CLINICAL

Furcation perforation: current approaches

and future perspectives
Manal Farea,1 Adam Husein2 and Cornelis H Pameijer3

During root canal treatment many procedural accidents may occur of which perforation
of the root canal system plays a significant role. Perforation is defined by the American
Association of Endodontics (AAE) Glossary of Endodontic Terms (2003) as a
mechanical or pathological communication between the root canal system and the
external tooth surface, which is caused by caries, resorption or iatrogenic factors. It
has been identified as the second greatest cause of endodontic failure that accounts
for 9.6% of all unsuccessful cases (Pitt Ford et al, 1995).
As a result of furcation perforation, destruction of the periodontal tissues may occur,
1
Manal Farea is a dentist with a which ultimately lead to loss of the tooth (Arens, Torabinejad, 1996; Tsesis, Fuss,
BDS degree from Sana’a University, 2006). The prognosis of the tooth depends upon several factors:
Sana’a, Yemen in 2003. She received 1. The severity of initial damage to the periodontal tissue
her MSc degree in endodontics from
2. The location and size of perforations
Universiti Sains Malaysia (USM),
Malaysia in 2010. In 2015, she 3. The bacterial contamination
completed her PhD degree at the 4. The sealing ability or cytotoxicity of the repair materials (Tsesis, Fuss, 2006; Sinai,
USM in regenerative endodontics. 1977; Balla et al, 1991).
Dr Manal was granted a scholarship
Even if a biocompatible material is used to treat a perforation, extensive injury may
from Sana’a University, Yemen in
2007 and a fellowship from USM in cause irreversible damage to the attachment apparatus at the furcation area (Sinai et
2011. al, 1989).
In large perforations, the complete sealing of the defect with a repair material is
2
Professor Dr Adam Husein is a
problematic and allows irritants to continuously penetrate into the furcation area (Balla
senior lecturer in the restorative unit
(prosthodontics) and the dean of et al, 1991). Perforations close to the gingival sulcus produce persistent inflammation
School of Dental Sciences, Universiti and a down-growth of sulcular epithelium into the defect (Tsesis, Fuss, 2006). Sinai
Sains Malaysia. He got his BDS from (1977) stated that coronally located perforations including furcal perforations were
University of Adelaide, Australia in more serious than those in the middle and apical third of a canal. It is the objective of
1996. In 2004, he optained his
graduate diploma in clinical dentistry,
this review to collect and review the data that is available in the scientific literature and
doctor in clinical dentistry and to reach a conclusion as to the best treatment options.
fellowship of the Royal Australasian
College of Dental Surgeons (FRACDS) Methods
from the University of Adelaide.
Retrieval of literature
3
Cornelis H Pameijer DMD MScD An English-limited Medline search was performed of articles published from 2002 to
DSc PhD graduated from the 2015. The searched keywords included ‘perforations and endodontics’, ‘furcation
University of Utrecht with a DDS in perforation’, ‘root canal and perforation’, and ‘perforation and mineral trioxide
The Netherlands in 1967 and went
aggregate (MTA)’. Then, a hand search was done of the references of collected articles
on to further his studies at Boston
University in the USA. He is currently to determine if more papers relevant to the topic should be included.
professor emeritus at the University of
Connecticut in Farmington, Results
Connecticut, USA. He has lectured
A total of 820 articles were found, which, in order of their related keywords, accounted
extensively worldwide and has
published more than 300 publications for the following: perforations and endodontics: 285; furcation perforation: 92; root
in mostly peer-reviewed journals. canal and perforation: 299; and perforation and mineral trioxide aggregate (MTA): 144.

