Aust Endod J 2007; 33: 112118

2 0 0 7 P O S TG R A D U AT E C A S E R E P O RT C O M P E T I T I O N W I N N E R

Contemporary management of lateral root perforation

diagnosed with the aid of dental computed tomography
Geoffrey R. Young, BDS, DClinDent
School of Dental Science, University of Melbourne, Melbourne, Victoria, Australia

Keywords
cone beam computed tomography, diagnostic
imaging, mineral trioxide aggregate,
perforation repair, root perforation.
Correspondence
Dr Geoffrey Young, School of Dental Science,
University of Melbourne, 720 Swanston St,
Melbourne, Vic. 3010, Australia. Email:
[email protected]
doi: 10.1111/j.1747-4477.2007.00098.x

Abstract
Lateral root perforation unnoticed during post-space preparation, and followed
by post cementation, can subsequently be challenging to diagnose in the
labio-lingual plane due to the two-dimensional nature of conventional radiography. This paper demonstrates the application of a recently developed
three-dimensional imaging system, cone beam computed tomography, in the
diagnosis of iatrogenic root perforation. A clinical case is reported where labial
post perforation in a maxillary central incisor occurring 15 years previously
presented with a sinus tract and radiolucent lesion. Non-surgical retreatment
and perforation repair using mineral trioxide aggregate was performed with
the aid of an operating microscope. The sinus tract resolved with radiographic
evidence of healing at 1-year recall.

Introduction
Root perforation refers to the creation of a communication between the root canal system and the peri-radicular
tissues (1). While this may occur due to root resorption, it
is most commonly a result of iatrogenic damage sustained
during preparation of endodontic access cavities, root
canal shaping, and during post-space preparation (2).
Such a communication creates the potential for an
inflammatory lesion with destruction of the adjacent
periodontal tissues. The prognosis for teeth with root
perforation depends foremost on the prevention or
control of bacterial infection at the perforation site (1). In
addition, use of a biocompatible repair material to provide
the best possible seal against penetration of bacteria will
limit periodontal inflammation.
Lateral root perforations, caused accidentally and
unnoticed during post-space preparation, typically show
lateral bone defects on recall radiographs (3). Successful
treatment of such defects depends on elimination of
bacteria from the root canal system and perforation site.
While post perforations can be repaired non-surgically,
surgically or from both approaches (4), it is non-surgical
management that has the greatest potential to achieve
microbial control. This requires removal of the post and
the potentially infected root canal filling, followed by
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chemomechanical debridement and shaping of the root

canal (3). Mineral trioxide aggregate (MTA) is a suitable
perforation repair material due to its excellent biocompatibility (5,6) and sealing ability (7,8), which is not
affected by blood contamination (9). This material has the
unique ability to promote regeneration of cementum and
periodontal ligament (5,6,10).
Accurate preoperative determination of the presence of
a root perforation is important for evaluating prognosis
and treatment planning. Radiographic detection toward
the labial or lingual root surface is challenging, because
the image of the perforation is superimposed on that
of the root. Taking preoperative radiographs from two
different horizontal angles (tube shift technique) can
facilitate identification of a labio-lingually misdirected
post (11). However, the greatest limitation of conventional radiography is the inability to fully describe the
three-dimensional (3-D) anatomy of teeth and their
related structures (12). In recent years, a new method,
cone beam computed tomography (CBCT) has been
introduced specifically for dental applications (13,14).
CBCT is a 3-D imaging technique where a small coneshaped X-ray beam is directed through the area of interest
and onto an opposing X-ray detector while making a
360-degree rotation about the patients head (12). During
the scan, a series of exposures or projections is acquired

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G. Young

Management of Lateral Root Perforation

which provides the raw data for reconstruction of the

exposed volume by computer algorithm. Multi-planar
reconstruction of the primary data allows for both 3-D
images and two-dimensional (2-D) images of any selected
plane to be made. At a radiation dose similar to that from
two to three intraoral radiographs (15), the CBCT method
provides considerably more information for oral diagnostic purposes (12).
This case report demonstrates the use of CBCT as an
effective diagnostic tool for the assessment of post perforations, and describes the non-surgical repair of a post
perforation in the middle third of the root of a maxillary
central incisor using MTA with the aid of an operating
microscope.

Case report

Figure 2 Preoperative photograph showing draining sinus tract on the

attached gingiva labial to tooth 21.

