Received: 28 December 2021

| Accepted: 31 March 2022

DOI: 10.1111/iej.13748

REVIEW ARTICLE

Present status and future directions –­Managing

perforations

Thomas Clauder

Private Practice for Endodontics, Abstract

Hamburg, Germany
Correspondence
Thomas Clauder, Private Practice
for Endodontics, Rahlstedter
Bahnhofstrasse 33, 22143 Hamburg,
Germany.
Email: thomas.clauder@praxis-clauder.de
Root perforations are severe complications and are associated with compromised
endodontic treatment outcomes, especially when bacterial infection is allowed to
establish. Perforations may occur due to pathological processes or treatment conse-
quences. Various dental materials have been proposed over the years for perforation
repair with varying degrees of success. The use of bioactive materials, such as mineral
trioxide aggregate (MTA) and other calcium-­silicate cements, promotes a favourable
environment for regeneration and has been used successfully for perforation repair.
This is in contrast to materials used previously that often led to unpredictable out-
comes. With the increasing range of new bioactive endodontic materials available,
the number of potential materials being used for repair of root perforations is grow-
ing. Though promising to date, there is little evidence to support the use of most of
these new materials. The aim of this narrative review is to provide the background,
clinical techniques and outcome of nonsurgical and surgical perforation repair.

KEYWORDS
MTA, perforation, perforation repair, resorption, review

I N T RO DU CT ION demonstrated that one of the factors significantly affecting

Root perforations may arise pathologically, i.e. by resorptive
processes or by caries, or may occur iatrogenically as a com-
plication during or after root canal treatment (Roda, 2001)
(Figure 1). The American Association of Endodontists
(AAE) Glossary of Endodontic Terms defines perforations
as mechanical or pathological communications between
the root canal system and the external tooth surface (2003).
The subsequent injury to the periodontium results in the
development of inflammation, destruction of periodontal
fibres, bone resorption, formation of granulomatous tis-
sue, proliferation of epithelium, and the development of
a periodontal defect (Arens & Torabinejad, 1996; Beavers
et al., 1986; Seltzer et al., 1970; Tsesis & Fuss, 2006). Root
perforations are significant complications during root
canal treatment; if not detected and properly treated, the
breakdown of the periodontium may ultimately lead to loss
of the tooth. An outcome study on root canal retreatment
the success rate of the root canal retreatment was the pres-
ence of a preoperative perforation (Farzaneh et al., 2004).
The incidence of perforations is quoted in the literature as
being between 0.7% and 10% (Eleftheriadis & Lambrianidis,
2005; Fuss & Trope, 1996; Ingle, 1961; Olcay et al., 2018).
The percentage of teeth extracted due to endodontic failure
with perforations is described as 2.9% to 4.2% (Olcay et al.,
2018; Toure et al., 2011).
BACKGROUND
Occurrence of perforations during root
canal treatment
Root perforations may occur in any part of the root and
can be divided according to the time a perforation occurs
in relation to root canal treatment:

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CLAUDER    873

(a) (b) (c) (d)

(e) (f) (g)

(h) (i) (j)

(k)

F I G U R E 1 Radiographs showing various localizations of perforations. (a) Furcal perforation due to misangulation of the bur in a mandibular
molar showing no bone destruction. (b) Furcal perforation in a mandibular molar showing bone destruction in the furcal region. (c) Perforation
in the middle aspect of a lower premolar during orthograde retreatment. (d) Radiograph showing bone destruction after perforation of a glass
fibre post in a lower, anterior tooth. (e) The surgical site demonstrates a wide strip perforation in the middle region of the tooth. (f) Radiograph
showing bone destruction and breakdown of the periodontium after perforation of a post in a lower premolar. (g) Radiograph showing massive
bone destruction after perforation of a parapulpal pin in the furcal region. (h) The clinical view shows bleeding around the pin. (i) and excessive
bleeding after removal of the pin. (j) Radiograph showing a resorptive process. (k) The clinical view showing a pink spot with a small perforation

