Etnlod Dent Trawmttol 1996: 12: 255 264 Co/)vr/,?

/(/ © Munksi;uard 1996

Printed in Dennutrk . .Ill lii^lit.'i le.serveil
Endodontics &
Dental Traumatology
AV.S'A' 0109-2502

Root perforations: classification and

treatment choices based on prognostic
factors
Lss Z, Trope M. Root perforations: elassifieation and treatment
choices based on prognostic factors. Endod Dent Tranmatol 1996;
12: 255-264. © Munksgaard, 1996.
Abstract Root perforations are common complications of endo-
dontic treatment or post preparation and often lead to tooth extrac-
tion. Successful treatment depends mainly on immediate sealing of
the perforation and prevention of infection. Several factors aOect the
achievement of these goals, most important of which are: time of
occurrence, size, and location of the perforation. A classihcation
of root perforations, based on the above factors, is presented to
assist the clinician in the choice of the treatment jDrotocol which will
give the best possible results when a perforation is diagnosed.
Z. Fuss, M. Trope
Department of Endodontology, School of Dental
Medicine, Tel Aviv University, Istael, Department of
Endodonlics, University of North Carolina School
of Dentistry, Chapel Hill North Carolina, USA
Key words: root perforation: endodontic treattnent:
endodontic complications
Zvi Fuss, Department of Endodontics, School of
Dental Medicine, Tel Aviv University,
Tel Aviv, 69978, Israel
Accepted June 12. 1996

Purpose inflamtnation and failure. However, when a baeterial

The purpose of this paper was to review the factors
which affect the prognosis of root perforations, to sug-
gest a classihcation reflective of these prognostic j^re-
dictors, and to suggest treatment protocols which will
result in the higliest possible success rate.
Artifieial commnnication betweeri the root canal
systetn and supporting tissues ofthe tooth or oral cav-
ity lowers the prognosis of endodontic treatment, and
often leads to extraction ofthe tooth (1). higle et al.
(2) have found that the second most common reason
for failure associated with endodontic treatment is
root perforation. Perforations can occur dtiring oper-
ative procedures such as post preparation (Fig. 1), as
well as during endodontic treattnent (Fig. 2) (3). The
frequency of root perforations has been reported to
range from 3% to as high as 10% (2, 4). Howe\-er,
more dentists with vaiying degrees of training and
skill are now providing endodontic treatment and en-
dodontic cases for the specialist have become more
dilFictilt, so that an inci^eased frequency of perfor-
ations in the liiture is not an unrealistic expectation.
In addition, factors not related to operator mishaps
such as pathological jjrocesses like root resorption or
caries may restilt in root perforations.
Theoretically, a perforation into i\\v supporting
tissues alone might not necessaiily cause irreversible
inleetion and/or an irritative restoratiN'e material is
superimposed on the trauma of the perforation, heal-
ing will not take place. Consequences such as gingival
downgrowth of epithelium into the perforation area
(5), inflammation, l:)one resorption and/or necrosis (6,
7) can result (Fig. 3). Repair of a perforation without
periradicular inliatnmation may take place pro\ ided
infection is avoided and asepsis maintained during
treatment (cS) (Fig. 4).
Prognosis
Prognosis is de]:)endent on the pre\ enfion or treatment
of baeterial infection of the perforation site. In ad-
dition, the use ofa non-irritating material whieh seals
the perforation will limit periodontal inflammation.
Several lactors related to infection of the perlbr-
ation site aflect the pi^ognosis of the treatment of root
perforations, the most important of w hieh are: time
betweeti occurrence and treatment, size, and loc ation
of the perforation.
Time
Fhe time between the occurrence of the perforation
and when appropriate treatment is performed has

255
 Fuss & Trope

Ftg. ''). Hislological .section of old (infected) furcation ])erfoi'alion,

tesulling in inllaniinatioii and hone resorption and gingi\al epilhel-
iurn ijroliferalion in llie perforation arc-a (H&M).

