Drs. Manal Farea, Adam Husein, and Cornelis H. Pameijer discuss current approaches and a new perspective for repair and regeneration in endodontology
D
uring root canal treatment, many procedural accidents may occur of which perforation of the root canal system plays a significant role. Perforation is defined by the American Association of Endodontics (AAE) Glossary of Endodontic Terms (2003) as a mechanical or pathological communication between the root canal system and the external tooth surface, which is caused by caries, resorption, or iatrogenic factors. It has been identified as the second greatest cause of endodontic failure that accounts for 9.6% of all unsuccessful cases (Pitt Ford, et al., 1995). As a result of furcation perforation, destruction of the periodontal tissues may occur, which ultimately lead to loss of the tooth (Arens, Torabinejad, 1996; Tsesis, Fuss, 2006). The prognosis of the tooth depends upon several factors: 1. The severity of initial damage to the periodontal tissue 2. The location and size of perforations 3. The bacterial contamination 4. The sealing ability or cytotoxicity of the repair materials (Tsesis, Fuss, 2006; Sinai, 1977; Balla, et al., 1991). Even if a biocompatible material is used to treat a perforation, extensive injury may cause irreversible damage to the attachment apparatus at the furcation area (Sinai, et al., 1989.) In large perforations, the complete sealing of the defect with a repair material is problematic and allows irritants to continuously penetrate into the furcation area (Balla,
Educational aims and objectives
This clinical article aims to discuss current approaches in the literature to furcation perforation and repair and regeneration in endodontology.
Expected outcomes
Endodontic Practice US subscribers can answer the CE questions on page 32 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •
Identify surgical and non-surgical approaches that have been utilized for periodontal tissue re-establishment at the perforation site.
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Realize specific criteria for selecting repair material.
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Identify some essential prerequisites for the success of a perforation repair.
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Identify possible materials used for furcation perforation repair.
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Realize the essential role of cementum regeneration in the furcation perforation repair process.
et al., 1991). Perforations close to the gingival sulcus produce persistent inflammation and a down-growth of sulcular epithelium into the defect (Tsesis, Fuss, 2006). Sinai (1977) stated that coronally located perforations, including furcal perforations, were more serious than those in the middle and apical third of a canal. It is the objective of this review to collect and review the data that is available in the scientific literature and to reach a conclusion as to the best treatment options.
Methods Retrieval of literature An English-limited Medline search was performed of articles published from 2002 to 2015. The searched keywords included
Manal Farea, BDS, PhD, MSc, obtained her degree from Sana’a University, Sana’a, Yemen in 2003. She received her MSc degree in endodontics from Universiti Sains Malaysia (USM), Malaysia, in 2010. In 2015, she completed her PhD degree at the USM in regenerative endodontics. Dr. Manal was granted a scholarship from Sana’a University, Yemen, in 2007 and a fellowship from USM in 2011. Professor Dr. Adam Husein, BDS, is a senior lecturer in the restorative unit (prosthodontics) and the dean of School of Dental Sciences, Universiti Sains Malaysia. He obtained his BDS from University of Adelaide, Australia, in 1996. In 2004, he obtained his graduate diploma in clinical dentistry, doctor in clinical dentistry, and fellowship of the Royal Australasian College of Dental Surgeons (FRACDS) from the University of Adelaide. Cornelis H Pameijer, DMD, MScD, DSc, PhD, graduated from the University of Utrecht with a DDS in The Netherlands in 1967 and went on to further his studies at Boston University in Massachusetts. He is currently professor emeritus at the University of Connecticut in Farmington, Connecticut. He has lectured extensively worldwide and has published more than 300 publications in mostly peer-reviewed journals.
Volume 11 Number 1
perforations and endodontics, furcation perforation, root canal and perforation, and perforation and mineral trioxide aggregate (MTA). Then a hand search was done of the references of collected articles to determine if more papers relevant to the topic should be included. Results A total of 820 articles were found, which, in order of their related keywords, accounted for the following: perforations and endodontics: 285; furcation perforation: 92; root canal and perforation: 299; and perforation and mineral trioxide aggregate (MTA): 144. Perforation repair techniques and their prognosis Surgical and non-surgical approaches have been utilized for periodontal tissue re-establishment at the perforation site. In both surgical and non-surgical approaches, two factors should be considered: 1. An appropriate material selection 2. The use of a matrix (Clauder, Shin, 2009). The repair material should be selected based on the following criteria: • Perforation site accessibility • Biocompatibility (be nontoxic and noncarcinogenic) Endodontic practice 25
CONTINUING EDUCATION
Furcation perforation: current approaches and future perspectives