A healthy 51-year-old female patient was referred to the

Endodontic Department of the Royal Dental Hospital of
Melbourne for consultation and treatment concerning
tooth 21. The patients dental history indicated that tooth
21 had been endodontically treated along with several
other teeth approximately 15 years previously. An extensive fixed prosthesis was then constructed, spanning from
tooth 15 to tooth 27, with all units fused together by the
metal substructure (Fig. 1). Following this treatment, the
patient had been asymptomatic until mid-2005, when a
sinus tract was noticed labial to tooth 21.
On presentation, the patient reported no symptoms.
Clinically, the dentition was heavily restored and the
patients oral hygiene was significantly hampered by the
maxillary fixed prosthesis. The patient wore a mandibular
removable partial denture and there was a deep anterior
overbite. A sinus tract was present on the labial attached
gingiva adjacent to tooth 21 (Fig. 2), which traced with a

Figure 3 Preoperative radiograph showing gutta-percha cone tracing a

sinus tract to the lateral aspect of tooth 21.

Figure 1 Preoperative panoramic radiograph showing extensive xed

prosthesis spanning from tooth 15 to tooth 27. All units were fused
together.

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gutta-percha cone toward the lateral root surface of this

tooth (Fig. 3). Tooth 21 was not tender to percussion;
however, the labial mucosa related to the area was tender
to palpation. No abnormal probing depths were detected.
Radiographic examination showed that tooth 21 contained a post, and a well-compacted root filling extending
close to the radiographic apex (Fig. 3). There was loss of
lamina dura with an associated radiolucent lesion on the
distal aspect of the root, corresponding to the apical level
of the post. A horizontal tube shift radiograph (Fig. 4)
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G. Young

Figure 5 Coronal sectional image through tooth 21 obtained by the 3D

Accuitomo (slice thickness 1 mm). The post perforates the labial root
surface. Associated expansion of a periradicular lesion with discontinuity
of the labial cortical bone is evident.
Figure 4 Horizontal (mesial) tube shift radiograph showing that the post
in tooth 21 was misdirected labially.

demonstrated that the post did not follow the long axis of
the root, but rather was misdirected labially. Also noted
were periapical radiolucent lesions associated with teeth
12 and 42.
A diagnosis of suppurative periradicular abscess was
made for tooth 21. Possible aetiologies included lateral
root perforation, root fracture or leaching of microbial
irritants via a lateral canal. To ascertain more precisely the
3-D relationship between post and root structure, CBCT
imaging was performed using the 3D Accuitomo XYZ
Slice View Tomograph (3D Accuitomo, J. Morita Mfg.
Corp, Kyoto, Japan). This imaging confirmed that tooth
21 had a labial post perforation at mid-root level with an
associated bony defect (Fig. 5).
The overall dental status, including periodontal implications of fused crowns, was discussed with the patient,
and a recommendation was made to remove the existing
fixed partial denture with a view to full-mouth rehabilitation. As the patient declined to have the fixed prosthesis
removed, treatment options considered for tooth 21
included: (i) root amputation with retention of the existing fixed partial denture; (ii) surgical perforation repair;
or (iii) internal perforation repair with MTA followed by
construction of a new post-core and crown. The patient
was advised that an internal retreatment approach was
the best option due to the greater ability to control intraradicular infection. The patient accepted internal repair of
the perforation with MTA.
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After local anaesthesia and rubber dam isolation, the

crown on tooth 21 was sectioned from the adjacent
crowns using a high-speed diamond bur and removed.
The post was loosened and removed with ultrasonic
instruments. Inspection with an operating microscope (Mller Denta 300, Mller-Wedel GmbH, Wedel,
Germany) confirmed a labial root perforation (approximately 0.5 1 mm). There was no evidence of root fracture and the remaining tooth structure was restorable,
with 2 mm of supragingival dentine available for a ferrule
(16). The perforation was cleaned with a small pulp bur
in a slow-speed handpiece and rinsed gently with 1%
sodium hypochlorite. Cavit (ESPE, Dental AG, Norristown, PA, USA) was used to temporarily seal the perforation prior to removal of the existing root filling with
hand files and chloroform (Fig. 6). The perforation was
sealed at this early stage to control bleeding into the
canal, to confine irrigation and infected root filling material, and to permit controlled compaction of the new
root filling. Definitive perforation repair with MTA was
delayed due to the risk of disrupting the material during
canal preparation and obturation procedures.
Working length was confirmed by using both a radiograph and an electronic apex locator (Tri-Auto ZX,
J. Morita Mfg. Corp). The root canal was cleaned and
shaped using ProFile rotary instruments (Dentsply Tulsa
Dental, Johnson City, TN, USA) under copious irrigation
with 1% sodium hypochlorite solution. The canal was
prepared to size #60 and dressed with calcium hydroxide
paste (Pulpdent Corp., Watertown, MA, USA) before
sealing the coronal access with Cavit and Fuji IX (Kerr

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G. Young

Figure 6 Radiograph after temporary perforation repair with Cavit and

removal of the previous root lling.

