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Case Report

Management of Iatrogenic Errors: Furcal Perforation

Gaurav Lal Aidasani, Sanjyot Mulay

Department of Conservative Perforations as a possible complication during a root canal treatment may increase

Abstract
Dentistry and Endodontics,
Dr. D. Y. Patil Dental College
and Hospital,
Dr. D. Y. Patil Vidyapeeth,
Pune, Maharashtra, India
Received: February, 2018.
Accepted: February, 2018.
the risk of failure for the affected tooth. The influencing factors include the
location and the size of the perforation, potential microbial colonization of the
endodontic system, the time lapse between the occurrence of the perforation and
repair, and the filling material. For the long‑term success of the root canal system,
it is essential to emphasize on disinfection and sterilization at the perforation site
and in the remaining root canal system. Nonsurgical management is possible with
predictable prognosis is possible if correct treatment is planned and executed.
Keywords: Furcation perforation, iatrogenic errors, mineral trioxide aggregate

Introduction the floor of pulp chamber [Figure 1]. No bleeding periodontal

R oot perforation is an artificial communication between
the root canal system to the supporting tissues of
teeth or to the oral cavity. Perforation can be of two types,
one that results from a resorptive process and the other,
that is iatrogenically produced, which can occur during
access cavity preparation and location of canal orifices or
biomechanical preparation of the root canal or during a
postendodontic procedure. Factors of significance to the
prognosis for treatment are time, size, and shape of the
perforation as well as its location impacts the potentials
to control infection at the perforation site. Frequently,
the cause is iatrogenic as a result of the misaligned use
of rotary burs amid endodontic access preparation and
search for root canal orifices.[1]
This case report explains the management of iatrogenic
perforations at a coronal and middle third of the root,
below the alveolar margin.
Case Report
A 29‑year‑old male patient was referred to the Department
of Conservative Dentistry and Endodontics, from an
unskilled trainee for the management of perforation that
was occurred during the root canal treatment procedure.
At the time of reporting, the patient was asymptomatic.
On intraoral examination, tooth showed no signs of pain and
two large perforations were observed on the lingual aspect of
pockets were observed on either side of the tooth. On
radiographic examination, with #10 K file in the perforation
site was revealed and excess of tooth structure loss was
observed with the remaining dentine thickness of <1 mm
making the tooth more prone to fracture [Figure 2].
Treatment plans were as follows;
Plan A:
• Location of canals and working length determination
• Perforation repair using mineral trioxide
aggregate (MTA)
• Reinforcement of remaining tooth structure
• Cleaning and shaping followed by obturation
• Postendodontic restoration.
Plan B:
• Extraction and replacement with FPD.
Plan C:
• Extraction and implant.
The treatment plans were discussed with the patient. The
existing clinical condition and treatment procedure was
explained. The decision was taken to retain the tooth by
Address for correspondence: Dr. Gaurav Lal Aidasani,
Department of Conservative Dentistry and Endodontics,
Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil
Vidyapeeth, Sant Tukaram Nagar, Pimpri, Pune ‑ 411 018,
Maharashtra, India.
E‑mail: gauravaidasani20@gmail.com

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DOI: 10.4103/jicdro.jicdro_2_18 How to cite this article: Aidasani GL, Mulay S. Management of iatrogenic
errors: Furcal perforation. J Int Clin Dent Res Organ 2018;10:42-6.

