Root perforations: aetiology, IN BRIEF

• Explains the aetiology of root

management strategies and perforations.

PRACTICE
• Reviews factors associated with the
success of perforation repair.

outcomes. The hole truth • Discusses the management of

perforations.
• Highlights prevention strategies for
practitioners to follow.
S. Mohammed Saed,*1 M. P. Ashley2 and J. Darcey3
VERIFIABLE CPD PAPER

The purpose of this clinical article is to emphasise that root perforations can occur both during and after endodontic treat-
ment. These reduce the chance of a successful treatment outcome and can jeopardise the survival of the tooth. The aetiol-
ogy and diagnosis of root perforations are described. The article also focusses on the non-surgical and surgical manage-
ment of root perforations and describes how selection of the appropriate treatment depends on an accurate diagnosis.

INTRODUCTION in this region. Typically this will follow an used in narrow canals. It may also occur
aggressive crown-down approach with large during preparation of the canals, if files are
A perforation is a communication that arises instruments such as Gates Glidden burs, too large or the filing technique shapes the
between the periodontium and the root canal
space. Perforations can be pathological, result-
ing from caries or resorptive defects, but most
commonly occur iatrogenically (during or
after root canal treatment). Indeed, perfora-
tions occurring during root canal therapy
may account for as many as 10% of all failed
endodontic cases.1

AETIOLOGY

Iatrogenic perforations

Perforations of the coronal third:

Perforations of the coronal third often result
whilst attempting to locate and open canals
(Fig. 1). Calcifications of the pulp chamber
and the orifices, misidentification of canals,
significant crown-root angulations and
excessive removal of coronal dentine can
easily result in perforations in the coronal
or furcation regions.

Perforations of the middle third:

Strip perforations of the middle third may
occur if there is overzealous instrumentation

1
Dental Core Trainee, Oral and Maxillofacial surgery,
Bradford Royal Infirmary; 2Consultant and Honorary
Senior Lecturer in Restorative Dentistry, Associate
Clinical Head of Division, University Dental Hospital of
Manchester, Higher Cambridge Street, Manchester,
M15 6FH; 3Consultant and Honorary Lecturer in Re-
storative Dentistry, University of Manchester
*Correspondence to: S. Mohammed Saed Fig. 1 In an attempt to locate the canal of
Email: [email protected]
the 12 the dentist has perforated through
Refereed Paper the buccal aspect of the tooth. The figures
Accepted 15 January 2016 clearly demonstrate the divergence of the
DOI: 10.1038/sj.bdj.2016.132 access cavity from the canal structure
© British Dental Journal 2016; 220: 171-180

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 PRACTICE

canals too aggressively away from the centre

of the root. Classically, this occurs in curved
molar roots when the instrumentation is too
heavy on the inside curvature resulting in
a furcational strip perforation (Figs 2a and
2b). Perforations of the middle third may
also occur during the pursuit of sclerosed
canals. In these instances the dentist may
need to use rotary or ultrasonic instruments
well into the root of the tooth risking lateral
perforation.

Perforations of the apical third: Fig. 2 Not only has an instrument fractured in the mesiobuccal canal of the 37 but there
has been a perforation of the middle third of the tooth in an attempt to remove and/or
Inadequate cleaning and shaping of the bipass the instrument
canal can lead to blockages and ledges.
Once formed, these can cause instruments
to deviate, transporting the canal away from
the centre of the root, until a perforation
occurs. Stiff instruments placed into curved
canals may also straighten the canal, causing
zip perforations (Figs 3a and 3b). An apical
perforation occurs when the clinician does
not respect the apical anatomy and passes
endodontic files too aggressively through the
apical constriction (Fig. 4).

Post-space preparation:
Following obturation, careless post space Fig. 3 a) There is an acute curve distally in the apical region of the 24. b) This has not been
preparation may result in perforation.2 respected during instrumentation resulting in straightening of the canal and apical perforation
Traditional approaches to placement of post
retained restorations focus on achieving
good length and width for the post. This
creates the risk of both apical and strip per-
foration. Sometimes the post is not placed
into the root canal but the adjacent den-
tine, resulting in catastrophic consequences
(Fig. 5).

