Managing iatrogenic root perforation masked by deceptive radiographic presentation in maxillary central incisor

This case report describes the diagnosis and treatment of an iatrogenic buccal root perforation in the maxillary right central incisor (#11). Teeth #11 and #21 (Fédération Dentaire Internationale) exhibited discolouration and incisal-third crown fractures. Preoperative radiographs revealed poorly compacted radiopaque material in the root canals of both teeth, with #21 presenting a wide-open apex and periapical lesion. The radiographic presentation of #11 was perplexing, showing a mature root apex superimposed over a blunderbuss apex. Cone-beam computed tomography confirmed a labial root perforation in #11. A pulpal diagnosis of previously initiated therapy was established for both teeth. #21 was diagnosed with asymptomatic apical periodontitis, while #11 had symptomatic apical periodontitis with labial root perforation. Treatment included non-surgical root canal therapy followed by surgical perforation repair. At the 4-year follow-up, both teeth were functional and asymptomatic, with complete periapical healing.