Figure 7 Vacuum-formed removable prosthesis issued for use between

treatment visits.

Corp., Orange, CA, USA). A vacuum-formed removable

prosthesis was issued as an interim measure (Fig. 7).
The patient returned 2 weeks later for completion of
endodontic retreatment, having remained free of any
symptoms. The sinus tract had resolved. After rubber
dam isolation, the canal was irrigated with 1% sodium
hypochlorite to remove the calcium hydroxide dressing
and dried with sterile paper points. The root canal was
filled by lateral compaction of gutta-percha and AH-26
sealer (DeTrey Dentsply, Konstanz, Germany), with the

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Journal compilation 2007 Australian Society of Endodontology

Management of Lateral Root Perforation

Figure 8 Radiograph of tooth 21 immediately after root canal obturation

and denitive MTA perforation repair.

root filling subsequently heated out to below the perforation level with a System B (SybronEndo, Orange, CA,
USA) heat source. Cavit was carefully removed from
the perforation site using a DG16 endodontic explorer
(Hu-Friedy, Chicago, IL, USA), and the perforation
margins re-cleaned with a small pulp bur. MTA (ProRoot
MTA, Dentsply Tulsa Dental) was mixed with sterile
water to a paste consistency, and carefully placed into the
root canal incrementally with a 5/7 endodontic hand
plugger (Dentsply Tulsa Dental) so as to seal the perforation and re-create a smoothly tapered post space (Fig. 8).
Direct observation of the perforation site through the
operating microscope was helpful to control correct
placement of the repair material and avoid inadvertent
blockage of the post space. A moist cotton pellet was then
placed in contact with the MTA to encourage setting and
the canal sealed with Cavit and Fuji IX.
The patient was recalled for construction of a cast postcore and crown. An acrylic crown was placed, with fabrication of a metal-ceramic crown withheld until after a
suitable observation period with evidence of healing. To
reduce the risk of vertical root fracture, the occlusion on
this tooth was constructed to provide light contact with
protection during excursive movements. Following treatment of tooth 21, a carious lesion on tooth 44 (Fig. 1) was
restored, and tooth 34 extracted, prior to fabrication of a
new mandibular removal partial denture in order to
improve posterior support. Tooth 42 was endodontically
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Figure 9 Photograph 1 year after perforation repair, showing resolution

of the sinus tract.

retreated, and was also found to have sustained a labial

post perforation. The patient declined to have the asymptomatic radiolucent lesion associated with tooth 12
treated at this time.
At 1-year recall, the patient reported no symptoms.
Tooth 21 was not tender to percussion and the labial
mucosa related to the area was not tender to palpation.
There was no sinus tract (Fig. 9), and probing depths
were within normal limits. The radiographs showed
reduction in size of the lateral radiolucency (Fig. 10).
Given the satisfactory outcome, the patient was advised
to have the acrylic crown replaced with a metal-ceramic
crown for improved durability. The patient will be
recalled annually for long-term follow up.

Discussion
In endodontic practice, there are some cases where
conventional intraoral radiography does not provide
adequate information on pathologic conditions and
positional relationships. With the recent introduction of
CBCT scanners for dental use, 3-D imaging has become a
possibility. The 3D Accuitomo, known in some countries
as the 3DX Multi-Image Micro-CT, is of particular relevance to endodontics as it is specifically designed to
capture information from a small region of the maxilla
or mandible. A high-resolution 3-D image of a columnshaped imaging area, 40 mm in diameter and 30 mm in
height, is produced, which is sufficient to analyse two to
three teeth in detail (17). The imaged area can be arbitrarily sliced and observed from three different directions.
CBCT technology is able to provide significantly higher
resolution images than conventional medical CT at a
small fraction of the radiation dose (15,18). The dose per
exposure to the 3D Accuitomo is similar to that from
panoramic radiography (15,17).
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G. Young

