Root perforations may occur due to pathological processes or treatment consequences. Such perforations are severe complications and are associated with dramatically compromised endodontic treatment outcomes, especially when bacterial infection is allowed to establish. A new material, mineral trioxide aggregate (MTA), promotes a favorable environment for regeneration and has been successfully used for perforation repair. This is in contrast to previously-used materials that often led to variable outcomes. Based on the currently-available literature, the guidelines for perforation repair and treatment options need to be re-evaluated and usage parameters for MTA need to be optimized.