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Table of Contents
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 53-56

Revitalizing pulpo perio complex

1 Department of Periodontology, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
2 Department of Periodontology, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India; Department of Periodontics, College of Dentistry, Imam Abdulrahman Faisal University, Dammam, KSA
3 Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India, India

Date of Submission05-Jan-2022
Date of Decision08-Mar-2022
Date of Acceptance18-Jun-2022
Date of Web Publication23-Aug-2022

Correspondence Address:
Dr. Subraya G Bhat
Department of Periodontology, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India; Department of Periodontics, College of Dentistry, Imam Abdulrahman Faisal University, Dammam, KSA

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jid.jid_1_22

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Endodontic–periodontal combined lesions pose a treatment challenge for clinicians, especially when the lesion is persistent and does not show signs of healing after nonsurgical endodontics. This case report describes interdisciplinary management of a nonhealing combined lesion related to a periapical cyst through an integrated approach of apicoectomy and regenerative periodontics. A 51-year-old male patient presented with a sinus tract for 4 months after endodontic retreatment of the maxillary right central and lateral incisor. Surgical enucleation of the cystic lesion together with regenerative periodontics using bone graft, advanced platelet-rich fibrin plus membrane, and guided tissue regeneration membrane to treat the tunnel bony defect was done. Clinical and radiographic examination at 6 months showed resolution of lesion, reduction in probing depths, and good bone fill of the defect.

Keywords: Apicoectomy, tunnel defect, advanced platelet-rich fibrin plus, bone graft, guided tissue regeneration, periradicular cysts

How to cite this article:
Yewale MD, Bhat SG, Mullick T. Revitalizing pulpo perio complex. J Interdiscip Dentistry 2022;12:53-6

How to cite this URL:
Yewale MD, Bhat SG, Mullick T. Revitalizing pulpo perio complex. J Interdiscip Dentistry [serial online] 2022 [cited 2023 Mar 22];12:53-6. Available from: https://www.jidonline.com/text.asp?2022/12/2/53/354447

   Clinical Relevance to Interdisciplinary Dentistry Top

  • The use of regenerative periodontics during endodontic surgery to manage large periapical lesions with tunnel bony defect is the optimum treatment strategy to accelerate bone healing.

   Introduction Top

Endodontic–periodontal continuum lesions present significant treatment challenges when nonsurgical endodontic treatment fails due to periapical cystic lesions.[1] Apicoectomy proves to be the last resort to revitalize teeth with combined lesions. The success of apicoectomy after 1–10 years is reported to be 59.1%–93%, with higher success rates attributed to advancements in materials and techniques.[2]

Regenerative periodontal therapy involving guided tissue regeneration (GTR) has proven to be noteworthy as it magnifies the overall success rate of treatment of large periapical defects, by providing access for root decontamination and placement of regenerative materials.[3] Platelet-rich fibrin (PRF) introduced by Dohan et al. has emerged as a promising regenerative grafting material due to its beneficial effects on wound healing and relative lack of complications.[4],[5]

This case report describes interdisciplinary management of an endodontic–periodontal lesion, treated via combined apicoectomy/GTR with advanced PRF (A PRF) plus on a maxillary central and lateral incisor.

   Case Report Top

A 51-year-old male patient with the chief complaint of pus discharge in the upper left front teeth in the past 3 weeks was referred to the Department of Periodontology in Manipal College of Dental Sciences, Manipal. Clinically, a sinus tract was present between #21 and #22 [Figure 1]a. Both 21, 22 had no response to electric pulp testing and cold testing. 5–7 mm probing depths were present interproximally. The intraoral periapical (IOPA) radiograph revealed well-defined periapical radiolucency. 21, 22 were diagnosed as necrotic pulp with acute apical abscess. Nonsurgical root canal treatment (NSRCT) by an endodontist was done. Despite repeated change of intra canal medicament dressing along with calcium hydroxide, the lesion persisted post 4 months of NSRCT. A cone-beam computed tomography (CBCT) scan was done which revealed extensive periapical radiolucency extending from distal aspect of 21 to mesial aspect of 23. It further revealed perforation in the buccal wall [Figure 1]b. Diagnosis of Type II Lesion – tunnel defect (Von Arx and Cochran 2001) – was made. Final diagnosis of endodontic–periodontal lesion without root damage in a nonperiodontitis patient, Grade 3 (classification 2017) was made. A collaborative surgery was conducted to treat the lesion through apicoectomy of 21, 22 with regenerative periodontics (alloplast + GTR + A PRF Plus membrane).
Figure 1: (a) Clinical view of sinus tract with relation to 21, 22, (b) preoperative cone-beam computed tomography with periapical radiolucency with relation to 21, 22 along with buccal plate perforation

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Case management

After obtaining written informed consent, the perioral soft tissues were painted with povidone iodine. The surgical area was anesthetized with 3.4 mL of 2% ligocaine with 2:100,000 epinephrine. A full-thickness mucoperiosteal flap with triangular flap design was elevated from 21 to 23 flap on the buccal aspect [Figure 2]a.
Figure 2: (a) Tunnel shaped bone defect seen post cyst enucleation. Biodentine™ placed at root apices and apical seal achieved, (b) bone graft mixed with saline placed in the bone defect. Placement of advanced platelet-rich fibrin membrane placement of Periocol CG™ guided tissue regeneration membrane

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On exposure, the periapical pathological tissue was curetted to enhance the visibility and accessibility of the surgical field [Figure 2]a. It was placed in 10% formalin for biopsy. Tunnel bony defect was seen postcyst enucleation [Figure 2]a. Thorough root planing was completed. Subsequently, the roots of 21, 22 were resected 3 mm from the root apices followed by formation of small retro cavity. After isolation of the surgical area, retrograde obturation was performed and Biodentine™ (Septodont, USA) was used as root-end sealing material [Figure 2]a. The site was filled with hydroxyapatite β tricalcium phosphate [Figure 2]b. The graft was covered by A PRF plus membrane (1300 rpm for 8 min) [Figure 2]b. Resorbable GTR membrane was placed on A PRF plus membrane [Figure 2]b. The flap was repositioned and sutured with 3–0 silk sutures using the interrupted suturing technique [Figure 3].
Figure 3: Suturing with 4-0 silk with interrupted method

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Postoperative care

Tablet amoxicillin 500 mg was prescribed three times a day for 7 days, ibuprofen 800 mg painkiller SOS, and 0.12% 10 ml chlorhexidine mouthwash was given twice daily for 14 days.