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 CLINICAL

matrices such as calcium sulphate, hydroxyapatite, collagen,

demineralised freeze-dried bone and Gelfoam have been
used (Clauder, Shin, 2009; Roda, 2001; Bargholz, 2005).
The internal matrix concept was introduced by Lemon
(1992) in order to adequately seal the furcation perforation
and avoid extrusion of the material. He also recommended
the use of hydroxyapatite as a matrix under amalgam.
Calcium sulphate and calcium hydroxide prevented extrusion
of composite resin when used as a furcal repair material
(Imura et al, 1998). In 1999, Jantarat and colleagues
demonstrated that amalgam placed with plaster of Paris as
a matrix for furcal perforation repair improved its sealing
ability. Hapset (65% non-resorbable hydroxyapatite and
Figure 1: This illustration depicts a furcation perforation repair 35% plaster of Paris) and hydroxyapatite showed similar
using stem cells, scaffold and growth factor. This method has the healing responses when used as internal matrices under
potential to open new avenues in furcation repair treatment in
amalgam (Rafter et al, 2002). Rafter et al (2002) further
the foreseeable near future. This image relates to the text under
‘future perspectives for the perforation repair’ on page 40.
reported that there was marked extrusion of amalgam into
the underlying bone with an associated severe inflammatory
response when used alone without a matrix.
Although it has been reported that without using an internal
Perforation repair techniques and their prognosis matrix the optimal strength and excellent sealability of MTA
Surgical and non-surgical approaches have been utilised for was achieved in the presence of moisture (Arens,
periodontal tissue re-establishment at the perforation site. In Torabinejad 1996; Holland et al, 2001; Torabinejad et al,
both surgical and non-surgical approaches, two factors 1994), conflicting results have been reported by some
should be considered: authors regarding the use of an internal matrix under MTA.
1. An appropriate material selection In 2004, Kratchman suggested that the perforation site
2. The use of a matrix (Clauder, Shin, 2009). should be soaked with sodium hypochlorite after haemostasis
The repair material should be selected based on the had been achieved and that a physical barrier such as
following criteria: collagen or calcium sulfate must be used at the perforation
• Perforation site accessibility site to prevent MTA from being packed into the bone.
• Biocompatibility (be nontoxic and noncarcinogenic) According to Bargholz (2005), excellent clinical results
• Ability to induce osteogenesis and cementogenesis were achieved when collagen matrix was used under MTA.
• Moisture control A study by Al-Daafas and Al-Nazhan (2007) showed that
• Easy handling calcium sulfate prevented extrusion of the repair material.
• Aesthetic considerations (Clauder, Shin, 2009; Bryan, However, an unfavourable inflammatory reaction – epithelial
Woollard, Mitchell, 1999; Yildirim et al, 2005; Samiee et tissue migration into the defected perforation and the inability
al, 2010). to induce bone regeneration – were detected. Thus, the
authors concluded that using calcium sulphate as an internal
Matrix use matrix for MTA is not recommended. When used as an
Controlling haemostasis and placement of the repair material internal matrix for furcal perforation repair, calcium sulfate
in the perforation site without extrusion into surrounding and Collaplug (Calcitek, Carlsbad, CA) did not improve the
periodontal structures are essential prerequisites for the sealing ability nor reduce the incidence of MTA
success of a perforation repair. In order to achieve a fluid- overextension. Therefore, the authors concluded that these
tight seal, haemostasis has to be controlled (Clauder, Shin, two materials are not recommended as an internal matrix for
2009). Delayed perforation repair can lead to extrusion of MTA (Zou et al, 2008). Furthermore, calcium sulfate and
repair materials as a result of breakdown of the surrounding hydroxyapatite did not improve the sealing ability of MTA
periodontium that is replaced by granulation tissue. Thus, in when used as internal matrices for furcation perforation repair
an attempt to avoid extrusion of the repair material, internal (Taneja, Kumari 2011).

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FA R E A E T A L

Figure 2: The three key elements of dental tissue engineering are stem cells, scaffolds and signals.

