PERFORATIONS &

MANAGEMENT
Dr. Aparna Aarathi Sreekumar
III MDS
CONTENTS

• Introduction
• Definition
• Causes
• Classification
• Diagnosis
• Prevention of Perforation
• General Aspects in Treatment 2
CONTENTS
• Non-surgical Management
• Surgical Management
• Management of Specific Conditions
• Perforation Repair Materials
• Factors Affecting Prognosis
• Sequelae of Root Perforation
• Conclusion
• References
3
INTRODUCTION

• Perforations – serious complication

• Pathologic / mechanical in origin

• Iatrogenic perforations during RCT – 2-12% (Ingle)

• Iatrogenic – occurs during search of canal orifices, access preparation,
cleaning & shaping & excessive dentin removal during post space
preparation
4
• Perforations can lead to failure of endodontic treatment

• Early diagnosis & appropriate management – important in

determining the prognosis

• Various methods & techniques – available to repair the

defect

• The most commonly used material with high success rate –

MTA – 80.9% (Siew et al, 2012)

5
DEFINITION

• Perforation is an opening in the tooth or its root, created by the clinician

during entry to the canal system or by a biologic event such as pathologic
resorption or caries that results in a communication between root canal &
periodontal tissue
- Ingle, 6th Ed.

6
Root canal perforation is a technical accident
that results in communication between the
crown or the root canals & the periodontal
space (Estrela, Vol. 2, 2nd Ed.)

Root perforation is an artificial

communication between the root canal
system to the supporting tissues of teeth or to
the oral cavity (AAE Glossary – 9th Ed.)

7
• A furcation perforation refers to a mid-curvature opening
into the periodontal ligament space
- Ingle, 6th Ed.

• A post space perforation is defined as a communication

between the lateral root surface & the surrounding
periodontal structures due to misdirection or an excessively
large post enlargement
- Weine, 6th Ed.

8
CAUSES

PATHOLOGIC

PERFORATIO
N
IATROGENIC

9
Pathologic Causes:

Caries Pathologic
Resorption

10
Unmanaged carious lesions can proceed
to perforation or near-perforation in the
cervical region of the tooth, at or below
the level of the crestal bone

Common in older patients where salivary

quality & quantity is diminished &
gingival recession has led to dentin
exposure
11
Resorption:
• Physiologic or pathologic process
• Resulting in loss of dentin,
cementum & sometimes bone
• Can be classified as external,
internal or cervical

12
Iatrogenic Perforations – Causes:

•Perforations during access preparation

•Root perforations during cleaning and shaping

•Root perforations during post space preparation

 Endodontics: Principles and Practice, Torabinejad, 4 th Ed.

13
During Access Cavity Preparation:

• Failure to achieve straight-line access - main etiologic

factor
• Excess removal of tooth structure during attempts to
locate canals -> perforation
• Lack of attention to the degree of axial inclination of a
tooth in relation to adjacent teeth & to alveolar bone
results in gouging & perforation of the crown or the root

14
• Searching for the pulp chamber or orifices
of canals through an underprepared access
cavity

• Failing to recognise when bur passes

through a small or flattened (disklike) pulp
chamber in a multirooted tooth may also
result in gouging or perforation of the
furcation
• Calcified pulp chamber

15
• A cast crown often is not aligned in the long axis of the
tooth
• Directing the bur along the misaligned crown can result
in a coronal or radicular perforation

PERFORATIO
N

16
Root Perforations During Cleaning & Shaping:

• Roots may be perforated at different levels during

cleaning & shaping

• Location (apical, middle or cervical) of perforation &

stage of treatment affect prognosis
• The periodontal response to the injury is affected by
the level & size of the perforation

17
Apical Perforations:
• Occur :
• Through apical foramen
-overinstrumentation
• Through body of the root
-perforated new canal
18
• Instrumentation of the canal beyond the apical constriction
results in perforation

• Incorrect working length or inability to maintain proper

working length causes “zipping” or “blowing out” of the
apical foramen

19
 Lateral/Mid-root Perforations:
• Inability to maintain canal curvature ->
ledge formation
• Negotiation of ledged canals is not
always possible & misdirected pressure
& force applied to file - result in
formation of an artificial canal and
eventually in an apical or midroot
perforation
20
Strip Perforations:
• Endodontic stripping is an oblong, vertical perforation
that occurs especially in the middle section of a curved
root canal, caused by excessive instrumentation of the
internal wall during the removal of the organic material
from the endodontic space and the tridimensional shaping
of the canal by a progressive conical preparation
- Hulsmann

21
Coronal root perforations
• Occur during access preparation
as the operator attempts to
locate canal orifices or during
flaring procedures with files,
GG drills or Peeso reamers
22
Perforations During Post Space Preparation:

• Violation of post space diameter would lead to gauging of

dentinal walls, stripping & perforations
• Kvinnsland et al (1989) found 47% of perforations
occurred during endodontic treatment & 53% were due to
post space preparation
• Kuttler & Mclean : post space preparation in mandibular
molars carries significant risk of perforation because of
the presence of anatomical danger zones

 Tinaz AC, Alaçam T, Topuz O, Er O, Maden M. Lateral perforation in parallel post space preparations. J
Contemp Dent Pract. 2004 Aug 15;5(3):42-50. 23
CLASSIFICATION

• Based on the prognostic factors

• By Fuss & Trope (1996)

• Assist the clinician to select a treatment strategy

24
 Based on Time:

1. “Fresh perforation" :
• Associated with a perforation at the same visit
which if treated immediately & with an aseptic
technique has a good prognosis

2. "Old perforations" :
• Associated with previously untreated accidental
operative procedures where a bacterial infection
may be established
• Questionable prognosis
25
 Based on Size:

1. “Small perforations” :
• Are those which occur with endodontic instruments
of size 15 or 20
• Mechanical damage to the tissue as a result of these
perforations is minimal & chance that the
perforation is occurred under the aseptic conditions
required of endodontic treatment (rubber dam,
sodium hypochlorite irrigation)
• Infection is less likely
• Good prognosis

26
2. “Large perforation” :

• Perforation which occurs in post preparation results

in significant tissue damage
• Difficulty in providing an adequate seal
• Chances of infection from salivary contamination,
or coronal leakage along temporary restoration are
much greater
• Poor prognosis

