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Furcal-perforation repair with mineral trioxide aggregate: Two years follow-

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Article  in  Indian journal of dental research: official publication of Indian Society for Dental Research · July 2012
DOI: 10.4103/0970-9290.104967 · Source: PubMed

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Emmanuel João Nogueira Leal Silva Carlos Vieira Andrade Junior

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Lidia Yileng Tay Daniel R Herrera

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 Volume 23 Issue 04 July-August 2012
Indian Journal of Dental Research • Volume 23 • Issue 4

} Accuracy of two face-bow/semi-adjustable articulator

systems in transferring the maxillary occlusal cant
} An investigation of social judgments made by young
adults towards appearance of dental fluorosis
} Digital radiograph of the middle phalanx of the third
finger (MP3) region as a tool for skeletal maturity
assessment
} Comparative analysis of presence of Cytomegalovirus
(CMV) and Epsteinbarr virus -1 (EBV-1) in cases of
chronic periodontitis and aggressive periodontitis with
controls
} Determination of the comfort zone for intergingival
height and its practical application to treatment planning:
• July - August 2012 • Pages 000-000

A survey
} Analysis of two different surgical approaches for
fractures of the mandibular condyle
} In vitro antimicrobial activity of AH Plus, EndoREZ and
Epiphany against microorganisms
} Evaluation of reliability and reproducibility of linear
measurements of cone-beam-computed tomography
} Corrosion behavior of titanium wires: An in vitro study
Case Report

Furcal-perforation repair with mineral trioxide aggregate:

Two years follow-up

Emmanuel João Nogueira Leal da Silva, Carlos Vieira Andrade-Junior1, Lidia Yileng Tay2,
Daniel Rodrigo Herrera

Department of Restorative
Dentistry, Endodontic Division,
ABSTRACT
Piracicaba Dental School, Furcal perforations are significant iatrogenic complications of endodontic treatment and could
State University of Campinas,
Piracicaba, SP, 1Department
lead to endodontic failure. Mineral trioxide aggregate (MTA) has been regarded as an ideal
of Health, Dentistry Division, material for perforation repair, retrograde filling, pulp capping, and apexification. This case
Southwest State University of report describes a furcal perforation in a maxillary first molar, which was repaired using MTA.
Bahia, Jequié, BA, 2Department
The tooth was endodontically treated and coronally restored with resin composite. After 2 years,
Dentistry, State University of
Ponta Grossa, PR, Brazil the absence of periradicular radiolucent lesions, pain, and swelling along with functional tooth
stability indicated a successful outcome of sealing the perforation using MTA.

Received : 26-07-11
Review completed : 01-11-11
Accepted : 18-12-11 Key words: Furcal perforation, mineral trioxide aggregate, 2% chlorhexidine gel

Furcation perforations are significant iatrogenic complications
of endodontic treatment and could lead to endodontic
failure.[1] Perforations may occur during preparation of
access cavities, post-space preparation or as a result of the
extension of an internal resorption into the perirradicular
tissues.[2]Factors that influence the outcome of perforated
teeth include size of the perforation, time of repair, level and
location of the perforation, presence of periodontal disease
and pre-endodontic pulp vitality status.[3]On the basis of these
characteristics, it can be decided if the perforation can be
managed either surgically or non-surgically, and the prognosis
is generally excellent if the problem is well diagnosed and the
repair is well-performed with a material which can provide
proper sealing ability and biocompatibility.
Historically, different materials have been used for furcal
perforations, including amalgam, Intermediate Restorative
Material (IRM), SuperEBA, Cavit, Glass Ionomer and
composites; however,none fulfill the criteria of an ideal
Address for correspondence:
Mr. Emmanuel João Nogueira Leal da Silva
E-mail: nogueiraemmanuel@hotmail.com
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DOI:
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repair material which include the ability to seal and
biocompatibility.[4]Mineral trioxide aggregate (MTA) has
been regarded as an ideal material for perforation repair,
retrograde filling, pulp capping, and apexification since its
introduction in 1993.[5] The principle compounds present
in MTA are several mineral oxides that are responsible for
the chemical and physical properties of this material.[5] MTA
is a mineral powder that consists of hydrophilic particles,
with principal components as tricalcium silicate, tricalcium
aluminate, tricalcium oxide, and other mineral oxides. It
has a pH of 12.5, which is comparable to that of calcium
hydroxide, and sets in the presence of moisture in
approximately 4 hours.[5] MTA is currently marketed in
2 forms, gray (GMTA) and white (WMTA). Lower amounts
of iron, aluminum, and magnesium are present in WMTA
compared to GMTA.
When used as a repair material for furcal perforations,
MTA has many favorable properties, including good
sealing capability, biocompatibility, bactericidal activity,
radiopacity, and ability to set up in the presence of blood.[5,6]
Several studies have shown better perforations’ repair
with MTA when compared with that repairs done with
amalgam, IRM, Zinc oxide Eugenol (ZOE), or SuperEBA,
by using both dye and bacteria leakage methods.[1,4,6] The
biocompatibility makes MTA a suitable material for the
treatment of root perforations with the goal of regenerating
a periodontal attachment.[5,6] It can also induce osteogenesis
and cementogenesis.[6,7] Perforated roots treated with MTA
showed no inflammatory tissue layer, and root cementum
was formed and attached to the MTA.[6] Thus, the following

