2. An endodontic perforation is an artificial opening in the
tooth or its root
,created by clinician during entry to the canal
system
or
by biologic event such as pathogenic resorption or
caries
Main complication: 2dry inflammation and infection of
pdl + tooth loss
3. *Root perforations
Roots may be perforated at
different levels during cleaning
and shaping
(apical,middle,cervical)
4. * Coronal Subgingival perforations (Acess cavity related)
Searching or canal orifices perforation of crown thru side of crown
(restoration)
floor of chamber
5. coronal root perforations
Abobe periodontal attachment Below periodontal attachment
saliva or irrigant leakage through oral cavity pain and bleeding
6. Management
Isolate the perforation
If perforation site is clean uninfected repair
immediately
For esthetics :calcium sulphate barrier with tooth coloured
restoration .
For non esthetic areas
Cavit,amalgam,calcium hydroxide
paste,super EBA,
Glassionomer.
MTA ( when no sulcular communication)
8. Management
Non surgical ttt: MTA offers best results after hemorrhage control and proper
visibility
Other materials: cavit calcium hydroxide paste,amalgam,zic oxide eugenol
• MTA takes 3 hrs to set so should be covered with fast setting cement
• Other canal orifices should be protected by paperpoints to prevent
blockage
Prognosis:
Poorest long term prognosis
Defect is inaccessible for adequate repair
9. Lateral (midroot )perforations Below the
periodontal ligament
Caused by files, GG drills , large misdirected post
sign : sudden bleeding,sudden pain
10. Management
Same technical considerations as coronal 1/3 except that we are dealing with a deeper defects
Factors for successful repair : hemostasis, access, microinstrumentation techniques,
Selection of suitable material.
If the m1/3 perforation is small repaired during obturation.
If large perforation repaired first and retrievable material in the canal
to prevent blockage.
Dealing with two canals one natural and the other is iatrogenic
Take W.L and clean , shape and obturate
MTA is the material of choice
Prognosis : good no communication with oral cavity
11. Furcation Perforation
Management: immediately if possible
repaired with MTA
If proper conditions exists (dryness)
composite or glass ionomer can seal the
defect
Prognosis is good if repaired
immediately
12. If not repairable non
surgicaly or inaccessible
Surgical:
Hemisection,
Bicuspidization
Root amputation
Intention replantation
13. Apical perforation
Occur thru apical foramen (Over instrumentation)
or thru body of root (perforated new canal)
Especially in curved canals
15. Treatement
Overinstrumentation :restablish tooth length short of the
original oneand then enlarge with larger instruments
Place MTA as an apical barrier and Obturate to the new length
Through body of root : deal with one canal with two foramina
Obturation by vertical compacting technique with heat
softened gutta-percha .
Prognosis: depends primarily on size and shape of
defect
but prognosis is better as no any communication
with oral cavity.
16. Prognosis for healing
1.Timing of repair Immediate is better than delayed , infected un treated defects
lead to marked inflammation ,abcess formations and cervicular epithelium
proliferation
2.Location of perforation eg furcation perforation decreased success due to
inc.epithelial proliferation and periodontitis
Perforation near gingival sulcus inflammation and loss of epithelial
attachment + pdl pocket
More apical perforation offer better prognosis
3. Size of perforation
small defects direct and immediate restoration + few chances of pdl
breakdown
Large defects difficult to place well condensed restoration + large contact
surface area with peiodontium allow inflammation .
17. 4. Perforation Repair materials must be antimicrobial , non toxic provide adequate seal non
absorpable ,RO ,promote oeteogenesis and cementogenesis.
ZOE Cements …. Chronic inflammatory response
Calcium hydroxide ….. Prevent in groth of granulation tissue into perforation
Cavit …..mild to modetare inflammatory response
Amalgum…. assessing healing potential but carcinogenic
Super EBA……proper seal and adaptation to defect
Glass ionomer…… same properties as amalgam
MTA
• composition include calcium and phosphorus ions with pH 10.2
• Least toxic
• Biologicaly compatible
• Allow groth of cementum like substance on surface of material
• Less inflammatory infiltrative cells
• Good marginal adaptation to dentin
• Leak less than amalgam in lateral perforations
No current available material meets all requirements
18. 5. Hemostatics
To stop hemorrhage wjich may affect assecibility calcium hydroxide or calcium sulphate
6.Vision or accessibility
Magnification loupes , head lamps , transilluminating devices and dental microscopes
Are imp in addressing perforations
7.Treatement sequence
Repairing perforation will allow control of bleeding , confine irrigation ,and facilitate
obturation .
Maintain the pathway of canal to avoid blockage
19. Case presentation
A 32-year-old Indian female 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.
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.Intra-oral periapical
radiograph revealed short of length radiopaque filling material in tooth #21 and
poorly condensed root canal filling in tooth #22 .
However, no evidence of periapical pathology was present in relation to either
tooth.
20. (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. Access was regained gutta-percha was retrieved with gutta-percha Endosolv-E solvent and H-files
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
surgical exposure of the perforation and its sealing with biodentine (Septodont).
calcium hydroxide was administered as intracanal medicament.
The access preparation was sealed with a cotton pellet and Cimpat® pink (Septodont).
22. After 1 week, obturation was completed with gutta-percha and AH plus sealer
(a) Working length IOPA radiograph of tooth . (b) Master cone IOPA radiograph. (c) Radiograph showing obturation
23. Repair of the perforation with biodentine. clinical view of the pulp chamber following obturation of the
root. canal, showing perforation located labial to the canal orifice
Clinical view of the pulp chamber following perforation repair
25. Discussion
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.
