JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2018  |  Volume : 10  |  Issue : 1  |  Page : 42-46

Management of iatrogenic errors: Furcal perforation

Department of Conservative Dentistry and Endodontics, Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Web Publication6-Jul-2018

Correspondence Address:
Dr. Gaurav Lal Aidasani
Department of Conservative Dentistry and Endodontics, Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri, Pune - 411 018, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicdro.jicdro_2_18

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Perforations as a possible complication during a root canal treatment may increase the risk of failure for the affected tooth. The influencing factors include the location and the size of the perforation, potential microbial colonization of the endodontic system, the time lapse between the occurrence of the perforation and repair, and the filling material. For the long-term success of the root canal system, it is essential to emphasize on disinfection and sterilization at the perforation site and in the remaining root canal system. Nonsurgical management is possible with predictable prognosis is possible if correct treatment is planned and executed.

Keywords: Furcation perforation, iatrogenic errors, mineral trioxide aggregate

How to cite this article:
Aidasani GL, Mulay S. Management of iatrogenic errors: Furcal perforation. J Int Clin Dent Res Organ 2018;10:42-6

How to cite this URL:
Aidasani GL, Mulay S. Management of iatrogenic errors: Furcal perforation. J Int Clin Dent Res Organ [serial online] 2018 [cited 2023 Mar 27];10:42-6. Available from: https://www.jicdro.org/text.asp?2018/10/1/42/236089

   Introduction Top

Root perforation is an artificial communication between the root canal system to the supporting tissues of teeth or to the oral cavity. Perforation can be of two types, one that results from a resorptive process and the other, that is iatrogenically produced, which can occur during access cavity preparation and location of canal orifices or biomechanical preparation of the root canal or during a postendodontic procedure. Factors of significance to the prognosis for treatment are time, size, and shape of the perforation as well as its location impacts the potentials to control infection at the perforation site. Frequently, the cause is iatrogenic as a result of the misaligned use of rotary burs amid endodontic access preparation and search for root canal orifices.[1]

This case report explains the management of iatrogenic perforations at a coronal and middle third of the root, below the alveolar margin.

   Case Report Top

A 29-year-old male patient was referred to the Department of Conservative Dentistry and Endodontics, from an unskilled trainee for the management of perforation that was occurred during the root canal treatment procedure. At the time of reporting, the patient was asymptomatic.

On intraoral examination, tooth showed no signs of pain and two large perforations were observed on the lingual aspect of the floor of pulp chamber [Figure 1]. No bleeding periodontal pockets were observed on either side of the tooth. On radiographic examination, with #10 K file in the perforation site was revealed and excess of tooth structure loss was observed with the remaining dentine thickness of <1 mm making the tooth more prone to fracture [Figure 2].
Figure 1: perforation site on the lingual aspect of 36

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Figure 2: intraoral periapical revealing perforation wrt 36

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Treatment plans were as follows;

Plan A:

  • Location of canals and working length determination
  • Perforation repair using mineral trioxide aggregate (MTA)
  • Reinforcement of remaining tooth structure
  • Cleaning and shaping followed by obturation
  • Postendodontic restoration.
Plan B:

  • Extraction and replacement with FPD.
Plan C:

  • Extraction and implant.

The treatment plans were discussed with the patient. The existing clinical condition and treatment procedure was explained. The decision was taken to retain the tooth by attempting a nonsurgical root canal treatment with repair of the perforation with MTA. Written consent was then obtained from the patient.

Treatment was carried out in multiple visits, during the first session, perforation site was located, and hemorrhage from the perforation site was completely controlled, and hemostasis was achieved using a local anesthetic with adrenaline. All the canals were negotiated, and coronal enlargement of the canal orifices was done and blocked using #25 gutta-percha cones.

MTA was mixed in a 3:1 proportion as suggested by the manufacturer and was delivered to the perforation site with an amalgam carrier. A hand plugger was used to accommodate the MTA inside the defect with minimal pressure. Moist cotton was placed in the chamber, and the temporary dressing was given using Cavit (3M) [Figure 3].
Figure 3: placement of mineral trioxide aggregate in perforation

