Endodontik Tedavi Sırasında Görülen Kök Perforasyonları ve Yönetimi
Özet
Kök perforasyonları, kök kanalı ile periodontal dokular arasında iyatrojenik veya patolojik nedenlerle oluşan yapay açıklıklardır ve endodontik tedavi başarısızlıklarının %3-10'unu oluştururlar. Teşhisinde klinik bulguların yanı sıra apeks bulucular, konik ışınlı bilgisayarlı tomografi (CBCT) ve operasyon mikroskopları kullanılır. Perforasyonlar; oluştuktan sonra geçen süre, boyut, konum (koronal, krestal, apikal) ve destek dokularla ilişkisine (lateral, furkasyon) göre sınıflandırılır. Tedavi başarısı; defektin yeri, boyutu, kontaminasyon durumu, tedaviye kadar geçen süre ve kullanılan materyalin biyouyumluluğuna bağlıdır. Genellikle cerrahi olmayan tedaviler tercih edilmekte, kanama kontrolü ve dezenfeksiyon sonrası sızdırmaz bir tamir hedeflenmektedir. Cerrahi dışı yaklaşımların yetersiz kaldığı büyük lezyonlarda veya anatomik olarak ulaşılamayan bölgelerde hemiseksiyon, kök amputasyonu, apikoektomi ya da kasıtlı replantasyon gibi cerrahi seçenekler uygulanır. Perforasyon tamirinde ideal materyalin sızdırmaz, stabil ve biyouyumlu olması gerekir. Amalgam ve cam iyonomer gibi geleneksel ajanların yerini günümüzde nemli ortamda sertleşebilen, sement ve sert doku oluşumunu indükleyen Mineral Trioksit Agregat (MTA) ve Biodentine gibi kalsiyum silikat esaslı biyoaktif biyoseramik materyaller almıştır. Yüksek pH ve kalsiyum salınımı sağlayan bu yeni nesil materyaller, yüksek bağlanma dirençleri ve antimikrobiyal etkinlikleri sayesinde tedavi prognozunu önemli ölçüde artırmaktadır.
Root perforations are artificial openings created between the root canal and periodontal tissues due to iatrogenic or pathological reasons, accounting for 3-10% of endodontic treatment failures. For diagnosis, clinical findings, apex locators, cone-beam computed tomography (CBCT), and operating microscopes are utilized. Perforations are classified according to time elapsed, size, location (coronal, crestal, apical), and relationship with supporting tissues (lateral, furcation). Treatment success depends on the defect's location, size, contamination status, time elapsed before repair, and biocompatibility of the material used. Non-surgical treatments are generally preferred, aiming for a leak-proof repair following disinfection and bleeding control. In large lesions where non-surgical approaches are insufficient or in anatomically inaccessible areas, surgical options such as hemisection, root amputation, apicoectomy, or intentional replantation are performed. An ideal repair material must be sealing, stable, and biocompatible. Traditional agents like amalgam and glass ionomer have been replaced today by calcium silicate-based bioactive bioceramic materials, such as Mineral Trioxide Aggregate (MTA) and Biodentine, which can set in moisture and induce cementum and hard tissue formation. Providing high pH and calcium release, these next-generation materials significantly improve treatment prognosis through their high bond strength and antimicrobial efficacy.
Referanslar
Fuss Z, Trope M. Root perforations: classification and treatment choices based on prognostic factors. Dental Traumatology. 1996;12(6):255-264.
Grossman L. The management of accidents encountered in endodontic practice. Dent Clin North Am. 1957;11:903-912.
Krause TA, Liewehr FR, Hahn C-L. The antimicrobial effect of MTAD, sodium hypochlorite, doxycycline, and citric acid on Enterococcus faecalis. Journal of Endodontics. 2007;33(1):28-30.
Alhadainy HA. Root perforations: a review of literature. Oral surgery, oral medicine, oral pathology. 1994;78(3):368-374.
