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Year : 2017  |  Volume : 7  |  Issue : 2  |  Page : 123-127

Management of long-standing perforation with mineral trioxide aggregate using metronidazole-containing collagen as an internal matrix

Division of Conservative Dentistry and Endodontics, Centre for Dental Education and Research, All Institute of Medical Sciences, New Delhi, India

Date of Web Publication25-Apr-2017

Correspondence Address:
Ajay Logani
Division of Conservative Dentistry and Endodontics, Centre for Dental Education and Research, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-5984.205127

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The time elapsed from the development of the perforation is a critical factor influencing the posttreatment prognosis. Long-standing perforations usually show a worse prognosis than fresh perforations. Mineral trioxide aggregate (MTA) is widely used to seal perforations because of its biocompatibility and sealing ability in the presence of blood and moisture. Metrogene sponge is a metronidazole-containing absorbable collagen having significant antibacterial activities. It can be an added advantage when used as an internal matrix for long-standing perforation repair. Three cases of long-standing perforation were selected and were sealed with MTA using metrogene sponges as an internal matrix. Finally, the teeth were endodontically treated and coronally restored. The absence of periradicular radiolucent lesions, pain, and swelling along with functional tooth stability at follow-up indicated a successful outcome of sealed perforations. To conclude, MTA with metrogene sponges as a matrix provides an effective seal of root perforations and clinical healing of the surrounding periodontal tissue.

Keywords: Collagen, long-standing perforation, mineral trioxide aggregate, perforation repair

How to cite this article:
Sharma S, Kumar V, Logani A. Management of long-standing perforation with mineral trioxide aggregate using metronidazole-containing collagen as an internal matrix. Saudi Endod J 2017;7:123-7

How to cite this URL:
Sharma S, Kumar V, Logani A. Management of long-standing perforation with mineral trioxide aggregate using metronidazole-containing collagen as an internal matrix. Saudi Endod J [serial online] 2017 [cited 2022 May 17];7:123-7. Available from: https://www.saudiendodj.com/text.asp?2017/7/2/123/205127

  Introduction Top

Perforation is defined as “a mechanical or pathological communication between the root canal system and the external tooth surface.” Factors that affect the treatment prognosis include size and location of the perforation, biocompatibility of the sealing material, and time elapsed between the injury and repair. Sterility of the perforation site is an important criterion that dictates treatment success, particularly in long-standing cases.[1] The following materials have been utilized for sealing perforations: Cavit, silver amalgam, calcium hydroxide,[2] super ethoxy benzoic acid cement,[3] hydroxyapatite,[3] calcium phosphate cement,[4] light-cured glass ionomer,[5] and decalcified freeze-dried bone.[6] None of these perforation sealing materials is adequately biocompatible to ensure a good treatment outcome when it comes into direct contact with bone tissue. Mineral trioxide aggregate (MTA) has the properties of the ideal material for perforation repair. The biocompatibility of MTA, ability to seal root perforations effectively, and its setting properties in the presence of moisture and even blood are important characteristics that may result in greater success rates when used for treating root perforations.[7] Animal studies, case reports, and case series are available on the successful use of MTA as a perforation sealing material.[8],[9],[10] Use of a biocompatible matrix has been recommended to achieve hemostasis as well as control placement of the material. Collagen is often the matrix of choice because of its biocompatible, hemostatic, handling, and resorbable properties.[9] Metrogene sponge is a resorbable collagen fiber containing 4.5 mg metronidazole and thus having antibacterial properties.

The purpose of this report was to present three long-standing cases of perforation repair using metronidazole-containing collagen as an internal matrix.