Fig. I. RadiogTa])li of inandibiilar hist molar with ]K-rforation of

lurcation diii-iiig |)c)st p r e p a r a t i o n . Note the radioliiceuc y in the
htrcation area icild perforation), 't'he prognosis for coiiservati\e
treatment is poor.

Fig 2. Radiograph of maxillary lirsl molar inunecliately after the

mesiobuccal root was perforatc-d by a small size endotlontic iiislru-
ment (fresh jK-rforatioiij iu proximity to tbe lc-\el ofthe c restal bone.
'I'he iJi'ognosis is uncertain.
l)ccn found to be an important factor in healing (7
9). Lantz & Pcrsson (9) experimentally i^roduccd root
perforations in dogs and then treated the perforations
cither immediately or after a delay. The most favor-
able healing occurred when the j^erforations were
scaled immediately. Thus, reducing the likelihood of
an inlcction being established resulted in a better
periradicular environment around the ]:)cr(oration.
256
Fig 4. Radiograph oCmaxillaiy Icfl lat(>ral incisor which was perfor-
ated apical to the crestal bone and treated with calc iimi hydroxide
Ior 2 weeks and then obtm-ated with gutta-|ierclia and Kelac IMUIO
rooi (anal seal(-r ilvspe, Sc-cfcld, C;eniiany). Three years following
treatment the tooth is asyni])toniatic and no signs of a radioluccnl
area atljaceiil to ihe perforalioti is apparenl.
Seltzer ct al. (7) Ibllowed 22 perforations in mon-
keys tliat were treated at intervals ranging from im-
mediately to 10 months post perforation. 'I'lie i)eri-
 Root perforations: classification and treatment

Fig. 5 . D i a g r a m o f m a n d i b n l a r lneilar w i t h di.stal a t t a e l i i i K - n t loss.

Fig. 7. D i a g r a m e)f i n a n d i b t i l a r i n e ) l a r w i t l i p e - r f e ) r a t i o n i n t h e ' middle
Determination o f c r i t i c a l /.one- f o r reiot p e r f o r a t i o n s i n te-rins e)f
third o \ t h e - t n e - s t a l re)e)t. I h e - | ) r e > g i K ) s i s l e i r e e m s e - i A a t i x e - t r e - a t m e - n t i s
p r e i g n o s i s s h o t t l d be- a t t r i b t i t e ' e l te) t h e - le-\e-l o f t h e ' e t e ' s t a l be)iie- a n e l
g e ) e ) d b e - c a t t s e t h e ] ) e t 4 e ) r a t i e ) n i s l e ) c a t e - d a p i e - a l te) t l u - e ' r i t i c a l e r e - s t a l
e]:)ilbelial a t t a c l n n e ' i i t a n d n e ) t te) t h e ' l e ) e ' a t i e ) t i e ) f t h e - pe-rfe)ratie)ii
ze)iu-.
a l o t i g t h e - re)e)t. 'I'lie-re-feire-, i n t h e - t n e s i a l re)e)t t h e c r i t i e a l ere-stal
z o n e - i s f o n n d i n t h e - e ' o r e i n a l t b i r e l e)f t h e i'e)e)t, w b e r e a s t h e - e r i t i e a l
cre-stal ze)tu- i n the- elistal roe)t is le)catetl i n t h e t n i d d k - tbirel o f t b e
root. periodontal healing' which was allribuled mainly to
immediate obturation of the perforations and an
aseptic technique.

