Retratamiento y reparación de una perforación radicular. Informe clínico, radiográfico e histológico / Retreatment and healing of a case of root perforation. Clinical, radiographic and histological report

Objetivo: Describir los aspectos clínicos, radiográfi- cos e histológicos del retratamiento realizado en un segundo molar superior en el que se había producido previamente una perforación radicular durante el tratamiento original. Caso clínico: Un paciente masculino de 50 años con- currió a la consulta para realizar un retratamiento endodóntico en un segundo molar superior derecho. El examen radiográfi- co reveló la presencia de un tratamiento incompleto, un área radiolúcida periapical y una perforación radicular producida por un poste roscado insertado fuera del espacio del conducto mesio vestibular. Una vez retirado el poste, se selló la perfo- ración con Biodentine y se realizó el retratamiento. Luego de dos años, el paciente regresó a la consulta con dolor a la mas- ticación, localizado en el área correspondiente al segundo mo- lar superior derecho previamente tratado. Durante el examen clínico y radiográfico se detectó la presencia de una fractura vertical en la raíz palatina. A causa del severo compromiso radicular el molar fue extraído y derivado para su análisis his- tológico. El informe del laboratorio reveló que la perforación había sido reparada por medio de la aposición de un nuevo tejido calcificado y que el remanente periodontal adherido a la raíz se encontraba dentro de los límites normales. El presente caso clínico resalta la importancia que tiene el conocimiento cabal de la anatomía del sistema de conductos radiculares con el objeto de evitar errores de procedimiento que puedan influir negativamente en el pronóstico del tratamiento (AU)

Aim: To describe the clinical, radiographic and histo- logical aspects of the retreatment of a second upper molar in which root perforation had occurred during the original treatment. Clinical case: A 50-year old male was referred for endo- dontic retreatment of the right second maxillary molar. Radi- ographic examination revealed the presence of an incomplete root canal treatment, a radiolucent periapical area and a root perforation produced by a threaded post placed outside of the mesiobuccal root canal. After post removal, the root perfo- ration was sealed with Biodentine and the root canals were retreated. Two years later, the patient returned to the office com- plaining of severe pain during mastication, in the area of the previously retreated right second maxillary molar. Clinical and radiographic examination revealed the presence of a ver- tical fracture on the palatal root. Since this kind of root dam- age non-restorable, the tooth was extracted and submitted to histologic analysis. The laboratory report revealed that the perforation site had healed by the apposition of new calci- fied tissue, and that the remnants of periodontal tissue which persisted attached to the root were within normal limits. This clinical case highlights the importance of thorough knowl- edge of the anatomy of the root canal system in order to avoid procedural errors which may compromise the prognosis of the treatment (AU)

Empleo de Biodentine como alternativa para el tratamiento de perforaciones radiculares: informe de un caso clínico / The use of Biodentine for root perforation therapy: report of a clinical case

Objetivo: Presentar un caso clínico de dos premolares inferiores con perforación radicular iatrogénica obturadas con Biodentine. Caso clínico: Una paciente de 54 años de edad fue derivada para realizar el tratamiento endodóntico en las piezas dentarias 44 y 45. Los exámenes clínico y radiográfico revelaron la presencia de perforaciones radiculares, cuya localización fue confirmada por medio de una tomografía computarizada de haz cónico. Luego de la desinfección y la instrumentación de los conductos radiculares, ambas perforaciones fueron selladas con Biodentine. Finalmente, los conductos fueron obturados, y las cavidades de acceso, restauradas con resina compuesta. Una semana después los dientes se encontraban asintomáticos y sin tumefacción. La paciente fue controlada nuevamente a los 20 meses postratamiento. Al examen clínico, ambos dientes estaban asintomáticos y funcionales. No hubo signos de infección, inflamación o sensibilidad a la percusión y la palpación. Las imágenes radiográficas y tomográficas revelaron espacio periodontal y cortical ósea normales. Conclusión: En el presente caso clínico, el Biodentine resultó un material adecuado para la obturación de perforaciones radiculares de origen iatrogénico ubicadas en la unión de los tercios medio y coronal (AU)

