Apical surgery in a tooth with root perforation: therapeutic approach and clinical results. A case report
Main Article Content
Abstract
Introduction: Root perforations represent one of the most challenging complications in endodontics, especially when located in the middle or cervical third, where the prognosis tends to be guarded. The incorporation of bioceramic materials significantly improves the success rate in sealing perforations, thanks to their biocompatibility and ability to induce tissue repair. Objective: To present the clinical and microsurgical management of a buccal and distal root perforation in tooth 2.1, previously treated, as well as its clinical and radiographic evolution at six months. Materials and methods: Endodontic retreatment was performed using a vertical compaction technique, followed by apical microsurgery for perforation sealing with Biodentine® (Septodont, France). Retrograde preparation was performed with NSK ProUltra® ED45 ultrasonic tips (NSK America Corp., USA). Clinical, radiographic, and tomographic findings were documented, and follow-up examinations were performed at 15 days, 1 month, and 6 months. Results: The patient recovered well, without pain or inflammation. Percussion and palpation tests were negative, and the follow-up tomography scan showed a significant reduction in the periapical lesion and reparative bone formation. Conclusions: Although multiple root perforations present a guarded prognosis, the application of microsurgical techniques and bioceramic materials allowed for the preservation of the tooth and the achievement of a satisfactory functional and aesthetic repair. General area of study: Dentistry. Specific area of study: Endodontics. Type of study: Clinical case.
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Saldaña Ayala, K. E., & Rodríguez Reyes, F. G. (2026). Apical surgery in a tooth with root perforation: therapeutic approach and clinical results. A case report. Anatomía Digital, 9(2), 57-73. https://doi.org/10.33262/anatomiadigital.v9i2.3670
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Articulos de revisión bibliográfica
References
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21. Zoya A, Ali S, Fatima A. Management of iatrogenic root perforation with grade II furcation involvement through guided tissue regeneration technique: a case with comprehensive review of clinical literature. Saudi Endodontic Journal [Internet]. 2022 [cited 2025Dec.15];12(1):129–137. Available from: https://journals.lww.com/senj/fulltext/2022/12010/management_of_iatrogenic_root_perforation_with.19.aspx
22. Alshehri MM, Alhawsawi BF, Alghamdi A, Aldobaikhi SO, Alanazi MH, Alahmad FA. The management of root perforation: a review of the literature. Cureus [Internet]. 2024 [cited 2025Dec.15];16(10):e72296. Available from: http://dx.doi.org/10.7759/cureus.72296
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24. Bliggenstorfer S, Chappuis V, Von Arx T. Outcome of periapical surgery in molars: a retrospective analysis of 424 teeth. Journal of endodontics [Internet]. 2021 [cited 2025Dec.15];47(11):1703–1714. Available from: http://dx.doi.org/10.1016/j.joen.2021.08.016
25. Peralta Escandón A, Gahona Campoverde AS, Oviedo Delgado AN, Rodriguez Reyes FG. Successful management of root perforation with bioceramics: a case report with clinical and radiographic follow-up. Anatomía Digital [Internet]. 2025Oct.8 [cited 2025Dec.15];8(4):6-21. Available from: https://doi.org/10.33262/anatomiadigital.v8i4.3525
26. Soto Zumbana JA, Piedra Andrade RB, Lugo Pinto MA, Rodriguez Reyes FG. Applied regenerative endodontics: periapical surgery and sealing of root drilling with A-PRF and photodynamic therapy. Case Report. Anatomía Digital [Internet]. 2025Apr.22 [cited 2025Dec.15];8(2):89-101. Available from: https://doi.org/10.33262/anatomiadigital.v8i2.3402
