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Table of Contents
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 87-90

Effective seal completes the deal: Periodontal management of an iatrogenic endodontic perforation

Department of Periodontology, Government Dental College and Hospital, Aurangabad, Maharashtra, India

Date of Web Publication5-Jan-2017

Correspondence Address:
Arati Seetaram Maurya
Department of Periodontology, Government Dental College and Hospital, Aurangabad, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2229-5194.197692

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Perforations are undesirable complications and unfortunate incidents that can occur during root canal therapy. The present case report describes the surgical management of extensive iatrogenic perforation of the pulpal floor of the first mandibular molar in furcation area. Radiographic analysis confirmed Grade II furcation involvement. Therefore, the diagnosis of primary endodontic and secondary periodontal lesion was made. Surgical debridement of the furcation area with simultaneous repair of perforation was considered. After flap reflection and proper debridement, perforation was located. The perforation was sealed with biodentine. In the furcation area, regeneration was done by placing bone graft and covering it with guided tissue regeneration membrane. Postoperatively, the healing was uneventful. After healing, prosthetic restoration was done. Thus, the case was successfully managed.
Clinical Relevance To Interdisciplinary Dentistry
Biodentine has a wide range of applications including endodontic repair (root perforations, apexification, resorptive lesions, and retrograde filling material in endodontic surgery) and pulp capping and can be used as a dentine replacement material in restorative dentistry. Its lack of cytotoxixity and tissue acceptability properties make it biocompatible with pulpal and periodontal tissue.

Keywords: Biodentine, iatrogenic perforation, regeneration, surgical management

How to cite this article:
Indurkar MS, Maurya AS. Effective seal completes the deal: Periodontal management of an iatrogenic endodontic perforation. J Interdiscip Dentistry 2016;6:87-90

How to cite this URL:
Indurkar MS, Maurya AS. Effective seal completes the deal: Periodontal management of an iatrogenic endodontic perforation. J Interdiscip Dentistry [serial online] 2016 [cited 2023 Mar 30];6:87-90. Available from: https://www.jidonline.com/text.asp?2016/6/2/87/197692

   Introduction Top

Accidental perforation of pulp chamber or root is one of the major complications of endodontic treatment [1] and results in the loss of integrity of root and adjacent periodontium. [2],[3] Unrepaired perforation leads to chronic inflammatory reaction characterized by the formation of granulation tissue. These led to irreversible attachment loss and bone loss or may lead to tooth loss. [1]

A wide range of materials has been tried for surgical and nonsurgical repair of perforation including zinc oxide eugenol, calcium hydroxide, cavit, amalgam, glass ionomers, composite resins, mineral trioxide aggregate (MTA), and biodentine. [4],[5] The elusive goal of present day dentistry is not only repair of perforation but also regeneration of lost periodontium. The present article illustrates the use of biodentine for repair of the endodontic perforation and guided tissue regeneration (GTR) for lost periodontium.

   Case Report Top

An 18-year-old female patient reported to the outpatient Department of Periodontology with the chief complaint of swelling and pus discharge from gums in the lower right back region of the jaw for 15 days. On clinical examination, periodontal abscess was present on the buccal-attached gingiva with tooth number 46 which was draining through gingival sulcus [Figure 1]. Incomplete root canal treatment (RCT) was noticed with that tooth. On the past dental history, the patient visited some private practitioner for pain with the same tooth 3 months back, where RCT was advised. After beginning of the treatment due to some unexplained reason, she was advised for extraction of that tooth. As the patient was reluctant for extraction and wanted to save that tooth, she visited this institute. Careful clinical examination revealed perforation in the pulpal floor in furcation area. The probing pocket depth (PPD) was 11 mm on the mid-buccal area of tooth 46. In the rest area, the PPD was in the range of 2-3 mm suggestive of localized periodontal destruction. The tooth was not mobile with no marginal tissue recession. The gutta-percha point was used to track the abscess, and intraoral periapical radiograph was taken that pointed toward the furcation area [Figure 2]. Radiograph also revealed bone loss in the furcation area and Grade II furcation involvement. The condition was diagnosed as retrograde periodontitis along with Grade II furcation (Glickman's classification) involvement with definitive pulpal perforation resulting in primary endodontic secondary periodontal lesion (Simon's classification).
Figure 1: Baseline photograph: Probing pocket depth of 11 mm with periodontal abscess

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Figure 2: Radiograph with gutta-percha point

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Re-RCT and repair of the perforation along with regenerative therapy for Grade II furcation were planned. Treatment plan comprised scaling and root planing followed by surgical repair of perforation and regeneration in the furcation area.


After completing the obturation, surgical intervention was planned. Periodontal surgery was performed under local anesthesia. Inferior alveolar nerve block and buccal infiltration were given using 2% lignocaine with adrenaline (1:80,000). Full-thickness mucoperiosteal flap was elevated on buccal aspect of the tooth 45, 46, and 47. After complete debridement, perforation was located with the help of gutta-percha points [Figure 3]. After achieving isolation and hemostasis with Gelspon, perforation was repaired by biodentine to form a complete layer on the floor of pulp chamber [Figure 4]. Isolation was maintained for next 12 min, i.e., for the initial setting time of biodentine. Temporary sealing was done with the help of zinc-oxide eugenol cement, and the gingival contour was maintained by placing matrix band. Hydroxyapatite bone graft was placed in the furcation area, and collagen membrane was placed over it [Figure 5]. Interrupted suture was given with composite stop in the mid-buccal area to avoid recession [Figure 6]. Immediate postoperative intraoral periapical radiograph was taken to confirm the perforation seal which appeared as radiopacity in that area [Figure 7]. Periodontal pack (Coe-pak) was applied. Written postoperative instructions were given to the patient, and analgesic (ibuprofen 400 mg thrice daily) was prescribed for 3 days. Antibiotic (amoxicillin 500 mg thrice daily) for 7 days and 0.2% chlorhexidine mouthwash twice daily for 2 weeks were instructed. Pack and sutures were removed on the 14 th postoperative day. The patient was asymptomatic, and healing was uneventful. The patient was followed up at 1 month, 3 months, 6 months, and under maintenance phase. Temporary crown was given with tooth 46. Permanent metal ceramic crown was given after 6 months.
Figure 3: Intraoperative location of perforation with gutta-percha point

