In periodontal-endodontic lesions there is usually an open wound area. Combined endodontic-periodontal lesions have poor prognoses, even if treatment is aided by a microscope. Two cases in which two regenerative procedures were applied are presented as examples for successful treatment concepts of complex cases.
In periodontal-endodontic lesions there is usually an open wound area. Combined endodontic-periodontal lesions have poor prognoses, even if treatment is aided by a microscope. Two cases in which two regenerative procedures were applied are presented as examples for successful treatment concepts of complex cases.
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In periodontal-endodontic lesions there is usually an open wound area. Combined endodontic-periodontal lesions have poor prognoses, even if treatment is aided by a microscope. Two cases in which two regenerative procedures were applied are presented as examples for successful treatment concepts of complex cases.
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PERIODONTOLOGY/ENDODONTICS require surgical intervention. In periodon- tal-endodontic lesions particularly, there is usually an open wound area, for which special treatment concepts are needed. Kim et al 3 could show that combined end- odontic-periodontal lesions have poor prognoses, even if treatment is aided by a microscope. Two cases in which two regenerative procedures for the treatment of periodontal- endodontic lesions were applied are pre- sented as examples for successful treat- ment concepts of complex cases. CASE REPORTS Case 1 A 60-yoar-old woman prosontod to nor don- tist. A radiograpn snowod a doop bony defect with an apical lesion at the distal root of the mandibular right rst molar (Fig 1a). Four weeks after root canal treatment, the patient was referred with pain to the Department of Operative Dentistry, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany. The radiograph showed a deep intraosseous defect on the distal root of this tooth and approximately 2 mm of extruded gutta-percha (Fig 1b). The clinical picture A spooiho protoool is noodod or tno man- agement of endodontic-periodontal lesions, because the clinical picture shows inam- mation of pulpal and periodontal tissues. Different therapy concepts can be con- sidered, depending on the severity of inammation and the clinical situation. Healing processes can occur through regeneration and reconstitution of the origi- nal function or through regenerative pro- oossos witn various matorials. Pogonorativo techniques based on the local application of bone substitute materials are widely used. 1 Furthermore, bone morphogenic proteins and commercially available enamel matrix derivatives (cEMD) have been described to support the regenerative process. 2 The clinical success of all these treat- ments depends mainly on the shape, local- ization, and extent of the original bony lesion. Lesions of endodontic origin seldom 1 Associate Professor, Department of Operative Dentistry, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany. 2 Head, Department of Operative Dentistry, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany. Correspondence: Prof Dr Brita Willershausen, Department of Operative Dentistry, University Medical Centre of the Johannes Gutenberg University Mainz, Augustusplatz 2, 55131 Mainz, Germany. Email: willersh@uni-mainz.de The frst and second authors contributed equally to this work. Postendodontic treatment periodontal surgery: A case report Adriano Azaripour, DSS 1 /Ines Willershausen, DDS 1 /Philipp Kmmerer, DDS 1 /Brita Willershausen DDS, PhD 2 Two patients were diagnosed with combined endodontic-periodontal lesions. Endodontic treatment was performed, followed by surgery. In addition, the regeneration process was supported by the application of an enamel matrix derivate
alone or in combination with guidod bono rogonoration toonniquos. At rooall visits ator 24 montns, tno tootn woro asymptomatic and marked bone regeneration had occurred in both patients. The suc- cessful postendodontic treatment of combined endodontic-periodontal lesions, using periodontal surgery and as adjunct guided tissue regenerative techniques, is presented. Further, the possibility of saving teeth, even with severely apparent pathology, should be highlighted. (Quintessence Int 2013;44:123126) Key words: periodontal-endodontic lesion, root canal treatment, surgery 124 VOLUME 44 NUMBEP 2 FEBPUAPY 2013 QUI NTESSENCE I NTERNATI ONAL Azari pour/ Wi l l ershausen et al presented a distal probing depth (PD) of 12 mm (Fig 1c) and bleeding. A muooporiostoal hap proooduro was performed to access the area between the mandibular right second premolar and the right second molar (Fig 1d). The extruded gutta-percha was removed. cEMD (Emdogain, Straumann) was applied to the root surface, and the ap was repositioned (Fig 1o). Padiograpns takon 10 and 24 months after surgery showed good perira- dioular rogonoration (Figs 1 and 1g). A reduction of PD to 5 mm and of furcation involvement to 1 mm was observed (Fig 1h). Case 2 A 65-yoar-old man prosontod to tno Department of Operative Dentistry, University Medical Centre of the Johannes Gutenberg University Mainz, with pain on the left side of his mandibular jaw. The dis- tal side of the mandibular left rst premolar and the mesial side of the mandibular left sooond promolar nad a PD o >14 mm witn blooding on probing (BoP). Tootn mobility of the mandibular left rst premolar was grade II to III. The radiograph showed a deep intraosseous defect in the interdental space between the two teeth and apical losions on botn tootn (Fig 2a). An imago was also taken with a cone beam computed tomograpny (CBCT) dovioo (Morita) and revealed a circular three-walled bony defect (Fig 2b). The rst premolar had two