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CASE Presentation2 - Copy.pptx
1. NON- SURGICALMANAGEMENT OF AN APICALROOTPERFORATION OF A
LATERAL INCISOR
USINGMTA
Presented by
Dr Chandana Menon
PG
2. Introduction
According to the glossary of endodontic terms, perforation is defined as the mechanical or pathological
communication between the root canal system and the external tooth surface.
It is one of the endodontic complications during root canal treatment.
It may occur during any stage of the treatment, access cavity, cleaning and shaping, or as a result of internal
resorption that is extended to the periapical tissues.
Eventually, chronic inflammation will occur in the periodontium, which is characterized by the formation of
granulation tissue and loss of bone attachment around the perforation
3. Patient should be immediately informed of, together with the procedures to be followed, the treatment
options and the prognosis.
It needs to be diagnosed early and treated immediately and appropriately.
Lack of understanding of root perforations and their consequences, to the extent that could delay diagnosis
and treatment, may cause future problems leading to tooth loss.
4. PREDISPOSING FACTORS
Inadequate knowledge of tooth anatomy
Improper use of drilling instruments leading to gouging
Forceful/unregulated canal instrumentation leading to ledge formation,
zipping with or without elbow formation and loss of apical constriction
Irregular tooth morphology inclined crown, curved root canals,
calcified pulp chamber.
5. CLASSIFICATION OF ROOT PERFORATIONS
Fuss and Trope classified root perforations based on the factors affecting the outcome of
treatment:
• Fresh perforation -treated as soon as possible after first observation under aseptic
conditions - Good Prognosis.
• Old perforation-previous perforation not treated which is contaminated with bacteriaQuestionable
Prognosis.
• Small perforation (smaller than #20 endodontic instrument) trauma to the tissue is small
with ease of sealing- Good Prognosis.
• Large perforation usually seen while post preparation, with high amount of trauma to the
tissue and there is difficulty in providing an optimum seal, along with bacterial contamination with
coronal leakage along temporary restoration- Questionable Prognosis.
6. • Coronal perforation seen coronal to the level of crestal bone and epithelial attachment
with less trauma to adjacent tissues and easy access possible- Good Prognosis.
• Crestal perforation into the crestal bone at the level of the epithelial attachment-Questionable
Prognosis.
• Apical perforation, apical to the crestal bone and the epithelial attachment- Good
Prognosis
7. Types of Perforations:
1. Coronal
2. Furcation
3. Lateral wall or Strip Perforation
4. Root canal Perforation
a) Cervical
b)Mid root
c)Apical
5. Post space Perforation
8. DIAGNOSIS AND PROGNOSIS OF ROOT PERFORATION
There are various clinical diagnostic aids to determine root perforations.
The basis of diagnosing root perforation is by clinical and radiographic examination.
If there is persistent bleeding with during coronal access or root canal preparation is a
sign of perforation.
A paper point inserted into the root canal soaked with blood suggests perforation.
Another method for accurate diagnosis is by applying calcium hydroxide paste in the canals to detect the direction of
perforation.
9. If there is crestal perforation, precaution should be taken as it may result in extrusion of the material into the periodontal
tissue spaces and produce unnecessary irritation, thus affecting the prognosis of the treatment.
The dental operating microscope and Cone-beam computed tomography (CBCT) also aid in detecting perforations during
surgical endodontics.
10. MATERIALS USED TO REPAIR PERFORATION
The repair material should be biocompatible as it is kept in close contact with hard tissue
and the structures of periodontium.
Several intracanal medicaments have been studied to treat the infected root canals.
Among which Calcium hydroxide has been extensively utilized and shows promising results.
Nowadays, the selection of material for root perforation is focused more on the ability to demonstrate antibacterial
potential for infection control of the root canal system promoting the healing by mineralized tissue deposition and
sealing ability.
12. CASE REPORT
• 18 yr old male patient reported to the department with c/o broken teeth in the upper front
teeth region since 9 years.
• O/E : Ellis Class 11 fracture in 22.
• No history of pain
• History of trauma 9 years ago due to fall.
• TOP -ve
• Cold test : Negative response, non-vital
• Preoperative IOPA shows periapical radioluceny irt 22 suggestive of irreversible pulpitis
with asymptomatic apical periodontitis.
• Treatment plan : Endodontic treatment of 22 followed by crown.
PREOPERATIVE
13. FIRST VISIT
Access opening done
Working length was established- 17mm
Apical enlargement upto 30
Cleaning and shaping done upto 45
Calcium hydroxide placed
14. Deviation of GP from the canal- Lateral exit
Apical Perforation
(instrument goes beyond the confines of the root canal and by overuse of
chelating agents along with straight and stiffer large-sized instruments to
negotiate ledge, canal blockage, or zipping, etc)
SECOND VISIT
15. Healing lesion shown after one month
Apex was re-determined using apex locator- confirmed
lateral exit.
MTA Angelus
THIRD VISIT
18. Discussion
Many factors affect the prognosis of root perforation, including the location, size, and time of the
contamination.
The location of the apical perforation has a good prognosis.
Currently, MTA has superior properties and sealing ability when compared to different materials.
It also has a high pH of around 12.5, which promotes new tissue formation and repair.
It has the ability to release calcium since it has calcium silicate which is one of its components that are
believed to increase the sealing ability of the material.
Fuss Z, Trope M. Root perforations: classification and treatment choices based on prognostic factors. Dental Traumatology. 1996 Dec;12(6):255-64.