27
 Based on Location:

• The relationship of the perforation site to the ‘critical

crestal zone’

1. Coronal / supracrestal perforations

2. Crestal perforations
3. Apical / Subcrestal perforations

28
1. “Coronal perforation” :
• Coronal to the level of crestal bone & epithelial
attachment with trauma to adjacent tissues are less
& easy access possible
• Good prognosis
2. “Crestal perforation” :
• At the level of the epithelial attachment into the
crestal bone
• Questionable prognosis
3. “Apical perforation” :
• Apical to the crestal bone & the epithelial
attachment
• Good Prognosis
29
 Fuss Z, Trope M. Root perforations: classification and treatment choices based on prognostic factors.
Dental Traumatology. 1996; 12: 255-64. 30
CLASSIFICATION OF FURCAL PERFORATIONS:

• Direct Perforation –
• Usually occurs during searching for a canal, commonly a
calcified canal
• Punched-out defect into the furcation area with a bur
• Normally, this type of defect is accessible and should be
repaired as soon as possible

• Stripping Perforation –
• Results from excessive enlargement of the canal with files or
GG or similar drills
• Occur in narrow curved canals
• This type of perforation is generally inaccessible
 Endodontics: Principles and Practice, Torabinejad, 4th Ed. 31
Microperforation : Size of
furcal perforation <0.5mm

Macroperforation : Size of
furcal perforation >0.5mm
 Jantarat, J. (1998). Surgical Management Of A Tooth With Stripping Perforation.
32
Australian Endodontic Journal, 24(3), 111–114.
DIAGNOSIS

SIGNS:

• Warning signals of a potential root perforation during

instrumentation of root canals or post space preparations in teeth

33
1. Sudden bleeding :

• During vital root canal preparation, after removal of pulp

tissue, persistent bleeding during coronal access or root
canal preparation
• Immediate & continuous hemorrhage which makes canal or
chamber is difficult to dry
• Placement of a paper point or cotton pellet may increase or
renew the bleeding

34
2. Sudden pain during WL determination when LA was
adequate during access preparation

3. Burning pain or a bad taste during irrigation with

sodium hypochlorite

4. Unusually severe postoperative pain may result from

cleaning & shaping procedures performed through an
undetected perforation

35
5. Suppurations resulting in tender teeth, abscesses &
sinus tract including bone resorptive processes may
occur

6. Down-growth of gingival epithelium to the perforation

site

7. A narrow isolated deep pocket

8. Extension of the largest (final) file beyond the

radiographic apex – sign of apical perforation
36
ELECTRONIC APEX LOCATORS (EALs):

• EALs can accurately determine the location of root

perforations, making them significantly more reliable
than radiographs (Kaufman et al, 1997)
• PDL reading from an apex locator that is far short of
the WL on an initial file entry

37
DENTAL OPERATING MICROSCOPE:

• A helpful tool effective in detecting root perforations

during orthograde root canal therapy (Wong, 1997)

Wong R, Cho F. Microscopic management of procedural errors.

38
Dent Clin North Am 1997:41:455–479
RADIOGRAPHIC DETECTION:

1. Normal & angled radiographs

• A radiolucency associated with a communication between
the root canal walls & periodontal space

2. Unusual exit of exploratory instruments

39
3. Placing a highly radiopaque calcium-hydroxide paste,
containing barium sulfate, in the root canal – to identify
potential areas of perforation

40
CBCT:
• CBCT can be incorporated to aid in the diagnosis &
prognosis of these pathologic & iatrogenic conditions
• Shemesh et al (2011) compared ex vivo the sensitivity &
specificity of CBCT scans & digital periapical
radiographs (PR) in detecting strip & root perforations in
curved mesial roots of mandibular molars :
• Risk in misdiagnosing strip perforations was high with
both methods, but CBCT scans showed a significantly
higher sensitivity than PR

41
• Metallic artifacts associated with intracanal posts -
misdiagnosis, particularly when root perforation or bone
destruction is suspected
• A map-reading strategy to diagnose root perforations near
metallic intracanal posts using CBCT images was suggested by
Bueno et al (2011):
• By making sequential axial slices of each root with an image
navigation protocol from the coronal to the apical direction (or
apical to coronal) with axial slices of 0.1 mm
• This directional orientation provides precious information
concerning exact localization of root perforations
 Bueno, M. R., Estrela, C., De Figueiredo, J. A. P., & Azevedo, B. C. (2011). Map-reading Strategy to Diagnose
Root Perforations Near Metallic Intracanal Posts by Using Cone Beam Computed Tomography. Journal of 42
Endodontics, 37(1), 85–90.
43
• Dynamic navigation of CBCT images –

• In the slices located near the post apex, the beam hardening
effect is reduced, because CBCT allows us to capture a
lesser amount of metal on the images
• A new software program - to reduce metallic artifacts in
reconstructions of CBCT images (e.g., e-Vol DX, CDT)

 Estrela C, Decurcio DA, Rossi-Fedele G, Silva JA, Guedes OA, Borges IH.Root
perforations: a review of diagnosis, prognosis and materials. Braz. Oral Res.
2018;32(suppl):e73, 133-146

44
PREVENTION OF
PERFORATIONS
CLINICAL EXAMINATION:

• Thorough knowledge of tooth morphology - is mandatory to

prevent pulp chamber perforations
• Location & angulation of the tooth related to adjacent teeth &
alveolar bone – should be assessed to avoid a misaligned access
preparation

45
• Crown-root alignment should always be evaluated &
bony eminences noticed

• Palpation is useful to detect the direction of the root

relative to the crown

• Use of magnification - to observe canal orifices & the

coronal alignment of the root canal

46
 • Radiographs from
different angles provide
information about the size
& extent of the pulp
RADIOGRAP chamber
HS:
• Presence of internal
changes such as
calcification or resorption –
can be identified

47
OPERATIVE PROCEDURES:

• In cases where problems are anticipated in locating pulp

chambers (eg: tilted teeth, misoriented castings, or
calcified chambers), initiating access without a rubber
dam is preferred
• As it allows better crown-root alignment

48
• A small bur is placed during access preparation when
orientation is a problem & radiograph is taken
• This provides information such as angulation & depth of
bur penetration

• After penetration of the roof of the chamber, a safe ended

access bur, such as the Endo Z / pulp shaper bur – used
to prevent perforation of the chamber floor

