Root Perforations: Etiology, Diagnosis, Prognostic Factors, and Contemporary Repair Materials: A Narrative Review

Root perforations represent a pathological communication between the root canal system and the external root surface and are among the most serious complications in endodontics. Their occurrence leads to bacterial contamination and inflammatory tissue destruction, resulting in resorption of dentin, cementum, and alveolar bone, thereby compromising the tooth's long-term prognosis. Objective: The aim of this review is to summarize current data regarding the etiology, diagnosis, treatment strategies, and contemporary materials used in the management of root perforations, with particular emphasis on recent advances in non-surgical treatment. Methods: A narrative literature review was conducted using sources from PubMed, Scopus, Web of Science, Embase, CINAHL, and the Cochrane Library. After applying a predefined search strategy of inclusion and exclusion criteria, 60 scientific sources published between 2003 and 2026 were included. Results: Current evidence indicates that the treatment outcome depends primarily on the location and size, prompt perforation sealing, bacterial contamination, and selection of restorative material. Cone-beam computed tomography has improved diagnostic accuracy, while a non-surgical approach remains the preferred approach in most clinical situations. Mineral trioxide aggregate (MTA) continues to be the reference standard material due to its biocompatibility, bioactivity and sealing ability. New-generation calcium-silicate bioceramics offer improved physicochemical properties, while maintaining favorable biological properties. Regenerative materials have shown promising potential to enhance healing processes, but available evidence remains limited. Conclusions: Successful treatment of root perforations requires early diagnosis, timely repair of the defect, effective bacterial control, and use of bioactive materials with reliable sealing and regenerative properties. Modern calcium-silicate bioceramics have improved non-surgical treatment predictability, whereas regenerative approaches appear to be a promising alternative that requires further clinical studies to develop standardized therapeutic protocols.