Printer Friendly




Furcal perforation is usually undesirable and unfortunate incident commonly encountered during an endodontic access cavity or exploration of orifices of canal/s. A randomized control trial was conducted on 90 patients with furcal perforation. The objective was to compare effectiveness of Mineral Trioxide Aggregate (MTA) with Calcium Hydroxide in furcal repair in lower molars. radiographic assessment was done at 3 and 6months interval.the collected data was analyzed using SPSS version 14. 90 patients with furcal perforation divided into group A and group B with 45 patients in each group. Group A was treated with MTA and Group B with Calcium Hydroxide respectively. After 3 and6 months, a radiographic effectiveness was considered with the resolution of peri-radicular lesion.

In group A, 43 patients showed complete recovery (success rate 95.6%). In Group B, 21 patients showed complete recovery(success rate 46.6%). It was concluded, MTA was better material for repair of furcal perforation than Calcium hydroxide.

Key Words: Furcal Perforation, Mineral Trioxide Aggregate, Calcium Hydroxide, Root Canal Treatment.


A major complication of endodontic treatment is accidental perforation of roots and/or the pulp chamber which accounts for 9.6% of failed cases.1,2,3 Perforation complicates promotion of osseous regeneration through removal of bacteria and seal root canal.1 Perforation of root may occur during endodontic treatment, retreatment, and post space preparation either iatroganically or by caries/resorptive process. Causes of perforations are aberrant canal anatomy (extra canal, excessive curvature, calcification), misguided access preparation, overzealous instrumentation.3 The prognosis maybe questionable, if treatment involves furcal region. Furcal perforation has poor prognosis because of close proximity to oral environment which has higher potential to cause periodontal defect.2,8 However, prognosis is good if the perforation is diagnosed correctly and treated with material with suitable sealing ability and biocompatibility.25

Perforation in cervical 1/3rd of root or in the floor of pulp chamber has had poorer prognosis than at apical 1/3rd or middle 1/3rd of root canal.If repaired immediately, there is good prognosis.2,4,5 Various materials have been used to treat furcal perforations including zinc oxide eugenol, amalgam, cavit, super EBA, GIC, Ca (OH) , IRM, DFDB 2,3,9 and Ormocer.4,5,7 Novel materials in the field are CEM (Calcium enriched mixture) and Biodentine.32,33 The ideal material for treating radicular perforations should be nontoxic, nonabsorbable, radiopaque, and bacteriostatic or bactericidal37; it should also provide a seal against microleakage from the perforation.26,29,36

Mineral trioxide aggregate (MTA) is the main perforation repair material which has ideal characteristics like biocompatibility, less susceptibility to inflammation and less solubility in oral fluids. It also has a good capacity to create seal between the pulpal chamber and periodontal tissues.34 Its clinical applications include direct pulpal coverage and radicular resorption.27,28,30

Others are; sealing communications between the root canal space and external root surfaces, filling root canals of teeth with mature and open apices as well as management of dens invaginatus.31

Calcium hydroxide is also used as repair material for repairing furcal perforations.but it tends to soften, disintegrate over time, leaving voids and other potential pathways for bacterial infiltration.10,11,12,35 Both Ca(OH) and MTA has pH= 12.5.

The aim of this study was to compare the effectiveness of Mineral Trioxide Aggregate and Calcium hydroxide as furcal perforation repair material.


This randomised control trial was conducted on 90 perforation cases visiting Department of Operative Dentistry, de'Montmorency College of Dentistry/Punjab Dental Hospital, Lahore from April 2009 to October 2009. Informed consent for participation in the study was obtained from each patient. After completion of root canal treatment subjects were divided into two groups using random number table. In Group A (n=45) MTA mixed with normal saline was condensed in perforation area with ball-ended instrument and damp cotton pledget was placed over it. In Group B (n=45)furcal perforation was covered with thick paste of Calcium hydroxide mixed with normal saline using ball ended instrument and damp cotton pledget. Post-operative radiograph was taken after placement of both materials. A follow up radiograph was taken after 3 and 6months duration. Assessment of Repair of furcal perforation was compared.


The collected data was analysed using SPSS version 14. Frequencies and percentages were calculated for qualitative data. Chi-square test was applied to compare the effectiveness of both materials and a p value < 0.05 was considered significant.

