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Repair of a Large Furcation Perforation: A Four-Year Follow-Up
Case Report/Clinical Techniques
Repair of a Large Furcation Perforation: A Four-Year Follow-Up Jose L. Ibarrola, DDS, MS, Stephen G. Biggs, DDS, and Thomas J. Beeson, DDS Abstract This case report describes the management of a large furcation perforation in a maxillary first molar. Although the majority of the pulpal floor was destroyed and the mesiobuccal root was damaged, an attempt was made to repair the defect and restore the tooth. An absorbable gelatin sponge matrix was placed, and the defect was repaired with gray ProRoot mineral trioxide aggregate. Subsequently the endodontic treatment was completed; the tooth was restored and was later used as a fixed partial denture abutment. A 55-month recall showed no evidence of periodontal breakdown, no symptoms, and complete healing of all periradicular lesions. (J Endod 2008;34:617– 619)
Key Words Biocompatibility, furcation perforation, MTA
From the Department of Endodontics, Creighton University School of Dentistry, Omaha, Nebraska. Address requests for reprints to Thomas J. Beeson, DDS, Creighton University School of Dentistry, 2500 California Plaza, Omaha, NE 68178. E-mail address: thomasbeeson@ creighton.edu. 0099-2399/$0 - see front matter Copyright © 2008 by the American Association of Endodontists. doi:10.1016/j.joen.2008.01.017
JOE — Volume 34, Number 5, May 2008
F
urcation perforations can have a negative impact on the prognosis of the affected tooth by compromising the attachment apparatus (1). Factors that influence the outcome of perforated teeth include size, time of repair, and level and location of the perforation (1, 2). Other prognostic indicators include the presence of periodontal disease and pre-endodontic pulp vitality status. These factors should be taken into account when selecting materials and techniques for perforation repair. Historically, restorative materials such as amalgam, SuperEBA, Cavit, glass ionomer (GI), and composite have been used with different degrees of success (3–5). A material with excellent sealing properties, mineral trioxide aggregate (MTA), was introduced by Torabinejad et al. (6) in 1993. Main et al. (7) reported 16 successful cases of perforation repair with MTA. Among these were 3 furcation perforations with an average recall time of 25 months. The authors found the material suitable for repair of such perforations. Ferris and Baumgartner (8) compared gray MTA (GMTA) with white MTA (WMTA) and found no difference in their ability to seal perforations. Hamad et al. (9) also found no difference in the sealing ability between GMTA and WMTA. However, they found significantly more leakage when perforations were repaired from an orthograde approach compared with a retrograde approach. Bozeman et al. (10) found WMTA and GMTA released the same amount of calcium, but GMTA precipitates formed more hydroxyapatite (HA) crystals. They suggested that HA crystals play a role in hard tissue deposition and improved healing when MTA is used as a repair material. In a dye leakage experiment Tsatsas et al. (11) found MTA to exhibit less dye penetration than Cavit W when used to repair perforations. Nakata et al. (12) used a bacterial leakage model in furcation perforations to assess the sealing ability of MTA and amalgam. They found MTA to be significantly better than amalgam in preventing leakage to Fusobacterium nucleatum. In addition to its superior sealing properties, studies have shown MTA to have excellent biocompatibility when placed in contact with the periradicular tissues. Yildrim et al. (13) studied the histologic response of dogs to MTA and SuperEBA. MTA had less inflammation than SuperEBA and also showed new cementum deposition in the perforation area. In an experiment with dogs, Torabinejad and Chivian (14) showed histologic evidence of cementum deposition around MTA that had been extruded into the surrounding periradicular tissues. The presence or absence of material extruded into the periradicular tissues can affect the outcome of perforation repairs. Placement of an artificial matrix before insertion of the repair material has been recommended (15). In addition to confining the repair material to the perforation site, placement of a matrix also helps with hemorrhage control. Different combinations of matrix and repair materials have been studied. Jantarat et al. (16) used a bacterial penetration technique to evaluate perforation repair in vitro. They found that using a plaster of Paris matrix improved the seal of amalgam but not that of Ketac Silver (3M ESPE, St Paul, MN). Krupalini et al. (17) measured artificial perforation leakage on human extracted teeth and found that MTA, used as a matrix, allowed the least amount of leakage compared with calcium sulfate, HA, and resin modified GI cement. Mittal et al. (18) used methylene blue to measure the effectiveness of plaster of Paris matrices during perforation repair and found that a plaster barrier improved the seal of AH 26, intermediate restorative material, composite resin, and GI cement, but it did not improve the seal of amalgam. Rafter et al. (19) found healing responses to be more favorable when HAPSET (65% HA, 35% plaster of Paris) and HA internal matrices were used to repair experimental perforations on baboons. Walia et al. (20) used Gelfoam (Pfizer, New York, NY) as a matrix when repairing furcal
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Case Report/Clinical Techniques
Figure 1. (A) Preoperative radiograph showing radiolucencies at apex of MB and DB roots. (B) Radiograph showing immediate repair with GMTA.