A Preoperative, typically pathologically, e.g. resorption
or caries,
B Intra-­operative procedural accidents, e.g. during access
cavity preparation or canal instrumentation, or
C Postoperative procedural errors, e.g. during prepara-
tion of a post space.
According to Kvinnsland et al. (1989), 53% of iat-
rogenic perforations occur during insertion of posts
(prosthodontic treatment); the remaining 47% occur
during routine root canal treatment. In 74.5% of all
cases, the complications occurred in the maxilla and
the remaining 25.5% occurred in the mandibular arch.
 |
874   
In order to prevent complications during root canal
treatment, a complete understanding of the location
and dimensions of the pulp chamber as well as the an-
atomical variations of the specific tooth and its canal
system is essential. Careful examination of radio-
graphic views is important to evaluate the shape and
depth of the pulp chamber and width of the furcation
floor (Tsesis & Fuss, 2006).
In anterior teeth, perforations are often located on the
labial aspect of the root and are the result of misalignment
of the bur with the long axis of the tooth due to underes-
timation of the root inclination (Figure 2). In multirooted
teeth, furcal perforations can occur when removing den-
tine from the chamber floor whilst searching for canal
orifices (Arens & Torabinejad, 1996). Significant crown-­
root angulations, calcifications of the pulp chamber and
orifices, anatomical variations, misidentification of ca-
nals, and excessive removal of coronal dentine are often
the reason for perforations in the coronal part of the tooth
(Figure 3). Attempts to locate calcified orifices or excessive
flaring of the cervical portion of curved roots in molars
can cause lateral root perforations in the root canal (Lee
et al., 1993). Perforations caused by overzealous instru-
mentation occur mostly in the coronal or middle aspect of
the root, are usually ovoid in shape, and are termed strip
perforations (Figure 4). Perforations in the apical area of
roots result mainly from a failure to properly clean and
shape the canal and are often initiated by blockages and
ledges that cause endodontic instruments to deviate from
the canal and gouge the dentine eventually creating a false
pathway (Ruddle, 2002) (Figure 5).
Post-­space preparation may result in a perforation due
to over-­enlargement or misdirected angulations (Figure 6).
It has been often reported that the best way to manage per-
forations is to prevent them (Gutmann et al., 2006); how-
ever, it is imperative to diagnose and treat a perforation if
one has occurred.
(a) (b)
F I G U R E 2 (a) Radiograph showing an instrument in the
perforation site of the lower anterior tooth. (b) The CBCT shows a
false angulation of the access leading to a perforation
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T. CLAUDER, PRIVATE PRACTICE, HAMBURG, GERMANY
Diagnosis of perforations
The diagnosis of the presence and localization of a perfo-
ration, as well as the determination of a treatment plan,
can be challenging. Because the time elapsed between
the creation of the perforation and its repair is critical to
the prognosis for the tooth, early and accurate determi-
nation of the presence of a perforation is of paramount
importance (Lemon, 1992; Regan et al., 2005; Tsesis &
Fuss, 2006). The diagnosis should be confirmed by clini-
cal observations including aetiological aspects and ra-
diographical findings.
Clinical examination
The first clinical appearance of a perforation is fre-
quently associated with profuse bleeding from the de-
fect within the chamber or canal (Alhadainy & Himel,
1994; Bryan et al., 1999). If anaesthesia is less than ad-
equate, the patient may experience sudden pain when
the perforation occurs. Indirect assessment of bleeding
using paper points has been demonstrated to be help-
ful to identify smaller perforations or strip perforations
within the canal. The use of magnification (i.e. operat-
ing microscope) has gained increased popularity, pro-
viding better visualization and enhanced magnification
and illumination enabling easier and clearer diagnosis.
Minute perforations can be easily missed, compromising
the treatment outcome. Using an operating microscope
during treatment is considered an important factor when
repairing a perforation site, and high success rates with
the use of MTA can be attributed to that combination
(Siew et al., 2015; Torabinejad et al., 2018).
Apex locators
Another way to diagnose a perforation is to use an elec-
tronic apex locator. Normally used to determine work-
ing length, an electronic apex locator connected to a file
and inserted into the perforation is a reliable tool to de-
tect and confirm the perforation (Kaufman et al., 1997;
Kaufman & Keila, 1989). It can help to locate the perfo-
ration, which might not be visible on two-­dimensional
radiographs (Altunbaş et al., 2017). However, it must be
appreciated that the contents of the canal may have an
impact on the accuracy of apex locators, e.g. the type
of irrigant (D’Assunção et al., 2014). Furthermore, read-
ings have to be interpreted with caution, as potential
misreadings could pretend to be a perforation, requiring
further verification.
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CLAUDER    875

F I G U R E 3 (a) Preoperative (a) (b)

radiograph of a upper molar shows
no signs of a perforation, as the defect
is covered by the crown. (b) During
accessing little signs of bleeding are visible
in the calcium hydroxide. The source
could be remnant pulp tissue or a furcal
perforation. (c) After cleaning the pulp
chamber the perforation site as well as the
canal orifice is visible. (d) After cleaning
and shaping the original canal next to the
perforation
(c) (d)

F I G U R E 4 Radiograph showing a perforation in the middle

aspect of a lower molar with large overextension of the filling
material into the bone

F I G U R E 5 CBCT showing a perforation in the apical aspect of

Radiographic examination an upper molar

Angulated radiographic views are also essential for accu-

rate diagnosis. However, the radiographical detection of
root perforations, especially on the labial/buccal or lin-
gual/palatal root surfaces, is often impractical because
the image of the perforation is superimposed on intact
root structure. Three-­dimensional information acquired
from cone-­ beam computed tomography (CBCT) scans
can provide additional and more conclusive information
(D’Addazio et al., 2010; Shemesh et al., 2011; Tsurumachi
& Honda, 2007; Venskutonis et al., 2014) (Figure 7). In
general, images with small field of view (FOV) are rec-
ommended for detection and treatment planning of
perforations (Kamburoğlu et al., 2015; Shemesh et al.,
2011; Venskutonis et al., 2014). A small FOV scan reduces
the volume of exposed tissue and, therefore, the effective
radiation dose. In addition, it has the benefit of reducing
scatter which improves image quality (Patel et al., 2019).
Although CBCT imaging can provide 3D visualization of
the perforation, scatter and beam hardening caused by
high-­density neighbouring structures or materials can
affect the quality and diagnostic accuracy of CBCT im-
ages. Crowns, bridges, implants, restorations, root filling
materials, and intracanal posts with higher density can
 |
876   
create streak artefacts and distort the area of interest. This
can mimic endodontic complications, hide existing ones,
or induce false interpretation by simulating loss of tooth
structures (Bueno et al., 2011; Costa et al., 2011; Lofthag-­
Hansen et al., 2011; Venskutonis et al., 2014) which can
limit the effectiveness of CBCT imaging. Changing the
F I G U R E 6 Radiograph showing lateral bone destruction after
perforation of a post in a lower molar
(a)
(b)
F I G U R E 7 (a) Panoramic radiograph hiding a perforation at the tooth. (b) Two-­dimensional radiograph hiding a perforation at the
same tooth. (c) The horizontal CBCT scan demonstrates a missed distobuccal canal. (d) Gutta-­percha penetrating the bone in the furcation
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T. CLAUDER, PRIVATE PRACTICE, HAMBURG, GERMANY
contrast mode in the digital software can additionally help
to reduce this problem.
Periodontal examination
In all perforations, it is essential to assess the periodontal
status of the tooth in question as cervical and occasion-
ally mid-­root perforations are associated with epithelial
downgrowth and subsequent periodontal defects, which
will compromise the prognosis (Krupp et al., 2013; Main
et al., 2004; Seltzer et al., 1970).
CLASSIFIC ATION OF
PERFORATIONS AND FACTORS
AFFECTING PROGNOSIS
The aim of perforation management is to maintain
healthy periodontal tissues adjacent to the perforation
without persistent inflammation or loss of periodontal
attachment. In the case of established periodontal tissue
breakdown, the aim is to re-­establish tissue attachment
(c)
(d)