Clinical outcomes

The patient was seen at 2 weeks, 3 months [Figure 4], and 6 months [Figure 5]a and [Figure 5]b after treatment, with a postsurgical IOPA radiograph obtained at 6 months. The biopsy report confirmed definitive diagnosis of periapical granuloma. At 3 months, the site healed uneventfully with slight recession and the absence of a sinus tract [Figure 4]. At 6 months, the patient was asymptomatic and IOPA radiograph showed excellent bone fill, integration of graft, and resolution of periapical lesion compared to baseline CBCT [Figure 1]b and [Figure 5]b.
Figure 4: Three-month postoperative radiograph demonstrating resolution of periapical lesion

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Figure 5: (a) Six-month postoperative clinical picture showing healthy periodontium with probing depths ranging between 3 and 4 mm, (b) 6-month postoperative radiograph showing substantial bone fill with graft integration noted at site. Resolution of periapical lesion

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   Discussion Top

The optimum purpose of a successful apical surgery should be achieved by root-end resection, bacteria-tight closure of the root canal system at the cut root end, and debridement of pathology. In this case, a meticulous combined treatment plan with apicoectomy of 21, 22 combined with regenerative periodontics (alloplast + GTR + A PRF plus) was used to treat this challenging lesion.

Biodentine is a calcium silicate-based material that was advocated for root apexification. It has bioactive properties such as formation of hydroxyapatite crystals which encourage successful marginal integrity.[6] After flap reflection, we observed a tunnel lesion, characterized by an eroded buccal and palatal bone plate. In our testing tunnel defect, GTR was a ray of light as it accelerated periradicular healing and gave access to root decontamination and placement of regenerative materials.[5] We decided to use a composite bone graft with combination of 70% nanocrystalline hydroxyapatite and 30% β tricalcium phosphate as it has been shown to stimulate osteogenic cells by adhesive glycoprotein, fibronectin, and Type I collagen combined with β tricalcium promoting osteogenesis.[7]

For the treatment of the buccal and palatal perforation, we used Periocol™, a novel bioresorbable collagen barrier membrane. It acts as a scaffold which enhances and directs cell growth to repopulate specific parts of the periodontium. Utilizing the optimized PRF with low-speed concept, we formulated A PRF plus which was a reservoir in several growth factors such as vascular endothelial growth factor, platelet-derived growth factor, and transforming growth factor beta-1.[8] A PRF membrane was a game-changer as it chiefly helped in the natural healing process by providing a stable fibrin scaffold for initial clot stabilization and reduced pain as well as postoperative edema due to decrease in inflammatory response.[9]

Clinical significance

With proper diagnosis of lesion and integrated advanced skilled surgical procedures, clinical management of endodontic–periodontal lesions associated with a periapical cyst can be treated successfully.

   Conclusion Top

Within the limitations of this report, including the limited follow-up duration, it can be said that the combination of surgical endodontics with regenerative periodontics proved to be a successful alternative in the resolution of persistent periradicular infection with tunnel bony defect.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Nair PN. On the causes of persistent apical periodontitis: A review. Int Endod J 2006;39:249-81.  Back to cited text no. 1
Chércoles-Ruiz A, Sánchez-Torres A, Gay-Escoda C. Endodontics, endodontic retreatment, and apical surgery versus tooth extraction and implant placement: A systematic review. J Endod 2017;43:679-86.  Back to cited text no. 2
Tsesis I, Rosen E, Tamse A, Taschieri S, Del Fabbro M. Effect of guided tissue regeneration on the outcome of surgical endodontic treatment: A systematic review and meta-analysis. J Endod 2011;37:1039-45.  Back to cited text no. 3
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part I: Technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e37-44.  Back to cited text no. 4
Schmidt JC, Walter C, Amato M, Weiger R. Treatment of periodontal-endodontic lesions – A systematic review. J Clin Periodontol 2014;41:779-90.  Back to cited text no. 5
Khandelwal A, Karthik J, Nadig RR, Jain A. Sealing ability of mineral trioxide aggregate and Biodentine as root end filling material, using two different retro preparation techniques – An in vitro study. Int J Contemp Dent Med Rev 2015;2015:1-6.  Back to cited text no. 6
Sreedevi PV, Varghese NO, Varugheese JM. Prognosis of periapical surgery using bone grafts: A clinical study. J Conserv Dent 2011;14:68.  Back to cited text no. 7
[PUBMED]  [Full text]  
Fujioka-Kobayashi M, Miron RJ, Hernandez M, Kandalam U, Zhang Y, Choukroun J. Optimized platelet-rich fibrin with the low-speed concept: Growth factor release, biocompatibility, and cellular response. J Periodontol 2017;88:112-21.  Back to cited text no. 8
Sattur D. Platelet-rich fibrin as a grafting material in periapical surgery: A case series. Int J Periodontics Restorative Dent 2019;39:e123-7.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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