  Case Reports Top

Case 1

A 30-year-old male presented with pain and swelling associated with the maxillary left first molar. The tooth was root canal treated by a private practitioner 8 months before this visit. On examination, a draining sinus tract on the swollen buccal mucosa at about the mid-root level was found. On reentering the access cavity, a diagnosis of complete furcal perforation was confirmed. After discussing the treatment options, written consent was obtained from the patient. A treatment plan of repairing the perforation with MTA (ProRoot MTA, Dentsply Tulsa Dental, Tulsa, OK, USA) and collagen (Metrogene, Septodont, Saint-Maur-des-Fosses, France) sponge was decided. After providing the local anesthesia (xylocaine, lidocaine HCl injection, USP), the access cavity was modified followed by canal orifice location. The canals were filled with poorly compacted Gutta-percha. Gutta-percha was removed with a Hedstrom file. The perforation site was cleaned using ultrasonic diamond-coated CPR 3 tips (Spartan, Fenton, MI, USA), irrigated copiously with 2.5% sodium hypochlorite (NaOCl) (Cmident, New Delhi, India), and dried. Following this, a radiopaque dye incorporated metrogene collagen was placed through the perforation as an internal matrix. The canal orifices were blocked with absorbant paper points. Since the defect was large, a two-step repair technique was followed. In the primary step, the perforation was sealed with MTA mixed in 3:1 proportion which was delivered by an MTA gun (MAP System, Dentsply Tulsa Dental, OK, USA). A hand plugger was used to accommodate the MTA inside the defect with minimal pressure. A moist cotton pellet was placed into the pulp chamber, and the access cavity was sealed with Cavit (3M ESPE, Seefeld, Germany). A radiographic examination was undertaken to confirm the correct MTA positioning. According to operator's experience, primary repair is not sufficient in large defects. At the next visit, the material should be checked to determine if it has set hard and remains positioned in the perforation site. Hence, after 72 h, the seal was reassessed and a secondary repair step was performed in a similar way. Working length was determined using an apex locator (Tri Auto ZX, J Morita USA Inc., California, USA) and a #15 K-file. Biomechanical preparation was completed using rotary ProTaper files (Dentsply Maillefer; Ballaigues, Switzerland) and copious 2.5% NaOCl irrigation. Final irrigation was completed with 2% chlorhexidine (R4, Septodont, Saint-Maur-des-Fosses, France). This was followed by calcium hydroxide dressing (Prevest Denpro Limited, Jammu, India) as an intracanal medicament. After a week, the canals were obturated by warm Gutta-percha vertical compaction technique using AH Plus (Dentsply Detrey, Konstanz, Germany) sealer. The tooth was restored with composite material. The clinical findings at 2-year after treatment were absence of a periodontal defect in the area of perforation, pain, swelling, and sinus. The radiographic criteria for healing were absence of radiolucency adjacent to the repair site and periradicular lesions [Figure 1].
Figure 1: (a) Preoperative intraoral periapical, (b) furcal perforation, (c) collagen placement, (d) intraorifice barrier, (e and f) first stage mineral trioxide aggregate repair, (g and h) second stage mineral trioxide aggregate repair, (i) postoperative intraoral periapical, (j) followup

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Case 2

A 25-year-old male presented with pain associated with the left mandibular first molar. The tooth was previously root canal initiated 6 months before this visit. After clinical and radiographic examinations, a diagnosis of furcal perforation involving the distal root was established. After access cavity modification, the perforation site was cleaned with ultrasonics and 2.5% NaOCl. The defect was repaired with MTA under dental operating microscope (PROergo, Carl Zeiss Meditec, Jena, Germany) in two steps after finding the primary repair insufficient. Metrogene sponge was used as a matrix. Moist cotton pellet was placed for 72 h and the access was sealed temporarily. The endodontic therapy was completed in two visits using ProTaper rotary files and calcium hydroxide was used as an interim medication. Obturation was accomplished with warm vertical compaction technique. The access cavity was sealed with composite restoration. The clinical and radiographic findings at 2 years after treatment suggested adequate healing of the tooth supporting structures [Figure 2].
Figure 2: (a) Preoperative intraoral periapical, (b) canal location, (c) furcal perforation seen under dental operating microscope, (d and e) mineral trioxide aggregate repair with collagen, (f) postoperative, (g) follow up

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Case 3

A 42-year-old male presented with pain and swelling associated with a previously root canal initiated mandibular left second molar. A diagnosis of furcal perforation (on the lingual aspect) of 1-month duration was established. After redefining the access cavity, the repair procedure was performed with MTA and metrogene sponge as mentioned earlier. In this case, only primary MTA repair was sufficient since the defect was small. After setting of MTA, biomechanical preparation was completed using ProTaper rotary files. Calcium hydroxide was used as an intracanal medicament. Obturation was done with warm vertical compaction technique. This was followed by a composite restoration. The clinical and radiographic findings at 1 year after treatment suggested adequate healing of the tooth supporting structures [Figure 3].
Figure 3: (a) Preoperative intraoral periapical, (b and c) mineral trioxide aggregate repair with collagen, (d) postoperative intraoral periapical, (e) 1-year follow-up

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  Discussion Top

The control of inflammation in the defect area represents one of the main goals of the perforation repair in addition to promoting the health of the surrounding tissue. In long-standing cases, the chronic inflammatory reaction provokes periodontal attachment loss and compromising tooth stability. This makes long-standing perforations, a real treatment challenge. The goal to reestablish tissue attachment was extremely difficult to achieve before the advent of MTA.[8] MTA induces osteogenesis and cementogenesis which is unique and had not been demonstrated with any other material.[11]

