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Table of Contents
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 117-120

The management of complex perforation in a maxillary central incisor

Department of Conservative Dentistry and Endodontics, SRM Dental College, SRM Institute of Science and Technology, Ramapuram Campus, Chennai, Tamil Nadu, India

Date of Submission15-Jul-2022
Date of Acceptance16-Nov-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Dr. Sekar Mahalaxmi
Department of Conservative Dentistry and Endodontics, SRM Dental College, SRM Institute of Science and Technology, Ramapuram Campus, Bharathi Salai, Ramapuram, Chennai - 600 089, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jid.jid_17_22

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Root perforations severely affect the prognosis of the teeth. This case report presents the successful management of a complex perforation with mineral trioxide aggregate (MTA) and fiber post. MTA was used to seal the perforation site since it is regarded as one of the ideal materials for perforation repair. Following retreatment and perforation repair, the root canal was rehabilitated using fiber post and composite resin. The elimination of the clinical signs and symptoms is the primary goal of successful treatment. One-year follow-up showed healthy periodontium with no clinical signs and symptoms.

Keywords: Fiber post, mineral trioxide aggregate, perforation, perforation repair, retreatment

How to cite this article:
Kumar PS, Karthikeyan K, Mahalaxmi S. The management of complex perforation in a maxillary central incisor. J Interdiscip Dentistry 2022;12:117-20

How to cite this URL:
Kumar PS, Karthikeyan K, Mahalaxmi S. The management of complex perforation in a maxillary central incisor. J Interdiscip Dentistry [serial online] 2022 [cited 2023 Feb 5];12:117-20. Available from: https://www.jidonline.com/text.asp?2022/12/3/117/365607

   Clinical Relevance to Interdisciplinary Dentistry Top

Although the prognosis is guarded, the tooth has been restored endodontically which facilitated periodontal healing.

   Introduction Top

Root perforation can occur either iatrogenically during access cavity, root canal, and post space preparations or pathologically due to caries and extension of internal resorption. Root perforation is the artificial communication between the root canal and the periradicular tissues or with the oral cavity.[1] It is the second-most common cause for endodontic failure accounting about 9.62%.[2] Root perforations are substantial impediments of endodontic treatment. Nevertheless, when teeth are of judicious value, perforation repair is distinctly pertinent.[3]

Although various materials such as amalgam, Cavit, super-ethoxy benzoic acid, glass ionomer, and composite resin were used in the past for perforation repair, with the advent of bioinductive materials mineral trioxide aggregate (MTA) and other calcium silicate-based materials are being preferred. MTA was initially developed as root end-filling material but later its use has been extended to pulp capping, apexification, and for perforation repair.[4] MTA has good sealing ability, biocompatibility, bactericidal effect, radiopacity, and ability to set in the presence of blood.[5] Hence, MTA has been widely advocated to seal the perforations. This case report describes the management of complex perforation in a maxillary central incisor.

   Case Report Top

A 21-year-old female patient reported to the department with dull, continuous, and localized pain in the upper front tooth region for the past 1 month, with a history of root canal treatment done 1 year ago. The patient's medical history revealed no relevant findings. Upon clinical examination [Figure 1]a and [Figure 1]b, caries was observed in the cervical region extending subgingivally on the facial surface of the maxillary left central incisor communicating with a palatal opening. The tooth was tender to percussion and the radiograph [Figure 2]a revealed intracanal radiopaque material, radiolucency extended from the middle third of the crown to the coronal one-third of the root.
Figure 1: (a) Preoperative buccal view, (b) Preoperative palatal view, (c) postoperative, (d) Veener preparation, (e) Isolation with retraction cord and Teflon tape, (f) Postoperative after composite veneering

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Figure 2: (a) Preoperative radiograph, (b) Master cone, (c) Ca (OH) 2 intracanal medicament, (d) Obturation, (e) Post space preparation and perforation repair with MTA, (f) FRC postluted and core buildup, (g) 6-month follow-up, (h) 1-year follow-up. MTA = mineral trioxide aggregate, FRC = Fiber-reinforced composite

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The case was diagnosed as previously treated 21 with large crestal root perforation. The tooth had guarded prognosis due to the large complex perforation. Treatment options were discussed with the patient and an informed consent was obtained. The patient desired to retain the tooth until the time she could afford implant placement, and treatment planning of perforation repair with MTA (MTA Angelus, Londrina-PR Brazil) was suggested. Local anesthesia was administered and anterior teeth were isolated with a rubber dam using a split-dam technique. The access cavity preparation was redefined, and old gutta-percha was removed using gutta percha solvent (RC solve, Prime Dental Products PVT LTD, India). Cleaning and shaping were done in step-back motion with apical size of 60# K-file (Mani INC. Tochigi, Japan) [Figure 2]b and calcium hydroxide (ApexCal, Ivoclar Vivadent, Liechtenstein) was kept as an intracanal medicament for 7 days [Figure 2]c. The coronal access was sealed with Cavit G (3M ESPE, Germany).

A week later on the next appointment, the tooth was asymptomatic. Obturation was performed using gutta-percha and AH Plus sealer (Dentsply, Germany) by lateral condensation technique [Figure 2]d. The post space preparation was done using peeso reamer till no 3 size (Mani INC. Tochigi, Japan) after 24 h during the next appointment followed by perforation repair with MTA [Figure 2]e. In the subsequent visit, fiber-reinforced composite (FRC) post (Ivoclar Vivadent, Liechtenstein) was luted using dual resin cement (Variolink N, Ivoclar Vivadent, Liechtenstein) and the core buildup was done using composite resin (Tetric N-Ceram, Ivoclar Vivadent, Liechtenstein) [Figure 2]f. Direct composite veneering was done to mask the discoloration and improve the esthetics [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f. Follow up radiographs were taken at 6 months [Figure 2]g and 1year [Figure 2]h.