perforations with amalgam. They presented 2 successful case reports by using this method. A case report of an unusually large perforation and its subsequent repair is presented, with a follow-up of 55 months.
Case Report On April 15, 2003, a 66-year-old man presented to the dental clinic at Creighton University Medical Center for endodontic therapy on asymptomatic tooth #3. The tooth was nonresponsive to pulp vitality tests and showed radiolucencies at the apices of the mesiobuccal (MB) and distobuccal (DB) roots (Fig. 1A). Tooth #3 had no caries and normal mobility, and probing depths were in the 2–3 mm range. A diagnosis of pulpal necrosis with chronic apical periodontitis was established. In addition, tooth #4 was asymptomatic, had previous endodontic therapy, and had recurrent caries on the mesial surface. Tooth #4 was treatment-planned for crown removal and reevaluation at a later date. Endodontic treatment was initiated on tooth #3 by an undergraduate dental student. On endodontic access, the student encountered excessive bleeding and asked for the assistance of his clinical instructor. On examination, the instructor rinsed the site with a diluted mixture of NaOCl, attempted to control hemorrhage, and assessed the situation. The student had overestimated the depth of the pulp chamber, resulting in a large perforation (approximately 5 ⫻ 6 mm) in the trifurcation area. The perforation resulted in significant interradicular bone destruction, and the distal aspect of the MB root was severely gouged. The situation was addressed first with the student and then the patient. Risks, benefits, 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 iatrogenic defect. The perforation site was packed with Gelfoam to control bleeding and to establish a matrix (20). GMTA (ProRoot MTA; Dentsply Tulsa
Dental, Tulsa, OK) was placed in the defect by using an amalgam carrier and condensed with a sterile cotton pellet. A moist cotton pellet was placed in the pulp chamber, and the access was closed with Cavit (3M ESPE). The rubber dam was removed, and a postoperative radiograph was exposed. In spite of the Gelfoam matrix, an excessive amount of MTA was extruded into the trifurcation area (Fig. 1B). The patient was informed of the treatment rendered. A guarded prognosis was given, and extraction was recommended. The patient requested that if at all possible, an attempt should be made to retain the tooth. The patient was rescheduled for the following week for reassessment and to attempt completion of endodontic therapy. On reassessment at 1 week the patient said he experienced mild symptoms for the first 2 days after treatment but was now comfortable. On clinical examination, no evidence of periodontal breakdown was observed, and tooth #3 was not sensitive to percussion. The patient was again informed of the guarded prognosis as well as risks, benefits, and alternatives to continued endodontic therapy. He gave informed consent and was anesthetized via infiltration with 1.8 mL 2% lidocaine with epinephrine 1:100,000 (AstraZeneca LP for Dentsply Pharmaceutical, York, PA), and a rubber dam was placed. On access the moist cotton pellet was removed, and the MTA was observed to be set and intact with no evidence of dislodgement or leakage. Three canals were located by one of the authors by using a dental operating microscope. An MB2 canal was not located. Working lengths were established, and the canals were enlarged by a senior dental student with K-files (Dentsply Maillefer, Johnson City, TN) and Gates-Glidden drills (Dentsply Maillefer) by using a crown-down technique. All canals were obturated with laterally condensed gutta-percha and AH Plus sealer (Dentsply Maillefer). The access cavity preparation was closed with silver amalgam (Fig. 2A).
Figure 2. (A) Immediate postoperative radiograph showing completed endodontic therapy. (B) Eighteen-month recall showing partial osseous repair of apical radiolucencies. (C) Fifty-five–month recall radiograph showing complete healing of periradicular radiolucencies. There is no evidence of furcation involvement.
