Clinical Research
Treatment Outcome of Mineral Trioxide Aggregate: Repair of
Root Perforations
Johannes Mente, DMD,* Nathalie Hage,* Thorsten Pfefferle, DMD,* Martin Jean Koch, MD, DMD,
PhD,* Beate Geletneky,* Jens Dreyhaupt, DSc,† Nicolas Martin, BDS, PhD, FDS, RCS,‡
and Hans Joerg Staehle, MD, DMD, PhD*
Abstract
Introduction: The use of biocompatible materials like
mineral trioxide aggregate (MTA) may improve the
prognosis of teeth with root perforations. Methods:
The treatment outcome of root perforations repaired
between 2000 and 2006 with MTA was investigated.
Twenty-six patients received treatment with MTA in
26 teeth with root perforations. Treatment was per-
formed by supervised undergraduate students (29%),
general dentists (52%), or dentists who had focused
on endodontics (19%). Perforation repair by all treat-
ment providers was performed using a dental operating
microscope. Calibrated examiners assessed clinical and
radiographic outcome 12 to 65 months after treatment
(median 33 months, 81% recall rate). Pre-, intra-, and
postoperative information relating to potential prog-
nostic factors was evaluated. Results: Of 21 teeth
examined, 18 teeth (86%) were classified as healed.
None of the analyzed potential prognostic factors had
a significant effect on the outcome. Conclusions:
MTA appears to provide a biocompatible and long-
term effective seal for root perforations in all parts of
the root. (J Endod 2010;36:208–213)
Key Words
Mineral trioxide aggregate, perforation, repair
From the *Department of Conservative Dentistry and
†
Institute of Medical Biometry and Informatics, Ruprecht-
Karls-University of Heidelberg, Heidelberg, Germany; and
‡
Department of Adult Dental Care, University of Sheffield, Shef-
field, United Kingdom.
Address requests for reprints to Dr Johannes Mente, Univer-
sity Clinic Heidelberg, Department of Conservative Dentistry,
Division of Endodontics, Im Neuenheimer Feld 400, 69120 Hei-
delberg, Germany. E-mail address: johannes.mente@med.
uni-heidelberg.de.
0099-2399/$0 - see front matter
Copyright ª 2010 American Association of Endodontists.
doi:10.1016/j.joen.2009.10.012
208 Mente et al.
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R oot perforations are artificial connections between the root canal system and the
periodontium and/or the oral cavity. They can be iatrogenic or noniatrogenic.
Examples of iatrogenic causes are incorrectly aligned trephination (mostly by high
speed bur) or post perforations. Perforations can also occur while the root canal is
being prepared. The main noniatrogenic causes are progressive resorption and caries.
Sealing perforations of iatrogenic, resorptive, or carious origin poses a challenge
even for dentists with endodontic experience. The rationale of treatment of such cases
should be immediate sealing with a biocompatible material that is insoluble in the pres-
ence of tissue fluids (1) and allows regeneration of surrounding tissues (2).
The following materials have been recommended for sealing root perforations:
Cavit (3), silver amalgam (4, 5), super EBA cement (6), calcium hydroxide (7),
hydroxyapatite (8), calcium phosphate cement (9), light-cured glass ionomer (10),
and decalcified freeze-dried bone (11). None of these perforation sealing materials
is adequately biocompatible to ensure a good treatment outcome when it comes into
direct contact with bone tissue. Inadequate biocompatibility of the sealing material
frequently causes problems when it comes into contact with the neighboring tissue,
especially when the perforation is large and there is an increased likelihood of the mate-
rial extruding into the surrounding tissue (12). Therefore, the prognosis for teeth with
root perforations was considered very uncertain before the introduction of mineral
trioxide aggregate (MTA) (13, 14). Many studies have documented the biocompatibility
of MTA (15–18). In addition, its ability to set is not affected by the presence of body
fluids such as blood (19).
The biocompatibility of MTA, the ability of this material to seal root perforations
effectively (20, 21), and its setting properties in the presence of moisture and even
blood are important characteristics that may result in greater success rates when
used for treating root perforations. Animal studies (22–24), case reports, and case
series are available on the successful use of MTA as a perforation sealing material
(25–30).
