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Year : 2014  |  Volume : 4  |  Issue : 3  |  Page : 141-144

Management of iatrogenic root perforation with pulp canal obliteration

Departments of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India

Date of Web Publication6-Aug-2014

Correspondence Address:
Aishvarya Kaushik
Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, Bahadur Shah Zafar Marg, New Delhi 110 002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-5984.138148

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Iatrogenic root perforations, which may have serious implications, occur in approximately 2-12% of endodontically treated teeth. Successful management of root perforations is dependent on early diagnosis of the defect, location of the perforation, choice of treatment, materials used, host response, and the experience of the practitioner. This report presents the successful management of an iatrogenic perforation in a tooth with radiographic evidence of pulp canal obliteration.

Keywords: Dental operating microscope, iatrogenic root perforation, pulp canal obliteration

How to cite this article:
Kaushik A, Talwar S, Yadav S, Chaudhary S, Nawal RR. Management of iatrogenic root perforation with pulp canal obliteration. Saudi Endod J 2014;4:141-4

How to cite this URL:
Kaushik A, Talwar S, Yadav S, Chaudhary S, Nawal RR. Management of iatrogenic root perforation with pulp canal obliteration. Saudi Endod J [serial online] 2014 [cited 2023 Feb 1];4:141-4. Available from: https://www.saudiendodj.com/text.asp?2014/4/3/141/138148

  Introduction Top

Root perforation is an artificial communication between root canal system and the supporting tissues of teeth or the oral cavity. [1] Causes of root perforations include iatrogenic causes, root resorption and caries. [2],[3],[4] Often, the cause is iatrogenic as a result of misaligned use of rotary burs during endodontic access preparation and search for root canal orifices. [5] Inappropriate post space preparation for permanent restoration of endodontically treated teeth is another common iatrogenic cause of iatrogenic perforation. [5]

Bacterial infection emanating either from the root canal or the periodontal tissues, or both, prevents healing and brings about inflammatory sequelae where exposure of the supporting tissues is inflicted. [6] 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 perforations or perforations in furcation of multirooted teeth. [7]

The present case report illustrates the successful surgical management of an iatrogenic perforation at a level just apical to the cemento-enamel junction on the labial aspect of an upper central incisor. The case was complicated with the filling of the perforation canal with gutta-percha.

  Case report Top

A 32-year-old Indian female reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of redness in gingiva in relation to the front tooth since 6 months. The patient had underwent root canal treatment of her upper left central (#21) and lateral incisors (#22) about 1 year ago, following which redness and occasional pus discharge started from the gingiva in relation to the central incisor. Prior to reporting to the institution, the patient managed the symptoms with over the counter prescription drugs.

At the time of clinical presentation, there was erythema in the labial attached gingiva in relation to tooth #21. Periodontal probing revealed a 4 mm deep periodontal pocket on the labial aspect of tooth #21 corresponding to the area of erythema [Figure 1]a]. Intra-oral periapical radiograph revealed short of length radiopaque filling material in tooth #21 and poorly condensed root canal filling in tooth #22 [Figure 1]b]. However, no evidence of periapical pathology was present in relation to either tooth. Also, radiographic evidence of pulp canal obliteration was seen in the apical two thirds of the root canal of tooth 21. Based on the clinical findings, retreatment of tooth #21 was planned.
Figure 1: (a) Pre operative clinical view depicting localized area of erythema in relation to attached gingiva of tooth #21 (b) Pre operative radiograph of tooth #21

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Access was regained under rubber dam isolation (Hygienic dental dam, Coltene, Whaledent, Germany), following which gutta-percha was retrieved with gutta-percha Endosolv-E solvent (Septodont, Paris, France) and H-files (Dentsply, Maillefer, Tulsa, USA). It was only following complete removal of gutta-percha that it was realized that it was an iatrogenically created perforation canal into which the gutta-percha was condensed. This perforation communicated with the oral cavity. The identification of the root canal orifice was done (palatal to the perforation) while operating under the dental operating microscope (Carl Zeiss Meditec, Inc., USA) [Figure 2]. The orifice was enlarged with Gates-Glidden drills. It was decided to complete the root canal treatment followed by surgical exposure of the perforation and its sealing with biodentine (Septodont). Following working length determination and shaping and cleaning with K type instruments (Dentsply, Maillefer, Tulsa, USA) [Figure 3]a], calcium hydroxide (Endocal, Septodont) was administered as intracanal medicament. The access preparation was sealed with a cotton pellet and Cimpat® pink (Septodont).
Figure 2: Clinical view of the root canal orifice located palatal to the perforation

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After 1 week, obturation was completed with gutta-percha and AH plus sealer [Figure 3]b and c]. In the same appointment, an envelope flap was raised, perforation identified just apical to the cemento-enamel junction of tooth #21 [Figure 4]a and b]. While maintaining hemostasis, the perforation was sealed with biodentine (Septodont) [Figure 4]c and d]. Following the setting of biodentine, polishing was done with polishing stones (Shofu Dental Corporation, San Marcos, CA, USA) with light pressure. The flap was reapproximated with 3-0 silk sutures. The access preparation was restored with light cured composite. (Tetric N Ceram, Ivoclar, Vivadent). The patient was put on periodic follow-up examinations. At the 2 month recall visit, satisfactory periodontal healing was elicited with return of probing depth to physiologic levels (2 mm). Following uneventful healing, the tooth was permanently restored with full coverage restoration [Figure 5]. At 6 month follow-up visit, the patient was symptom free with favourable healing of periradicular tissues.
Figure 3: (a) Working length IOPA radiograph of tooth #21. (b) Master cone IOPA radiograph. (c) Radiograph showing obturation

