Root perforation. Special patient with severe pain and the indication by the colleague, of resolution in a single visit, without removal of the prosthesis and conventional intervention.

On clinical examination, there was swelling in the vestibular gingival region of tooth 21. Radiographic and tomographic exams revealed periapical radiolucent image and palatal/distal region, due to perforation related to the retainer. We opted for surgical resolution, with apicectomy and retropreparation of the apical remnant and ultrasound preparation in the region of the perforation.

Both were obtained with MTA. After 2 weeks, remission of signs and symptoms was observed and the patient was indicated for follow-up.   

Dr. Vanessa Pessoti: angelus.com.br:

During endodontic treatment, it is important to consider not only the outcome, but also the possible complications that can occur during the treatment procedure - among them is root perforation. It is therefore recommended that all dentists know how to suspect, diagnose, and treat root perforation.

To answer the main questions on the subject, we invited Prof. Dr. Vanessa Pessotti (CRO: ES 2069), dentist specialized in Endodontics. Check out, below, the interview!

What factors can lead to a root perforation?

Root perforation is directly related to endodontic treatments, and is mainly considered a complication of these procedures - that is, it is an iatrogenic consequence.

This does not mean, however, that it cannot be avoided: root perforation is related, especially, to the failure to observe the anatomical particularities of the different dental groups. The most critical phases are during the coronary access and during the shaping of the root canal system.

Some factors (anatomical and extra-anatomical) are related to an increased risk of root perforations. These are:

• irregular morphology of the root canals;
• calcified canals;
• root thinning;
• error during access to the pulp chamber;
• excessive wear of the root canal walls;
• inadequate preparation for placing intraradicular pins.

What is the best way to diagnose?

The first step in diagnosis is the clinical examination and observation of the root perforations via an operating microscope. The definitive diagnosis, however, depends on imaging examinations, which must be chosen carefully.

The periapical radiograph has a limited capability in root perforation: as it offers a two-dimensional image, there is an overlapping of structures, especially if the perforation occurs in the buccal-lingual direction.

Therefore, the most indicated exams for diagnosis are those that allow a three-dimensional visualization. According to Dr. Vanessa, the most indicated is the high-resolution Cone Beam Computed Tomography, which provides more precise information about the location of the root perforations.

Do root perforations have a classification?

Yes. The most commonly used classifications are:

• as to size: small or large;
• as to location: coronal perforations, perforations in the bone crest area, or apical perforations;
• as to the time elapsed after the perforation: "immediate" or "delayed".

According to the classification, how will the prognosis be?

According to our interviewee, we were able to metric the prognosis according to some characteristics of the classifications (Fuss and Trope, 1996; Thesis and Fuss, 2006). We divided the prognosis between "good" and "questionable". Check out the characteristics of each one below.

Signs of good prognosis

• drilling done under an aseptic medium and treated immediately or at short notice;
• small perforations;
• coronal perforations;
• apical perforations (in most cases).

Signs of questionable prognosis

• perforations in the bone crest area;
• wide-ranging perforations.

How will "immediate" and "late" root perforations be treated?

As you might expect, immediate perforations are treated differently from late perforations - since they can be diagnosed intraoperatively and require faster intervention.

In immediate perforations, Dr. Vanessa recommends, in a single session, disinfecting with 2.5% sodium hypochlorite, then sealing with a bioceramic repair material and lining with ionomer. If indicated, finish with resin restoration or cementation of a pin.

In late ones, however, the treatment is performed in two sessions. In the first session, we must clean and decontaminate the perforation, remove the granulation tissue, and irrigation with 2.5% sodium hypochlorite. Then we must proceed with the photodynamic therapy (low intensity laser) and place a Calcium Hydroxide dressing for 15 days.

In the second session, it starts with the removal of the calcium hydroxide dressing and a new disinfection. Then sealing with a restorative bioceramic material should be done, followed by lining with ionomer and, if indicated, finishing with a resin restoration or pin cementation.

What is the benefit of bioceramic cements in cases of root perforations?

Our interviewee emphasizes that bioceramic cements increase root resistance and are well tolerated by the tissues. Moreover, they have the ability to induce an interaction with the tissues and dentin, stimulating the formation of hydroxyapatite, thus promoting tissue regeneration.

For better results, having quality products is fundamental. This is the main focus of Angelus, a company that seeks, day after day, to innovate with the the best materials in the market.