Reparation and revision 3. Perforations during root canal treatment

Iatrogenic perforations from the pulp cavity towards the periodontium result in complications that often lead to root or tooth removal. Identification of perforations is possible by direct observation of bleeding, indirect bleeding assessment using paperpoints, radiography and an apex locator. Successful treatment depends mainly on immediate sealing and prevention of infection. Several factors affect the achievement of these goals, such as time of occurrence, size and location of the perforation and the lability of the repair material to seal the lesion. An overview is presented of diagnosis, prognosis and non-surgical treatment of perforations.     

Root perforations

Repairing root perforations in a timely manner is vital to successful treatment. Three case reports are presented in which successful root perforations were treated intracoronally using a fast-setting zinc oxide and eugenol cement.     

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一个成功的根管治疗包括正确的诊断、充分的根管预备和完善的根管充填,而这些步骤成功的基础是对根管形态的充分掌握。变异根管的错误诊断和治疗以及根管遗漏是造成根管治疗失败的主要原因。本文对根管解剖形态、根管数目的确定方法、临床常见的变异根管形态及根管形态研究方法的发展进行简要介绍。     

Root perforations: classification and treatment choices based on prognostic factors

Abstract Root perforations are common complications ofendo-dontic treatment or post preparation and often lead to tooth extraction. Successful treatment depends mainly on immediate sealing of the perforation and prevention of infection. Severnt factors ailed the achievement of these goals, most important of which are: time of occurrence, size, and location of the perforation. A classification of root perforations, based on the above factors, is presented lo assist the clinician in the choice of the treatment protocol which will give the best possible results when a perforation is diagnosed.     

Perforation repair with mineral trioxide aggregate: a modified matrix concept

AIM: To present a modified matrix concept for repair of root perforations using mineral trioxide aggregate (MTA). SUMMARY: Root perforations may occur during preparation of endodontic access cavities or during post-space preparation. The perforation creates the potential for an inflammatory reaction in the periodontal ligament. A concept for the repair of root perforations is presented using a matrix of resorbable collagen. This matrix reconstructs the outer shape of the root and facilitates the adaptation of MTA. The indications for the use of MTA are discussed. Two clinical cases of 5-year successful root perforation repair using the technique are presented. KEY LEARNING POINTS: Long-term perforations with periodontal inflammation can be successfully treated with MTA. Matrices for MTA placement can be developed with commercially available collagen. Infection control within the root canal and at the perforation site is required for satisfactory perforation repair and healing.     

Osteochondroma of the coronoid process of the mandible.

A case of osteochondroma of the coronoid process is presented. The proper diagnosis of ill-defined symptoms in the temporomandibular joint requires conformity between clinical manifestations and radiologic findings. The importance of a thorough radiologic examination is stressed for the correct diagnosis of these rare, insidious, slow-growing tumors. A short review of the literature is presented, and the treatment and surgical approach to these tumors are discussed.     

Persistent sinus tract formation 1 year following cast post-and-core replacements: a case report.

Sinus tracts are paths of drainage for abscesses and can occur both intraorally and extraorally. It is a fact that sinus tracts can heal with proper endodontic therapy. However, there are those types that are persistent and will not respond to any treatment. In these perplexing cases, it may be necessary to elevate a surgical flap to unveil the real etiologic factor. In this article, a case is presented in which 2 persistent and nonhealing sinus tracts were observed around the maxillary left incisor area of a 53-year-old female patient. A difficult cast post-and-core removal had been accomplished to the compromised tooth 1 year previously. A surgical flap had to be reflected, and the cause of the persistent inflammation was determined to be 2 separate root perforations. The granulation tissue was removed, the perforations were sealed with mineral trioxide aggregate, and bone graft was packed in the resorptive bone areas. The symptoms subsided by the time of the 2-week recall. No complaints were noted from the patient during the 4-month follow-up period. This case is a good example that demonstrates the possible complications of post preparation and the necessity of explorative surgery for unveiling the etiologic factor of persistent sinus tract formation.     

Calcium hydroxide: a review

Calcium hydroxide is a multipurpose agent, and there have been an increasing number of indications for its use. Some of its indications include direct and indirect pulp capping, apexogenesis, apexification, treatment of; root resorption, iatrogenic root perforations, root fractures, replanted teeth and interappointment intracanal dressing. The purpose of this paper is to review the properties and various indications for the use of calcium hydroxide.     

Root perforations following endodontics: a case for surgical management

Despite technological advancements in dental instrumentation and techniques, endodontic mishaps remain commonplace. Perforations during access preparation, canal instrumentation, root filling, or preparation of post space are not unusual and instruments may fracture during filing or reaming or when attempting to bypass fractured instruments in the root canal. Many of these complications are hard to avoid due to extreme variations in root canal anatomy, root shapes, curvatures, and canal calcification. Procedural errors impede proper endodontic therapy and increase the risk of treatment failure; as a result, the prognosis is compromised, especially in nonvital teeth or teeth with periradicular lesions. Perforations may lead to short-term or long-term complications (that is, infection, periapical cyst, or granuloma formation); in addition, restorative material may be extruded through the perforation. Clinicians often have difficulty diagnosing and treating root perforations, particularly in posterior teeth (specifically in the area of the mandibular bifurcation); however, such complications do not mean that the tooth must be extracted. This article discusses treatment of perforations near the bifurcation of a mandibular first molar and an apical perforation in a premolar. Both teeth were salvaged via surgery without the use of additional biomaterials.     