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In the second appointment, coronal temporary restoration was removed. Working length was determined with electronic apex locator (EAL) and confirmed radiographically. The repair site was sealed using resin-modified glass-ionomer cement (GC Fuji II), and the lingual wall was built up using composite resin cement [Figure 4]. The canals were irrigated with 3% sodium hypochlorite and normal saline. EDTA gel (RC Help, Prime dent) was used for lubrication during instrumentation. Mesial canals were instrumented using 6% #25 Hero Shaper rotary files and distal canal until 6% #30 Hero Shaper rotary files. Canals were dried using paper points and obturated using lateral compaction technique using Sealapex sealer. MTA was placed on the floor of the chamber to strengthen the furcation area [Figure 5]. After MTA placement, moist sterile cotton was placed into the pulp chamber, and the access cavity was sealed with the temporary restorative material. The patient was recalled after 24 h. On the recall appointment, the hardening of MTA was checked, and the postendodontic coronal restoration was performed using resin-modified glass ionomer cement (GC Fuji II) followed by composite restoration (Z350 XT, 3M) [Figure 6]. A postoperative cone-beam computed tomographic was advised to check the outcome of the treatment [Figure 7].
Figure 4: lingual wall built up of 36 using composite resin

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Figure 5: floor of the chamber reinforced with mineral trioxide aggregate

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Figure 6: obturation followed by composite resin core

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Figure 7: postoperative cone-beam computed tomography image for perforation repair in 36

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   Discussion Top

The etiology of root perforations can be pathological, i.e., secondary to resorption or caries, or iatrogenic that occurs during root canal treatment. An average 2%–12% of endodontically treated cases have reported accidental root perforations.[2],[3]

Perforations may also occur during access cavity preparation, postspace preparation or as a result of pathological internal resorption extending into the periradicular tissues.[4]

Fuss and Trope based on the factors impacting the outcome of treatment classified perforation as:

  • Fresh perforation – treated as soon as possible after first observation under aseptic conditions, Good Prognosis
  • Old perforation – previously not treated that is contaminated with bacteria. Questionable Prognosis
  • Small perforation (smaller than #20 endodontic instrument) – trauma to the tissue is small with ease of sealing, Good Prognosis
  • Large perforation – this is usually seen while postpreparation, with a high amount of trauma to the tissue and there is difficulty in providing an optimum seal, along with contamination from bacteria's, or coronal leakage along temporary restoration, questionable prognosis
  • Coronal perforation – this is seen coronal to the level of crestal bone, and epithelial attachment with trauma to adjacent tissues are less and easy access possible, good prognosis
  • Crestal perforation – at the level of the epithelial attachment into the crestal bone, questionable prognosis
  • Apical perforation – apical to the crestal bone and the epithelial attachment, good prognosis.[5]

The factor that is within the control of operator is the choice of material to be utilized for furcation repair. The repair material that is kept in near contact with hard tissue and the structures of periodontium ought to be biocompatible as it can cause harmful response either by leaching of the material or by the material itself. Earlier different material including amalgam, gutta-percha, zinc oxide and glass ionomer cements, calcium hydroxide, composites were used. Newer materials such as MTA, biodentine, dentin chips, bioceramics, calcium enriched material, with and without the use of barrier could be used to seal the perforation.[6]

MTA has been considered as an ideal material for perforation repair, apexification, retrograde filling, pulp capping, etc. MTA is a mineral powder that is made up of hydrophilic particles, whose principal components are dicalcium silicate, tricalcium of slica aluminum and oxide along with other mineral oxides. Main et al. took note that MTA gives an ideal repair of tooth perforations and enhanced the prognosis of perforated teeth.[7]

Economides et al. conducted an in vitro study on dog's teeth and showed that MTA can be used in root end cavities, being a biocompatible material, MTA stimulated reparation of periradicular tissues, it also showed no inflammation.[8],[9] It also could induce hard tissue formation.[10]

This superior properties of MTA such as lesser bacterial leakage, biocompatibility, and better adaptation to cavity walls makes it a useful material in sealing the root and furcal perforation.[11]

However, the drawback of the MTA is its difficult handling, slow setting, 24 h initially available and now up to 3–4 h, with the possibility of solubilized by being in contact with oral fluids as this process occurs,[5] of the two commercially available MTA angelus and ProRoot MTA, MTA Angelus has shorter setting time compared to MTA pro-root according to manufactures.[11]

In this case, perforation site was lingually placed, and the access cavity was wide and deep, with very less remaining dentine on the floor of the chamber, thus making the prognosis questionable.

