PERFORATION REPAIR

1. Delayed repair of multiple
perforations compounded with
formocresol osteo‐gingival necrosis
A case report
Shah DY, Khopade ST, Jain PM, Dadpe AM. Saudi Endod J 2018;8:50‐4.
Presented By:
Dr.Raazia Khan

2. SUMMARY
This case report describes the management of formocresol osteo‐gingival
necrosis in a mandibular molar with lingual and furcal perforations using
resorbable demineralized bone matrix and mineral trioxide aggregate
(MTA).
Three‐year postoperative follow‐up showed resolution of the osseous
defect as well as a clinically and radiographically sound periodontium.
Further, this report warrants that formaldehyde‐containing medicaments
have no role in contemporary endodontics.

3. INTRODUCTION
Iatrogenic perforations are undesirable complications occurring
during the endodontic therapy that can adversely affect the overall
prognosis of the tooth.
Prognosis is fair - level of perforations is more apical in the root and
perforation is small and is sealed immediately.
Calcium silicate‐based cements such as mineral trioxide aggregate
(MTA) are the current clinical materials of choice for sealing
perforations.[1,2]

4. CASE REPORT
AGE : 20years
SEX : Female
CHIEF COMPLAINT : Pain and discomfort in left mandibular region
for the past 2 days.
Perforation had occurred when root canal therapy was initiated in the
left mandibular frst molar 2 weeks ago.
Formocresol medicament and temporary restoration placed in the
concerned tooth.

5. C/E : Yellowish slough with inflamed surrounding tissues in the lingual gingival
region and tenderness on percussion with the tooth.
Buccal gingiva indicated probing depths of 1–1.5 mm.
R/E : Radiolucency in the pulp chamber floor (furcal and lingual perforations)
furcal alveolar bone area extending along the lateral surface of the distal root
and its apex suggestive of an overextended access preparation
Diagnosis : Osteo‐gingival necrosis secondary to perforations and apical
periodontitis.

6. Preoperative records of tooth #36. C/e revealed a yellowish
necrotic slough on the linguogingival aspect

7. Overextended access cavity, radiolucency in the furcal area
as well as along the distal root suggestive of chronic apical
periodontitis

8. Intraoperative records: Healthy lingual gingiva and the
complete extent of lingual perforation seen after
periodontal healing

9. tooth #36 after sealing of the lingual and furcal
perforations

10. Postoperative radiograph: Immediately after
deFInitive restoration

11. Postoperative radiograph: 1‐year follow‐up showing
reduction of the radiolucency in the furcation area and
along the distal root

12. Three‐year follow‐up:Clinical photograph showing
healthy gingiva

13. Three year follow‐up: radiograph showing healing of
the furcation area

14. Stage I: Surgical debridement and initiation of endodontic
therapy
Under local anesthesia, necrotic slough was removed with universal
curette - the area was debrided and irrigated with 5% povidone‐iodine
antiseptic solution.
A mobile bony sequestrum was separated from the healthy viable bone
and was sent for histopathological examination.
The exposed wound area was covered with tin foil and surgical
dressing (GC Coe‐Pak, GC, USA).
Tin foil is not routinely used along with periodontal dressing.
“modified matrix concept” for repair of perforation utilizes resorbable
collagen as a biocompatible matrix, followed by condensation of MTA.

15. Stage I: Surgical debridement and initiation of endodontic
therapy
Such a matrix in the area of bone destruction provides a base on which
the sealing material can be placed and packed in the perforation.
achieves hemostasis & prevents the extrusion of the material into the
periodontal tissues.
Exploring the mesiobuccal root canal revealed a perforation on the
furcal side of the mesial root
Saline was used as an irrigant, necrotic pulp tissue was extirpated, and
working length was determined.
calcium hydroxide (RC Cal, Prime Dental Products Pvt. Ltd., Mumbai,
India) intracanal medicament placed, and a closed dressing given.

16. Stage I: Surgical debridement and initiation of endodontic
therapy
oral analgesic and antibiotic along with a 0.2% chlorhexidine
mouthwash was prescribed.
after 1 week, the patient was asymptomatic and there was a decrease
in the extent of the gingival inflammation.
The affected area was irrigated with the antiseptic solution and a
periodontal dressing was again placed on the wound.
The same procedure was repeated at the recall appointments in the 2nd
and 3rd
week.
After 1 month, the lingual marginal gingiva appeared healthy and 2 mm
of gingival recession was measured from the cementoenamel junction.
Thus, the lingual perforation defect became supragingival and the
patient was scheduled for the second stage of treatment.

17. Stage II: Perforation repair and completion of endodontic therapy
Following local anesthesia and quadrant isolation with rubber dam, clinical
procedures were carried out using a dental operating microscope.
Light‐cured composite resin (Filtek Z350, 3M ESPE, Salt Lake City, UT,
USA) was used to seal the lingual perforation and build up the lingual wall
incrementally using a modified T‐band matrix.
Appropriate size gutta‐percha points were used to block the root canal
orifices.
The furcal perforation was scrubbed with betadine, and #2 Munce bur was
used to freshen the dentinal margins around the furcal perforation defect.
With the help of curette, inter‐radicular necrotic tissue from the furcation area
was debrided and bleeding was induced to confirm healthy bone.