Indian Journal of Dental Research, 23(4), 2012 542

Furcal-perforation repair with MTA Silva, et al.
case report describes the repair of a furcal perforation
in the maxillary molar tooth using MTA, and here, the
underlying periodontal tissue healing could be observed
radiographically at the 24-month follow-up.
CASE REPORT
A healthy 25 year old woman was referred to the Endodontics
Department of Campinas State University, with pain in the
left first maxillary molar, after attempting of endodontic
treatment by her dentist one week before. The intraoral
examination revealed that the tooth was sealed coronally
with temporary cement. At the time of presentation, the
tooth was sensitive to percussion and palpation. The mean
probing pocket depth was within normal level (2  mm).
Periradicular radiographic examination revealed a little
radiolucent area in the furcal region of left first maxillary
molar and apical radiolucencies from pulp necrosis were
also observed [Figure 1]. Treatment options which were
indicated for the tooth were extraction and non-surgical
repair of the perforation. As per the patient preference, the
Figure 1: Initial periradicular radiograph of a maxillary left first molar
showing a large furcal perforation and apical radiolucencies in the
patient in the study
a b
d e
Figure 2: (a) Intraoral photograph showing obtured root canal and a large furcal perforation; (b) MTA being placed into the furcal perforation;
(c) MTA adapted into the furcal perforation; (d, e and f) Restoration with resin composite
543
option of saving the tooth via a non-surgical procedure, that
is, furcal perforation repair with MTA was chosen.
After the administration of local anesthesia 2% lidocaine
with 1:100.000 epinephrine (Alphacaine, DFL), the
tooth was isolated with a rubber dam, the temporary
restorative material was removed and the access cavity
was prepared, and the perforation area could be clinically
seen. Hemorrhage was controlled with copious irrigation
with 0.9% saline solution. A cotton pellet was placed in the
orifice of perforation.The working length was then checked
by using an apex locator (Novapex, Fórum Technologies,
Israel). The root canals were cleaned and shaped using
rotary files (Profile files, DentsplyMaillefer, Ballaigues,
Switzerland) in a crown-down technique. Before the use of
each instrument, an irrigation of the canal was performed
using a syringe (27-gauge needle) containing 1 mL of 2%
chlorhexidine (CHX) gel (Endogel, Itapetininga, SP, Brazil),
and immediately rinsed afterwards with 3  mL of saline
solution. After the root canals were dried with paper points,
they were obturated. For obturation, gutta-percha points
were used and Endomethasone N (Septodont, Saint-Maur,
France) was used as a root canal sealer. The root canal sealer
was mixed according to the manufacturer’s instructions,
and applied by coating the canal walls using the main cone
itself.The root canals were then filled using the lateral
condensation technique.
After the obturation of the root canals, the cotton pellet
was removed from the perforation, exposing the site of
the perforation [Figure 2a]. The furcal perforation was
irrigated with saline solution and 2% chlorhexidine gel.
MTA (Angelus, Londrina, Parana-Brazil) was prepared
according to the manufacturer’s instructions, and placed into
the pulp chamber with an amalgam carrier [Figure 2b]. It
was then gently packed with a cotton pellet to obtain a good
adaptability [Figure 2c]. Afterward, the MTA and part of
dental floor was covered with a resin composite (Filtek Z250,
c
f
Indian Journal of Dental Research, 23(4), 2012
Furcal-perforation repair with MTA Silva, et al.
3 M ESPE, Saint Paul, Minneapolis-USA) [Figure  2d-f]),
and the tooth was restored usingglass ionomer cement.
The patient was then referred for a permanent coronal
restoration.
The patient did not attend the recall of 6, 12 and 18 months
as mentioned after the treatment. Only after 24 months, did
the patient returned to the University complaining of pain in
another tooth. At the two-year recall, the originally treated
tooth remained asymptomatic. The clinical examination
showed that the tooth had no pain, and no response to
percussion, palpation and there were no attachment loss
or periodontal problems, as indicated by normal probing
depths. The tooth revealed adequate clinical function,
and radiographic findings showed adequate sealing of the