Pathological perforations
These can result from root resorption or car-
ies. Root resorption is the progressive loss Fig. 5 It’s a boy! A threaded post has been
of dentine and cementum by the continued placed though the furcation
action of osteoclastic cells.3 When occurring Fig. 4 A lack of control during the distal canal
within the root canal system it is known as preparation of the 46 has resulted in over
internal inflammatory root resorption. It preparation and significant over extension of
is seen radiographically as an oval shape the gutta percha (as well as separation of an
instrument in the mesial canal)
enlargement of the root canal system. The
exact cause is not known, but this process upon the type, site and extent. Readers are
can follow trauma, pulpal inflammation referred to more comprehensive papers on
and pulpotomy procedures. Though the pro- the management of resorption.4,5,6
cess is uncommon and often self-limiting, Extensive carious lesions can also lead to
it can progress into a perforation. Thus, perforations. These lesions are defined by
early detection and intervention is essen- a destruction of dental tissues as a result
tial to control the disease before such an of microbial action. An untreated carious
event occurs.4,5 lesion may either perforate the pulp chamber
External inflammatory root resorption can floor or extend along the root, resulting in
occur following damage to the cementum perforation of the root. Treatment of these
and periodontal ligament cells on the root perforations may require root canal treat-
surface. There are different types of exter- ment, crown lengthening, and either root
nal resorption, but all have the potential to extrusion or root resection in order to retain
continue until the resorptive defect com- valuable radicular segments. Unfortunately, Fig. 6 External cervical resorption of the 13.
municates with the root canal (Fig. 6). The perforation in most of these cases renders the The lesion has perforated into the pulp canal
space
ability to control the resorption is dependent tooth unrestorable.7

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 PRACTICE

EPIDEMIOLOGY
The frequency of root perforations has been
reported to range from 3% to as high as
10%.1,8,9 However, as more complex endo-
dontic treatment cases are being attempted,
it is not an unrealistic expectation that there
will be an increased frequency of perfora-
tions in the future.1 According to Kvinnsland
et al.,2 53% of iatrogenic perforations occur
during insertion of posts, the remaining 47%
occur during routine endodontic treatment.
73% of all cases occur in the maxilla and Fig. 8 The post in the 45 perforates the mesial
the rest in the mandibular arch. In maxillary aspect of the root wall. A periodontal pocket
anterior teeth the study found that all perfo- has resulted from the chronic inflammation
rations were located at the labial root aspect
Fig. 7 Profuse bleeding resulting from a
due to the operator’s underestimation of the Cone beam computed tomography is
perforation during endodontic access of the 15
palatal root inclination. In multi-rooted increasingly important in the assessment of
teeth, however, furcation perforations may perforations (Figs  9a‑c). There is evidence
occur whilst searching for the canal orifices, the position and extent of the perforation. that resorptive lesions and post perforations
as dentine is removed from the pulpal floor. Radiographs can be used at the time of perfo- can be accurately identified and assessed
ration, but do have their limitations: they are using CBCT. These 3‑dimensional scans are,
DIAGNOSIS only a two-dimensional representation and so however, associated with increased exposure
Iatrogenic perforations are invariably iden- it may be difficult to accurately assess the site to ionising radiation and as such, referral for
tified from the profuse bleeding that fol- and extent of the perforation. Taking a sec- CBCT must only be considered if it could
lows the injury (Fig.  7). This can often be ond film and shifting the radiographic beam change the clinical outcome.11 The presence
seen directly when a perforation occurs in angulation to the mesial or distal aspect can of pre-existing GP, posts and core restorative
the coronal portion of the tooth, but some- partly overcome this. materials will create artefacts and both the
times, when a strip or apical perforation Late diagnosis of pathological perforations referred patient and the practitioner must be
occurs further within the canal, a paper point is largely a combination of clinical assess- aware that this may compromise the diag-
inserted into the canal reveals the bleed- ment, radiographs and the nature of the nostic yield.
ing. If no local anaesthetic is given, sudden presenting complaint. Untreated perforations
unexpected pain during treatment may also may be revealed by the presence of serous Sequelae and outcomes
indicate a perforation. exudate or sinus from the site of perforation, Following the initial acute inflammatory
Apex locators are very useful in detect- sensitivity to percussion, localised periodon- response there may follow destruction of
ing perforations. By placing the file onto tal pocketing and chronic inflammation of periodontal fibres, bone resorption and the
the perforation this will give a zero reading, the gingiva when the inflammation has pen- formation of granulomatous tissue. In the
indicating a communication with the peri- etrated the alveolar bone.10 In addition to the mid and apical portions of the root this may
odontal ligament. Operating microscopes are methods described above, radiographs may manifest as a radiolucency adjacent to the
becoming increasing popular in identifying reveal radiolucent lesions that have devel- perforation. If this is in close proximity to the
perforations. The bright operating light and oped since the perforation occurred, as there supra crestal attachment there may be pro-
magnification make it excellent for visualising may be local osteolysis (Fig. 8). liferation of epithelium and, ultimately, the

