An overview of the possible types of perforation that may occur during endodontic treatment with their management. This slide presentation covers multiple management possibilities of said perforation proposed by various clinicians from around the world which can aid the readers in their treatment plan for the repair of a tooth perforation

1. Iatrogenic Perforation
An Endodontic Mishap with its Management
Dr. Taseef Hasan Farook (BDS), Dhaka
Dental Surgeon & Intern Doctor

2. What is Endodontic Perforation?
The mechanical or pathological communication
between the root canal system and the external
tooth surface – Glossary of Endodontic Terms
(AAE)

3. Predisposing Factors

4. Local Factors that may predispose to
perforation
• 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 ex inclined crown,
curved root canals, calcified pulp chamber.

5. Inclination of tooth Abnormal tooth morphology
Curved canals
Calcified pulp chamber

6. Gouging
Artificially created cavity in crown of tooth due
to misdirection of bur during access cavity
preparation. Most commonly seen in
mandibular anterior teeth.

7. Ledge
Artificially created irregularity on surface of root
canal wall that prevents passage of instruments
to apex in previously patent canal

8. Zipping
Transposition of the apical portion of the canal. Rigid
Instrumentation of a curved canal tends to produce an
elliptical extension on the outer portion of canal wall,
often resulting in “elbows” (biomechanical defect)

9. Other predisposing abnormalities

10. Types of Perforation
1. Coronal Perforation
2. Furcation Perforation
3. Lateral wall perforation (Strip Perforation)
4. Root canal perforation
a. Cervical Canal Perforation
b. Mid root Perforation
c. Apical Perforation
5. Post space perforation

11. Coronal Perforation

12. Coronal Perforation
Hallmark Clinical Feature:
1. If above the periodontal attachment –
leakage of saliva into the access cavity or
leakage of irrigating solution into the
mouth
2. If below periodontal attachment –
bleeding into the pulp chamber
Other features:
pain felt by patient, complaints of taste of
irrigating solution

13. Coronal Perforation Management
Management:
Immediate management: hemostasis of the site to
stop bleeding. (hemostatics used are Calcium
hydroxide, calcium sulphate, freeze dried bone,
MTA, any biocompatible material)
Definitive management: Closure of perforation
using amalgam, IRM, Super EBA, MTA, dentin chips
(small perforation), hydroxyapatite, Glass ionomer
(if proper isolation from moisture is achieved)

14. Furcation Perforation

15. Furcation Perforation
Iatrogenic perforation of the furcation area in
multi-rooted molars during preparation of the
access cavity can potentially lead to tooth
extraction

16. Furcation Perforation
Hallmark features:
1. Continuous dull localized
pain on the tooth
undergoing root canal
treatment
2. Localized inflammation on
the buccal mucosa overlying
the furcal region
3. Tenderness on mastication
4. May or may not exhibit fluid
discharge from the access
cavity

17. Furcation Perforation
Possible treatment options
• Non surgical-
– tooth extraction
– tooth preservation using zinc oxide eugenol, calcium
hydroxide, Cavit, amalgam, glass ionomer, composite resin,
mineral trioxide aggregate (MTA) and calcium enriched
mixture (CEM) cement
• Surgical – Endodontic surgery (example hemisection)

18. Furcation Perforation Mx (Non-Surgical)
Steps of management according to various clinicians (NCBI,
Pubmed)
1. Evaluation of the extensiveness of the perforation. Very
large openings have very poor prognosis
2. Isolate and obtain adequate hemostasis
3. Flair the canal orifice and irrigate perforation site
adequately
4. Place solid fillers (Gutta percha) into the canal to prevent
blockage of canals
5. Pack the repair material into the perforation and obtain
proper marginal adaptation
6. Provide adequate time for the material to set
7. Resume/ restart root canal preparation. Complete
obturation as necessary

19. Furcation Perforation Mx (Surgical)
A surgical Approach by Rhythm and Vivek Bains of Lucknow, India
(A)Preoperative radiograph showing the perforations present in mandibular
right 1st and 2nd molars
(B)Clinical evaluation of pulpal floor perforation of 1st molar under
endomicroscope. Endodontic retreatment was carried out and the canals
were dressed with calcium hydroxide and obturated with gutta percha on
the subsequent visit
(C)Blood sample was collected from the Cubital region of forearm and
Platelet rich fibrin (PRF) was separated from the blood. The PRF was
collected in dappen dish and mixed with hydroxyapatite graft material.
A B C