   Discussion Top

Root perforation impairs the prognosis of the tooth. There are several factors which effect the prognosis of a tooth, namely, location, size, and the time delay before repair. The crestal, old, and large perforations over a size of 20 size K-file have a guarded prognosis. The present case had an old, large, crestal, and old perforation, which may have been an iatrogenic perforation with additional caries causing a large defect; hence shows guarded prognosis.[1] Hence, this was referred to as a complex perforation. Crestal perforations have guarded prognosis due to close interproximity with the gingival sulcus. Since it is difficult to completely seal such large perforations, chances of bacterial contamination during and after their repair is higher, thereby having a guarded prognosis.[6] Due to the degree of the tooth structure loss, the tooth was initially planned for extraction but owing to the favorable periodontal conditions and the age of the patient. The possibility of conserving the tooth till the time of implant placement was considered through a combination of nonsurgical endodontic retreatment, MTA perforation repair followed by fiber post reinforcement.

Coronal and apical seals play an important role in the success of root canal treatment. The coronal seal will impede the microleakage of saliva into the root canal space. Once when the coronal seal is lost, saliva microleakage ensues leading recolonization of microbes and their byproducts in the root canal space.[7] Hence, the old gutta-percha was removed and thorough cleaning and shaping were done. In the present case, calcium hydroxide was used as an interappointment dressing. Apart from antibacterial activity, calcium hydroxide aids to prevent interappointment flare up. A recent systematic review had also reported that the placement of calcium hydroxide tends to reduce pain 24–48 h following the first visit of endodontic treatment.[8] MTA is biocompatible with the surrounding tissues and also has the ability to allow the regeneration of these periradicular hard tissues. Since the pH is alkaline, it inhibits the growth of microorganisms. Moreover, studies have shown that MTA possesses good sealing ability and sets in the presence of moisture.[9]

The occlusal loading in anterior teeth results in the formation of cervical stress with significant increase of tensile stress. This eventually leads to the loss of tooth structure in the cervical region.[10] Owing to the above-mentioned concept, in the present case report, the tooth has been reinforced using fiber post. In addition to this, more homogeneous distribution of stress is achieved when a fiber post is used instead of a rigid post and thereby preventing the fracture of the root. The elastic modulus of the fiber post which is similar to that of dentin and the adhesive bonding of the post to the root canal and composite core material.[11]

Esthetic management of such defects in the anterior teeth is challenging, especially when the loss of tooth structure is extensive. For this purpose, the most conservative treatment option of veneer was chosen. At 1-year recall on clinical and radiological evaluation, the tooth and the periapical area showed signs of normality, and the patient was satisfied to keep the tooth. A good seal provided by the MTA and composite resin could be a deciding factor in the long-term survival of the tooth.

   Conclusion Top

The treatment done can be regarded as successful both clinically and radiographically because at 1-year recall, the tooth remained asymptomatic with healing was evident in the perforation site. However, the follow-up needs to be continued further on a yearly period to evaluate the long-term effect of the treatment protocol.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Fuss Z, Trope M. Root perforations: Classification and treatment choices based on prognostic factors. Endod Dent Traumatol 1996;12:255-64.  Back to cited text no. 1
Ingle JI. A standardized endodontic technique utilizing newly designed instruments and filling materials. Oral Surg Oral Med Oral Pathol 1961;14:83-91.  Back to cited text no. 2
Breault LG, Fowler EB, Primack PD. Endodontic perforation repair with resin-ionomer: A case report. J Contemp Dent Pract 2000;1:48-59.  Back to cited text no. 3
Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197-205.  Back to cited text no. 4
Malhotra N, Agarwal A, Mala K. Mineral trioxide aggregate: A review of physical properties. Compend Contin Educ Dent 2013;34:e25-32.  Back to cited text no. 5
Tsesis I, Fuss ZV. Diagnosis and treatment of accidental root perforations. Endod Top 2006;13:95-107.  Back to cited text no. 6
Swanson K, Madison S. An evaluation of coronal microleakage in endodontically treated teeth. Part I. Time periods. J Endod 1987;13:56-9.  Back to cited text no. 7
Ahmad MZ, Sadaf D, Merdad KA, Almohaimeed A, Onakpoya IJ. Calcium hydroxide as an intracanal medication for postoperative pain during primary root canal therapy: A systematic review and meta-analysis with trial sequential analysis of randomised controlled trials. J Evid Based Dent Pract 2022;22:101680.  Back to cited text no. 8
Main C, Mirzayan N, Shabahang S, Torabinejad M. Repair of root perforations using mineral trioxide aggregate: A long-term study. J Endod 2004;30:80-3.  Back to cited text no. 9
Reddy K, Reddy S, Rao B, Kshitish D, Mannem S. Cervical stress due to normal occlusal loads is a cause for abfraction? A finite element model study. J Orofac Sci 2012;4:120.  Back to cited text no. 10
Lamichhane A, Xu C, Zhang FQ. Dental fiber-post resin base material: A review. J Adv Prosthodont 2014;6:60-5.  Back to cited text no. 11


  [Figure 1], [Figure 2]


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