Fig. 9 a) A conventional film of the 21 suggests there may be an aberrant access cavity.
b-c) CBCT confirms there is a perforation of the mid buccal aspect of the 21

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 PRACTICE

Fig. 11 a) In an attempt to locate the disto-buccal canal of the 26, there were multiple
perforations of the pulp chamber floor. b) Upon re-entry the disto-buccal canal could not
be located but the perforation was repaired with MTA. There was radiographic evidence of
furcational bone loss. The tooth remained symptomatic and the tooth was removed

Fig. 10 The critical zone: a perforation

into the gingival sulcus and the crestal
attachment may have the most significant
consequences as bacterial entry and
pocket formation can quickly ensue. It is
important to recognise the critical zone
may not necessarily be at the CEJ but rather
follows the biological width, thus if there is
recession, the critical zone will be located
more apically accordingly

Fig. 12 In an attempt to locate the distobuccal canal of the 36 the operator perforated
formation of a periodontal pocket (Fig. 8).8
into the furcation. The perforation was immediately repaired with MTA and the RCT
If the perforation is not detected early and completed (to date) successfully
repaired, then the breakdown of the periodon-
tium may ultimately lead to a loss of tooth.
Though irreversible inflammation may not Table 1 The prognosis for success when considering site, size and time to repair of perforations
always result, if an irritating restoration is
present or a microbial infection ensues, it is Prognosis Site Size Time to repair
unlikely that healing will take place.1 Indeed, Favourable Apical or supra-crestal Small Immediate
it can significantly reduce the odds of suc-
Unfavorable Equi-crestal Large Delayed
cess of root canal treatment by 56%, largely
attributable to bacterial contamination during
or after treatment.12 Several key factors have furcation of multi-rooted teeth, then this can preventing bacteria from reaching the
been associated with the pathological seque- also be regarded in the critical zone due to its peri-radicular tissues.1
lae and thus the prognosis of the tooth. These proximity to the epithelial attachment and
include the site of the perforation, the size of the gingival sulcus (Figs 11a and 11b).8,17,18 Time
the perforation, the time to repair and, most Perforations that are coronal to the critical The time delay between the occurrence of
recently, the material with which the repair zone have a good prognosis. This is because the perforation and repair has been found
is made (Table 1).13 they are easily accessible and an adequate to be an important factor in healing. The
seal with conventional materials is possi- most favourable healing is found when the
Site ble without periodontal involvement. If the perforations are sealed immediately; thereby
The position of the perforation relative to canal is accessible and root canal treatment reducing the likelihood of an infection and
the level of the crestal bone and the epi- possible, perforations that are located apical chronic granulation tissue or periodontal
thelial attachment is critical when assessing to the critical zone also have a more favour- pocket occurring (Figs 12a and 12b).8,14,21
prognosis. This is named the critical zone able prognosis as they can be cleaned and
(Fig. 10). The worst prognosis lies when the sealed with a much lower risk of bacterial Appropriate repair material
perforation is within this critical zone. The entry from the oral cavity and a chronic Historically, used repair materials are amal-
close proximity to the gingival tissues can inflammatory lesion developing.18,19 gam, zinc oxide – eugenol cement, calcium
lead to the contamination of the perfora- hydroxide, gutta percha, glass-ionomer
tion with bacteria from the oral cavity.1 A Size cement, IRM, composite resin and SuperEBA
periodontal defect will be created if there A small perforation is usually associated cement. Best practice suggests that perfora-
is apical migration of the epithelium into with less tissue destruction and inflamma- tions should now be treated using a bio-
the perforation site.14,15 This rapid pocket tion. Therefore, healing is more predict- active material such as mineral trioxide
formation leads to the lowest success rate able and has a better prognosis.20 Smaller aggregate (MTA (ProRoot, Dentsply/Tulsa
of repair.2,16 If the perforation occurs in the perforations are easier to seal effectively, Dental, Tulsa, OK, USA)).22 This material