The number of cases in the clinical trials available to date is, however, rather small
so it is important to collect further clinical data on the use of this material in the repair of
root perforations. In Part II of this Heidelberg Study project for determining the success
of MTA treatment, the outcome of 21 endodontically treated teeth with root perfora-
tions, which were repaired exclusively with MTA (ProRoot MTA, gray version; Dents-
ply-Maillefer, Ballaigues, Switzerland), are evaluated.
Material and Methods
The study protocol was approved by the Ethics Committee of the University of Hei-
delberg (Ref. 132/2006). All patients who had a root perforation repaired with MTA in
the Department of Conservative Dentistry at the University Hospital of Heidelberg
between 2000 and 2006 were identified by use of recall data. MTA was available in
the Department of Conservative Dentistry at the University Hospital of Heidelberg
from the year 2000.
The retrospective cohort was assembled in accordance with the following inclu-
sion criteria: patients who had undergone root perforation repair using MTA at the
Department of Conservative Dentistry at the University Hospital of Heidelberg. The
interval between perforation repair and last follow-up examination had to be at least
JOE — Volume 36, Number 2, February 2010

1 year. Criteria for exclusion were compromised immune status, preg-
nancy at the time of follow-up, incomplete pre- or intratreatment
records, and unwillingness to participate in the study.
Recruitment of Patients
Subjects who met the inclusion criteria were contacted by letter
and subsequently by telephone and were invited to attend the follow-
up examinations. On the day of the follow-up examination, the patients
were again given a detailed explanatory information sheet and were
asked to sign a declaration of informed consent to participate in the
study. The patients were also given the opportunity to ask the examiner
any questions concerning the study and the planned procedure. Clinical
and radiographic follow-up examinations were performed after written
informed consent had been given.
Calibration
Because the clinical recall examinations for the clinical study
‘‘Mineral Trioxide Aggregate Apical Plugs in Teeth With Open Apical
Foramina: A Retrospective Analysis of Treatment Outcome’’ (31) and
the present study were running concurrently, the calibration of the clin-
ical investigators (NH and JT) was undertaken for both study projects at
the same time.
Calibration was performed by both investigators independently
examining 21 patients on the same day. The clinical parameters re-
corded were entered into separate database sheets and analyzed statis-
tically for interexaminer reliability. These duplicate examinations were
also approved by the Ethics Committee of the University of Heidelberg
and undertaken only after the patient had given written permission.
One independent investigator (MK) was designated to perform all
the radiographic interpretations. Before the study radiographs were
evaluated, this examiner (MK) was calibrated for radiographic interpre-
tation using the periapical index (PAI) calibration kit of 100 periapical
radiographs (32). Intraexaminer reliability and interexaminer agree-
ment with the calibration kit’s ‘‘gold standard’’ were assessed by using
Cohen kappa statistic.
Endodontic Treatment Intervention
Teeth had been treated in accordance with current endodontic
techniques using a rubber dam for isolation. Six of the root canal treat-
ments (29%) were performed by supervised undergraduate students,
11 teeth (52%) by general dentists, and four teeth (19%) by dentists
who had focused on endodontics for at least 3 years (EN). The latter
performed the complete treatment with the aid of a dental operating
microscope (Zeiss, Oberkochen, Germany). All treatment providers
used a dental operating microscope when applying the MTA cement it-
self.
Before the perforation was sealed, the defect was carefully irri-
gated, first with 3% sodium hypochlorite and then with 0.12% CHX solu-
tion (Glaxo Smith Kline GmbH, Bühl, Germany). If necessary, it was then
dried with sterile paper tips, or, if the perforation was in the furcation
area, sterile cotton pellets were also used. In cases in which bleeding
from the perforation area would have complicated the sealing process,
a mixture of calcium hydroxide powder and CHX solution (0.12%) was
applied to the perforation area and the root canals for a few days so that
the sealing of perforation using MTA could be undertaken under ‘‘ideal’’
conditions.
The MTA cement was applied to the perforation area in small
portions using an MTA gun (Dentsply-Maillefer, Ballaigues,
Switzerland). The MTA cement was thoroughly compressed and com-
pacted in the defect using Machtou pluggers (Dentsply Maillefer) of
different sizes (0, 1⁄2 , and 3⁄4 ). An absorbable matrix was not used.