CLAUDER
(Pitt Ford et al., 1995; Silva et al., 2019). Thus, successful
perforation repair depends on the ability to seal the perfo-
ration and to re-­establish a healthy periodontal ligament
(Seltzer et al., 1970).
To determine an ideal treatment strategy, Fuss and
Trope introduced a classification system based on the
factors affecting the prognosis of perforations and their
treatment (Fuss & Trope, 1996), including time of repair,
size of perforation and location of the perforation. They
emphasized that delayed repair, large perforations as well
as the location in the cervical region of the tooth decreases
the chance of successful repair. In a systematic review and
meta-­analysis Siew et al. found that maxillary teeth had a
significantly greater chance to heal when compared with
their mandibular counterparts as well as clinical cases
with no preoperative radiolucent area adjacent to the per-
foration site (2015). Other recent studies indicate that the
historical prognostic factors for teeth after perforation re-
pair are no longer as important as they were before the
introduction of MTA (Mente et al., 2014). Most authors
agree that the size of the perforation does not influence
the treatment success (Gorni et al., 2016; Krupp et al.,
2013; Pontius et al., 2013).
To date, there is no clear agreement on the significant
prognostic factors due to the fact that perforation repair
does not occur frequently. Therefore, it is a difficult topic
to study clinically, and often results in small sample sizes,
limiting statistical power and compromising conclusions.
It should be noted that the variety of different clinical sit-
uations challenges the comparisons and standardization
of studies.
These factors should be taken into careful consid-
eration at the time of treatment planning, although the
usual prognostic factors associated with traditional mate-
rials might not be applied when MTA is used (Torabinejad
et al., 2018).
The decision to treat a perforation also depends on
the periodontal condition of the defect. The presence of
periodontal involvement frequently requires additional
procedures for management and reduces the progno-
sis for a successful outcome. If a defect is not associated
with increased probing depths and loss of attachment,
then the treatment method of choice is usually nonsur-
gical perforation repair, which should be done as soon as
possible because timing is essential for a successful long-­
term prognosis. However, if a defect is associated with in-
creased probing depth, the loss of attachment and the risk
of epithelial downgrowth decrease the chances of regen-
eration drastically. When periodontal defects have already
formed, any conservative treatment is compromised (Pitt
Ford et al., 1995). These defects usually require nonsurgi-
cal periodontal management or may even need surgical
intervention. Based on the probability for regeneration,
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   877
the treatment options (namely surgical, nonsurgical, or a
combination of both) require careful consideration. The
experience of the operator seems also to have an impact
on treatment outcome and most clinical studies mention
that the treatment was performed by endodontists or den-
tists with special training being educated for treating such
severe complications as perforations. In addition, clinical
procedures were aided by operating microscopes (Mente
et al., 2014; Siew et al., 2015). The increased willingness of
patients to keep their teeth in combination with improve-
ments in technology necessitates a re-­evaluation of the in-
dications to treat and retain perforated teeth. When teeth
are of strategic value and treatment prognosis is adequate,
perforation repair is clearly indicated.
MTA AS A PERFORATION REPAIR
MATERIAL
Various materials have been used to repair root perfora-
tions. Traditionally, the most commonly used repair ma-
terials have been amalgam, zinc oxide eugenol cement,
calcium hydroxide, gutta-­percha, glass ionomer cement,
IRM (Dentsply Sirona), composite resin, and SuperEBA
(Keystone Industries). Many materials were advocated
for perforation repair; however, none provided a favour-
able environment for re-­establishing the normal tissue
architecture, predictable healing after treatment and have
invariably produced disappointing results (Aguirre et al.,
1986; Balla et al., 1991; Bryan et al., 1999; ElDeeb et al.,
1982; Seltzer et al., 1970). The inadequacy of these mate-
rials can be attributed to their inability to seal the com-
munication between the oral cavity and the underlying
tissues, or their lack of biocompatibility.
F I G U R E 8 ProRoot MTA (Dentsply Tulsa Dental Specialties,
Johnson City, TN, USA)
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878    T. CLAUDER, PRIVATE PRACTICE, HAMBURG, GERMANY

(b)

(a)

(c) (d)

(e) (f)

(g)

F I G U R E 9 Case of external cervical resorption. (a) The radiograph demonstrates loss of tooth structure in the cervical region. (b) CBCT
shows perforation of the defect in three dimensions. (c) Tooth demonstrating typical pink spot. (d) Surgical access and removal of resorption
tissue. (e) Excellent hemostasis is very important for ideal application of Geristore. (f) After 6 weeks supragingival coating of Geristore with
composite. (g) A 5-­year recall shows no signs of inflammation
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CLAUDER    879

