Endodonics

Long-term observation of endodontic surgical intervention to treat root perforation and apicai periodontitis: A case report of an amalgam-restored tooth
Tamotsu Tsurumachi, DDS, PhDVMakoto Hayashi, DDS,
A case ot crestal root perforation and periapicai lesion in a maxillary ieft iaterai incisor is reported. Teeth with root perforation present technical diflicuilies in their ciinicai management because of their complex defects. In the present case, surgical endodontic treatment was chosen. The apical and iaterai pathology was curetted, the tooth root was resected, and a retrograde root restoration of amalgam was placed in a root-end cavity and perforation site. A 10-year follow-up ciinicai and radiographie examination showed an asymptomatic tooth with osseous healing proceeding. (Quintessence Int 2003:34:674-677) Key words: amalgam, apical pericdontitis, root perforation, surgicai endcdontic treatment

oot perforations are common complications of endodontic treatment or post preparation' and often lead to tooth extraction. The prognosis of root perforation depends on the size and location of the defect, the duration that the perforation is open to contamination, and the ability to hermetically seal the defect^'' Generally, nonsurgical root canal treatment is indicated in the management of root perforations, while surgical intervention is reserved for cases that have failed in response to nonsurgical treatment^ or where concomitant management of the periodontium is indicated. Crestal root perforations are the most difficult to manage hecause of their proximity to the epithelial attachment and possible communication with the gingival sulcus,' The purpose of this article is to report on the clinical management of a case of crestal root perforation involving the maxillary left lateral incisor, with a periapicai lesion.

CASE REPORT

'Assistant Professor, Department of Erdodontics, Division ot Advanced Dentai Treatment, Nihon University School of Dentistry. Tokyo, Japan. ^Senior Lecturer, Department ot Endodontics, Division o( Advanced Dental Tteatrrent, Nihon University School ol Dentistry, Tokyo, Japan. Reprint requests; DrTamotsj Tsjrumachi, Department of Endodontics, Nihon University School of Dentistry, 1-B-13, Kanda-Surugadai, Chiyodaku Tokyo 101-8310, Japan. E-maii: tsjrumaclii@dent.nihon-L.ac.jp

The subject was a 22-year-old woman who presented with dull pain at the maxillary left lateral incisor. Her medical history was noncontributory. Clinical examination showed that there was a slight white scar on the mucosa of the lateral incisor (Fig 1}. The tooth was sensitive to percussion and failed to respond to electric pulp sensitivity testing. Radiographie examination of the left lateral incisor indicated an incomplete root canal filling and a radiolucent lesion at the apex, as well as root perforation on the distal side of the root (Fig 2). A radiopaque material was observed in the lateral lesion. It was assumed that the perforation of the lateral incisor had been surgically treated 2 years prior The treatment plan comprised instrumentation of the root canal of the lateral incisor and sealing of the perforation defect. Foiiowing isolation of the tooth with rubber dam, the pulp chamber was opened, and the filling materials were removed by using a size 25 Hedstroem file (MANf). The working length was established and recorded {Fig 3), The main canal was instrumented to size 40-K file. Copious irrigation with 2.6% sodium hjfpochlorite solution was used throughout tbe procedure. A perforation of the distal wall seemed to be present; bleeding was consistently noted near that area when drying with paper points but was
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Fig 1 Preoperative clinical view ol the maxiliary lateral incisor showing a scar on the mucosa and a temporary crown. Fig a (right) Preoperative radiograph of the maxiliary lateral incisor showing inadequate root filiing, periapicai radioiucency, and extrusion ot the materiai at the perforation area.

Fig 3 (left) Length determination radiograph.

Fig 4 (below) Ciinicai view of tooth atter elevation of the tiap. Note the extensive bone destruction and perforation-seal m g materiai

not associated with pain. The root canal was dressed with a calcium hydroxide paste, A cotton pellet was placed in the pulp chamber, and the tooth was temporarily sealed with Cavit (ESPE). Despite several attempts, root eanal retreatment was not effective. The perforated area showed persistent bleeding, so the main canal of the root was not thoroughly instrumented. It appeared that residual infection was suspected, and adequate sealing was impossible in the perforation site. Therefore, surgical intervention was necessary. Under local anesthesia, a full-thickness mucogingival flap was raised from the maxillary left lateral canine to the maxillary right central incisor (Fig 4). It was found that cervical area of the offended tooth was devoid of alveolar hone. A sealing materiai
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was observed at the lateral lesion. Endodontic surgery was performed with eurettage of the apieal and lateral region, and the retrograde amalgam-restored cavities were prepared. Following this, the main canal was instrumented and obturated hy lateral condensation of gutta-percha and zinc oxide-eugenol sealer (Canals, Showa Yakuhin), and a retrograde amalgam restoration was placed in both cavities (Figs 5 and 6). The flap was replaced to its original position and fixed by sutures. The sutures were removed 1 week postoperatively, and the healing was uneventful. A postoperative radiograph was taken (Fig 7), Healing has sinee been uneventful, and at the 2-year recall, radiographs showed a nearly complete osseous repair in both lesions (Fig 8). The recall radiograph at 10 years showed
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Fig 5

Raot-end resection and ,oot-end fiiiing with amaigam.