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Clinical Research
In all cases in which the repair of a perforation was performed
during the course of endodontic treatment by undergraduates, the
application of the MTA cement to seal the root perforation was under-
taken by an endodontically experienced supervisor, whereas the re-
maining root canal treatment (cleaning, shaping, and obturation)
was executed by the student. Because of the partly retrospective design
of the study, the obturation process was not the same in every case. The
root canals of 16 teeth (70 %) were filled using the cold lateral conden-
sation technique. The root canals of three teeth (14%) were filled with
vertically compacted warm gutta-percha using System B (SybronEndo,
Orange, CA) and an injectable gutta-percha device (Obtura II; Obtura
Spartan, Fenton, MO). The gutta-percha was used in conjunction with
AH Plus Sealer (Dentsply Maillefer). In one tooth (5%), the complete
root canal filling was performed using MTA cement, and in one tooth
(5%) a bonded composite material was used to fill the canal space
beside the MTA cement (Tetric ceram; Vivadent, Schaan, Lichtenstein).
The temporary dressing routinely used between appointments was
IRM (Dentsply, Konstanz, Germany). When the root canal filling was
completed, access cavities were sealed with composites of different
manufacturers (Herculite XRV; Kerr, West Collins, Orange, CA) or Tetric
Ceram (Vivadent, Schaan, Lichtenstein).
Preoperative and Intraoperative Data
Pre- and intraoperative information pertaining to clinical variables
was gathered from the patients’ records and radiographs and entered
into a specifically designed database spread sheet. Preoperative data
included sex, age, tooth location, time interval between occurrence
and repair of perforation, number of roots, clinical signs and symp-
toms, response to cold test, tooth mobility, probing pocket depths
(six per tooth) and attachment loss, furcation involvement, sinus tract,
periapical radiolucency, signs of root resorption, and previous root
filling. Intraoperative data included the following: the date of perfora-
tion repair, number of treatment sessions, intracanal medication, clean-
ing and shaping technique, root-filling technique, complications,
temporary seal, and treatment providers.
Follow-up Examination
The follow-up examinations were performed at different time
intervals ranging from 12 to 65 months after treatment, with a median
follow-up period of 33 months. The presence of clinical signs and symp-
toms, response to cold test, tooth mobility, type and quality of restora-
tion, probing of pocket depths and attachment loss, furcation
involvement, and presence of a sinus tract were recorded and entered
in a structured recall form especially designed for this study.
The quality of the coronal restoration was assessed both clinically
(visual inspection with mirror and explorer) and radiographically by
evaluating the presence of signs of marginal leakage or decay.
Outcome Assessment
Radiographs were coded and stored and subsequently assessed by
the designated examiners. Pretreatment, immediate posttreatment, and
follow-up radiographs were examined independently in random order.
They were evaluated in a darkened room using an illuminated viewer
box (Kentzler-Kaschner Dental GmbH, Ellwangen, Germany) with 2
magnification.
Radiographs were assessed by a PAI index-calibrated examiner
(MK) with several years of clinical experience. In addition, all radio-
graphs were evaluated by two independent examiners (MK and TP)
to determine the presence or absence of any pathologic changes adja-
cent to the perforation site and the periapical area (eg, root resorption).
The localization and the size of perforation as well as preexisting root
Treatment Outcome of MTA in the Repair of Root Perforations 209
Clinical Research
fillings were documented. If they did not agree, both examiners met to TABLE 1. Outcome Distribution across Preoperative Variables
discuss the radiographic findings and come to a consensus.