20. Furcation Perforation Mx (Surgical cont.)
A surgical Approach by Rhythm and Vivek Bains of Lucknow, India
(D) Full thickness mucoperiosteal envelop flap was reflected from the
lingual aspect of tooth 45, 46 and 47. The area was debrided and
hydroxyapatite graft+ PRF was applied into the furcation. The flap
was readapted and stabilized.
(E) The perforation was repaired using MTA and then the tooth was
completely sealed using Type II glass ionomer cement
(F) Post operative radiograph after 4 months
D E F

21. Lateral Wall (Strip)
Perforation

22. Lateral Wall Perforation (Strip
Perforation)
• Can be caused by over Instrumentation in a
thin walled root or a curved root.
• Can be identified by radiograph
or clinically by hemorrhage or pain
Success of repair depends on location of the
perforation in relation to the position of crestal
bone with the strip above the crest having
better prognosis

23. Strip Perforation Mx
• Steps of management according to various clinicians (NCBI,
Pubmed)
1. Isolate the area, gain adequate access, obtain hemostasis
and irrigate copiously
2. Create a biological barrier in the perforated root using zinc
oxide eugenol, IRM, glass ionomer cement, calcium
hydroxide and mineral trioxide aggregate (MTA)
3. Use pre curved instruments and anti curvature filing
motion to reshape the canal following the safety zone.
Avoid scraping the walls near the danger zone
4. Obturate the other canals using filler material like gutta
percha.

24. Strip Perforation

25. Root Canal Perforation

26. Root Canal Perforation (Cervical)
1. Cervical canal perforation
• Commonly occurs during location of canal
orifice and flaring of coronal 1/3rd of canal.
• Bleeding into the chamber is the first sign of
perforation

27. Root Canal Perforation (Mid root)
2. Mid root perforation
• Commonly occurs in curved canals or in canals
which have ledge formed and further
instrumented
• Often accompanied by strip perforation as the
curved canal is straightened out

28. Root Canal Perforation (Apical)
3. Apical Perforation
• Usually caused when working length is not
established.
• Over-instrumentation beyond the apical
constriction also factors in

29. Root Canal Perforation (Apical)
3. Apical Perforation (continued)
• Hall mark clinical feature: loss of previously
tactile resistance at apical stop accompanied
by patient complaining of pain.
• Bleeding at tip of paper point can be a telltale
sign of apical perforation

30. Root Canal Perforation (Management)
• Clinical Detection- In all cases patient may complain of
sudden pain in a previously painless appointment
session with taste of irrigating solution. The clinician
may also detect bleeding into the canal and chamber.
• Obtain Proper Isolation
• Immediate Hemostasis- using any biocompatible
material that will not obstruct final obturation of canal
(example. Calcium Hydroxide, Calcium Sulphate etc.)
• Radiographic Detection- by Intraoral Periapical
Radiograph or Cone Beam Commuted Tomography
(CBCT)

31. Root Canal Perforation (Management cont.)
Definitive Management according to Ingle’s Endodontics
• Apical- fill as is, and if symptomatic, handle as
alveolar abscess (root end resection)
• Middle- Force a softened gutta percha plug into the
root and remove it to ascertain the extent and
nature of perforation. Then fasten the plug to a
condenser and pack it tightly into the perforation
with restorative material like copper amalgam.
• Coronal- pack perforation (with restorative
material) in similar manner to that for the middle
being careful not to force excess material into the
tissue

32. Root Canal Perforation (Management cont.)
Some Practical Points
• Apical- create an apical stop by fresh dentin chips. This can
be done by passing a large sized reamer or file into the
reestablished working length and carrying out filing motion.
• Use instrument into canal while placing repair material to
maintain canal patency. Move the instrument up and down
in short strokes to prevent the repair material setting onto
the instrument
• Mid root and cervical perforation- MTA (or similar
materials) yield better results clinically. Cervical perforation
management has poorer prognosis of the three because of
its contamination with the gingiva and oral environment

33. The Use of Internal Matrix
• Used to prevent overfilling of repair material
into the periodontium
• A material used as matrix should be
biocompatible, easy to manipulate and stimulate
osteogenesis.
• Commonly used matrix is hydroxyapatite
• Indicated in
• Used in accessible perforations
• Middle or apical root canal perforations
• Strip perforations in straight canal

34. Internal Matrix
• Contraindications
• External root perforation
• Perforation above the level of crestal bone
• Disadvantage
• Radiographic evaluation of bone fill is difficult
especially if radiodensities of materials and bone are
same
• Technique sensitive and require special devices for
placement