90 Teeth were treated in 90 patients {33 were male (36.7%) and 57 were female (63.3%)}. The age of patients ranged between 15 to 40 years.


Groups###Resolution of Lesion###Total

of pa-###No###After###After 6


Group A###2###23###20###45

Group B###24###12###9###45



Groups of###No. of###Resolution###Percent-

patients###patients###of Lesion###age

Group A###45###43###95.6

Group B###45###21###46.7


###Value###df###P value



Out of 90 patients 26 (28.9%) showed no resolution of lesion, 35 (38.9%) showed resolution of lesion after 3months while 29 (32.2%) showed resolution of lesion after 6 months {Table 1}.


Radiographic evaluation of teeth in both groups revealed that

In Group A, 2 patients (4.4%) showed no healing, 23 patients (5.11%) showed resolution of lesion after 3 months while 20 patients (44.4%) showed resolution of lesion after 6 months. In Group B, 24 patients (53.3%) showed no resolution of lesion, 12 patients (26.6%) showed resolution of lesion after 3 months and 9(19.8%) patients showed resolution of lesion after 6 months. {Table 2}

The overall success rate in Group A is 95.6% and in Group B 46.7%. Chi-square analysis for the absence of lesion, between two groups is 26.245 and p value is significant (p < 0.05) {Table 2}


In the study by Himel et al. Ca(OH) and tricalcium phosphate were used as furcal repair materials. It was observed that Ca (OH) showed initial toxicity and tissue destruction due to continuing inflammatory response but later showed induction of hard tissue apposition.13

Tricalcium phosphate group showed evidence of healing with layers of epithelium, collagen and bone with few inflammatory cells.

Barnante and Berbert in their study used Ca(OH)2 with iodoform for perforation repair. Despite its rapid absorption, reorganization of periodontal tissue and formation of biological sealing, it also showed that its action diminishes when comes in contact with blood clot.

They concluded that Ca(OH)2 paste with iodoform showed necrosis at the perforation site and different levels of cementum hyperplasia.14

In a study by Schwartz et al, different case reports showed the same results as that of present study. MTA gave promising results after 6 months follow u. In addition, there were no sign or symptoms of pathology and the radiolucency in the furcation area also resolved.16

In a study by Holland et al results concluded that after 30 days of placing MTA in non-contaminated perforation area, there is evidence of deposition of newly formed cementum, thereby leading to formation of biological seal plus after 6 months follow up complete absence of inflammatory cells. In a study by Pitt Ford et al it was observed that non contaminated MTA sealed perforations had better repair than contaminated perforations.18This findings is consistent with present study.

In a study by Ghanbari and Ghoddusi, there was significantly less inflammation in groups in which perforations were sealed immediately with MTA. A period of 4 months was considered enough to observe the healing process in the perforation area. Results of present study are similar to this study and 3 and 6 months follow up was used to observe the healing process.19

In a study by Ashofteh Yazdi et al perforations were repaired with MTA, Glass ionomer and Amalgam. Their results showed that MTA and Glass ionomer showed less inflammation and both are biocompatible. They conclude that application of MTA for repairing perforations was superior to Glass ionomer and Amalgam due to high moisture resistance.20 These results are similar to present study.

The results of present study are similar to Pace study in which sealing of the defect with MTA is done without internal matrix. The clinical and radiographic follow ups were done at 6 months, 1 year, 2 year and 5 year. The results confirmed that MTA without matrix provides an effective seal of root perforations and clinical healing of the surrounding periodontal tissue.21

Arens and Torabinejad observed better results when furcal perforations were repaired by using MTA without internal matrix as opposed to MTA with internal matrix. They concluded that MTA does not need a barrier when used to repair large furcal perforation.22

2 cases studies of perforation with repair using MTA was conducted by Sanchez-Ayala et al 3 and 6 month radiographic follow up provided evidence of bone formation adjacent to the MTA. Although prognosis is typically better for smaller lesions, and although the location of these perforations at the level of epithelial attachment and crestal bone suggested a guarded prognosis, yet MTA treatment was successful.23 These results are conducive to the present study. The present study is particularly important in that it appears to be the first time that MTA has ever been applied in repairing furcal perforations in patients visiting Punjab Dental Hospital Lahore.