Size
The size of a perforation also has an important effect
on the prognosis of treatment. A small jDerforation
is usually associated with less tisstic destruction and
inflammation; thcrcibre. healing' is more predictable.
Himcl ct al, [\{)) ha\e c\aluated the eflcct of three
materials on the biological repair of a defect created
by perforating the J^ulp chamber floor of mandibular
posterior teeth in dogs. It was ibund that the prog-
nosis of treatment was directh' j^roportional with the
size of the tooth: the larger teeth (with proportiotially
smaller perforations) had the best results. Since the
aim of obturating perlbrations is to prexent l)at t(Mia
from the oral ca\ity Irom reaching the periradicular
tissues, and to avoid irritation ol the j^eriodontal

Fig. (). D i a g r a m o l t n a i i e l i b i i l a r l n e i l a r w i t h p ( - r l o r a t i e ) i i i n t h e - middle

Table 1. Classification of root perforatiotis according fo factors which affect
Iliird n \ t h e - e l i s t a l re)e)t. T h e - p r e ) g i i e ) s i s l o r e - e ) n s e - r \ ' a t i \ ' e - t r e a t m e n t i s prognosis. To the left of the horizontal line are predictors suggestive of a good
])e)e)r b e - c a t i s e - e)f t h e - | ) r e ) x i i n i t y te) t h e - c r i t i e a l e r e - s t a l z o n e . prognosis while to the right are factors suggestive of a poor prognosis

Root perforation
Lateral or furcal
odontium was damaged in all the teeth in\-ol\'ed., hut Fresh Old
the most severe destruction was found in the tin- Small Large
treated perforations and in the teeth where treatment Apical-coronal Crestal
was delayed.
Good prognosis Poor prognosis
Beavers et al. (8) reported a high success rate in

257
 Fuss & Trope

Fig. 8. a. Pholograph of maxillaiy IcIl cciilial incisor showing- a

sinus Iracl on the l)n((al asprcl ol'the (oolh in the rritical rrcslal
zone. 1). Pholograph showing 2 orilirrs lo 2 canals. TIH' huccal
oiilicc Iracls lo a perforation of the lool and ihe palatal orifice
to ihe loot (anal. c. Radiograph showing location of endodonlic
inslrumcnl following determination of root peifoiation site b\- eler-
Ironic apex locator, d. Radiograph showing obuiralion ofthe root
and perforation eatial wilh gulta jiercha and sealer (CIRCS, Hyg-

I i enic, Akron, OH, USA), e. Snrgery performed to xrrify the seal of

258
 Root perforations: classification and treatment

Fig. !). a. Radic)g'ra])h of maxillary lirst p r e m o l a r with large crestal ]ieii()ratic)ii sealed with amalgaiii. Note the- c-xirusioii o f t h e liialcrial
into the i^eriodonlal lissties. b. R a d i o g r a p h showing the same tooib :i \ e a r s after trc-atnu-nt. Periodoiital pocketing or disease is absent in
spile (ll the exlrusion ol the anialgatn. T h e crown was pre]xn'cd sttpragingi\aly lo a\'oitl any jieriodoiiUil iiixoKcment with ihe perforation
site.