In the 1990s, mineral trioxide aggregate (MTA) was that MTA was the most popular material for perforation
introduced first in 1993 in the dental literature and repair (Ha et al., 2016; Lee et al., 2009).
later commercially launched in 1999 as ProRoot MTA With increasing and promising research on the use
(Dentsply Tulsa Dental Specialties) in the United States. of bioactive endodontic cements (Wang, 2015), a general
Since then other similar bioactive endodontic cements group of materials to which MTA also belongs, the choice
have been developed and launched to the dental market. of material for repairing root perforation is growing. The
MTA was initially introduced as a root-­end filling mate- newer bioactive endodontic cements might have a similar
rial for surgical endodontic procedures (Lee et al., 2004; potential compared to MTA, but to date there is a lack of
Torabinejad, et al., 1995; Torabinejad, et al., 1995). Since available clinical data.
then, its clinical applications have broadened to include
perforation repair, pulp capping, pulpotomy, and apexifi-
cation. The original grey and white formulations of MTA ALTERNATIVE MATERIALS
were reported to work equally well (Ferris & Baumgartner, FOR PERFORATION REPAIR IN
2004; Regan et al., 2005). SPEC IFIC INDICATIONS
The bond strength of most dental materials is signifi-
cantly reduced by moisture contamination from the tissue, As previously discussed, in most cases MTA is the mate-
whereas MTA requires the presence of moisture for set- rial of choice, if the perforation is located below the crestal
ting. Therefore, set MTA can acquire its optimal strength bone. In some indications, MTA has disadvantages and
and produce excellent sealability in the presence of tissue preference should be given to other materials. A limita-
fluids (Torabinejad et al., 1994). Due to its excellent bio- tion of MTA is the long setting time up to 3 h (Torabinejad,
compatibility and osteoconduction property, MTA is able et al., 1995; Torabinejad, et al., 1995). It has a potential of
to allow the growth of cementoblasts with deposition of being washed out whenever there is a communication
cementum over its surface (Holland et al., 2007; Wang,
2015). A characteristic that differentiates MTA and simi-
lar bioactive endodontic cements from other materials is
their ability to promote regeneration of cementum, thus
facilitating the regeneration of the periodontal apparatus
(Arens & Torabinejad, 1996; Pitt Ford et al., 1995) (Figure
8). Until the advent of MTA, repair materials were unable
to stimulate this regenerative process (Main et al., 2004).
Lack of adverse effects after extrusion of MTA into the
furcation in both cases indicates biocompatibility (Arens
& Torabinejad, 1996; Pitt Ford et al., 1995). According to
available data, MTA establishes an effective seal (Hamad
et al., 2006; Hashem & Hassanien, 2008; Torabinejad et al.,
1994; Weldon et al., 2002) and enhances the prognosis of
perforation repair (Main et al., 2004; Pitt Ford et al., 1995;
Torabinejad et al., 2018).
On the other hand, the formation of fibrous tissues
encapsulating or walling-­off other materials such as resin
composite, intermediate restorative material, or zinc
ethoxybenzoic acid cement was a commonplace finding
(Bérnabe et al., 2005); often there may be varying degrees
of chronic inflammation in the periodontal tissue adja-
cent to these materials (Bérnabe et al., 2005).
Siew et al. concluded that nonsurgical repair using
MTA resulted in a higher success rate when compared
with other materials. With an overall success rate for
perforation repair of about 81% when using MTA mate-
rial, saving the tooth nonsurgically with such a method is
worthwhile (Siew et al., 2015). Two surveys amongst active
Diplomates of the American Board of Endodontics in the F I G U R E 1 0 (a) MAP system for orthograde application of
USA and Australian Society of Endodontology reported MTA. (b) MAP system for surgical application of MTA
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880    T. CLAUDER, PRIVATE PRACTICE, HAMBURG, GERMANY

between the oral cavity and the perforation. This limits its
application above the crestal bone. In such clinical situa-
tions, preference should be given to other bioactive endo-
dontic cements, resin-­bonded glasionomers or composites.
Another disadvantage is the colour of MTA and its potential
for discolouration (Bortoluzzi et al., 2007; Możyńska et al.,
2017; Torabinejad et al., 2018) which might compromise
aesthetic demands. Other bioactive endodontic cements
like Biodentin (Septodont, Saint-­Maur-­des-­Fossés, France),
BC EndoSequence RRM putty or BC EndoSequence RRM
fast set paste (Brasseler) do have a lower potential for dis-
coloration (Kohli et al., 2015).
Aesthetic demands have to be considered in the ante-
rior region, especially when treating patients with a high

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

(j) (k)

F I G U R E 1 1 Repair of a furcal and mesial supracrestal perforation. (a) The working length radiograph from the referring dentist shows
the instrument placed in the perforation site and not inside the canal. (b) Slight bleeding of the infected perforation. (c) After cleaning the
perforation. (d) Clinical view of the mesial supracrestal perforation which was not visible on the radiograph. (e) After proper hemostasis.
(f) Bonding with filter for adhesive procedures. (g) After perforation repair with Geristore. (h) After proper cleaning the perforation
and stopping the bleeding. (i) Placement of a barrier with calcium sulfate before applying MTA. (j) Perforation repair with MTA. (k)
Postoperative radiograph showing both perforation sites