49
CLEANING & SHAPING:

• Flexible nickel titanium instruments along with copious

irrigation and lubrication were proposed for curved
canals to prevent apical perforations
• Pre-curving of instruments
• Maintaining correct WL through out the procedure &
confirming with EAL
• Anticurvature filing – to prevent strip perforations

50
POST SPACE PREPARATION:

• Utmost care should always be exercised during post

preparations so that root canals are not overextended
• A safe preparation is best attained with the surgical
microscope immediately after completion of a root canal
filling

51
GENERAL ASPECTS IN TREATMENT

Case Selection for Perforation Repair:

Indications: Contraindications:
1. Accessible perforations below the 1. Perforations inaccessible to
crestal bone, approx. 1mm or smaller matrix placement like strip
2. Large perforation in the middle or perforation
apical third of the root in straight 2. Perforations on the external root
canals surface at or above the level of
the crestal bone
52
Suggestions by Rud et al (1998):

• Even if a small bridge of crestal bone remains, it should

be preserved by all means

• Intentional replantation may be considered when

orthograde & surgical treatments are not possible,
undesirable, or have already failed

 Rud J, Rud V, Munksgaard EC. Retrograde sealing of accidental root perforations

with dentin-bonded composite resin. J Endod 1998:24:671–677

53
Internal Matrix Concept:

• Lemon et al (1992) introduced the

“internal matrix concept” for treatment
of root perforations
• He recommended the use of amalgam
for sealing the perforation, which would
be condensed against an external
matrix of hydroxyapatite, carefully
pushed through the perforation thus
serving as an external barrier of matrix

 Lemon RR. Nonsurgical repair of perforation defects. Internal matrix concept. Dent Clin
North Am. 1992 Apr;36(2):439-57. 54
Collaplug, calcium sulphate, PoP are used as
internal matrix

55
Modified Matrix Concept:

• It is described by Bargholz (2005)

• Small pieces of collagen are used to push
the granulation tissue out of the perforation
& keep it in place outside the root
• MTA may be layered against the collagen
until the perforation is repaired

 Bargholz, C. (2005). Perforation repair with mineral trioxide aggregate: a modified

matrix concept. International Endodontic Journal, 38(1), 59–69

56
•Freshly mixed MTA has a soft consistency and may be
applied without pressure
•Direct observation of the material site through the operating
microscope - to avoid inadvertent blockage of empty root
canal space with MTA & to confirm correct placement of the
repair material

57
58
NON-SURGICAL MANAGEMENT

• The rationale for non-surgical treatment of root perforations is

same as that of a conservative endodontic procedure
Þ Prevention or treatment of periradicular inflammation
• This is achieved by ensuring that the perforation site is either
not infected or disinfected at the time of treatment
• The material used to treat perforation provides the best
possible seal to bacterial penetration & the material is itself
not irritating to the surrounding tissues & promotes healing

59
 Indications:
• Lateral perforations – coronal,
crestal, apical & strip
perforations
• Furcation perforations
• Post space preparation
perforations
60
• Coronal perforations – managed with restorations like
caries or other tooth defects

• Crestal perforations – although surgical intervention is

mostly needed, smaller perforations – treated by sealing with
a biocompatible material (MTA, Biodentine)
• Earlier – amalgam was used

61
• Apical perforations due to overinstrumentation -
managed like immature roots

• Apical perforation through body of canal & strip perforations –

after cleaning & shaping of root canal, GP cones are placed, MTA is
placed

62
Post space perforation
repair:
• Lemon’s “Internal Matrix
Concept” / Bargholz’s
“Modified Matrix Concept”
can be used
63
SURGICAL MANAGEMENT

•Perforations in the ‘critical crestal zone’ have less favorable outcome &
are difficult to manage
•Most susceptible to epithelial migration & rapid periodontal pocket
formation & often requires surgical interventions
•Goals of the surgical procedure are to debride the granulation tissue &
seal the defect to prevent further egress of microorganisms from the
canal system or from the oral cavity into the periradicular tissues

64
 Before surgical intervention, the following
parameters should be considered:
• Amount of remaining bone
• Extent of osseous destruction
• Duration of the defect
• Periodontal disease status
• Soft tissue attachment level
• Patient’s oral hygiene
• Surgeon’s expertise in tissue management
 Regan JD, Witherspoon DE, Foyle DM. Surgical repair of root and tooth perforations. Endodontic 65
Topics 2005, 11, 152–178
Indications:
1. Perforations in areas not accessible by non-surgical means
alone
2. Perforations of the root with a concomitant periodontal
component
3. Perforations that have not responded favorably to non-
surgical repair
4. Extensive defects that provide no physical boundaries
against which to apply repair material
5. Perforations of a root that require a separate apical
surgical procedure
6. Perforations owing to resorptive activity which are not
easily managed from within the canal system

66
 Strip perforations

3 broad categories of
CRESTAL ZONE
PERFORATION Furcation perforations
DEFECTS that can be
repaired surgically:

Perforations related to
external cervical root
resorption
67
Surgical management involves two procedures:
• Surgical curettage
• Surgical alteration of the tooth
SURGICAL CURETTAGE
• To remove extruded repair material
• The difficulty of controlling the internal repair material may
result in overfill & under-fill or lack of seal
SURGICAL ALTERATION OF THE TOOTH
• When perforation is too large or inaccessible without bone
removal, procedures such as root amputation, hemisection,
bicuspidization & internal replantation are attempted
68
 Soft-Tissue Management during Surgical Repair
of Perforation Defects:

• Horizontal relieving incision:

• Horizontal intrasulcular incision should extend from the
gingival sulcus through the periodontal ligament fibers &
terminate at the crestal bone & pass adjacent to each tooth
• When a defect extends interproximally, the tissue is
reflected on both the lingual & buccal sides of the tooth
• As the horizontal relieving incision extends beyond the
tooth with the defect, other forms of intrasulcular incisions
such as the papillary-base incision can be used

69
•Vertical relieving incision:
• If a vertical relieving incision is required to improve access
to the defect, several general principles should be followed:
1. Incision should be parallel to the long axis of the tooth
where possible & should not involve frenum, muscle
attachments or bony eminences
2. Incision should be made over healthy bone distant from
the site of the defect, beginning at the midpoint between
the dental papilla & the horizontal aspect of the buccal
gingival sulcus, thereby avoiding dissection of the
dental papilla

