Case Report/Clinical Techniques
Conventional and Surgical Retreatment of Complex
Periradicular Lesions With Periodontal Involvement
Bekir Karabucak, DMD, MS, and Frank C. Setzer, DDS, MS, PhD
Abstract
A periradicular pathosis with an associated periodontal
breakdown creates a complex problem during
endodontic therapy. In cases in which nonsurgical re-
treatment does not have a successful outcome, a surgical
retreatment has to be taken into consideration. With the
introduction of microsurgical techniques in endodontics,
surgical treatment success has improved considerably.
The surgical treatment of combined lesions, however,
is still considered to have a less favorable prognosis.
The presented cases illustrate successful treatments in
which a periodontal breakdown and an endodontic
breakdown were present. (J Endod 2009;35:1310–1315)
Key Words
Endodontic microsurgery, endo-perio lesion, root end
surgery
From the Department of Endodontics, School of Dental
Medicine, University of Pennsylvania, Philadelphia, Pennsylva-
nia.
Address requests for reprints to Frank C. Setzer, DDS, MS,
PhD, Lecturer, Department of Endodontics, School of Dental
Medicine, University of Pennsylvania, 240 S 40th St, Philadel-
phia, PA 19104 E-mail address: fsetzer@dental.upenn.edu.
0099-2399/$0 - see front matter
Copyright ª 2009 American Association of Endodontists.
doi:10.1016/j.joen.2009.05.007
1310 Karabucak and Setzer
T he necessity for periradicular surgery might occur in cases with an unsuccessful
outcome after primary root canal therapy or nonsurgical retreatment. The goal of
periradicular surgery is the removal of diseased periapical tissues and the sealing of
the apical root canal system to facilitate the regeneration of hard and soft tissues,
including the formation of a new attachment apparatus (1). After the introduction
of microsurgical techniques in endodontics, surgical treatment outcomes have
improved considerably. The modern surgical techniques apply the use of a dental
operating microscope, microsurgical instruments, and ultrasonic preparation of
the root-end cavity, as well as a biocompatible root-end filling material. Several
studies have reported significantly higher success rates of microsurgery in compar-
ison to traditional surgical techniques, ranging from 87%–97%, on the basis
of short-term (1 year) and long-term (7 years) follow-ups. These higher success
rates were credited to a superior inspection of the surgical site and to precise prep-
aration of root ends with microinstruments under high magnification and enhanced
illumination (1–7).
Besides microsurgical principles, the outcome of endodontic surgery depends on
the preexisting condition of the tooth (8). It is essential to evaluate surgical cases on the
basis of preoperative clinical and radiographic findings to obtain a predictably high
success rate. In 2002, Rubinstein and Kim (3) introduced a set of classifications
focusing on the presence of preoperative periradicular and periodontal disease, which
at that time was designed to identify the parameters for successful microscopic
endodontic surgery and to define case selection inclusion and exclusion criteria specific
to each category. In their review article, Kim and Kratchman (8) also recommended this
classification as a clinical guideline to assess treatment modalities and the prognosis of
surgical cases. The classifications are as follows.
Class A represents cases without the presence of a periapical lesion; the tooth has
no mobility and a normal pocket depth; however, the patient presents with unresolved
symptoms after all conventional endodontic approaches have been carried out. The
only reason for the surgical procedure is the presence of clinical symptoms. Class B
demonstrates a small periapical lesion accompanied by clinical symptoms. There are
normal periodontal probing and no mobility. Class C represents a large periapical
lesion that progresses coronally but does not show extended periodontal probing or
mobility. Class D is clinically similar to class C, differing only in the presence of deep
periodontal pockets. Class E shows a deep periapical lesion with endodontic-
periodontal communication toward the apex but no apparent fracture. Class F consists
of teeth with a periapical lesion and a complete denudement of the buccal bone but no
mobility. Higher success rates were achieved with cases in classes A, B, or C, whereas
surgical procedures carried out in teeth classified as D through F resulted in higher
failure rates, although carried out with identical microsurgical armamentarium and
skills (2, 3).
Teeth in classes D, E, and F present with a loss of supporting bone with a partial or
complete root exposure. Treatment of these cases requires not only endodontic micro-
surgery but also bone and new attachment regenerative techniques. Skoglund and Pers-
son (9) reported that the success of the surgical procedure dropped to 37% with
a traditional apical surgical approach when the buccal cortical plate was destroyed
by the pathologic process. Therefore, they suggested extraction in these cases. On
the other hand, in a recent prospective clinical trial, a higher success rate of 77.5%
was shown for teeth in classes D, E, or F, with a statistically significant difference
compared with classes A, B, or C (95.2%) (10).
