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 Table of Contents  
Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 105-108

Single-visit endodontic management of iatrogenic supracrestal root perforation associated with dual sinus using MTA and collagen

1 Department of Conservative Dentistry and Endodontics, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India
2 Department of Conservative Dentistry and Endodontics, All India Institute of Medical Sciences, New Delhi, India
3 Department of Conservative Dentistry and Endodontics, Mulana Dental College, Ambala, Haryana, India

Date of Web Publication4-Jul-2014

Correspondence Address:
Navin Mishra
A79, Palam Vihar, Gurgaon, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2231-6027.135987

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Iatrogenic perforation is usually an undesired complication that results in an artificial communication between the root canal system to the supporting tissues of the teeth or to the oral cavity. It can occur during preparation of endodontic access cavities and exploration of calcified canal orifices. Successful treatment depends on the proper diagnosis and immediate sealing of the perforation site to eliminate the risk of infection. On the basis of the physical and biologic properties, mineral trioxide aggregate (MTA) has shown superior sealing ability and is suitable for closing the perforation site. The purpose of this case report is to describe the successful orthograde retreatment of iatrogenically perforated lower central incisor associated with dual sinuses. The perforation site was cleaned with 5.25% sodium hypochlorite and 0.9% normal saline solution and sealed with MTA with an internal collagen matrix. Finally, the tooth was endodontically treated and coronally restored with composite resin. After 6 and 12 months of follow-up, the absence of periradicular radiolucent lesion, disappearance of dual sinus, pain and swelling indicated a successful outcome of non-surgical sealing of the perforation.

Keywords: Collagen matrix, dual sinuses, iatrogenic supracrestal perforation, MTA

How to cite this article:
Narang I, Mishra N, Singh K. Single-visit endodontic management of iatrogenic supracrestal root perforation associated with dual sinus using MTA and collagen. Int J Oral Health Sci 2013;3:105-8

How to cite this URL:
Narang I, Mishra N, Singh K. Single-visit endodontic management of iatrogenic supracrestal root perforation associated with dual sinus using MTA and collagen. Int J Oral Health Sci [serial online] 2013 [cited 2022 Aug 9];3:105-8. Available from: https://www.ijohsjournal.org/text.asp?2013/3/2/105/135987

  Introduction Top

Iatrogenic supracrestal root perforation is usually an undesired complication that can occur during the preparation of endodontic access cavities or overzealous instrumentation in a tooth that has thin and slender roots. [1] Such perforations are managed surgically or non-surgically. [2] Various materials have been used in repairing perforations, including zinc oxide-eugenol, amalgam, calcium hydroxide and composite resin glass ionomer. [3] These materials either show inadequate sealing ability or have no biomimetic action and hence contribute to a poor outcome. Mineral trioxide aggregate (MTA) has been regarded as an ideal material for perforation repair. [4] The chemical composition of MTA was determined by Torabinejad et al. [5] The material consists of fine hydrophilic particles, and the main components are tricalcium silicate, tricalcium aluminate, tricalcium oxide and silicate oxide and bismuth oxide. Plethora of studies has demonstrated its excellent sealing ability and biocompatibility. [6] It is an ideal material for treating root perforation as it is non-toxic, non-absorbable, radiopaque and has antimicrobial properties. [7] The repair capacity of MTA can in turn be attributed to its antimicrobial properties due to high pH (12.5). These characteristics of MTA promote the growth of cementum and formation of new bone. [8] Treatment of large crestal perforations carries a guarded prognosis because of their proximity to the epithelial attachment; hence, in these clinical situations, orthodontic extrusion is recommended so as to bring the perforation to a coronal position, where it can be sealed without surgical contemplation. There are few reports on the non-surgical retreatment of supracrestal perforation with MTA and collagen. The aim of this paper is to present a case of successful treatment outcome of a long-standing, iatrogenic, supra-crestal perforation sealed by MTA and collagen as an internal matrix in a single visit.