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Figure 4: Perforation sealed with biodentine

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Figure 5: Bone graft placed in the defect

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Figure 6: Suturing

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Figure 7: Pre- and immediate postoperative radiograph comparison

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   Result Top

The PPD was reduced to 2 mm from 11 mm with no gingival recession at 6-month follow-up [Figure 8]. The gain in clinical attachment level was of 9 mm. Radiographic analysis revealed bone regeneration in the furcation area [Figure 9]. The perforation sealing was effectively maintained.
Figure 8: Follow-up probing pocket depth of 2 mm

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Figure 9: Follow-up radiograph at 6 months

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   Discussion Top

The Grade II furcation involvement in the mandibular molars has good prognosis and can be successfully treated by regenerative therapy combined with the concept of GTR. However, when endodontic is the cause of such lesion, it should be managed first. [6] The prognosis of a perforation repair is dependent on many factors such as level of perforation, size of perforation, and the time elapsed between the perforation and its repair. It also depends on the sealing ability and biocompatibility of the material used for repair. When time elapsed is more, it leads to chronic inflammatory reaction, granulation tissue formation, bone loss and attachment loss. [7],[8]

Among different materials used for perforation repair, MTA has been used most commonly with good treatment outcome because of its biocompatibility, good seal even in the presence of moisture or blood. Recently, calcium silicate-based cement "Biodentine" has gain popularity because of their resemblance to MTA and designated as "Dentin Replacement" material. Favorable features of biodentine include - (1) no effect of blood contamination on push-out bond strength of material irrespective of setting time. (2) In case of its use as retrograde filling material or groove sealing material where there is a continuously moist environment, lesser porosity that occurs by biodentine is advantageous. (3) During scanning electron microscopy analysis, biodentine crystals appeared firmly attached to the underlying dentine surface. [9] In a study by Guneser et al., biodentine showed considerable performance as a perforation repair material even after being exposed to various endodontic irrigants as compared to MTA. [10] Aggrawal et al. concluded that 24 hrs push out strenght of MTA was less than that of biodentin and it was affected by contamination of blood. [11] Hassan et al. in one study found that as perforation repair material, biodentine showed comparable minimal leakage in retrograde and orthograde direction as compared to MTA, it had better handling property and was more cost effective. [12]

In the present case around 3 months has elapsed since the occurrence of perforation and its repair. The perforation was old in nature, large, and crestal in location. The overall prognosis of perforation repair was questionable. However, regeneration of Grade II furcation involvement in the mandibular molars had a good prognosis. The sealing of perforation with biodentine and regeneration of Grade II furcation with bone graft and GTR membrane saved the tooth with good prognosis which was questionable at baseline.

However, very few literatures are available regarding the use of biodentine as perforation repair material. The use of biodentine seems promising in the present case.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Silveira CM, Sánchez-Ayala A, Lagravère MO, Pilatti GL, Gomes OM. Repair of furcal perforation with mineral trioxide aggregate: Long-term follow-up of 2 cases. J Can Dent Assoc 2008;74:729-33.  Back to cited text no. 1
Gahanbari H, Ghoggusi J, Mohtasham N. A comparison between amalgam and MTA in repairing furcal perforations. J Dent 2008;5:115-9.  Back to cited text no. 2
Shahi S, Rahimi S, Hasan M, Shiezadeh V, Abdolrahimi M. Sealing ability of mineral trioxide aggregate and Portland cement for furcal perforation repair: A protein leakage study. J Oral Sci 2009;51:601-6.  Back to cited text no. 3
Samiee M, Eghbal MJ, Parirokh M, Abbas FM, Asgary S. Repair of furcal perforation using a new endodontic cement. Clin Oral Investig 2010;14:653-8.  Back to cited text no. 4
Balachandran J, Gurucharan. Comparison of sealing ability of bioactive bone cement, mineral trioxide aggregate and Super EBA as furcation repair materials: A dye extraction study. J Conserv Dent 2013;16:247-51.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
Bains R, Bains VK, Loomba K, Verma K, Nasir A. 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;3 Suppl 2:S223-7.  Back to cited text no. 6
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. 7
Tsesis I, Fuss Z. Diagnosis and treatment of accidental root perforations. Endod Topics 2006;13:95-107.  Back to cited text no. 8
Malkondu Ö, Karapinar Kazandag M, Kazazoglu E. A review on biodentine, a contemporary dentine replacement and repair material. Biomed Res Int 2014;2014:160951.  Back to cited text no. 9
Guneser MB, Akbulut MB, Eldeniz AU. Effect of various endodontic irrigants on the push-out bond strength of biodentine and conventional root perforation repair materials. J Endod 2013;39:380-4.  Back to cited text no. 10
Aggarwal V, Singla M, Miglani S, Kohli S. Comparative evaluation of push-out bond strength of ProRoot MTA, biodentine, and MTA Plus in furcation perforation repair. J Conserv Dent 2013;16:462-5.  Back to cited text no. 11
[PUBMED]  Medknow Journal  
Hassan FN, Al Hadi D, Saeed MH. Furcal perforation repair using MTA and biodentine™, an in vitro evaluation using dye extraction method. Int J Recent Sci Res 2015;6:3172-5.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]


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