Abstract This is a successfully managed clinical case report of a young lady whose tooth # 11 was root treated in 2010 which reinfected after three years. The root treatment was repeated but was iatrogenically perforated because of the operating dentist&apos;s error. The tooth was therefore opened for surgical correction. During the procedure, it was found that labial wall of the tooth was missing in the mid-root area. The labial wall was built using glass ionomer cement keeping the endodontic file in the canal to avoid obliteration of canal space by glass ionomer. The rebuilt canal was treated with Calcium Hydroxide dressings at an interval of 7 days. In two weeks as the sinus healed, swelling subsided and the canal became effortlessly dryable using just two absorbent points, the canal was obturated with a custom made gutta percha cone, employing glass ionomer as a canal sealer

Asaad Javaid Mirza

Khalid Shafiq

Maaz Asad

Shaheen Abubakar

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International Journal of Dental Sciences and Research, 2016, Vol. 4, No. 3, 49-51 
Available online at http://pubs.sciepub.com/ijdsr/4/3/4 
© Science and Education Publishing 
DOI:10.12691/ijdsr-4-3-4 
Repair of Accidentally Perforated Labial Wall of a 
Central Incisor Having Failed Root Treatment – A Case 
Report  
Asaad Javaid Mirza1,*, Khalid Shafiq2, Maaz Asad3, Shaheen AbuBakar2 
1Department of Restorative Dental Sciences, College of Dentistry, Ha’il University, KSA 
2Department of Operative Dentistry, Baqai Dental College, Baqai Medical University, Karachi 
3Department of Periodontolgy, Baqai Dental College, Baqai Medical University, Karachi 
*Corresponding author: asaajmirza@gmail.com 
Abstract  This is a successfully managed clinical case report of a young lady whose tooth # 11 was root treated in 
2010 which reinfected after three years. The root treatment was repeated but was iatrogenically perforated because 
of the operating dentist’s error. The tooth was therefore opened for surgical correction. During the procedure, it was 
found that labial wall of the tooth was missing in the mid-root area. The labial wall was built using glass ionomer 
cement keeping the endodontic file in the canal to avoid obliteration of canal space by glass ionomer. The rebuilt 
canal was treated with Calcium Hydroxide dressings at an interval of 7 days. In two weeks as the sinus healed, 
swelling subsided and the canal became effortlessly dryable using just two absorbent points, the canal was obturated 
with a custom made gutta percha cone, employing glass ionomer as a canal sealer. 
Keywords: root perforation, endodontic procedural errors, iatrogenic perforation 
Cite This Article: Asaad Javaid Mirza, Khalid Shafiq, Maaz Asad, and Shaheen AbuBakar, “Repair of 
Accidentally Perforated Labial Wall of a Central Incisor Having Failed Root Treatment – A Case Report.” 
International Journal of Dental Sciences and Research, vol. 4, no. 3 (2016): 49-51. doi: 10.12691/ijdsr-4-3-4. 
1. Introduction 
Root perforation is an unnatural communication between 
root canal system and its periodontal apparatus of an 
affected tooth. It occurs due to radicular pathology or as 
consequence of procedural error by the dentist [1]. The 
procedural mistake (iatrogenic perforation) may happen 
during access preparation, canal location, canal instrumentation 
or post -space creation [2] in 2-12 % of endodontically 
treated teeth [3].  
The clinical case report presents the management of 
accidental perforation which took place when the dentist 
attempted to remove the root filling done three years ago. 
2. History 
A 21-year old female was referred to outpatient department 
of Endodontic division at Baqai Dental College Hospital. 
The patient’s chief complaint was pain and swelling in the 
region of her upper anterior teeth (Figure 1). Her physical 
and mental health was sound and medical history was 
non-contributory. On the contrary, the Past Dental History 
she narrated was attention-grabbing. It revealed that she 
underwent root treatment of the tooth # 11 in 2010 and 
was referred to the Orthodontic Department for alignment 
of her misaligned teeth. On completion of Orthodontic 
treatment in three years, she developed infection in the same 
tooth again. The patient came back to the Endodontic 
division where RCT was repeated by some junior doctor. 
The patient remained symptoms free for a period of 4 
months after the redoing when she felt tenderness and 
slight swelling in the same area. She also complained of 
persistent but insignificant salty taste. Intraoral 
examination showed a draining sinus on the labial 
gingival mucosa opposite to mid-root area and grade -2 
mobility of tooth # 11. Extraoral examination did not 
divulge any abnormality except minor swelling of upper 
lip. The perforation in the root apical to crestal bone was 
apparent on the Periapical I/O radiographs (Figure 2) but 
damage to labial wall was not detectable as diagnostic 
value of a radiograph is restricted in case of palatal or 
labial wall destruction [4]. 
 