Materials used for furcation perforation repair iron, and MTA-Angelus (Angelus) (Asgary et al, 2005). MTA-
In an attempt to repair a furcation perforation, several Angelus was introduced to address the long setting time from
materials such as amalgam, tricalcium phosphate (TCP), two hours for Proroot MTA to 10 minutes for MTA-Angelus.
hydroxyapatite, gutta percha, calcium hydroxide, zinc oxide- MTA-Angelus contains 80% Portland cement and 20%
eugenol-based cement (IRM and Super-EBA), glass ionomer bismuth oxide, with no addition of calcium sulfate, while
cement, composite resins, resin-glass ionomer hybrids, Proroot MTA is composed of 75% Portland cement, 20%
demineralised freeze-dried bone and MTA have been used bismuth oxide, and 5% calcium sulfate dehydrate (Hashem
over the years (Arens, Torabinejad, 1996; Balla et al, et al, 2008). The constituents of the Portland cement are
1995; Bryan, Woollard, Mitchell, 1999, Yildirim et al, minerals, amongst which the most important are dicalcium
2005; Salman et al, 1999). However, none fulfil all requisite silicate, tricalcium silicate, tricalcium aluminate, tetracalcium
qualifications for an ideal biomaterial. ironaluminate and dehydrated calcium sulfate (Oliveira et al,
Balla et al (1991) reported that no hard tissue was formed 2007; Asgary et al, 2009a). The only significant difference
at the furcation perforation defect site when treated with either between the dominant compounds of white and gray MTAs
tri-calcium phosphate, hydroxyapatite, amalgam or calcium and associated Portland cements is bismuth oxide, which is
hydroxide (Life); instead, the defect site was occupied by present in MTAs (Asgary et al, 2009a; Asgary et al, 2004).
epithelium and acute inflammatory cells (Balla et al, 1991). It has been reported that the sealing ability of MTA (Loma
MTA is water-based cement that is derived from Portland Linda University, Loma Linda, CA) was significantly better
cement (type I). It was introduced as a root-end filling material compared to amalgam in preventing leakage of
in the early 1990s (Torabinejad, Watson, Pitt Ford, 1993; Fusobacterium nucleatum through furcal perforations
Torabinejad, Chivian, 1999). It was subsequently determined (Nakata, Bae, Baumgartner, 1998). When used to seal a
that it was a suitable material for various clinical applications large furcation perforation, Proroot MTA with/without internal
such as pulp capping, repair of furcal perforations as well as matrix and MTA-Angelus with internal matrix showed the
root-end closure (Sinai et al, 1989; Torabinejad et al, 1995). lowest dye absorbance compared to zinc oxide-eugenol
MTA promotes periradicular tissue regeneration (Pitt Ford et cement (IRM) with/without internal matrix and MTA-Angelus
al, 1995; Yildirim et al, 2005; Holland et al, 2001; Zhu, without internal matrix. Additionally, the authors reported that
Xia, Xia, 2003; Noetzel et al, 2006) and it differs from other IRM without internal matrix had the highest dye absorbance
materials by its ability to promote cementum regeneration, (Hashem, Hassanien, 2008). However, white and gray MTA
thus facilitating the regeneration of the periodontal apparatus (Dentsply Tulsa Dental) showed no significant differences in
(Pitt Ford et al, 1995; Arens, Torabinejad, 1996). Its microleakage when used for furcal perforation repair (Ferris,
biocompatibility nature is suggested by its ability to form Baumgartner, 2004; Hamad, Tordik, McClanahan, 2006).
hydroxyapatite when exposed to simulated body tissue fluid Furcal perforations have been repaired with Proroot gray
(Sarkar et al, 2005). MTA (Dentsply) and Geristore (Denmat). Geristore has been
Two commercial forms of MTA are available; Proroot MTA used as a root end filling material and in the restoration of
(Dentsply Tulsa Dental), which is available in both gray or subgingival surface defects such as root surface caries and
white form, of which the latter contains a lower amount of iatrogenic perforations, surgical repair of root perforations

