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QUI NTESSENCE I NTERNATI ONAL
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 first 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 íor tno man-
agement of endodontic-periodontal lesions,
because the clinical picture shows inflam-
mation of pulpal and periodontal tissues.
Different therapy concepts can be con-
sidered, depending on the severity of
inflammation 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.
Post–endodontic treatment periodontal surgery:
A case report
Adriano Azaripour, DSS
1
/Ines Willershausen, DDS
1
/Philipp Kämmerer,
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 aítor 24 montns, tno tootn woro
asymptomatic and marked bone regeneration had occurred in both patients. The suc-
cessful post–endodontic 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;44:123–126)
Key words: periodontal-endodontic lesion, root canal treatment, surgery
124 VOLUME 44 º NUMBEP 2 º 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 flap was repositioned
(Fig 1o). Padiograpns takon 10 and 24
months after surgery showed good perira-
dioular rogonoration (Figs 1í 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 first premolar
and the mesial side of the mandibular left
sooond promolar nad a PD oí >14 mm witn
blooding on probing (BoP). Tootn mobility
of the mandibular left first 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 first 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 oí
tno losions (Fig 2o). Surgory took plaoo 6
montns aítor ondodontio troatmont. A muoo-
periosteal flap 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
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QUI NTESSENCE I NTERNATI ONAL
Azari pour/ Wi l l ershausen et al
Booauso oí tno oxtont oí tno doíoot, a
bovino-dorivod xonograít (BioOss,
Straumann) was used, and the flap was
ropositionod. A provisional partial donturo
was used to stabilize the mandibular left
first premolar, and tooth mobility improved
to grado í. Tnoro was no BoP. Tno 2-yoar
recall radiograph shows considerable inter-
dental bone regeneration (Fig 2e). The
mandibular left first premolar was no longer
mobilo, PD was roduood by 10 mm. A
CBCT snowod tnat tno oiroular doíoot nad
nearly disappeared and that a new lingual
wall had formed (Fig 2f).
DISCUSSION
The origin of a periodontal-endodontic
lesion can be difficult 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 influence 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 doíoots. Booauso oí 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 º NUMBEP 2 º 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 oí up to 24
months. In case 1, cEMD was applied in
spite of the large size of the intrabony
defect, because the prepared flap 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.
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3. Kim E, Song JS, Jung IY, et al. Prospective clinical study
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