|Year : 2013 | Volume
| Issue : 1 | Page : 34-38
Retreatment and surgical repair of the apical third perforation and osseous defect using mineral trioxide aggregate
A Savitha1, A Sri Rekha1, Ida Ataide2, Jayshree Hegde1
1 Department of Conservative Dentistry and Endodontics, Oxford Dental College and Hospital, Bangalore, India
2 Department of Conservative Dentistry and Endodontics, Goa Dental College and Hospital, Bambolim, Goa, India
|Date of Web Publication||7-Aug-2013|
Department of Conservative Dentistry and Endodontics, Oxford Dental College and Hospital, Bommanahalli, Hosur Road, Bangalore - 560 068, Karnataka
Source of Support: None, Conflict of Interest: None
One of the causes of non-healing periapical pathosis in endodontically treated tooth is root perforation. This can occur pathologically by resorption and caries, iatrogenically during endodontic therapy (zip, strip, furcal perforations). Root perforation results in bacterial contamination, periradicular tissue injury, inflammation, and bone resorption. The purpose of this case report is to describe endodontic retreatment and surgical management of a longstanding periapical lesion on maxillary lateral incisor, associated with perforation and osseous defects using mineral trioxide aggregate (MTA). Although the majority of bone support and root dentin was damaged, an attempt was made to repair the defect and restore the tooth. After the surgical intervention and root canal treatment, the perforation was subsequently sealed with MTA. Later, the root was reinforced with composites and the tooth was restored with direct veneer. Conclusion: Four-and-a-half year (54 months) recall examination showed no evidence of periodontal breakdown, no symptoms of further deterioration, and complete healing of periradicular lesions when examined by radiography. This case report presents a treatment strategy that could improve the healing process and beneficial outcomes for patients with perforation and osseous defect.
Keywords: Guided tissue regeneration, mineral trioxide aggregate, osseous defect, root perforation, root reinforcement, surgical repair
|How to cite this article:|
Savitha A, Rekha A S, Ataide I, Hegde J. Retreatment and surgical repair of the apical third perforation and osseous defect using mineral trioxide aggregate. Saudi Endod J 2013;3:34-8
|How to cite this URL:|
Savitha A, Rekha A S, Ataide I, Hegde J. Retreatment and surgical repair of the apical third perforation and osseous defect using mineral trioxide aggregate. Saudi Endod J [serial online] 2013 [cited 2020 Jun 2];3:34-8. Available from: http://www.saudiendodj.com/text.asp?2013/3/1/34/116282
| Introduction|| |
Most root canals fail mainly due to microleakage and bacterial infection. The presence of a new or persistent periapical radiolucency adjacent to a root filled tooth is often used as a criterion for endodontic treatment failure.  Most common causes of endodontic failure are due to incomplete obturation, inadequate coronal seal, missed canals, iatrogenic events like radicular fractures, instrument separation, and lateral perforations. Regardless of the etiology, the sum of all causes is leakage or repeated bacterial contamination.  One of the most perplexing conditions is to treat a tooth with constant purulent exudation associated with large apical radiolucency. Difficulty in endodontic treatment of such cases may be compounded by the presence of root perforation. Such perforation is induced by iatrogenic causes, resorptive processes, or caries. 
Perforations can be managed surgically or non-surgically depending on various factors such as accessibility and visibility, duration and size of perforation, periodontal status, the quality of root canal treatment (RCT), the strategic importance of the tooth, patient's preference, operator's experience and skill, technical feasibility, and overall cost. 
A material with excellent sealing property, mineral trioxide aggregate (MTA) was introduced by Torabinejad et al.,  who later described clinical procedures for application of MTA in capping of pulps with reversible pulpitis, apexification, repair of root perforations non-surgically and surgically, as well as its use as a root-end filling material.  Studies reported that perforated roots treated with MTA showed non-inflammatory tissue layer  and less leakage when compared with other materials such as amalgam, intermediate restorative material (IRM), super EBA, etc., , MTA induces osteogenesis and cementogenesis,  and newly formed cementum coverage occurred which is unique and had not been demonstrated with any other material. 