Farzaneh M, Abitbol S, Friedman S. Treatment outcome in endodontics: the Toronto study. Phases I and II: Orthograde retreatment. Journal of Endodontics. 2004;30(9):627-633.
Kvinnsland I, Oswald R, Halse A, Grønningsaeter, AG. A clinical and roentgenological study of 55 cases of root perforation. International endodontic journal. 1989;22(2):75-84.
Estrela C, Decurcio DdA, Rossi-Fedele G, Silva JA,Guedes OA, Borges ÁH. Root perforations: a review of diagnosis, prognosis and materials. Brazilian oral research. 2018;32.
Sinai IH. Endodontic perforations: their prognosis and treatment. The Journal of the American Dental Association. 1977;95(1):90-95.
Vajda TT. Treatment of internal resorption--involving lateral root perforation--by immediate root resection technique. Case report. Australian Dental Journal. 1969;14(5):325-326.
Trope M. Root resorption of dental and traumatic origin: classification based on etiology. Practical periodontics and aesthetic dentistry: PPAD. 1998;10(4):515-522
Bakland L. Endodontic mishaps: perforations. Journal of the California Dental Association. 1991;19(4):41-44, 46.
Kaufman AY, Keila S. Conservative treatment of root perforations using apex locator and thermatic compactor—case study of a new method. Journal of endodontics. 1989;15(6):267-272
Saed SM, Ashley M, Darcey J. Root perforations: aetiology, management strategies and outcomes. The hole truth. British dental journal. 2016;220(4):171.
Taatz H, Stiefel A. Zur therapie von zahnperforationen. Zahnaertztl Welt. 1965;66:814-819
Estrela C, Estrela CR, Barbin EL, Spanó JCE, Marchesan MA Pécora, JD. Mechanism of action of sodium hypochlorite. Brazilian dental journal. 2002;13:113-117.
Bueno MR, Estrela C, De Figueiredo JA, Azevedo BC. Map-reading strategy to diagnose root perforations near metallic intracanal posts by using cone beam computed tomography. J Endod. 2011 Jan;37(1):85-90.
Weisman MI. Treatment of an unusual perforation of an anterior tooth: Report of a case. Oral Surgery, Oral Medicine, Oral Pathology. 1959;12(6):732-735.
Arens DE, Torabinejad M . Repair of furcal perforations with mineral trioxide aggregate: two case reports. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996; 82: 84–88
Lemon R R, Steele P J, Jeansonne B G . Ferric sulfate hemostasis: effect on osseous wound healing. I. Left in situ for maximum exposure. J Endod 1993; 19: 170–173.
Carr GB . Ch. 24: retreatment. In Cohen S, Burns RC (eds). Pathways of the pulp. 7th ed. St. Louis: Mosby, 1998.
Jeansonne B G, Boggs W S, Lemon R R . Ferric sulfate hemostasis: effect on osseous wound healing. II. With curettage and irrigation. J Endod 1993; 19: 174–176
Jeansonne BG, Boggs WS, Lemon RR. Ferric sulfate hemostasis: effect on osseous wound healing. II. With curettage and irrigation. Journal of endodontics. 1993;19(4):174-176.
Alsubait SA. Effect of sodium hypochlorite on push-out bond strength of four calcium silicate-based endodontic materials when used for repairing perforations on human dentin: an in vitro evaluation. J Contemp Dent Pract. 2017;18(4):289-294.
do Prado M, de Lima CO, das Neves Marques J, Balbal V, Simão R, Campos CN. Effect of different irrigation regimens on the bond strength of Biodentine used for furcal perforation repair. International Journal of Prosthodontics. 2019;32(2).
Allam CR. Treatment of stripping perforations. Journal of endodontics. 1996;22(12):699-702
Roda R, Gettleman B H . Nonsurgical retreatment. In S. Cohen K M. Hargreaves (eds) Pathways of the Pulp. 9th ed. St. Louis: Mosby, 2006.
