Journal of Conservative Dentistry
Home About us Editorial Board Instructions Submission Subscribe Advertise Contact e-Alerts Login 
Users Online: 1032
Print this page  Email this page Bookmark this page Small font sizeDefault font sizeIncrease font size

Table of Contents   
Year : 2011  |  Volume : 14  |  Issue : 1  |  Page : 83-85
Non surgical perforation repair by mineral trioxide aggregate under dental operating microscope

Department of Conservative Dentistry and Endodontics, Dr. R Ahmed Dental College and Hospital, Kolkatta, India

Click here for correspondence address and email

Date of Submission01-Apr-2009
Date of Decision18-Apr-2009
Date of Acceptance18-Mar-2010
Date of Web Publication11-May-2011


Root perforation repair has historically been an unpredictable treatment modality, with an unacceptably high rate of clinical failure. Recent developments in the techniques and materials utilized in root perforation repair have dramatically enhanced the prognosis of both surgical and nonsurgical procedures. Mineral Trioxide Aggregate is a relatively new material that is being successfully used to repair perforations. Technological advancements such as the use of a Dental Operating Microscope for correction of these inevitable procedural errors are a major breakthrough in dentistry today. This article presents one clinical case of nonsurgical root perforation repair by Mineral Trioxide Aggregate, using the Dental Operating Microscope.

Keywords: Perforation; mineral trioxide aggregate; microscope

How to cite this article:
Biswas M, Mazumdar D, Neyogi A. Non surgical perforation repair by mineral trioxide aggregate under dental operating microscope. J Conserv Dent 2011;14:83-5

How to cite this URL:
Biswas M, Mazumdar D, Neyogi A. Non surgical perforation repair by mineral trioxide aggregate under dental operating microscope. J Conserv Dent [serial online] 2011 [cited 2023 Sep 28];14:83-5. Available from:

   Introduction Top

Root perforations are undesired complications of endodontic treatment. Once a perforation has been diagnosed, treatment must be rendered to seal the perforation site effectively to minimize injury and prevent contamination of the surrounding periodontal attachment apparatus. Although successful treatment and prognosis depend on many factors, the location of the perforation and the time lapse between exposure and repair are the two most important factors for determining the treatment and prognosis of the tooth. [1],[4] Perforations have been treated mainly through surgical means earlier. However, now, with the introduction and widespread use of the operating microscope, together with the power of ultrasonics, the nonsurgical repair of perforation is more predictable, safe, and easy. [1],[2]

This present case illustrates concepts and techniques of using the operating microscope to visualize and repair the perforation nonsurgically.

   Case Report Top

A 35-year-old female patient reported to the Department of Conservative Dentistry and Endodontics, Dr. R. Ahmed Dental College and Hospital, Kolkata, with pain in tooth No 11. She gave a history of root canal treatment (RCT) having been attempted elsewhere on that tooth, about one month prior.

Clinical examination revealed that access preparation had been attempted in the grossly carious maxillary right central incisor. Under rubber dam isolation, the access opening was carefully examined under a Dental Operating Microscope (FS - 1-11; MOELLER - WEDDEL INTERNATIONAL, Germany) (16X Magnification). Distolateral midroot perforation with ledge formation was clearly visualized under the microscope [Figure 1].
Figure 1: Perforation site in disto-lateral mid-root area of tooth 11 under Microscope in 16X magnification

Click here to view

An intraoral periapical radiograph was taken with a #60 size gutta percha (GP) point placed in the perforation, which aided in further localizing the site of the perforation, and it was confirmed that the defect was subcrestal [Figure 2]. A slight periodontal ligament (PDL) widening was seen.

The decision to nonsurgically manage the perforation using Mineral Trioxide Aggregate, under a Dental Operating Microscope, was taken with the patient's consent.
Figure 2: IOPA radiograph of tooth 11 with GP point placed through the perforation