Endodontics: Part 9. Calcium hydroxide, root resorption, endo-perio lesions

For more than 70 years calcium hydroxide has played a major role in endodontic therapy, although many of its functions are now being taken over by the recently introduced material MTA. Calcium hydroxide may be used to preserve the vital pulp if infection and bleeding are controlled; to repair root fractures, perforations, open apices and root resorptions. Endo-perio lesions are complex and the correct diagnosis is essential if treatment is to be successful. However, root canal treatment will always be the first phase in treating such lesions.     

Vertical root fractures in endodontically treated teeth: diagnostic signs and clinical management

A most frustrating complication to root canal therapy is vertical root fracture (VRF) in an endodontically treated tooth. Prognosis most often is hopeless and differential diagnosis from other pathoses may be difficult at times. Nevertheless, proper diagnosis is critical to distinguish a fracture complication from clinical manifestations of periodontal and endodontic diseases. This review emphasizes the importance of the correct diagnosis of VRF, describes the more typical clinical and radiographic features of this disorder, and summarizes its prevalence and multifactorial etiology.     

Conservative treatment of root perforations using apex locator and thermatic compactor--case study of a new method

Endodontic perforation, a serious complication in dental practice, is among the most common problems associated with endodontic procedures. Recommended methods of treatment are surgical or conservative using calcium hydroxide paste. A method in which perforations can be obturated immediately after their detection is described. The method utilizes an apex locator for measurement and detection of the perforation and a two-step treatment of thermatic compaction for filling the root canal as well as the perforation. A number of cases with a long follow-up are presented.     

髓腔穿孔的修复现状及策略

髓腔穿孔是根管治疗失败的主要原因之一。在临床治疗中对出现髓腔穿孔的病例,如果不及时修复或修复方法不当,可严重影响根管治疗患牙的预后。目前我国口腔临床髓腔穿孔的修复现状令人堪忧,本文对髓腔穿孔的修复方法及材料进行论述,以帮助临床医生选用正确的方法和材料修复髓腔穿孔,从而提高根管治疗患牙的保存率。     

Occurrence and Risk Factors of Dental Root Perforations: A Systematic Review

BackgroundIatrogenic root perforations are an unfortunate accident that can occur during dental treatment and can lead to peri-radicular damage, poor treatment outcome and extraction of the tooth. The aim of this review was to analyse the occurrence and risk factors for root perforation.MethodsA systematic search of the literature was conducted in CINAHL, Cochrane, EMBASE, Medline and SCOPUS in May 2019. Additional literature was identified through a hand search. Clinical studies enrolling adults with permanent dentition were included. Single case studies and case reports were excluded. Duplicate articles were removed, titles and abstracts were screened and studies were selected according to the inclusion criteria. Data were collected and reported in accordance with PRISMA guidelines. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools.ResultsA total of 916 articles were screened, from which 47 full-text articles were analysed and 22 articles were finally included in the study. The data were analysed qualitatively because meta-analysis could not be conducted owing to lack of heterogeneity among the studies. Most of the articles were retrospective cross-sectional studies on root canal treatments performed by undergraduate students. The occurrence of perforation ranged from 0.6% to 17.6%. Risk factors for perforation included experience of the practitioner, tooth type, and tooth morphology. The risk of bias in most of the studies included was assessed as low.ConclusionsThis systematic review suggests a need for additional studies on the risk factors associated with iatrogenic root perforation as the current literature is insufficient. Educational efforts in dental schools should address the issue of perforations and provide more clinical experience prior to graduation in order to improve the clinical skills of graduates.     

Map-reading strategy to diagnose root perforations near metallic intracanal posts by using cone beam computed tomography

Introduction

To determine the diagnostic hypothesis on the basis of periapical radiography (PR) is a great challenge for radiologists and endodontists. Visualization of three-dimensional structures, available with cone beam computed tomography (CBCT), favors precise definition of the problem and treatment planning. However, metallic artifact effect of intracanal posts might also induce untrue images. The aim of this article is to suggest a map-reading strategy to diagnose root perforations near metallic intracanal posts (ICPs) by using CBCT.

Methods and Results

The incapacity to locate correctly the position of root perforation might lead to clinical failures. One strategy to minimize metallic artifact in root perforation associated with ICP is to obtain sequential axial slices of each root, with an image navigation protocol from coronal to apical (or from apical to coronal), with axial slices of 0.2 mm/0.2 mm. This map reading provides valuable information showing dynamic visualization toward the point of communication between the root canals and the periodontal space, associated with radiolucent areas, suggesting root perforation.