70
Soft-tissue access window:
• Formed by combining a horizontal relieving incision &
if necessary vertical relieving incisions
• If defect is close to the marginal tissues, a vertical
relieving incision may not be required or if required may
not need to extend to the depth of the vestibule

71
The basic window for soft-tissue access is
similar for each type of perforative defect
with slight modifications

3 variations of soft-tissue access window:

• Limited triangular: One vertical relieving incision
• Limited rectangular: Two vertical relieving incisions
• Envelope: No vertical relieving incision

72
Tissue elevation & reflection:
• Elevation & reflection of the entire mucoperiosteal flap - to
minimize hemorrhage
• Once the tissue adjacent to the defect has been elevated,
gentle rocking motion is used to continue the elevation &
reflection in mesial & distal directions
• Defects that involve the furcation & mid-root region will
require either a limited triangular or limited rectangular soft
tissue access window
• Once the tissue is elevated, it must be retracted to provide
adequate access for management of damaged radicular
tissues
• Goal of tissue retraction - to provide a clear view of bony
surgical site & to prevent further soft-tissue trauma
73
 Hard Tissue Management

Hard-tissue management involves five phases:

1. Removal of healthy tissue to gain access to the diseased tissues

2. Removal of the diseased tissues and foreign material
3. Formation of an appropriate cavity form to receive the
restorative material
4. Achieve a dry surgical field using appropriate hemostatic
techniques and materials followed by placement of the
restorative material in the cavity
5. Root surface is conditioned prior to tissue re-approximation

74
A surgical high-speed bur is used in phase
one and two of the procedure

For greater refinement of the perforation

site increases, ultrasonically energized tips
can be used in phases two & three
Temperature increases above normal body
temperature have been shown to be
detrimental to the osseous tissue
75
76
Guided Tissue Regeneration And Repair Of Root
Perforations (Leder et al, 1997) :

• Indication - Presence of an apico-marginal defect or

dehiscence that is distinguished by a total loss of
alveolar bone over the entire root length
• The basic principle of guided tissue and bone
regeneration is based on the fact that different types of
cells repopulate a wound at different rates during
healing
• Since soft-tissue cells are more motile than the hard-
tissue cells, they tend to migrate into the wound more
rapidly during healing

77
• A barrier place between gingival tissue & exposed root
surfaces & supporting alveolar bone prevents
colonization of gingival cells

• Use of a semi-permeable barrier allows PDL cells &

other cells with osteogenic potential to colonize around
the defect, resulting in new connective tissue
attachment & bone formation

 Joshi, R., & Thomas, M. B. M. (2018). Surgical root perforation repair with guided
tissue regeneration: a case report. Dental Update, 45(2), 155–162.

78
79
BARRIER
MATERIALS:
• Absorbable Barriers –
CollaCote, Freeze dried
bone, Calcium sulfate
• Non-absorbable Barriers –
MTA, Biodentine
80
 • Resorbable membranes are generally better suited for
endodontic applications, as a second surgical procedure
is not required to remove the membrane
• Barrier materials - functions:
• As a mechanical substructure to support a membrane
& overlying soft tissues
• As a biological component that enhances bone
formation
• To produce a ‘dry field’ & provide an internal matrix
or ‘back stop’ against to which restorative materials
can be condensed

 Regan JD, Witherspoon DE, Foyle DM. Surgical repair of root and tooth perforations.
Endodontic Topics 2005, 11, 152–178
81
MANAGEMENT OF SPECIFIC
CONDITIONS

Fresh perforations that occur during

either operative or endodontic procedures
are followed by hemorrhage:
• The first step is to control the hemorrhage by
pressure or irrigation
• The perforation should be adequately sealed
82
Infected apical perforations:
• Need to be medicated with an antibacterial intracanal
dressing before obturation

Large apical perforations:

• Should be treated similar to teeth with immature apices,
i.e. with long-term calcium hydroxide treatment to
achieve a hard tissue barrier

83
Coronal Perforations:

• Not difficult to seal externally

• Material selected for sealing will depend on aesthetic
considerations
• Acid etch bonded composite resins or GIC may be used in
anterior teeth, whereas amalgam is an additional option in
posterior teeth

84
Crestal perforations:

• Most difficult to manage because of their proximity to the

epithelial attachment & possible communication with the gingival
sulcus

• Smaller crestal perforations - any biocompatible material, with a

short setting time, should be selected to minimize the effect of the
unset material on the periodontal tissue with which it is in contact

• Cavit can be used to seal the perforations during endodontic

treatment

85
• With large crestal perforations,
whether fresh or old, surgical
intervention will usually be needed
in order to seal the defects
externally

• Another treatment possibility -

orthodontic extrusion of the tooth
to bring the perforation to a coronal
position where it can be sealed
without surgical intervention

86
Furcal Perforations:

• Perforations of the furcal region of molars are especially

troublesome because they cause considerable mechanical
damage & frequently lead to communication with the
gingival sulcus
• Apical small furcation perforations - if sealed by a fast
setting material - favourable prognosis
• Large furcation perforations make control of the repair
material difficult & extrusion of the filling material into
the periodontal ligament space is common

87
• Microperforation (<0.5mm) :
• Small perforations on the pulp floor is disinfected using
NaOCl & EDTA
• Area over the perforation is either acid etched with
phosphoric acid & then restored with conventional flowable
composite or conditioned & restored with RMGIC

• Larger perforation (>0.5mm) :

• Following disinfection, repair material can be directly
packed into the perforation site
• If there is bony resorption – a significant osseous defect is
present – matrix is placed & repair material is placed over it

88
• Surgical methods of furcal perforation
repair:
• After anesthetising, a full-thickness
mucoperiosteal flap was reflected
• An external bevel gingivectomy was
done to expose the furcation area
• After thorough root surface
debridement, osteoplasty &
ostectomy were performed using a
pear-shaped carbide bur at low-speed
and copious saline irrigation in the
interradicular bone

89
 • The amount of bone removed should
correspond to the space required to pass an
interdental brush through the furcation region
to ensure adequate plaque control
• A smooth and positive architecture without
any bony spicules, sharp bony margins or
ledges remained in the furcal space – should be
maintained
• Flap was subsequently positioned apically &
sutured