Figure 1. Draining sinus & upper Lip swelling 
 
Figure 2. Root perforation apical to bone crest visible 
50 International Journal of Dental Sciences and Research  
3. Treatment 
Patient’s consent was taken for surgical correction of 
the midradicular perforation. A trapezoidal flap was raised 
exposing maxillary bone from distal aspect of tooth #11 to 
distal aspect of tooth #21. Previously filled gutta percha 
was clearly evident (Figure 3) which was removed using 
‘H” file and Gates Glidden burs. Working length was 
reestablished (Figure 4) and canal was apically prepared 
with size 80 of ‘K’ file. A custom made Gutta Percha 
(GP)( Diadent, Korea) cone was prepared by slightly 
heating and rolling multiple GP points (Figure 5) in 
between two clean glass slabs. The marginally loose GP 
was trial tested in the prepared canal and preserved in an 
empty container of GP points. The middle part of labial 
wall of the root of tooth # 11 was so extensively damaged 
that the file inserted into the canal was openly visible 
(Figure 6). It required build up. Leaving the file in the canal 
up to full working length, conventional glass ionomer 
cement (Fuji GC, USA) (GIC)was used to construct the 
lost part of labial wall (Figure 7). To enhance bonding 
between GIC and damaged root and reconditioning of root 
surface a two minutes application of citric acid was 
performed. This application is recommended to etch 
diseased root surfaces in order to facilitate formation of 
new attachment and cementogenesis [5]. After rock- hard 
setting of GIC, the flap was sutured back in its place. The 
patient was advised rest for 24 hours with Capsule 
Amoxicillin 250 mg every 8 hourly for five days and 
Tablet Ibuprofen 400mg every 12 hourly for two days. 
Sutures were removed after five days after which Calcium 
Hydroxide treatment of the canal was performed using 
non-setting calcium Hydroxide (Pulpdent Corporation). 
The Calcium Hydroxide dressing was changed on 7th and 
14th days until the canal became easily dryable using 
merely two absorbent points. Each absorbent point was 
left in the canal for 15 seconds. Surgical wound and sinus 
tract also had healed i. The canal was then obturated with 
the preserved GP as core material and glass ionomer based 
sealer (3 M ESPE) as sealing material in a conventional 
manner. This technique helped to fill GP without applying 
any pressure for condensation. Application of any pressure 
might have caused failure of the constructed labial wall. 
The access -opening was filled with resin composite. 
 
Figure 3. Previously filled GP visible after flap reflection 
 
Figure 4. New working established. Big apical radiolucency is visible 
 
Figure 5. Custom made GP cone 
 
Figure 6. Extensive loss of labial wall showing inserted file 
 
Figure 7. Wall fabricated using GIC 
In a follow up after eight months, it was observed that 
the patient was clinically comfortable having no intra or 
extraoral sign and symptoms (Figure 8). Radiographically, 
periapical radiolucency had decreased as bone was seen 
forming around the apex (Figure 9). 
 
Figure 8. Patient feeling comfortable after wound healing 
 
Figure 9. Tooth standing firm with reduced radiolucency after eight 
months 
4. Discussion 
Radicular perforations if left untreated, have many 
complications which may lead to inflammation of 
periodontium with eventual loss of the tooth [6]. Majority 
of perforations occur in maxillary anterior teeth involving 
labial walls [7]. Also in this case, perforation occurred 
 International Journal of Dental Sciences and Research 51 
through the labial wall which like other such perforations, 
posed a challenge in diagnosis and its management [8]. 
Another reason for electing surgical repair of this case was 
location of the perforation. The perforations on cervical 
third of a root have adverse effect on the prognosis [9]. 
Moreover, perforations occurring closer to alveolar bone 
crest is highly perilous and have poor prognosis as they 
create a periodontal defect [10] but those apical to crestal 
bone have better success rate if endodontic treatment is of 
high quality as it reduces the chances of producing 
periodontal pockets [11]. In this case, as the perforation 
was apical to crest, best efforts were exercised to attain an 
unblemished root treatment. 
The other difficulties faced during the accomplishment 
of the case were; controlling hemorrhage, selecting 
material for the lost wall fabrication, keeping the patency 
of root canal space intact and finally hermetic obturation 
without condensation pressure. 
Hemorrhage control is very important not only to keep 
the operating sight clearly visible but also to avoid 
contamination of the restorative material during unset 
state. In this case GIC – a very technique sensitive 
material was used for rebuilding the labial wall. Minor 
contamination with blood might cause failure of the 
optimal properties GIC gives in a perfectly isolated 
condition. It was therefore mandatory to attain bloodless 
field. To achieve this, a gauze pellet soaked in 0.5 % 
Povidone Iodine was placed in the periapical cavity for a 
minute and then the wound was flooded with normal 
saline [12]. 
A variety of biorestorative material have been tried and 
tested for managing root perforations. Glass ionomer is 
one of the materials used with abundant success as its 
properties highly suit such applications. It is frequently 
used for retrograde obturation, closing of perforations, 
especially those located in the cervical third, where use of 
adhesive restorative materials has been recommended [13]. 
While using glass ionomer for wall construction, there 
was a danger that having good flowing property, it will 
occupy the canal space and obliterate the canal. To 
overcome this issue, a thick endodontic file with slight 
coating of cocoa butter to avoid its adhesion with glass 
ionomer, was kept in the canal space to the full working 
length. Once the glass ionomer set hard, the file was 
retrieved gently as patency of the canal was thus 
maintained. Using any condensation pressure during 
obturation would have been detrimental. The newly built 
labial wall might have crumbled under the condensation 
force. This problem was resolved with the use of a custom 
made GP cone prepared while the canal was open, easily 
accessible and visible with the naked eye. The slightly 
loose fit cone when loaded with GIC based sealer fitted 
well inside the canal. 
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[7] Kvinnsland, I., Oswald, R.J., Halse, A., Gronningdeter, A.G., A 
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[9] Dotto RF, Barbosa AN, Dotto SR, Hermes CR. Sealing of root 
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[10] Seltzer S, Sinai I, August D. Periodontal effects of root 
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[11] Beavers RA, Bergenholtz G, Cox CF. Periodontal wound healing 
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Repair of Accidentally Perforated Labial Wall of a Central Incisor Having Failed Root Treatment -A Case Report

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Repair of Accidentally Perforated Labial Wall of a Central Incisor Having Failed Root Treatment -A Case Report

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