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and as an adjunct in guided-tissue regeneration (GTR) In 2006, Asgary and colleagues introduced a new
(Mehrvarzfar et al, 2010). It also leaked significantly less endodontic cement, a calcium-enriched mixture (CEM)
than amalgam (Mehrvarzfar et al, 2010). In the cement. Major components of CEM cement powder are
aforementioned study, the authors reported that the sealing 51.75 wt.% calcium oxide, 9.53 wt.% sulfur trioxide, 8.49
ability of MTA and Geristore was reduced when bioglass wt.% phosphorous pentoxide, and 6.32 wt.% silicon
was used as a matrix underneath. dioxide; whereas the minor essential constituents are
Sluyk, Moon and Hartwell (1998) assessed the effect of aluminium oxide > sodium oxide > magnesium oxide >
time and moisture on setting, retention and adaptability of chlorine. CEM cement has a similar pH but an increased
MTA when used for furcal perforation repair. Findings showed flow compared to MTA. However, working time, film
that MTA adaptation to perforation walls increased in the thickness and price are considerably less (Asgary et al,
presence of moisture. They further suggested that a moistened 2008a). Unlike MTA, mixed CEM cement releases calcium
matrix can be used under MTA to prevent under- or overfilling and phosphate ions and forms hydroxyapatite not only in
of the material. Furthermore, Main et al (2004) indicated that simulated body tissue fluid but also in normal saline solution
MTA provided an effective seal for root perforations. (Asgary et al, 2009a; Amini et al, 2009).
Yildirim et al (2005) investigated the histologic response Although the chemical composition of CEM cement and
to MTA and Super EBA (Bosworth Company) when used in MTA are different, they have similar clinical applications
furcation perforation repair in dogs. In their study, less (Asgary et al, 2008b; Asgary et al, 2008c; Asgary et al,
inflammation and new cementum formation was observed 2009b; Asgary, Ehsani, 2009c). Similar to MTA, CEM
with MTA compared to Super EBA, which demonstrated cement had low cytotoxic effects on different cell lines
connective tissue repair without inflammation. Similar abilities (Asgary et al, 2009d). However, it showed a better
to seal furcal perforations were observed for both Portland antibacterial effect comparable to calcium hydroxide (Asgary
cement and MTA (De-Deus et al, 2006; Noetzel et al, et al, 2008d). Similar sealing ability was demonstrated by
2006) evaluated histologically the inflammatory reactions both Proroot MTA and CEM when used to repair furcal
and tissue responses to experimental tricalciun phosphate perforation of primary molar teeth (Haghgoo et al, 2014).
(TCP) and MTA when used as repair materials in furcation
perforations in dogs. Results showed no significant Non-surgical approach
differences between MTA and TCP in terms of bone When a perforation repair is indicated, it is recommended
reorganisation or deposition of fibrous connective tissue. to first attempt an intracoronal approach (non-surgical) to
Thus, MTA is considered the gold standard and material preserve the periodontium thus increasing the chances of
of choice for perforation repair and has demonstrated good success (Regan, Witherspoon, Foyle, 2005). Generally,
potential for clinical success. However, it has some perforations coronal to the crestal bone fall into the category
disadvantages, including the inability to degrade to allow of a non-surgical approach. The use of a surgical microscope
for replacement with natural tissues, low resistance to operated at high magnification and with ample illumination
compression over the long-term, extended setting time, poor allows for better management of perforation repairs
handling, and difficult insertion into cavities because of its (Kratchman, 2004; Daoudi, Saunders, 2002).
granular consistency, while additional moisture is required to A surgical approach may complicate the treatment and lead
activate the cement setting, and lastly, the high cost, despite to loss of periodontal attachment, chronic inflammation and
its widespread use (Torabinejad et al, 1995; Chng et al, furcal pocket formation (Arens, Torabinejad 1996). Experience
2005; Kogan et al, 2006; Coomaraswamy, Lumley, has shown that buccally located perforations are easier to repair
Hofmann, 2007; Parirokh, Torabinejad, 2010). Many than lingual or proximal lesions. Lingual located perforations,
dental materials have been demonstrated in the literature to especially in the mandible, should be treated non-surgically or
exhibit cytotoxic effects during setting. Low cell numbers were orthodontically. If they are not responding to treatment, the tooth
demonstrated in vivo with freshly mixed MTA (pH=10.2) should be extracted (Regan et al, 2005). If a tooth can be
compared to preset MTA (pH=12.5) (Tronstad, Wennberg, extruded orthodontically to a point where the perforation
1980). However, histologically, no difference in bone and reaches a supragingival level, repair of the defect will be greatly
cementum regeneration was observed after periradicular facilitated (Smidt, Lachish-Tandlich, Venezia, 2005). Whether
surgery in dogs between fresh and preset Proroot MTA clinically practical or not, one case of intentional reimplantation
(Apaydin, Shabahang, Torabinejad, 2004). was reported after repair of the perforation was performed on