JOE — Volume 35, Number 9, September 2009

We recognize an increasing number of patients who either oppose
the idea of extraction and subsequent placement of a dental implant or
simply want to retain their teeth for a maximum amount of time despite
a guarded prognosis. This article presents 2 clinical cases in which the
individual decision was made to keep the natural tooth in lieu of extrac-
tion and potential implant placement.
Case 1
A 23-year-old dental student presented to the Endodontic Depart-
ment at the University of Pennsylvania School of Dental Medicine with
periapical pathology associated with tooth #30. The tooth had previ-
ously undergone root canal therapy. The patient was asymptomatic,
and the periapical pathology was discovered after a routine full-mouth
x-ray series. Besides a history of heart murmur, which required no anti-
biotic prophylaxis, the patient’s medical history was noncontributory.
There were no known drug allergies.
Clinically, tooth #30 was restored with a stainless steel crown with
ill-fitting margins and exhibited a buccal probing of 7 mm into the
furcation area. The buccal gingiva next to the crown margins showed
slight swelling and clear signs of inflammation. The tooth did not
respond to percussion and palpation tests. There was no mobility.
The adjacent teeth #29 and #31 were clinically and radiographically
within normal limits. Periapical radiolucencies were present around
the mesial and distal roots and in the furcation area (Fig. 1A). The
mesial and distal apices showed signs of resorption. Radiographs taken
from different angles showed a second periodontal ligament around the
mesial root, indicating a possible untreated second mesial canal. The
restorative material in the pulp chamber was close to the furcation
area, indicating the possibility of an existing perforation. Overextended
crown margins were visible. The patient did not recall how many years
ago the root canal treatment and the crown had been carried out.
Considering the dental history, clinical tests, and radiographs, the diag-
Case Report/Clinical Techniques
nosis of a previous root canal treatment with asymptomatic periapical
lesion was made.
The treatment alternatives included nonsurgical or surgical re-
treatment, extraction, or no therapy, which were offered to the patient.
The need for a new crown to improve the prognosis was emphasized.
The complexity and prognosis of endodontic periodontal involvement
were explained to the patient. The patient was also informed that
a surgical retreatment might be necessary if the symptoms persisted
after a nonsurgical retreatment. The patient consented to have a nonsur-
gical retreatment and crown restoration.
On removal of the stainless steel crown, it was discovered that the
entire access cavity was filled with gutta-percha. Close inspection under
high magnification with the dental operating microscope did not show
any signs of perforation or cracks on the pulpal floor, but a missed me-
siolingual canal was seen. The gutta-percha filling was removed from
the distal and the mesiobuccal canals. Biomechanical instrumentation
to ISO sizes 70 (distal), 55 (mesiobuccal), and 50 (mesiolingual) with
Profile Series 29 (Dentsply Tulsa Dental Specialties, Tulsa, OK) and
LightSpeed (Discus Dental, Culver City, CA) rotary instruments was
completed, with copious irrigation with 3% sodium hypochloride.
Ultrasonically activated 3% sodium hypochloride, 2% chlorhexidine,
and 17% ethylenediaminetetraacetic acid solution were used. Calcium
hydroxide in aqueous suspension was placed inside the root canal
system as a medication, and the tooth was temporized. One week after
the first visit the patient presented without symptoms. The buccal gingiva
appeared clinically healthy; however, probing depth in the furcation
area was still present. After removal of the calcium hydroxide and an
identical irrigation protocol as mentioned above, the root canal system
was obturated with gutta-percha and Grossman’s sealer (Roth Interna-
tional, Chicago, IL) by using a warm vertical compaction technique. The
tooth was temporized with a thin cotton layer on the pulp floor and
a glass ionomer cement (Ketac Silver; 3 M ESPE, St Paul, MN)
(Fig. 1B, C). Because 4 walls remained intact after treatment but the

Figure 1. Case 1. (A) Preoperative diagnostic radiograph. Concomitant lesions of periodontal and endodontic origin. (B, C) Postoperative radiographs after
nonsurgical retreatment; orthograde and distally angulated views. Note the obturated second mesial canal that had been missed during the initial root canal treat-
ment. (D) Six-month recall after nonsurgical retreatment demonstrating a true combined Class E periodontal-endodontic defect before periradicular microsurgery.
New coronal restoration in place. (E) Postoperative radiographs after surgical retreatment. (F) Recall 28 months after microsurgery.