 Chopra A, Sivaraman K. Management of Furcal

Perforation with Advanced Furcation Defect by a
Minimally Invasive Tunnel Technique. Contemp Clin
Dent. 2018;9(4):670-673.
90
 • Hemisection
Other • Bicuspidisation
surgical • Root resection
methods: • Intentional
replantation
91
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 cases where the material is not constantly
contaminated by saliva
• Prognosis: Poor-Fair

92
Apical perforations:

• Should be treated according to routine endodontic principles for

regular root canals

• Difficulty is to access & adequately treat the main root canal

93
Apical, small & fresh perforations :

• Should preferably be completed in one visit &

the perforation is sealed with GP & root canal
sealer
• The use of an aseptic technique is essential

Apical, small & old perforations:

• Treated with an antibacterial intracanal

medicament such as calcium hydroxide & sealed
with GP & sealer at the second visit
94
Apical, large & old/fresh perforations:

• Should be treated like teeth with immature apices - with long-

term calcium hydroxide treatment
• Calcium hydroxide is used as an intracanal medicament for
several months until a hard tissue barrier is formed &
regular root canal obturation can be carried out
• Placement of MTA as an apical barrier can prevent extrusion
of obturating materials

If canal is not accessible & apical periodontitis

develops:

• Root end resection is indicated

95
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

96
Strip perforations:

• A strip perforation or middle 1/3rd perforation - caused

by over use of Gates-Glidden burs or rotary coronal
flaring instruments
• A narrow slit-like perforation on the internal curvature of
the root canal
• Preparation & cleaning are completed using NaOCl &
EDTA, canal is dried & Ca(OH)2 medicament is packed
into it – 1ST appointment

97
• 2nd appointment:

• Medicament is washed out pushing NaOCl & EDTA, canal

is dried, GP cones are placed in root canals to prevent their
blockage & MTA is being vibrated ultrasonically to make
the material flow into perforation defect
• After the perforation repair, GP cones are removed & canals
are obturated

98
Strip Perforation with Periodontal Pocket:

• After anaesthetizing, a full-thickness flap was reflected

• A small access to the furcation was made & cavity of the
bony lesion was detected under the cortical bone
• Granulation tissue was removed

99
• Bioactive ceramic (eg:- Bioglass,
PerioGlas) was mixed with anaesthetic
solution & placed in the furcation area

• Once the defect was filled, barrier

material (eg:- PoP) was placed as a
barrier 1.5mm thick over the bony defect

• Tissue closure was obtained &

postoperative radiograph was taken

 Jantarat, J. (1998). Surgical Management Of A Tooth With Stripping Perforation.

100
Australian Endodontic Journal, 24(3), 111–114.
Post space perforation repair:

•Previous restoration is dismantled & perforation should be cleaned

passively with irrigant solutions
•Lemon’s “Internal Matrix Concept” - Hydroxyapatite is used as the
external matrix & the defect was filled with amalgam is packed through
the defect & used to push the granulation tissue extraradicularly
•Bargholz’s “Modified Matrix Concept” - Collacote is used to push the
granulation tissue out of the perforation & keep it in place outside the
root & MTA is placed into the defect with an MTA Gun or picked up on
a plugger tip & packed into place

101
Management of perforations due to external cervical root
resorption:

102
Category I & II - should be approached from the external or periodontal
structure

Category III - can be attempted by either an internal or external approach

depending on which procedure produces the least amount of tooth and
periodontal destruction

Category IV defects - unrestorable

 The external approach to the management of cervical root resorption has been
achieved using two techniques:
1. A chemical cauterization of the lesion using 90% trichloroacetic acid
2. Surgical removal of the lesion 103
 PERFORATION REPAIR MATERIALS

IDEAL REQUIREMENTS
• According to Hartwell & England (1993):
1.It should provide adequate seal
2.It should be biocompatible
3.It should have ability to produce osteogenesis & cementogenesis
4.It should be bacteriostatic & radiopaque
5.It should also be beneficial to use as a resorbable matrix in which a sealing
material can be condensed
6.It should be relatively inexpensive
7.It should be non-toxic, non-cariogenic & easy to place
 Abhijeet Kamalkishor Kakani et al., A Review on Perforation Repair Materials. Journal of Clinical and 104
Diagnostic Research. 2015 Sep, Vol-9(9): ZE09-ZE13
Ability to induce bone & cementum formation
Ability to provide a fluid-tight seal
Biocompatible
Radio-opaque
Non-resorbable
Non-carcinogenic
Ability to provide a bacteria-tight seal
Unaffected by blood
Possible to prevent extrusion of material into surrounding tissues
Readily available, easy to use
Relatively inexpensive
 von Loetzen, Sophie Curtius Seutter, and Michael Hülsmann. "Root perforation repair
105
concepts and materials: A review." ENDO (Lond Engl) 12.2 (2018): 87-100.
VARIOUS MATERIALS USED FOR PERFORATION
REPAIR

1. Indium foil:

• Indium foil was used as a perforation repair material mainly

to prevent gross overfilling (Auslander & Weinberg, 1969)
• Disadv: use of indium foil lead to greater severity of bone
resorption than in perforations repaired without it

 Auslander WP, Weinberg G. Anatomic repair of internal perforations with indium

foil and silver amalgam : outline of a method. NY J Dent1969:39:454–457.

106
 Aguirre et al (1986) proposed that
amalgam & indium foil would
coalesce to provide a satisfactory
seal

• They condensed amalgam over indium foil

matrices to prevent extrusion of amalgam
• But it was found that amalgam alone provided
significantly better clinical & histological results
than indium foil matrices for the repair of
furcation perforations

 Aguirre R, Mahmoud E, Mohamed E. Evaluation of the repair of mechanical furcation perforations using
amalgam, guttapercha or indium foil. J Endod. 1986;12(6):249-56.
107
2. Amalgam:

• Though it is most commonly used as restorative material

but was also experimented to fill endodontic perforations
• First recommended by Grossman (1957)
• Disadv: poor sealing properties leading to inflammation
& poor periodontal tissue regeneration
• Cu & Zn causes cytotoxicity

 Roane, J. B., & Benenati, F. W. (1987). Successful management of a perforated mandibular molar
using amalgam and hydroxyapatite. Journal of Endodontics, 13(8), 400–404.

