Root perforation is a significant complication during root canal treatment. Root perforation can result in loss of integrity of the root structure and severe periodontal and bone defect. Repair of lateral root perforation presents a clinical challenge to the operator. This report is of root perforation during post space preparation in a right maxillary central incisor that has caused an extensive periodontal lesion. Since the bone lesion was large and unreachable from either a coronal access cavity or buccal surgical flap, a combination of mineral trioxide aggregate sealing, bone grafting, and intentional replantation was used as the method of treatment. The patient’s symptoms ceased and the existing lesions resolved during the 5-year follow-up.published_or_final_versio

Chan, AWK

Dissanayaka, WL

Zhang, C

HKU Scholars Hub

Title Mineral trioxide aggregate repair of lateral root perforation usingintentiional replantation and bone graftingAuthor(s) Zhang, C; Chan, AWK; Dissanayaka, WLCitation Hong Kong Dental Journal, 2011, v. 8 n. 1, p. 51-55Issued Date 2011URL http://hdl.handle.net/10722/134992Rights Creative Commons: Attribution 3.0 Hong Kong License   © Hong Kong Dental Association    51Mineral trioxide aggregate repair of lateral root perforation using intentional replantation and bone graftingCorrespondence	to:Dr.	Chengfei	Zhang3A15,	Prince	Philip	Dental	Hospital,	34	Hospital	Road,	Hong	KongTel	 :	(852)	2859	0287Fax	 :	(852)	2559	9013email	 :	zhangcf@hku.hkABSTRACTRoot	perforation	is	a	significant	complication	during	root	canal	treatment.	Root	perforation	can	result	in	loss	of	integrity	of	the	root	structure	and	severe	periodontal	and	bone	defect.	Repair	of	lateral	root	perforation	presents	a	clinical	challenge	to	the	operator.	This	report	is	 of	 root	perforation	during	post	 space	preparation	 in	 a	 right	maxillary	 central	 incisor	that	 has	 caused	 an	 extensive	 periodontal	 lesion.	 Since	 the	 bone	 lesion	was	 large	 and	unreachable	from	either	a	coronal	access	cavity	or	buccal	surgical	flap,	a	combination	of	mineral	trioxide	aggregate	sealing,	bone	grafting,	and	intentional	replantation	was	used	as	 the	 method	 of	 treatment.	 The	 patient’s	 symptoms	 ceased	 and	 the	 existing	 lesions	resolved	during	the	5-year	follow-up.Key words:	Root	canal	therapy;	Treatment	outcomeHong Kong Dent J 2011;8:51-5Chengfei Zhang*†DDS,	PhDAlex Wai-Kwok Chan*BDS,	MDS,	MSc,	FRACDS,	FCDSHK,	FHKAM	(Dental	Surgery)	Waruna Lakmal Dissanayaka*BDS	*	 Comprehensive	Dental	Care,	Endodontics,	Faculty	of	Dentistry,	The	University	of	Hong	Kong†	 Endodontic	Section,	Special	Dental	Service	Department,	Peking	University	School	and	Hospital	of	Stomatology,	Beijing,	ChinaIntroductionRoot	perforation	may	occur	during	 root	 canal	 therapy,	 post	 space	preparation,	 or	 as	 a	result	of	caries	or	internal	resorption	1.	Such	perforations	result	in	loss	of	integrity	of	the	root	and	the	destruction	of	adjacent	periodontal	tissues.	When	the	tooth	has	a	strategic	value,	repair	of	the	perforation	is	indicated.	This	can	be	carried	out	through	the	coronal	access	cavity	 (intracanal	 repair)	or	by	surgical	 intervention	2.	Many	materials	have	been	used	 to	 repair	perforations,	 including	amalgam,	Cavit	 (3M	ESPE	AG,	Seefeld,	Germany),	super	 ethoxybenzoic	 acid	 (super	 EBA),	 glass	 ionomer	 cement,	 and	 mineral	 trioxide	aggregate	 (MTA).	 The	 success	 of	 these	 materials	 has	 been	 variable,	 but	 MTA	 shows	 a	marked	improvement	in	the	prognosis	3.This	 report	 describes	 the	 treatment	 of	 a	 lateral-palatal	 perforation	 in	 a	 maxillary	central	 incisor	 using	 a	 combination	 of	 MTA	 sealing,	 bone	 grafting,	 and	 intentional	replantation.	