The protocol for cleansing and repairing perforation has been described by Arens and Torabinejad.[10] Although the periradicular tissues provide some moisture from the external surface of the material, the use of a moist cotton pellet has been recommended to assure proper setting. Allowing the MTA to set undisturbed for 72 h or longer prior to placement of a coronal restoration has also been reported to decrease the chance of MTA displacement in furcation perforation repairs.[12]

In cases of long-standing large perforation, the use of biocompatible matrices such as calcium sulfate, hydroxyapatite, or HAPSET has been recommended to control the extrusion of the material. In addition, its placement also helps achieving hemostasis. Al-Daafas and Al-Nazhan reported that the use of calcium sulfate did not aid bone regeneration or prevent epithelium migration into the defected perforation area.[13] They concluded that using calcium sulfate as an internal matrix for MTA is not recommended. A study reported the use of “modified internal matrix” concept in which collagen was used as a completely resorbable barrier material and MTA for sealing of the perforation.[14] Small pieces of collagen were used to push the granulation tissue out of the perforation and keep it in place outside the root.

The management of bacterial infection of the perforation site dictates the success of the attempted repair in long-standing cases. Pitt Ford, et al. demonstrated that in the group with delayed repair, more specimens were associated with inflammation, which appeared to be linked to the presence of infection in spite the use of MTA as perforation repair material.[15] Thus, the successful outcome of long-standing perforations seems to be attributed to removal of contaminants as well as cleansing of the pulp chamber and perforation before repairing under aseptic conditions.[1] Most of the floras seen during long-standing perforation cases are anaerobic in nature. Metronidazole covers most of the flora responsible for periodontal disease, for example, Bacteroides fragilis, Bifidobacterium, Fusobacterium, Peptostreptococcus, Prevotella, and Porphyromonas.[16] Hence, the use of a resorbable collagen matrix containing metronidazole may provide additional antimicrobial activities in long-standing cases. The antibacterial property is due to fast release of metronidazole from sponges, i.e., approximately 6.5–58 mg/L in 0–30 min and 1 mg/L for period of 5–7 days after laying.

  Conclusion Top

The outcome of the furcal perforations treated with MTA and metrogene sponge in the study showed radiographic and clinical healing in all the cases. This is the first case report/series to report the benefit of using metronidazole-containing collagen matrix in long-standing perforation repair cases. This not only results in repair of the defect but also promotes healing of the periodontal ligament due to its antibacterial efficacy. Further clinical studies are necessary to investigate the predictability of the outcome of the technique.


We would like to thank the patients who participated in the treatment.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Clauder T, Shin SJ. Repair of perforations with MTA: Clinical applications and mechanisms of action. Endod Topics 2009;15:32-55.  Back to cited text no. 1
ElDeeb ME, ElDeeb 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;8:459-66.  Back to cited text no. 2
Lemon RR. Nonsurgical repair of perforation defects. Internal matrix concept. Dent Clin North Am 1992;36:439-57.  Back to cited text no. 3
Chau JY, Hutter JW, Mork TO, Nicoll BK. An in vitro study of furcation perforation repair using calcium phosphate cement. J Endod 1997;23:588-92.  Back to cited text no. 4
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;20:449-52.  Back to cited text no. 5
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. 6
Mente J, Hage N, Pfefferle T, Koch MJ, Geletneky B, Dreyhaupt J, et al. Treatment outcome of mineral trioxide aggregate: Repair of root perforations. J Endod 2010;36:208-13.  Back to cited text no. 7
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. 8
Pace R, Giuliani V, Pagavino G. Mineral trioxide aggregate as repair material for furcal perforation: Case series. J Endod 2008;34:1130-3.  Back to cited text no. 9
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;82:84-8.  Back to cited text no. 10
Savitha A, Rekha AS, 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.  Back to cited text no. 11
  [Full text]  
Vanderweele RA, Schwartz SA, Beeson TJ. Effect of blood contamination on retention characteristics of MTA when mixed with different liquids. J Endod 2006;32:421-4.  Back to cited text no. 12
Al-Daafas A, Al-Nazhan S. Histological evaluation of contaminated furcal perforation in dogs' teeth repaired by MTA with or without internal matrix. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e92-9.  Back to cited text no. 13
Bargholz C. Perforation repair with mineral trioxide aggregate: A modified matrix concept. Int Endod J 2005;38:59-69.  Back to cited text no. 14
Pitt-Ford TR, Torabinazad 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;79:756-63.  Back to cited text no. 15
Soares GM, Figueiredo LC, Faveri M, Cortelli SC, Duarte PM, Feres M. Mechanisms of action of systemic antibiotics used in periodontal treatment and mechanisms of bacterial resistance to these drugs. J Appl Oral Sci 2012;20:295-309.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3]


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