JOE — Volume 35, Number 9, September 2009 Retreatment of Complex Periradicular Lesions with Periodontal Involvement 1311
Case Report/Clinical Techniques
pulpal floor was extremely thin, an adhesive build-up was recommen-
ded in lieu of a post placement combined with a conventional restorative
material. Because of the furcation involvement, the prognosis was
judged as fair, and the patient was informed that follow-up appoint-
ments were needed. The patient remained asymptomatic and received
a crown restoration and dental cleaning shortly after the endodontic
therapy.
At the 3-month recall the patient was still asymptomatic, yet radio-
graphically, healing of the periradicular bone was inadequate. The
buccal gingiva was clinically healthy. Probing depths remained the
same. The patient was informed about the progress and expressed
interest in following up without any further treatment at that time.
Three months after the first recall the patient presented with a buccal
swelling in the furcation area and sensitivity to palpation, tenderness to
percussion, and some exudate through the buccal sulcus. The probing
had increased to 10 mm in direction of the distal root tip (Fig. 1D).
The mobility was within normal limits. The guarded prognosis and the
possibility of a vertical root fracture were discussed with the patient.
Endodontic surgical retreatment and extraction of the tooth were pre-
sented as treatment options. The patient chose to try to retain the tooth
and to attempt a microsurgical approach. He was aware that the presence
of a vertical root fracture would result in extraction.
Figure 2. Case 1. (A) Class E defect. (B) Distal root-end filling with white MTA. (C) Mesial root-end filling with white MTA. (D) Bone grafting with osteoconductive
material. (E) Bilayer collagen membrane covering the bony defects and the grafting material. (F) Soft tissue at 28-month recall.
1312 Karabucak and Setzer
The microsurgical technique and the guidelines recommended by
Kim and Kratchman (8) were followed during this surgical procedure.
After local anesthesia with 2% lidocaine with 1:100,000 epinephrine for
the mandibular block and 2% lidocaine with 1:50,000 epinephrine for
buccal infiltration, a mucoperiosteal flap was raised. The cortical bone
was fenestrated, with an isolated periradicular lesion on the mesial root,
and a class E–type lesion was present toward the distal root (Fig. 2A).
With the aid of a surgical operating microscopic, access to the mesial
and distal root tips was obtained, and the granulation tissue was excised.
After resecting the resorptive root ends, the resected root surfaces were
inspected under high magnification. Methylene blue dye was applied to
the resected root surfaces to identify the periodontal ligaments, root
outlines, and canals. There was no apparent root fracture. The root-
end cavities were prepared with KiS microsurgical ultrasonic instru-
ments (Obtura Spartan, Fenton, MO) and subsequently filled with
mineral trioxide aggregate (MTA) (ProRoot; Dentsply, York, PA)
(Fig.2 B, C). Before repositioning of the flap, the bony defects were
grafted with an osteoconductive bone substitute (Bio Oss; Osteohealth,
Shirley, NY) (Fig. 2D) and covered with a bilayer collagen membrane
(Bio Gide; Osteohealth) (Fig. 2E) to prevent soft tissue ingrowth and
reinfection of the surgical site (Fig. 1E). The patient received postoper-
ative instructions. It is the authors’ clinical experience that patients who
JOE — Volume 35, Number 9, September 2009

receive grafting material present with postoperative complications more
frequently. Amoxicillin 500 mg antibiotic coverage, 4 times a day for 7
days, and ibuprofen 600 mg for pain, 4 times a day if needed, were
prescribed. One-year and 2-year recalls after microsurgery revealed
that the patient was without symptoms, periodontal probings were
within normal limits, and radiographic examinations showed complete
periradicular bone healing (Fig. 1F, 2F).
Case 2
A 26-year-old patient presented to the University of Pennsylvania
School of Dental Medicine for emergency care and was referred to
the endodontic department to evaluate tooth #30. On review of the
medical history the patient reported mild asthma and no known drug
allergies. The dental history indicated that tooth #30 had a previous
root canal treatment and crown restoration.
Clinical examination revealed that tooth #30 had inflamed buccal
mucosa and a buccal sinus track. The tooth was restored with a well-
fitting crown. Periodontal examination showed probing depths within
normal limits except for an 8-mm pocket through the buccal furcation
alongside the distal aspect of the mesial root. The tooth was slightly
sensitive to palpation and percussion tests. There was no mobility.
