Management of perforations: four cases from two private practices with medium- to long-term recalls.

Purpose:

  • Present 4 clinical cases of perforation repair with medium to long-term recalls.

Materials/Methods:

  • N= 4 cases.
  • Three nonsurgical cases were retreated, repaired with mineral trioxide aggregate, and restored. The fourth case was strictly a surgical repair. Recalls up to 13 years are presented.

Results:

  • Patient 1 – 13 year old female. Periapical radiolucency associated with the mesial root of tooth #19. In addition, the mesiobuccal canal appeared to be transported and perforated.
  • Patient 2 – 41 year old female. Tooth #2. Apical and lateral radiolucency associated with the mesiobuccal root and a midroot perforation with extrusion of the filling material. The apical portion of the mesiobuccal root was not filled.
  • Patient 3 – 51 year old female. Tooth#7. A mixture of blood and pus appeared immediately in the post space. After the drainage stopped, the post space was irrigated and dried and inspected under the microscope. It was decided to proceed with treatment. Shortly thereafter, the crown debonded from the tooth.
  • Patient 4 – 46 year old male. Tooth#7. During root canal treatment in 1984, perforation had occurred during post space preparation. The canal space and perforation were filled with gutta-percha and sealer. A cast post and core were fabricated and cemented, and a metal-ceramic crown was placed.

Clinical Significance:

If managed properly, perforation repairs can result in long-term clinical success.

Treatment outcome of mineral trioxide aggregate: repair of root perforations.

Purpose:

  • Evaluate the success rate of root perforation repairs using MTA.

Materials/Methods:

  • N= 21 cases.
  • Retrospective evaluation of perforations repaired with MTA at the University of Heidelberg between 2000 and 2006. Teeth with pre-op, post-op, and at least 1 year recall radiograph included. 4 of the perforations were in the furcation area, 7 at crestal bone level, 5 at the midroot level and 5 in the apical third of the root

Results:

  • Healing rates = 100% furcal, 86% crestal, 80% midroot, 80% apical third
  • Healing rate for single rooted teeth – 92%
  • Healing rate for multi-rooted teeth – 75%
  • Perforation size and healing percentage:
    • >3mm – 67%
    • 1-3mm – 88%
    • <1mm – 90%

Clinical Significance:

MTA can provide a biocompatible and long-term effective seal for root perforations in all parts of the root.

Mineral trioxide aggregate as repair material for furcal perforation: case series.

Purpose:

Evaluate the success rate of furcal perforation repairs using MTA without an internal matrix.

Materials/Methods:

  • N= 10 cases.
  • Furcal perforation cases were selected at the department of Endodontics, University of Florence. All the perforations were cleaned with NaOCl, EDTA, and ultrasonic tips and sealed with MTA without internal matrix. The teeth were endodontically treated and coronally restored. Clinical and radiographic follow-ups were done at 6 months, 1 year, 2 years, and 5 years.

Results:

  • After 5 yrs 9 out of 10 teeth had no radiolucencies and were free of clinical symptoms.
  • The 10th patient wasn’t able to be recalled beyond 1 yr.

Clinical Significance:

Repairing furcal perforations with MTA is associated with a good short-term (5 yr) clinical outcome.

Repair of root perforations using mineral trioxide aggregate: a long-term study

Purpose:

  • Evaluate the success rate of root perforation repairs using MTA.

Materials/Methods:

  • N= 16 cases.
  • All patients who were treated for root perforation at Loma Linda were evaluated. Cases had pre and post – treatment and at least 1 yr recall radiographs. Recall radiographs were double-blind evaluated by 3 examiners for the presence or absence of pathological changes adjacent to the perforation site. Teeth were also evaluated clinically.

Results:

  • All 16 cases demonstrated normal tissue architecture adjacent to the repair site at the recall visit.
  • Teeth with existing lesions showed resolution of the lesion, and teeth without preoperative lesions continued to demonstrate absence of lesion formation at the follow-up visit.

Clinical Significance:

MTA provides an effective seal of root perforations and shows promise in improving the prognosis of perforated teeth that would otherwise be compromised.

Reaction of the Lateral Periodontium of Dogs’ Teeth to Contaminated and Noncontaminated Perforations Filled with Mineral Trioxide Aggregate

Purpose:

Compare perforation healing with MTA placed immediately vs. 7 days after perforation vs. CaOH for 2 weeks and then repaired

Materials/Methods:

N= 15 premolars in 2 dogs

Instrumented and filled with gutta percha using lateral condensation, went back in and made a lateral perforation

1st group was immediately repairwith MTA, 2nd group was left open for 7 days-then cleaned and filled with MTA, 3rd was the same as the 2nd but CaOH placed for 2 weeks and then repaired with MTA, animals sacrificed after 90 days

Results:

1.Immediate repairs healed the best-significantly better cementum formation

2.Placement of CaOH in contaminated perforation didn’t improve results when compared with contaminated without CaOH

Clinical Significance:

Best healing occurred when perforation was repaired immediately with MTA

Perforation Repair Comparing Two types of MTA

Purpose:

To compare the sealing abilities of gray and off-white MTA  in furcal perforations on extracted teeth using anaerobic bacterial leakage model

Materials/Methods:

N=40 extracted molars

Occlusal Surface removed, apical 5mm removed, perforation made and enlarged to #80, randomly selected 18 for each group-1 group repaired with off white and the other with gray MTA, 2 perforated and not repaired, 2 not perforated

Results:

2 out of 17 of gray MTA leaked

3 out of 18 of white MTA Leaked

Clinical Significance:

No statistical difference between white  and gray MTA in repairing furcal perforations

Perforation Repair Comparing Mineral Trioxide Aggregate and Amalgam Using an Anaerobic Bacterial Leakage Model

Purpose:

Evaluate the ability of mineral trioxide aggregate (MTA) and amalgam to seal furcal perforations in extracted human molars using an anaerobic bacterial leakage model.