18. Stage II: Perforation repair and completion of endodontic therapy
A sterile resorbable demineralized bone matrix (OsseograftTM Advanced Biotech
Products, India) was used as an internal matrix and condensed in the area with a
#80 plugger, below the furcation over the viable bone taking care that no material
came in contact with cavosurface margins of the tooth.
MTA was inserted into the perforated pulp chamber floor and the mesial root and
condensed. A moist cotton pellet was placed over the MTA and the gutta‐percha
stoppers in the orifices were carefully removed.
The canals were dried with paper points, and the distal canal and the mesiolingual
canal were medicated with calcium hydroxide. The endodontic access was sealed
with glass ionomer cement.
under isolation, a re‐entry into the access preparation was gained.
the intracanal calcium hydroxide was removed using endodontic hand files and
2.5% sodium hypochlorite.
final rinse of 17% ethylenediaminetetraacetic acid was used, and the canals were
dried with paper points.

19. Stage II: Perforation repair and completion of endodontic
therapy
Obturation was carried out. Immediate postobturation restoration with
composite resin (Filtek Z350, 3M ESPE, Salt Lake City, UT, USA) was
placed to obtain the coronal seal.
A week later, the tooth was restored with a full coverage metal fused to
ceramic crown.
1 year follow - up, clinically, the patient was asymptomatic, had no pain
to percussion/palpation, and had no evidence of periodontal disease.
Radiographically, the tooth demonstrated complete resolution of the
furcal radiolucency with new bone filling the defect. Further, the apical
radiolucency showed signs of healing
3‐year follow‐up, the tooth remained asymptomatic, healthy, and
functional

20. Discussion
This case report is a minimal interventional approach for the successful
management of iatrogenic perforations with associated formocresol
osteo‐gingival necrosis.
the placement of any caustic agent like formocresol can convolute
iatrogenic mishaps such as perforations.
Formocresol contains formaldehyde and cresol.
Formaldehyde (CH2
O), is the most simple and reactive of all aldehydes,
colorless, reactive, and readily polymerizing gas at room temperature.
The International Agency for Research on Cancer of the World Health
Organization has declared formaldehyde as a human carcinogen.

21. Discussion
in the present case, although osteo‐gingival necrosis was present, a
successful attempt was made to salvage the tooth using bone graft
combined with perforation repair and nonsurgical endodontic therapy.
Since the furcal perforation defect was wide, a direct intra‐coronal access
was preferred for perforation repair.
Reflection of a surgical flap for perforation repair in the present case would
have led to further destruction of cortical bone and delayed the wound
healing.
Immediate repair of perforation is better than delayed repair.
the perforation was superimposed with osteo‐gingival necrosis, a staged
therapy was planned.
The healing of the periodontium following Stage I therapy facilitated
isolation procedure, necessary for sealing of the perforation defects.

22. Discussion
MTA was used as the repair material because of its outstanding
sealing ability, good marginal adaptation, osteoconductivity, and
cementoconducivity.
when the perforation is associated with a large osseous defect,
extrusion of sealing material in the periodontium may occur.
Lemon advocated the use of a matrix when the perforation diameter is
larger than 1 mm.
“modified matrix concept” for repair of perforation utilizes resorbable
collagen as a biocompatible matrix, followed by condensation of MTA.
Such a matrix in the area of bone destruction provides a base on which
the sealing material can be placed and packed in the perforation.
achieves hemostasis & prevents the extrusion of the material into the
periodontal tissues.

23. Discussion
materials recommended for the fabrication of matrix, resorbable collagen, calcium
sulfate, calcium hydroxide, hydroxyapatite, tricalcium phosphate, and
demineralized bone.
Osseograft (Encoll, Fremont, USA) consists of demineralized freeze‐dried bone
matrix - prepared from bovine cortical bone sample
osteoinductive, osteoconductive, and totally resorbable.
In the present case, use of this material in the osseous defect in the furcal area
provided an excellent matrix for the compaction of MTA. In addition, this radiolucent
matrix had an advantage that the radiographic assessment of compaction of
radiopaque MTA was possible. Thus, it served a dual purpose of acting as a
resorbable matrix and aiding in bone regeneration.
Immediate coronal seal after completion of endodontic therapy also ensured
elimination of any possibility of microleakage.

24. Conclusion
Staged periodontal‐endodontic approach resulted in a favorable
treatment of root perforations.
use of MTA in combination with demineralized bone graft in delayed
repair of root perforation associated with necrotic bony defects can
lead to successful treatment outcome.
With the known risk and proven effective alternatives, the use of
formocresol in root canal therapy is unwarranted.