It was concluded that when a perforated site is immediately sealed with MTA, the prognosis is promising. Treatment time is also very much reduced in MTA.


1 Hamad HA,Tordik PA,McClanaban SB.Furcation perforation repair comparing gray and white MTA:A dye extraction study. Journal of Endodontics. 2006; 32:337-40.

2 Main C,Mirzayan N,Shabahang S,Torabinejad M.Repair of root perforations using Mineral trioxide aggregate:A long term study. Journal of Endodontics. 2004; 30:80-83.

3 Nandini S,Ballal S,Kandaswany D.Influence of Glass ionomer cement on interface and setting reaction of Mineral trioxide aggregate when used as a furcal repair material using laser Raman Spectroscopic Analysis. Journal of Endodontics. 2007; 33:167-72.

4 Hardy I,Liewehr FR, Joyce AP et al.Sealing ability of one up bond and MTA with and without a secondary seal as furcation perforation repair materials. Journal of Endodontics. 2004; 30:658-61.

5 Holland R et al.Reaction of lateral periodontium of dog's teeth to contaminated and non-contaminated perforations filled with Mineral trioxide aggregate. Journal of Endodontics. 2007; 33:1192-97.

6 De-Deus G et al.The ability of portland cement,MTA, and MTA Bio to prevent through and through fluid movement in repaired furcal perforations. Journal of Endodontics. 2007; 33:1374-77.

7 Tang HM,Torabinejad M,Kettring JD.Leakage evaluation of root end filling materials using endotoxin. Journal of Endodontics. 2002; 28:5-7.

8 Nicholls E.Treatment of traumatic perforations of pulp cavity. journal of Oral surg Oral med Oral pathology 1962; 15:603-12.

9 Ferris DM, Baumgartner C.Perforation repair comparing two types of Mineral trioxide aggregate. Journal of Endodontics. 2004; 30:422-24.

10 Alhadainy HA, Himel VT. Evaluation of the sealing ability of amalgam, cavit and glass ionomer cement in the repair of furcation perforations. journal of Oral surg Oral med Oral pathology Oral radiology Endodontics. 1993; 75:362-66.

11 Balla R,Lo Monaco CJ,Skribner J,Lin LM.Histological study of furcation perforations treated with tricalcium phosphate,hydroxylapatite,amalgam and life. Journal of Endodontics. 1991; 17:234-38.

12 Fridland M,Rosado R.Mineral trioxide aggregate solubility and porosity with different water to powder ratios. Journal of Endodontics 2003; 29:814-17.

13 Himel VT, Brady J,Weir J. Evaulation of repair of mechanical perforations of the pulp chamber floor using biodegradable tricalcium phosphate or calcium Hydroxide. Journal of Endodontics.1985; 11:161-65.

14 Bramante CM,Berbert A.Root perforations dressed with Ca (OH)2 or Zinc oxide and Eugenol. Journal of Endodontics. 1987; 13:392-95.

15 Bramante CM,Berbert A. Influence of time of calcium hydroxide iodoform paste replacement in the treatment of root perforations. Brazilian Dental journal . 1994; 1:45-51.

16 Schwartz RS,Mauger M,Clement DJ,Walker WA.Mineral trioxide aggregate:A new material for Endodontics.JADA. 1999; 130:967-75.

17 Holland R,OtoboniFilho JA, Souza Aet al.Mineral trioxide aggregate repair of lateral root perforations. Journal of Endodontics. 2001; 27:281-84.

18 Pitt ford TR,Torabinejad M et al.Use of Mineral trioxide aggregate for repair of furcal perforations.Oral surg Oral med Oral pathology Oral radiology Endodontics. 1995; 79:756-62.

19 Ghanbari H,Ghoddusi J,Mohtasham N.A comparison between Amalgam and MTA in repairing furcalperfpration.Journal of Dentistry Tehran. 2008; 5:115-19.

20 Ashofteh-yazdi K,Masoodi M,Shokouhinejad N.Comparison of tissue reaction of pulp chamber perforations in dog's teeth treated with MTA,light cured glass ionomer and amalgam.J of Dentistry Tehran. 2006; 3:57-62.