35. Post Space Perforation

36. Post Space Perforation
Iatrogenic perforation during the
preparation and flaring of obturated
canals with the intention of placing
prosthesis (dowels) of post
endodontic restoration
Kvinnsland et al found 47% of perforations occurred
during endodontic treatment and 53% were due to
restorative/prosthodontic treatment
(Kvinnsland I, Oswald RJ, Halse A, Grønningsaeter AG. A clinical and roentgenological
study of 55 cases of root perforation. Endod J. 1989;22 (2):75-84)

37. Post Space Perforation (Evidence based Dentistry)
According to an article by Tinaz (DDS, PhD) in the journal of contemporary
dental practice
• A wider post provides only slightly better retention,
and its use also means a thinner and weaker residual
root dentin
• There was no correlation between root curvature
degree and perforation. However, more perforations
were found in short roots with larger drills
According to Kuttler and Mclean of Nova Southeastern University, USA
• Post space preparation in mandibular molars carries
significant risk of perforation

38. Post Space Perforation (non surgical Mx)
Non surgical approach is the same as other
perforations.
1. Obtain hemostasis
2. repair perforation using materials like dental
amalgam, Calcium hydroxide, glass ionomer,
composite resins, freezed dried bone,
calcium phosphate

39. Post Space Perforation (Surgical Mx)
A surgical approach to post space perforation, by Marga Ree (DDS, MSc), Netherlands
(A) A radiograph taken in 1999 showed periapical and lateral
radiolucencies. The original treatment had occurred in 1984, and the
treating dentist had filled the perforation with gutta-percha.
(B) A radiograph of tooth #7 in 2003 before endodontic surgery. The
lateral and apical radiolucencies did not appear to have reduced in
size.
(C) Surgical access was made with a full-thickness flap, the area was
debrided, and the perforation site was visualized.

40. Post Space Perforation (Surgical Mx cont.)
A surgical approach to post space perforation, by Marga Ree (DDS, MSc), Netherlands
(D) The perforation and root-end preparation were filled with MTA.
(E) At the 1-year recall, there was a reduction of both
radiolucencies.
(F) At the 8-year recall, periapical radiographs showed no evidence
of endodontic disease

41. Prognosis of
Perforation Repair
Points to consider during treatment planning of repair

42. Factors Affecting the Success of
Perforation Repair
According to Louis E. Rossman, DMD; James Bahcall, DMD, MS, FICD, FACD;
and Frederic Barnett, DMD in the Compendium of continuing Education in
Dentistry
• Location of perforation- If perforation is above the
alveolar crest, epithelial migration causes pocket
formation and contamination with oral environment
leading to poorer prognosis
• Size of Perforation- smaller osseus perforations have
less tissue damage and hence easier to repair
• How quickly it is sealed- should be repaired as quickly
as possible to prevent loss of attachment and sulcular
breakdown

43. Factors Affecting the Success of
Perforation Repair (cont.)
• Visualization- If the perforation cannot be directly
visualized, the root-canal treatment should be
completed and then obturated with gutta-percha and a
bioceramic-type sealer.
• In cases of perforation that can be directly visualized
(coronal one-third), a matrix should be used to fill the
perforation before placing a permanent restoration
• Over compensation of perforation repair-
Unintentional extrusion of a restorative material into
the alveolar bone may further compromise the
prognosis of the perforated tooth

44. Factors Affecting the Success of
Perforation Repair (cont.)
• Surgical or Non surgical intervention? - External
or surgical repair of a perforation is necessary
when either the internal repair cannot properly
seal the perforation or the perforation was not
sealed in a timely fashion and clinical evidence
indicates the peri-radicular tissue is beginning to
break down.
• Is Extraction of tooth necessary? -If this
breakdown of tissue has advanced and the tooth
has become severely compromised, extraction is
usually the treatment of choice

45. Factors Affecting the Success of
Perforation Repair (cont.)
• Contamination: Coronal (microbial) leakage
in teeth with untreated perforations has been
associated with persistent inflammation and
attachment loss.
• Strategic Importance of tooth in association
with its periodontal condition
• Esthetics- Determines the technique and
material to be used for perforation repair

46. Statistics involved in Success of
Perforation Repair
• According to Siew K, Lee AH and Cheung GS’ article; Treatment outcome of
repaired root perforation: a systematic review and meta-analysis ( J Endod.
2015;41(11):1795-1804)
• The overall success rate was 72.5% after non-
surgical repair of perforations.
• The use of MTA increased the success rate to
80.9%.
• The presence of preexisting radiolucencies
adjacent to the perforation sites was associated
with decreased success rates.
• The favorable success rate associated with the
non-surgical repair of perforations >80% when
using bioactive materials

