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Treatment of a Gross Perforation

Terry Pannkuk, DDS, MScDInstructional, Instructional, Clinical Endodontic Technique Instruction, Clinical Endodontic Technique Instruction, Access, Access, Complications: Advanced Management, Complications: Advanced Management, Perforations, Perforations, Sample Cases, Sample Cases, All by Date, All by Date

Description

The patient presented on 3/5/2020 with a gross perforation of the distocervical root when the patient's dentist had attempted root canal treatment. The root canal system had not been located.

Description

The patient presented with normal periodontal findings but was experiencing severe biting and chewing sensitivity. Immediate treatment of the perforation was planned (3/5/2020)

Description

A CBCT scan was taken and was of great value in finding the true root canal system by triangulating from known external tooth landmarks (3/5/2020)

Description

The tooth was isolated with multiple rubber dam holes, a single clamp on the first bicuspid and ligation with dental floss (3/6/2020). The perforation was prepped and cleaned with 90% trichloracetic acid. The improved visibility aided in finding the true root canal system. (3/6/2020)

Description

A periapical check radiograph was taken to verify the length measurement (3/6/2020)

Description

The root canal system was cleaned shaped and filled with calcium hydroxide. Small balls of Cavit were placed to seal the orifice making sure to keep the perforation site clean and clear of any debris and materials. Subsequently Biodentine was placed into the perforation defect and condensed. (3/6/2020)

Description

A periapical radiograph was taken at the end of the first visit to assess the filling with Biodentine and canal placement of calcium hydroxide (3/6/2020)

Description

An immediate post-treatment radiograph taken at the completion of treatment 3 1/2 months later demonstrates apical and lateral perforation filling control. The patient was without symptoms (6/26/2020)

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Patient: 76 year-old male, with a history of controlled hypertension and non-hodgkin’s lymphoma (14 years remission)

Chief Complaint: severe biting and chewing pain

Dental History: The patient’s dentist had started root canal treatment on tooth #26, created a false path and perforated the cervical root. The root canal system had not been located.

Significant Findings (#26): Clinical examination normal periodontal findings, severe percussion sensitivity, Class 2 mobility, and a negative response to cold thermal testing. The periapical radiographs and CBCT scan demonstrated a gross perforation exiting the distocervical root.

Pulp and Periradicular Diagnosis (#26): Previous access with Acute Periradicular Periodontitis

Treatment Prognosis: Fair (#26)

Treatment Plan: Nonsurgical Endodontic Therapy and internal perforation repair (#26)

Special Considerations of Performed Treatment:
The first important consideration was elimination of pain which required palliative treatment (Ibuprofen and Acetaminophen), pulp extirpation, and management of the inflamed periradicular perforation site.

The sequence of treatment steps were as follows:

First Treatment Visit (3/6/2020)

  1. Strategically extended access (SEE) to achieve a direct line to the perforation site and the true canal orifice. True canal system located and negotiated via CBCT triangulation utilizing clinically identifiable landmarks.

  2. Cleaning and shaping of the true canal system to final shape utilizing sodium hypochlorite (8.25%), 17% EDTA, and controlling hemostasis from the perforation with 90% trichloracetic acid.

  3. Intracanal calcium hydroxide was placed and small balls of Cavit were placed to seal the true canal orifice keeping the temporary filling material completely clear of the perforation defect.

  4. Biodentine (Septodont) as placed over the sealed canal and densely packed into the prepared and dry perforation defect.

  5. An occlusal seal of Cavit was placed over the Biodentine repair material.

Interim Re-evaluation (6/17/2020): The patient presented without symptoms and the periodontal and clinical findings were within normal limits. The patient was cleared to finish root canal treatment.

Second Treatment Visit (6/26/2020, extended 3 ½ months due to the COVID19 pandemic shutdown)

  1. Temporary filling was removed and the true canal system was re-entered knowing previously CBCT landmarks utilizing triangulation.

  2. The calcium hydroxide was completely flushed from the root canal system with irrigant (NaOCl) activated with an ultrasonic file.

  3. The previous Biodentine repair was noted to be extremely hard and sealing the perforation defect.

  4. The final apical prep and cone fit was performed.

  5. The root canal system was obturated via the vertical compaction of warmed gutta percha technique (Schilder Technique) with a ZOE based sealer (Kerr, regular set)

  6. The access was repaired with a bonded resin (Photobond/Luxacore/Filtek Z250 surface)
    A recall examination is scheduled for one year after treatment completion.

Key Learning Points:

  1. It is very important to note abrupt root curvatures, dilacerations, or abnormal tilting. The gross perforation in this case was most likely due to failure to recognize an anomalous root angle.

  2. Gross perforations are treatable as long as the tooth has structural integrity. The greatest risk of failure is a function related fracture.

  3. An intact sulcus greatly simplifies the treatment of a perforation and bioactive materials like Biodentine (tricalcium silicate) maintain and preserve periodontal attachment with a high degree of predictability.

  4. Immediate repair of the perforation protects the periodontal attachment.

  5. 90% trichloracetic acid (TCA) facilitates perforation control via excellent hemostasis and seems to reduce post-operative inflammation.

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