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Ibarrola et al.
JOE — Volume 34, Number 5, May 2008
Case Report/Clinical Techniques One-, 3-, and 8-month follow-up appointments showed no signs of periodontal breakdown. The tooth was not sensitive to percussion, and there was no indication of swelling or draining sinus tracts. The trifurcation area could not be probed. At 8 months a radiograph showed continued healing, but it was noted that tooth #2 was missing. When questioned, the patient explained that he had seen a different dentist as a result of biting pain. The patient said the dentist determined the source of the symptoms to be tooth #2 and extracted the tooth. At 18 months there were no detectable signs of periodontal breakdown, and the patient reported no symptoms. Radiographs showed evidence of osseous repair at the apex of the MB and DB roots (Fig. 2B). The patient had again seen another provider and had endodontic treatment completed on tooth #4. The radiograph revealed a large post in the canal space, with a minimal amount of gutta-percha in the apical third of the root. No symptoms were noted with tooth #4. Mobility and probing depths were normal. Twenty-six months after the perforation repair, the patient presented to the treatment clinic complaining of pain to mastication on the upper right quadrant. Clinical examination revealed tooth #4 with class III mobility and sensitivity to percussion. Tooth #3 tested normal to percussion and mobility. There were no signs of swelling or sinus tracts present. Probing depths were in the range of 2–3 mm around the circumference of tooth #3, and the trifurcation area was not probable. A radiograph of tooth #3 showed no signs of periradicular breakdown. Radiolucency was observed around the entire root of tooth #4. It was determined that tooth #4 had a vertical root fracture, which was confirmed on extraction. A single-tooth implant and removable and fixed appliances were considered for replacement of tooth #4. After evaluation by a periodontist and informing the patient of the risks, benefits, and alternatives, the patient requested placement of a fixed partial denture (FPD) by using teeth #3 and #5 as abutments. The FPD was permanently cemented in February 2007, 46 months after the perforation occurred. Clinical examination at 55 months showed no evidence of swelling or sinus tracts. Teeth #3 and #5 were not sensitive to percussion, and the furcation area of tooth #3 was intact to probing. A radiograph showed complete healing of the periradicular area (Fig. 2C). The patient did not report any symptoms and was satisfied with the FPD.
Discussion This case illustrates several interesting points. The extent of the perforation was unusually large. Iatrogenic destruction of interradicular bone was extensive, with damage to the distal aspect of the MB root. An attempt to provide a matrix by using Gelfoam did not prevent gross extrusion of MTA into the trifurcation area. Other materials such as a collagen-based matrix or calcium sulfate might have reduced the amount of MTA extrusion. Yildrim et al. (13) and Torabinejad and
JOE — Volume 34, Number 5, May 2008
Chivian (14) found minimal inflammation when MTA came in contact with surrounding periradicular tissues. This can explain why the trifurcation area remained periodontally sound in the presence of large amounts of MTA. The extrusion of the material was unintended, but it does demonstrate some of the excellent properties of MTA. At 55 months the radiograph showed complete osseous repair of preoperative periradicular pathosis. The trifurcation area remained intact with no radiographic or clinical signs of pathology, and the tooth remained asymptomatic.