  Case Report Top

A 20-year-old man reported to the Department of Conservative Dentistry and Endodontics, with pain and pus discharge from the left lower anterior teeth. He gave a history of prior root canal treatment of tooth #31 1 month back by a local dentist. The medical history was non-contributory. On clinical examination, dual intraoral sinuses, one located at the periapical region and the other at the cervical region of #31, were seen [Figure 1]. The tooth showed mild sensitivity to percussion and palpation. The intra-oral periapical radiograph showed a large, cervical perforation defect on the mesial side and diffuse periapical radiolucency. The root canal filling was seen to be poorly condensed [Figure 2]. After removal of the coronal restoration and gutta-percha from the canal, hemorrhage was noted from the cervical end, which was controlled with copious irrigation with 1% sodium hypochlorite and by applying pressure with cotton pellets in the access cavity. The perforation site was supracrestal and was large. It was sealed in an orthograde manner with the help of collagen as an internal matrix and MTA (Dental Tulsa; Dentsply, DeTrey Konstanz, Germany). The canal was prepared in a crown-down fashion using protaper files (Dentsply) with copious irrigation with 5.25% sodium hypochlorite and 17% EDTA. The final rinse was with 2% chlorhexidine. The root canals were then obturated with gutta-percha points and AH 26 (Dentsply) using the lateral condensation technique. The tooth was restored with composite resin [Figure 3]. At the 1-week follow-up visit, dual sinuses were healed [Figure 4]. The patient was clinically asymptomatic and, radiographically, healing of the periapical lesion was seen at the 6-month and 1-year follow-up visits [Figure 5].
Figure 1: Pre-operative intraoral view showing dual sinuses

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Figure 2: Pre-operative intraoral periapical radiograph with gutta-percha tracing

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Figure 3: Post-operative intraoral periapical radiograph

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Figure 4: Intraoral view after 1 week

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Figure 5: Intraoral periapical radiograph after 1 year

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  Discussion Top

Iatrogenic perforation is the artificial communication between the root canal system to the periodontium or to the oral cavity. Several materials have been used to repair perforations, like IRM, Super-EBA, glass ionomer cement, composite resins, resin-glass ionomer hybrids and MTA. [9] MTA was developed at the Loma Linda University in the 1990s, and is apparently superior to these materials with respect to marginal adaptation, [10] bacterial leakage [11] and cytotoxicity. [12],[13] MTA provides an effective seal of root perforations hence enhancing the prognosis of such teeth that would otherwise be compromised. [14] MTA is a biocompatible material when used in root-end cavities. It stimulates repair of periradicular tissues and deposition of cementum. [15] The desirable properties of MTA make it a useful material in repairing the root and furcal perforation; hence, in the present case, MTA was used. The prognosis of perforations depends on the location, size and time of repair [16] ; the location of perforation at the level of the epithelial attachment and crestal bone has a questionable prognosis. [17] The size of a perforation is the other important factor in determining the success of the repair procedure. In cases of large perforation, the use of internal matrix avoids the extrusion of the sealing material and consequent periradicular tissue inflammation. [18] In the present case, the perforation was large that collagen was used as an internal matrix and as a hemostatic agent. The interval between perforation and repair is one of the critical factors for success. [19] Studies suggest that immediate sealing of perforation enhances the repair process due to a reduced chance of bacterial contamination of the defect. Root perforations sealed with MTA after contamination presented worse repair than the non-contaminated, immediately sealed perforations. [20] In the present case, although the time between perforation and repair was 1 month, MTA treatment was successful, as indicated by clinical and radiographic examination at 6 months and 1 year. MTA is not adversely affected by the presence of moisture, and has an antimicrobial action on account of its high pH. [21] Sealing the perforation immediately followed by endodontic therapy in the following visit generally improves the outcome of the therapy. In the present case, the patient had to go abroad and wanted to complete the root canal in a single sitting; hence, the root canal preparation was done simultaneously and final irrigation was done with 2% chlorhexidine. Contaminated perforations must be washed out with sodium hypochlorite, which disinfects the surrounding tissues, resulting in an increase in healing kinetics. [22] Hence, in the present case, 1% sodium hypochlorite was used as it is bactericidal and mild to periodontal tissues.

  Conclusion Top

MTA is the material of choice for perforation repair. With collagen as an internal matrix, a non-surgical repair of large supracrestal perforation is possible and can be successful, as documented in the present case.

  Acknowledgments Top

The authors deny any conflict of interests related to this study. The authors affirm that they have no financial affiliation (e.g., employment, direct payment, stock holdings, retainers, consultant ships, patent licensing arrangements or honoraria) or involvement with any commercial organization with direct financial interest in the subject or materials discussed in this manuscript, nor have any such arrangements existed in the past 3 years. Any other potential conflict of interest is disclosed.