Case reportIn	 2003,	 a	 23-year-old	Chinese	woman	presented	 to	 the	 Endodontic	 Section	of	 Peking	University	 School	of	 Stomatology,	 Beijing,	China,	with	pain,	 buccal	 swelling,	 and	 tooth	mobility	 in	 the	 right	maxillary	 central	 incisor	 region.	There	was	 a	 history	 of	 root	 canal	treatment	on	a	tooth	with	a	vital	pulp	and	post-crown	restoration	of	the	right	maxillary	CASE REPORT 52   Hong Kong Dent J Vol 8 No 1 June 2011Zhang et alloss	 of	 the	 labial	 cortical	 plate,	 was	 observed	 mesial	 to	the	 right	 maxillary	 incisor.	 The	 tooth	 was	 extracted	 with	minimal	 trauma	 and	 placed	 in	 a	 sterile	 saline	 solution.	The	 perforation	 area	 was	 prepared	 by	 ultrasonic	 retro-tip	 (P5	 Ultrasonic	 Retrotips;	 Satelec,	 Mérignac,	 France)	as	 for	 a	 retrograde	 root	 canal	procedure	 in	 apical	 surgery	and	repaired	by	MTA	(ProRoot	MTA;	Dentsply	Tulsa	Dental	Specialties,	Tulsa	[OK],	USA)	[Figure	2].	Debridement	of	the	tissue	at	the	defect	site	was	followed	by	irrigation	with	sterile	saline	solution.	During	the	preparation,	the	metal	post	was	dislodged	and	the	post	space	was	filled	with	glass	ionomer	cement.	The	tooth	was	replanted	into	the	alveolus	without	a	 splint	within	 10	minutes	 after	 extraction.	 Graft	material	(BIO-Oss;	Geistlich	Pharma	AG,	Wolhusen,	Switzerland)	was	mixed	with	a	little	of	the	patient’s	blood	and	packed	into	the	defect.	The	flap	was	sutured	with	Vicryl	sutures	(Ethicon	Inc.,	Somerville	[NJ],	USA).	Ibuprofen	400	mg	3	times	a	day	orally	for	2	days,	as	well	as	amoxicillin	500	mg	3	times	a	day	orally	for	5	days	were	given.	Also,	0.2%	chlorhexidine	gluconate	mouth	rinse	was	prescribed	for	7	days.At	the	3-month	recall	examination,	the	sinus	tract	was	healed	and	the	patient	was	asymptomatic.	At	the	6-month	recall,	a	new	post	and	crown	were	placed.	The	radiolucency	was	 absent	 at	 the	 6-month,	 1-year,	 and	 5-year	 follow-up	visits	 (Figure	 3).	 However,	 at	 the	 6-year	 recall	 examination	the	sinus	tract	was	again	noted	and	a	radiolucent	lesion	was	present	at	the	repair	site	(Figures	4	and	5).	The	patient	had	remained	 asymptomatic.	 The	 patient	 was	 referred	 to	 the	central	incisor	3	years	previously.	The	medical	history	of	the	patient	was	non-contributory.	On	examination,	the	maxillary	central	 incisor	 exhibited	 grade	 III	 mobility	 with	 a	 swelling	and	sinus	tract	on	the	labial	side	of	the	alveolus.	A	periapical	radiograph	revealed	a	post	in	the	root	canal,	which	deviated	to	 the	mesial	 root	 surface	with	a	 lateral	 root	perforation.	A	large	 apical	 and	 lateral	 radiolucency	 presented	 adjacent	 to	the	perforation	(Figure	1).	Owing	to	the	technical	difficulties	for	 intracoronal	 retreatment,	 a	 combination	 of	 intentional	replantation	with	perforation	 repair,	 curettage	of	 inflamed	tissue,	and	bone	graft	was	planned.	The	guarded	nature	of	the	 prognosis	 was	 explained	 to	 the	 patient	 and	 consent	obtained.A	 full-thickness	 mucoperiosteal	 flap	 was	 elevated	under	 local	anesthesia	(Xylestesin-A;	3M	ESPE	AG,	Seefeld,	Germany)	 extending	 from	 distal	 to	 the	 right	 maxillary	lateral	 incisor	 to	distal	 to	 the	 left	maxillary	 central	 incisor.	A	 large	 bony	 defect	 of	 10	 x	 8	mm	 in	 size,	with	 complete	Figure 1 Periapical	radiograph	showing	a	post	in	the	root	canal	with	a	perforation	at	the	site	of	the	post	end.	