References 1. Cohen S, Hargreaves K. Pathways of the pulp. 9th ed. St Louis: Mosby, 2006. 2. Weine FS. Endodontic therapy. 6th ed. St Louis: Mosby, 2004. 3. Aguirre R, ElDeeb ME, ElDeeb ME. Evaluation of the repair of mechanical furcation perforations using amalgam, gutta-percha, or indium foil. J Endod 1986;12:249 –56. 4. Alhadainy HA, Himel VT. Evaluation of the sealing ability of amalgam, Cavit, and glass ionomer cement in the repair of furcation perforations. Oral Surg 1993;75:62– 6. 5. Bryan EB, Wollard G, Mitchell WC. Nonsurgical repair of furcal perforations: a literature review. Gen Dent 1999;47:274 – 8. 6. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod 1993;19:591–5. 7. Main C, Mirzayaln N, Shabahang S, Torabinejad M. Repair of root perforations using mineral trioxide aggregate: a long term study. J Endod 2004;30:80 –3. 8. Ferris DM, Baumgartner JC. Perforation repair comparing two types of mineral trioxide aggregate. J Endod 2004;30:422– 4. 9. Hamad HA, Tordick PA, McClanahan SB. Furcation perforation repair comparing gray and white MTA: a dye extraction study. J Endod 2006;32:337– 40. 10. Bozeman TB, Lemon RR, Eleazer PD. Elemental analysis of crystal precipitate from gray and white MTA. J Endod 2006;32:425– 8. 11. Tsatsas DV, Meliou HA, Kerezoudis NP. Sealing effectiveness of materials used in furcation perforations in vitro. Int Dent J 2005;55:133– 41. 12. Nakata TT, Bae KS, Baumgartner JC. Perforation repair comparing mineral trioxide aggregate and amalgam using an anaerobic bacterial leakage model. J Endod 1998;24:184 – 6. 13. Yildrim T, Gencoglu N, Firat I, Perck C, Guzel O. Histologic study of furcation perforations treated with MTA and SuperEBA in dogs teeth. Oral Surg 2005;100:120 – 4. 14. Torabinejad M, Chivian C. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197–205. 15. Ruddle CJ. Microendodontic nonsurgical retreatment. Dent Clin North Am 1997; 41:429 –54. 16. Jantarat J, Dashper SG, Messer HH. Effect of matrix placement on furcation perforation repair. J Endod 1999;25:192– 6. 17. Krupalini KS, Udayakumar, Jayalakshmi KB. A comparative evaluation of medicated calcium sulphate, hydroxylapatite, mineral trioxide aggregate (MTA) as a barrier and their effect on the sealing ability of furcation perforation repair material an in vitro study. Indian J Dent Res 2003;14:156 – 61. 18. Mittal M, Chandra S, Chandra S. An evaluation of plaster of Paris barriers used under various materials to repair furcation perforations (an in vitro study). J Endod 1999;25:385– 8. 19. Rafter M, Baker M, Alves M, Daniel J, Remeikis N. Evaluation of healing with use of an internal matrix to repair furcation perforations. Int Endod J 2002;35:775– 83. 20. Walia H, Streiff J, Gerstein H. Use of a hemostatic agent in the repair of procedural errors. J Endod 1988;14:465– 8.
Repair of a Large Furcation Perforation
619
Repair of a Large Furcation Perforation: A Four-Year Follow-Up Jose L. Ibarrola, DDS, MS, Stephen G. Biggs, DDS, and Thomas J. Beeson, DDS Abstract This case report describes the management of a large furcation perforation in a maxillary first molar. Although the majority of the pulpal floor was destroyed and the mesiobuccal root was damaged, an attempt was made to repair the defect and restore the tooth. An absorbable gelatin sponge matrix was placed, and the defect was repaired with gray ProRoot mineral trioxide aggregate. Subsequently the endodontic treatment was completed; the tooth was restored and was later used as a fixed partial denture abutment. A 55-month recall showed no evidence of periodontal breakdown, no symptoms, and complete healing of all periradicular lesions. (J Endod 2008;34:617– 619)
Key Words Biocompatibility, furcation perforation, MTA
From the Department of Endodontics, Creighton University School of Dentistry, Omaha, Nebraska. Address requests for reprints to Thomas J. Beeson, DDS, Creighton University School of Dentistry, 2500 California Plaza, Omaha, NE 68178. E-mail address: thomasbeeson@ creighton.edu. 0099-2399/$0 - see front matter Copyright © 2008 by the American Association of Endodontists. doi:10.1016/j.joen.2008.01.017
JOE — Volume 34, Number 5, May 2008
F
urcation perforations can have a negative impact on the prognosis of the affected tooth by compromising the attachment apparatus (1). Factors that influence the outcome of perforated teeth include size, time of repair, and level and location of the perforation (1, 2). Other prognostic indicators include the presence of periodontal disease and pre-endodontic pulp vitality status. These factors should be taken into account when selecting materials and techniques for perforation repair. Historically, restorative materials such as amalgam, SuperEBA, Cavit, glass ionomer (GI), and composite have been used with different degrees of success (3–5). A material with excellent sealing properties, mineral trioxide aggregate (MTA), was introduced by Torabinejad et al. (6) in 1993. Main et al. (7) reported 16 successful cases of perforation repair with