perforation region with no radiolucency at the furcal area
[Figure 3].
DISCUSSION
The clinical applications of MTA have proved that
it is suitable for solving the problems derived from
perforation.[2,3,8] The desirable properties of MTA make it a
useful material in repairing the root and furcal perforations.
MTA offers a biologically active substrate for bone and
cells, and osteoblasts also have shown a favorable response
to MTA. [5,6,8] It has also no mutagenic potential, low
cytotoxicity, and stimulates the formation of mineralized
tissue.[2,3,5,6,8] The high levels of calcium leached out from
the cement also account for it biocompatibility.[3,5,8]One of
the factors influencing the prognosis of furcal perforations
is the period of time elapsed since the occurrence of the
perforation, as the possibility of an infection in the wound
site increases with the passing time.[6,8] Immediate sealing of
perforations enhances the repair process due to the reduced
possibility of bacterial contamination of the defect. Root
perforations sealed after contamination presented worse
Figure 3: Two-year follow up radiograph showing adequate sealing
of the perforation region and no radiolucency at the furcal area in the
maxillary left first molar of the patient in the study
Indian Journal of Dental Research, 23(4), 2012
repair than the non-contaminated and immediately sealed
perforations.[8] Previous studies have shown that the time
gap from the time of the perforation, till the time of repair
should not exceed 6 months.[9] In our case, the time elapsed
between the perforation and treatment instituted was one
week. Even though the tooth was sealed coronally with only
temporary cement, the material was present even at the time
of presentation, thus avoiding contamination.
The control of inflammatory processes in the defect area
during the management of perforation represents one of the
main goals of the treatment, in addition to promoting the
health of the surrounding tissue.[9] To achieve a better tissue
response, the perforation sites were disinfected with 2%
chlorhexidine gel. In this case, we decided not to use sodium
hypochlorite (NaOCl) because it is known that it can be
extremely aggressive, and cause damage to the surrounding
tissues. Chlorhexidine has been recommended by several
authors as an auxiliary chemical substance,[10] as, in addition
to being relatively non-toxic when compared to NaOCl, it
has excellent antimicrobial power and prolonged time of
action.[10] These properties may offer clinical advantages of
using chlorhexidine in furcal perforations.
Because of the hydrophilic characteristics of MTA, moisture
in the surrounding tissue acts as an activator of a chemical
reaction in this material.[5] To assure proper setting, some
authors suggested that moisture must be provided from the
internal aspect of the teeth by using a wet cotton pellet.[2]
In our case, blood from the site of perforation was adequate
to keep the hydrophilic powder moist, and thus the use
of cotton pellet could be avoided. After the insertion of
MTA, a resin composite was used to cover the MTA and a
part of dental floor. As MTA is not an adhesive material, it
could suffer a displacement during the coronal restoration
of the tooth. Hence, resin composite was used to ensure
that MTA did not suffer any kind of dislodgement. Resin
composite could also reinforce the tooth structure as MTA
is not a hard enough material.MTA is a suitable material
for the treatment of furcal perforations, with the goal of
regenerating periodontal attachment. In this case, furcal
perforation of the maxillary left first molar was treated
using non-surgical placement of MTA. The repaired tooth
was clinically and radiographically healthy and continued
to satisfy the functional demands. Based on the outcome of
the case presented, MTA is a good material for the repair
of furcal perforations, and has been proven effective even
for larger perforations.
ACKNOWLEDGEMENTS
The authors deny any conflicts of interest related to this study.
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How to cite this article: da Silva EN, Andrade CV, Tay LY, Herrera DR. Furcal-
perforation repair with mineral trioxide aggregate: Two years follow-up. Indian
J Dent Res 2012;23:542-5.
Source of Support: Nil, Conflict of Interest: The authors deny any conflicts
of interest related to this study. None declared. 
Indian Journal of Dental Research, 23(4), 2012