Materials/Methods:

N=42 extracted molars, removed occlusal surface and last 5mm of roots, perforations opened to size #80 file, randomly selected half for MTA and half for amalgam, tested to see the leakage  F. nucleatum

Results:

8 of 18 amalgam repairs leaked at 45 days

0 of 18 MTA repairs leaked at 45 days

Clinical Significance:

MTA may be a better material than amalgam at sealing perforations possibly due to its hydrophilic properties along with its similar mineral composition to dentin

Evaluation of Setting Properties and Retention Characteristics of Mineral Trioxide Aggregate When Used as a Furcation Perforation Repair Material

Purpose:

Compare force strengths when using wet and dry cotton pellets with different set times for MTA.

Materials/Methods:

N=32 freshly extracted maxillary and mandibular molars divided into 4 equal groups – wet cotton pellet 24 hours, wet cotton pellet 72 hours , dry cotton pellet 24 hours, dry cotton pellet 72 hours

Teeth sectioned to leave the furcation only and Mounted in acrylic. ISO size 014 perf made. Plexiglass fitted over specimen to act as a guide plate for an Instron force probe for “pushout” test. Saline soaked Gelfoam placed on coronal side to simulate clinical conditions. Placed MTA mixed with 2% xylocaine with 1:100k epi into perforation.  MTA condensed with a wet cotton pellet. Wet or dry cotton pellet left for either 24 or 72h. Instron force probe placed vertical force until 0.2mm displacement of MTA. Max force recorded. Specimens left in humidity for 14 days. Re-performed pushout test to evaluate if readhesion occurred between dentin wall & MTA.

Results:

Force strength comparisons:

     72h wet > 24 wet

      72h dry > 24 dry

      24h wet in 2 wks > 24h wet

      24h dry in 2 wks > 24h dry

      72h wet > 72h wet in 2 weeks

      72h dry > 72h dry in 2 weeks

Clinical Significance:

Recommendations for procedure to placeme MTA :  place matrix (e.g., GelFoam) moistened with an anesthetic. Place MTA and then a Cotton pellet (wet or dry) then the temporary restoration. Wait 72 hours. Place permanent restoration.

Histologic study of furcation perforations treated with MTA or Super EBA in dogs’ teeth

Purpose:

Compare placement of MTA and Super EBA in furcation perforations.

Materials/Methods:

N=90 teeth (Mandibular molar & premolars) of 9 adult mongrel dogs divided into 3 groups – Super EBA, MTA, control (n = 36, 36, 18). 1 side of each treated by either MTA or Super EBA.

All canals cleaned and shaped then obturated by lateral condensation + Grossman’s sealer. 1 week later, ISO size 014 perforation made in the furcation until bleeding was observed. Immediate repair by either MTA or Super EBA. Xray taken. Access was restored with amalgam. Dogs sacrificed at 1, 3, 6 months and their mandibles were removed. Serial sections made. H&E stain interpreted by 2 examiners.

Eval Criteria: (1) 0-3 scale of presence of # & type of inflammatory cells (absent, mild, moderate, severe). (2) type of healing present (soft tissue, hard tissue)

Results:

  1 month 3 month 6 month Tissue growth
MTA Mild inflamm ↓ inflamm No inflamm Cementum in all by 6 months
Super EBA Mod inflamm ↓ inflamm Same as 3 months Inflamm present – irregular connective tissueNo inflamm – dense connective tissue
Control No inflamm No inflamm No inflamm Normal

Clinical Significance:

No difference in success rate bw molars & premolars despite increased perforation-tooth ratio in premolars

(1)Both materials show increased rate of repair indicating good biocompatibility.

(2)MTA > Super EBA for furcation perforation repairs.

Histologic Assessment of Mineral Trioxide Aggregate as a Root-End Filling in Monkeys

Purpose:

  • To examine the periradicular response to MTA and amalgam as root-end fillings

Materials/Methods:

  • N= 12 maxillary incisors from 3 Cynomolgus monkeys
  • Rubber dam isolation. Cleaned and shaped and obturated with lateral condensation; access closed with amalgam. At 1 week, resection of apices between apical and middle thirds and 2 mm retropreparation completed. ½ of the  incisors were randomly selected to be restored with zinc-free amalgam, and ½ with MTA. Animals were given post-procedural Penicillin injection & 3 days of analgesics.
  • At 5 months, the  animals were sacrificed for histologic examination; 2 independent investigators reviewed the samples for concentration & predominant inflammatory cell type, extent and severity of inflammation, presence of bacteria and fibrous capsule, cementum deposition, and new bone formation adjacent to root end and filling material

Results:

  Dominant inflamm cell type Periradicular tissue inflam Fibrous capsule Bacteria presence (root end or canal) Cementum Bone formation
Amalgam -Lymphocytes-PMNs adjacent to amalgam 6/6 moderate to severe 6/6 0/6 6/6 over root end 0/6 over amalgam 6/6
MTA Lymphocytes 1/6 severe 0/6 0/6 6/6 over root end 5/6 over MTA (6th partially formed) 6/6

Clinical Significance:

Amalgam causes inflammation in the periradicular tissues and does not allow regeneration of dentoalveolar structures. MTA exhibits many favorable characteristics as a root-end filling material and should be chosen over amalgam, if available.