MTA. Among these were 3 furcation perforations with an average recall time of 25 months. The authors found the material suitable for repair of such perforations. Ferris and Baumgartner (8) compared gray MTA (GMTA) with white MTA (WMTA) and found no difference in their ability to seal perforations. Hamad et al. (9) also found no difference in the sealing ability between GMTA and WMTA. However, they found significantly more leakage when perforations were repaired from an orthograde approach compared with a retrograde approach. Bozeman et al. (10) found WMTA and GMTA released the same amount of calcium, but GMTA precipitates formed more hydroxyapatite (HA) crystals. They suggested that HA crystals play a role in hard tissue deposition and improved healing when MTA is used as a repair material. In a dye leakage experiment Tsatsas et al. (11) found MTA to exhibit less dye penetration than Cavit W when used to repair perforations. Nakata et al. (12) used a bacterial leakage model in furcation perforations to assess the sealing ability of MTA and amalgam. They found MTA to be significantly better than amalgam in preventing leakage to Fusobacterium nucleatum. In addition to its superior sealing properties, studies have shown MTA to have excellent biocompatibility when placed in contact with the periradicular tissues. Yildrim et al. (13) studied the histologic response of dogs to MTA and SuperEBA. MTA had less inflammation than SuperEBA and also showed new cementum deposition in the perforation area. In an experiment with dogs, Torabinejad and Chivian (14) showed histologic evidence of cementum deposition around MTA that had been extruded into the surrounding periradicular tissues. The presence or absence of material extruded into the periradicular tissues can affect the outcome of perforation repairs. Placement of an artificial matrix before insertion of the repair material has been recommended (15). In addition to confining the repair material to the perforation site, placement of a matrix also helps with hemorrhage control. Different combinations of matrix and repair materials have been studied. Jantarat et al. (16) used a bacterial penetration technique to evaluate perforation repair in vitro. They found that using a plaster of Paris matrix improved the seal of amalgam but not that of Ketac Silver (3M ESPE, St Paul, MN). Krupalini et al. (17) measured artificial perforation leakage on human extracted teeth and found that MTA, used as a matrix, allowed the least amount of leakage compared with calcium sulfate, HA, and resin modified GI cement. Mittal et al. (18) used methylene blue to measure the effectiveness of plaster of Paris matrices during perforation repair and found that a plaster barrier improved the seal of AH 26, intermediate restorative material, composite resin, and GI cement, but it did not improve the seal of amalgam. Rafter et al. (19) found healing responses to be more favorable when HAPSET (65% HA, 35% plaster of Paris) and HA internal matrices were used to repair experimental perforations on baboons. Walia et al. (20) used Gelfoam (Pfizer, New York, NY) as a matrix when repairing furcal
Repair of a Large Furcation Perforation
617
Case Report/Clinical Techniques
Figure 1. (A) Preoperative radiograph showing radiolucencies at apex of MB and DB roots. (B) Radiograph showing immediate repair with GMTA.
perforations with amalgam. They presented 2 successful case reports by using this method. A case report of an unusually large perforation and its subsequent repair is presented, with a follow-up of 55 months.
Case Report On April 15, 2003, a 66-year-old man presented to the dental clinic at Creighton University Medical Center for endodontic therapy on asymptomatic tooth #3. The tooth was nonresponsive to pulp vitality tests and showed radiolucencies at the apices of the mesiobuccal (MB) and distobuccal (DB) roots (Fig. 1A). Tooth #3 had no caries and normal mobility, and probing depths were in the 2–3 mm range. A diagnosis of pulpal necrosis with chronic apical periodontitis was established. In addition, tooth #4 was asymptomatic, had previous endodontic therapy, and had recurrent caries on the mesial surface. Tooth #4 was treatment-planned for crown removal and reevaluation at a later date. Endodontic treatment was initiated on tooth #3 by an undergraduate dental student. On endodontic access, the student encountered excessive bleeding and asked for the assistance of his clinical instructor. On examination, the instructor rinsed the site with a diluted mixture of NaOCl, attempted to control hemorrhage, and assessed the situation. The student had overestimated the depth of the pulp chamber, resulting in a large perforation (approximately 5 ⫻ 6 mm) in the trifurcation area. The perforation resulted in significant interradicular bone destruction, and the distal aspect of the MB root was severely gouged. The situation was addressed first with the student and then the patient. Risks, benefits, 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 iatrogenic defect. The perforation site was packed with Gelfoam to control bleeding and to establish a matrix (20). GMTA (ProRoot MTA; Dentsply Tulsa
