Let’s talk about root perforations.  I wanted to share a case from my associate doctor, who is incredible,  and I love her passion for saving teeth.  I really hit the jackpot finding her. (Okay, well, she actually found me, and I can’t believe how lucky I am!)  We couldn’t be more aligned with our core values. 

Check out this amazing case that she just did!  She has some impressive follow-up. 

I honestly thought when I first saw this preoperative radiograph that this tooth was toast.  But, this girl went for it, and she doesn’t like to give up.  

What Affects Root Perforations

The things that affect a perforation are TIME, SIZE, and LOCATION.  

The longer the perforation has been there, the worse the prognosis.

The larger the perforation, the worse the prognosis.

The more coronal the perforation, the worse the prognosis.  


Because anything that comes in contact with the sulcus bacteria will likely leak and break down and has already been contaminated. So, the more apical the perforation (free from bacteria), the better the prognosis.

A Closer Look at Root Perforations

The tooth was previously treated, and there was a sinus tract.

So the diagnosis was Previously Treated and Chronic Apical Abscess #5. Since we always want to know the true etiology of failure, it’s standard for us to take a CBCT in our practice.

You can clearly see the path of the bone loss headed to the apex, and the patient had a 9mm probing depth in that area. But, the axial view shows you the etiology!!

There is a missed buccal canal and a possible root perforation!! Who knows how long this perforation has been there, but it seems rather small, and it is in the mid-root. So, a fair prognosis. 

The coronal image shows you the missed buccal canal a little bit better…

How many people thought this was cracked or that it was not saveable for some reason or another? (Leave a comment and let me know what you think!)

I am in the camp of “You just don’t know until you try!” My associate retreated the tooth, found the missed buccal canal, and repaired the perforation on the distal with MTA.  She then medicated the tooth for two months with calcium hydroxide.

Root Perforation with a Happy Ending

After two months, the probing was now at 6mm, and the bone was starting to fill back in. Fast forward a few months since the obturation, and this is the tooth.

The PDL is starting to restore itself, and the patient is getting her bone back. If I do one thing in my life, it is to change the way people think about teeth… and saving them. 

A case like this is not heroic, and I wish it wasn’t standard for us.  How do we prevent this from happening, and how do we know we can fix after it happens?

I hope that the stories that I share give you hope that many more teeth can be saved.