Teeth Healed
The outcome was assessed on the basis of clinical and radio-
graphic findings. All elicitation of clinical and radiographic findings p
in this study was undertaken by calibrated examiners (MK, JT, and Variable n % n % value*
TP), who themselves had not performed any of the perforation sealing Age 0.59
procedures and were therefore unbiased. A case was classified as #45 y 10 48 8 80
‘‘healed’’ when there was no indication of apical periodontitis (PAI >45 y 11 52 10 91
#2), no radiolucency adjacent to the perforation site, no continuing Sex 0.55
Female 9 43 7 78
root resorption, no clinical signs and symptoms, and no loss of func- Male 12 57 11 92
tion. Outcome was classified as ‘‘diseased’’ if one of the following find- Number of roots 0.53
ings was observed at the follow-up examination: clinical signs and 1 13 62 12 92
symptoms (such as sensitivity to percussion, sinus tract, longitudinal $2 8 38 6 75
fracture, loss of function, pain, or discomfort experienced by the patient Tooth type 1.00
Anterior 10 48 9 90
regarding the tooth with the repaired perforation), apical periodontitis Posterior 11 52 9 82
(PAI $3), radiolucency adjacent to the perforation site, or signs of Tooth location 1.00
continuing root resorption. Multirooted teeth were assessed according Maxilla 13 62 11 85
to the highest score given to any one of the roots. Mandible 8 38 7 87.5
Localisation of 1.00
perforation
Statistical Analysis Furcal 4 19 4 100
Crestal 7 33 6 86
Median, first and third quartile, minimum and maximum, and Midroot 5 24 4 80
relative and absolute frequencies were calculated for descriptive anal- Apical third 5 24 4 80
ysis. The Fisher exact test was performed to investigate the effect of of root
potential outcome predictors as shown in Tables 1 through 3. The Time between 1.00
data were processed by using the SAS statistical package (Version occurrence and repair
of perforation
9.1; SAS Institute Inc, Cary, NC). Because of the exploratory nature of #1 d 6 29 5 83
the study, no adjustment was made for multiple testing. All tests were >1 d to 31d 5 24 4 80
performed at a significance level of 0.05. > 1 mo 10 48 9 90
Size of perforation 0.52
#1 mm 10 48 9 90
Results 1-3 mm 8 38 7 88
The details of clinical and radiographic calibration have been >3 mm 3 14 2 67
Signs and symptoms 1.00
described previously (31). There was a high level of consensus Absent 10 48 9 90
regarding the clinical findings performed by the two designated inves- Present 11 52 9 82
tigators. Pulp status 1.00
Intraexaminer reliability for the PAI calibration results was k = Responsive 3 14 3 100
Nonresponsive 18 86 15 83
0.77, indicating ‘‘substantial agreement’’ (33). The interexaminer Apical periodontitis 1.00
agreement (examiner scores vs. the calibration kit ‘authorized scores’) Absent 9 43 8 89
was k = 0.82, indicating ‘almost perfect agreement’ (33). Present 12 57 10 83
Thirty-four subjects (34 teeth) were initially identified for potential Overall 21 100 18 86
inclusion, eight of whom were excluded because the follow-up period Type of treatment 1.00
Initial treatment 13 62 11 85
was too short (follow-up of at least 1 year was one of the inclusion Retreatment 8 38 7 87.5
criteria). Twenty-six patients met the inclusion criteria. Of these, 21
patients took part in the follow-up study (recall rate 81%). Four of *Fisher exact test.
the perforations were in the furcation area (Fig. 1A-C), seven at crestal
bone level, five at the midroot level (Fig. 2), and five in the apical third of
the root (Fig. 3). ration). Interestingly, the healed rate for single-root teeth (12/13 teeth,
The reasons for drop out were recorded; three patients (11.5%) 92%) was higher than that for multirooted teeth (6/8 teeth, 75%). The
could not be reached despite repeated letter writing or telephone calls healed rate for teeth with larger perforations (size >3 mm) was less (2/
and two patients (7.5%) had moved away. Eighteen teeth (86%) could 3 teeth, 67%) than the healed rate for those with smaller perforations
be classified as healed and three (14%) as diseased. Two of the three (size 1-3 mm) (7/8 teeth, 88%) and very small perforations (size #1
diseased teeth were found to have a longitudinal root fracture. The third mm, 9/10 teeth [90%]). However, none of the differences observed was
tooth was extracted elsewhere 34 months after the endodontic treat- statistically significant.
ment.
