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Endodontics Mishaps (Perforations) Marwa Shaker An endodontic perforation is an artificial opening in the tooth or its root

,created by clinician during entry to the canal systemorby biologic event such as pathogenic resorption or caries Main complication: 2dry inflammation and infection of pdl + tooth loss

2*Root perforations

Roots may be perforated at different levels during cleaning and shaping

(apical,middle,cervical)

* Coronal Subgingival perforations (Acess cavity related) Searching or canal orifices perforation of crown thru side of crown (restoration) floor of chamber

coronal root perforations

Abobe periodontal attachment Below periodontal attachment saliva or irrigant leakage through oral cavity pain and bleeding

ManagementIsolate the perforation If perforation site is clean uninfected repair immediately

For esthetics :calcium sulphate barrier with tooth coloured restoration .For non esthetic areas Cavit,amalgam,calcium hydroxide paste,super EBA,Glassionomer.

MTA ( when no sulcular communication)

Strip perforation excessive flaring with files or drills

ManagementNon surgical ttt: MTA offers best results after hemorrhage control and proper visibility Other materials: cavit calcium hydroxide paste,amalgam,zic oxide eugenolMTA takes 3 hrs to set so should be covered with fast setting cement Other canal orifices should be protected by paperpoints to prevent blockage

Prognosis:Poorest long term prognosisDefect is inaccessible for adequate repair

Lateral (midroot )perforations Below the periodontal ligament

Caused by files, GG drills , large misdirected post

sign : sudden bleeding,sudden pain

Management

Same technical considerations as coronal 1/3 except that we are dealing with a deeper defects

Factors for successful repair : hemostasis, access, microinstrumentation techniques,Selection of suitable material.

If the m1/3 perforation is small repaired during obturation.If large perforation repaired first and retrievable material in the canal to prevent blockage.

Dealing with two canals one natural and the other is iatrogenic Take W.L and clean , shape and obturate

MTA is the material of choice

Prognosis : good no communication with oral cavity

Furcation PerforationManagement: immediately if possible repaired with MTA If proper conditions exists (dryness) composite or glass ionomer can seal the defect Prognosis is good if repaired immediately

If not repairable non surgicaly or inaccessibleSurgical:Hemisection,

Bicuspidization

Root amputation

Intention replantation

Apical perforationOccur thru apical foramen (Over instrumentation)

or thru body of root (perforated new canal)Especially in curved canals

Indicators Pain, loss of apical stop Bleeding at tip of paperpoint

Prevention maintain proper working lengths

Treatement

Overinstrumentation :restablish tooth length short of the original oneand then enlarge with larger instrumentsPlace MTA as an apical barrier and Obturate to the new length

Through body of root : deal with one canal with two foramina Obturation by vertical compacting technique with heat softened gutta-percha .

Prognosis: depends primarily on size and shape of defect but prognosis is better as no any communication with oral cavity.

Prognosis for healing1.Timing of repair Immediate is better than delayed , infected un treated defects lead to marked inflammation ,abcess formations and cervicular epithelium proliferation

2.Location of perforation eg furcation perforation decreased success due to inc.epithelial proliferation and periodontitis Perforation near gingival sulcus inflammation and loss of epithelial attachment + pdl pocket More apical perforation offer better prognosis

3. Size of perforation small defects direct and immediate restoration + few chances of pdl breakdown Large defects difficult to place well condensed restoration + large contact surface area with peiodontium allow inflammation .

Perforation Repair materials must be antimicrobial , non toxic provide adequate seal non absorpable ,RO ,promote oeteogenesis and cementogenesis.

ZOE Cements . Chronic inflammatory response Calcium hydroxide .. Prevent in groth of granulation tissue into perforationCavit ..mild to modetare inflammatory response Amalgum. assessing healing potential but carcinogenic Super EBAproper seal and adaptation to defectGlass ionomer same properties as amalgam MTAcomposition include calcium and phosphorus ions with pH 10.2 Least toxic Biologicaly compatible Allow groth of cementum like substance on surface of material Less inflammatory infiltrative cells Good marginal adaptation to dentin Leak less than amalgam in lateral perforations

No current available material meets all requirements

5. Hemostatics To stop hemorrhage wjich may affect assecibility calcium hydroxide or calcium sulphate

6.Vision or accessibility Magnification loupes , head lamps , transilluminating devices and dental microscopes Are imp in addressing perforations

7.Treatement sequence Repairing perforation will allow control of bleeding , confine irrigation ,and facilitate obturation .Maintain the pathway of canal to avoid blockage

Case presentation A 32-year-old Indian female had underwent root canal treatment of her upper left central (#21) and lateral incisors (#22) about 1 year ago, following which redness and occasional pus discharge started from the gingiva in relation to the central incisor.

clinical presentation, there was erythema in the labial attached gingiva in relation to tooth #21. Periodontal probing revealed a 4 mm deep periodontal pocket on the labial aspect of tooth #21 corresponding to the area of erythema.Intra-oral periapical radiograph revealed short of length radiopaque filling material in tooth #21 and poorly condensed root canal filling in tooth #22.

However, no evidence of periapical pathology was present in relation to either tooth.

(a) Pre operative clinical view depicting localized area of erythema in relation to attached gingiva of tooth #21(b) Pre operative radiograph of toothAccess was regainedgutta-percha was retrieved with gutta-percha Endosolv-E solvent and H-files it was realized that it was an iatrogenically created perforation canal into which the gutta-percha was condensed. This perforation communicated with the oral cavity. The identification of the root canal orifice was done (palatal to the perforation) while operating under the dental operating microscopesurgical exposure of the perforation and its sealing with biodentine (Septodont).calcium hydroxide was administered as intracanal medicament. The access preparation was sealed with a cotton pellet and Cimpat pink (Septodont).

After 1 week, obturation was completed with gutta-percha and AH plus sealer

(a) Working length IOPA radiograph of tooth . (b) Master cone IOPA radiograph. (c) Radiograph showing obturation

Repair of the perforation with biodentine. clinical view of the pulp chamber following obturation of the root. canal, showing perforation located labial to the canal orifice

Clinical view of the pulp chamber following perforation repairPost treatment radiograph of tooth

Discussion

Out of the various factors affecting the prognosis of teeth with iatrogenic perforations, timely intervention and the level of perforation (relative to crestal bone and epithelial attachment) are probably the most important.[4]The present case posed a treatment challenge as the perforation was crestal in position (it impinged on the epithelial attachment with periodontal pocket formation) with a 1 year long history.

A perforation occurring relatively close to the crestal bone and the epithelial attachment is critical as it may lead to bacterial contamination from the oral environment along the gingival sulcus. Furthermore, apical migration of the epithelium to the perforation site can be expected, creating a periodontal defect. Such lesions which present with both endodontic and periodontal involvement are known as endo-perio lesions. The present case is a primary endodontic lesion with secondary periodontal involvement. (Simon's classification of endo-perio lesions).[8]Once the periodontal pocket is formed, persistent inflammation of the perforation site is most likely maintained by continuous ingress of irritants from the pocket. In the present case also, loss of periodontal attachment and formation of periodontal pocket (4 mm) were seen. Treatment of crestal perforations carries a guarded prognosis because of their proximity to the epithelial attachment.

References

INGLE ENDODONTICS ENDODONTIC PRINCIPLES AND PRACTICE http://www.saudiendodj.com/article.

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