Access-Related Root Perforation Mishap Correction in a poorly Obturated and Apically Dilacerated Mandibular Second Premolar with a Posttreatment Disease: A Case Report with a 2-Month Follow-up

Introduction: Iatrogenic perforation is a common complication that requires prompt intervention. Nowadays, recent technologies and the use of bioactive materials promote a favorable environment for regeneration and have been successfully used for perforation repair. Body: A 45-year-old female patient complained of a persistent sinus and pain related to a previously endodontic-treated mandibular tooth. Clinical examination revealed the sinus tract on the buccal vestibule corresponding to mandibular premolar. The tooth was sensitive to palpation and percussion. A panoramic radiograph showed short obturation in the offending tooth. Cone Beam Computed Tomography (CBCT) was requested, which revealed gutta percha in a false canal and mid-root perforation, together with a dilacerated root and peri-apical radiolucency. Re-treatment was done under a dental operating microscope, including removing old gutta-percha using three braided H-files. CBCT helped to detect the correct canal orifice. A small, curved K-file obtained patency in the original canal. Blue Ni-Ti rotary files prepared the dilacerated root. Activated NaOCl (5.25%) disinfected the canal. Two-thirds of the canal was obturated using warm vertical compaction technique. Calcium silicate-based fast-set putty sealed the perforation. At one-week follow-up, the patient expressed no postoperative pain related to the offending tooth and healing of the sinus tract. A 2-month periapical radiograph showed a decrease in the periapical radiolucency. Conclusion: Proper treatment of iatrogenic perforation is possible using recent technologies and materials such as magnification, calcium silicate-based root repair material, proper disinfection, and canal obturation, which facilitated the treatment procedures and improved the treatment outcome. However, prevention is better than treatment.