Indian Journal of Dental Research

: 2012  |  Volume : 23  |  Issue : 4  |  Page : 542--545

Furcal-perforation repair with mineral trioxide aggregate: Two years follow-up

Emmanuel Joćo Nogueira Leal da Silva1, Carlos Vieira Andrade2, Lidia Yileng Tay3, Daniel Rodrigo Herrera1,  
1 Department of Restorative Dentistry, Endodontic Division, Piracicaba Dental School, State University of Campinas, Piracicaba, SP, Brazil
2 Department of Health, Dentistry Division, Southwest State University of Bahia, Jequié, BA, Brazil
3 Department Dentistry, State University of Ponta Grossa, PR, Brazil

Correspondence Address:
Emmanuel Joćo Nogueira Leal da Silva
Department of Restorative Dentistry, Endodontic Division, Piracicaba Dental School, State University of Campinas, Piracicaba, SP


Furcal perforations are significant iatrogenic complications of endodontic treatment and could lead to endodontic failure. Mineral trioxide aggregate (MTA) has been regarded as an ideal material for perforation repair, retrograde filling, pulp capping, and apexification. This case report describes a furcal perforation in a maxillary first molar, which was repaired using MTA. The tooth was endodontically treated and coronally restored with resin composite. After 2 years, the absence of periradicular radiolucent lesions, pain, and swelling along with functional tooth stability indicated a successful outcome of sealing the perforation using MTA.

How to cite this article:
da Silva EN, Andrade CV, Tay LY, Herrera DR. Furcal-perforation repair with mineral trioxide aggregate: Two years follow-up.Indian J Dent Res 2012;23:542-545

How to cite this URL:
da Silva EN, Andrade CV, Tay LY, Herrera DR. Furcal-perforation repair with mineral trioxide aggregate: Two years follow-up. Indian J Dent Res [serial online] 2012 [cited 2021 Dec 1 ];23:542-545
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Full Text

Furcation perforations are significant iatrogenic complications of endodontic treatment and could lead to endodontic failure. [1] Perforations may occur during preparation of access cavities, post-space preparation or as a result of the extension of an internal resorption into the perirradicular tissues. [2] Factors that influence the outcome of perforated teeth include size of the perforation, time of repair, level and location of the perforation, presence of periodontal disease and pre-endodontic pulp vitality status. [3] On the basis of these characteristics, it can be decided if the perforation can be managed either surgically or non-surgically, and the prognosis is generally excellent if the problem is well diagnosed and the repair is well-performed with a material which can provide proper sealing ability and biocompatibility.

Historically, different materials have been used for furcal perforations, including amalgam, Intermediate Restorative Material (IRM), SuperEBA, Cavit, Glass Ionomer and composites; however,none fulfill the criteria of an ideal repair material which include the ability to seal and biocompatibility. [4] Mineral trioxide aggregate (MTA) has been regarded as an ideal material for perforation repair, retrograde filling, pulp capping, and apexification since its introduction in 1993. [5] The principle compounds present in MTA are several mineral oxides that are responsible for the chemical and physical properties of this material. [5] MTA is a mineral powder that consists of hydrophilic particles, with principal components as tricalcium silicate, tricalcium aluminate, tricalcium oxide, and other mineral oxides. It has a pH of 12.5, which is comparable to that of calcium hydroxide, and sets in the presence of moisture in approximately 4 hours. [5] MTA is currently marketed in 2 forms, gray (GMTA) and white (WMTA). Lower amounts of iron, aluminum, and magnesium are present in WMTA compared to GMTA.

When used as a repair material for furcal perforations, MTA has many favorable properties, including good sealing capability, biocompatibility, bactericidal activity, radiopacity, and ability to set up in the presence of blood. [5],[6] Several studies have shown better perforations' repair with MTA when compared with that repairs done with amalgam, IRM, Zinc oxide Eugenol (ZOE), or SuperEBA, by using both dye and bacteria leakage methods. [1],[4],[6] The biocompatibility makes MTA a suitable material for the treatment of root perforations with the goal of regenerating a periodontal attachment. [5],[6] It can also induce osteogenesis and cementogenesis. [6],[7] Perforated roots treated with MTA showed no inflammatory tissue layer, and root cementum was formed and attached to the MTA. [6] Thus, the following case report describes the repair of a furcal perforation in the maxillary molar tooth using MTA, and here, the underlying periodontal tissue healing could be observed radiographically at the 24-month follow-up.

 Case Report

A healthy 25 year old woman was referred to the Endodontics Department of Campinas State University, with pain in the left first maxillary molar, after attempting of endodontic treatment by her dentist one week before. The intraoral examination revealed that the tooth was sealed coronally with temporary cement. At the time of presentation, the tooth was sensitive to percussion and palpation. The mean probing pocket depth was within normal level (2 mm). Periradicular radiographic examination revealed a little radiolucent area in the furcal region of left first maxillary molar and apical radiolucencies from pulp necrosis were also observed [Figure 1]. Treatment options which were indicated for the tooth were extraction and non-surgical repair of the perforation. As per the patient preference, the option of saving the tooth via a non-surgical procedure, that is, furcal perforation repair with MTA was chosen.{Figure 1}

After the administration of local anesthesia 2% lidocaine with 1:100.000 epinephrine (Alphacaine, DFL), the tooth was isolated with a rubber dam, the temporary restorative material was removed and the access cavity was prepared, and the perforation area could be clinically seen. Hemorrhage was controlled with copious irrigation with 0.9% saline solution. A cotton pellet was placed in the orifice of perforation.The working length was then checked by using an apex locator (Novapex, Fórum Technologies, Israel). The root canals were cleaned and shaped using rotary files (Profile files, DentsplyMaillefer, Ballaigues, Switzerland) in a crown-down technique. Before the use of each instrument, an irrigation of the canal was performed using a syringe (27-gauge needle) containing 1 mL of 2% chlorhexidine (CHX) gel (Endogel, Itapetininga, SP, Brazil), and immediately rinsed afterwards with 3 mL of saline solution. After the root canals were dried with paper points, they were obturated. For obturation, gutta-percha points were used and Endomethasone N (Septodont, Saint-Maur, France) was used as a root canal sealer. The root canal sealer was mixed according to the manufacturer's instructions, and applied by coating the canal walls using the main cone itself.The root canals were then filled using the lateral condensation technique.

After the obturation of the root canals, the cotton pellet was removed from the perforation, exposing the site of the perforation [Figure 2]a. The furcal perforation was irrigated with saline solution and 2% chlorhexidine gel. MTA (Angelus, Londrina, Parana-Brazil) was prepared according to the manufacturer's instructions, and placed into the pulp chamber with an amalgam carrier [Figure 2]b. It was then gently packed with a cotton pellet to obtain a good adaptability [Figure 2]c. Afterward, the MTA and part of dental floor was covered with a resin composite (Filtek Z250, 3 M ESPE, Saint Paul, Minneapolis-USA) [Figure 2]d-f), and the tooth was restored usingglass ionomer cement. The patient was then referred for a permanent coronal restoration.{Figure 2}

The patient did not attend the recall of 6, 12 and 18 months as mentioned after the treatment. Only after 24 months, did the patient returned to the University complaining of pain in another tooth. At the two-year recall, the originally treated tooth remained asymptomatic. The clinical examination showed that the tooth had no pain, and no response to percussion, palpation and there were no attachment loss or periodontal problems, as indicated by normal probing depths. The tooth revealed adequate clinical function, and radiographic findings showed adequate sealing of the perforation region with no radiolucency at the furcal area [Figure 3].{Figure 3}


The clinical applications of MTA have proved that it is suitable for solving the problems derived from perforation. [2],[3],[8] The desirable properties of MTA make it a useful material in repairing the root and furcal perforations. MTA offers a biologically active substrate for bone and cells, and osteoblasts also have shown a favorable response to MTA. [5],[6],[8] It has also no mutagenic potential, low cytotoxicity, and stimulates the formation of mineralized tissue. [2],[3],[5],[6],[8] The high levels of calcium leached out from the cement also account for it biocompatibility. [3],[5],[8] One of the factors influencing the prognosis of furcal perforations is the period of time elapsed since the occurrence of the perforation, as the possibility of an infection in the wound site increases with the passing time. [6],[8] Immediate sealing of perforations enhances the repair process due to the reduced possibility of bacterial contamination of the defect. Root perforations sealed after contamination presented worse repair than the non-contaminated and immediately sealed perforations. [8] Previous studies have shown that the time gap from the time of the perforation, till the time of repair should not exceed 6 months. [9] In our case, the time elapsed between the perforation and treatment instituted was one week. Even though the tooth was sealed coronally with only temporary cement, the material was present even at the time of presentation, thus avoiding contamination.

The control of inflammatory processes in the defect area during the management of perforation represents one of the main goals of the treatment, in addition to promoting the health of the surrounding tissue. [9] To achieve a better tissue response, the perforation sites were disinfected with 2% chlorhexidine gel. In this case, we decided not to use sodium hypochlorite (NaOCl) because it is known that it can be extremely aggressive, and cause damage to the surrounding tissues. Chlorhexidine has been recommended by several authors as an auxiliary chemical substance, [10] as, in addition to being relatively non-toxic when compared to NaOCl, it has excellent antimicrobial power and prolonged time of action. [10] These properties may offer clinical advantages of using chlorhexidine in furcal perforations.

Because of the hydrophilic characteristics of MTA, moisture in the surrounding tissue acts as an activator of a chemical reaction in this material. [5] To assure proper setting, some authors suggested that moisture must be provided from the internal aspect of the teeth by using a wet cotton pellet. [2] In our case, blood from the site of perforation was adequate to keep the hydrophilic powder moist, and thus the use of cotton pellet could be avoided. After the insertion of MTA, a resin composite was used to cover the MTA and a part of dental floor. As MTA is not an adhesive material, it could suffer a displacement during the coronal restoration of the tooth. Hence, resin composite was used to ensure that MTA did not suffer any kind of dislodgement. Resin composite could also reinforce the tooth structure as MTA is not a hard enough material.MTA is a suitable material for the treatment of furcal perforations, with the goal of regenerating periodontal attachment. In this case, furcal perforation of the maxillary left first molar was treated using non-surgical placement of MTA. The repaired tooth was clinically and radiographically healthy and continued to satisfy the functional demands. Based on the outcome of the case presented, MTA is a good material for the repair of furcal perforations, and has been proven effective even for larger perforations.


The authors deny any conflicts of interest related to this study.


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