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 PRACTICE

Fig. 14 Following
extraction the size
of the perforation
is evident

treatment deemed impossible to complete,

the patient must be counselled upon the
benefits of extraction and possible pros-
thodontic options. For some teeth, access to
Fig. 13 a–b) A perforation occurred
the perforation may be impossible without
during endodontic access of the 45. c–d)
The cavity was repaired with Biodentine. significant risk of collateral damage or risk
The setting time of 12 minutes allowed of failure, therefore, extraction may be the
the operator to continue RCT without only option (Figs 14a and b).
significant delay to the patient’s care If the tooth is considered restorable, repair
may be considered. An important factor to
consider is good visibility as this is essential
to see the damaged site. Access to an operat-
ing microscope is recommended.13
consists of fine particles of tricalcium sili- Newer similar materials such as Biodentine
cates, which are hydrophilic and set in the (Septodont) may overcome these handling Non-surgical management of
presence of moisture. It is biocompatible problems: it is a calcium silicate with cal- perforations
and promotes tissue repair and regenera- cium chloride to speed the setting time.
tion.23 Either under or over filling a per- As such it can be prepared, placed and set
General principles:
foration defect with MTA does not appear within 12 minutes. (Figs 13a‑d) Furthermore, If possible, root canal treatment and defini-
to affect the ability to seal the root.24 With it has improved handling ability with a con- tive obturation should be completed. If not,
most dental materials, the bond strength sistency closer to IRM or Kalzinol facilitat- the canals should be protected with an easily
significantly reduces when it is contami- ing placement. As yet there is however a removable material such as Cavit (3M ESPE,
nated with moisture, but MTA requires the paucity of data to support the use of such Seefeld, Germany), cotton wool, gutta percha
presence of water when setting. Therefore, materials.13,29,30 or paper points. This prevents iatrogenic block-
set MTA can acquire its optimal strength age of the canals with the reparative material.
and produce excellent sealability in the MANAGEMENT One must then consider the time-lapse
inherently wet environment of the perfo- The aim of perforation management is between the development of the perfora-
ration.25 Once placed, MTA is biocompatible regeneration of healthy periodontal tissues tion and the repair. If a non-contaminated
and can result in new cementum forma- against the perforation without persistent perforation is repaired immediately then
tion and periodontal regeneration, despite inflammation or loss of periodontal attach- this prevents breakdown of the periodontal
its extrusion into periradicular tissues.26,27 ment. If there is a case of periodontal break- ligament. If the perforation has been long
There are however, disadvantages of using down, then the aim here is to re-establish standing then it may be chronically infected.
MTA: tissue attachment.26,31 Therefore, successful Any restorative material within the perfora-
• It is difficult to manipulate and handling perforation repair depends on the ability to tion defect should be removed (Figs 15a‑c
requires both time and practice seal the perforation and re-establishing a and 16a‑c). The success of treatment for
• The setting time of around four hours healthy periodontal ligament.8 infected perforations depends on remov-
may compromise the application. In Clearly, irrespective of site, size or time ing the contaminants and repairing under
supra-crestal cases the material may be to repair, if a tooth is symptomatic, treat- aseptic conditions.32 If dentine must be
washed out before it has set28 ment must be offered. There are only two removed then this can be done with burs or
• Both grey and white MTA can discolour options in this case: repair or extraction. ultrasonic instruments under magnification.
the tooth and therefore compromise The tooth must first be assessed for restor- Ultrasonic tips are the preferred choice as
aesthetics. This needs to be considered ability. Extensive pathological perforations they are least destructive to the adjacent tis-
especially in the anterior region and with invariably render the tooth unrestorable. sues. Arens & Torabinejad33 described further
those patients who have a high lip line. If the tooth is unrestorable or endodontic enlargement and cleaning of the infected