Dental, Tulsa, OK) was placed in the defect by using an amalgam carrier and condensed with a sterile cotton pellet. A moist cotton pellet was placed in the pulp chamber, and the access was closed with Cavit (3M ESPE). The rubber dam was removed, and a postoperative radiograph was exposed. In spite of the Gelfoam matrix, an excessive amount of MTA was extruded into the trifurcation area (Fig. 1B). The patient was informed of the treatment rendered. A guarded prognosis was given, and extraction was recommended. The patient requested that if at all possible, an attempt should be made to retain the tooth. The patient was rescheduled for the following week for reassessment and to attempt completion of endodontic therapy. On reassessment at 1 week the patient said he experienced mild symptoms for the first 2 days after treatment but was now comfortable. On clinical examination, no evidence of periodontal breakdown was observed, and tooth #3 was not sensitive to percussion. The patient was again informed of the guarded prognosis as well as risks, benefits, and alternatives to continued endodontic therapy. He gave informed consent and was anesthetized via infiltration with 1.8 mL 2% lidocaine with epinephrine 1:100,000 (AstraZeneca LP for Dentsply Pharmaceutical, York, PA), and a rubber dam was placed. On access the moist cotton pellet was removed, and the MTA was observed to be set and intact with no evidence of dislodgement or leakage. Three canals were located by one of the authors by using a dental operating microscope. An MB2 canal was not located. Working lengths were established, and the canals were enlarged by a senior dental student with K-files (Dentsply Maillefer, Johnson City, TN) and Gates-Glidden drills (Dentsply Maillefer) by using a crown-down technique. All canals were obturated with laterally condensed gutta-percha and AH Plus sealer (Dentsply Maillefer). The access cavity preparation was closed with silver amalgam (Fig. 2A).
Figure 2. (A) Immediate postoperative radiograph showing completed endodontic therapy. (B) Eighteen-month recall showing partial osseous repair of apical radiolucencies. (C) Fifty-five–month recall radiograph showing complete healing of periradicular radiolucencies. There is no evidence of furcation involvement.
618
Ibarrola et al.
JOE — Volume 34, Number 5, May 2008
Case Report/Clinical Techniques One-, 3-, and 8-month follow-up appointments showed no signs of periodontal breakdown. The tooth was not sensitive to percussion, and there was no indication of swelling or draining sinus tracts. The trifurcation area could not be probed. At 8 months a radiograph showed continued healing, but it was noted that tooth #2 was missing. When questioned, the patient explained that he had seen a different dentist as a result of biting pain. The patient said the dentist determined the source of the symptoms to be tooth #2 and extracted the tooth. At 18 months there were no detectable signs of periodontal breakdown, and the patient reported no symptoms. Radiographs showed evidence of osseous repair at the apex of the MB and DB roots (Fig. 2B). The patient had again seen another provider and had endodontic treatment completed on tooth #4. The radiograph revealed a large post in the canal space, with a minimal amount of gutta-percha in the apical third of the root. No symptoms were noted with tooth #4. Mobility and probing depths were normal. Twenty-six months after the perforation repair, the patient presented to the treatment clinic complaining of pain to mastication on the upper right quadrant. Clinical examination revealed tooth #4 with class III mobility and sensitivity to percussion. Tooth #3 tested normal to percussion and mobility. There were no signs of swelling or sinus tracts present. Probing depths were in the range of 2–3 mm around the circumference of tooth #3, and the trifurcation area was not probable. A radiograph of tooth #3 showed no signs of periradicular breakdown. Radiolucency was observed around the entire root of tooth #4. It was determined that tooth #4 had a vertical root fracture, which was confirmed on extraction. A single-tooth implant and removable and fixed appliances were considered for replacement of tooth #4. After evaluation by a periodontist and informing the patient of the risks, benefits, and alternatives, the patient requested placement of a fixed partial denture (FPD) by using teeth #3 and #5 as abutments. The FPD was permanently cemented in February 2007, 46 months after the perforation occurred. Clinical examination at 55 months showed no evidence of swelling or sinus tracts. Teeth #3 and #5 were not sensitive to percussion, and the furcation area of tooth #3 was intact to probing. A radiograph showed complete healing of the periradicular area (Fig. 2C). The patient did not report any symptoms and was satisfied with the FPD.
