.
103. Shuman IE. Repair of a root perforation with a resinionomer using an intentional replantation technique.
Gen Dent 1999: 47: 392–395.
107