The outcome in relation to the recorded pre-, intra-, and postop-
erative variables is shown in Tables 1 through 3. Minor differences in Discussion
the healed rate were observed for several variables, whereas larger All available patients at the Department of Conservative Dentistry at
differences ($15%) were noted for four preoperative variables the University Hospital of Heidelberg who had undergone endodontic
(number of roots, localization of perforation, size of perforation, and treatment with repair of root perforations using MTA and who fulfilled
pulp status), three intraoperative variables (root filling technique, treat- the inclusion criteria were considered for this study. Twenty-six patients
ment sessions, and experience of the treatment providers), and two who had undergone endodontic treatment with perforation repair
postoperative variables (quality of coronal restoration and type of resto- between 2000 and 2006 were identified. Twenty-one of these patients

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 Clinical Research
TABLE 2. Outcome Distribution across Intraoperative Variables TABLE 3. Outcome Distribution across Postoperative Variables
Teeth Healed Teeth Healed
Postoperative
Variable n % n % p value* variable n % n % p value*
Root-filling technique 1.00 Quality of coronal 0.14
Lateral compaction 16 70 13 81 restoration† after
Warm vertical 3 14 3 100 treatment
compaction Acceptable 20 95 18 90
Pure MTA filling 1 5 1 100 Unacceptable 1 5 0 0
Other† 1 5 1 100 Type of restoration 0.121
Treatment sessions 0.55 TemporaryA — — — —
for whole Amalgam fillingB — — — —
endodontic Composite fillingC 11 52 11 100
treatment Crown and access 3 14 2 67
2 5 24 5 100 cavity sealed with
>2 16 76 13 81 composite fillingD
Treatment providers 1.00 CrownE 7 33 5 71
Supervised 6 29 5 83 Lost restorationF — — — —
undergraduate Post or screw 1.00
student after treatment
General dentists 11 52 9 82 Absent 16 76 14 87.5
EN‡ 4 19 4 100 Present 5 24 4 80
*Fisher exact test. *Fisher exact test.
† †
One tooth pure root filling with composite beside of MTA. Based on radiographic and clinical assessment.
‡ 1
Dentists who had focused on endodontics for at least 3 years. C versus D.

were available for recall; thus, the recall rate was 81%. The recall rate
should be $80% in order to obtain significant interpretations of find-
ings (34).
Mineral trioxide aggregate (MTA) was used as perforation repair
material in all cases. As described by other authors (30), in cases of
excessive hemorrhaging, calcium hydroxide was placed in the perfora-
tion site for a few days so that the perforation repair using MTA could be
performed under ‘‘ideal’’ conditions.
All investigation criteria and the documentation of the study data
were established with standardized protocols before the start of the
follow-up examinations. Both clinical and radiographic evaluations
were performed after the examiners had been calibrated. Examiners of
follow-up examinations and radiographs should not be identical with
the providers of treatment because their interpretation may be biased
toward a more favorable assessment (34, 35). The PAI index used in
the present study (32) is a validated, reproducible method for unbiased
assessment of the periapical situation (34). Despite this, when designing
future clinical studies, consideration should be given to whether
advanced three-dimensional imaging methods (such as cone-beam
computed tomography scans) could be used instead of two-dimensional
images for radiograph diagnosis of the periapical region and the perfo-
ration site. In a cross-sectional study, Estrela et al. (36) clearly showed
the superiority of the cone-beam technology compared with the periap-
ical radiograph in the diagnosis of apical periodontitis.
Because the PAI index is unsuitable for assessing the region adja-
cent to the perforation site, in the present study two independent exam-
iners also assessed the radiographs of the perforation site in addition to
the PAI assessment. Only when all radiographic and clinical findings at
the recall examinations were normal (PAI #2, no radiolucency adja-
cent to the perforation site, no continuing root resorption, and no clin-
ical signs or symptoms and no loss of function) was a case classified as
‘‘healed.’’

Figure 1. (A) A radiograph of a maxillary first molar with large perforation of furcation area (almost the entire pulp chamber floor is affected). (B) A follow-up
radiograph after 5 years (see Fig. 1A). The outcome is classified as healed. The MTA cement has extensive contact with the bone tissue. (C) A photograph of
perforation repair with MTA (clinical picture corresponding to 1A and B). The perforation covers the entire floor of the pulp chamber.