108
• Eldeeb et al (1982): amalgam when used as repair
material for furcation perforation showed superior sealing
properties as compared to cavit & calcium hydroxide

• Benenati et al (1986) : that amalgam was found to be a

more acceptable repair material than vertically condensed
warm gutta-percha

 Eldeeb M, Tabibi A, Jensen JR. An evaluation of the use of amalgam, cavit and calcium
hydroxide in the repair of furcation perforations. J endod. 1982;8:459-66.
 Benenati FW, Roane JB, Biggs JT, Simon JH. Recall evaluation of iatrogenic root perforations
repaired with amalgam and guttapercha. J Endod. 1986;04:161-66.

109
3. Plaster of Paris:

• β-calcium sulphate hemihydrate

• Guliford (1901) recommended Plaster of Paris for
furcation perforation repair
• Placement is difficult - overcome with the provision of a
biocompatible matrix
• As the matrix material remains in the periodontal
ligament space, it must be biocompatible & preferably
resorbable

110
• Rate of resorption of PoP = rate of new bone growing
into the tissue
• Used as a substitute for filling defects & also acts as
a space filler

• Jantarat et al (1999): PoP matrix improved the seal of

furcal perforation repair with amalgam

 Jantarat J, Dashper SG, Messer HH. Effect of matrix placement on furcation perforation
repair. J Endod. 1999;25(3):192-96.

111
4. Zinc Oxide Eugenol:

• Good alternative to amalgam

• Bramante et al (1987) : perforations repaired with ZOE
showed poor prognosis
• Disadv: ZOE can cause severe inflammatory reactions
leading to abscess formation & resorption of the alveolar
crest when used as furcation perforation repair material

112
5. Super Ethoxy Benzoic Acid (Super EBA):

• Super EBA : alumina-reinforced ZnE cement

• Used for sealing perforations of the floor of the pulp
chamber or further down inside the root canal
• Advantages:
1. Ease of manipulation
2. Outstanding biocompatibility with the periapical
tissues
3. High adhesiveness & adaptation to the dentinal
walls

113
• EBA cement provided a superior seal in lateral root
perforations than silver GIC while amalgam was
intermediate between the two (Moloney et al, 1993)

• Weldon et al (2002): Super-EBA allowed significantly

less microleakage than MTA at 24 hours & the
combination of MTA & Super-EBA provided a more
rapid seal than MTA alone

 Abhijeet Kamalkishor Kakani et al., A Review on Perforation Repair Materials. Journal of Clinical and
Diagnostic Research. 2015 Sep, Vol-9(9): ZE09-ZE13

114
6. Intermediate Restorative Material (IRM):

• IRM - reinforced ZnE cement

• When used without an internal matrix it showed a
significant leakage, so it should be used only with the aid
of a matrix
• IRM showed significantly less leakage than amalgam
when used for repair of experimentally induced lateral
perforations

 Mannocci F, Vichi A, Ferrari M. Sealing ability of several restorative materials used

for repair of lateral root perforations. J Endod. 1997;23(10):639-41.

115
When amalgam, IRM & MTA
were compared, it was found
that MTA had significantly less
leakage than IRM & amalgam

 Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate

for repair of lateral root perforations. J Endod. 1993;19:541-44.

116
7. Cavit:

• Cavit - pre-mixed polyvinyl paste that does not contain eugenol

• Due to its properties such as ease of manipulation & adequate
sealing ability, it was preferred to fill endodontic perforation
• Cavit produced a seal superior to ZnE cement, Zn phosphate
cement, GP & equal to amalgam
• Widerman et al (1971) stated that Cavit did not inhibit the
healing of lesions at the site of a perforation

 Abhijeet Kamalkishor Kakani et al., A Review on Perforation Repair Materials. Journal of Clinical and
Diagnostic Research. 2015 Sep, Vol-9(9): ZE09-ZE13
117
8. Guttapercha:

• When used for repair of perforation, Lantz & Persson

(1967) reported that GP resulted in lesser inflammation
than zinc phosphate cement or amalgam
• Benenati et al (1986) concluded that GP repairs failed
more than amalgam repairs

 Lantz B, Persson P. Periodontal tissue reactions after root perforations in dogs teeth : a
histologic study. Odonto Revy. 1967;75:209-20
 Benenati FW, Roane JB, Biggs JT, Simon JH. Recall evaluation of iatrogenic root
perforations repaired with amalgam and guttapercha. J Endod. 1986;04:161-66

118
9. Glass Ionomer Cement:

• It is shown that GIC exhibits a greater sealing potential

than conventional materials due to its adhesion property
• When used as furcation perforation repair material,
Alhadainy & Himel (1993) found that light-cured GIC
exhibited a better seal than amalgam or Cavit
• It was also found that light-cured GIC has superior
sealing ability compared to chemically cured GIC

119
Chau et al (1997) concluded that there was no
significant difference in the extent of
methylene blue dye leakage among the three
groups that is light-cured GIC, calcium
phosphate cement or light-cured GIC placed
over a Calcium Phosphate Cement matrix
when used for perforation repair

 von Loetzen, Sophie Curtius Seutter, and Michael Hülsmann. "Root perforation repair
concepts and materials: A review." ENDO (Lond Engl) 12.2 (2018): 87-100.

120
10. Metal-modified GIC:

• Silver glass-ionomer cement is a product of sintering

pure silver to aluminosilicate
• It has the properties like bonding to dentin, radiopacity,
rapid set & ease of delivery
• Due to these properties it has also been used for
perforation repair

121
• Fuss et al (2000) : compared sealing ability of silver GIC
& amalgam in treating furcation perforations in vitro &
found that perforations repaired with silver GIC leaked
significantly less than those with amalgam

• RMGIC provided a better seal than amalgam or Cavit &

was superior to the conventional, chemically set GIC &
composite resin when used to seal furcation perforations

 Fuss Z, Abramovitz L, Metzger Z. Sealing Furcation Perforations with Silver Glass

lonomer Cement: An Invitro Evaluation. J Endod. 2000;26(8):466-68.