tissues by extrusion of sealing materials, it ap]:)ears
logical that small perforations lia\ e a better jirognosis
because they arc easier to seal ellectixely without forc-
ing tlic lillino- material into the stn-roundino- tissties.
Location
The location of a perforation i.s piobahly the mo.st
imj^ortant lac tor alfccting ti'eatmcnt prognosis. C'losc
proximity ol the perforation to the oingixal suleus can
lead to contamination of the peiforation with bacteria
from the oral cax'ity through the snlcus. Furthermore,
if the wound is large and not treated immediately, the
proximity to the e]3itlu^lial attachment i.s critical and
apical migration of c])ithclium to the perforation site
will create a periodontal delect (cS, 1 I). Thus a critical
zone in terms of prognosis is the lc\ cl of the crestal
hone and the e])i(helial attachment (Fig. 5). Perfor-
ations which are located coronal to this zone ha\e a
good ]M-()gnosis. /Vccess to the ]:)erlbration is attain-
able, and adequate sealing is j)ossil)le without peri-
odontal involvement. Crestal root perforations (Fig. 6)
the perforation re\ealecl thai ihe giitla-]ierc'ha lilling w a s
c x a c l l y at t h e p e r f o r a t i o n s i t e a s itulic a t e d b y t h e a | ) e x loc a t o r r e a d -
i n g . 1. I h e p e r l o r a l i o n s i t e w a s s e a l e d w i t l i l i g h t c u r e d
rcsiii alter acid etching il'ertac. lvSPlv Seeleld, Cierinaiiy).
l ' l i o t c ) g r a | ) l i s h o w i n g clinic al IOHONV u p 12 m o n t h s a f t e r
I h e siiitis t r a d is c l o s e d a n d llie g i n g i x a is h e a l t l n with a p r o b i n g
( l e | ) t b o f 1-2 n u n in the- a r e a o f the- p c - r f o r a t i o u .
are most susceptible to epithelial migration and rapid
pocket formation, thereby having the lowest success
rate of rejDair (3, 6, 7, 9). Orthograde fillings are
usualK' not sullicicnt to prcxcnt infection originating
from the gingixal suleus, and surgical intcrxcntion is
recommended (1). Perforations which are located api-
cal to the critical zone (^Fig. 7) should have a good
prognosis provided adequate endodontic treatment is
rendered, and the main canal is accessible (12, 13).
Perforations in the furcation area of multirooted teeth
are regarded usually as cix^stal root perforations be-
cause of the proximity to the epithelial attachment
and the gingiNal suleus (3, 6, 9, 12 14). Seltzer et al.
(7) ha\e stated that perforations ofthe lurca region of
molars are especially troublesome because they cause
considerable damage and frequently lead to peri-
odontal inxoKement of the furcation. Beavers et al.
(8), however, showed a 100% success rate in treat-
ment of furcation perforations. They studied peri-
c^dontal woiuicl healing following intentional root per-
forations in monkeys. Hard-setting calcium hydroxide
and tetlon discs were used to seal the perforations.
Asepsis was strictly controlled and zinc-oxide eugenol
cement and amalgam were used to seal and restore
the tciHh. All 24 furcation perforations healed, dis-
localcd
])layino- normal periodontal contour with no epithelial
migration to the wound site. 1 he study demonstrates
composite
lhat wounds created into the periodontal ligament be-
g.
treatment.
low the le\-el of the epithelial attachment hom the
ptilp chamber may heal without j^eriodontal involve-
ment. Furthermore, the authors show liealinc, in a