21 Pace R,Giuliani V,Pagavino G.Mineral trioxide aggregate as repair material .for fircalprforation Journal of Endodontics. 2008; 34:1130-33.

22 Adiga S, Ataida I et al. Non-surgical approach to strip perforation repair using mineral trioxide aggregate. J Conservative Dentistry. 2010; 13(2): 97-101.

23 Arens DE,Torabinejad M et al.Repair of furcal perforations with Mineral trioxide aggregate:Two case reports.Oralsurg Oral med Oral pathology Oral radiology Endodontics. 1996; 82:84-88.

24 Silveira CMM,Ayala AS,Lagravere MO et al.Repair of furcal perforation with Mineral trioxide aggregate.JADC. 2008; 74: 729-33.

25 Tsesis I, Fuss Z. Diagnosis and treatment of accidental root perforations. Endod Top 2006; 13:95-10.

26 De-Deus G, Reis C, Brandao C, Fidel S, Fidel RA. The ability of Portland cement, MTA, and MTA Bio to prevent throughand-through fluid movement in repaired furcal perforations. Journal of Endodontics .2007; 33(11):1374-77.

27 Torabinejad M, Chivian N. Clinical application of mineral trioxide aggregate. Journal of Endodontics. 1999; 25(3):197-205.

28 Fuad Abdo Al-Sabri, Ahmed Mohammed El-Marakby, Nashwan Mohammed Qaid. Role of Mineral Trioxide Aggregate (MTA) and Calcium Hydroxide in Conservative Dentistry as Pulp Capping Material: A Review. American Journal of Health Research. Vol. 5, No. 1, 2017, pp. 1-6. doi: 10.11648/j.ajhr.20170501.11

29 Torabinejad,M..Mineral Trioxide Aggregate:Properties and Clinical Applications. Hoboken : Wiley, (c)2014

30 Rahimi S, Mokhtari H, Shahi S, Kazemi A, Asgary S, Eghbal MJ, Mesgariabbasi M, Mohajeri D. Osseous reaction to implantation of two endodontic cements: Mineral trioxide aggregate (MTA) and calcium enriched mixture (CEM). Med Oral Patol Oral Cir Bucal. 2012 Sep 1;17(5):e907-11.

31 Utneja S, Nawal RR, Talwar S, Verma M. Current perspectives of bio-ceramic technology in endodontics: calcium enriched mixture cement-review of its composition, properties and applications. Restorative dentistry and endodontics. 2015 Feb 1;40(1):1-3.

32 Haghgoo R, Arfa S, Asgary S. Microleakage of CEM cement and ProRoot MTA as furcal perforation repair materials in primary teeth. Iranian endodontic journal. 2013 Oct 7;8(4):187-90.

33 Rahimi S, Ghasemi N, Shahi S, Lotfi M, Froughreyhani M, Milani AS, Bahari M. Effect of blood contamination on the retention characteristics of two endodontic biomaterials in simulated furcation perforations. Journal of endodontics. 2013 May 31;39(5):697-700.

34 Mente J, Leo M, Panagidis D, Saure D, Pfefferle T. Treatment outcome of mineral trioxide aggregate: repair of root perforations-long-term results. Journal of endodontics. 2014 Jun 30;40(6):790-96.

35 Moazami F, Sahebi S, Jamshidi D, Alavi A. The long-term effect of calcium hydroxide, calcium-enriched mixture cement and mineral trioxide aggregate on dentin strength. Iranian endodontic journal. 2014 Jun 29;9(3):185-89.

36 aziz s,akbar a k,moeen f. Two successful cases of root perforation repair using mineral trioxide aggregate. Pakistan Oral and Dent. Jr. 2008 jun20;28(1):103-06.

37 al khatani a m. Antibacterial activity of grey mineral trioxide aggregate (mta) mixed with different vehicles. Pakistan Oral and Dent. Jr. 26 (2) Dec. 2006.261-64.
COPYRIGHT 2017 Asianet-Pakistan
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2017 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:mineral trioxide aggregate
Publication:Pakistan Oral and Dental Journal
Article Type:Report
Date:Jun 30, 2017

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters