239

ENDO (Lond Engl) 2013;7(3):239242

REVIEW ARTICLE
Key words biocompatibility, furcal perforation, MTA, root perforation, wound healing
Ricardo Machado, Luiz Fernando Tomazinho, Melissa Randazzo, Emmanuel Joo Nogueira Leal Silva,
Luiz Pascoal Vansan
Repair of a large furcal perforation with mineral
trioxide aggregate: a 21-month follow-up
The purpose of treating a furcal perforation is to seal the articial communication between the
endodontic space and the periradicular tissue to prevent alveolar bone resorption and damage to
the periodontal ligament. These complications are not infrequent in cases of large furcal and/or old
perforations, which have a worse prognosis than recent, small, coronal and apical perforations. Min-
eral trioxide aggregate (MTA) is widely used to seal perforations, because of its biocompatibility and
sealability. This case report describes the management of a large furcal perforation in a mandibular
rst molar. Although most of the pulpal oor was destroyed and the roots were damaged, an attempt
was made to repair the defect and restore the tooth. The perforation was cleaned with saline solution
and ultrasonic tips. Finally, the perforation was sealed with MTA and the tooth restored coronally. A
21-month recall showed no evidence of periodontal breakdown, no symptoms, and complete healing
of the surrounding periodontal tissue.
Ricardo Machado,
DDS, MSc, PhD
student
Professor of the Specializa-
tion Course in Endodontics,
Ing University
Rondonpolis/MT, Brazil
Professor of Endodontics,
Regional University of
Blumenau, Blumenau/SC,
Brazil

Luiz Fernando
Tomazinho, DDS, PhD
Professor of the Specializa-
tion Course in Endodontics,
Ing University,
Rondonpolis/MT, Brazil
Professor of Endodontics,
Paranaense University,
Umuarama/PR, Brazil
Melissa Randazzo,
DDS
Specialist in Endodontics,
Ing University,
Rondonpolis/MT, Brazil

Emmanuel Joo
Nogueira Leal Silva,
DDS, MSc, PhD
Professor of Endodontics,
Grande Rio University
(UNIGRANRIO),
Rio De Janeiro/RJ, Brazil