In this case, examination with the 3D Accuitomo

revealed clear evidence of a post perforation through the
labial root surface of tooth 21. The presence and position
of the perforation and associated bone defect were confirmed preoperatively, allowing the operator to be confident in the diagnosis and treatment plan. In addition, the
patient found the CBCT images extremely helpful in
understanding her endodontic problem. While CBCT has
been increasingly applied in treatment planning for
periapical surgery (19), as well as diagnosis of periapical
lesions (20) and dento-alveolar trauma (21), this is the
first reported use of this new technology for the diagnosis
of lateral root perforation.
Three important factors relating to the potential to
control infection at the perforation site influence the
prognosis for perforation repair procedures. These are
the time elapsed since creation of the perforation, the
size of the perforation, and the site of perforation in
relation to the level of crestal bone and epithelial
attachment (1). The time factor relates to whether or
not the wound site has become infected, while larger
defects make it more difficult to create an effective seal
and are associated with greater trauma to the adjacent
tissues (22). Perforations occurring close to the critical
crestal zone may be complicated by periodontal breakdown, with connection between the perforation defect
and the oral cavity via a periodontal pocket (23). Once
a pocket has formed, management is problematic
because persistent inflammation of the perforation site
will be maintained by continuous ingress of bacteria via
the pocket. Such perforations have a poor prognosis
from a periodontal standpoint, with endodontic treatment often unable to improve the condition (24). In the
case presented here, the perforation was located in the
mid-root region and there was no evidence of pocketing
to the perforation site. As such, treatment of the defect
was deemed possible and dependent on control of
intraradicular infection.
Few clinical studies have drawn conclusions regarding
the influence of perforation on the outcome of endodontic treatment as this complication occurs infrequently.
Most studies indicate that perforation will adversely affect
prognosis (2527); however, these studies were conducted prior to the introduction of the operating microscope and contemporary perforation repair materials.
Farzaneh et al. found that the presence of a preoperative
perforation was the strongest predictor of a negative
outcome following non-surgical retreatment: 42% of
teeth with perforation healed compared with 89%
without (28). Importantly though, most perforations in
this study already had established infection and perforations were repaired with resin-modified glass ionomer
cement.

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Management of Lateral Root Perforation

G. Young

(a)

(b)

Figure 10 One-year follow up radiographs of tooth 21: (a) showing signicant healing of the lateral bone defect; (b) mesial tube shift.

Both MTA and SuperEBA have been recommended as

suitable materials for repair of lateral root perforations
(7,29). SuperEBA is a modified zinc-oxide eugenol
cement that has been shown to produce a more effective
perforation seal than either amalgam or glass ionomer
cement (29). While the tissue response to SuperEBA is
mild (30), this material does not possess the same regenerative properties as MTA (10). Main et al. reported on 16
clinical cases in which perforations at various levels of the
root were repaired with MTA (2). Time from perforation
to repair ranged from 12 to 45 months; seven of 16
perforations had an associated radiolucency and none
were associated with a periodontal pocket. All cases demonstrated complete healing after at least 1-year follow up.
Comparison of the results of this study with the results of
reports on root perforations repaired with other materials
shows a marked improvement in the prognosis of teeth
repaired with MTA. In the case reported here, healing
was achieved following MTA repair of a 15-year-old post
perforation associated with a sinus tract and radiolucent
lesion.

Conclusion
The presented case demonstrates that CBCT imaging
technology is a useful addition to the endodontists
armamentarium for the diagnosis and management of
complex endodontic problems. Root perforation in the
middle third of a maxillary central incisor occurring
15 years previously was treated with a non-surgical
approach using MTA with the aid of an operating microscope. The repaired tooth demonstrated resolution of a

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sinus tract, absence of symptoms and radiographic

healing at 1-year recall.

References
1. Fuss Z, Trope M. Root perforations: classification and
treatment choices based on prognostic factors. Endod
Dent Traumatol 1996; 12: 25564.
2. Main C, Mirzayan N, Shabahang S, Torabinejad M.
Repair of root perforations using mineral trioxide aggregate: a long-term study. J Endod 2004; 30: 803.
3. Bargholz C. Perforation repair with mineral trioxide
aggregate: a modified matrix concept. Int Endod J 2005;
38: 5969.
4. Behnia A, Strassler HE, Campbell R. Repairing iatrogenic
root perforations. J Am Dent Assoc 2000; 131: 196201.
5. Yildirim T, Genoglu N, Firat I, Perk C, Guzel O. Histologic study of furcation perforations treated with MTA or
SuperEBA in dogs teeth. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2005; 100: 1204.
6. Holland R, Filho JA, de Souza V, Nery MJ, Bernabe PF,
Junior ED. Mineral trioxide aggregate repair of lateral
root perforations. J Endod 2001; 27: 2814.
7. Lee SJ, Monsef M, Torabinejad M. Sealing ability of a
mineral trioxide aggregate for repair of lateral root perforations. J Endod 1993; 19: 5414.
8. Nakata TT, Bae KS, Baumgartner JC. Perforation repair
comparing mineral trioxide aggregate and amalgam
using an anaerobic bacterial leakage model. J Endod
1998; 24: 1846.
9. Torabinejad M, Higa RK, McKendry DJ, Pitt Ford TR.
Dye leakage of four root end filling materials: effects of
blood contamination. J Endod 1994; 20: 15963.

