Case Report/Clinical Techniques

Mineral Trioxide Aggregate as Repair Material for Furcal

Perforation: Case Series
Riccardo Pace, MD, DMD, Valentina Giuliani, DMD, and Gabriella Pagavino, MD, DMD
Abstract
The purpose of treating furcal perforation is to seal the
artificial communication between the endodontic space
and the periradicular tissue to prevent alveolar bone
resorption and damage to the periodontal ligament.
These complications are not infrequent in cases of
furcal and/or old perforations, which show a worse
prognosis than fresh, small, coronal, and apical perforations. Mineral trioxide aggregate (MTA) is widely
used to seal perforations because of its biocompatibility
and sealability. Ten cases of furcal perforation were
selected at the department of Endodontics, University
of Florence. All the perforations were cleaned with
NaOCl, EDTA, and ultrasonic tips and sealed with MTA
without internal matrix. Finally, the teeth were endodontically treated and coronally restored. Clinical and
radiographic follow-ups were done at 6 months, 1 year,
2 years, and 5 years. After 5 years, the absence of
periradicular radiolucent lesions, pain. and swelling
along with functional tooth stability indicated a successful outcome of sealing perforations in 9 out of 10
teeth. One patient dropped out of the study after the
1-year follow-up and could not be contacted for
further recalls. The results confirm that MTA without
matrix provides an effective seal of root perforations
and clinical healing of the surrounding periodontal
tissue. (J Endod 2008;34:1130 1133)

Key Words
Furcal perforation, mineral trioxide aggregate, root perforations

From the Department of Endodontics, The University of

Florence, Florence, Italy.
Address requests for reprints to Dr Riccardo Pace, Department of Dentistry, University of Florence, Via del Ponte di
Mezzo 46-48, 50127 Florence, Florence, Italy. E-mail address:
r.pace@odonto.unifi.it.
0099-2399/$0 - see front matter
Copyright 2008 American Association of Endodontists.
doi:10.1016/j.joen.2008.05.019

urcal perforation may be the consequence of procedural error or a pathologic

process such as caries and root resorption (1). The etiology and location of the
perforation as well as the size and the time delay before perforation repair are significant factors for the prognosis and treatment planning (2).
A good prognosis can be expected in case of fresh, small, coronal, and apical
perforation (2, 3). When left untreated, perforations in the cervical third of the root or
on the floor of the pulp chamber have the worst prognoses.
The time elapsed from the development of the defect is another critical factor
influencing the posttreatment prognosis; a delay in repairing a perforation opens the
way to bacterial contamination. In animal studies, teeth with contaminated intentional
lateral perforation were associated with a poorer repair process than teeth with no
contaminated defects (4, 5).
Ideally, a material with good sealability might be used to prevent continuous
exposure to a contaminating environment (6). Using different leakage approaches,
fluid filtration technique (7, 8), dye-leakage model (9, 10), bacterial leakage model
(11, 12), and dye-extraction leakage method (13), mineral trioxide aggregate (MTA)
experimentally showed better sealing ability than other materials, such as amalgam
(11), zinc oxide-eugenol cement (10), resin-modified glass ionomer cements (9), and
resin materials (7).
The use of biocompatible materials to repair perforations might be advocated to
reduce the incidence of inflammatory reactions in the surrounding tissues (6, 14).
When MTA was used to seal intentional furcal perforations in dog teeth, cementum was
formed over the MTA; furthermore, there was no inflammatory cells infiltrate (15). In
addition, the material of choice for repairing root perforations should be nontoxic and
insoluble in the presence of moisture, and it should be able to promote the healing of
the periradicular tissue (16). MTA has the properties of the ideal material for perforation repair.
In cases of teeth with large-size furcal perforation, the repair material can extrude
into the interradicular area, triggering tissue inflammation and foreign body reaction
(17, 18). The use of biocompatible material has been advocated to avoid extrusions and
the ensuing complications (18, 19).
In a recent animal study in which MTA without internal matrix was used to repair
contaminated intentional furcal perforations, there was a low score of inflammation and
a high score of bone deposition (17). Treating contaminated root perforation is not
infrequent in daily clinical practice.
A recent PUBMED search for MTA to repair root and pulp chamber perforation
produced one long-term case series study (20) and numerous case reports showing the
good healing results when MTA was used to seal root and pulp chamber perforations
(2123). There are no other results of human control studies or case series studies.
The purpose of this report was to present the 5-year follow-up results of 10 cases
treated for furcal perforation repaired with MTA without internal biocompatible matrices.

Materials and Methods

The experimental study was conducted on 10 adult patients aged between 25 and
35 years who were referred to the University Dental School of Florence, Italy, from
February 2001 to May 2002 for the treatment of perforations of the furcal area with the
absence of pathologic periodontal probing. During the first visit, ethical approval was
requested and granted, and informed consent was obtained from all patients. The

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Pace et al.

