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Case Report 


Maha A. Alturki, 2019;3(9):790–793.

International Journal of Medicine in Developing Countries

Repair of long standing latrogenic perforation with mineral trioxide aggregate: a case report

Maha A. Alturki1*

Correspondence to: Maha A. Alturki

*Consultant in Restorative Dentistry, Department of Restoratives, Dental Faculty of National Guard Hospital, King Abdulaziz City Dental Clinic, Riyadh, Saudi Arabia.

Email: mahaalturki [at] yahoo.com

Full list of author information is available at the end of the article.

Received: 20 March 2019 | Accepted: 02 May 2019


ABSTRACT

Background:

Iatrogenic perforations within the floor of the pulp chambers are undesirable complications and unfortunate incidents that occur most commonly during endodontic procedures. With the recent physical and biological property investigations of the generally new presented mineral trioxide aggregate (MTA), it can be said that this material might be appropriate for shutting the correspondence between the pulp chamber and underlying periodontal tissues.


Case Presentation:

A 27-year-old man presented to the clinic complaining of slight pain in tooth 36. The perforation of the molar tooth had been done in emergency (ER) dental clinic 4 months ago. Periodontal surgery and removal of granulation tissue were performed, the perforation was cleaned with a saline solution and sealed with MTA, cotton pellet was placed and also a temporary filling. Finally, the tooth was endodontically treated and restored with amalgam build up and covered by the crown. After 3 and 6 months follow up, there was no pain and swelling along with functional stability; radiograph showed an absence of periarticular radiolucency, and the absence of lesion formation of periodontal ligament at the perforation site.


Conclusion:

The applied treatment procedure is a successful method of sealing perforation.


Keywords:

Latrogenic perforation, mineral trioxide aggregate, repair, case report.


Introduction

One of the most difficult cases in clinical treatment is iatrogenic perforations. Often, the problem is iatrogenic as a result of misaligned use of rotary burs during endodontic access preparation or during the search for root canal orifices. Iatrogenic perforations can occur at the different levels. The issue is a chronic inflammatory reaction of the periodontium (formation of granulation tissue) that can lead to irreversible loss of attachment apparatus [1]. Agents that affect the prognosis of perforation repair include the location of the perforation, size and shape of perforation, time delay before perforation repair, proper isolation techniques, previous contamination by microorganisms, and the biological and physical characteristics of the restorative materials [2].

Mineral trioxide aggregate (MTA) is a dental cement which has been recommended to seal artificial communications between the teeth and periodontal tissues [1]. MTA can facilitate normal periradicular architecture by inducing hard tissue barriers. Formation of surrounding MTA was observed even after extrusion of MTA into a furcation [3].

The following case report demonstrates the use of MTA as a sealing material to promote healing of a mandibular first molar with a longstanding furcal perforation.


Case Presentation

A 27-year-old man presented to the clinic complaining of slight pain in tooth 36. The patient gave a history of dental treatment on the offending tooth 4 months back by a general dental practitioner after which the pain started. Intraoral examination revealed a large cavity on 36 restored with a temporary restoration. The periodontal breakdown in the furcal region of tooth 36, the tooth was tender on both percussion and palpation. The mean propping depth was within normal level except at the mid lingual and buccal which were 5 mm in depth. The radiographic examination showed a radiolucent area in the periapical and furcal region of tooth 36 (Figure 1).

Considering the time passed since iatrogenic perforation, size, and position of the defect a clinical decision of repairing the defect with periodontal surgery to remove the granulation tissue and using MTA along with endodontic treatment of 36 was taken. The patient was informed about the condition, and the possible consequences were explained. The temporary restorative material was extracted, and the perforation area was detected clinically. With 1:80,000, adrenaline containing 2% local anesthesia. A full thickness flap was reflected to expose the lesion (Figures 2 and 3).

Removed granulation, tissue, aggregate-sterile saline paste ProRoot MTA (Dental DENTSPLY, DE Trey Konstanz, Germany) mixed in a 3:1 proportion.

In this appointment, which MTA was employed with the help of an MTA carrier, a damp cotton pellet was then arranged in the pulp chamber to produce a humid ambient for the MTA with the aim of achieving solidification, and the tooth was temporarily filled with cavity temporary restoration material.