Luiz Pascoal Vansan,

DDS, MSc, PhD
Professor of Endodontics,
Ribeiro Preto Dental
School, University of
So Paulo,
Ribeiro Preto/SP, Brazil
Correspondence to:
Emmanuel J. N. L. Silva,
Rua Herotides de Oliveira
61/902,
Icara, Niteri, RJ, Brazil
Fax: 55 21 26108439
Email: nogueiraemmanuel@
hotmail.com
Introduction
Furcal perforations are severe iatrogenic complica-
tions of root canal treatment and may lead to tooth
loss
1,2
. Perforations may occur during preparation
of access cavities, post space preparation, or as a
result of the extension of internal resorptions into
the periradicular tissues
3
. Factors that inuence the
survival of perforated teeth include size of the per-
foration, time of repair, level and location of the
perforation, presence of periodontal disease and
pre-endodontic pulp vitality status
1,2,4
. Depend-
ing on the particular characteristics of the furcal
perforation, it can be managed either surgically or
non-surgically
5,6
. The prognosis is generally excel-
lent if the problem is well-diagnosed, and the repair
is well-performed with a material that can provide
proper sealing ability and biocompatibility
2,6
. Min-
eral trioxide aggregate (MTA) is regarded as an
ideal material for perforation repair, due to its fa-
vourable properties, including good sealing capabil-
ity, biocompatibility, bactericidal activity, radiopac-
ity, and the ability to set in the presence of blood
or tissue uids
7-10
. These properties make MTA a
suitable material for treating root perforations, in
order to regenerate periodontal attachment and
induce osteogenesis and cementogenesis
9,11
. Al-
though several perforation treatment cases have
been reported in the endodontic literature, there is
a limited number of studies published on long-term
outcomes following perforation repair.
The following case report describes the repair
of an old and large furcal perforation in a right rst
mandibular molar using MTA. In this case, the under-
lying periodontal tissue healing was observed radio-
graphically at the 21-month follow-up evaluation.
Machado et al Repair of a large furcal perforation with mineral trioxide aggregate 240
ENDO (Lond Engl) 2013;7(3):239242
Case report
A 37-year old female patient with no general health
problems, but complaining about pain in the region
of the right rst mandibular molar, was referred to
the clinic of one of the authors (RM). The patient
reported that the tooth had been root canal treated
19 months earlier. The patient complained of painful
swelling of the mucosa, following conclusion of the
root canal treatment. Clinically, the tooth revealed
gingival inammation associated to a furcal lesion
and slight mobility. No communication between the
furcation and the oral cavity was observed. Radio-
graphic examination suggested a large perforation
in the furcal region of tooth 46, lled with a radio-
paque material. Moreover, a large radiolucency was
evident below the material (Fig 1). The patient was
informed about the condition and required inter-
vention regarding the furcal defect. Risks, benets,
and alternatives were discussed with the patient. It
was agreed that although the prognosis was less
than ideal, an attempt would be made to repair the
defect.
After the administration of local anaesthesia
with 4% articaine with 1:100.000 epinephrine (Ar-
ticaine; DFL, Rio de Janeiro, Brazil), a rubber dam
was placed and an access cavity was performed
at high-speed rotation with diamond burs, in an
attempt to reach the furcal perforation. After locat-
ing the furcal perforation lling material, the ma-
terial was completely removed with ultrasonic tips
(ET40D; Satelec, Merignac, France) and surgical
curettes. Intense haemorrhage and a granulation
tissue were observed when the furcal lling material
was removed. The granulation tissue was removed
using surgical curettes, and the haemorrhage was
controlled with copious irrigation using a 0.9% sa-
line solution. The perforation caused marked in-
terradicular bone destruction and the roots were
severely gouged. The perforation site was cleaned
using ultrasonic tips (ET40D). MTA (Angelus; Lon-
drina, PR, Brazil) was prepared according to the
manufacturers instructions, placed in the furcal
perforation with an amalgam carrier, and gently
packed with a cotton pellet to obtain good adapt-
ability. The MTA and part of dental oor were im-
mediately covered with glass ionomer (Vitrebond;
Campinas, SP, Brazil), and the tooth was restored
using resin composite (Z250; 3M ESPE, Campinas,
SP, Brazil). The postoperative radiographic exam-
ination revealed that an excessive amount of MTA
had been extruded into the furcation area (Fig 2).
The patient was informed of the treatment ren-
dered, and it was decided that an attempt should
be made to retain the tooth.
The 2-month recall showed that there was no
pain caused by the tooth, no response to percussion
or palpation, and no attachment loss or periodontal
problem. Periodontal probing depths were within
normal limits. Moreover, no swelling or draining si-
nus tract were observed. The tooth revealed an ad-
equate clinical function, and radiographic ndings
showed adequate sealing of the perforation region,
with bone healing in the furcation region (Fig 3). The
Fig 1 Preoperative radiograph showing large radiolucency
in the furcal region.
Fig 2 Immediate postoperative radiograph showing an
excessive amount of MTA extruded into the furcation area.
Machado et al Repair of a large furcal perforation with mineral trioxide aggregate 241
ENDO (Lond Engl) 2013;7(3):239242
furcation area could not be probed. Radiographi-
cally, the 21-month follow-up showed no periodon-
tal problems and normal periapical structures, while
the clinical examination revealed absence of any
symptoms (Fig 4).
Discussion
The present case report describes the 21-month
preservation of a mandibular molar that presented
with an extensive and long-established furcal per-
foration. The time elapsed since the occurrence of
the perforation is one of the factors that may inu-
ence the prognosis of furcal perforation, because the
possibility of an infection occurring in the wound
site increases with time
11
. In the present case, the
time elapsed since perforation and treatment was
21 months, demonstrating that adequate clean-
ing achieved using copious irrigation, associated to
mechanical cleaning of the furcal perforation with
ultrasonic tips, promoted perforation disinfection.
In addition, the size of a perforation represents
another important factor in determining the success
of the repair procedure
1,2,12,13
; the extent of the
perforation in the present case was unusually large.
An extensive destruction of interradicular bone can
be observed in Fig 1. In this extensive destruction
granulation tissue was observed clinically. Although
this granulation tissue may be regarded as chronic
inammatory tissue, which can be the rst stage
of healing in the right environment, it was essential
to remove it in order to create an environment that
could be adequately cleaned, dried and sealed with
MTA. The result of the granulation tissue removal
was a massive extrusion of MTA (Fig 2).
Extrusion of MTA can be prevented by apply-
ing a resorbable collagen matrix before placing the
MTA; however, the use of a matrix proved unable
to prevent extrusion of MTA in extensive perfora-
tions
12
. Moreover, success has been reported in the
literature, both with
14
and without the matrix
15
. In
an animal study
16
, hard-tissue deposition and ce-
mentum were observed attached to MTA, along
with periodontal apparatus regeneration, when MTA
was accidentally extruded into the periradicular tis-
sue. Extrusion of the material was unintentional, but
it does demonstrate some of the excellent biologi-
cal, physical and chemical properties of MTA. At the
21-month follow-up, the radiograph showed com-
plete osseous repair of the preoperative periradicular
lesion. The furcation area remained intact, with no
radiographic or clinical signs of pathology, and the
tooth remained asymptomatic.
Although the use of MTA has been suggested for
several different endodontic treatments, literature
reporting successful treatment outcomes in cases of
furcal perforation is limited. Although the prognosis
is generally better for smaller lesions (<2 mm), the
location of the perforation at the level of the cr-
estal bone and the huge amount of extruded MTA
suggested a guarded prognosis in the present case.
However, the treatment was successful as indicated
by the 21-month follow-up. One of the key points
Fig 3 Two-month recall showing partial osseous repair of
furcal radiolucency.
Fig 4 Twenty-one month recall radiograph showing com-
plete healing and no evidence of furcal involvement.
Machado et al Repair of a large furcal perforation with mineral trioxide aggregate 242
ENDO (Lond Engl) 2013;7(3):239242
that may have favoured the prognosis of the present
case was the absence of a communication between
the furcation perforation and the oral cavity.
It can be concluded that MTA is a remarkable
material and that endodontists should be prepared
to deal with cases that previously would have been
regarded as hopeless. However, clinical trials or long-
term follow-ups of large patient cohorts are still re-
quired to determine the limitations of the use of
MTA.
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