Radiographic examination revealed a periradicular, j-shaped radiolu-
cency around the mesial root (Fig. 3A). A radiograph taken with
a gutta-percha cone placed into the sinus tract pointed to the source
of infection around the mesial root end (Fig. 3B). The root fillings of
all 4 canals appeared adequate. The adjacent teeth #29 and #31 were
clinically and radiographically within normal limits.
On the basis of the dental history, clinical tests, and radiographs,
a diagnosis of previous root canal treatment with asymptomatic perira-
Figure 3. Case 2. (A, B) Preoperative diagnostic radiographs. Class E defect. Defect tracing with gutta-percha cone in distally angulated view. (C, D) Postoperative
radiographs after periradicular microsurgery; orthograde and distally angulated views. Note the obturated second mesial canal that had been missed during the
initial root canal treatment. (E, F) Recall 1 year after microsurgery.
JOE — Volume 35, Number 9, September 2009
Case Report/Clinical Techniques
dicular pathology was made. The treatment alternatives of nonsurgical
or surgical endodontic retreatment, extraction, or no therapy were
offered to the patient. The patient’s choice was to retain the tooth
with the existing crown and to try a surgical attempt, even if the likeli-
hood of success was decreased as a result of the endodontic and peri-
odontal involvement. Because of the radiographic appearance of the
periapical lesion the patient was also informed about the high possibility
of a vertical root fracture, which would result in the need for extraction.
The same microsurgical techniques and guidelines as described
above were followed for this surgical procedure. After local anesthesia
a mucoperiosteal flap was raised. The buccal cortical bone was intact;
however, a furcation defect with granulation tissue was apparent. With
the aid of a surgical operating microscopic, access to the mesial root
tip was gained. The granulation tissue was curetted around the mesial
root, exposing the full extent of the periapical bone destruction. Methy-
lene blue dye was applied to enhance the details on the root surfaces.
Close inspection of the resected root surface under high magnification
showed the presence of an isthmus connecting the mesiobuccal and
mesiolingual canals (Fig. 4A). There was no apparent root fracture. By
using diamond-coated KiS surgical ultrasonic tips (Obtura Spartan),
the root-end cavity was prepared and filled with white MTA (ProRoot)
(Fig. 4B). An osteoconductive bone grafting material (Bio Oss) was
packed into the defect (Fig. 4C). A resorbable bilayer collagen
membrane (Bio Gide) was placed over the defect and the osteotomy
to facilitate better bone healing (Fig. 4D). The flap was repositioned
and sutured with 5-0 nylon nonresorbable interrupted sutures (Assut
Medical Inc, Pully-Lausanne, Switzerland). Postoperative radiographs
were taken (Fig. 3C, D). The patient was given postoperative instructions
and provided with prescriptions for amoxicillin 500 mg, 4 times a day for
7 days, and ibuprofen 600 mg for pain, 4 times a day if required.
Retreatment of Complex Periradicular Lesions with Periodontal Involvement 1313
Case Report/Clinical Techniques
The patient returned in 4 days for suture removal. Two weeks after
the surgical procedure no trace of the previous sinus tract was evident.
At a 1-year recall, the patient was asymptomatic. The clinical and radio-
graphic appearances were normal (Fig. 3E, F). A periodontal examina-
tion revealed no probing depths exceeding normal limits, including the
buccal furcation area. The tooth exhibited no mobility.
Discussion
The presented cases illustrate successful treatments in which peri-
odontal and endodontic breakdowns are present (Class E). A periradic-
ular pathosis with a periododontal breakdown creates a complex
problem during an endodontic treatment. If the source of irritation
can be identified and removed by a nonsurgical endodontic treatment,
lesions of purely endodontic origin have an excellent prognosis (11). If
the nonsurgical treatment fails, then future treatment must include
a combination of surgical endodontics and periodontal intervention.
The successful application of guided tissue regeneration in endodontic
microsurgery has been described in numerous case reports; however,
the surgical treatment of combined lesions is considered to have a less
favorable prognosis (12, 13). The routine incorporation of endosseous
implants into dental practice and its reported high success rates have
led many practitioners to favor tooth extraction in such cases to
preserve the bone structure with subsequent implant placement instead
of retaining the natural dentition.