Sutured the flap and covered patient with antibiotic and anti-inflammatory drugs (Ibuprofen 500 mg). Two weeks later, the solidification of the MTA was checked (Figure 4).

The tooth was isolated with rubber dam then performed root canal treatment, the canals orifices were found and negotiated with no 15 K file (main) working length was determined radiographically (Figure 5).

The distal and the mesial canals were cleaned and shaped using manual files crown. Down technique and copious irrigation was done with 2% sodium hypochlorite. Calcium hydroxide was placed in the canals, then cotton pellet that covered the cavity by temporary filling. A week later temporary filling and cotton pellet were removed, irrigated with 2% sodium hypochlorite Master Cone selection was done, and the root canals were then obdurate with gutta-percha points and AH Plus (Dentsply, DeTray Konstanz, Germany) using lateral condensation technique. Glass ionomer cement was placed as a temporary restoration shown in Figure 6.

Amalgam build up was done, gained retention from pulp chamber, and 2–3 mm from the canal orifices. The final restoration was porcelain fused to metal crown Figure 7.

The final restorations and the condition after 3 months are shown in Figures 8 and 9, respectively.


Discussion

Perforations in the furcal region of molars are particularly challenging but prognosis was favorable even after few months. The prognosis of perforation depends on prevention or treatment of bacterial infection at the perforation site. Also, the use of a non-irritating material that seals the perforation will limit periodontal inflammation [1]. In the present case, the long-standing perforation was in the midlingopulpal floor, more circumscribed characteristic of accidental perforation with a diamond bur, the perforation site was repaired surgically to remove a granulation tissue to ensure an environment free of microbial contamination and necrotic tissue.

Figure 1. Tooth 36 shows a radiolucent area in periodicals and furcation region.

Figure 2. The periodontal prop was passing through the perforation. The perforation was sealed with mineral trioxide.

Figure 3. The periodontal prop was passing through the perforation. The perforation was sealed with mineral trioxide.

Figure 4. The MTA sealing the furcal perforation.

Figure 5. The working length of the roots.

Figure 6. The tooth after obturation.

Figure 7. Tooth 36 post crown cementation and formation of PDL around the furcation.

Figure 8. Clinical picture of tooth 36 with final restoration porcelain fused to metal crown.

Figure 9. Tooth #36 after 3 months.

Property investigations of the generally new presented MTA shows that this material might be appropriate for shutting the correspondence between the pulp chamber and a poor prognosis is probably due to lack of biocompatibility and sealing capacity [2].

For this reason, the selection of suitable sealing material is essential for the successful management of root perforation [3]. MTA was stated to be an excellent material for retrograde filling and perforation repair [4]. Main et al. [5] concluded that MTA provides effective sealing of a root perforation and can be considered a potential repair material that enhances the prognosis of perforated tooth.

MTA was developed as a root-end filling material in surgical endodontic treatments, its contact with adjacent tissues may extend the sealant capacity of MTA, since an acidic environment (such as tissue) may increase this property [6].

It has been used for both surgical and nonsurgical applications, such as root-end filling, resorptive defect repair, direct pulp capping, apexification, and perforation repair [7]. MTA has many advantages as a material for perforation repair, including good sealing characteristics, biocompatibility, bactericidal effects, radiopacity, and the ability to set in the function of blood [8,9]. Perforated roots treated with MTA showed a non-inflammatory tissue layer and root cementum attached to the MTA [10]. In the present patient, MTA was used as a sealing material after removing the granulation tissue from around the perforation site. The follow-up radiographic and clinical evaluations indicated that MTA was a good sealing material and promoted the formation of periodontal ligament (PDL) at the function area.


Conclusion

The prognosis of perforated teeth is better nowadays than it was in the past, and this is due to the MTA that can be successfully used in the surgical management of perforation. This case highlights the need for particular attention during open access to decrease the risk of tooth damage.


List of Abbreviations

MTA Mineral trioxide aggregate
PDL Periodontal ligament

Conflict of interest

The author declares that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from the patient.


Ethical approval

Ethical pproval is not required at our institute to publish an anonymous case report.