42 42 © 2018 Journal of the International Clinical Dental Research Organization | Published by Wolters Kluwer - Medknow
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Aidasani and Mulay: Management of iatrogenic perforation
attempting a nonsurgical root canal treatment with repair
of the perforation with MTA. Written consent was then
obtained from the patient.
Treatment was carried out in multiple visits, during the
first session, perforation site was located, and hemorrhage
from the perforation site was completely controlled, and
hemostasis was achieved using a local anesthetic with
adrenaline. All the canals were negotiated, and coronal
enlargement of the canal orifices was done and blocked
using #25 gutta‑percha cones.
MTA was mixed in a 3:1 proportion as suggested by
the manufacturer and was delivered to the perforation
site with an amalgam carrier. A hand plugger was
used to accommodate the MTA inside the defect with
minimal pressure. Moist cotton was placed in the
chamber, and the temporary dressing was given using
Cavit (3M) [Figure 3].
In the second appointment, coronal temporary restoration
was removed. Working length was determined
with electronic apex locator  (EAL) and confirmed
radiographically. The repair site was sealed using
resin‑modified glass‑ionomer cement  (GC Fuji II), and
the lingual wall was built up using composite resin
cement [Figure 4]. The canals were irrigated with 3%
sodium hypochlorite and normal saline. EDTA gel
(RC Help, Prime dent) was used for lubrication during
instrumentation. Mesial canals were instrumented
using 6% #25 Hero Shaper rotary files and distal canal
Figure 1: perforation site on the lingual aspect of 36
Figure 3: placement of mineral trioxide aggregate in perforation
Journal of the International Clinical Dental Research Organization | Volume 10 | Issue 1 | January-June 2018
until 6% #30 Hero Shaper rotary files. Canals were
dried using paper points and obturated using lateral
compaction technique using Sealapex sealer. MTA
was placed on the floor of the chamber to strengthen
the furcation area [Figure 5]. After MTA placement,
moist sterile cotton was placed into the pulp chamber,
and the access cavity was sealed with the temporary
restorative material. The patient was recalled after 24 h.
On the recall appointment, the hardening of MTA was
checked, and the postendodontic coronal restoration
was performed using resin‑modified glass ionomer
cement (GC Fuji II) followed by composite restoration
(Z350 XT, 3M) [Figure 6]. A postoperative cone‑beam
computed tomographic was advised to check the outcome
of the treatment [Figure 7].
Discussion
The etiology of root perforations can be pathological,
i.e., secondary to resorption or caries, or iatrogenic that
occurs during root canal treatment. An average 2%–12%
of endodontically treated cases have reported accidental
root perforations.[2,3]
Perforations may also occur during access cavity
preparation, postspace preparation or as a result of
pathological internal resorption extending into the
periradicular tissues.[4]
Fuss and Trope based on the factors impacting the
outcome of treatment classified perforation as:
Figure 2: intraoral periapical revealing perforation wrt 36
Figure 4: lingual wall built up of 36 using composite resin
43
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Aidasani and Mulay: Management of iatrogenic perforation
Figure 5: floor of the chamber reinforced with mineral trioxide aggregate
• Fresh perforation – treated as soon as possible after first
observation under aseptic conditions, Good Prognosis
• Old perforation  –  previously not treated that is
contaminated with bacteria. Questionable Prognosis
• Small perforation  (smaller than #20 endodontic
instrument) – trauma to the tissue is small with ease
of sealing, Good Prognosis
• Large perforation  –  this is usually seen while
postpreparation, with a high amount of trauma to the
tissue and there is difficulty in providing an optimum
seal, along with contamination from bacteria’s,
or coronal leakage along temporary restoration,
questionable prognosis
• Coronal perforation – this is seen coronal to the level
of crestal bone, and epithelial attachment with trauma
to adjacent tissues are less and easy access possible,
good prognosis
• Crestal perforation  –  at the level of the epithelial
attachment into the crestal bone, questionable
prognosis
• Apical perforation  –  apical to the crestal bone and
the epithelial attachment, good prognosis.[5]
The factor that is within the control of operator is the
choice of material to be utilized for furcation repair. The
repair material that is kept in near contact with hard
tissue and the structures of periodontium ought to be
biocompatible as it can cause harmful response either by
leaching of the material or by the material itself. Earlier
different material including amalgam, gutta‑percha, zinc
oxide and glass ionomer cements, calcium hydroxide,
composites were used. Newer materials such as MTA,
biodentine, dentin chips, bioceramics, calcium enriched
material, with and without the use of barrier could be
used to seal the perforation.[6]
MTA has been considered as an ideal material for
perforation repair, apexification, retrograde filling, pulp
capping, etc. MTA is a mineral powder that is made up
44 Journal of the International Clinical Dental Research Organization | Volume 10 | Issue 1 | January-June 2018
Figure 6: obturation followed by composite resin core
of hydrophilic particles, whose principal components
are dicalcium silicate, tricalcium of slica aluminum
and oxide along with other mineral oxides. Main et al.
took note that MTA gives an ideal repair of tooth
perforations and enhanced the prognosis of perforated
teeth.[7]
Economides et al. conducted an in vitro study on
dog’s teeth and showed that MTA can be used in root
end cavities, being a biocompatible material, MTA
stimulated reparation of periradicular tissues, it also
showed no inflammation.[8,9] It also could induce hard
tissue formation.[10]
This superior properties of MTA such as lesser bacterial
leakage, biocompatibility, and better adaptation to cavity
walls makes it a useful material in sealing the root and
furcal perforation.[11]
However, the drawback of the MTA is its difficult
handling, slow setting, 24 h initially available and now
up to 3–4 h, with the possibility of solubilized by being
in contact with oral fluids as this process occurs,[5] of the
two commercially available MTA angelus and ProRoot
MTA, MTA Angelus has shorter setting time compared
to MTA pro‑root according to manufactures. [11]
In this case, perforation site was lingually placed, and
the access cavity was wide and deep, with very less
remaining dentine on the floor of the chamber, thus
making the prognosis questionable.
Prevention of such iatrogenic errors can be achieved by
proper preoperative evaluation of the case which includes
a few considerations such as position of the roots of the
tooth, relationship of the crown to the root, rotation of
the tooth in the arch, the relationship of the incisal edge
or cusp tip to the long axis of the root.[12]
Determination of the presence and location of root
perforation as accurate detection of root perforations
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Aidasani and Mulay: Management of iatrogenic perforation

