• Root perforation is an artificial communication between the root canal system to the supporting tissues of teeth or to the oral cavity. (AAE Glossary)
  • Accidental root perforations, which may have serious implications, occur in approximately 2–12% of endodontically treated teeth, according to Ingle, Kerekes, Seltzer and many other authors.


Causes of Perforations:

  • Misaligned use of rotary burs during endodontic access preparation and search for root canal orifices.
  • Negotiating calcified and curved canals
  • Lateral extension of the canal preparation (to a so-called strip perforation)
  • Inappropriate post space preparation

Signs and Symptoms of Perforations:

  • Sudden bleeding and pain during instrumentation of root canals or post preparations in teeth are warning signals of a potential root perforation.
  • Suppurations resulting in tender teeth, abscesses, and sinus tract including bone resorptive processes may occur.
  • Down-growth of gingival epithelium to the perforation site.


Detection of root perforations

  • Sudden bleeding from canal (Paper points are useful aids)
  • Radiopaque instruments going to the periodontal tissues, confirmed with radiographs or CBCT
  • Use of electronic apex locator
  • Use of operating microscope for additional illumination and magnification
  • A narrow isolated deep pocket (in long standing root perforations)


Sequels of root perforation:

  • Bacterial infection emanating either from the root canal or the periodontal tissues, or both, prevents healing.
  • Once an infectious process has established itself at the perforation site, prognosis for treatment is precarious and the complication may prompt extraction of the affected tooth.


Measures for Prevention:

Before accessing canals:

  • Check crown-root alignment
  • Careful examination of radiograph
    • Shape and depth of pulp chamber
  • Width of furcation floor

Before root canal preparation:

  • Use of magnification
  • Avoid rubber dam before access in teeth with:
    • Narrow or calcified pulp chambers
    • Crowned teeth
  • Pulp chamber is centrally located at the level of CEJ.



During Root canal Preparation:

  • Avoid overzealous preparation
  • Use flexible instruments with copious irrigation and lubrication



During Post Space Preparation:

  • Avoid excessive pressure with post drills, GG or Peeso reamers
  • Stop when gutta-percha is not coming out from the canal and verify with magnification to see if you are going to the right direction.


Factors of Significance on Prognosis of the Treatment

  • Time from the perforation to detection
  • Size and shape of the perforation
  • Location
  • Repair material
  • Over extrusion of repair material
  • Preoperative radiolucency adjacent to perforation site


Ideal material properties for root perforation repair

  • Biocompatible
  • Easy manipulation
  • Hydrophillic
  • Fast setting
  • Insoluble
  • Antimicrobial activity
  • Smooth surface
  • Adequate sealing
  • No discoloration
  • Radiopaque


Materials in the market for root perforation repair

  • Amalgam
  • Composite resin
  • Resin modified glass ionomer
  • Cavit
  • Super EBA
  • Zinc Oxide Eugenol / IRM
  • MTA and other calcium silicate based materials

Treatment modalities

Apical level / Mid-root level

  • Nonsurgical approach and repair with calcium silicate base material.
  • Monitor for signs or symptoms.
  • Surgical approach when a periapical lesion develops after monitoring period.
  • Prognosis: Fair-Good


Crestal / Furcal level

  • Orthodontic extrusion or surgical crown lengthening procedure have been recommended for single-rooted teeth to bring the perforation to a coronal position.
  • Nonsurgical approach and repair with composite resin, resin modified glass ionomer or fast set calcium silicate base material in scenarios where the material is not constantly challenged by saliva.
  • Prognosis: Poor-Fair.


Reported Success Rates

  • According to the Systematic Review and Meta-analysis by Siew et al. (JOE 2012):
  • An overall pooled success rate of 5% (confidence interval, 61.9%–81.0%) was estimated for nonsurgical repair of root perforations.
  • The use of MTA appeared to enhance the success rate to 80.9%.
  • Pre-op radiolucency decreases success rate
  • Maxillary teeth showed significantly higher success rate after perforation repair than Mandibular teeth (P < .05).