CLAUDER
F I G U R E 1 2 Repair of a furcal
perforation. (a) The preoperative (a)
radiograph shows extensive loss of tooth
structure. (b) Access to the pulp chamber
shows an infected, large perforation.
(c) After instrumenting the canals and
cleaning the perforation. (d) One year
postop shows no signs of Infection.
(e) 14 years postop shows no signs of
inflammation. (f) Ten years postop with
CBCT shows no signs of inflammation of
the furcation site
(c)
(e)
lip line. Careful consideration is necessary how the optimal
red and white aesthetics can be achieved. Above the crestal
bone level the application of adhesive materials can provide
an adequate seal and a fast setting time (Alhadainy, 1994).
To restore subgingival defects in the crestal area a resin-­
bonded glass ionomer material such as Geristore (DenMat)
is recommended for perforation repair. This material has
been shown to be an acceptable material for repair of root
caries and cervical erosions in a number of clinical studies
(Behnia et al., 2000; Dragoo, 1996, 1997; Nakazawa et al.,
1994). Breault et al. (2000) reported sustained tissue health
and minimal probing depths at the surgical site when a
root perforation was repaired with Geristore. Geristore, in
some indications in combination with composites might be
an interesting alternative in the aesthetic zone and espe-
cially subgingival in the crestal region, when MTA or its
derivates do not promote ideal outcomes (Figure 9) and
aesthetic demands. In all other supracrestal indications
composites are materials of choice. However, some authors
(Menezes et al., 2005) have reported the use of MTA in su-
pracrestal areas in the posterior region.
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   881
(b)
(d)
(f)
TECHNIQUES AND
CONSIDERATIONS TO CLINIC AL LY
REPAIR PERFORATIONS
If careful judgement favours retaining the tooth and repair-
ing the perforation, other factors further influence the choice
of treatment procedure. Good visibility of the damaged site
is essential to achieve the treatment goals. The microscope
is now an indispensable tool to facilitate the delicate tech-
niques and improves the management of procedural errors
(Daoudi & Saunders, 2002). Besides time after perforation,
two factors appear to be most important in relation to clini-
cal perforation repair: an appropriate material selection as
previously discussed, and the option to use a matrix.
Use of a matrix
The two main challenges a clinician faces when attempt-
ing to repair a perforation are haemostasis and the con-
trolled placement of a restorative material. Most materials
 |
882   
(a) (b)
(c) (d)
F I G U R E 1 3 Repair of perforations in the middle third. (a)
Incorrect angulation of the post burs led to middle root perforation
of tooth 11 developing a pronounced lesion. (b) Six years postop
shows no signs of inflammation. (c) Six years postop with CBCT
shows no signs of inflammation of the perforation site. (d) 10 years
postop shows no signs of inflammation
used for repair are sensitive to moisture, frequently com-
promising the seal of the repair material and resulting
in unfavourable outcomes; controlling haemostasis is of
major importance in achieving a seal. MTA sets in the
presence of moisture and blood does not affect its sealing
ability (Torabinejad et al., 1994). Sluyk et al. demonstrated
that the presence of moisture in perforations during the
placement of MTA increased its adaptation to perforation
walls (Sluyk et al., 1998). For that reason, it is suggested
that MTA does not require the use of an internal matrix
when sealing furcal perforations (Arens & Torabinejad,
1996; Sluyk et al., 1998). However, it has to be clear that in
cases with large bony defect, the application of repair ma-
terials without any barrier can lead to excessive extrusion
of the applied material. The extrusion of repair materials
should be expected in cases of delayed repair compared to
immediate repair (Al-­Daafas & Al-­Nazhan, 2007).
In the past, attempts have been made to control extru-
sion and to increase the sealing ability of the repair ma-
terials with internal biocompatible barriers (Auslander &
Weinberg, 1969; Imura et al., 1998; Jantarat et al., 1999;
Lemon, 1992; Rafter et al., 2002). Internal matrices such
as calcium sulphate did prevent extrusion of the mate-
rial used for repair into the surrounding area (Al-­Daafas
& Al-­Nazhan, 2007; Alhadainy, 1994; Rafter et al., 2002).
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T. CLAUDER, PRIVATE PRACTICE, HAMBURG, GERMANY
Other research showed that extrusion of MTA into the
alveolar bone does not pose a problem (Pitt Ford et al.,
1995; Torabinejad, et al., 1995; Torabinejad, et al., 1995).
The overfilled MTA may either be absorbed and thus will
not interfere with periradicular tissue healing, or in some
cases will result in persistent symptoms that require fur-
ther treatment such as apical surgery to provide relief and
assist healing (Nosrat et al., 2012).
However, several publications have also shown excel-
lent clinical results with barriers using calcium sulphate or
collagen (Bargholz, 2005; Kratchman, 2004). A variety of
resorbable barriers exist (e.g. collagen, freeze-­dried demin-
eralized bone allograft, hydroxy apatite, Gelfoam (Pfizer),
or calcium sulphate) (Roda, 2001; Ruddle, 2002); if the use
of a barrier is required (e.g. after inflammatory breakdown
of the adjacent tissues), then collagen and calcium sulphate
based-­materials are the best options because of their ease of
handling and the clinical results obtained (Ruddle, 2002).
Collagen is biocompatible, is easy to handle, provides rapid
haemostasis (2–­5 min), and is resorbable in 10–­14 days. The
material is cut into small pieces and placed one after the
other in the bony crypt until it reaches the periodontal liga-
ment to prevent the extrusion of MTA. As the material will
be absorbed, collagen should stay within the bone margins.
Collagen's use in conjunction with adhesive dentistry is not
recommended as it absorbs moisture and contaminates the
restorative interface (Ruddle, 2002).
Calcium sulphate is biocompatible, has a predictable
haemostatic effect, and is bioresorbable in about 4 weeks
(Murashima et al., 2002; Pecora et al., 1995, 1997; Ruddle,
2002; Yoshikawa et al., 2002), depending on the density of
the material. It is delivered with a plugger or the MTA Gun
System (MAP–­Micro Apical Placement System, Produits
Dentaires SA, Vevey, Switzerland) (Figure 10) to the bony
defect. After the material is set, it is important to clean the
dentinal walls of the perforation, for example, with ultra-
sonic tips. After the material is set, it can be cleaned care-
fully and used for dentine bonding procedures, improving
the seal (Zou et al., 2007). Some authors suggest placing a
Platelet-­rich fibrin matrix into the bony crypt as a barrier
prior to placing an apical plug of tooth-­coloured ProRoot
MTA (Yadav et al., 2015).
NONSURGIC AL MANAGEMENT O F
PERFORATIONS
Crown, pulpal floor and furcation areas
The first step is to isolate the defect and provide good
visualization. Repair of furcal perforations should be
attempted through a nonsurgical intracoronal ap-
proach because surgical treatment can often lead to