JOE — Volume 36, Number 2, February 2010 Treatment Outcome of MTA in the Repair of Root Perforations 211
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Clinical Research
Figure 2. Perforating internal resorption at the midroot level of a maxillary
central incisor. The midtreatment radiograph after obturation of the resorptive
defect and apical third of the root canal with MTA.
The follow-up period of 13 to 65 months (median 33 months) is
long enough to reveal a stable treatment outcome (34). An overall rate
of 86% healed was ascertained. Thus, the rate healed in the present
study is considerably better than in other clinical studies of teeth with
root perforations in which sealing materials other than MTA were
used (13, 14).
All perforation repairs were orthograde, which meant that the
cement (MTA) in the perforation site often came into direct contact
with the adjacent periodontal tissues. Before the introduction of MTA,
the adverse effect on the periodontal structures of overfilled root filling
or repair materials was often observed and discussed (37, 38). In the
present study, no case of a direct reaction (radiolucency, clinical signs,
or symptoms) to the perforation sealing material itself (MTA) was iden-
tified, even when the MTA cement had had extensive contact with bone
tissue (Fig. 1B and C). An absorbable matrix was not used in any of these
cases. These indicators for the good biocompatibility of MTA are consis-
tent with the results of animal trials (22, 23, 39) and other clinical
studies (25, 28, 29).
Because the prognosis when treating teeth with root perforations
does not depend on the successful repair of the perforation alone, other
prognostically significant factors for endodontic treatment were also
evaluated (34, 40) (Tables 1-3). No significant effect on the healed
rate could be shown for any of the potential prognostic parameters
(Tables 1-3), which may be caused in part by the small number of cases
in the present study. Because the present study project was designed to
include new patients and further follow-up examinations in the future,
this prognostic factor will have to be re-evaluated at a later date.
Of the three teeth that were classified as unsuccessful, two were
found to have a $9 mm-deep, narrow, isolated periodontal pocket
on the buccal aspect. Both follow-up radiographs showed a lateral
212 Mente et al.
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Figure 3. A radiograph of a mandibular canine with a perforation at the
apical third of root caused by post preparation after repair with MTA.
radiolucency corresponding to the periodontal pocket. A vertical root
fracture was diagnosed in both teeth, and in one of them the radiograph
also revealed an intraradicular post, which had been inserted in the
tooth in the course of prosthetic treatment elsewhere after root canal
obturation (with sealing of the perforation), which was a clue to the
possible cause of the vertical fracture. The third tooth in the ‘‘diseased
category’’ was extracted elsewhere 34 months after the perforation had
been sealed and the root canal filled. A few weeks before the tooth was
extracted, however, a defective coronal restoration of this tooth had
been recorded in the patient’s file so one can assume there was coronal
leakage. The insufficient coronal restoration may at least be a cofactor
for the failure, which ultimately resulted in the decision for extraction
(41). The perforation itself or a failure of the repair with MTA does
not appear to be the direct cause for failure in any of the 3 cases that
were classified as diseased. Many known potential prognostic factors
(12), such as the time lapse between occurrence and treatment or
the size and location of the perforation, were evaluated separately in
the present study.
These factors, which can potentially influence the prognosis in the
treatment of root perforations negatively, could not be confirmed as
prognostically significant factors in the present study (Table 1). Further
clinical studies are required to evaluate whether or not these factors are
still affecting the prognosis in cases when MTA is used.
JOE — Volume 36, Number 2, February 2010

Conclusions
Although this study was limited by the relatively small sample size
and the lack of a control group, the results indicate that (1) a high
success rate for treatment of root perforations in all areas of the root
can be achieved with MTA; (2) the use of MTA to repair root perfora-
tions appears to be a valid treatment option, even in undergraduate clin-
ical courses, when students are supervised by endodontically
experienced dentists; and (3) further longitudinal prospective clinical
studies on the use of MTA for repairing root perforations that include
more teeth are necessary.
Acknowledgment
The authors would like to thank Dag Ørstavik for providing the
PAI reference radiographs. In addition, the authors wish to thank
Mrs Joanna Voerste and Mrs Kirsten Stoik for his assistance in prep-
aration of this manuscript and Mr Jens Trautmann for his valuable
help with this study.
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Clinical Research
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Treatment Outcome of MTA in the Repair of Root Perforations 213