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Case Report/Clinical Techniques

Figure 1. Microscopic image of perforation repair with ProRoot MTA.

diagnosis of perforation was confirmed by clinical and radiographic

examinations. The clinical findings including the presence of pain, episodes of swelling, or abscess were recorded along with the date of the
last treatment of the affected tooth. In three cases, additional radiographs, with different angulations, were needed to properly assess the
location of the perforation and to detect the presence of radiolucent
lesions.

Perforation Repair Technique

We isolated the teeth with a rubber dam and removed the coronal
temporary filling material. We corrected the access opening with ultrasonic tips in order to visualize the access to the root canals and found
the site of the perforation under microscopic vision. We irrigated copiously with 5% sodium hypochlorite; we gently cleaned the site using
ultrasonic diamond-coated CPR 3 (Spartan, Fenton, MI) tips and then
irrigated the defect with 5% sodium hypochlorite (NaOCl, 3 mL) and
10% EDTA.
Under microscopic vision (Global Surgical Corp, St Louis, MO),
we applied a thermoplasticized gutta-percha plug into the orifice of the
root canals to avoid filling endodontic space with filling perforation

material and then irrigated abundantly with 5% sodium hypochlorite

with a final rinse of saline solution.
We sealed the perforation with MTA-sterile saline paste mixed in a
3:1 proportion as suggested by the manufacturer, gently dried the floor
of the pulp chamber with a cotton pellet, and delivered the Gray ProRoot
MTA cement (Maillefer, Ballaigues, Switzerland) into the perforation
with an Endo-Gun (Maillefer). We used a hand plugger to accommodate
the MTA inside the defect with minimal pressure.
We placed a moist sterile cotton pellet into the pulp chamber and
temporarily sealed the access cavity with glass ionomer cement (Ketac
Fill; 3M ESPE AG, Seefeld, Germany); a radiographic examination was
performed to control the correct positioning of the MTA. After 72 hours,
we reaccessed the root canal system and checked the hardening of the
MTA (Fig. 1) before proceeding with root canal therapy. The coronal
restoration was performed 1 week later. A final x-ray was taken immediately after the procedure.
The findings of the clinical controls at 6 months, 1 year, 2 years,
and 5 years after treatment were absence of a periodontal defect in the
area of perforation, absence of pain, absence of swelling, and fistula.
The radiographic criteria for healing were absence of radiolucency
adjacent to the repair site and absence of periradicular lesions.

Results
Table 1 shows the clinical findings. Out of the 10 clinical cases
included in this study, only one patient reported an episode of swelling
before the treatment. The time between the creation of perforation and
the repair ranged from 1 to 6 months. Furcal and periapical radiolucent
lesions were present in all teeth.
Starting from the follow-up at 6 months through to the end of the
5-year period, 9 of 10 cases were clinically healed. There were no
episodes of swelling or pain, and the periodontal probing depths were
less than 4 mm in all teeth.
At the 6-month recall, radiographs showed a reduction of periapical radiolucent lesions in all teeth (Fig. 2A and B). At the 1-year
radiographic follow-up, only one case showed the persistence of furcal
and periapical lesion (Fig. 2C); in this case, the time elapsed from the
creation of perforation to repair of the defect was 6 months. This patient
was dropped from the study because he did not present for the 2- and
5-year recall visits. The remaining nine teeth did not present radio-

TABLE 1. Patients Variables

Age Sex

Tooth Size of Perforation

#
(diameter in mm.)

27

#18

34

#30

1.5

33

#30

1.5

28

#3

1.5

25

#15

31

#19

35

#12

29

#31

30

#5

31

#30

1.5

JOE Volume 34, Number 9, September 2008

Position of
Perforation
Floor of the pulp
chamber
Floor of the pulp
chamber near distal
root (Fig. 2 AC)
Cervical third of distal
root (Fig. 3 AD)
Floor of the pulp
chamber
Floor of the pulp
chamber
Cervical third of the
mesial root
Floor of the pulp
chamber
Floor of the pulp
chamber
Cervical third of the
buccal root
Floor of the pulp
chamber

Follow-up
Time

Final Clinical
Assessment

Adverse Effects
Observed Reported

6 months, 1, 2, Clinical and radiographic

5 years
healing
6 months,
Clinical and radiographic One episode of swelling
1 year
healing
before the treatment
6 months, 1, 2,
5 years
6 months, 1, 2,
5 years
6 months, 1, 2,
5 years
6 months, 1, 2,
5 years
6 months, 1, 2,
5 years
6 months, 1, 2,
5 years
6 months, 1, 2,
5 years
6 months, 1, 2,
5 years

Clinical radiographic
healing
Clinical and radiographic
healing
Clinical and radiographic
healing
Clinical and radiographic
healing
Clinical and radiographic
healing
Clinical and radiographic
healing
Clinical and radiographic
healing
Clinical and radiographic
healing

MTA as Repair Material for Furcal Perforation

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Case Report/Clinical Techniques

Figure 2. Radiograph of mandibular right first molar with furcal perforation.