Click here to view

The lateral walls of the perforation were refined and cleaned with light brushing strokes using an Endo 4 ultrasonic tip (Dentsply Tulsa Dental, Tulsa, Oklahoma). Hemostasis was achieved. A #60 size gutta percha point was used to establish the length from the incisal reference point up to the perforation site inside the root canal. [1] Healiguide (ENCOLL, Fremont, CA, USA), an absorbable collagen material was chosen to provide complete hemostasis and a controlled barrier, to pack the restorative material against it. Working length was established and a #40 size GP point was placed in the canal [Figure 3]. Pieces of healiguide were appropriately cut and carried out into the access cavity [Figure 4]. These were progressively placed into the chamber with an appropriate plugger and firmly pressed through the perforation defect. A solid barrier was established [Figure 5]. The access cavity and perforation defect were flushed thoroughly with normal saline and dried. Mineral trioxide aggregate (MTA - ANGELUS; Peterborough, UK) was mixed and carried to the perforation site with the help of a carrier and packed with an appropriately fitted plugger. Repair of the perforation was carried out by progressive placement and packing of small increments of the Mineral Trioxide Aggregate. The gutta percha point was removed and moist cotton pellets were placed over the Mineral Trioxide Aggregate, and closed with noneugenol temporary restoration (Cavit, 3MESPE). The Mineral Trioxide Aggregate was allowed to set for approximately four hours and the patient was recalled after four hours. The canal was opened and it was found that the well-adapted, hard Mineral Trioxide Aggregate had sealed the perforation site and ledge area [Figure 6]. Biomechanical preparation was carried out using the step back method. Apical preparation was performed up to size #60 and obturation was done by lateral condensation of the gutta percha [Figure 7].
Figure 3: GP point placed in the canal

Click here to view
Figure 4: Piece of Healiguide resorbable collagen matrix carried out into the access cavity

Click here to view
Figure 5: Collagen matrix placed corresponding to the cavosurface of the root

Click here to view
Figure 6: After 48 hours well adapted hard MTA visible under 24X magnification - completely filled the perforation defect

Click here to view
Figure 7: Obturation done in tooth 11

Click here to view

After one month the patient was recalled and was found to be asymptomatic. The glass fiber post was cemented by dual cure resin cement (Calibra - DENTSPLY). The crown was restored by a light cure composite resin [Figure 8]. A one-year recall examination, clinically demonstrated an asymptomatic tooth, with normal attachment and architecture of the soft tissues. A radiographic analysis at this recall evaluation revealed no development of a periapical lesion and no further widening of the PDL [Figure 9]. The patient was advised to put in a crown, but she did not report back, as she had migrated.
Figure 8: Light Cure Composite build up done in tooth 11

Click here to view
Figure 9: 1 year postoperative radiograph of tooth 11

Click here to view

   Discussion Top

A perforation is defined as the pathological or iatrogenic communication between the root canal space and the periodontal tissue. [7] In the present case, the perforation was present in the distolateral midroot area of the upper right central incisor, which might have been caused during access preparation. To avoid such an occurrence, preparation of the access cavity should be carried out with regard to the anatomy of the tooth, and help of the microscope should be taken, to locate the canal orifice. In the present case the Dental Operating Microscope was used to repair the perforation defect. A midrange magnification (16×) was used because it was the recommended magnification for any surgical purpose. [1],[10]

The increased magnification and dual light source of the microscope is invaluable to diagnose and locate accurately the exact perforation site. [2],[3] Incremental placement of restorative material like the Mineral Trioxide Aggregate over the perforation site can be carried out successfully and precisely under a microscope.

As the perforation was in the middle third of the root and sufficient access was available through the pulp chamber, the perforation was repaired nonsurgically. [4] The perforation site was cleaned and refined by Endo 4 ultrasonic tip (Dentsply Tulsa Dental, Tulsa, Oklahoma) to ensure an environment free of microbial contamination and necrotic tissue.

The internal matrix concept, in conjunction with the microscope, is an efficient and effective technique for treating accessible perforations nonsurgically. [1] In the present case we placed a sterile, resorbable, and biocompatible collagen material Healiguide into the perforation site, to control hemostasis and prevent overfills, and it acted as an internal matrix.

The Mineral Trioxide Aggregate forms a colloidal gel upon hydration, which solidifies in approximately four hours. Therefore, when used as a root repair material, moisture must be provided from the internal aspect of the root (using a moist cotton pellet). [7] The Mineral Trioxide Aggregate was initially introduced as a root end filling material, however, because of its biocompatibility it is now also considered as a material of choice to seal perforations. [8],[9],[11],[12],[14] Although Mineral Trioxide Aggregate is an expensive material, it has become indispensible in procedures such as perforation repair. [13],[15]

The location of the perforation is an important factor for its successful repair. More apical the perforation, the better the prognosis. [7] In the present case the perforation was in the midroot, but yet prognosis was favorable even after one year.

   Conclusion Top

Training, practice, and technology allow clinicians to expand their abilities greatly in endodontic treatment. Correction of procedural errors can now be performed with a higher degree of clinical confidence by using a Dental Operating Microscope. The use of the microscope and its inherent precision is closing the gap between theoretical possibility and clinical reality.