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Figure 4: (a) Surgical exposure of the perforation located just apical to the cemento - enamel junction. (b) Clinical view of the pulp chamber following obturation of the root canal, showing perforation located labial to the canal orifice. (c) Repair of the perforation with biodentine. (d) Clinical view of the pulp chamber following perforation repair

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Figure 5: Post treatment radiograph of tooth #21

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  Discussion Top

Out of the various factors affecting the prognosis of teeth with iatrogenic perforations, timely intervention and the level of perforation (relative to crestal bone and epithelial attachment) are probably the most important. [4] The present case posed a treatment challenge as the perforation was crestal in position (it impinged on the epithelial attachment with periodontal pocket formation) with a 1 year long history.

A 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. Such lesions which present with both endodontic and periodontal involvement are known as endo-perio lesions. The present case is a primary endodontic lesion with secondary periodontal involvement. (Simon's classification of endo-perio lesions). [8] Once the periodontal pocket is formed, persistent inflammation of the perforation site is most likely maintained by continuous ingress of irritants from the pocket. In the present case also, loss of periodontal attachment and formation of periodontal pocket (4 mm) were seen. Treatment of crestal perforations carries a guarded prognosis because of their proximity to the epithelial attachment. [6] For sealing such perforations, a biocompatible material with a short setting time and good sealability should be selected. [9] It is due to its excellent biocompatibility, fast setting time of 10-12 minutes, and good sealability, that biodentine (Septodont) was chosen as the material of choice in this case. [10] It has been shown that subgingival lesions restored with glass ionomer and resin composite materials show favourable periodontal healing with the formation of long junctional epithelium. [11] A similar favourable periodontal response in this case, signified by the return to physiologic probing depth (2 mm), can be attributed to the formation of long junctional epithelium. Both the factors of high biocompatibility and polished smooth surface of biodentine seem to have resulted in the favourable healing of the periodontal tissues.

Radiographic evidence of pulp canal obliteration in the apical two thirds of the root of tooth 21 pre-empted the authors to the possible difficulty in locating the root canal orifice, as a result of which the dental operating microscope was employed in identifying the orifice. Treating complex endodontic cases under higher magnifications is now an established norm in clinical practice. Favourable periradicular healing ensued following completion of treatment.

  Conclusion Top

Crestal root perforations compromise the prognosis of the affected teeth due to high probability of persistent periradicular inflammation even after perforation repair. Biodentine, due to its high sealability, fast setting time and superior mechanical properties, seems to be a good alternative to existing materials routinely used for managing such conditions. However, due to the lack of substantial supporting scientific literature, further studies need to be done in order to establish its superiority over the currently used materials like MTA and glass ionomer cement.

  References Top

1.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
2.Nicholls E. Treatment of traumatic perforations of the pulp cavity. Oral Surg Oral Med Oral Pathol 1962;15:603-12.  Back to cited text no. 2
3.Eleftheriadis GI, Lambrianidis TP. Technical quality of root canal treatment and detection of iatrogenic errors in an undergraduate dental clinic. Int Endod J 2005;38:725-34.  Back to cited text no. 3
4.Fuss Z, Tsesis I, Lin S. Root resorption--diagnosis, classification and treatment choices based on stimulation factors. Dent Traumatol 2003;19:175-82.  Back to cited text no. 4
5.Kvinnsland I, Oswald RJ, Halse A, Grønningsaeter AG. A clinical and roentgenological study of 55 cases of root perforation. Int Endod J 1989;22:75-84.  Back to cited text no. 5
6.Lantz B, Persson PA. Experimental root perforation in dog's teeth. A roentgen study. Odontol Revy 1965;16:238-57.  Back to cited text no. 6
7.Seltzer S, Sinai I, August D. Periodontal effects of root perforations before and during endodontic procedures. J Dent Res 1970;49:332-9.  Back to cited text no. 7
8.Peeran SW, Thiruneervannan M, Abdalla KA, Mugrabi MH. Endo perio lesions. Int J Sci Tech Res 2013;2:268-74.  Back to cited text no. 8
9.Hartwell GR, England MC. Healing of furcation perforations in primate teeth after repair with decalcified freeze-dried bone: A longitudinal study. J Endod 1993;19:357-61.  Back to cited text no. 9
10.Biodentine. Active Biosilicate Technology. Scientific file. 2010. Available from: www.septodont.fr/fichiers_upload/biodentinescientificfile.pdf.  Back to cited text no. 10
11.Martin TM, Bosco AF, Nóbrega FJ, Nagata MJ, Garcia VG, Fucini SE. Periodontal tissue response to coverage of root cavities restored with resin materials: A histomorphometric study in dogs. J Periodontol 2007;78:1075-82.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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