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 PRACTICE

Fig. 15 Careless access with no consideration

to the position of the root resulted in a distal
perforation of the 12 distally. Furthermore an
instrument separated during preparation. This was
removed before conventional RCT and perforation
repair was undertaken

perforation and the wound site with copi- cavity. In the past, attempts have been made works favourably when it is extruded into
ous irrigation of 2.5% sodium hypochlorite to control this and to increase the sealing the periradicular tissues. Thus, the use of
before placement of the repair material. ability of the repair materials with internal barriers is not strictly necessary with cal-
Sodium hypochlorite should be used with biocompatible barriers/matrices such as cium silicates such as MTA. If, however,
caution due to the increased risk of severe collagen or calcium sulphate (Fig. 17).38-41 there is a large cavity it may be worth
complications. Sterile water can be used if However, there is some evidence to sug- considering placing a barrier to facilitate
the operator is concerned about extrusion gest that an excellent success rate is achiev- control of the material. Propriety cellu-
into peri-radicular tissues, but they must be able when MTA is used without a barrier.20 lose materials used in surgical haemostasis
aware this will not help decontaminate the Furthermore, when MTA was accidently control are inexpensive, easy to manipulate
site. Chlorhexidine may be a preferable alter- extruded into the periradicular area, it was and ideal for this. Once placed, the MTA
native if the patient is not sensitised to this. shown that hard tissue was deposited over or other such material can be condensed
When the lesions are larger they can the material with the presence of a healthy against the barrier permitting improved
often present with hyperplastic and vascular periodontium. All this confirms that MTA control of the repair.
granulation tissue, which then protrudes into
the defect. This granulation tissue should be
carefully curetted and removed. Endodontic
excavators, probes and rose-head long shank
burs may also aid the clinician in achiev-
ing a clean cavity, but can result in further
profuse bleeding. Commonly used clotting
agents such as ferric sulphate can cause
irreversible damage to the delicate alveolar
bone and delay healing, as such their use
is not recommended.34-36 It is preferable to
achieve haemostasis using collagen, calcium
sulphate or calcium hydroxide. If bleeding
cannot be controlled it may be sensible to
dress the tooth and provisionally fill the
resorption defect with Cavit or non-setting
calcium hydroxide and arrange a further
appointment for the repair.
Controlling haemostasis and skillful
placement of a restorative material is essen-
tial in achieving a seal. In cases of delayed
repair there is invariably breakdown of the
periodontal ligament and surrounding bone Fig. 16 a –b) The treating practitioner perforated through the mid buccal of of the 12. The
into which granulation tissue proliferates. root canal treatment was completed but the referring practitioner was completely unaware
they were obturating the periodontal tissues. c) Orthograde root canal treatment was
Removal of such granulation tissue may
completed and the perforation repaired with composite as the defect was supra gingigval. The
therefore leave a bone cavity around the site was surgically explored to remove extruded GP. Note the significant bone loss around the
perforation site.37 The operator must antici- apex of the 12
pate extrusion of repair material into this

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 PRACTICE

Coronal third perforations:

The location of the perforation will deter-
mine which access technique is used and
how the perforation is sealed. Supracrestal
perforations have no periodontal involve-
ment as they communicate directly with the
oral environment. Conventional restorative
materials such as glass ionomer and compos-
ite may be used but care should be taken to
ensure the margins of the repair are smooth
externally and do not become a plaque-trap.
If feasible, MTA or equivalents should be
used for those lesions in and just apical to
the critical zone. The root canal treatment
may be completed and the repair performed Fig. 17 During the repair of the perforation
or, if the perforation is bleeding and impair- in Figure 2, MTA was extruded into the
ing RCT, it may be sensible to repair the per- peri radicular tissues. Arguably, though
foration before completing RCT (Fig.  18). challenging to place, a barrier may have
MTA can be delivered to the perforation prevented this
using micro-syringes such as the MTA MAPS larger this may prevent adequate healing
System or Dogvan Carrier. Micro pluggers or and some attempt must be made to repair it.
micro spatulas can then be used to condense It is necessary to be vigilant in placing the
the material. Though ultrasonic instruments instruments in the original canal and not Fig. 18 The root canal treatment of the 21
can be used to help ‘slump’ the material into the perforation. This is facilitated by pre- and 11 (from Figure 9) was completed and
the site and improve adaptation, it is in the bending root canal instruments and filing the buccal perforation to the 21 was repaired
with MTA
authors’ belief that this can irritate the tis- away from the defect.
sues and result in unwanted bleeding.13 There are two options for repairing these canal from obstruction with the repair
Once MTA is placed precisely, a paper point perforations: material. This must be placed deeper
or cotton pledget can be used to remove the 1. Sealing the defect with MTA after than the perforation. Different space-
excess moisture, which further solidifies the obturating the canal apical to the maintainers have been recommended
material.42 After placement is complete, a damp perforation. The gutta percha can be including severed files,42 but a GP cone
cotton pledget is placed on top allowing MTA heated and placed against the canal or paper points are readily available,
to set, as it needs more moisture during setting. wall opposing the perforation. This inexpensive and easy to remove once
This protracted setting time dictates a delay eases the application of MTA to the the repair is complete.
in the placement of the final restoration. The perforation, which is placed at the level
recommendations vary from one day to one of the defect and condensed by hand. These operators feel it is invariably
week.33 Sluyk et al.43 showed that at a time The disadvantage that comes with this easier to obturate the canal apical to the
range of 72 h, the resistance to dislodgement technique is the risk of extruding the defect, repair the defect then backfill the
improves significantly. During the next visit, obturation material into the perforation canal around the repair with warm flow-
it is recommended to check if the material is 2. Clean and shape the canals then, after able gutta percha, but this is clearly per-
set and whether it has remained correctly posi- hemostasis has been achieved, use sonal preference and clinical flexibility
tioned at the perforation site. Immediate adhe- a ‘space-maintainer’ to protect the is essential.
sive reconstruction of the tooth provides less
possibility for coronal leakage and strengthens
the tooth. In the authors’ opinion, when MTA
is used it is not unreasonable to place a bar-
rier of resin modified GIC over the MTA and
restore the tooth immediately. If Biodentine is
used, the restoration may be placed immedi-
ately onto the repair. Indeed it may be sensible
to initially restore the whole tooth completely
with Biodentine (Figs 19a and 19b).

Middle third perforations:

These are usually ovoid in shape and typi-
cally consist of a large surface area to seal.32
Strip perforations are frequent problems
in thin and concave roots.44 These defects
are almost impossible to repair in a truly Fig. 19 Once the bleeding in Figure 7 was controlled (using adrenalin containing local
controlled manner (Fig. 17). If only a small anaesthetic injected interproximally and gentle pressure with cotton wool pledgets) the
defect is suspected, and haemostasis is perforation was repaired with Biodentine. Again, this permitted the clinician to continue
achieved immediately, it may be sensible endodontic therapy during that visit
to obturate conventionally. If the defect is

