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183]

Effective seal completes the

Case Report

deal: Periodontal
management of an iatrogenic
endodontic perforation
Maya Sanjiv Indurkar, Arati Seetaram Maurya
Department of Periodontology, Government Dental College and Hospital,
Aurangabad, Maharashtra, India

Address for correspondence: Dr. Arati Seetaram Maurya, E- mail:

aartimaurya91@gmail.com

ABSTRACT
Perforations are undesirable complications and unfortunate incidents that
can occur during root canal therapy. The present case report describes the
surgical management of extensive iatrogenic perforation of the pulpal floor of
the first mandibular molar in furcation area. Radiographic analysis confirmed
Grade II furcation involvement. Therefore, the diagnosis of primary
endodontic and secondary periodontal lesion was made. Surgical
debridement of the furcation area with simultaneous repair of perforation was
considered. After flap reflection and proper debridement, perforation was
located. The perforation was sealed with biodentine. In the furcation area,
regeneration was done by placing bone graft and covering it with guided
tissue regeneration membrane. Postoperatively, the healing was uneventful.
After healing, prosthetic restoration was done. Thus, the case was
successfully managed.

CLINICAL RELEVANCE TO INTERDISCIPLINARY

DENTISTRY
Biodentine has a wide range of applications including endodontic repair (root
perforations, apexification, resorptive lesions, and retrograde filling material in endodontic
surgery) and pulp capping and can be used as a dentine replacement material in
restorative dentistry. Its lack of cytotoxixity and tissue acceptability properties make it
biocompatible with pulpal and periodontal tissue.

Key words: Biodentine, iatrogenic perforation, regeneration, surgical

management
bone loss or may lead to tooth loss.[1]

A wide range of materials has been

INTRODUCTION tried for surgical and nonsurgical repair
of perforation including zinc oxide

A ccidental perforation of pulp

chamber or root is one of the major
eugenol, calcium hydroxide, cavit,
amalgam, glass ionomers, composite
resins, mineral trioxide
complications of endodontic
Access this article online
treatment[1] and results in the loss of
Quick Response Code:
integrity of root and adjacent Website:
periodontium.[2,3] Unrepaired www.jidonline.co
perforation leads to chronic m
inflammatory reaction characterized by
the formation of granulation tissue.
These led to irreversible attachment DOI:
10.4103/2229-
loss and 5194.197692

aggregate (MTA), and biodentine.[4,5]
The elusive goal of present day
dentistry is not only repair of
perforation but also regeneration of lost
periodontium. The present article
illustrates the use of biodentine for
repair of the endodontic perforation and
guided tissue regeneration (GTR) for
lost periodontium.
CASE REPORT
An 18-year-old female patient
reported to the outpatient Department
2016 Journal of Interdisciplinary Dentistry | Published by Wolters Kluwer - Medknow
87
of Periodontology with the chief
complaint of swelling and pus
discharge
This is an open access article distributed under the terms of
the Creative Commons
Attribution-NonCommercial-ShareAlike 3.0 License, which
allows others to remix, tweak, and build upon the work
non-commercially, as long as the author is credited and the
new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
How to cite this article: Indurkar MS, Maurya
AS. Effective seal completes the deal:
Periodontal management of an iatrogenic
endodontic perforation. J Interdiscip Dentistry
2016;6:87-90.
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Indurkar and Maurya: Management of iatrogenic perforation

floor of pulp chamber [Figure 4]. Isolation was

from gums in the lower right back region of maintained for next 12 min, i.e., for the initial
the jaw for 15 days. On clinical examination, setting time of biodentine. Temporary sealing
periodontal abscess was present on the was done with the help of zinc-oxide eugenol
buccal-attached gingiva with tooth number 46 cement, and the gingival contour was
which was draining through gingival sulcus maintained by placing matrix band.
[Figure 1]. Incomplete root canal treatment Hydroxyapatite bone graft was placed in the
(RCT) was noticed with that tooth. On the past furcation area, and collagen membrane was
dental history, the patient visited some private placed over it [Figure 5]. Interrupted suture
practitioner for pain with the same tooth 3 was given with composite stop in the
months back, where RCT was advised. After mid-buccal area to avoid recession [Figure 6].
beginning of the treatment due to some Immediate postoperative intraoral periapical
unexplained reason, she was advised for radiograph was taken to confirm the
extraction of that tooth. As the patient was
reluctant for extraction and wanted to save that
tooth, she visited this institute. Careful clinical
examination revealed perforation in the pulpal
floor in furcation area. The probing pocket
depth (PPD) was 11 mm on the mid-buccal
area of tooth 46. In the rest area, the PPD was
in the range of 23 mm suggestive of localized
periodontal destruction. The tooth was not
mobile with no marginal tissue recession. The
gutta-percha point was used to track the
abscess, and intraoral periapical radiograph
was taken that pointed toward the furcation
area [Figure 2]. Radiograph also revealed bone
loss in the furcation area and Grade II
furcation involvement. The condition was
diagnosed as retrograde periodontitis along
with Grade II furcation (Glickmans
classification) involvement with definitive
pulpal perforation resulting in primary
endodontic secondary periodontal lesion
(Simons classification).