CLAUDER
(a) (b)
(c)
F I G U R E 1 4 Repair of a perforation in the middle third.
(a) Incorrect angulation of the posts in tooth 24 and 25 led to
perforations in the middle root area, developing a pronounced
lesion at tooth 25. (b) Six years postop shows no signs of
inflammation. (c) Six years postop with CBCT shows no signs of
inflammation of the perforation sites
loss of periodontal attachment, chronic inflammation,
and furcal pocket formation (Arens & Torabinejad,
1996; Oswald, 1979). Prior to debriding the defect, root
canals should be instrumented to allow proper intraca-
nal medication and closure of the orifices. If preferred
and time allows final obturation of the canals can be
performed. Obturation has to be carried out with care,
not to extrude obturation materials into the perforation
site unnecessarily.
As previously discussed, the lapse of time between the
development of a perforation and the moment of repair is
critical for the prognosis. For an older, chronic and probably
infected perforation, success in the treatment is attributed
to removal of contaminants before repairing under aseptic
conditions (Arens & Torabinejad, 1996; Kvinnsland et al.,
1989; Nicholls, 1962; Pitt Ford et al., 1995). If dentine must
be removed, this can be accomplished ideally with slight
enlargement using burs or ultrasonics under magnification.
|
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   883
Ultrasonic tips are preferred because they are gentler on the
adjacent tissues. In their protocol, Arens and Torabinejad
(1996) described further enlargement and cleaning of the
infected perforation and the wound site with copious ir-
rigation of 2.5% sodium hypochlorite before placement
of the repair material. The use of a disinfecting solution
such as sodium hypochlorite can improve antimicrobial
interaction and is helpful, but it should be used carefully,
with an awareness of the increased risk of severe complica-
tions of hypochlorite accident, if injected into the bone. In
large lesions, in proximity to vital tissues and nerves, or to
control bleeding, sterile saline can be advantageous. They
frequently present hyperplastic and hypervascular granu-
lation tissue which protrudes into the defect; the removal
of these tissues is necessary but can make haemostasis
challenging. The use of nonspecific intravascular clotting
agents (e.g. ferric sulphate: stasis [21% ferric sulphate]
Gingi-­Pak; Astringedent [15.5% ferric sulphate], Ultradent)
commonly used to control bleeding should not be used
because these chemicals can irreversibly damage delicate
alveolar bone and delay healing (Carr, 1998; Lemon et al.,
1993). Haemostasis should be achieved using collagen, cal-
cium sulphate, or calcium hydroxide.
The next important factor is the degree of bone de-
struction and the resulting defect surrounding the per-
foration. If there is no intraosseous defect, no barrier is
needed. With larger osseous defects, careful use of a bar-
rier can facilitate proper placement and adaptation of the
filling material as well as prevent overcontouring. To pre-
vent damage to adjacent vital structures, no force should
be used (Roda & Gettleman, 2006).
MTA, as the repair material of choice, is placed either
directly on bone or on the previously placed matrix. The
easiest way to apply MTA is to use an appropriate carrier
(MAP–­Micro Apical Placement System, Produits Dentaires
SA; Dovgan MTA Carrier, G. Hartzell & Son) (Figure 10).
Pluggers (Schilder-­Plugger, Dentsply Sirona) or micro spat-
ulas (West Perforation Repair Instruments, Sybron Endo)
are used for effective condensation. The technique of ul-
trasonic activation, i.e. condensation by vibrating MTA
into place to achieve a seal, is helpful when placing the
material in difficult anatomical situations. Although ultra-
sonic activation is frequently used in this context by clini-
cians, its benefit has been not verified in outcome studies
(Aminoshariae et al., 2003; Yeung et al., 2006).
After placing MTA precisely, the use of a blunt paper
point can be helpful in removing excess moisture and gen-
tly compacting the material (Roda & Gettleman, 2006).
Because MTA needs moisture during setting, after place-
ment is complete, a wet cotton pellet is placed on top of
the material, allowing it to set. For temporary restoration
of the access cavity, a good seal is necessary, preferably
using materials that increase the fracture resistance
 |

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884    T. CLAUDER, PRIVATE PRACTICE, HAMBURG, GERMANY

(b) F I G U R E 1 5 Repair of perforations

(a) using a space maintainer. (a) Panoramic
radiograph hiding a perforation at the
tooth. (b) A CBCT scan showing the
perforation in the coronal third of the
canal, bone destruction in the apical area,
resulting in swelling of the sinusmucosa,
as well as bone destruction at the
perforation site. (c) Perforation showing
gutta-­percha sticking in the defect. (d)
(c) (d) After retreating gutta-­percha from the
bone crypt. (e) Searching for MB2. (f)
After instrumenting MB2. (g) Using a
gutta-­percha point as a space maintainer
whilst placing MTA. (h) After placement
of MTA. (i) Postoperative control

(e) (f)

(g) (h)