Charrier M, Medioni E. Microleakage of three filling materials for furcation perforation. Eur Cell Mater. 2007;13: 9.
Beavers R, Bergenholtz G, Cox C. Periodontal wound healing following intentional root perforations in permaent teeth of Macaca mulatta. International Endodontic Journal. 1986;19(1):36-44.
Grossman LK. Endodontic failures. Dent Clin North Am 1972;16:59-70.
Lemon RR. Nonsurgical repair of perforation defects. Internal matrix concept. Dental Clinics of North America. 1992;36(2):439-457.
Nicholls E. Treatment of traumatic perforations of the pulp cavity. Oral Surgery, Oral Medicine, Oral Pathology. 1962;15(5):603-612.
Seltzer S, Sinai I, August D. Periodontal effects of root perforations before and during endodontic procedures. Journal of dental research. 1970;49(2):332-339.
Elnaghy AM. Influence of QMix Irrigant on the Micropush-out Bond Strength of Biodentine and White Mineral Trioxide Aggregate. J Adhes Dent. 2014;16(3):277-283
Ford TRP, Torabinejad M, McKendry DJ, et al. Use of mineral trioxide aggregate for repair of furcal perforations. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 1995;79(6):756-763.
Setzer FC, Boyer KR, Jeppson JR, et al.Long-term prognosis of endodontically treated teeth: a retrospective analysis of preoperative factors in molars. Journal of endodontics. 2011;37(1):21-25.
Hashem AAR, Amin SAW. The effect of acidity on dislodgment resistance of mineral trioxide aggregate and bioaggregate in furcation perforations: an in vitro comparative study. Journal of endodontics. 2012;38(2):245-249.
Simon JH, Kelly WH, Gordon DG, Ericksen GW. Extrusion of endodontically treated teeth. The Journal of the American Dental Association. 1978;97(1):17-23.
Frank A. Resorption, perforations, and fractures. 1974
Bryan EB, Woollard G, Mitchell W. Nonsurgical repair of furcal perforations: a literature review. General dentistry. 1999;47(3):274-278; quiz 279.
Mitsis F. Flap operation techniques for the treatment of certain endodontic and periodontic problems. International Endodontic Journal. 1970;4(1):6-9.
Tsesis I, Fuss Z. Diagnosis and treatment of accidental root perforations. Endodontic Topics. 2006;13(1):95-107.
Meister Jr F, Lommel TJ, Gerstein H, Davies EE. Endodontic perforations which resulted in alveolar bone loss: report of five cases. Oral Surgery, Oral Medicine, Oral Pathology. 1979;47(5):463-470
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(2), 80-83.
Koch K, Brave D, Nasseh AA. A review of bioceramic technology in endodontics. CE article. 2012;4:6-12.
Atmeh A, Chong E, Richard G, Festy F, Watson TF. Dentin-cement interfacial interaction: calcium silicates and polyalkenoates. Journal of dental research. 2012;91(5):454-459.
Sarkar N, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. Physicochemical basis of the biologic properties of mineral trioxide aggregate. Journal of endodontics. 2005;31(2):97-100.
Parirokh M, Torabinejad M, Dummer P. Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview–part I: vital pulp therapy. International endodontic journal. 2018;51(2):177-205.
Holland R, Otobani Filho JA, Souza V, Nery MJ, Bernabé PF, Dezan Junior E. Mineral trioxide aggregate repair of lateral root perforations. J Endod. 2001 Apr;27(4):281-4.
Ford TR, Torabinejad M, McKendry DJ, Hong CU, Kariyawasam SP. Use of mineral trioxide aggregate for repair of furcal perforations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995 Jun;79(6):756-63.
Ingle JI. A standardized endodontic technique utilizing newly designed instruments and filling materials. Oral Surg Oral Med Oral Pathol. 1961;14:83–91.