47. Materials Used to
Repair Perforation

48. Perforation Repair Materials
According to Abhijeet Kamalkishor Kakani’s article A Review on Perforation
Repair Materials, J Clin Diagn Res. 2015
Indium foil Prevents overfilling but also increases bone resorption
Dental Amalgam
Plaster of Paris used to fill bone resorption defects but difficult to obtain
perfect seal
Zinc Oxide Eugenol (not preferred)- cause severe inflammatory reaction,
abscess formation and resorption of alveolar crest
Super EBA An alumina reinforced ZnOE. Easy to manipulate and
excellent biocompatibility

49. Perforation Repair Materials (Cont.)
Intermediate restorative
material (IRM)
prone to leakage and should be applied with matrix
Cavit- an eugenol-free
polyvinyl paste
Easy to manipulate, can produce adequate seal and does
not impede healing of tissue
Glass ionomer cement Light cured GI produces better seal than cavit
Metal Modified Glass
Ionomer cement
It has the properties like bonding to dentin, radiopacity,
rapid set and ease of delivery
Gutta Percha has poorer success rate as opposed to the other materials

50. Zinc oxide Eugenol Super Ethoxy benzoic Acid Plaster of Paris
Intermediate Restorative Cavit Bisfil-2B
Material

51. Perforation Repair Materials (Cont.)
Bisfil 2B: self-curing
hybrid composite
better sealing ability than amalgam and Intermediate
Restorative Material however has the highest rate of
overfilling when used to repair lateral perforations
Dentin Chips It is used as matrix in repair of perforation defects. They
reported periodontal pocket formation apical to the
perforation regardless of the technique used.
Decalcified Freezed
Dried Bone (DFDB)
DFDB chips are biocompatible, relatively nontoxic, easy to
obtain, easy to use, relatively inexpensive, easy to
manipulate, completely degrades during the repair process
and acts as an excellent barrier against which filling
material could be placed.
Calcium Phosphate
Cement (CPC)
The end setting reaction produces hydroxyapatite which
causes osteoconduction and concurrent cement absorption
to produce new bone
Tricalcium Phosphate showed evidence of healing by the presence of layers of
epithelium, collagen, and bone. However causes
inflammatory reaction at perforation site

52. Perforation Repair Materials (Cont.)
Hydroxyapatite It can be used both as an internal matrix and as a direct
perforation repair material. When used as furcation perforation
repair material has shown to reconstruct furcation bone loss
due to iatrogenic root perforation
Calcium Hydroxide calcium hydroxide as matrix and Super EBA as the material for
perforation repair yield good results. However calcium
hydroxide paste plus iodoform for perforation repair showed
necrosis at the site of perforation and different levels of
cementum hyperplasia
Portland Cement It induces bone and cementum formation when used as
perforation repair material but does not provide a fluid tight
seal
Mineral Trioxide
Aggregate (MTA)
Most Preferred. MTA stimulates cementoblasts to produce
matrix for cementum formation and is biocompatible with the
periradicular tissues thus shows a superior sealing ability when
used for perforation repair

53. Decalcified Freezed Dried
Bone (DFDB)
Tricalcium Phosphate Hydroxyapatite Powder
Portland Cement
Mineral Trioxide Aggregate

54. Perforation Repair Materials (Cont.)
Biodentine Easy to manipulate and a short setting time
approximately 12 minutes, has high alkaline pH
and is a biocompatible material makes it a
favourable material for perforation repair
Endosequence (Bioceramic) It has a working time of more than 30 minutes
and a setting reaction initiated by moisture with a
final set achieved in approximately 4 hours. Its
nanosphere particles produce exceptional
dimensional stability
Bioaggregate It has comparable biocompatibility and sealing
ability to MTA. MTA is more influenced by acidic
pH than Bioaggregate when used as perforation
repair material.
New Endodontic Cement/
Calcium Enriched Mixture
CEM cement preferable as a furcal perforation
repair material in close proximity to the exposed
periodontium.

55. Biodentine Endosequence
Bioaggregate Calcium Enriched Mixture

56. In Conclusion
• The treatment planning involved in repairing an
iatrogenic perforation is influenced by a variety of
factors.
• Regardless of the approach, surgical or non
surgical; there are certain factors (as mentioned
before) that can significantly affect the success of
repair
• The clinician should have proper knowledge of
tooth morphology, sound clinical judgement and
adequate operative skills so as to avoid ending up
with a perforation in the first place.

57. • All in all, a perforation is an unfortunate
mishap during treatment that can happen to
the best of us.
• A good clinician does not cause perforations
during treatment but is equipped to treat it
should his/her colleague be unfortunate
enough to accidentally cause one!