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the extracted tooth (Poi et al, 1999). is fully set (Clauder, Shin, 2009). The other option is to use
In cases of large perforations, bleeding should be a gutta percha point and soften it with heat to the dentinal
controlled first using sterile saline. Alternatively, calcium wall opposing the perforation. MTA is then placed at the
hydroxide, calcium sulphate, or collagen has been used defect site (Clauder, Shin, 2009). Perforations at the apical
(Clauder, Shin 2009). For bleeding control, non-specific one-third are quite challenging and difficult to manage.
intravascular clotting agents should be avoided as they may Successful treatment cannot always be achieved for all cases
lead to alveolar bone damage and delay in healing (Lemon, necessitating apical surgery or extraction of the tooth to
Steele, Jeansonne, 1993). In cases of perforations that are remedy the problem (Clauder, Shin, 2009).
infected or perforation sites that need further enlargement
and cleaning, burs or ultrasonic tips may be used. However, Surgical approach
ultrasonic tips are preferable as they are gentler to the Surgical intervention (external approach) is indicated in areas
adjacent periodontium tissues (Pitt Ford et al, 1995; Arens, that are not accessible by non-surgical means alone, cases
Torabinejad, 1996; Clauder, Shin, 2009). For cleaning of that have not responded to non-surgical treatment or in
infected perforations, 2.5% sodium hypochlorite has been repairing a perforating resorption (Regan et al, 2005). The
used (Arens, Torabinejad, 1996), however, sterile saline is surgical approach is performed by reflecting a flap at the
indicated in large perforations (Clauder, Shin, 2009). To perforation site followed by cleaning and preparing the
avoid blockage of the canals with repair material, gutta perforated area and finally packing the repair material
percha points, paper points, cotton pellets or an easily (Alhadainy, 1994).
removable material (such as Cavit) should be placed over During the surgical repair procedures, cortical bone
the canal orifices (Clauder, Shin, 2009). damage is involved, which may result in reduced success of
A resin-bonded material such as Geristore (Denmat) is the corrective surgical procedure. Thus, a GTR technique has
recommended to restore subgingival defects (Clauder, Shin, been recommended for successful treatment outcomes by
2009), which also serves as an adjunct to GTR (Abitbol et using either non-resorbable or resorbable membranes as a
al, 1996; Behnia, Strassler, Campbell, 2000). It is less barrier (Duggins et al, 1994; Barkhordar, Javid 2000;
sensitive to moisture than conventional glass ionomer cement Rankow, Krasner, 1996; Dean et al, 1997; Leder et al,
while a drier environment improved the results (Cho, Kopel, 1997). This barrier guides selected cells to populate at the
White, 1995). Adhesive materials can be used in perforation defect, ie, placing the barrier between the
supracrestal perforations, whereas MTA is preferable in gingival tissue and the perforation defect will facilitate the
subcrestal perforations (Clauder, Shin, 2009). If a perforation repopulation of the defect by periodontal ligament cells and
defect involves bone destruction (intraosseus defect), a barrier other osteogenic cells and prevents the colonisation by
is needed to facilitate controlled placement of the repair gingival cells (Linde et al, 1993; Sandberg, Dahlin, Linde,
material. This is not necessaary if the defect does not include 1993). A resorbable membrane is generally preferable, as
an intraosseus defect (Clauder, Shin, 2009). If MTA is used it does not need a second surgical procedure to remove it.
a moist cotton pellet should cover the material to allow setting However, in some cases, titanium-tented membrane or a
of the material. After perforation repair the final restoration supporting graft material is needed to prevent collapsing the
can be placed either after one day or one week. Once repair membrane into the defect (Abitbol et al, 1996).
has been achieved the root canal(s) can be cleaned, shaped
and filled (Pitt Ford et al, 1995; Arens, Torabinejad, 1996). Cementum regeneration and role in the periodontium
If a perforation is present in the middle third of the root, reconstruction
the canal(s) should be prepared first before closing the defect Cementum formation is very essential in the furcation
to avoid blocking the canal. With the aid of an operating perforation repair process (Pitt Ford et al, 1995; Clauder,
microscope, obturation of the canal apical to the defect Shin, 2009; Samiee et al, 2010; Zairi et al, 2012). Pitt
should be done first, followed by filling the remainder of the Ford and colleagues (1995) evaluated the histologic
canal and the perforation site with MTA (Clauder, Shin, response to experimentally induced furcation perforations in
2009). Alternatively, the root space beyond the perforation dog mandibular premolars repaired by either MTA or
can be maintained by means of a file or gutta percha cone. amalgam and found that most of the MTA samples showed
In case a file is used, it should be loosened after finishing no inflammation and cementum deposition, whereas with the
the repair procedure to allow easy removal before the MTA use of amalgam, moderate to severe inflammation with no