  References Top

1.Bargholz C. Perforation repair with mineral trioxide aggregate: A modified matrix concept. Int Endod J 2005;38:59 69.  Back to cited text no. 1
2.Frank RJ. Endodontic mishaps: Their detection, correction, and prevention. In: Ingle JI, Bakland LK, editors. Endodontics. 5th ed. London: BC Decker Inc; 2002. p. 769 94.  Back to cited text no. 2
3.Roda RS. Root perforation repair: Surgical and nonsurgical management. Pract Proced Aesthet Dent 2001;13:467 74.  Back to cited text no. 3
4.Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations. J Endod 1993;19:541 4.  Back to cited text no. 4
5.Osorio RM, Hefti A, Vertucci FJ, Shawley AL. Cytotoxicity of endodontic materials. J Endod 1998;24:91 6.  Back to cited text no. 5
6.Hashem AA, Hassanien EE. ProRoot MTA, MTA Angelus and IRM used to repair large furcation perforations: Sealability study. J Endod 2008;34:59 61.  Back to cited text no. 6
7.De Deus G, Reis C, Brandão C, Fidel S, Fidel RA. The ability of Portland cement, MTA and MTA Bio to prevent through and through fluid movement in repaired furcal perforations. J Endod 2007;33:1374 7.  Back to cited text no. 7
8.Roberts HW, Toth JM, Berzins DW, Charlton DG. Mineral trioxide aggregate material use in endodontic treatment: A review of the literature. Dent Mater 2008;24:149 64.  Back to cited text no. 8
9.Torabinejad M, Pitt Ford TR, McKendry DJ, Abedi HR, Miller DA, Kariyawasam SP. Histologic assessment of mineral trioxide aggregate as a root end filling in monkeys. J Endod 1997;23:225 8.  Back to cited text no. 9
10.Wu MK, Kontakiotis EG, Wesselink PR. Long term seal provided by some root end filling materials. J Endod 1998;24:557 60.  Back to cited text no. 10
11.Shabahang S, Torabinejad M, Boyne PP, Abedi H, McMillan P. A comparative study of root end induction using osteogenic protein 1, calcium hydroxide, and mineral trioxide aggregate in dogs. J Endod 1999;25:1 5.  Back to cited text no. 11
12.Bates CF, Carnes DL, del Rio CE. Longitunal sealing ability of mineral trioxide aggregate as a root end filling material. J Endod 1996;22:575 8.  Back to cited text no. 12
13.Keiser K, Johnson CC, Tipton DA. Cytotoxicity of mineral trioxide aggregate using human periodontal ligament fibroblasts. J Endod 2000;26:288 91.  Back to cited text no. 13
14.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. 14
15.Economides N, Pantelidou O, Kokkas A, Tziafas D. Short term periradicular tissue response to mineral trioxide aggregate as a root end filling material. Int Endod J 2003;36:44 8.  Back to cited text no. 15
16.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. 16
17.Fuss Z, Trope M. Root perforations: Classification and treatment choices based on prognostic factors. Endod Dent Traumatol 1996;12:255 64.  Back to cited text no. 17
18.Tsesis I, Rosen E, Schwartz Arad D, Fuss Z. Retrospective evaluation of surgical endodontic treatment: Traditional versus modern technique. J Endod 2006;32:412 6.  Back to cited text no. 18
19.Rafter M, Baker M, Alves M, Daniel J, Remeikis N. Evaluation of healing with use of an internal matrix to repair furcation perforations. Int Endod J 2002;35:775 83.  Back to cited text no. 19
20.Holland R, Bisco Ferreira L, de Souza V, Otoboni Filho JA, Murata SS, Dezan E Jr. Reaction of the lateral periodontium of dogs′ teeth to contaminated and noncontaminated perforations filled with mineral trioxide aggregate. J Endod 2007;33:1192 7.  Back to cited text no. 20
21.Nicholls E. Treatment of traumatic perforations of the pulp cavity. Oral Surg Oral Med Oral Pathol 1962;15:603 12.  Back to cited text no. 21
22.Ford TR, Torabinejad M, McKendry DJ, Hong CU, Kariyawasam SP. Use of mineral trioxide aggregate for repair of furcal perforations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:756 63.  Back to cited text no. 22


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


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