Fig 6

Perforation cavity-filiing with amaig

Fig 7 Postsurgicai radiograph showing foot canai fiiiing with gutta-percha, rootend, and perforation-filling with amaigam.

Fig 8 Two-year follow-up radiograph cf the maxiiiary lateral incisor. Radiograph perforation area.

Fig g

^EE=BBi SSr'-s
osseous repair; the patient remained asymptomatic (Figs 9 and 10).
DISCUSSION

Ten-year foiiow-up radiograph ol iiiary i t i i i T

Fig 10 Ten-year foliow-up photograph of the maxillary laterai incisor The final restoration is a porcelain-fused metal crown and has now been in lunction.

The success or failure of root perforafions is dependent on the treatment of infection of the perforation site Perforations of the crestal region of teeth are especially troublesome hecause they frequently lead to communi cation with the gingival sulcus and create periodontal involvement. Also, large crestal perforations make controi of the repair material difficult, and extrusion of the restorative material into the periodontal ligament space IS common. The extruded material may feet or
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delay healing.^' In tbese cases, surgical intervention appears to he the reasonable treatment modality, but It must be ebosen only after nonsurgical root canal treatment bas proven to be ineffective. In tbe present case, root canal retreatment was not sufficient to get adequate cleaning and sealing of tbe main canal as well as the perforation defect. Tbus, surgicai endodontic treatment was performed on tbe involved tooth, and the result was satisfactory. Sealing material selection is another important factor for a good prognosis, because tbe prognosis is affected by tbe material's biocompatibility and its ability to provide a hermetic seal. A wide variety of materials have been suggested to seal perforations, including amalgam, resin composite, glass ionomer, and more recently, mineral trioxide aggregate.*-"* Amalgam bas been used in tbe past witb good success.''"'^ Two years later, tbe apical radiolucency on the lateral incisor was completely resolved. On the other hand, the lateral radiolucent area adjacent to the perforation was markedly reduced. Surgical approach and amalgam sealing of the crestal root perforation seemed to have been performed successfully (Fig 8). However, radiograpbic examination at tbe 10-year postoperative period revealed a rsorption radiolucency on tbe distocervical aspect of tbe root (Fig 9). This may possibly be related to a resorptive defect on the root surface. In this case, there is potential for an eventual long-term periodontal problem, because tbere was no labial bone and epitbelial attacbment over tbe ground tootb surface tbat was sealed witb amalgam. The opportunity for irritants to reach the perforation site through the gingival sulcus appears well establisbed. Tbus, the amalgam sealing will he an imporiant issue for predicting long-term prognosis.

clinically healthy and continued to satisfy esthetic and functional demands.

ACKNOWLEDGMENT This study was supported in pan by ^ Grant-in-Aid for Scientific Research from [he Ministry of Edut:ation (No.13672012 and 307055).

REFERENCES 1. Kvinnsland I, Oswald RJ, Halse A, Gronningsaeter AG. A clinical and raentgenological study of 55 cases of root perforation. Int Endod J 1989;22:75-84, 2. Siriai IH. Endodontic perforations: Their prognosis and treatment. J Am Dent Assoc 1977;95:90-95. 3. Lemon RR. Nonsurgical repair of perforation defects. Dent Clin North Am 1992;36:459-457. 4. Nichoils E. Treatment of traumatic perforations of the pulp cavity. Orai Surg Orai Med Oral Pathol 1962;15:603-612. 5. Fuss Z, Trope M. Root perforations: Classification and treatment choices based on prognostic factors. Endod Dent Traumatol 1996;12:255-264. 6. Benenati FW, Roane JB, Biggs JT. Simon JH. Recali evaluation of iatrogenic root perforations repaired with amalgam and gutta-percha. J Endod 1986;12:161-166. 7. Dazey S, Senia ES. An in vitro comparison of the sealing ability of materiais piaced in iaterai root perforations. J Endod 1990;t6:19-23. 8. Jantarat J, Dashper SG, Messer HH. Effect of matrix placement on furcation perforation repair. ] Endod 1999;25: 192-196. 9. Torabinejad M, Chivian N. Ciinicai applications of mineral trioNJde aggregate. J Endod 1999;25:197-205. 10. Fuss Z, Abramovitz I, Metzger Z. Sealing furcation perforations with siiver glass ionomer cement: An in vitro evaluation. J Endod 2000:26:466-468. 11. El Deeb ME, Ei Deeb M, Tabibi A, ensen JR. An evaluation of the use of amalgam, Cavit, and calcium hydroxide in the repair of furcation perforations. J Endod t982;8:459-466. 12. Aguirre R, El Deeb ME, El Deeb iVIE. Evaiuation of the repair of mechanical furcation perforations using amaigam, gutla-percha, or indium foil. J Endod 1986; 12:249-256.

CONCLUSION

Root perforation in the crestal area of the maxillary left lateral incisor was treated using surgical placement of an amalgam restorative material into the perforation site and root-end cavity. The repaired tooth was

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