Discussion This case illustrates several interesting points. The extent of the perforation was unusually large. Iatrogenic destruction of interradicular bone was extensive, with damage to the distal aspect of the MB root. An attempt to provide a matrix by using Gelfoam did not prevent gross extrusion of MTA into the trifurcation area. Other materials such as a collagen-based matrix or calcium sulfate might have reduced the amount of MTA extrusion. Yildrim et al. (13) and Torabinejad and
JOE — Volume 34, Number 5, May 2008
Chivian (14) found minimal inflammation when MTA came in contact with surrounding periradicular tissues. This can explain why the trifurcation area remained periodontally sound in the presence of large amounts of MTA. The extrusion of the material was unintended, but it does demonstrate some of the excellent properties of MTA. At 55 months the radiograph showed complete osseous repair of preoperative periradicular pathosis. The trifurcation area remained intact with no radiographic or clinical signs of pathology, and the tooth remained asymptomatic.
References 1. Cohen S, Hargreaves K. Pathways of the pulp. 9th ed. St Louis: Mosby, 2006. 2. Weine FS. Endodontic therapy. 6th ed. St Louis: Mosby, 2004. 3. Aguirre R, ElDeeb ME, ElDeeb ME. Evaluation of the repair of mechanical furcation perforations using amalgam, gutta-percha, or indium foil. J Endod 1986;12:249 –56. 4. Alhadainy HA, Himel VT. Evaluation of the sealing ability of amalgam, Cavit, and glass ionomer cement in the repair of furcation perforations. Oral Surg 1993;75:62– 6. 5. Bryan EB, Wollard G, Mitchell WC. Nonsurgical repair of furcal perforations: a literature review. Gen Dent 1999;47:274 – 8. 6. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod 1993;19:591–5. 7. Main C, Mirzayaln N, Shabahang S, Torabinejad M. Repair of root perforations using mineral trioxide aggregate: a long term study. J Endod 2004;30:80 –3. 8. Ferris DM, Baumgartner JC. Perforation repair comparing two types of mineral trioxide aggregate. J Endod 2004;30:422– 4. 9. Hamad HA, Tordick PA, McClanahan SB. Furcation perforation repair comparing gray and white MTA: a dye extraction study. J Endod 2006;32:337– 40. 10. Bozeman TB, Lemon RR, Eleazer PD. Elemental analysis of crystal precipitate from gray and white MTA. J Endod 2006;32:425– 8. 11. Tsatsas DV, Meliou HA, Kerezoudis NP. Sealing effectiveness of materials used in furcation perforations in vitro. Int Dent J 2005;55:133– 41. 12. Nakata TT, Bae KS, Baumgartner JC. Perforation repair comparing mineral trioxide aggregate and amalgam using an anaerobic bacterial leakage model. J Endod 1998;24:184 – 6. 13. Yildrim T, Gencoglu N, Firat I, Perck C, Guzel O. Histologic study of furcation perforations treated with MTA and SuperEBA in dogs teeth. Oral Surg 2005;100:120 – 4. 14. Torabinejad M, Chivian C. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197–205. 15. Ruddle CJ. Microendodontic nonsurgical retreatment. Dent Clin North Am 1997; 41:429 –54. 16. Jantarat J, Dashper SG, Messer HH. Effect of matrix placement on furcation perforation repair. J Endod 1999;25:192– 6. 17. Krupalini KS, Udayakumar, Jayalakshmi KB. A comparative evaluation of medicated calcium sulphate, hydroxylapatite, mineral trioxide aggregate (MTA) as a barrier and their effect on the sealing ability of furcation perforation repair material an in vitro study. Indian J Dent Res 2003;14:156 – 61. 18. Mittal M, Chandra S, Chandra S. An evaluation of plaster of Paris barriers used under various materials to repair furcation perforations (an in vitro study). J Endod 1999;25:385– 8. 19. Rafter M, Baker M, Alves M, Daniel J, Remeikis N. Evaluation of healing with use of an internal matrix to repair furcation perforations. Int Endod J 2002;35:775– 83. 20. Walia H, Streiff J, Gerstein H. Use of a hemostatic agent in the repair of procedural errors. J Endod 1988;14:465– 8.
Repair of a Large Furcation Perforation
619