122
11. Geristore:

• RMGIC specifically developed for repair – due to good

adhesion to dentin
• Prior to repair, dentin surfaces are pretreated with
phosphoric acid conditioner
• Material is placed & light-cured

123
12. Composite:

• Bisfil 2B a self-curing hybrid composite had been tried as

perforation repair material
• Bisfil had shown better sealing ability than amalgam &
IRM when used for lateral perforation repair
• Drawback of this material is it had shown highest rate of
overfilling when used to repair lateral perforations 

124
13. Dentin Chips:

• Used as matrix in repair of perforation defects

• Petersson et al (1985) used dentin chips as matrices
under AH26 for obturating perforation defects
• They reported periodontal pocket formation apical to the
perforation regardless of the technique used

125
14. Decalcified Freezed Dried Bone (DFDB):

• DFDB chips are biocompatible, relatively nontoxic, easy

to obtain, easy to use, relatively inexpensive, easy to
manipulate
• Completely degrades during the repair process & acts as
an excellent barrier against which filling material could
be placed
• When packed into the bony defect they mix with the
blood present & together forms a solid mass to
completely fill the defect

126
•Hartwell et al (1993) found excellent clinical &
radiographic findings at the end of 6 months
• All teeth exhibited normal periodontal soft tissues, absence
of periodontal pockets or furcation defects & absence of
inflammation in 85% of samples

•Disadvantages - absence of new bone formation &

epithelial growth

 Singh I, Jain AA, Bagga SK, Setia V. Root Perforations: Brief Review. Int J
Res Health Allied Sci 2016;2(2):18-21.

127
15. Calcium Phosphate Cement (CPC):

• A mixture of 2 calcium phosphate compounds of which

one is acidic [dicalcium phosphate dehydrate or
anhydrous dicalcium phosphate] & basic tetra calcium
phosphate
• Water is used as a vehicle for dissolution of the reactants
and precipitation of the product
• Setting reaction:
Ca4(PO4)2 + CaHPO4.2H2O -----> [Ca5(PO4)]3OH+
2H2O
• End-product is hydroxyapatite
128
• Highly compatible with hard & soft tissues & is replaced
by bone via osteoconduction & cement absorption

• Chau et al (1997) : CPC showed no significant

differences in the leakage or perforation depth when
compared with light-cure GIC
• CPC – extruded; GIC - exhibited no extrusion

 von Loetzen, Sophie Curtius Seutter, and Michael Hülsmann. "Root perforation repair
concepts and materials: A review." ENDO (Lond Engl) 12.2 (2018): 87-100.

129
16. Tricalcium Phosphate:

• Tricalcium phosphate consist of biodegradable ceramic

(Synthograft)
• Superior biocompatibility with periodontal tissues
• When used as perforation repair material tricalcium
phosphate showed evidence of healing by the presence of
layers of epithelium, collagen & bone, with few
inflammatory cells at the perforation site
• Degree of inflammation - greater than amalgam &
hydroxyapatite & less than calcium hydroxide
130
17. Hydroxyapatite:

• It can be used both as an internal matrix & as a direct

perforation repair material
• When used as furcation perforation repair material -
reconstruct furcation bone loss due to iatrogenic root
perforation
• When used as an internal matrix to prevent the extrusion
of materials such as amalgam or GIC, it acts as a stable
matrix supporting the repair material that is going to be
placed subsequently
131
18. Calcium Hydroxide:
• Biocompatible with pulpal & periodontal tissues
• Bogaerts et al (1997) used calcium hydroxide as matrix &
Super EBA as the material for perforation repair & found
good clinical results with positive outcome
• Specimens dressed with calcium hydroxide paste plus
iodoform for perforation repair showed necrosis at the site of
perforation & different levels of cementum hyperplasia

132
19. Portland Cement:
• Composed of tricalcium silicate, dicalcium silicate,
tricalcium aluminate, tetra calcium alumino ferrate &
hydrated calcium sulfate
• Induces bone & cementum formation when used as
perforation repair material but does not provide a fluid
tight seal
• Shahriar et al (2009) found that Portland cement showed
better sealing ability than MTA when used for furcal
perforation repair
 Shahriar S, Saeed R, Maryam H, Vahab S, Majid A. Sealing ability of mineral trioxide aggregate and
Portland cement for furcal perforation repair: a protein leakage study. Journal of Oral Science.
133
2009;51(4):601-06.
20. Mineral Trioxide Aggregate (MTA):
• MTA consists of fine hydrophilic particles of Tricalcium
silicate, Tricalcium aluminate, Tricalcium oxide, Silicate
oxide, calcium sulphate dihydrate, tetracalcium
aluminoferrite & small amounts of mineral oxides (bismuth
oxide)
• MTA stimulates cementoblasts to produce matrix for
cementum formation & is biocompatible with the
periradicular tissues
• Shows superior sealing ability when used for perforation
repair
134
• When amalgam, IRM & MTA were compared, results
showed that the MTA had significantly less leakage than
IRM or amalgam

 Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate

for repair of lateral root perforations. J Endod. 1993;19:541-44.

• According to Weldon et al (2002), the combination of

MTA & Super-EBA provided a more rapid seal than MTA
alone
 Weldon JK, Pashley DH, Loushine RJ, Weller RN, Kimbrough WF. Sealing ability
of mineral trioxide aggregate and super-EBA when used as furcation repair
materials: a longitudinal study. J Endod. 2002;28(6):467-70.

135
 • Difficult handling
• Slow setting (3-4 hrs)
• Possibility of
Drawbacks solubilized when in
contact with oral
of MTA: fluids

136
21. Biodentine:
• It is a calcium silicate-based bioactive material
• Powder - Tri-calcium silicate, Di-calcium silicate,
Calcium carbonate & oxide, Iron oxide, Zirconium oxide
• Liquid - Calcium chloride & Hydrosoluble polymer
• Advantages:
• Easy to handle - ease of manipulation & short setting
time (approx. 12 min)
• High alkaline pH
• Biocompatible 137
 Guneser et al (2013):

• Biodentine showed considerable

performance as a perforation
repair material even after being
exposed to various endodontic
irrigants as compared to MTA
 Abhijeet Kamalkishor Kakani et al., A Review on Perforation Repair Materials. Journal of Clinical and
Diagnostic Research. 2015 Sep, Vol-9(9): ZE09-ZE13 138
22. Bioceramics:
• Bioceramic material refers to a mixture of calcium
silicate & calcium phosphate
• Examples:
• Endosequence
• Bioaggregate
• Bioglass
• PerioGlas