The present paper describes management strategy and favorable clinical outcome in case of long-standing lesion in maxillary lateral incisor associated with iatrogenic apical third perforation with one-walled osseous defect using MTA.
| Case Report|| |
A 38-year-oldmale patient, reported to the Department of Endodontics with complaints of pain in relation to maxillary left lateral incisor for the past 1 month. History revealed that the patient hadtrauma to that particular tooth about 10 years agoandhad undergone RCT by a general dentist about a year ago. The dull aching intermittent pain persisted even after RCT. So the patient chose to seek a second opinion. On clinical examination, tooth was found to bediscolored. Soft tissue examination revealed an intraoral sinus opening between maxillary left lateral incisor and canine with pus discharge. Left lateral incisor was tender on percussion with probing depth of more than 6 mm.
Radiographic examination revealed large periapical radiolucency at the periapex of the root canal treated left maxillary lateral incisor [Figure 1]a, and diagnosed as a secondary root canal infection with chronic periradicular periodontitis. Treatment options were discussed with the patient and retreatment of the tooth was initiated.
|Figure 1: (a) Preoperative radiograph showing root canal filling in maxillary lateral incisor, large radiolucency with radio-opaque piece of material at the periapex, (b) Arrows showing the extension of radiolucency. Radiograph with #20 file in place confirming lateral perforation in the distal aspect of the toot|
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On removing gutta percha (GP) from the canal, copious exudate was observed. A lateral root perforation was suspected and confirmed with a radiograph [Figure 1]b. Cleaning and shaping was performed with copious irrigation of 2.5% sodium hypochlorite (NaOCl), saline, and then calcium hydroxide (Ca(OH) 2 ) mixed with 2% chlorhexidine intracanal medicament was placed in the canal for 2 weeks.
Bleeding and purulent discharge persisted in the subsequent visit and surgical intervention seemed inevitable. Following local anesthesia (Lidocaine 2%) sulcular incision was placed from the mesial surface of the left maxillary central incisor to the distal surface of left maxillary canine. A full-thickness mucoperiosteal flap was reflected beyond the apical portion to expose the defects [Figure 2]a. Complete loss of the buccal cortical plate in left lateral incisor with intact palatal cortical plate was noted in maxillary left incisors and canine. Inspite of the extensive bone loss, no mobility of the tooth was noted and no root fracture was detected. Granulomatous tissue within the defect area and the epithelium from the inner surface of the flap were carefully removed using 4R/4L curette (Hu-Friedy, Chicago, IL, USA); followed by thorough planning of root surface [Figure 2]b. The area was rinsed with saline solution, and the flap was placed back. Subsequently RCT in lateral incisor was completed after obturating #80 size GP master cone and AH-plus sealer (Dentsply, Maillefer, Ballaigues, Switzerland) using the lateral condensation technique. Access cavity was restored with IRM (Dentsply Konstanz, Germany). After the removal of the rubber dam, the flap was re-reflected, defect area was rinsed and the perforation defects were sealed with MTA [Figure 3]a.
|Figure 2: (a) After flap reflection exposing the apical perforation defect and complete loss of the buccal cortical plate on lateral incisor, (b) Granulation tissue curettage to visualize the labial and distal perforation defects at the apical third of the root|
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|Figure 3: (a) Perforation defects were sealed with MTA, after root canal obturation, (b) Periapical radiograph after root reinforcement (1 week post-op)|
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The flap was repositioned without tension and sutured interproximally with non-absorbable sutures (Silk; Dogsan Turkey). After the surgery, Amoxicillin 500 mg thrice daily (TID) for 7 days and Ibuprofen 400 mg (TID) for 3 days were prescribed to the patient. On recall after a week, healing was uneventful, the desired gingival contour was achieved, and sutures were removed.
Thin root dentin of the maxillary lateral incisor was reinforced using paracore composite resin (Coltene Whaledent Inc, USA) along with the light-transmitting post (Luminex post Dentatus, Weissman Technology). After reinforcement, Tenax fibre trans (Coltene Whaledent Inc USA) was bonded in the canal according to manufacturer's instructions and the access cavity was restored with composite resin [Figure 3]b. Then the tooth was restored with direct composite veneer as a temporary esthetic restoration.
Follow-up appointments (3, 6, 18, and 54 months) showed no signs of periodontal breakdown and the tooth was asymptomatic with normal probing depth. Follow-up radiographic examination up to 54 months [Figure 4] suggested favorable healing of periradicular pathosis.
|Figure 4: Fifty-four months recall radiograph showing complete healing of lateral and apical radiolucencies|
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| Discussion|| |
Perforations during endodontic procedures are cited as the second greatest cause of treatment failures.  Transportation of the apical region occur because the instrument straightens itself in the apically curved canals.  In the present case, iatrogenic apical perforation in maxillary lateral incisor had resulted in bacterial infection with excessive bone resorption creating an osseous defect. The perforation was diagnosed by tracing the sinus tract using periapical radiography, which was accompanied by a deep periodontal pocket.