58. Reference:
• Louis E. Rossman, DMD; James Bahcall, DMD, MS, FICD, FACD; and Frederic Barnett, DMD. The
Endodontically Perforated Tooth: Hopeless or Savable? Compendium of Continuing Education In Dentistry.
April 2016; Volume 37, Issue 4
• Abhijeet Kamalkishor Kakani, Chandrasekhar Veeramachaneni, Chandrakanth Majeti, Muralidhar
Tummala, Laxmi Khiyani. A Review on Perforation Repair Materials. J Clin Diagn Res. 2015 Sep; 9(9): ZE09–
ZE13. Published online 2015 Sep 1. doi: 10.7860/JCDR/2015/13854.6501 PMCID: PMC4606360
• Kuttler S, McLean A, Dorn S, Fischzang A. The impact of post space preparation with Gates-Glidden drills
on residual dentin thickness in distal roots of mandibular molars. J Am Dent Assoc. 2004 Jul;135(7):903-9
• Tinaz AC, Alaçam T, Topuz Ö, et. al. Lateral Perforation in Parallel Post Space Preparations. J Contemp Dent
Pract 2004 August;(5)3:042-050.
• Marga Ree, DDS, MSc, Richard Schwartz, DDS. Management of Perforations: Four Cases from Two Private
Practices with Medium- to Long-term Recalls (2012); Journal of endodontics, ISSN: 1878-3554, Vol: 38,
Issue: 10, Page: 1422-7
• Rhythm Bains, Vivek K. Bains, Kapil Loomba, Kavita Verma, Afreena Nasir. Management of pulpal floor
perforation and grade II Furcation involvement using mineral trioxide aggregate and platelet rich fibrin: A
clinical report; Contemp Clin Dent. 2012 Sep; 3(Suppl 2): S223–S227. doi: 10.4103/0976-237X.101100
PMCID: PMC3514927
• 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
• Sinai IH. Endodontic perforations: their prognosis and treatment. J Am Dent Assoc. 1977 Jul;95(1):90-5.
• Eghbal MJ, Fazlyab M, Asgary S. Repair of an Extensive Furcation Perforation with CEM Cement: A Case
Study . Iranian Endodontic Journal. 2014;9(1):79-82.
• homesteadschools.com/dental/courses/CurrentEndodonticTreatment/Chapter01
• P.Carrotte. Endodontics: Part 4 Morphology of the root canal system. British Dental Journal volume 197,
pages 379–383 (09 October 2004) doi:10.1038/sj.bdj.4811711

59. Reference:
• Adiga S, Ataide I, Fernandes M, Adiga S. Nonsurgical approach for strip perforation repair using
mineral trioxide aggregate. Journal of Conservative Dentistry : JCD. 2010;13(2):97-101.
doi:10.4103/0972-0707.66721.
• Endodontic Mishaps in detail. Iraqi Dental Academy.
iraqidental.wordpress.com/2016/09/12/endodontic-mishaps-in-detail/
• Surendrakumar K Bahetwar, Ramesh Kumar Pandey. An unusual case report of generalized pulp
stones in young permanent dentition; Contemporary Clinical Dentistry. 2010, Vol 1, issue 4; 281-
283
• pocketdentistry.com/6-treatment-of-nonvital-teeth/
• Abbas Shokri, Amir Eskandarloo , Maruf Noruzi-Gangachin , Samira Khajeh. Detection of root
perforations using conventional and digital intraoral radiography, multidetector computed
tomography and cone beam computed tomography. J Restorative Dentistry & Endodontics. ISSN
2234-7658 (print) / ISSN 2234-7666 (online) dx.doi.org/10.5395/rde.2015.40.1.58
• IGOR TSESIS ZVI FUSS. Diagnosis and treatment of accidental root perforations. Endodontic Topics
Vol 13, Issue 1, page 95-107
• Siew K, Lee AH and Cheung GS’ article; Treatment outcome of repaired root perforation: a
systematic review and meta-analysis ( J Endod. 2015;41(11):1795-1804)
• (Kvinnsland I, Oswald RJ, Halse A, Grønningsaeter AG. A clinical and roentgenological study of 55
cases of root perforation. Endod J. 1989;22 (2):75-84)
• Nisha Garg, Amit Garg. Textbook of Endodontics, 3rd edition. Jaypee Publication
• John I. Ingles, Leif K. Bakland. Ingle’s Endodontics, 6th edition. BC Decker Inc
• Images from Google

60. Thank You
And Hope you have a perforation free day!