Figure 7: postoperative cone-beam computed tomography image for perforation repair in 36

and determination of location are crucial to the
treatment outcome, certain signs, and tools should be
recognized in making the diagnosis. Sudden bleeding
and pain during instrumentation of root canals or
postpreparations in teeth are warning signals of
potential root perforation. The appearance of blood on
paper points but unreliable as bleeding may originate
from the apical foramen or from residues of vital
pulp tissue. To enhance radiographic detection, it has
been proposed to place a highly radiopaque calcium
hydroxide paste, by the inclusion of barium sulfate, in
the root canal. However, caution should be exercised
in crestal perforations as this measure can result in
extrusion of the material into the periodontal tissues and
cause unnecessary mechanical and chemical irritation
impairing the treatment prognosis. Radiographs taken
at different angles with radiopaque instruments in
the root canal are a better option and may confirm
the presence of root perforation. However, when the
perforation is located at the buccal or palatal aspects
of the root, the diagnostic value of radiographs is
limited. Anatomical structures, as well as radiopaque
materials superimposing on the image of the root, may
also obscure the perforation site. EALs can accurately
determine the location of root perforations, making
them significantly more reliable than radiographs.
After root instrumentation, it is recommended that the
working length is verified with EALs. Readings that are
significantly shorter than the original length can be an
indication of perforation. A dental operating microscope
is another helpful tool effective in detecting root
perforations during orthograde root canal therapy and
in surgical endodontic treatments. High magnification
with coaxial illumination allows precise detection and
visualization of perforations along straight noncurved
root canals. A narrow isolated periodontal defect
is a possible sign of periodontal breakthrough due
to root perforation. Probing the gingival sulcus to
reveal possible communication with the oral cavity
is recommended in such teeth. To determine locally
isolated vertical bone losses, periodontal probing should
be carried out by walking the probe around the tooth
while pressing gently on the floor of the sulcus. In
the presence of narrow isolated periodontal defects,
differential diagnosis from vertical root fracture should
be made with explorative surgery.[13]
Conclusion
With proper anatomic knowledge and magnification,
iatrogenic errors can be avoided. Conservative approach
should be considered first with proper diagnosis,
advanced biomaterials, and operator skills; the outcome
is more predictable thus improving the prognosis.

Journal of the International Clinical Dental Research Organization | Volume 10 | Issue 1 | January-June 2018 45
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Aidasani and Mulay: Management of iatrogenic perforation
Declaration of patient consent
The authors certify that they have obtained all
appropriate patient consent forms. In the form the
patient(s) has/have given his/her/their consent for his/
her/their images and other clinical information to be
reported in the journal. The patients understand that their
names and initials will not be published and due efforts
will be made to conceal their identity, but anonymity
cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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