259
Fuss & Trope
/'(ij. ID. a. Radiograph of mandibular canine with a lateral perfor-
ation apparently as a result of apical surgery pcrlbrmcd on tlie
laleral incisor. Radiolueeneies are present on bolh leelh. b. Adei'
IH months o( calcium hydroxide therapy, a hard tissue Ijairier has
formed al the pei'foration site of the canine allowing obiuration ol
the c anal with minimal exti'tision of gutta-]:)ereha and/or sealer.
(From IVojie M, Tronstad L. Long-term calcium hydroxide treat-
ment of a toolh with iatrogenic root perforation and lateral peri-
odontitis. iMidod Dent Traumatol 1985; 1: 35 8.)
similar fashion in 23 additional lateral root j^erfor-
ations (8). According lo the graphical illustrations of
the publication, it appears that the location of the
furcation perforations were apical to the level ol the
crestal bone. Therefore, it is conceivable that the high
rate of repair reported in this study is related to the
aj:)ieal location of the perforation, in addition to the
fact that the time lapse between the occurrence ofthe
perforations and treatment was short, and that strict
asepsis was maintained. Hartwell & I'^ngland (11) also
evaluated the repair of iureation perforations in mon-
keys, and showed a clinically high success rate using
freeze dried bone to hll the hony fnrcation defeet.
Howev^er, e]:)ithelial tissue was seen between the per-
foration site in ihe floor of the ]3nlp chamber and
the eonnective tissue layer in eveiy case. The authors
attributed the presence of the epithelium (o the
irauma that occurred dnring the preparation of the
bony perforation defect, resulting in stimulation oi the
periodontal ligatnent tissue adjacent to the perfor-
ation site. From the radiographs presented in the
paper, it seems that the perforation defects were
located at the creslal bone level, and thus were sus-
ceptible to epithelial migration and pocket formation.
Classification
The elassifieation shown in Table 1 is based on the
j)rognostic factors j^reviotisly discussed. In this classi-
260
heation "fresh" is assoeiated with a perforation at the
same visit, whic h if treated immediately and with an
aseptic technique has a good prognosis. "Old" perfor-
ations are assoeiated with previously untreated acci-
dental operative procedures where a bacterial infee-
tion may be established.
Small perforations are those which occitr with en-
dodontic instruments of size 15 or 20. Since the ma-
chanical damage to the tissue as a result of these per-
forations is minimal and the chance that the perfor-
ation occurred under the aseptic conditions lequired
of endodontic treatment (rubber dam, sodium hypo-
chlorite iirigation etc.) fairly good, infection is less
likely. For these reasons small perfor;itions are ]Dlaeed
in the good prognosis eategoiy. A large perforation
such as that whieh occurs in post preparation restilts
in signifieant tissue damage and the chanees of inlec-
tion frcMiT saliva or leakage are much greater. There-
lore, the prognosis in these cases is considered poor.
In this classification, the position ofthe perforation
in relation to the supporting tissues (and not only its
position on the root location) is taken into account
(Fig. 5-7).
Thus CORONAL=coronal to the crestal bone
and epithelial attachment and has a good prognosis.
GRESTAL=at the level ofthe epithelial attachment
and crestal bone and has a poor prognosis. API-
CAL=apical to the erestal bone and epithelial attach-
ment and has a good prognosis. In Fable 1, lateral is
placed in the good prognosis and ftireation in the
poor prognosis columns since the furca is ttsttally close
to the crestal bone while lateral could be coronal or
apical as well.
Treatment
Since we ehoose our treatment method based on the
position of the perlbration relative to the crestal bone
and attachment apparatus it is imperative to accu-
rately loeate the perforation.
Localization of the perforafion
Diagnosis and localization of tJie root perforation is
frequently a dilTieult task. When located on the buceal
or lingual aspects ofthe root, the perforation is super-
imposed radiographically on the root surface. 'Fhe
clinician should probe the gingival sulcus to evaluate
possible communication with the oral cavity. An apex
locator (15,16 ) is helpful in locating the exact position
of the commiuiication with the periodoutal ligament.
Once the apex locator has indicated when the peri-
odontal ligament has been reaehed, it is prudent to
take a radiograph to assess its relationship to the eriti-
cally important level of the erestal bone (Fig. 8 c).
Generally, nonsurgieal treatment is indicated in the
management of root perforations, while surgical inter-
 Root perforations: classification and treatment

lug. 1 1 . a . R a d i o g r a p h o l l i i a i u l i h u l a r lirsl m o l a r w i t h o l d a n d lait^c l u r c a t i t M i p c i i o r a l i o n . llic ])ros;nosis w a s c o n s i d e r e d u n c c n a i n . Alter