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 PRACTICE

Fig. 20 a) Whilst attempting to locate the canal of the 22 the operator perforated the distal aspect of the apical third. b) The canal was
correctly identified and shaped. Following this GP was used to obturate the apical canal before MTA was placed over the perforation.
c) The canal was backfilled with warm flowable GP

Fig. 21 a) A perforation occurred during RCT of the 12 resulting in a persistent sinus. b–c) An intra-sulcular incison was made and a flap
raised without relieving incisions. Surgical repair with MTA was performed. d) There was evidence of healing and no pocketing at a 4 week
review

Apical third perforations surgery or extraction, should pathology and • There is an apical third perforation
These perforations can be difficult to man- symptoms persist.42 with persistent disease that cannot be
age. They often occur during cleaning and adequately cleaned and repaired
shaping of the root canal.32 Access is invari- Surgical management of • There is external cervical resorption not
ably limited and negotiating these frequently perforations amenable to internal repair
blocked and ledged canals is difficult. Using In the past, before technology such as Essentially, surgical management is indi-
MTA to restore these defects may be impos- magnification and illumination became cated if either the case is not amenable or
sible unless it is a straight wide canal and the readily available, perforations were often not responding to non-surgical treatment,
operator can sufficiently visualise the lesion managed surgically. With these advances, or if management of the affected periodon-
(Figs 20a‑c). We advocate attempting to re- it is now considered appropriate to use a tium is required.13,45 Root canal treatment
access the original anatomy and, following non-surgical approach whenever possible.13 should be completed. A surgical flap is then
cleaning and shaping, obturation with warm However, surgical intervention may be reflected at the perforation site to provide
vertical compaction of gutta percha, relying considered when: access for surgical repair. In instances when
upon the sealer and some GP to flow into the • There is uncertainty about the shape/ the defect is in the coronal half of the tooth
defect. If re-access is not possible then obtu- nature of the defect it is prudent to lift a full mucoperiosteal flap.
ration to the defect may be carried out, with • The defect is sub-crestal and associated It provides good access and can be a rec-
warm vertical compaction of gutta percha. It with pathology and/or symptoms tangular flap with mesial and distal vertical
must be noted, however, that apical perfora- • Internal access is not possible because of relieving incisions, triangular with just one
tions with uninstrumented canals may face an extensive intracoronal/extra coronal or, if the flap can be mobilised sufficiently,
a much poor prognosis and cannot be man- restoration it may be possible to access the lesion with-
aged successfully in all cases. Consideration • There is a large defect preventing control out a relieving incision (Figs 21a‑d). In cases
should be given to the options of apical over materials where the lesion is located more apically it

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CONCLUSION
Perforations can result in chronic infection
and ultimately tooth loss. Prevention of
iatrogenic damage is an essential part of
all healthcare interventions. Table  2 con-
tains some tips on good preventive strate-
gies. Nonetheless, perforations can and do
occur for a variety of reasons. It is essential
the clinician recognises when a perforation
has occurred and has knowledge of the best
strategy for correcting the damage. A refer-
ral to a more experienced colleague may
result in a delay in treatment, which may
have serious impact upon the outcome of
treatment, therefore, all clinicians should
consider immediate repair with the appro-
priate materials. Patients must be informed
that long standing perforations may be
unpredictable to repair and consent must
include the risks and benefits of either leav-
ing the tooth unrepaired or extraction and
prosthetic replacement.
Fig. 22 a) Localised chronic inflammation around a perforation on the mesial aspect of
the 21. The lesion was surgically accessed after definitive restoration and repaired with 1. Fuss Z, Trope M. Root perforations: classification
Biodentine. b) Radiographic review at 6 months reveals evidence of bony healing and the and treatment choices based on prognostic factors.
suggestion of the formation of new periodontal ligament Dent Traumatol 1996; 12: 255–264.
2. Kvinnsland I, Oswald R J, Halse A, Grønningsaeter
A G. A clinical and roentgenological study of 55
cases of root perforation. Int Endod J 1989; 22:
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