117

Management of Lateral Root Perforation

10. Baek SH, Plenk H Jr, Kim S. Periapical tissue responses

and cementum regeneration with amalgam, SuperEBA,
and MTA as root-end filling materials. J Endod 2005; 31:
4449.
11. Goerig AC, Neaverth EJ. A simplified look at the buccal
object rule in endodontics. J Endod 1987; 13: 5702.
12. Grndahl HG, Huumonen S. Radiographic manifestations of periapical inflammatory lesions. Endod Top
2004; 8: 5567.
13. Arai Y, Tammisalo E, Iwai K, Hashimoto K, Shinoda K.
Development of a compact computed tomographic apparatus for dental use. Dentomaxillofac Radiol 1999; 28:
2458.
14. Arai Y, Hashimoto K, Iwai K, Shinoda K. Fundamental
efficiency of limited cone-beam X-ray CT (3DX multi
image micro CT) for practical use. Dent Radiol 2000; 40:
14554.
15. Hashimoto K, Arai Y, Iwai K, Araki M, Kawashima S,
Terakado M. A comparison of a new limited cone beam
computed tomography machine for dental use with a
multidetector row helical CT machine. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2003; 95: 3717.
16. Stankiewicz NR, Wilson PR. The ferrule effect: a literature review. Int Endod J 2002; 35: 57581.
17. Nakata K, Naitoh M, Izumi M, Inamoto K, Ariji E, Nakamura H. Effectiveness of dental computed tomography
in diagnostic imaging of periradicular lesion of each root
of a multirooted tooth: a case report. J Endod 2006; 32:
5837.
18. Nair MK, Nair UP. Digital and advanced imaging in
endodontics: a review. J Endod 2007; 33: 16.
19. Tsurumachi T, Honda K. A new cone beam computerized tomography system for use in endodontic surgery.
Int Endod J 2007; 40: 22432.
20. Simon JH, Enciso R, Malfaz JM, Roges R, Bailey-Perry
M, Patel A. Differential diagnosis of large periapical

118

G. Young

21.

22.

23.

24.
25.

26.

27.

28.

29.

30.

lesions using cone-beam computed tomography measurements and biopsy. J Endod 2006; 32: 8337.
Terakado M, Hashimoto K, Arai Y, Honda M, Sekiwa T,
Sato H. Diagnostic imaging with newly developed ortho
cubic super-high resolution computed tomography
(Ortho-CT). Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2000; 89: 50918.
Balla R, LoMonaco CJ, Skribner J, Lin LM. Histological
study of furcation perforations treated with tricalcium
phosphate, hydroxyapatite, amalgam, and Life. J Endod
1991; 17: 2348.
Seltzer S, Sinai I, August D. Periodontal effects of root
perforations before and during endodontic procedures.
J Dent Res 1970; 49: 3329.
Tsesis I, Fuss Z. Diagnosis and treatment of accidental
root perforations. Endod Top 2006; 13: 95107.
Kerekes K, Tronstad L. Long-term results of endodontic
treatment performed with a standardized technique.
J Endod 1979; 5: 8390.
Kvinnsland I, Oswald RJ, Halse A, Gronningsaeter AG.
A clinical and roentgenological study of 55 cases of root
perforation. Int Endod J 1989; 22: 7584.
Benenati FW, Roane JB, Biggs JT, Simon JH. Recall
evaluation of iatrogenic root perforations repaired
with amalgam and gutta-percha. J Endod 1986; 12:
1616.
Farzaneh M, Abitbol S, Friedman S. Treatment outcome
in endodontics: the Toronto study. Phases I and II:
orthograde retreatment. J Endod 2004; 30:
62733.
Moloney LG, Feik SA, Ellender G. Sealing ability of
three materials used to repair lateral root perforations.
J Endod 1993; 19: 5962.
Pitt Ford TR, Andreasen JO, Dorn SO, Kariyawasam SP.
Effect of SuperEBA as a root end filling on healing after
replantation. J Endod 1995; 21: 1315.

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Journal compilation 2007 Australian Society of Endodontology