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Case of the Month

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April 2002Lower Molar Furca Perforation Repaired with MTA

April's Case of the Month features one of the Endodontist's most frustrating scenarios. This 24 year old woman was referred to me for endodontic treatment of tooth #46.

Fig. 1 - Referral's Preop film

At the time of the referral I noted that the roots were not particularly thick in diameter and that that preparation of the 4 canals would not leave a lot of dentin in the furca area.

Fig. 2

Since most of my referrals desire a post space to allow them to retain their cores (sometimes against my better judgment) I prefer to prepare the post spaces myself, rather than have them risk post space perforation during preparation of an unfamiliar canal. The case was completed as usual and a post space prepared in the distal canal. Specific instructions were given to "not alter the post space preparation". This meant that the only thing that was meant to be placed in the distal canal was a PASSIVELY placed Parapost with NO "extra preparation" of the post space by either engine driven or hand driven Parapost drills.

About 6 months later, the referral informed me that the patient had developed swelling along the lingual attached gingiva, close to the gingival crest. The tooth was percussion and palpation sensitive and she was in moderate discomfort. She was seen immediately.

Fig. 3
Possible Post perf?

Clinical examination revealed swelling as described and lingual furcation involvement. The case resembled a Periodontal abscess in clinical appearance. Probing of the lingual perio pocket revealed involvement to the furca and hyerplasia of the gingiva. . Radiographic examination showed no obvious furcal perforation of the post BUT the post WAS perilously close to the furca. I suspected the problem to be there since the periapical areas showed no pathology. (Fig.3)
Fig. 4

I decided to remove the composite over the distal canal and to disassemble the post to ascertain whether there was a communication between the post space and the furca. Once the post was dislodged with ultrasonics ( and even before it was removed entirely) the access became flooded with heavy purulent drainage. I easily placed a file into the perforation site and took a film. (Fig.4)

At that point we were left with a less than optimal prognosis because of the post perforation. I irrigated the canal space with NaOCL and attempted to control the bleeding. After approximately 30 minutes, the drainage became clear and was responding to attempts to dry. A mix of ProRoot MTA ( Tulsa Dental) was placed into the space and the access was resealed with Cavit. (Fig.5) I told the referral that the prognosis was less than favorable but that I had seen some excellent results of similar cases treated with MTA. I was concerned about the severity of the perio abscess and whether the furca bone could be regenerated after such acute destructive inflammatory episode. I told the referral to place a composite over the MTA once the acute symptoms had subsided.

Fig. 5

Fig. 6

Remarkably, after only a two months, the furca bone had undergone significant regeneration, (Fig.6) the area was not probeable and all symptoms had resolved completely. I must admit I was initially quite skeptical about the rave reports of success of furcal and perforation repair with MTA . However, I have since come to rely upon it and have had much success with it. Quite amazing, considering it is basically the same compound that is known in the concrete industry as "Portland Cement".

ProRoot MTA has also recently become available in a "white" formula that is now suitable for repair of such cases in anterior areas where tooth staining (caused by the original formula containing Fe) had been of some aesthetic concern.

Is MTA an expensive material ? Yes. Worth it for cases like this ? Absolutely.

Check the manufacturer Tulsa Dental for more information.