A	large	apical-lateral	radiolucency	was	also	observedFigure 2 Extracted	tooth	after	the	mineral	trioxide	aggregate	repair   Hong Kong Dent J Vol 8 No 1 June 2011    53Treatment of lateral perforationFigure 4 Radiolucent	lesion	at	repair	site	at	6-year	recallFigure 3 (a)	The	tooth	replanted;	(b)	the	tooth	after	6	months	with	a	new	post-crown	restoration;	and	(c)	apical	radiolucency	was	absent	at	5-year	recall(a) (b) (c)Figure 5 Sinus	at	the	apical	region	at	6-year	recall54   Hong Kong Dent J Vol 8 No 1 June 2011Zhang et alresults	in	increased	amount	of	bone,	periodontal	ligament,	and	 cementum	 formation	when	 compared	with	open	flap	debridement	in	a	canine	model.The	 indications	 of	 apical	 surgery	 include	 the	 inability	to	negotiate	the	canal	due	to	canal	blockages	or	nonsurgical	revision	 resulting	 in	 significant	 destruction	 of	 dentin	 and	compromising	 the	 tooth	 structure	 12.	 The	 patient	 in	 this	report	had	a	metal	post,	perforation,	and	a	large	apical-lateral	lesion.	 Apical	 surgery	 with	 bone	 graft	 was	 the	 standard	method	of	treatment	indicated.	However,	for	root	perforation	management,	 the	 lateral-palatal	 site	was	unreachable	 from	the	surgical	opening,	and	therefore	intentional	replantation	was	necessary	for	complete	sealing	of	the	perforation	by	MTA.The	 main	 cause	 of	 failure	 in	 intentionally	 replanted	teeth	 is	 external	 root	 resorption	 and	 ankylosis	 caused	by	 damage	 to	 the	 periodontal	 ligament	 13,14.	 The	 ideal	treatment	 for	 the	 avulsed	 tooth	 is	 to	 replace	 it	 into	 the	socket	 as	 soon	 as	 possible.	 Regardless	 of	 the	 extraoral	period,	 the	 age	 of	 the	 patient,	 or	 whether	 the	 tooth	 is	intentionally	extracted	and	replanted	within	the	socket,	the	prognosis	 is	guarded	because	the	 likelihood	of	 replacement	resorption	is	high	12.	Regarding	our	patient,	the	presence	of	periodontal	 inflammation	 and	 bone	 resorption	were	 poor	prognostic	indicators	for	intentional	replantation.	However,	root	resorption	and	sinus	tract	formation	was	observed	only	6	years	after	the	operation.Traditionally,	 a	 tooth	 with	 a	 large	 apical	 lesion	 and	lateral	perforation	is	an	indication	for	extraction	if	it	cannot	be	treated	surgically.	Based	on	our	patient,	a	combination	of	intentional	replantation,	bone	graft,	and	MTA	repair	might	be	a	possible	choice	of	treatment	for	a	patient	who	is	reluctant	to	have	the	tooth	removed.	However,	due	to	the	poor	long-term	 prognosis,	 the	 ideal	 mode	 of	 treatment	 would	 be	extraction	of	the	tooth	and	immediate	replacement	with	an	implant	or	a	bridge.Division	of	Implantology	for	consideration	of	the	extraction	of	the	tooth	and	replacement	with	an	implant.DiscussionThe	 foremost	 factors	 that	 determine	 the	 success	 of	 root	perforation	repair	are	its	size	and	location,	the	time	elapsed	since	 the	 perforation	 occurred,	 the	 presence	 or	 absence	of	 infection,	 and	 the	 sealing	 ability	 and	 biocompatibility	of	 the	repair	material	 1,3.	The	main	goal	of	management	of	a	 perforation	 is	 to	 arrest	 the	 inflammatory	process	 and	 to	preserve	the	healthy	tissues	at	the	site	of	the	perforation.	If	a	 lesion	already	exists,	 as	 in	 this	patient,	 it	 is	 important	 to	restore	the	tissue	attachment	and	regenerate	the	lost	bone	4.Many	materials	have	been	used	to	repair	perforations	including	amalgam,	Cavit,	super	EBA,	glass	ionomer	cement,	and	MTA.	In	addition	to	providing	a	good	seal,	the	materials	for	 repair	 of	 root	 perforations	 must	 be	 biocompatible,	nontoxic,	 insoluble	 in	 the	 presence	 of	 tissue	 fluids,	 and	capable	 of	 promoting	 regeneration	 of	 the	 periradicular	tissues.	Based	on	 the	outcome	of	 some	 studies,	MTA	 is	 an	excellent	material	 for	 the	 repair	 of	 perforations	 at	 various	levels	of	the	root	5,6.The	successful	treatment	of	a	periapical	 inflammatory	lesion	 depends	 on	 reduction	 and	 elimination	 of	 the	offending	 organisms.	 