   References Top

1.DCNA, Microscopes in Endodontics 1997;41:3.  Back to cited text no. 1
2.Ingle, Bakland, Baumgartner: Ingle's Endodontics; 6th ed.   Back to cited text no. 2
3.Stephen C, Kenneth M. Hargreaves: Pathways of the Pulp. 9th ed.  Back to cited text no. 3
4.Roda RS. Root perforation repair: Surgical and nonsurgical management. Pract Proced Aesthet Dent 2001;13:467-72.  Back to cited text no. 4
5.Birte Nikolaisen Myrvang: Case Book; University of OSLO Dental Faculty; 2006.  Back to cited text no. 5
6.Ghoddusi J, Sanaan A, Shahrami F. Clinical and radiographic evaluation of root perforation repair using MTA. N Y State Dent J 2007;73:46-9.  Back to cited text no. 6
7.Aziz S, Ali AK, Moeen F. Two successful cases of root perforation repair using mineral trioxide aggregate. Pak Oral Dent J 2008;28:103-6.   Back to cited text no. 7
8.Silveira CM, Sánchez-Ayala A, Lagravère MO, Pilatti GL, Gomes OM. Repair of furcal perforation with mineral trioxide aggregate: long-term follow-up of 2 cases. J Can Dent Assoc 2008;74:729-33.  Back to cited text no. 8
9.Schwartz RS, Mauger M, Clement DJ, Walker WA 3rd. Mineral trioxide aggregate: A new material for endodontics. J Am Dent Assoc 1999;130:967-75.  Back to cited text no. 9
10.Castellucci A. Magnification in endodontics: The use of the operating microscope. Pract Proced Aesthet Dent 2003;15:377-84.  Back to cited text no. 10
11.Vajrabhaya LO, Korsuwannawong S, Jantarat J, Korre S. Biocompatibility of furcal perforation repair material using cell culture technique: Ketac Molar versus ProRoot MTA. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:48-50.  Back to cited text no. 11
12.Koulaouzidou EA, Economides N, Beltes P, Geromichalos G, Papazisis K. In vitro evaluation of the cytotoxicity of ProRoot MTA and MTA Angelus. J Oral Sci 2008;50:397-402.  Back to cited text no. 12
13.Juárez Broon N, Bramante CM, de Assis GF, Bortoluzzi EA, Bernardineli N, de Moraes IG, et al. Healing of root perforations treated with Mineral Trioxide Aggregate (MTA) and Portland cement. J Appl Oral Sci 2006;14:305-11.  Back to cited text no. 13
14.Moghaddame-Jafari S, Mantellini MG, Botero TM, McDonald NJ, Nör JE. In vitro Effect of ProRoot MTA on pulp cell apoptosis and proliferation. J Endod 2005;31:389-91.  Back to cited text no. 14
15.Qatharni HA. In vitro Effect of root perforation repair materials on morphology and attachment behavior of human PDL fibroblasts. Saudt Dent J 2004;16:113-7.  Back to cited text no. 15

Correspondence Address:
Mousumi Biswas
A10X/74, Kalyani, Post - Kalyani, District - Nadia, West Bengal-741 235, Kalyani
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-0707.80729

Rights and Permissions


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]

This article has been cited by
1 Comparison of optical performance among three dental operating microscopes: A pilot study
Poorya Jalali, Charles Kim, KarlF Woodmansey
Journal of Conservative Dentistry. 2020; 23(4): 374
[Pubmed] | [DOI]
2 The use of the operating microscope in general dental practice part 2: if you can see it, you can treat it!
Stephen J Bonsor
Dental Update. 2015; 42(1): 60
[Pubmed] | [DOI]
3 A pan-European comparison of the use of mineral trioxide aggregate (MTA) by postgraduates in paediatric dentistry
J. I. Foley
European Archives of Paediatric Dentistry. 2013; 14(2): 113
[Pubmed] | [DOI]
4 Washout resistance of fast-setting pozzolan cement under various root canal irrigants
Ga-Yeon Jang,Su-Jung Park,Seok-Mo Heo,Mi-Kyung Yu,Kwang-Won Lee,Kyung-San Min
Restorative Dentistry & Endodontics. 2013; 38(4): 248
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  

    Case Report
    Article Figures

 Article Access Statistics
    PDF Downloaded322    
    Comments [Add]    
    Cited by others 4    

Recommend this journal