Introduction
Root perforations can occur pathologically as a result of resorption and caries or iatrogenically during root canal treatment procedure.1 Such types of injury to the tooth might lead for compromising treatment outcome of the tooth and may lead to further complications, if not treated appropriately. This type of injury might occur during access cavity preparation for the endodontic treatment, might occur during post space creation for endodontically treated tooth to undergo post and core procedure, or may occur as a result of internal resorption.2 Errors during operative procedure can occur at any time during endodontic treatment and may lead to failure of the treatment.3 some factors may proceed to operative accidents, such as pulp stone, calcification, incorrect inclination of the tooth in the arch, grossly decayed tooth, or internal resorption, extra coronal restoration, may lead to perforation of the root.4, 5, 6, 7, 8, 9 Root perforation may contribute to doubtful or poor prognosis.10 The consequences of root perforation may lead to inflammatory response to the surrounding periodontal tissue which may lead to destruction of alveolar bone.9 Depending on the severity of the injury, and possible chronic inflammatory reaction, it may cause the development of granulomatous tissue, proliferation of the epithelium, and, eventually, the development of a periodontal pocket. Lack of knowledge of root perforation may result in future problem and may eventually lead to tooth loss.11
Classification:- According to Fuss and Trope12
2-12% of endodontically treated teeth have the chances of accidental root perforation. This injury act as an open channel for microorganisms to enter through periodontal tissue or root canal finally eliciting towards inflammatory responses that results in destruction of alveolar bone. When there is lateral perforation or injury occur in the furcation area, there might be a chance of growth of epithelium towards the site of injury, which finally results in poor prognosis.9 There are several factors which determines the prognosis of the defect, which includes, size of the perforation, location of the perforation, time, duration, material used for the repair, and the accessibility to the main CANAL.13 Always a small perforation/ injury which is apical to the crestal bone and which is closed immediately, always have the good prognosis.
Different materials used in the repair of perforation
Indium foil
Initially indium foil was used as repair material for root perforation, but it has shown that indium foil leads to more severity of bone resorption, and that’s why not using in now a days. It was mainly used to prevent gross filling. 14
Plaster of paris
One of the most common material, which has its wide use in the field of dentistry. Plaster of paris is a bio compatible, resorbable material. The rate of resorption of plaster of paris is equal to rate of growth of new alveolar bone in to the tissue. Plaster of paris has also been used as a bone substitute for filling the bone defects. 15
Zinc Oxide Eugenol
One of the most commonly used material in the field of dentistry in various aspects. According to Bramante et al, they stated that, tooth perforations treated with zinc oxide eugenol shows severe inflammatory response in the peri radicular tissue, which results in formation of abscess, and finally lead to resorption of alveolar bone. Tooth/teeth perforation treated with zinc oxide eugenol shows poor prognosis. 16
Gutta Percha
Most commonly used in endodontic treatment. Gutta percha when used in case of tooth/teeth perforation, cause less inflammation when compared to perforation treated with zinc oxide eugenol, zinc phosphate. Benenati et al stated that, perforation treated with gutta percha, shows poor prognosis and the repair in most of the cases is a failure. 17
GIC (Glass ionomer cement)
Glass ionomer cement shows higher sealing potential towards root perforation, because of its mechanism of adhesion. A study done by Alhadainy and Himel, stated that the glass ionomer cement which is light cured, shows more sealing towards the root perforation and provide better seal than the amalgam or cavit. 18
Metal modified glass ionomer cement
Metal modified GIC is manufactured by sintering of silver particles to aluminosilicate powder. It shows good properties of adhesion to the dentine, provide adequate sealing, adequate working time and good ease of delivery. Studies shown that perforations treated with resin modified GIC cement shows less amount of microleakage when compared with perforations treated with amalgam.19 Studies has also revealed that perforations treated with resin modified Glass ionomer cement provides much better seal when compared with amalgam, cavit and conventional GIC.20, 18
DFDB
Decalcified freezed dried bone, is one of the most biocompatible, non toxic which is easy to obtain, easy to manipulate, very much inexpensive, and can act as barrier against which filling material can be placed, and it is completely degradable while the repair process goes on. Whenever there is need to pack in the bony defect, it is mixed with the blood present and turns into a solid mass that will ultimately fill the defect.21
According to a study conducted by Hartwell et al, stated that Decalcified freezed dried bone has some of its negative points also like there is absence of new bone formation in the perforation area, when treated with Decalcified freezed dried bone along with some positive points that includes good clinical and radiographic findings at the end of six months, no formation of periodontal pocket and most importantly no signs of inflammation.21
Calcium Hydroxide
In 1920, Bernhard W. Hermann suggested the use of calcium hydroxide for dental pulp treatment. This material favors the healing process of pulp and periapical tissue.22, 23, 24, 25, 26, 27 Calcium hydroxide is obtained by the calcination of calcium carbonate, which is transformed into calcium oxide, and then hydrated to form calcium hydroxide. The reaction between calcium hydroxide and carbon dioxide forms calcium carbonate. The ionic dissociation of calcium hydroxide into calcium and hydroxyl ions, and the action of these ions on tissues and bacteria explains its biological and antimicrobial properties. 28 It is one of the most biologically compatible material which is used in dentistry. It is very much compatible with the pulp and the periapical tissue. A study conducted by P Bogaerts et al, they used calcium hydroxide as material of choice in sealing the root perforation and found excellent clinical results with positive outcome and with no signs of inflammation. 29
Mineral Trioxide Aggregate
It is one of the most commonly employed material in the field of dentistry, with its wide range of use. It was introduced by Mahmoud Torabinejad in the year 1992. It is composed of Tricalcium silicate, Tricalcium aluminate, Tricalcium oxide, Silicate oxide, calcium sulphate dihydrate, tetracalcium aluminoferrite and small amounts of mineral oxides (bismuthoxide) with a mean setting time of 165±5 minutes. 30, 31 MTA results in cementum formation by stimulating cementoblasts to produce matrix which in turn results in formation of cementum at the site earlier perforated and treated with mineral trioxide aggregate. It is highly biocompatible with periapical and periradicular tissue. 31
Biodentine
It is a calcium cement based bioactive material. It is a powder liquid system, powder composed of Tri-calcium silicate, Di-calcium silicate, Calcium carbonate and oxide, Iron oxide, Zirconium oxide. Liquid consist of Calcium chloride, Hydro soluble polymer. This material having some positive points like easy to handle, easy to manipulate, and very much important a short setting time of approximately 12 minutes, a biocompatible material, makes it material of choice in the repair of perforation. It showed excellent performance as a sealing material when the material is exposed to various endodontic irrigants as compared to MTA. 32
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