In both cases the possible treatment options presented to the
patient included retreatment with retention of the tooth followed by
conservative restoration or extraction followed by implant restoration
of the area. Both patients were aware that the endodontic-periodontal
communication resulted in a less favorable treatment outcome. In addi-
tion to the existence of comparable lesions, the common factor in both
Figure 4. Case 2. (A) Class E defect after root-end resection and excavation of granulation tissue. Note the gutta-percha fillings in the mesiobuccal and mesio-
lingual canals. (B) Root-end filling with white MTA. Note the preparation and filling of the isthmus connecting the mesiobuccal and mesiolingual canals. (C) Bone
grafting with osteoconductive material in the furcation and the periapical area. (D) Bilayer collagen membrane covering the bony defects and the grafting material
before flap closure.
1314 Karabucak and Setzer
cases was the patients’ wish to retain the natural tooth, albeit for
different reasons. Whereas a dentist’s treatment plan is considered to
be the method of choice, the patient’s role in the decision-making
has grown substantially. Besides providing high quality treatment,
a practitioner’s responsibility is to present the patient with alternative
treatment options with their expected outcomes and to let the patient
be involved in the decision-making process.
In a recent article, the criteria for the ideal treatment of failed
endodontics, eg, nonsurgical or surgical retreatment or extraction,
were discussed, and it was pointed out that the key factor in deci-
sion-making should be whether the procedure can eliminate the
etiology and improve the prognosis. Therefore, it was recommended
that the treatment plan should be based on the individual case, with
an effort to preserve natural tooth structure (14).
In case 1, there were many possible etiologies. Preoperative radio-
graphs revealed a second periodontal ligament around the mesial root,
indicating a possible untreated second mesial canal. Residual necrotic
and infected pulp tissue within the untreated mesial canal was the
primary reason for the periradicular infection; however, leaky crown
margins also contributed to the persistent infection. Furthermore, viola-
tion of periodontal tissues around the ill-fitting crown margins and pla-
que accumulation were possible factors in the periodontal breakdown.
There was the possibility of an iatrogenic pulpal floor perforation as
well. It was necessary to improve the quality of both the root canal treat-
ment and the crown restoration. Therefore, a nonsurgical endodontic
retreatment was necessary to identify and eliminate the contributing
factors. In case 2, radiographic and clinical examinations revealed that
tooth #30 had an adequate root canal filling and a well-fitted crown resto-
ration. The etiology was not apparent, but a root fracture or an isthmus
was considered as possible elements. The quality of the previous root
JOE — Volume 35, Number 9, September 2009

canal treatment and the request for preserving the restoration were crit-
ical in decision-making; thus, a surgical approach was preferred.
After unsuccessful healing and exacerbation of the lesion in case 1,
the second step of a surgical approach was initiated. After the removal of
the denuded bone and the granulation tissue, it was observed that the
root ends had been resorbed as a result of an apical abscess. An irregular
and resorbed apical foramen causes a challenge for clinicians to conven-
tionally remove the infected necrotic tissue efficiently and disinfect the
root canal system without pushing the debris out into the periapical
tissues, as well as to contain irrigation solutions and filling materials
within the root structure. After biomechanical cleaning, bacteria might
persist not only within the root canal system but also at the apical
foramen, in the apical periradicular region, or within the periapical
lesion (15). In a situation in which a lesion reappears after partial heal-
ing, bacteria that had been dormant or reduced in numbers reestablish
themselves and grow again within the root canal system. The bacteria
disintegration products have not been eliminated fully, or the canal
system is contaminated by a new coronal ingress of microorganisms
(16). Under high magnification the granulation tissue was carefully
removed. The infected root ends were resected and properly sealed.
The endodontic surgery in case 2 revealed that the underlining
cause of failure was an isthmus connecting mesiobuccal and mesiolin-
gual canals. In a clinical study it was shown that biomechanical instru-
mentation, even to larger apical sizes ISO 57.5–60, rendered 88.9% of
the cases bacteria-free in mandibular molar mesial roots (17). Surgical
in vivo studies on failed mandibular first molar demonstrated the inci-
dence of 83%–90% of untreated isthmus in the mesial roots (1, 2).
Tissue within an isthmus connecting 2 canals in the apical portion of
molar roots appears to be the ‘‘Achilles’ heel’’ of nonsurgical root canal
treatment (18). With the aid of a surgical microscope, ultrasonic tips,
and microinstruments, the root ends and the isthmus were cleaned
and sealed properly. These findings emphasize the importance of
endodontic microsurgery to achieve a successful outcome.