rcinoxal o f die posl the a r e a w a s ittis^ated g e n t h w i t h saline a n d d r i e d w i t h eottoti |)ellets. ( l l i e o l o n S i K c r • l',spe\ w a s tiiixed o n a slal),
j : ) l a c c ~ d ,U,('ntl\" o n t h e p e r i p h e r y o l t h e d e l e e t a n d t t s c d ( | t t i c k l \ ' t o c o v e r t h e d e f e i t t t s i t i o a s m a l l r o t i n d a j i p l i c a t o r . , 2 2 2 t i . T h e c e m e n t set
withiti li\e m i n t t t e s a t i d s e r x c d a s ati e x c e l l e n t b a t t i e r t o a x o i d e o t i t a m i t t a i i o t i o r irtitatioti dntitti;" r e t r e a t m e t i t o l t h e r o o t catials. h . T h t e e
y e a i s a l t e r t h e r i ' t r e a l t n e t i t . t h e r a t l i o l t t e e n t a r c - a i n ( h e l i t r e a t i o t t h a s h e , t i e d i n s]iit(~ o f t h e p r e s e n c e o f a s t n a l l j i a r t o f t h e p o s t t h a t was
p t t s l i e d i t t t o t h e p e r i o f l o t i t a l tissties dtititit;' t r e a t t n e n t . N o t e t h e t^lass i o t i o m e r e e i t t e t t t a t t h e p e r l o t a t i o t i s i t e . T h e t i ' i s t i o c e m e n t i t i tlic~
liitcalioti area.

vention i.s leserved ihv cases not amenable to, or those ionomer eements may be used in anterior teeth,
that have failed in response to nonsurgical treatment whereas amalgam is an additional option in posterior
Ol- where a concomitant management of the peri- teelh.
odontium is indicated. This section will focus on con- Crestal perjoratioiis - Crestal root perforations are the
ser\ati\'e treatment. most diilicult to manage because of their ]:)roximity to
the epithelial attachment, and possible communi-
eation with the gingival suleus. \\ ith large crestal per-
Nonsurgical treatment
forations whether fresh or old, surgical inten'ention
The rationale lor nonsurgieal treatment of root per- will usually be neeessaiy in order to seal the defeets
forations is the same as that ot a conser\ ati\ e endo- externally (Fig, 8 a-g). A further possibility is ortho-
dontic ])rocedure, namely, the prevention or treat- dontic extrusion ofthe tooth to bring the perforation
ment of periradicular infiammation. This is to a coronal position where it can be sealed without
achieved by ensuring that the |)erforation site is surgical interxention. However, since the differential
either not infected or clisinfeetecl at the time of diagnosis of apieal and crestal perforations often is
treatment, that the material used to treat the per- dillieult, one should tr\' a nonsurgical a]oproach in un-
foration i^rovides the best possible seal to baeterial certain eases, pio\ided the periodontium is healthy.
penetration and that the material is itself not irritat- 'Jlie material used for the non-surgical treatment of
ing to the surrounding tissues. The following proto- these cases has varied. Amalgam has been used iu the
col for treatment ol perforations is based on tliis l^ast with some success (Fig. 9). Any biocompatible
rationale, and is in accordance with the classifi- material, with a short setting time, should be seleeted
cation presented in this paper. for sueh eases to minimize the elleet ofthe unset ma-
terial on the ])eriodontal tisstie with \vhich it is in con-
tact
1. Lateral perforations
Apical j)ctjo)atious Apical perlbrations should be
Corottal /)er/()iatiotts Coronal root perforations should Ireated according to routine endodontic principles for
nol be dillieult to seal externally, and the material regular root canals. A main difliculty usually will be
selected for sealing will depend on esthetic consider- to access and adequately treat the main root eanal.
ations. Aeid etch bonded composite resins or glass Apical, small and fresh i)erloiations should preferably

261
Fuss & Trope

a
Fin. 12. a. R a d i o g r a p h ormaii(lil)iilar first m o l a r with old a n d larsrc liircation iM-rlhialion. T h e proj^nosis was regarded as uncc-rtain because
no ]:)r()l)ing lo llic Iureation was deieeted. Vhv a m a l g a m was gently removed t l n o n g h the root eanal a n d the large perforation was sealed
in the m a n n e r described in Fig. I I . b . 30 m o n t h s following treatment repair in the liircation is evident. Note that the material has not
been p u s h e d into the p e r i o d o n t a l tissues in sjjite o f t h e large extent o f t h e ])crforation.

/')X'. /.V. a. Radiografjh of m a n d i b u l a r lirsi iiii)l<n NAMII old a n d large IUK ation perl()i ation. 'ITie progn(;sis for conser\ atixc treatment is p o o r
because of the presence o f a periodontal pocket and ])rol)ing to the (urcation area. b. Radiograph taken three years alter removal ofthe
mesial rf)ot . 1 he distal root is asymptomatie and is used as a bridge abutment.

be completed in one visit, and the perforation scaled
with gutta-percha and root canal sealer. The use of
an aseptic technique is essential. Apical, small and old
perforations have to be treated with an antil)aeterial
inlraeanal medicament such as ealcium hydroxide,
and scaled with tlie main canal at the seeond visit.
Apical, large and old or fresh perforations should be
treated like teeth with immature apiees i.e. with long-
term calcium hydtT)xide treatment. Calcium hydrox-
ide is used as an intraeanal medieament for several
months utitil a hard tissue barrier is fornied and reg-
tilar root canal obttiration ean be earried out (Fig.

262

10). hi cases where the original eanal is not aeeessiblc,
and apieal periodonlitis develops, root end resection
is indicated.
2. Furcation perforations
Perforations of the furcal region of molars are es-
pecially tronblesonie l:)ecause they cause considerable
mechanical damage and frequently lead to commnni-
cation with the snlcus. Nevertheless, Beavers et al. (8)
have demonstrated the ]Dotential for healing of peri-
odonlal tissues surrounding furcation perforations,
provided adequate treatment is tendered. Apical-
small furcation perforations, if sealed l)y a last setting
material will have a favorable prognosis. However,
large furcation perforations make control of the repair
material clifTicult, and extrusion of the filling tnaterial
into the periodontal ligament space is common. Dif-
ferent materials have been used experimentally to seal
large fureation perforations. Grossman (17) found
amalgam to be a fa\'orable material, atid it is still
widely used for this jDurpose. Aguirre et al. (18), sug-
gests the use of itidiuni foil for the repair of extetisive
perforations in the floor of the chamber. The foil acts
as a matrix over which amalgam is condetised, thus
confining the materials within the tooth. Webber (19)
suggests the preparation of a retentive groove around
the perforation on the fiooi- of the chamber to allow
condensation of amalgam onto the line angles. He
indicates that this may reduce the chance of gross
overfilling.
The alcove-mentioned technicjues are time con-
suming and inconvenient. A diflerent approach is to
apply materials such as calcium hydroxide, tricalciuni
phosphate, hydroxylapatite, or dentin chips iti order
to accomplish a calcified l)arrier against which to con-
dense a filling material similar to amalgam (5, 6, 10,
20). Notie of these tiiaterials were superior to filling
materials such as amalgam, cavit, zinc oxide eugenol
or gutta-percha which are mentioned in the older
literature. By placing materials such as calcium hy-
droxide in perforations that are adjacent to the crestal
level, the resultant necrotic zone can reach the epi-
thelial attaclimcnt, thus cotnpromising the ptT)gtu)sis.
The rationale for treatment of uncertain cases should
be itntnediate sealing with a biocotiipatible material
that ]X)ssesses minimal or non-irritating character-
istics after a fast set (21 24). Glass ionomer cements,
bonded resins or mineral trioxide aggregate are newer
materials suggested as alternative retrofilling materials
which might jjossess some of these properties (25 27).
Also, the material should be radiopaque and con-
venient to use (Figs. If, f2). However, in cases of
lai-ge furcation perforations with periodontal invoKe-
ment the prognosis is poor and surgical remoxal of
one tT)ot is often recotnmended. (Fig. 13).
1 he success or failure of root perforations is de-
Root perforations: classification and treatment
pendent on the prevention or treatment of infection
of the perforation site. 'Fhis pajser has atttempted to
classify root perforations according to prognostic fac-
tors. Using these prognostic factors, treatment choices
are suggested which will result in the highest success
rate for these diflicult clinical cases.
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