139
• Endosequence:-
• Composed of calcium silicates, zirconium oxide, tantalum
oxide, calcium phosphate monobasic & fillers
• Working time >30 min & a setting reaction initiated by
moisture with a final set achieved in approx. 4 hrs.
• It is produced with nanosphere particles that allow the
material to enter into the dentinal tubules & interact with the
moisture present in the dentin
• Creates a mechanical bond on setting
• Has exceptional dimensional stability & superior
biocompatibility 140
• Bioceramics can be used in two forms either as premixed
putty or in a premixed syringe. The syringe eliminates need
of hand instruments and also need for mixing

• Jeevani et al (2014) compared the furcation repair with

Endosequence, Biodentine & MTA & showed that
Endosequence has better sealing ability compared to others

 Mithra Hegde, Litty Varghese, Sakshi Malhotra. Tooth Root Perforation Repair - A
141
Review. OHDM- Vol. 16- No.2-April, 2017, 1-5.
• Bioaggregate:-
• Composed of tricalcium silicate, dicalcium silicate, calcium
phosphate monobasic, amorphous silicon dioxide & tantalum
pent oxide
• It promotes mineralized tissue formation & leads to precipitation
of apatite crystals that become larger which increases on
immersion time suggesting it to be bioactive
• Sealing ability & biocompatibility is compared to that of MTA
• Hashem et al (2012) : MTA is more influenced by acidic pH than
Bioaggregate when used as perforation repair material
142
23. Calcium Enriched Mixture:

• A bioactive material that is mixture of calcium oxide, calcium

phosphate, calcium carbonate, calcium silicate, calcium sulphate,
calcium hydroxide & calcium chloride
• Preferred material for furcation repair as greater amount of
calcium & phosphate ions are formed thus producing higher
concentration of hydroxyapatite
• Asgary et al (2012) : cementogenesis & periodontal regeneration
when CEM was used as perforation repair material

 Asgary S, Moosavi SH, Yadegari Z, Shahriari S. Cytotoxic effect of MTA and CEM cement in human gingival
fibroblast cells. Scanning electronic microscope evaluation. N Y State Dent J. 2012;78(2):51-54.
143
FACTORS AFFECTING PROGNOSIS

Factors including time from the perforation to

detection, size and shape of the perforation as
well as its location impact the potentials to
control infection at the perforation site
 Estrela C, Decurcio DA, Rossi-Fedele G, Silva JA, Guedes OA, Borges IH.Root perforations: a
review of diagnosis, prognosis and materials. Braz. Oral Res. 2018;32(suppl):e73, 133-146

144
TIME:

• Most critical factor determining outcome of treatment

• Lantz & Persson (1970) produced root perforations in dogs

that were treated either immediately or after some delay &
found that the most favorable healing response was when
perforations were sealed immediately

• Perforations managed within 48-72hrs – good prognosis

145
SIZE:

• Large-sized perforations may not respond to repair as

well as smaller ones
• Himel et al (1985) found that the larger teeth with
proportionally smaller perforations showed better healing
response
• Small perforations are easier to repair & therefore
provide predictable healing

146
LOCATION:

• Most important parameter affecting prognosis

• Location of perforation wrt crestal bone
• Apical migration of the epithelium to the perforation site can be
expected, creating a periodontal defect
• Once the periodontal pocket is formed, persistent inflammation of
the perforation site occurs due to continuous ingress of irritants from
the pocket

147
• Perforations of the furcation areas of multi-rooted teeth -
similarly critical
• Inflammatory process may cause rapid & extensive
destruction of the periodontal tissues

• Perforations coronal to the crestal bone, are easy to

access & seal & teeth may be restored without
periodontal involvement

148
PERFORATION REPAIR MATERIALS:

• Must be antimicrobial, non-toxic, provide adequate seal,

non-absorbable, RO, promote osteogenesis &
cementogenesis

OTHER CLINICAL FACTORS :

• Hemostasis
• Vision & accessibility
• Treatment sequence
149
OTHER PATIENT-RELATED FACTORS:

• Patient-related factors (such as chronic disease, hormones

& age)
• Factors that can change the host’s immune defenses &
interfere in the treatment outcomes & healing process
also affect prognosis of teeth with repaired perforation

 Holland R, Gomes JE, Cintra LT, Queiroz ÍO, Estrela C. Factors affecting the periapical healing
process of endodontically treated teeth. J Appl Oral Sci. 2017 Sep-Oct;25(5):465-76.

150
SEQUELAE OF ROOT
PERFORATION

•Root perforations – 2ND greatest cause of failure of endodontic

treatment - 9.62% of all unsuccessful cases (Cohen, 9th Ed.)

•Seltzer et al (1996) - 3.52% of all endodontic failures – due to

perforation

151
Kauffman (1944): formation of granulation
tissue in most cases

• Closure with cementum – in some cases

Sealed perforations result in less

inflammation than unsealed ones, even
when those perforations were not
immediately repaired
152
• Bacterial infection - from root canal or periodontal
tissues, or both - prevents healing

• Once an infectious process has established itself at the

perforation site, prognosis decreases & complication may
lead to extraction of tooth

153
 Reported Success Rates:
• According to Siew et al (2012):
• Overall success rate for nonsurgical repair of
root perforations - 5%
• Use of MTA enhanced the success rate to
80.9%
• Pre-op radiolucency decreases success rate
• Maxillary teeth showed higher success rate
after perforation repair than mandibular teeth

 Siew K, Lee AH, Cheung GS. Treatment Outcome of Repaired Root Perforation: A 154
Systematic Review and Meta-analysis. J Endod. 2015 Nov;41(11):1795-804.
CONCLUSION

• The complications like iatrogenic perforation may occur during

endodontic procedures

• Even in cases with questionable prognosis, attempt shall be made

to repair

• The success or failure of root perforations is dependent on the

prevention or treatment of infection of the perforation site
155
• Diagnosis & immediate sealing, intensity of aggression,
control of contamination, relationship to crestal bone &
epithelial attachment - factors affecting prognosis

• Material recommended for treatment of root canal

perforations should have good physicochemical &
biological properties, proper sealing capacity,
antimicrobial activity & osteogenic potential

156
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• Endodontic Science. Carlos Estrela – vol. 2 – 2nd Ed.
• Endodontics: Principles and Practice, Torabinejad, 4th Ed.
• Endodontics - Arnaldo Castellucci – Vol. 2
157
• Textbook of Endodontology - Gunnar Bergenholtz – 2nd Ed.
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