Re-RCT and repair of the perforation along

with regenerative therapy for Grade II
furcation were planned. Treatment plan
comprised scaling and root planing followed
by surgical repair of perforation and
regeneration in the furcation area.

Procedure
After completing the obturation, surgical
intervention was planned. Periodontal surgery
was performed under local anesthesia. Inferior
alveolar nerve block and buccal infiltration
were given using 2% lignocaine with
adrenaline (1:80,000). Full-thickness
mucoperiosteal flap was elevated on buccal
aspect of the tooth 45, 46, and 47. After
complete debridement, perforation was located
with the help of gutta-percha points [Figure
3]. After achieving isolation and hemostasis
with Gelspon, perforation was repaired by
biodentine to form a complete layer on the
 Figure 2: Radiograph with gutta-percha point

Figure 1: Baseline photograph: Probing pocket

depth of 11 mm with periodontal abscess

Figure 3: Intraoperative location of perforation with

gutta-percha point

perforation seal which appeared as radiopacity

in that area [Figure 7]. Periodontal pack
(Coe-pak) was applied. Written postoperative
instructions were given to the patient, and
analgesic (ibuprofen 400 mg thrice daily) was
prescribed for 3 days. Antibiotic (amoxicillin
500 mg thrice daily) for 7 days and 0.2%
chlorhexidine mouthwash twice

88 Journal of Interdisciplinary Dentistry /

May-Aug 2016 / Vol-6 / Issue-2
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Indurkar and Maurya: Management of iatrogenic perforation

Figure 4: Perforation sealed with biodentine

Figure 6: Suturing

daily for 2 weeks were instructed. Pack and

sutures were removed on the 14th
postoperative day. The patient was
asymptomatic, and healing was uneventful.
The patient was followed up at 1 month, 3
months, 6 months, and under maintenance
phase. Temporary crown was given with tooth
46. Permanent metal ceramic crown was given
after 6 months.

RESULT

The PPD was reduced to 2 mm from 11 mm

with no gingival recession at 6-month
follow-up [Figure 8]. The gain in clinical
attachment level was of 9 mm. Radiographic
analysis revealed bone regeneration in the
furcation area [Figure 9]. The perforation
sealing was effectively maintained.

DISCUSSION

The Grade II furcation involvement in the

mandibular molars has good prognosis and can
be successfully

Figure 5: Bone graft placed in the defect
Figure 7: Pre- and immediate postoperative
radiograph comparison
treated by regenerative therapy combined with
the concept of GTR. However, when
endodontic is the cause of such lesion, it
should be managed first.[6] The prognosis of a
Journal of Interdisciplinary Dentistry / May-Aug 2016 / Vol-6 / Issue-2
89
perforation repair is dependent on many
factors such as level of perforation, size of
perforation, and the time elapsed between the
perforation and its repair. It also depends on
the sealing ability and biocompatibility of the
material used for repair. When time elapsed is
more, it leads to chronic inflammatory
reaction, granulation tissue formation, bone
loss and attachment loss.[7,8]
Among different materials used for perforation
repair, MTA has been used most commonly
with good treatment outcome because of its
biocompatibility, good seal even in the
presence of moisture or blood. Recently,
calcium silicate-based cement Biodentine
has gain popularity because of their
resemblance to MTA and designated as
Dentin Replacement material. Favorable
features of biodentine include (1) no effect
of blood contamination on push-out bond
strength of material irrespective of setting
time. (2) In case of its use as retrograde filling
material or groove sealing material where
there is a continuously moist environment,
lesser porosity that occurs by biodentine is
advantageous. (3) During scanning electron
microscopy analysis, biodentine crystals
appeared firmly attached to the underlying
dentine surface.[9] In a study by Guneser
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Indurkar and Maurya: Management of iatrogenic perforation
Figure 8: Follow-up probing pocket depth of 2 mm
et al., biodentine showed considerable
performance as a perforation repair material
even after being exposed to various
endodontic irrigants as compared to MTA. [10]
Aggrawal et al. concluded that 24 hrs push out
strenght of MTA was less than that of
biodentin and it was affected by contamination
of blood.[11] Hassan et al. in one study found
that as perforation repair material, biodentine
showed comparable minimal leakage in
retrograde and orthograde direction as
compared to MTA, it had better handling
property and was more cost effective.[12]
In the present case around 3 months has
elapsed since the occurrence of perforation
and its repair. The perforation was old in
nature, large, and crestal in location. The
overall prognosis of perforation repair was
questionable. However, regeneration of Grade
II furcation involvement in the mandibular
molars had a good prognosis. The sealing of
perforation with biodentine and regeneration
of Grade II furcation with bone graft and GTR
membrane saved the tooth with good
prognosis which was questionable at baseline.
However, very few literatures are available
regarding the use of biodentine as perforation
repair material. The use of biodentine seems
promising in the present case.
Financial support and
sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Figure 9: Follow-up radiograph at 6 months
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