Kerekes K, Tronstad L. Long-term results of endodontic treatment performed with a standardized technique. J Endod. 1979;5:83–90.
Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate for repair oflateral root perforations. J Endod 1993 Nov;19(11):541-4.
Roberts HW, Toth JM, Berzins DW, et al. Mineral trioxide aggregate material use in endodontic treatment: a review of the literature. Dental materials. 2008;24(2):149-164.
Estrela C, Decurcio DA, Rossi-Fedele G, et al. Root perforations: a review of diagnosis, prognosis and materials. Braz Oral Res. 2018 Oct 18;32(suppl 1):e73. doi: 10.1590/1807-3107bor-2018.vol32.0073. PMID: 30365614.
Swarup S, Rao A. Bioceramics in pediatric endodontics: Lap Lambert Academic Publishing 2013.
Wang Z. Bioceramic materials in endodontics. Endod Topics. 2015 May;32(1):3-30.
Al-Hezaimi K, Al-Hamdan K, Naghshbandi J, Oglesby S, Simon J-HS, Rotstein I. Effect of white-colored mineral trioxide aggregate in different concentrations on Candida albicans in vitro. Journal of endodontics. 2005;31(9):684-686.
Siqueira Jr J, Lopes H. Mechanisms of antimicrobial activity of calcium hydroxide: a critical review. International endodontic journal. 1999;32(5):361-369.
Al-Hezaimi K, Al-Shalan TA, Naghshbandi J, Simon J-HS, Rotstein I. MTA preparations from different origins may vary in their antimicrobial activity. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2009;107(5):e85-e88.
Stowe TJ, Sedgley CM, Stowe B, Fenno JC. The effects of chlorhexidine gluconate (0.12%) on the antimicrobial properties of tooth-colored ProRoot mineral trioxide aggregate. Journal of endodontics. 2004;30(6):429-431.
Kakani, Abhijeet K., and Chandrasekhar Veeramachaneni. "Sealing ability of three different root repair materials for furcation perforation repair: An in vitro study." Journal of Conservative Dentistry: JCD 23.1 (2020): 62.
Akbulut MB, Bozkurt DA, Terlemez A, et al. The push-out bond strength of BIOfactor mineral trioxide aggregate, a novel root repair material. Restorative dentistry & endodontics. 2019;44(1).
Torabinejad M, Hong C, McDonald F, et al. Physical and chemical properties of a new root-end filling material. Journal of endodontics. 1995;21(7):349-353.
Saghiri MA, Orangi J, Asatourian A, et al. Calcium silicate-based cements and functional impacts of various constituents. Dental materials journal. 2017;36(1):8-18.
Shokouhinejad N, Nekoofar MH, Iravani A, Kharrazifard MJ, Dummer PM. Effect of acidic environment on the push-out bond strength of mineral trioxide aggregate. Journal of endodontics. 2010;36(5):871-874.
Reyes-Carmona JF, Felippe MS, Felippe WT. The biomineralization ability of mineral trioxide aggregate and Portland cement on dentin enhances the push-out strength. Journal of endodontics. 2010;36(2):286-291.
Han L, Okiji T. Uptake of calcium and silicon released from calcium silicate–based endodontic materials into root canal dentine. International endodontic journal. 2011;44(12):1081-1087.
Reyes-Carmona JF, Felippe MS, Felippe WT. Biomineralization ability and interaction of mineral trioxide aggregate and white portland cement with dentin in a phosphate-containing fluid. Journal of endodontics. 2009;35(5):731-736.
Singla, Metashi, et al. "Comparison of push-out bond strength of furcation perforation repair materials–Glass ionomer cement Type II, hydroxyapatite, mineral trioxide aggregate, and biodentine: An in vitro study." Contemporary clinical dentistry 9.3 (2018): 410
Okabe T, Sakamoto M, Takeuchi H, et al.Effects of pH on mineralization ability of human dental pulp cells. Journal of endodontics. 2006;32(3):198-201