Aim: To present a clinical case of two lower premolars with iatrogenic root perforations in which both defects were repaired with Biodentine. Clinical case: A healthy 54-year old female was referred for endodontic treatment of teeth number 44 and 45. Clinical and radiographic examination revealed the presence of root perforations whose buccal localization was confirmed by a cone beam computed tomography scan. After the root canals were instrumented, both perforations were filled with Biodentine. The canals were obturated and the endodontic accesses were restored. A week later, the teeth were asymptomatic and without the presence of swelling. The patient was recalled 20-months after treatment and both teeth were asymptomatic and functional with no signs of infection, inflammation or sensitivity to percussion and palpation. Radiograph and cone beam computed tomography images showed a normal periodontal width and an intact lamina dura. Conclusion: Based on the outocome of this clinical case, Biodentine was an adequate material to repair iatrogenic root perforations (AU)

Tratamiento multidisciplinario de diente con pronóstico desfavorable. Reporte de caso / Multidisciplinary tooth treatment with unfavorable prognosis. Case report

RESUMEN: Las perforaciones radiculares son uno de los accidentes que pueden ocurrir dentro del tratamiento endodóntico rehabilitador de un diente y comprometen el pronóstico de éste. El objetivo de este reporte es describir el tratamiento y seguimiento de un diente con pronóstico desfavorable, con falsa vía y perforación en el 1/3 medio radicular. El manejo de la perforación se realizó con BiodentineTM y la rehabilitación con prótesis fija unitaria con poste de fibra individualizado. A los controles clínicos y radiográficos de 6, 12 y 24 meses el tratamiento se encontró asintomático y en función, pudiéndose considerar exitoso.

ABSTRACT: A radicular perforation is a mishap that can occur during the Endodontic and Restorative Treatment of a tooth and it can compromise its short and long-term prognosis. The aim of this report is to describe the treatment and follow up of a tooth with an unfavorable prognosis that had a perforation in the radicular middle third. The perforation was repaired with BiodentineTM and a fiber post and crown were placed. The patient had a follow up at 6, 12 and 24 months and the tooth was found asymptomatic and functional, which can be considered a clinical success.

Empleo del MTA en la obturación de perforaciones radiculares de origen iatrogénico / The use of MTA in the filling of root perforations of iatrogenic origin

Objetivo: Presentar una serie de casos clínicos con perforaciones radiculares obturadas con MTA. Casos clínicos: Este estudio retrospectivo muestra una serie de 5 casos clínicos correspondientes a elementos dentarios con perforaciones radiculares obturadas con MTA y evaluadas clínica y radiográficamente a distancia del tratamiento. Conclusión: El MTA es un material de obturación válido para el tratamiento de las perforaciones radiculares, permitiendo la reparación de los tejidos perirradiculares comprometidos (AU)

Aim: To present a series of clinical cases with root perforations filled with MTA. Case report: This retrospective study shows a series of five clinical cases corresponding to teeth with root perforations filled with MTA and assessed clinically and radiographically for a long period of time. Conclusion: MTA is a valid filling material for root perforation treatment allowing the healing of compromised periradicular tissues (AU)

Current situation and strategy on perforation repair / 华西口腔医学杂志

Perforations are common complications of root canal therapy. In clinic, perforations that were improperly and untimely repaired can seriously affect the prognosis of teeth after root canal treatment. At present, the status of perforation repair in our country is worrisome. This paper focused on the progress of perforation repair in the country by discussing the current situation of repair methods and materials. This review aims to improve knowledge and aid clinical doctors in the sophistication of perforation repair in order to improve the retention rate of root-canal-treated teeth.

Detection of root perforations using conventional and digital intraoral radiography, multidetector computed tomography and cone beam computed tomography

OBJECTIVES: This study aimed to compare the accuracy of conventional intraoral (CI) radiography, photostimulable phosphor (PSP) radiography, cone beam computed tomography (CBCT) and multidetector computed tomography (MDCT) for detection of strip and root perforations in endodontically treated teeth. MATERIALS AND METHODS: Mesial and distal roots of 72 recently extracted molar were endodontically prepared. Perforations were created in 0.2, 0.3, or 0.4 mm diameter around the furcation of 48 roots (strip perforation) and at the external surface of 48 roots (root perforation); 48 roots were not perforated (control group). After root obturation, intraoral radiography, CBCT and MDCT were taken. Discontinuity in the root structure was interpreted as perforation. Two observers examined the images. Data were analyzed using Stata software and Chi-square test. RESULTS: The sensitivity and specificity of CI, PSP, CBCT and MDCT in detection of strip perforations were 81.25% and 93.75%, 85.42% and 91.67%, 97.92% and 85.42%, and 72.92% and 87.50%, respectively. For diagnosis of root perforation, the sensitivity and specificity were 87.50% and 93.75%, 89.58% and 91.67%, 97.92% and 85.42%, and 81.25% and 87.50%, respectively. For detection of strip perforation, the difference between CBCT and all other methods including CI, PSP and MDCT was significant (p < 0.05). For detection of root perforation, only the difference between CBCT and MDCT was significant, and for all the other methods no statistically significant difference was observed. CONCLUSIONS: If it is not possible to diagnose the root perforations by periapical radiographs, CBCT is the best radiographic technique while MDCT is not recommended.

Perforación radicular asociada al uso de microtornillos en el anclaje ortodóncico: reporte de un caso / Root perforation associated with the use of micro-screws in orthodontic anchorage: a case report

Este reporte de caso describe el tratamiento quirúrgico de un primer molar maxilar como solución a la perforación iatrogénica de su raíz mesiovestibular tras la colocación de un microtornillo para el refuerzo del anclaje ortodoncico en un paciente adulto. El objetivo de este caso clínico es dar a conocer una de las posibles complicaciones asociadas a la colocación de microtornillos interradiculares asociados al refuerzo del anclaje en ortodoncia, su diagnóstico y tratamiento.

The aim of this publication is to present one of the possible complications associated with the placement of interradicular miniscrews for the reinforcement of anchorage in orthodontics. This case report describes the surgical treatment of a maxillary first molar as a solution for the iatrogenic perforation of its mesiobuccal root after the placement of a microscrew for the reinforcement of the orthodontic anchorage in an adult patient.

Accuracy of Root ZX in teeth with simulated root perforation in the presence of gel or liquid type endodontic irrigant

OBJECTIVES: To evaluate the accuracy of the Root ZX in teeth with simulated root perforation in the presence of gel or liquid type endodontic irrigants, such as saline, 5.25% sodium hypochlorite (NaOCl), 2% chlorhexidine liquid, 2% chlorhexidine gel, and RC-Prep, and also to determine the electrical conductivities of these endodontic irrigants. MATERIALS AND METHODS: A root perforation was simulated on twenty freshly extracted teeth by means of a small perforation made on the proximal surface of the root at 4 mm from the anatomic apex. Root ZX was used to locate root perforation and measure the electronic working lengths. The results obtained were compared with the actual working length (AWL) and the actual location of perforations (AP), allowing tolerances of 0.5 or 1.0 mm. Measurements within these limits were considered as acceptable. Chi-square test or the Fisher's exact test was used to evaluate significance. Electrical conductivities of each irrigant were also measured with an electrical conductivity tester. RESULTS: The accuracies of the Root ZX in perforated teeth were significantly different between liquid types (saline, NaOCl) and gel types (chlorhexidine gel, RC-Prep). The accuracies of electronic working lengths in perforated teeth were higher in gel types than in liquid types. The accuracy in locating root perforation was higher in liquid types than gel types. 5.25% NaOCl had the highest electrical conductivity, whereas 2% chlorhexidine gel and RC-Prep gel had the lowest electrical conductivities among the five irrigants. CONCLUSIONS: Different canal irrigants with different electrical conductivities may affect the accuracy of the Root ZX in perforated teeth.

Perfuração radicular cervical: relato de um caso clínico / Cervical root perforation: a clinical case report

O presente trabalho apresenta um caso clínico de um tratamento de uma perfuração radicular em nível do terço cervical de um pré-molar inferior direito com cimento de hidróxido de cálcio (dycal), MTA e o cimento AH Plus. A paciente do sexo feminino, 50 anos de idade, procurou a Clínica de Endodontia do Curso de Es¬pecialização na CPO em 2011 e, após exame clínico, foi constatado um sangramento abundante no elemento 45. Inicialmente, irrigou-se a área afetada com solução de hidróxido de cálcio (água de cal) com o intuito de realizar a hemostasia, pois a paciente relatava dor espontânea. Na consulta posterior, foi confirmada a perfuração radicular que foi selada com cimento dycal, MTA e cimento AH Plus. Nessa sessão realizou-se o preparo do canal radicular e o hidróxido de cálcio (Calen) foi utilizado como medicação intracanal. Depois de um mês, o canal foi obturado. E a proservação do caso foi realizada após 6 meses, obtendo-se sucesso na terapia endodôntica

The present work introduces the clinical case of a root perforation treatment at the PMID`s third cervical with calcium hydroxide cement, MTA and AH Plus cement. The pacient, female, 50 years old, looked for the CPO Endodontic Clinic in 2011 and after clinical examination was confirmed an abundant bloody in element 45. First, the area affected was irrigated with calcium hydroxide solution in order to realize the hemostasis, be¬cause the pacient had related spontaneous pain. In consultation after, was confirmed the root perfuration and it was sealed with calcium hydroxide cement, MTA and AH Plus cement. In that session, was realized the root canal preparation and calcium hydroxide was utilized as intra-root medication. After a month, the canal was obturated. And the case accompanying was realized after 6 months, with success at the endodontic treatment

Cirurgia parendodôntica: uma opção para resolução de perfuração radicular - apresentação de caso clínico / Paraendodontic surgery: an option to resolution of rootperforation - case report

Introdução: A cirurgia parendodôntica é um dos recursos utilizados toda vez que não se consegue a remoção do agente etiológico via endodonto, na tentativa de manter o elemento dentário em função, além de remover o tecido inflamado periapical e ter melhor acesso a limpeza, modelagem e selamento da porção apical do canal radicular. O objetivo deste trabalho é apresentar um caso clínico de cirurgia parendodôntica, utilizando-se a técnica de obturação simultânea ao ato cirúrgico como uma opção na resolução de perfuração radicular. Descrição do caso clínico: Paciente D.L.I.V.U. apresentou-se com dor contínua na região de segundo pré-molar inferior esquerdo, o qual se encontrava com tratamento endodôntico prévio, lesão periapical, perda óssea lateral e perfuração radicular lateral no terço apical. Como tratamento, realizou-se na primeira consulta a remoção do material obturador dos terços cervical e médio do canal, e a colocação de medicação intracanal. Na consulta seguinte, foi realizado um novo preparo químico-mecânico e cirurgia parendodôntica, associada à obturação simultânea. O caso foi acompanhado clínica e radiograficamente por dois anos. Conclusão: Por meio dos achados clínicos e radiográficos, concluiu-se que a cirurgia periapical conjugada aos benefícios da obturação simultânea do canal radicular é um recurso viável para resolução de perfuração radicular apical.

Introduction: The apical surgery is a technique used when it is not possible to remove the etiologic agent through a conventional procedure of retreatment, in an attempt to save the tooth. Besides, the apical surgery brings the possibility of removing the inflamed periapical tissues and cleaning, shaping and sealing the apical area of root canal. The aimof the present study was to report a clinical case of paraendodontic surgery using a technique to simultaneously fill the root canal, in order to treat the root perforation. Case report: Patient DLIVU felt continuous pain in the region of the second left mandibular premolar, which previously had endodontic treatment, periapical lesions, lateral bone loss, and lateral root perforation in apical third. In the first session, the root filling material was removed from the cervical and middle thirds and the intra-canal medication was placed in root canal. At the next session, a new chemo-mechanical preparation was made and a periradicular surgery was associated with simultaneous root canal filling. The case was clinically and radiographically followed for 2 years. Conclusion: According to clinical andradiographic findings, it was concluded that periapical surgery combined with the benefits of simultaneous root canal filling is a viable technique for the resolution of apical root perforation.

Influência do modelo experimental na atividade antimicrobiana do MTA e cimento portland / Influence of experimental model on antmicrobial activity of mineral trioxide agregate and portland cement

Estudou-se a influência do modelo experimental no efeito antimicrobiano do MTA (Cinza e Branco) e do cimento Portland (Cinza e Branco). Utilizou-se o Enterococcus faecalis, isoladamente ou associado a uma mistura com outros microrganismos: Staphylococcus aureus, Pseudomonas aeruginosa e Bacillus subitilis e um fungo, a Candida albicans. Para o teste por contato direto, 108 cones de papel foram contaminados e expostos aos materiais seladores por 24, 48 e 72 horas. Os cones de papel foram imersos em 10 mL de Letheen Broth e incubados a 37°C por 48 horas. Na seqüência, um inóculo de 0,1 mL do Letheen Broth foi transferido para 10 mL de Brain Heart Infusion sob as mesmas condições de incubação, para posterior avaliação do crescimento microbiano. Para o teste de difusão em ágar, 24 placas de Petri com 20 mL de BHI ágar foram inoculados com 0,1 mL das suspensões microbianas descritas. Para cada placa, cinco cavidades com 4 mm de profundidade e 4 mm de diâmetro foram preparadas e preenchidas com um dos seladores testados (n=10). As placas foram pré-incubadas por uma hora em temperatura ambiente e, a seguir, incubadas a 37ºC por 48 horas. As zonas de inibição microbiana foram medidas em milímetros. O modelo experimental empregado influenciou nos resultados. Os agentes seladores testados apresentaram efetividade antimicrobiana decorridas 24 horas de exposição por contato direto e inefetivos por meio de difusão em Agar.

The antimicrobial effect of MTA (gray and white) and of Portland cement (gray and white) was studied through two experimental methods. For this purpose, it was used Enterococcus faecalis, isolated or associated to a mixture of three microorganisms: Staphylococcus aureus, Pseudomonas aeruginosa, Bacillus subitilis, and Candida albicans. For direct contact test, 108 paper points were contaminated and exposed to sealer materials for 24, 48 and 72 hours. The paper points were immersed in 10 mL of Letheen Broth and incubated at 37 Celsius degrees for 48 hours. After that, an inoculum of 0,1 mL of Letheen Broth was transferred to 10,0 mL of Brain Heart Infusion under the same incubation conditions, and then microbial growth was evaluated. For agar diffusion test, 24 Petri plates with 20 mL of BHI agar were inoculated with 0,1 mL of microbial suspension using sterilized swabs. For each plate, five holes 4 mm deep and with 4 mm of diameter were prepared and filled with one of the tested sealers (n = 10). Plates were preincubated for one hour in room temperature and then incubated at 37 Celsius degrees for 48 hours. Microbial inhibition zones were measured in millimeters. The experimental model influenced in the results. All sealer agents tested were effective after 24 hours in direct contact with E. faecalis and the microbial mixture. The agar diffusion test showed that no agent presented antimicrobial effectiveness on biological indicators.

L929 cell response to root perforation repair cements: an in vitro cytotoxicity assay

This study compared the cytotoxicity of an experimental epoxy-resin and calcium hydroxide-based cement (MBPc), gray mineral trioxide aggregate (MTA) and white mineral trioxide aggregate (WMTA) using the agar overlay method with neutral red dye. L929 cells were seeded into 6-well culture plates where 48-h set test materials were placed on the agar overlay, in triplicate. Teflon and natural rubber served as negative and positive controls. After an incubation period of 24 h at 37ºC in a humidified atmosphere of 5 percent CO2 in air, a discolored area around the samples and the positive controls could be observed and measured per quadrant. The mean values were compared and converted into grades to classify the results according to the table of cytotoxicity grades according to the Standard Operating Procedures (SOP) of the Oswaldo Cruz Foundation, Brazil. The nonviable cell areas and the morphological changes in the cells were observed with an inverted microscope. The results showed grade 1 (slight) for the two types of MTA (p>0.05) and grade 2 (mild) for the MBPc (p<0.001). All samples met the requirements of the test as none of the cultures showed reactivity higher than grade 2.

O objetivo deste estudo foi comparar a citotoxicidade de um cimento experimental à base de resina epóxica e hidróxido de cálcio (MBPc), do agregado trióxido mineral (MTA) cinza e do MTA branco, utilizando o ensaio de difusão em agar com o corante vermelho neutro. Células L929 foram semeadas em placas de 6 poços e sobre elas a camada de agar, onde foram colocados os materiais endurecidos por 48 h, em triplicata, além de teflon como controle negativo e látex como controle positivo. Após 24 h em estufa umidificada a 37ºC com 5 por cento CO2, um halo claro se formou ao redor das amostras e dos controles positivos. As medidas foram tomadas, por quadrante, e as médias foram comparadas e convertidas em graus para qualificar os resultados, de acordo com a tabela de grau de citotoxicidade do POP/FIOCRUZ. As zonas de inibição e as alterações da morfologia celular foram avaliadas sob microscópio invertido. Os resultados revelaram grau 1 (leve) para os dois tipos de MTA (p>0,05) e grau 2 (branda) para o MBPc (p<0,001). Todas as amostras foram consideradas satisfatórias, pois nenhuma cultura exposta aos cimentos revelou toxicidade superior ao grau 2.