27. González Guachizaca GV, Morocho Morocho NP, Lugo Pinto MA, Rodriguez Reyes FG. Endodontic regeneration with A-PRF and I-PRF in a permanent tooth with immature apex: a clinical case report. Anatomía Digital [Internet]. 2025Nov.13 [cited 2025Dec.15];8(4):57-3. Available from: https://doi.org/10.33262/anatomiadigital.v8i4.3558
2. Azim A, Albanyan H, Azim K, Piasecki L. The Buffalo study: outcome and associated predictors in endodontic microsurgery- a cohort study. International endodontic journal [Internet]. 2021 [cited 2025Dec.15];54(3):301–18. Available from: http://dx.doi.org/10.1111/iej.13419
3. Ng Y ‐L., Mann V, Rahbaran S, Lewsey J, Gulabivala K. Outcome of primary root canal treatment: systematic review of the literature – Part 2. Influence of clinical factors. International Endodontic Journal [Internet]. 2008 [cited 2025Dec.15];41(1):6–31. Available from: http://dx.doi.org/10.1111/j.1365-2591.2007.01323.x
4. Farzaneh M, Abitbol S, Friedman S. Treatment outcome in endodontics: the Toronto study. Phases I and II: orthograde retreatment. Journal of Endodontics
[Internet]. 2004 [cited 2025Dec.15];30(9):627–33. Available from: http://dx.doi.org/10.1097/01.don.0000129958.12388.82
5. Torabinejad M, Landaez M, Milan M, Sun C, Henkin J, Al-Ardah A, et al. Tooth retention through endodontic microsurgery or tooth replacement using single implants: a systematic review of treatment outcomes. Journal of Endodontics [Internet]. 2015 [cited 2025Dec.15];41(1):1–10. Available from: http://dx.doi.org/10.1016/j.joen.2014.09.002
6. Alyousef H, Almohaimeed AA. Healing of a large periapical lesion using non-surgical root canal retreatment: a case report. Cureus [Internet]. 2024 [cited 2025Dec.15];16(9):e69586. Available from: http://dx.doi.org/10.7759/cureus.69586
7. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of endodontic surgery: a meta-analysis of the literature—part 1: comparison of traditional root-end surgery and endodontic microsurgery. Journal of Endodontics [Internet]. 2010 [cited 2025Dec.15];36(11):1757–1765. Available from: http://dx.doi.org/10.1016/j.joen.2010.08.007
8. Tsesis I, Rosen E, Schwartz-Arad D, Fuss Z. Retrospective evaluation of surgical endodontic treatment: traditional versus modern technique. Journal of Endodontics [Internet]. 2006 [cited 2025Dec.15];32(5):412–416. Available from: http://dx.doi.org/10.1016/j.joen.2005.10.051
9. Von Arx T, Peñarrocha M, Jensen S. Prognostic factors in apical surgery with root-end filling: a meta-analysis. Journal of Endodontics [Internet]. 2010 [cited 2025Dec.15];36(6):957–973. Available from: http://dx.doi.org/10.1016/j.joen.2010.02.026
10. Wang H, Xu X, Bian Z, Liang J, Chen Z, Hou B, et al. Expert consensus on apical microsurgery. International Journal of Oral Science [Internet]. 2025 [cited 2025Dec.15];17(1): 2. Available from: https://www.nature.com/articles/s41368-024-00334-8
11. Von Arx T, Jensen SS, Janner SFM, Hänni S, Bornstein MM. A 10-year follow-up study of 119 teeth treated with apical surgery and root-end filling with mineral trioxide aggregate. Journal of Endodontics [Internet]. 2019 [cited 2025Dec.15];45(4):394–401. Available from: http://dx.doi.org/10.1016/j.joen.2018.12.015
12. Kang S, Kim H, Lee C, Jung I, Kim E. Scanning electron microscopic examination of resected root apices obtained from endodontic microsurgery. Scanning [Internet]. 2016 [cited 2025Dec.15];38(5):455–461. Available from: http://dx.doi.org/10.1002/sca.21296
13. Ko M, Park J, Lee N, Yoon J, Kim Y, Cho S. Success rates comparison of endodontic microsurgery and single implants with comprehensive and explicit criteria: a systematic review and meta-analysis. Restorative Dentistry & Endodontics [Internet]. 2025 [cited 2025Dec.15];50(1):e8. Available from: http://dx.doi.org/10.5395/rde.2025.50.e8
14. Estrela C, Decurcio D de A, Rossi-Fedele G, Silva JA, Guedes OA, Borges ÁH. Root perforations: a review of diagnosis, prognosis and materials. Brazilian Oral Research [Internet]. 2018 [cited 2025Dec.15];32(suppl 1):e73. Available from: http://dx.doi.org/10.1590/1807-3107bor-2018.vol32.0073