In both cases, bone grafting material with a collagen membrane
was placed in the bony defect to promote healthy radicular bone forma-
tion and gingival attachment to the root surface. The use of barrier
membranes is not common after routine endodontic microsurgery
(Class A, B, C); however, marginal bone loss or the loss of the buccal
plate of bone can create avenues for microbial contamination of the
apex. In an animal study, Britain et al (19) reported that the treatment
of combined induced periodontal-endodontic lesions by using bioab-
sorbable collagen membranes alone or in combination with an anor-
ganic bovine bone matrix resulted in increased amounts of bone and
periodontal ligament and significant increases in the amount of new
cementum formation when compared with open flap debridement.
The 2 cases presented here demonstrate that by using a barrier tech-
nique, the healing of periradicular surgery in combined lesions might
be improved, compared with treatment without a barrier, by inducing
regenerative cells in the area and protecting the wound from epithelial
and connective tissue cell repopulation on the root surface.
JOE — Volume 35, Number 9, September 2009
Case Report/Clinical Techniques
In conclusion, with the advancements in dentistry, new tech-
niques and new materials provide dentists with different treatment
choices, providing a superior prognosis. The emphasis should
always be on preserving the natural tooth structure. The clinician
should have a complete knowledge of advantages and disadvantages
of these new treatment modalities and, although respecting their
patient’s desires, must base their decision for treatment on scientific
evidence.
References
1. von Arx T, Gerber C, Hardt N. Periradicular surgery of molars: a prospective clinical
study with a one-year follow-up. Int Endod J 2001;34:520–5.
2. Rubinstein RA, Kim S. Short-term observation of the results of endodontic surgery
with the use of a surgical operation microscope and super-EBA as root-end filling
material. J Endod 1999;25:43–8.
3. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed one year
after apical microsurgery. J Endod 2002;28:378–83.
4. Maddalone M, Gagliani M. Periapical endodontic surgery: a 3-year follow-up study.
Int Endod J 2003;36:193–8.
5. Gagliani MM, Gorni FG, Strohmenger L. Periapical resurgery versus periapical
surgery: a 5-year longitudinal comparison. Int Endod J 2005;38:320–7.
6. Zuolo ML, Ferreira MO, Gutmann JL. Prognosis in periradicular surgery: a clinical
prospective study. Int Endod J 2000;33:91–8.
7. Chong BS, PittFord TR, Hudson MB. A prospective clinical study of Mineral Trioxide
Aggregate and IRM when used as root-end filling materials in endodontic surgery.
Int Endod J 2003;36:520–6.
8. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review.
J Endod 2006;32:601–23.
9. Skoglund A, Persson G. A follow-up study of apicoectomized teeth with total loss of
the buccal bone plate. Oral Surg Oral Med Oral Pathol 1985;59:78–81.
10. Kim E, Song JS, Jung IY, Lee SJ, Kim S. 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;34:546–51.
11. Bergenholtz G, Hasselgren G. Endodontics and periodontics. In: Lindhe J, ed. Clin-
ical periodontology and implant dentistry. 3rd ed. Copenhagen, Denmark: Munks-
gaard; 1997:296–331.
12. Abramowitz PN, Rankow H, Trope M. Multidisciplinary approach to apical surgery
in conjunction with the loss of buccal cortical plate. Oral Surg Oral Med Oral Pathol
1994;77:502–6.
13. Jansson L, Sandstedt P, Låftman AC, Skoglund A. Relationship between apical and
marginal healing in periradicular surgery. Oral Surg Oral Med Oral Pathol Oral Ra-
diol Endod 1997;83:596–601.
14. Karabucak B, Setzer F. Criteria for the ideal treatment option for failed endodontics:
surgical or nonsurgical? Compend Contin Educ Dent 2007;28:391–7.
15. Nair PN, Sjögren U, Figdor D, Sundqvist G. Persistent periapical radiolucencies of
root-filled human teeth, failed endodontic treatments, and periapical scars. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:617–27.
16. Ricucci D, Langeland K. Apical limit of root canal instrumentation and obturation:
part 2—a histological study. Int Endod J 1998;31:394–409.
17. Card SJ, Sigurdsson A, Orstavik D, Trope M. The effectiveness of increased apical
enlargement in reducing intracanal bacteria. J Endod 2002;28:779–83.
18. Hsu YY, Kim S. The resected root surface: the issue of canal isthmuses. Dent Clin
North Am 1997;41:529–40.
19. Britain SK, Arx T, Schenk RK, Buser D, Nummikoski P, Cochran DL. The use of
guided tissue regeneration principles in endodontic surgery for induced chronic
periodontic-endodontic lesions: a clinical, radiographic, and histologic evaluation.
J Periodontol 2005;76:450–60.
Retreatment of Complex Periradicular Lesions with Periodontal Involvement 1315