Author details

Maha A. Alturki1

  1. Consultant in Restorative Dentistry, Department of Restoratives, Dental Faculty of National Guard Hospital, King Abdulaziz City Dental Clinic, Riyadh, Saudi Arabia

References

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  2. Hepworth MJ, Friedman S. Treatment outcome of surgical and non-surgical management of endodontic failures. J Canadian Dent Assoc. 1997;63(5):364–71.
  3. Tsesis I, Fuss ZV. Diagnosis and treatment of accidental root perforations. Endodont Topics. 2006;13(1):95–107. https://doi.org/10.1111/j.1601-1546.2006.00213.x
  4. Dietrich T, Zunker P, Dietrich D, Bernimoulin JP. Periapical and periodontal healing after osseous grafting and guided tissue regeneration treatment of apicomarginal defects in periradicular surgery: results after 12 months. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol. 2003;95(4):474–82. https://doi.org/10.1067/moe.2003.39
  5. 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. https://doi.org/10.4103/0976-237X.101100
  6. Alsanea R, Ravindran S, Fayad MI, Johnson BR, Wenckus CS, Hao J, et al. Biomimetic approach to perforation repair using dental pulp stem cells and dentin matrix protein 1. J Endodont. 2011;37(8):1092–7. https://doi.org/10.1016/j.joen.2011.05.019
  7. Mente J, Hage N, Pfefferle T, Koch MJ, Geletneky B, Dreyhaupt J, et al. Treatment outcome of mineral trioxide aggregate: repair of root perforations. J Endodont. 2010;36(2):208–13. https://doi.org/10.1016/j.joen.2009.10.012
  8. Zhang H, Pappen FG, Haapasalo M. Dentin enhances the antibacterial effect of mineral trioxide aggregate and bioaggregate. J Endodont. 2009;35(2):221–4. https://doi.org/10.1016/j.joen.2008.11.001
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How to Cite this Article
Pubmed Style

Maha Abdulaziz Alturki. Repair of long standing latrogenic perforation with mineral trioxide aggregate: a case report. IJMDC. 2019; 3(9): 790-793. doi:10.24911/IJMDC.51-1553113826


Web Style

Maha Abdulaziz Alturki. Repair of long standing latrogenic perforation with mineral trioxide aggregate: a case report. http://www.ijmdc.com/?mno=38490 [Access: July 09, 2020]. doi:10.24911/IJMDC.51-1553113826


AMA (American Medical Association) Style

Maha Abdulaziz Alturki. Repair of long standing latrogenic perforation with mineral trioxide aggregate: a case report. IJMDC. 2019; 3(9): 790-793. doi:10.24911/IJMDC.51-1553113826



Vancouver/ICMJE Style

Maha Abdulaziz Alturki. Repair of long standing latrogenic perforation with mineral trioxide aggregate: a case report. IJMDC. (2019), [cited July 09, 2020]; 3(9): 790-793. doi:10.24911/IJMDC.51-1553113826



Harvard Style

Maha Abdulaziz Alturki (2019) Repair of long standing latrogenic perforation with mineral trioxide aggregate: a case report. IJMDC, 3 (9), 790-793. doi:10.24911/IJMDC.51-1553113826



Turabian Style

Maha Abdulaziz Alturki. 2019. Repair of long standing latrogenic perforation with mineral trioxide aggregate: a case report. International Journal of Medicine in Developing Countries, 3 (9), 790-793. doi:10.24911/IJMDC.51-1553113826



Chicago Style

Maha Abdulaziz Alturki. "Repair of long standing latrogenic perforation with mineral trioxide aggregate: a case report." International Journal of Medicine in Developing Countries 3 (2019), 790-793. doi:10.24911/IJMDC.51-1553113826



MLA (The Modern Language Association) Style

Maha Abdulaziz Alturki. "Repair of long standing latrogenic perforation with mineral trioxide aggregate: a case report." International Journal of Medicine in Developing Countries 3.9 (2019), 790-793. Print. doi:10.24911/IJMDC.51-1553113826



APA (American Psychological Association) Style

Maha Abdulaziz Alturki (2019) Repair of long standing latrogenic perforation with mineral trioxide aggregate: a case report. International Journal of Medicine in Developing Countries, 3 (9), 790-793. doi:10.24911/IJMDC.51-1553113826