15. Contreras A. La promoción de la salud general y la salud oral: una estrategia conjunta. Revista Clínica de Periodoncia, Implantología y Rehabilitación Oral [Internet]. 2016 [citado 2025Dic.15];9(2):193–202. Disponible en: https://www.scielo.cl/scielo.php?pid=S0719-01072016000200018&script=sci_abstract
16. Chércoles-Ruiz A, Sánchez-Torres A, Gay-Escoda C. Endodontics, endodontic retreatment, and apical surgery versus tooth extraction and implant placement: a systematic review. Journal of Endodontics [Internet]. 2017 [cited 2025Dec.15];4(3):679–686. Available from: http://dx.doi.org/10.1016/j.joen.2017.01.004
17. Huang S, Chen N, Yu V, Lim H, Lui J. Long-term success and survival of endodontic microsurgery. Journal of Endodontics [Internet]. 2020 [cited 2025Dec.15];46(2):149–157.E4. Available from: http://dx.doi.org/10.1016/j.joen.2019.10.022
18. Estrela C, Pécora JD, Estrela CRA, Guedes OA, Silva BSF, Soares CJ, et al. Common operative procedural errors and clinical factors associated with root canal treatment. Brazilian Dental Journal [Internet]. 2017 [cited 2025Dec.15];28(2):179–190. Available from: http://dx.doi.org/10.1590/0103-6440201702451
19. Strbac GD, Schnappauf A, Giannis K, Moritz A, Ulm C. Guided modern endodontic surgery: a novel approach for guided osteotomy and root resection. Journal of Endodontics [Internet]. 2017 [cited 2025Dec.15];43(3):496–501. Available from: http://dx.doi.org/10.1016/j.joen.2016.11.001
20. Sutter E, Valdec S, Bichsel D, Wiedemeier D, Rücker M, Stadlinger B. Success rate 1 year after apical surgery: a retrospective analysis. Oral and Maxillofacial Surgery [Internet]. 2020 [cited 2025Dec.15];24(1):45–49. Available from: http://dx.doi.org/10.1007/s10006-019-00815-9
21. Zoya A, Ali S, Fatima A. Management of iatrogenic root perforation with grade II furcation involvement through guided tissue regeneration technique: a case with comprehensive review of clinical literature. Saudi Endodontic Journal [Internet]. 2022 [cited 2025Dec.15];12(1):129–137. Available from: https://journals.lww.com/senj/fulltext/2022/12010/management_of_iatrogenic_root_perforation_with.19.aspx
22. Alshehri MM, Alhawsawi BF, Alghamdi A, Aldobaikhi SO, Alanazi MH, Alahmad FA. The management of root perforation: a review of the literature. Cureus [Internet]. 2024 [cited 2025Dec.15];16(10):e72296. Available from: http://dx.doi.org/10.7759/cureus.72296
23. Malkondu Ö, Kazandağ MK, Kazazoğlu E. A review on biodentine, a contemporary dentine replacement and repair material. BioMed research international [Internet]. 2014 [cited 2025Dec.15];160951:1–10. Available from: http://dx.doi.org/10.1155/2014/160951
24. Bliggenstorfer S, Chappuis V, Von Arx T. Outcome of periapical surgery in molars: a retrospective analysis of 424 teeth. Journal of endodontics [Internet]. 2021 [cited 2025Dec.15];47(11):1703–1714. Available from: http://dx.doi.org/10.1016/j.joen.2021.08.016
25. Peralta Escandón A, Gahona Campoverde AS, Oviedo Delgado AN, Rodriguez Reyes FG. Successful management of root perforation with bioceramics: a case report with clinical and radiographic follow-up. Anatomía Digital [Internet]. 2025Oct.8 [cited 2025Dec.15];8(4):6-21. Available from: https://doi.org/10.33262/anatomiadigital.v8i4.3525
26. Soto Zumbana JA, Piedra Andrade RB, Lugo Pinto MA, Rodriguez Reyes FG. Applied regenerative endodontics: periapical surgery and sealing of root drilling with A-PRF and photodynamic therapy. Case Report. Anatomía Digital [Internet]. 2025Apr.22 [cited 2025Dec.15];8(2):89-101. Available from: https://doi.org/10.33262/anatomiadigital.v8i2.3402
27. González Guachizaca GV, Morocho Morocho NP, Lugo Pinto MA, Rodriguez Reyes FG. Endodontic regeneration with A-PRF and I-PRF in a permanent tooth with immature apex: a clinical case report. Anatomía Digital [Internet]. 2025Nov.13 [cited 2025Dec.15];8(4):57-3. Available from: https://doi.org/10.33262/anatomiadigital.v8i4.3558