(i)

of the tooth. Recommendations for placing the final
restorations vary from 1 day to 1 week after the repair
procedure (Arens & Torabinejad, 1996; Pitt Ford et al.,
1995). Other publications suggest that composite resin
with a bonding agent over MTA can be restored almost
immediately after MTA placement during a single visit
(Tsujimoto et al., 2013). If a patient is treated in multiple
sessions, at the next visit, the material should be checked
to determine if it has set hard and remains positioned in
the perforation site (Sluyk et al., 1998). If the MTA has
set and perforation repair has been accomplished, clean-
ing and shaping of canals should be finalized, followed
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CLAUDER    885

by root canal filling. Immediate adhesive reconstruction Apical one-­third of the root canal
of the tooth provides less possibility for coronal leakage
and strengthens the tooth, as the quality of the coronal Perforations occurring in the apical one-­third of roots
restoration is of major importance for treatment success primarily result from complications that occur during
(Balto, 2011; Ng et al., 2011). Perforations in the cervical canal cleaning and shaping procedures (Ruddle, 2002).
region, especially in anterior teeth with loss of dentinal Management of these perforations is quite difficult: ac-
structure, weaken the tooth in a strategically important cess is limited and therefore finding, negotiating, clean-
area. In selected cases, placement of an adhesively luted ing, shaping, and filling the frequently blocked and
post may be advantageous (Schwartz & Robbins, 2004) ledged original canal is a challenge. If the canal can be
(Figures 11 and 12). located and instrumented, filling can be accomplished
with gutta-­percha and sealer (Figure 16). This approach
is advantageous when the perforation is small or api-
Middle one-­third of the root canal cal to a curve and the handling of MTA, even with ul-
trasonic vibration, is difficult. MTA is the material of
Iatrogenic perforations in the middle one-­third of roots are choice, especially when it is difficult to dry the canal.
generally caused by endodontic files, Gates Glidden drills, Sometimes it can be helpful to place a prebent file into
or large, misdirected posts. Strip perforations are frequent the original canal, which stays as a space maintainer.
problems in thin and concave roots (Allam, 1996). The use
of an operating microscope facilitates technically demand- (a) (b)
ing treatments in this more restricted area. Before closing
the defect, the original canal should be instrumented to
at least a size that allows accurate protection of the canal,
thus preventing blockage.
Ideally the canal is instrumented as close to the final
apical size and shape as possible. Caution is necessary to
place instruments in the original canal and not the per-
foration. This is facilitated by prebending root canal in-
struments and ensuring good visibility of the defect. For
closure, basically two techniques can be recommended.
After initial three-­dimensional filling of the canal apical
to the perforation, the defect and the rest of the canal can F I G U R E 1 6 Repair of perforations in the apical third. (a) In
be filled with MTA. The disadvantage of this technique is this case, lack of apical control caused an apical perforation. (b)
the potential extrusion of the filling material into the per- Because the perforation was small in this case and apical control
foration (Figures 13 and 14). achievable, the perforation repair was done with a warm vertical
The other option is to use a space maintainer after hae- compaction technique
mostasis has been achieved. After the final canal shape is
almost accomplished, a space maintainer is placed into the
canal and used to maintain patency and the original canal (a) (b)
outlines. A versatile technique using a space maintainer is
to fit a gutta-­percha cone deeper than the perforation site
into the canal and melt it with heat to the dentinal wall of
the tooth. The gutta-­percha point should be fixed against
the canal wall opposing the perforation so that proper ap-
plication of the repair material is possible. MTA is then
placed at the level of the defect and condensed by hand or
with ultrasonic activation of the condensing instrument
(Figure 15).
A third, often more challenging option would be to
fill the entire root canal and the perforation site with
MTA. As proper placement MTA in a narrow root canal F I G U R E 1 7 Repair of perforations in the apical third. (b) A
can be technically demanding, a size of approximately 1-­year recall shows that the apical perforation in the distal root was
ISO 40 or larger facilitates a proper and dense filling of extensive and obturated using MTA for perforation repair and a
the root canal. warm vertical compaction technique for the mesial root
 |

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886    T. CLAUDER, PRIVATE PRACTICE, HAMBURG, GERMANY

After MTA is placed in the perforation site, the file must
be loosened before MTA sets in order to be able to nego-
tiate the original canal at the next visit. MTA can also be
used to fill the perforation and the original canal (Figure
17). Apical perforations cannot be managed successfully
in all cases and apical surgery or extraction of the tooth
may sometimes be better options for a stable outcome
(Roda & Gettleman, 2006).
SURGIC AL MANAGEMENT OF
PERFORATIONS
In the past, perforations were often managed surgically, but
in recent years nonsurgical perforation repair has been fa-
cilitated by the use of improved magnification and illumina-
tion, providing better visualization and access to the defect
(Roda, 2001). Currently, a nonsurgical approach is indicated

F I G U R E 1 8 Repair of perforations
(a) (b)
using a surgical approach. (a) The
radiograph of tooth 23 does not allow
the diagnosis of an apical perforation.
(b) After surgical access, the buccal
perforation becomes obvious. The
obturation material is protruding into
the periradicular tissues. (c) After careful
resection of the root to the perforation
area, an apical retrofilling with MTA was
placed. (d) The postoperative radiograph
shows the difficulties in this case due
(c) (d) (e)
to lack of space for an adequate apical
retrofill. (e) Six years postop shows no
signs of inflammation

