Dr Antonios Zampelis
The diagnostic and therapeutic challenge of endoperiodontal lesions.
The patient, a 71-year old woman in good general health, developed a deep buccal pocket at tooth 21 in 2013 (>10mm). The pocket was debrided without result. Soon after a pulp necrosis was diagnosed. The tooth was treated endodontically but the pocket persisted. The patient was eventually referred to a specialist.
Since the pocket had been treated non-surgically both before and after the endodontic treatment and the lesion had been in place for almost three years, a spontaneous healing after endodontic retreatment or apical surgery was highly unlikely. Regenerative treatment would also have a poor prognosis, with an active apical lesion.
It was decided to perform both apical surgery and regenerative surgery with Enamel Matrix Derivative (EMD) at the same time and by the same operator. The patient was informed about the poor prognosis of the tooth as well as the scant literature support for such a combined approach:
Von Arx & Cochran 2001, Milano & Melsen 1997 (Reviews on endodontic treatment and guided tissue regeneration with barrier membranes. The available literature consists of case reports, mostly combining orthograde endodontic treatment with GTR)
There is no literature on the use of EMD for treatment of apical-marginal lesions. The most relevant reference is of Cortellini et al 2011 (Treatment of hopeless teeth with pockets to the apex with EMD. Non vital teeth were endodontically treated prior to surgery).
The procedure: A buccal flap was elevated and all granulation tissue removed with hand instruments. The root was debrided with an ultrasonic handpiece. The apex was severed with a diamond burr and 2-3mm of gutapercha was removed with an endodontic ultrasonic tip. The apex was filled with Super-EBA cement. PrefGel (EDTA) was applied to the root surface for 2 minutes and the rinsed with saline. EMD was subsequently applied to the root surface and the flap was resutured with interrupted monofilament sutures (Prolene 6-0).
The postoperative protocol regarding oral hygiene was that of regenerative surgery with EMD (1) no oral hygienie, rinsing with CHX solution for two weeks, 2) tooth brushing with no interdental aids, local application of CHX gel for 4 weeks, 3) normal oral hygiene up to 6 months postop when a reevaluation was done).
At 6 months after surgery, no pockets could be probed around 21. A complete healing can be observed radiographically, both 6 and 12 months after surgery, with no radioluscency and an uninterrupted lamina dura.
(This case is part of a case series including 13 teeth with apical-marginal communication that were treated with an identical protocol and will be presented as a poster at Europerio 2018)
Tooth 21 during endodontic treatment, after the pocket buccaly was found and treated non-surgically.
At the time of referral to the specialist clinic.
At the day of surgery. The sizeable apical lesion is apparent.
Clinical view of 21. No visible signs of inflammation except for a lack of free gingiva buccally
Deep pocket buccally.
Advanced attachment loss which engages the entire circumference of the apical half of the root surface.
After removal of the granulation tissue and scaling with an ultrasonic tip.
After severing the apex with a diamond bur.
The gutapercha in the root canal can be seen.
The apical preparation is filled with Super-EBA cement.
Radiograph of 21 immediately postoperatively.
Three months after surgery, the radioluscency is still there but no visible signs of inflammation are noted intraorally.
Six months after surgery, no pcokets can be probed and the apical defect has resolved.
One year after surgery, tooth 21 has healthy periodontal conditions with no pockets or bleeding on probing. The radiographic defect is completely resolved and a normal lamina dura can be observed in the apical part of the root.