Conclusions

The accurate management of CBCT images might reveal abnormality that is unable to be detected in conventional PR. A map-reading approach reduces problems related to detection of root perforations near metallic artifacts. The final diagnosis should always be made in conjunction with the clinical findings.     

Complications after apicoectomy in maxillary premolar and molar teeth.

This study was designed to enumerate the number of perforations to the maxillary sinus while performing apicoectomy on maxillary premolar and molar teeth and to evaluate possible complications as a result of these perforations. A total of 472 apicoectomies were performed in 440 patients; perforations occurred in 10.4% of teeth, 23% in molars, 13% in second premolars and 2% in first premolars. No cases of acute or chronic sinusitis were recorded. It was concluded that apicoectomy, carried out using a meticulous surgical technique and proper postoperative care, should be considered as a treatment option before contemplating extraction.     

Interaction between endodontics and periodontics

Endodontic–periodontal lesions present challenges to the clinician regarding diagnosis, treatment planning and prognosis. Etiologic factors, such as bacteria and viruses, as well as contributing factors, such as trauma, root resorptions, perforations, cracks and dental malformations, play an important role in the development and progression of such lesions. Treatment and prognosis of endodontic–periodontal lesions vary, depending on the etiology, pathogenesis and correct diagnosis of each specific condition. This chapter will appraise the interrelationship between endodontic and periodontal lesions and provide biological and clinical evidence for diagnosis, prognosis and decision‐making in the treatment of these conditions.     

Reaction of the lateral periodontium of dogs' teeth to contaminated and noncontaminated perforations filled with mineral trioxide aggregate

It has been shown that the mineral trioxide aggregate (MTA) used to seal lateral/furcal perforations stimulates the deposition of newly formed cementum. Nevertheless, when the site of the perforation is contaminated, the healing process might occur under less favorable conditions. This study evaluated the repair healing process of noncontaminated and contaminated lateral perforations filled with MTA and the effect of previously filling the contaminated perforations with a bactericidal agent. Thirty lateral root perforations were prepared in endodontically treated dog's teeth, thus forming 3 groups with 10 specimens each. In group 1 the perforations were immediately sealed with MTA. In group 2 the perforations were left open for 7 days and thereafter sealed with MTA. In group 3 the perforations were left open for 7 days, filled temporarily with a calcium hydroxide-based paste for 14 days, and then sealed with MTA. The animals were killed after 90 days, and the pieces were prepared for histomorphologic and histomicrobiologic evaluations. The statistical analysis showed that group 1 had significantly better repair than groups 2 (P < .05) and 3 (P < .05), which validates the superior results obtained when MTA was immediately used to seal root perforations. Groups 2 and 3 had statistically similar repair to each other (P > .05). There were a larger number of cases of complete or partial biologic seal in group 1 compared with the contaminated groups. It might be concluded that the lateral root perforations sealed with MTA after contamination presented worse repair than the noncontaminated, immediately sealed perforations. The temporary filling with a bactericidal agent (calcium hydroxide-based paste) did not improve the repair of perforations exposed to contamination, and the contaminated groups presented similar results to each other.     

Treatment of root perforations with calcium hydroxide and SuperEBA cement: a clinical report

Iatrogenic root perforations sometimes occur during root canal treatment or when preparing the root canal for a post. The inflammation in the periradicular tissues caused by root perforation reduces the prognosis of the involved tooth. The situation may be further complicated if by coronal leakage, microorganisms are allowed to infect the canal and the periradicular region. This clinical report presents a nonsurgical technique, based on the internal matrix concept, using both calcium hydroxide and SuperEBA together to repair root perforations. The author has experienced good clinical results with this perforation repair technique.     

A clinical and roentgenological study of 55 cases of root perforation

Summary. The treatment outcome of 55 root perforations in man were related to pretreatment conditions and various treatment procedures used, with a mean recall period of 3 years 5 months. In this study maxillary teeth were perforated three times more often (74.5 per cent) than mandihular teeth (25.5 per cent); 47 per cent of the perforations were due to endodontic and 53 per cent due to prosthodontic treatment. The buccal and mesial root surfaces as well as the midroot areas w ere most often perforated. In 25 per cent, radiographic changes were directly related to the perforated areas.
Twenty-eight perforations were repaired by orthograde fillings with gutta-percha and Kloro-percha N-ø; eight received a combined orthograde and surgical repair, and in only three cases a surgical approach was used. Four cases received no treatment but were recalled, and twelve perforations showed a size and location hopeless for repair; the teeth were therefore extracted. Five failures of the primary orthograde treatment group later underwent surgical treatment and were followed up for 3 years 3 months.
The overall success rate in the primary treatment group of teeth was 56 per cent while 36 per cent became failures. Five failures were retreated, and four of these became successful. A combined orthograde and surgical repair of the perforations provided the most favourable outcome with 92 per cent successful.
The study stresses the importance of preventing this type of treatment complication.