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cementum deposition was present. comparing the effects of application of growth factor mixture
Healing after intentional perforations in dogs’ teeth was with MTA and MTA alone on tissue healing and
evaluated after repair with either MTA or Sealapex (Kerr) regeneration.
(Holland et al, 2001). Most samples sealed with MTA In a case report, Bains et al (2012) used tissue
showed new cementum deposition and an absence of engineering principles for the furcation perforation repair of
inflammation. In 2010, Samiee and colleagues reported that the pulpal floor of the right mandibular first molar of 39-year-
cementum-like hard tissue was formed using either MTA or old male patient using MTA and platelet-rich fibrin (PRF). The
CEM cement in the furcation perforation in dogs in the authors reported that this combination was able to repair the
presence of a mild inflammatory response. The authors perforation defect and regenerate the lost periodontium in
concluded that both materials showed a similar favourable the furcation area effectively. A case report (Eghbal, Fazlyab,
biological response in furcation perforation repair. Asgary, 2014) was published describing the nonsurgical
Zairi et al (2012) compared the inflammatory reactions endodontic management of an extensive perforation of the
and tissue response of furcal perforations in dogs’ teeth to floor of the pulp chamber in a first mandibular molar of a
growth factors, TGFβ1, basic fibroblast growth factor 28-year-old Caucasian female using CEM cement. The
(bFGF), osteogenic protein-1 (OP-1) and IGF-I, with MTA or authors reported that CEM was able to induce hard tissue
IRM as controls. The authors reported that a clear stimulatory formation, ie bone and cementum.
effect on cementum formation and inhibition of collagen
capsule formation was exerted by the growth factors. Cellular tissue engineering approach for cementum
However, MTA exhibited better results than the growth regeneration
factors. Based on that, the authors suggested a further study A proposed therapeutic approach was reported by the
FA R E A E T A L