As suggested by Alhadainy, several options exist, when considering treatment of teeth with failing endodontic therapy, including no treatment, endodontic retreatment, endodontic surgery, or extraction. 
Major goals of retreatment of endodontically failed teeth include cases that involve thorough debridement, disinfection and obturation of previously treated canals to remove all etiological factors, without compromising on the root dentin. Gaining access to prepare and seal the perforation and osseous defect with a biocompatible material and maintain an intact periodontal attachment apparatus. 
Surgical intervention is reserved for cases not amenable to, or which have failed to respond to non-surgical retreatment, or in which the concomitant management of the periodontium is indicated.  To obtain isolation and render the root canal sterile, during perforation repair surgical intervention appeared mandatory in this case.
Literature studies reported that surgical repair of the perforation and osseous defect involved periodontal flap reflection, curettage, restoration of the perforation defect with MTA, Geristore, or glass ionomer cement or composite. Osseous defects are managed by guided tissue regenerative (GTR) techniques ,,, like the placement of Goretex membrane to prevent invasion of epithelial tissue. Demineralized freezed dried bone and platelet-rich fibrin (PRF) mixed with graft materials  were also used to treat osseous defects. Recent successful approaches to repair perforation are use of biomimetic-based regenerative techniques and materials such as dental pulp stem cells (DPSC cells), dentin matrix protein (DMP1) and signaling molecule, delivered to the perforation site using a collagen scaffold. 
In this situation, MTA was used to repair the defect because there is evidence to suggest that periodontal reattachment is possible  and it can provide a biocompatible surface for the possible adhesion or attachment of bone and cementum. , In addition, MTA appears to provide a long-term effective seal for root perforations in all parts of the root,  which eliminates the microleakage  and inhibits the activity of bacteria.  MTA is not affected in the presence of moisture and blood, and also is able to harden and form a barrier because of its hydrophilic characteristics.  Moisture from the surrounding tissue acts as an activator of chemical reaction in this material as suggested by Torabinejad et al.  In previous studies, MTA was used as a barrier between the root canal space and the periodontal tissue in cases of root perforation in dogs , and humans.  The use of MTA as a repair material demonstrated favorable healing in root  and furcal perforations. , White and Bryant  reported an increase in radiodense crestal bone when the MTA was used in combination with GTR to fill an external root resorption associated with a bony defect.
In the present case white MTA-Angelus (Angelus, Londrina, PR, Brazil) was used because it has good handling characteristics in addition to faster setting time (setting time is 10 min since it does not contain calcium sulfate) and is cost effective when compared to ProRoot MTA. Studies have found that gray and the white versions of MTA perform similarly in terms of furcal sealing , and antimicrobial effectiveness.  In addition MTA-Angelus has a high pH and greater release of calcium in the first 24 h of activation possibly because of the greater amount of Portland cement (80%) or other calcium-releasing agents. 
In the present case, it is difficult to conclude unequivocally that true regeneration has occurred, because no histological sections were observed. However, Perinpanayagam and Al-Rabeah  showed that MTA surfaces support osteoblast cell attachment that is essential for osteogenesis; Hakki et al.,  have also demonstrated that MTA does not have a negative effect on the viability and morphology of cementoblasts and induced biomineralization of cementoblasts.
Anterior teeth having wide flared canals with thin root dentin are at high risk of fracture. Strengthening the root can be done by internally reinforcing the root with composite. Hence the root reinforcement procedure was considered. To achieve adequate cure of the material in the apical extent and to ensure greater composite thickness bonded to the internal aspect of the root canal, a light-transmitting Luminex post was used to direct light to the entire root canal. Studies proved that weakened teeth restored in this manner have been shown to be 50% more resistant to fracture than those without composite resin reinforcement. 
| Conclusions|| |
This case report presents a favorable clinical outcome in perforation repair with MTA. From the endodontic perspective, complications were successfully resolved due to the effective sealing of the perforation. From the periodontal perspective, the attachment apparatus has regenerated to establish periodontal health. So the prognosis for this tooth treated with MTA using the described procedure is considered to be very good.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]