A new approach to the treatment of true-combined endodontic-periodontic lesions by the guided tissue regeneration technique

Multidisciplinary management of concomitant pulpal and periodontal lesion: A case report

In this case report, the management of a concomitant endodontic-periodontal lesion case is described. A 31-year-old patient presented with symptomatic apical periodontitis of tooth #36 due to failed endodontic treatment and a generalized aggressive periodontitis. Following full-mouth scaling and root-planing, a root-canal retreatment (tooth #36) was initiated. While the distal and mesio-buccal canals were successfully treated, a transportation perforation of the mesio-lingual canal occurred and was repaired by the MTA. An apical microsurgery of the mesial root combined with surgical periodontal debridement for the lower left quadrant was performed. Three weeks later, resective and regenerative periodontal surgeries of the other 3 quadrants were accomplished. Because of the 6-month post-operative healing, the regenerative periodontal surgery for the lower-left quadrant was performed. The 6-month post-operative recall showed complete healing of the mesial root lesion and reduction of the distal root lesion. The multidisciplinary approach and advanced armamentarium contributed to favourable outcome.

Platelet-rich fibrin, "a faster healing aid" in the treatment of combined lesions: A report of two cases

Anatomically the pulp and periodontium are connected through apical foramen, and the lateral, accessory, and furcal canals. Diseases of one tissue may affect the other. In the present case report with two cases, a primary periodontal lesion with secondary endodontic involvement is described. In both cases, root canal treatment was done followed by periodontal therapy with the use of platelet-rich fibrin (PRF) as the regenerative material of choice. PRF has been a breakthrough in the stimulation and acceleration of tissue healing. It is used to achieve faster healing of the intrabony defects. Absence of an intraradicular lesion, pain, and swelling, along with tooth stability and adequate radiographic bone fill at 9 months of follow-up indicated a successful outcome.

Endodontic treatment enhances the regenerative potential of teeth with advanced periodontal disease with secondary endodontic involvement

Purpose

The aim of this study was to identify a role for endodontic intervention in enhancing the regenerative potential of the periodontal ligament when combined with periodontal treatment in seriously involved teeth with a secondary endodontic component.

Methods

Patients who exhibited radiolucency extending to the periapical region, abnormal electric pulp testing values, and deep probing depth derived from primary periodontal disease with secondary endodontic involvement were included. Intentional root canal treatment was applied to those teeth in which the apical lesions were presumed to communicate with those of the periodontal lesion of the teeth that remained vital. In all three selected cases, regenerative periodontal therapy incorporating either bone graft or guided tissue regeneration was instituted 3 months after the endodontic intervention.

Results

Remarkable enhancement in radiographic density was noticeable around the affected teeth as evidenced by changes in radiopacity. There was a significant reduction in the probing pocket depth and gain in the clinical attachment level. Chewing discomfort gradually disappeared from the commencement of the combined treatment.

Conclusions

An intentional endodontic intervention may be a worthwhile approach for the sophisticated management of teeth suffering from serious attachment loss and alveolar bone destruction with concomitant secondary endodontic involvement.

Pulpal perio relations: Interdisciplinary diagnostic approach - I

Lesions of pulpal and periodontal origin may perpetuate from either the infections of dental pulp or periodontium or alveolar bone. This review focuses on interdisciplinary diagnostic approach towards lesions of periodontal or endodontic origin.

A pilot study of treatment of periodontal-endodontic lesions

OBJECTIVE

A pilot study to evaluate a standardised treatment protocol for combined periodontal-endodontic lesions (involving staged endodontic and periodontal treatment).

PARTICIPANTS

Nine patients with a diagnosis of a combined periodontal-endodontic lesion.

METHODS

At baseline, root canal treatment (RCT) was performed by a standard protocol, and simple scaling/oral hygiene instruction provided. After one month, a standardised episode of non-surgical periodontal treatment was undertaken to address residual pocketing. Clinical measurements, including probing depths, attachment levels and bleeding on probing were recorded at baseline, month one and month three. Long-cone periapical radiographs taken using standardised projection geometry at baseline and month three were analysed for bone changes using digital subtraction radiography (DSR).

