VOLUME 44 t /6.#&32 t '$"3: 2013 123

QUINTESSENCE INTERNATIONAL

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 al3 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"ZFBSPMEXPNBOQSFTFOUFEUPIFSEFO-

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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

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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-

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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

1Associate Professor, Department of Operative Dentistry,

University Medical Centre of the Johannes Gutenberg

University Mainz, Mainz, Germany.

2Head, 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 first and second authors contributed equally to this work.

Postendodontic treatment periodontal surgery: A case reportAdriano Azaripour, DSS1/Ines Willershausen, DDS1/Philipp Kmmerer,

DDS1/Brita Willershausen DDS, PhD2

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 HVJEFECPOFSFHFOFSBUJPOUFDIOJRVFT"USFDBMMWJTJUTBGUFSNPOUITUIFUFFUIXFSFasymptomatic 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

VOLUME 44 t /6.#&32 t '$"3: 2013

QUINTESSENCE INTERNATIONA LAzaripour/Wil lershausen et al

presented a distal probing depth (PD) of

12 mm (Fig 1c) and bleeding.

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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

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months after surgery showed good perira-

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reduction of PD to 5 mm and of furcation

involvement to 1 mm was observed (Fig 1h).

Case 2" ZFBSPME NBO QSFTFOUFE UP UIF

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

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CMFFEJOH PO QSPCJOH #P1 5PPUINPCJMJUZ

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

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was also taken with a cone beam computed

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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

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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 first molar with an apical periododontal lesion of endodontic origin. (b) Radiograph after endodontic treatment with an extruded root canal filling material at the distal root. (c) Clinical situation showing a PD of > 12 mm. (d) Intraoperative photograph. After flap procedure the intrabony defect is visible. (e) Repositioned flap, secured with monofilament. (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 t /6.#&32 t '$"3: 2013 125

QUINTESSENCE INTERNATIONALAzaripour/Wil lershausen et al

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Straumann) was used, and the ap was

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was used to stabilize the mandibular left

rst premolar, and tooth mobility improved

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recall radiograph shows considerable inter-

dental bone regeneration (Fig 2e). The

mandibular left rst premolar was no longer

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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. In the present cases, cEMDs

were used to support the regeneration of

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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 first 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 confirms the observations of the radiograph, showing the three-dimensional gain in bone structure, including the buccal wall.

a

d

b

e

c

f

VOLUME 44 t /6.#&32 t '$"3: 2013

QUINTESSENCE INTERNATIONA LAzaripour/Wil lershausen et al

in the literature. 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.o

CONCLUSION

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TUBCMF SFTVMUT PWFS B QFSJPE PG VQ UP

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

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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-

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4. Trombelli L, Farina R. Clinical outcomes with bioac-

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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

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