Root	 canal	 therapy,	 periapical	surgery,	or	extraction	of	the	tooth	might	be	the	treatment	alternatives.	Periapical	surgery	includes	the	curettage	of	all	periapical	soft	tissues,	and	sometimes	application	of	different	biomaterials	to	enhance	new	bone	formation	at	the	defect	site.	 Bone	 grafts	 and	 barrier	 membranes	 can	 be	 used	 to	achieve	optimal	healing	and	regeneration	of	the	periapical	defect	 area	 after	 degranulation	 of	 the	 lesion	 7-9.	 Several	recent	studies	10,11	have	shown	that	treatment	of	perio-endo	lesions	 using	 biodegradable	 collagen	 membranes,	 alone	or	 in	 combination	 with	 an	 organic	 bovine	 bone	 matrix,	References1.	 Fuss	Z,	Trope	M.	Root	perforations:	classification	and	treatment	choices	 based	 on	 prognostic	 factors.	 Endod	 Dent	 Traumatol	1996;12:255-64.2.	 Yildirim	 G,	 Dalci	 K.	 Treatment	 of	 lateral	 root	 perforation	 with	mineral	 trioxide	 aggregate:	 a	 case	 report.	 Oral	 Surg	 Oral	Med	Oral	Pathol	Oral	Radiol	Endod	2006;102:e55-8.3.	 Main	 C,	 Mirzayan	 N,	 Shabahang	 S,	 Torabinejad	 M.	 Repair	 of	root	perforations	using	mineral	trioxide	aggregate:	a	long-term	study.	J	Endod	2004;30:80-3.4.	 Bashutski	JD,	Wang	HL.	Periodontal	and	endodontic	regeneration.	   Hong Kong Dent J Vol 8 No 1 June 2011    55Treatment of lateral perforationJ	Endod	2009;35:321-8.5.	 Torabinejad	M,	Chivian	N.	Clinical	applications	of	mineral	trioxide	aggregate.	J	Endod	1999;25:197-205.6.	 Holland	R,	Filho	JA,	de	Souza	V,	Nery	MJ,	Bernabé	PF,	Junior	ED.	Mineral	 trioxide	aggregate	 repair	of	 lateral	 root	perforations.	 J	Endod	2001;27:281-4.7.	 Hiremath	H,	Gada	N,	Kini	Y,	Kulkarni	S,	Yakub	SS,	Metgud	S.	Single-step	apical	barrier	placement	 in	 immature	 teeth	using	mineral	trioxide	aggregate	and	management	of	periapical	inflammatory	lesion	 using	 platelet-rich	 plasma	 and	 hydroxyapatite.	 J	 Endod	2008;34:1020-4.8.	 Stassen	LF,	Hislop	WS,	Still	DM,	Moos	KF.	Use	of	anorganic	bone	in	 periapical	 defects	 following	 apical	 surgery—a	 prospective	trial.	Br	J	Oral	Maxillofac	Surg	1994;32:83-5.9.	 Uchin	 RA.	 Use	 of	 a	 bioresorbable	 guided	 tissue	membrane	 at	an	adjunct	to	bony	regeneration	in	cases	requiring	endodontic	surgical	intervention.	J	Endod	1996;22:94-6.10.	 Taschieri	 S,	 Del	 Fabbro	 M,	 Testori	 T,	 Saita	 M,	 Weinstein	 R.	Efficacy	 of	 guided	 tissue	 regeneration	 in	 the	management	 of	through-and-through	 lesions	 following	 surgical	 endodontics:	a	 preliminary	 study.	 Int	 J	 Periodontics	 Restorative	 Dent	2008;28:265-71.11.	 Britain	SK,	Arx	T,	Schenk	RK,	Buser	D,	Nummikoski	P,	Cochran	DL.	The	use	of	guided	tissue	regeneration	principles	in	endodontic	surgery	 for	 induced	 chronic	 periodontic-endodontic	 lesions:	 a	clinical,	 radiographic,	 and	 histologic	 evaluation.	 J	 Periodontol	2005;76:450-60.12.	 Gutmann	 JL,	 Dumsha	 T,	 Lovdahl	 P.	 Problem	 solving	 in	endodontics:	 prevention,	 identification,	 and	management.	 4th	ed.	London:	Elsevier	Mosby;	2006.13.	 Drain	DE,	Petrone	JA.	Intentional	replantation:	a	case	report	and	review	of	the	literature.	J	N	J	Dent	Assoc	1995;66:63-5.14.	 Al-Hezaimi	 K,	 Naghshbandi	 J,	 Simon	 JH,	 Rotstein	 I.	 Successful	treatment	of	a	radicular	groove	by	intentional	replantation	and	Emdogain	therapy:	four	years	follow-up.	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Mineral trioxide aggregate repair of lateral root perforation using intentiional replantation and bone grafting

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Mineral trioxide aggregate repair of lateral root perforation using intentiional replantation and bone grafting

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