canals, while the second had only one. The root canals were obturated with gutta-percha and Soalapox (SybronEndo). A radiograpn takon 6 montns lator snows improvomont o tno losions (Fig 2o). Surgory took plaoo 6 montns ator ondodontio troatmont. A muoo- periosteal ap procedure was performed, and the extent of the three-wall defect became visible (Fig 2d). cEMD (Emdogain, Straumann) was applied to the root surface. Fig 1 Case 1. (a) Preoperative radiograph of the right mandibular frst molar with an apical periododontal lesion of endodontic origin. (b) Radiograph after endodontic treatment with an extruded root canal flling material at the distal root. (c) Clinical situation showing a PD of > 12 mm. (d) Intraoperative photograph. After fap procedure the intrabony defect is visible. (e) Repositioned fap, secured with monoflament. (f) Postoperative radiograph, 10 months after surgery. (g) Postoperative radiograph. After 24 months, good periodontal health with bone regeneration is seen. (h) Clinical situation after surgery, showing a clear reduction in PD. a e b f c g d h VOLUME 44 NUMBEP 2 FEBPUAPY 2013 125 QUI NTESSENCE I NTERNATI ONAL Azari pour/ Wi l l ershausen et al Booauso o tno oxtont o tno dooot, a bovino-dorivod xonograt (BioOss, Straumann) was used, and the ap was ropositionod. A provisional partial donturo was used to stabilize the mandibular left rst premolar, and tooth mobility improved to grado . Tnoro was no BoP. Tno 2-yoar recall radiograph shows considerable inter- dental bone regeneration (Fig 2e). The mandibular left rst premolar was no longer mobilo, PD was roduood by 10 mm. A CBCT snowod tnat tno oiroular dooot nad nearly disappeared and that a new lingual wall had formed (Fig 2f). DISCUSSION The origin of a periodontal-endodontic lesion can be difcult to determine, and both types of defects usually require treat- ments. In combined periodontal-endodontic lesions and lesions of uncertain origin, therapy should always begin with endodon- tic treatment, since the inuence of the endodontium on the periodontium is greater than vice versa. In the cases presented, reattachment can be observed. Healing of the periodontal tissue takes place in an open system, into which various periodontopathogens can enter and interfere. The clinical outcome of an application of bone allografts/bone sub- stitute materials or enamel matrix proteins, alone or in combination, to support the heal- ing process has been discussed in the lit- erature. 4,5 In the present cases, cEMDs were used to support the regeneration of tno intraossoous dooots. Booauso o tno extent of the defect in case 2, a bovine- derived xenograft was used to support the regenerative process, as has been shown Fig 2 Case 2. (a) Preoperative radiograph of the mandibular left frst and second premolars. The deep intraosseous defect between the teeth is noticeable, as is the apical periodontitis. (b) CBCT image of the teeth at baseline, showing the circular bone defect. (c) Six-month recall radiograph after the endodontic treatment with a moderate improvement of the lesion. (d) Intraoperative image 6 months after the endodontic treat- ment. The clinical situation demonstrates the extent of the intraosseous defect. (e) Two-year recall radiograph after surgery, showing extensive bone regeneration. (f) The CBCT image confrms the observations of the radiograph, showing the three-dimensional gain in bone structure, including the buccal wall. a d b e c f 126 VOLUME 44 NUMBEP 2 FEBPUAPY 2013 QUI NTESSENCE I NTERNATI ONAL Azari pour/ Wi l l ershausen et al in the literature. 4 The clinical outcome of an application of bone allografts/bone substi- tute materials or enamel matrix proteins, alone or in combination, to support the heal- ing process has been discussed in the lit- erature. 68
CONCLUSION Botn oasos snowod good rogonoration witn stablo rosults ovor a poriod o up to 24 months. In case 1, cEMD was applied in spite of the large size of the intrabony defect, because the prepared ap could contribute to the stabilization. In case 2, the decision to use a xenogeneic bone substi- tute material in addition to the cEMD was based on the size of the defect. These two cases underscore that if a combined end- odontic-periodontal treatment protocol is carried out, even teeth with a severely apparent pathology can be saved. REFERENCES 1. Bashutski JD, Wang HL. Periodontal and endodontic regeneration. J Endod 2009;35:321328. 2. Meng HX. Periodontic-endodontic lesions. Ann Periodontol 1999;4:8490. 3. Kim E, Song JS, Jung IY, et al. Prospective clinical study evaluating endodontic microsurgery outcomes for cases with lesions of endodontic origin compared with cases with lesions of combined periodontal- endodontic origin. J Endod 2008;43:546551. 4. Trombelli L, Farina R. Clinical outcomes with bioac- tive agents alone or in combination with grafting or guided tissue regeneration. J Clin Periodontol 2008;35(suppl):117135. 5. Schwatz SA, Koch MA, Deas DE, Powell CA. Combined endodontic-periodontic treatment of a palatal groove: A case report. J Endod 2006;32:573578. 6. Tsesis I, Rosen E,Tamse A, Taschieri S, Del Fabbro M. Efect of guided tissue regeneration on the outcome of surgical endodontic treatment: A systematic review and meta-analysis. J Endod 2011;37:10391045. 7. Esposito M, Grusovin MG, Coulthard P, Worthington HV. Enamel matrix derivative (Emdogain) for periodontal tissue regeneration in intrabony defects. Cochrane Database Syst Rev 2005 Oct 19;(4):CD003875. 8. Oh SL, Fouad AF, Park SH. Treatment strategy for guided tissue regeneration in combined endodon- tic-periodontal lesions: Case report and review. J Endod 2009;35:13311336. Copyright of Quintessence International is the property of Quintessence Publishing Company Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.