(A) Preoperative radiograph showing an incomplete root canal therapy, the
presence of one post near the pulp chamber of the tooth. A periapical and furcal
radiolucent lesion can be observed. (B) Six months follow-up: radiograph
showing a reduction of periapical radiolucent lesion and the persistence of
furcal lesion. (C) One years follow-up: radiograph showing an incomplete
resolution of radiolucent lesions.

graphic lesions nor did they develop radiolucent lesions during the
radiographic examinations at 1, 2, and 5 years (Fig. 3AD).

Discussion
The recent trend in evidence-based medicine underlines the importance of clinical data for evaluating clinical outcomes when new
materials are used in humans. The majority of published data dealing
with the use of MTA in root and furcal perforation are based on in vitro
and in vivo animal studies. In 2004, Main et al (20) suggested the need
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Pace et al.

for a clinical study to prove the efficacy of MTA as a perforation repair

material. The present study describes the treatment of 10 cases of root
perforations without pathologic periodontal probing using an orthograde approach to the defect; the treatment protocol consists in a primary sealing of the defect with MTA without internal matrix followed by
root canal therapy of the teeth.
In this study, 9 out of 10 cases were clinically and radiographically
healed. A timely sealing of the defect could prevent bacterial contamination from the pulp chamber area into the periodontum (6) as well as
the possibility of bacterial ingress from the periodontum into the pulp
chamber enhancing the healing process of the surrounding tissues
(20). This is especially important in furcal perforations because of the
greater proximity to the oral environment.
In the cases presented, the time elapsed from the creation of the
perforation to repair of the defect did not exceed 6 months. Immediate
repair of furcal perforations seems to reduce the possibility of bacterial
contamination of the defect (4 6, 16, 20).
The control of inflammatory processes in the defect area during management of perforation represents one of the main goals of
the treatment (20) in addition to promoting the health of the surrounding tissue. To achieve a better tissue response, the perforation
sites were sterilized with ultrasonic tips and sodium hypochlorite
irrigation (15, 17).
Recently, Holland et al (5) speculated on the importance of the
debris in the defect, which could obstruct the close contact between
MTA and the periodontal tissue and the subsequent healing process.
To reduce the amount of debris in the perforation defect, a rinse
with 17% EDTA was performed before positioning the filling materials.
The size of a perforation represents another important factor in
determining the success of the repair procedure; some authors
suggest the use of internal matrix to avoid the extrusion of the
sealing material and consequent periradicular tissue inflammation
(5, 18, 19).
In all of the cases in this study, the furcal perforations were fresh
and small (2 mm in diameter), with a low risk of filling material
extrusion (24). Because the tissue response seems to be influenced by
the nature of the sealing material, it is important to keep it within the
limits of the defect. However, in an animal study (17), when MTA was
accidentally extruded into the periradicular tissue, hard-tissue deposition and cementum were observed over the materials along with a
regeneration of periodontal apparatus.
Arens and Torabinejad (25) observed better results when furcal
perforations in dog teeth were repaired by using MTA without internal
matrix as opposed to MTA with internal matrix. They concluded that
MTA does not need a barrier when used to repair large furcal perforations.
Gray MTA with a wet cotton pellet was used to repair the perforation and maintained for 72 hours before proceeding with the root canal
therapy. MTA is hydrophilic; the moisture promotes expansion inside
the defect and setting (24, 26).
The disadvantage of the gray color of MTA was unimportant in the
cases presented because all teeth were posterior teeth. As suggested in
previous studies, gray and white MTA have similar chemical composition (27) and a high degree of biocompatibility (27), and no significant
differences have been found (12, 28).
The outcome of the furcal perforations treated with MTA shows
radiographic and clinical healing in 9 of the 10 teeth at the 5-year
follow-up. Further studies are needed to prove the efficacy of MTA and
better guide the practioner in the use of this material. We suggest using
the same protocol proposed for the treatment of furcal root perforations
to have a series of comparable studies.

JOE Volume 34, Number 9, September 2008

Case Report/Clinical Techniques

Conclusion
The use of MTA to seal small, fresh furcal root perforation is
associated with a good short-term (ie, 5 years) clinical outcome.

References

Figure 3. Radiograph of mandibular right first molar with furcal perforation

before, during, and after endodontic treatment and sealing of perforation. (A)
Preoperative radiograph showing periapical and furcal radiolucent lesion. (B)
Postoperative radiograph taken at six months; a reduction of periapical and
furcal radiolucent lesions were observed. (C) One-year follow-up shows complete resolution of periapical and furcal radiolucency. (D) Radiograph taken at
five years shows a complete healing of the radiolucent lesions.

JOE Volume 34, Number 9, September 2008

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