Prevention of such iatrogenic errors can be achieved by proper preoperative evaluation of the case which includes a few considerations such as position of the roots of the tooth, relationship of the crown to the root, rotation of the tooth in the arch, the relationship of the incisal edge or cusp tip to the long axis of the root.[12]

Determination of the presence and location of root perforation as accurate detection of root perforations and determination of location are crucial to the treatment outcome, certain signs, and tools should be recognized in making the diagnosis. Sudden bleeding and pain during instrumentation of root canals or postpreparations in teeth are warning signals of potential root perforation. The appearance of blood on paper points but unreliable as bleeding may originate from the apical foramen or from residues of vital pulp tissue. To enhance radiographic detection, it has been proposed to place a highly radiopaque calcium hydroxide paste, by the inclusion of barium sulfate, in the root canal. However, caution should be exercised in crestal perforations as this measure can result in extrusion of the material into the periodontal tissues and cause unnecessary mechanical and chemical irritation impairing the treatment prognosis. Radiographs taken at different angles with radiopaque instruments in the root canal are a better option and may confirm the presence of root perforation. However, when the perforation is located at the buccal or palatal aspects of the root, the diagnostic value of radiographs is limited. Anatomical structures, as well as radiopaque materials superimposing on the image of the root, may also obscure the perforation site. EALs can accurately determine the location of root perforations, making them significantly more reliable than radiographs. After root instrumentation, it is recommended that the working length is verified with EALs. Readings that are significantly shorter than the original length can be an indication of perforation. A dental operating microscope is another helpful tool effective in detecting root perforations during orthograde root canal therapy and in surgical endodontic treatments. High magnification with coaxial illumination allows precise detection and visualization of perforations along straight noncurved root canals. A narrow isolated periodontal defect is a possible sign of periodontal breakthrough due to root perforation. Probing the gingival sulcus to reveal possible communication with the oral cavity is recommended in such teeth. To determine locally isolated vertical bone losses, periodontal probing should be carried out by walking the probe around the tooth while pressing gently on the floor of the sulcus. In the presence of narrow isolated periodontal defects, differential diagnosis from vertical root fracture should be made with explorative surgery.[13]

   Conclusion Top

With proper anatomic knowledge and magnification, iatrogenic errors can be avoided. Conservative approach should be considered first with proper diagnosis, advanced biomaterials, and operator skills; the outcome is more predictable thus improving the prognosis.

Declaration of patient consent

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

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

American Association of Endodontists. Glossary of Endodontic Terms. 7th ed. Chicago: American Association of Endodontists; 2003.  Back to cited text no. 1
Seltzer S, Bender IB, Smith J, Freedman I, Nazimov H. Endodontic failures – An analysis based on clinical, roentgenographic, and histologic findings. II. Oral Surg Oral Med Oral Pathol 1967;23:517-30.  Back to cited text no. 2
Sinai IH, Romea DJ, Glassman G, Morse DR, Fantasia J, Furst ML, et al. An evaluation of tricalcium phosphate as a treatment for endodontic perforations. J Endod 1989;15:399-403.  Back to cited text no. 3
Bryan EB, Woollard G, Mitchell WC. Nonsurgical repair of furcal perforations: A literature review. Gen Dent 1999;47:274-8.  Back to cited text no. 4
Hegde M, Varghese L, Malhotra S. Tooth root perforation repair – A review. Oral Health Dent Manage 2017;16:1-4.  Back to cited text no. 5
Tanomaru Filho M, Tanomaru JM, Faleiros FC. Capacities machining and adaptation of materials used in furcation perforations. Rev Fac Odontol Lins 2004;16:19-24.  Back to cited text no. 6
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. 7
Economides N, Pantelidou O, Kokkas A, Tziafas D. Short-term periradicular tissue response to mineral trioxide aggregate (MTA) as root-end filling material. Int Endod J 2003;36:44-8.  Back to cited text no. 8
Holland R, Filho JA, de Souza V, Nery MJ, Bernabé PF, Junior ED, et al. Mineral trioxide aggregate repair of lateral root perforations. J Endod 2001;27:281-4.  Back to cited text no. 9
Yaltirik M, Ozbas H, Bilgic B, Issever H. Reactions of connective tissue to mineral trioxide aggregate and amalgam. J Endod 2004;30:95-9.  Back to cited text no. 10
Narasimhan D, Hedge P, Hedge NM. Comparative evaluation of the efficacy of three different dental materials in sealing perforation an in vitro study. Indian J Appl Res 2015;5:135.  Back to cited text no. 11
Moreinis SA. Avoiding perforation during endodontic access. J Am Dent Assoc 1979;98:707-12.  Back to cited text no. 12
Tsesis I, Fuss Z. Diagnosis and treatment of accidental root perforations. Endod Top 2006;13:95-107.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

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