F I G U R E 1 9 Repair of perforations
(a) (b)
using a surgical approach. (a) The
radiograph of tooth 26 shows canal
transportation and a perforation in
the apical third. (b) The CBCT shows
the exact size of the lesion and the
perforation, what results in better
treatment planning. (c) After retreatment
of the root canal filling, a microsurgical
approach was chosen to eliminate the
noninstrumented apical canal and
(c) (d) guarantee a tight apical seal. (d) One year
postop shows no signs of inflammation
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CLAUDER    887

whenever possible. Surgical intervention is reserved for tissue architecture adjacent to the repair site independ-
cases not amenable to, or which have not responded to, ent of the location of the defect at the recall visit. Teeth
non-­surgical treatment, or in which the concomitant man- with existing lesions were associated with resolution of
agement of the periodontium is indicated (Regan et al., the lesion, and teeth without preoperative lesions con-
2005). Perforations can occur circumferentially on the buc- tinued to demonstrate absence of lesion formation at the
cal, lingual, mesial or distal aspects of roots. The location of recall visit. Several clinical studies on perforation repair
the defect is not as important when nonsurgical treatment with MTA including larger sample sizes and long-­term
is selected but is critical in a surgical approach (Ruddle, follow-­up are confirming high success rates ranging
2002). Apical perforations especially complicate conven- from 73.3% to 92% and a good long-­term sealing abil-
tional instrumentation and filling of root canals. Surgical ity (Gorni et al., 2016; Krupp et al., 2013; Mente et al.,
repair of root perforations has been performed by reflecting 2014; Pontius et al., 2013). Gorni et al. reported that after
a flap at the perforation site and packing a repair material treatment with MTA and having obtained primary heal-
into the cleaned and usually mechanically prepared defect ing, the risk of progression of the inflammatory process
(Alhadainy, 1994). If the perforation is very close to the was very low (Gorni et al., 2016). Historical prognostic
apex, the entire perforation can be eliminated by resection factors for teeth after perforation repair are considered
of the apical part of the root (Figures 18 and 19). no longer as important as they were before the intro-
Surgical intervention may also be needed in the treat- duction of MTA (Gorni et al., 2016; Mente et al., 2014).
ment of a perforating resorption. A communication be-
tween the pulp space and the periodontal structures can
occur as a result of an extensive resorptive process if it has
been given adequate time (Alhadainy, 1994). However, the (a) (b)
complex irregularities of the root canal system, especially
in internal resorption defects, pose technical difficulties
for the thorough cleaning and filling of the root canal
(Sari & Sonmez, 2006). CBCT facilitates the diagnosis
of the perforating resorption defect and minimises risks
during treatment and helps in the management of the le-
sion (Bhuva et al., 2011).
The use of MTA in teeth with perforating internal
root resorption has been reported to provide optimal re-
sults and can preclude the need for surgical intervention
(Bendyk-­Szeffer et al., 2015) (Figure 20). If the resorption (c)
repair is surgically accessible, either surgical approach or
the combination of nonsurgical and surgical interventions
may provide a more favourable outcome (Altundasar &
Demir, 2009) (Figure 21). An approach was published by
Kaval et al. using a regenerative endodontic procedure in
one case successfully (Kaval et al., 2018).

C L I NI C A L O U TCOME S

A number of case reports and studies have demon-

strated consistent healing of perforations treated with
MTA (Arens & Torabinejad, 1996; Bortoluzzi et al.,
2007; Gorni et al., 2016; Hsien et al., 2003; Kratchman,
2004; Krupp et al., 2013; Main et al., 2004; Meire & Moor,
2008; Menezes et al., 2005; Mente et al., 2014; Pontius
F I G U R E 2 0 Repair of a perforating resorption using an
et al., 2013; Sari & Sonmez, 2006; Siew et al., 2015), orthograde approach. (a) Tooth 31 shows a resorption developing a
which has been described as the material of choice (Ree lateral lesion. (b) In this case, an ideal seal through the orthograde
& Schwartz, 2012; Torabinejad et al., 2018). The results approach was achievable. Nine years postop shows no signs of
support the use of this material for root perforation re- inflammation at the perforation site. (c) The CBCT 6 years after the
pair. Main et al. (2004) reported 16 cases with normal treatment shows no signs of inflammation at the perforation site
 |
888   
(a) (b)
(c) (d)
Evidence to date confirms that perforations can be re-
paired successfully with meticulous cleaning and shap-
ing, adequate disinfection, proper handling of the repair
material, and adequate filling followed by good coronal
restoration (Pontius et al., 2013). Although important for
the successful management besides the application of an
appropriate material is the use of magnification and the
experience of the operator (Mente et al., 2014).
CON C LUDI N G R E M AR K S
In conclusion, root perforations are severe complica-
tions that reduce the prognosis of root canal proce-
dures. Focus should be on prevention of perforations,
as every perforation weakens the integrity of the tooth
and can cause loss of the tooth. Modern guided endo-
dontic techniques can facilitate endodontic procedures
and lower the risk of unnecessary weakening or perfo-
rating a tooth in complicated clinical situations. If a per-
foration occurs, treatment relies on accurate diagnosis
and visualization. Perforation repair can be challenging
and sometimes requires creativity. MTA is an excellent
material for the repair of perforations. Other bioactive
endodontic cements might be able to achieve similar
results, but to date there is a lack of available clinical
data. Besides biological aspects, research should also
focus on stabilization of the remaining tooth structure.
More research is needed to evaluate clinical procedures
and outcomes in human subjects.
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T. CLAUDER, PRIVATE PRACTICE, HAMBURG, GERMANY
F I G U R E 2 1 Repair of a perforating
internal resorption using a surgical
approach. (a) The problems in the
apical regions are not apparent on two-­
dimensional radiographs. (b) The CBCT
shows the apical defect clearly. (c) In this
case, an ideal seal through the orthograde
approach was not achievable, so a
combined treatment was accomplished.
(d) A 2-­year recall shows no sign of
inflammation
CONFLICT OF INTEREST
The author has stated explicitly that there are no conflicts
of interest in connection with this article.
ORCID
Thomas Clauder https://orcid.
org/0000-0002-6081-6015
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How to cite this article: Clauder T. (2022) Present
status and future directions –­Managing perforations.
Int Endod J, 55(Suppl. 4), 872–­891. Available from:
https://doi.org/10.1111/iej.13748