RESULTS

During the study, one patient's affected tooth was extracted. From baseline to month three, there were statistically significant mean probing depth reductions (delta= 0.95mm, 95% CI= 0.20mm, 1.70mm; p= 0.02), mean attachment gains (delta= 1.13mm, 95% CI= 0.29mm, 1.96mm; p= 0.02) and reduction in mean bleeding on probing (delta= 29%, 95% CI= 10%, 49%; p= 0.01). DSR analysis revealed that between month 0 and month three, four teeth demonstrated bone gain, two teeth exhibited bone loss and two teeth showed no change. The mean bone change was in favour of bone gain but failed to achieve statistical significance (p>0.05).

CONCLUSIONS

Within the limitations of this pilot study, treatment of periodontal-endodontic lesions by performing RCT prior to periodontal treatment was effective, resulting in improvements in clinical parameters together with alveolar bone gains in a majority of teeth.

The Use of Guided Tissue Regeneration Principles in Endodontic Surgery for Induced Chronic Periodontic-Endodontic Lesions: A Clinical, Radiographic, and Histologic Evaluation

BACKGROUND

Chronic periodontic-endodontic lesions are not uncommon in clinical practice and their regenerative capacity has long been questioned. However, there are no published studies investigating the application of guided tissue regeneration techniques in combination with endodontic surgery using an induced perio-endo defect model. This study evaluated the clinical, radiographic, and histologic outcomes of three surgical procedures used to treat induced perio-endo lesions.

METHODS

Pulpal necrosis was induced in foxhounds along with surgical removal of radicular buccal bone. After 4 weeks, chronic lesions were clinically and radiographically assessed. Treatment surgery consisted of apicoectomy, root canal instrumentation, and retrofilling with mineral trioxide aggregate. Teeth were then assigned to one of the following treatment groups: open flap debridement only (OFD), OFD with bioabsorbable porcine-derived collagen membrane (BG), or OFD with BG and anorganic bovine bone matrix (BO/BG). Clinical parameters and standardized radiographs were assessed at defect creation; treatment surgery; and at 1, 2, 4, and 6 months. Animals were sacrificed at 6 months and specimens prepared for histometric analysis.

RESULTS

Clinical and radiographic conditions improved during the study period. Mean epithelial attachment was similar between all groups. Mean connective tissue attachment for groups OFD, BG, and BO/BG was 3.79 mm, 2.63 mm, and 1.75 mm, respectively, and mean radicular bone height was 2.16 mm, 3.24 mm, and 3.45 mm, respectively. Statistically significant increases in the amount of new cementum were observed in groups BG and BO/BG when compared with OFD (P <0.05).

CONCLUSIONS

Treatment of combined induced perio-endo lesions using bioabsorbable collagen membranes alone or in combination with anorganic bovine bone matrix resulted in increased amounts of bone, periodontal ligament, and significant increases in the amount of new cementum when compared to open flap debridement in a canine model.

Periapical and periodontal healing after osseous grafting and guided tissue regeneration treatment of apicomarginal defects in periradicular surgery: results after 12 months

OBJECTIVE

The aim of the present study was to evaluate the periapical and periodontal healing of apicomarginal defects 12 months after periradicular surgery and guided tissue regeneration in a series of consecutively treated patients.

STUDY DESIGN

Patients with apicomarginal defects who were referred for periradicular surgery were included. Apicomarginal defects were grafted with Bio-Oss bone mineral and covered with a Bio-Gide membrane. Periodontal probing depths (PPDs) and relative attachment levels were measured preoperatively and 12 months postoperatively with a manual force-controlled probe. Periapical healing was assessed clinically and radiographically.

RESULTS

Of the 23 defects in 22 patients for whom follow-up data were available, 19 were considered clinically and radiographically successful, 2 were doubtful, and 2 were failures. Overall, the baseline median PPD decreased from 9.0 mm to 3.0 mm, corresponding to a median relative attachment level gain of 2.8 mm. In the case of periodontic-endodontic lesions, the median baseline PPD decreased from 9.8 mm to 4.0 mm, corresponding to a median relative attachment level gain of 4.2 mm. Defects that involved a proximal root surface had a significantly higher residual PPD than did defects not involving a proximal root surface.

CONCLUSIONS

Guided tissue regeneration treatment of apicomarginal defects yields good results in terms of periapical and periodontal healing after 12 months and should be considered as an adjunct to periradicular surgery in such cases.