removal of autologous cells from the patient’s periodontal (Zeichner-David et al, 2003). Several in vivo studies have
ligament (PDL), culturing of the cells in vitro, which were then also shown the potential capability of PDLSCs to form
placed back onto the exposed root coated with chemo cementum and PDL-like tissues (Yang et al, 2009; Liu et al,
attracting factors, subsequently covering the area with an 2008; Feng et al, 2010; Park, Jeon, Choung, 2011).
artificial basement membrane (Terranova, 1990). However,
it is unknown whether this method produced the desired Regenerative therapy
effect. Lekic and colleagues (2005) reported that rat Tissue engineering is an interdisciplinary field that applies the
periodontal and bone marrow cells were able to differentiate principles of engineering and life sciences toward the
into periodontal ligament fibroblasts, osteoblasts and development of biological substitutes that restore, maintain, or
cementoblasts when transplanted into periodontal wounds in improve tissue function or a whole organ (Langer, Vacanti,
rats, thus contributing to periodontal regeneration. 1993). Tissue engineering aims to stimulate the body either to
Regeneration of cementum, PDL and alveolar bone have regenerate tissue on its own or to grow tissue outside the body,
been observed using auto-transplantation of bone marrow which can then be implanted as natural tissue (Nadig, 2009).
derived mesenchymal stem cells (BMMSCs) (Kawaguchi et
al, 2004) or periodontal ligament cell sheet (Akizuki et al, Triad components
2005) into periodontal osseous defects in dogs. However, Regenerative endodontics can be defined as biologically
the principle disadvantage of cell sheets is their delicate based procedures designed to replace damaged structures,
structure and difficult handling during surgery (Li, Jin, 2015). including dentine and root structures, as well as cells of the
Furthermore, the harvest of bone marrow (BM) is a highly pulp-dentine complex (Murray, Garcia-Godoy, Hargreaves,
invasive and a painful procedure for the donor. Moreover, it 2007). This approach consists of the following interactive
has been reported that the number, proliferation and triad: 1) an appropriate cell source; 2) a supportive matrix
differentiation potential of BMMSCs decline with increasing (scaffold); and 3) inductive biological factors or signals
age (Kern et al, 2006). (Figure 1). To create regenerative therapies, these disciplines
It has been reported that cementoblast-biodegradable are often combined rather than used individually (Murray,
poly(lactic-co-glycolic acid) (PLGA) polymer sponge-treated Garcia-Godoy, Hargreaves, 2007).
defects showed complete bone bridging and PDL formation,
whereas minimal evidence of osteogenesis was exhibited by Future perspectives for the perforation repair
follicle cell-treated defects along the root surface of athymic Reconstruction of the lost attachment via regeneration of the
rats (Zhao et al, 2004). Periodontal ligament stem cells periodontium components, such as cementum, PDL and
(PDLSCs) have the ability to differentiate into cementoblast bone, is essential in the repair of perforated areas.
and osteoblast (Isaka et al, 2001; Seo et al, 2004) and Replacement of the lost cementum (cementogenesis) is very
have shown potential therapeutic applications in critical and enhances the reattachment of the fibres of the
periodontium regeneration. However, the very low number periodontal ligament. Several studies have been published
of these cells residing in the PDL is indicative of the difficulty that demonstrate the ability of different materials to repair
acquiring a sufficient number for regenerative treatment furcation perforations, albeit with variable success rates.
remains and is an issue that remains unresolved (Maeda et However, during recent years, there has been a paradigm
al, 2011). Primary cultures of PDLSCs yielded small cell shift from conventional to regenerative endodontic therapy
numbers, therefore before application, PDLSCs must and repair of the periodontium is not an exception. To date,
proliferate at least 12 population doublings (Zhu, Liang, to the best of our knowledge, no studies have been
2015). Additionally, it has been found that the proliferation published in the literature reporting on the effect of the triad
and migration ability and differentiation potential of PDLSCs application (stem cells, scaffold and growth factor) for furcal
decreased with increasing age (Zhu, Liang, 2015). perforation repair and the response of surrounding tissues
Apical tooth germ cells conditioned medium were able to (cementum, PDL and alveolar bone). We propose a stem cell-
provide the cementogenic microenvironment and induced based tissue engineering approach for furcation perforation
the cementoblastic differentiation of PDLSCs (Yang et al, repair through enhancing of stem cell differentiation along
2009). Hertwig’s epithelial root sheath (HERS) cells, or their the cementoblastic lineage in association with scaffold and
secreted products, were able to induce PDL cells growth factor. The suggested biomimetic approach is
differentiation along the cementoblastic lineage in vitro illustrated in Figure 2. This will have the potential to open a

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new era and strategy in endodontic and periodontal tissue endodontics in the future and may therefore save many teeth
engineering therapies. that would otherwise have to be extracted due to a poor to
hopeless prognosis.
Conclusions Moreover, it will help and assist in designing regenerative
Perforation of the pulp chamber floor of multi-rooted teeth therapies based on sound biological principles, which can
constitutes a perplexing and frustrating problem. It is a major be applied in both endodontic and periodontal specialties.
cause of endodontic treatment failure. A furcation perforation
has to be regarded as an endodontic and periodontal Acknowledgements
problem. The inflammatory response in the periodontium, This study was financially supported by the Universiti Sains
leading to irreversible loss of periodontal attachment in the Malaysia Research University Grant 1001/PPSP/813058,
area, can result in loss of the tooth if the perforation is not PRGS (1001/PPSG/8146005) and short-term grants
successfully repaired. To re-establish the periodontal tissue in (304/PPSG/ 61312012 and 304/PPSG/61312018)
from the School of Dental Sciences, Universiti Sains
the perforation site, surgical and non-surgical techniques
Malaysia.
have been utilised.
For furcation perforation repair, several materials have
References
been used with varying results. However, the stem cell-based
A full list of references is available from the Publisher
tissue engineering approach is very promising and is suitable
for furcation perforation repair. This approach has the
Reprinted with permission by Endodontic Practice August
potential to revolutionise the practice of regenerative
2017

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FA R E A E T A L

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