Treatment of combined endodontic-periodontic lesions by intentional replantation and application of hydroxyapatites

A case of combined endodontic-periodontic lesions on a mandibular first molar was treated by intentional replantation and application of hydroxyapatites. Four months after the surgery, a porcelain-mental full crown restoration was completed. The 15-month follow-up examination showed that the tooth was clinically and radiographically healthy and functioned well.

Apicomarginal defects in periradicular surgery: classification and diagnostic aspects

The prognosis of periradicular surgery is affected by the amount and location of bone loss. Apicomarginal defects are localized bony defects encompassing the total root length, and periradicular surgery on these teeth is associated with a lower success rate. This paper reviews the etiology, pathogenesis, and morphology of apicomarginal defects as encountered in periradicular surgery on the basis of a series of 24 consecutively treated patients. Periodontal data were recorded before surgery in all patients, and apicomarginal defects were diagnosed after flap reflection or, if applicable, apicoectomy. On the basis of the findings in these cases and on theoretic considerations, a classification system for apicomarginal defects with potential therapeutic and prognostic implications is presented and several criteria for differential diagnosis are discussed.

Periodontal healing after replantation of intentionally rotated teeth with healthy and denuded root surfaces

The purpose of the study was to evaluate periodontal healing after replantation of intentionally rotated teeth with healthy and denuded root surfaces. Ten teeth with hopeless prognoses because of extensive alveolar bone loss and deep pockets extending to the apexes only on one or two surfaces, but with a healthy periodontal apparatus on the other surfaces, were selected. A mucogingival flap was elevated and the teeth were extracted carefully so as not to damage the healthy remnant of the periodontal membrane remaining on the root surfaces. Thorough extra-oral debridement was performed on the contaminated root surface and the remnant was carefully conserved. Retrofilling was also done to eliminate an endodontic cause of attachment loss. The teeth were horizontally rotated and then replanted so that the healthy root would face the connective tissue at the initially periodontally involved sites, and the root planed surfaces, which had been periodontally involved, would face the surfaces of the alveolar sockets at initially healthy sites. The teeth were splinted with adjacent teeth. Clinical parameters and radiographic examination were performed pre-operatively, and at 3 or 6 months, 1, 2, and 3 years postoperatively. One tooth was extracted 1.5 years postoperatively due to reduced support and the treatment strategy of the patient. The other nine teeth were well maintained without any discomfort for the whole maintenance period of 3 years. In all teeth, areas that previously had no pocketing but were now against denuded root surfaces maintained the previous pocket depth readings. In areas where a deep pocket was present but now had a root surface with healthy periodontium, a distinct decrease of mean pocket depth was observed at the first reexamination 3 months postoperatively. The mean radiographic alveolar bone level increased from 0.3% to 45.3% in 2 years and was thereafter maintained for the entire observation period. Loss of periodontal space and possible root resorption were observed in only one case without other ankylotic symptoms. These results suggest that the healing without ankylosis of an extensive denuded root surface may occur by mechanisms other than the maintenance of a viable periodontal ligament on the root surface.

Treatment of a human transosseous mandibular defect by guided bone regeneration

The treatment of through-and-through human periapical lesions by barrier membrane techniques has not been reported in the periodontal literature. However, periodontists frequently perform this treatment. The authors present a case that demonstrates radiopacity after regeneration surgery of a human periapical transosseous mandibular defect, suggesting local bone regeneration. The surgical technique performed in this case was based on the principles of guided bone regeneration using a demineralized freeze-dried bone membrane (DFDBM). The bone membrane acted as an efficient barrier that excluded the nonosteogenic tissue. Radiographic findings demonstrated bone fill after 8 months.

The effect of guided tissue regeneration on the healing of osseous defects in rat calvaria

The effect of guided tissue regeneration procedures on the healing of osseous defects was studied in Sprague-Dawley rats. A full thickness flap was reflected and two 5 mm defects were made in the calvaria of 17 rats. A resorbable membrane was placed over one defect in each animal, while the remaining defect served as a control. After 3, 5, or 7 wk, healing of the osseous defects was evaluated histologically. There was no statistical difference in bone regeneration between experimental and control sites at any time period.