Treatment of an intrabony

defect combined
with an endodontic lesion: a
case report
Geetha Ari, Anil Kumar K, Thyagarajan Ramakrishnan

ENDO (Lond Engl) 2010;4(3):215–222

DR.AMITHBABU.C.B
M.Sc.D-ENDO
 Introduction
• Periodontal therapy is mainly aimed at removal
of local factors, which leads to resolution of
inflammation in the supporting structures of the
tooth.
• This therapy predominantly involves scaling and
root planing as the main therapy, combined with
hard and soft tissue surgery.
• With proper postoperative maintenance care,
resolution of inflammation occurs, leading to
arrest of disease progression
• Combined periodontal–endodontic therapy is
widely used because of the close proximity of
the pulp and periodontal structures and their
mutual involvement in disease.
• The prognosis of the combined periodontal–
endodontic diseases depends upon the severity
of the periodontal disease and the response of
the perio dontal treatment.
• Yamasaki et al4 have reported that periradicular
lesions may initially expand horizontally through
cancellous bone and then proceed vertically
• The periodontal–endodontic lesion is used to
describe lesions due to inflammatory products
found in varying degrees in both the
periodontium and the pulpal tissues.
• Platelet-rich plasma (PRP) has become a valuable
adjunct in wound healing in dentistry.
• Post-surgically, blood clots initiate the healing
and regeneration of hard and soft tissues.
• PRP is a platelet concentrate that has been used
widely to accelerate soft and hard tissue healing.
• Platelet-rich fibrin (PRF) belongs to a new
generation of platelet concentrates, with
simplified processing and without biochemical
blood sampling.
• The use of platelet gel to improve bone
regeneration is a recent technique in
implantology and periodontology.
• PRF was first developed in France by Choukroun
et al5 for specific use in oral and maxillofacial
surgery.
• The present article reports on a tooth with a
combined lesion that has been treated using
both endodontic and periodontal measures.
• In this case, following root canal treatment, the
tooth was treated using bone grafting with PRF
gel and guided tissue regeneration (GTR)
membrane under open flap debridement.
CASE REPORT
• A 33-year-old female patient was referred to the
Department of Periodontics, Meenakshi Ammal
Dental College, from the Department of Oral
Medicine and Radiology.
• The patient complained of tooth pain that was
dull and excruciating, pus discharge and swelling
in the mandibular left posterior region (Fig 1).
• On examination, inflammation of the attached
gingiva and pain on percussion were present.
• An abnormal painful response to percussion on
tooth 36 indicated that inflammation of the
periodontal ligament could be of pulpal or
periodontal origin.
• The tooth showed attrition and presented with
plaque and calculus.
• Pulp sensitivity testing was performed using hot
and cold and the results were confirmed using a
pulse oximeter8, which indicated no response,
hence the pulp of tooth 36 swas considered to
be non-vital.
• Periodontal probing revealed a pocket depth of 8
mm and clinical attachment loss of 10 mm in
relation to tooth 36. There were no other
periodontally involved teeth in the remaining
dentition.
• Radiographic examination demonstrated severe
bone loss around the mesial aspect of tooth 36
(Fig 2).
• The initial phase of treatment included complete
scaling and root planing.
• After drainage of the abscess, antibiotics (amoxicillin
500 mg, 3 times a day for 5 days) and analgesics
(ibuprofen 400 mg, 3 times a day for 3 days) were
prescribed.
• The patient was referred to the Department of
Endodontics for root canal treatment of tooth 36.
• After 3 months, the patient was recalled and surgical
treatment was planned for the treatment of the
intrabony defect with bone graft, PRF and GTR
membrane.
 Presurgical therapy
• The initial phase of treatment included complete
scaling and root planing.
• Periodontal parameters (probing depth, mobility and
radiographic evidence of bone loss) were assessed
before and after surgery.
 Management
• Root canal therapy
• The first step in the treatment plan after phase 1therapy
was to deal with the endodontic procedure

Working length Master cone

3 months
Follow up

obturation
 Periodontal therapy
• After 3 months, the patient was recalled for management
of the intrabony defect.
• After proper isolation of the surgical field, the operative
sites were anaesthetised using 2% xylocaine
hydrochloride with adrenaline (1:200000).
• Crevicular incisions were made using a Bard–Parker
No.15 blade (BD, Franklin Lakes, NJ, USA) on the facial and
lingual surfaces of each tooth, with segment or area
involved.
• A full-thickness mucoperiosteal flap was reflected using a
periosteal elevator, taking care to preserve the maximum
amount of gingival connective tissue in the flap.
• The defect was thoroughly debrided and the root
surface was then planed and the flap trimmed to
remove granulation tissue tags and minimise
bleeding (Figs 7 and 8).
• This was followed by irrigation with Betadine®
(Purdue Products, Stamford, CT, USA) and sterile
saline solution.
 PRF preparation
• The advantages of PRF over PRP are its simplified
preparation and lack of biochemical handling of
the blood.
• A blood sample of the patient was drawn in 10
mL test tubes without an anticoagulant and
centrifuged immediately.
• Blood was centrifuged using a tabletop
centrifuge (REMY Laboratories, Chennai,
Tamilnadu, India) for 12 min at 2500 rpm.
• The resultant product consisted of the following
three layers (Fig 9):
• the upper layer of acellular PPP (platelet-poor
plasma)
• PRF clot in the middle
• red blood cells at the bottom

PRF gel.
• Because of the absence of an anticoagulant,
blood begins to coagulate as soon as it comes in
contact with the glass surface.
• Therefore, for successful preparation of PRF,
speedy blood collection and immediate
centrifugation, before the clotting cascade is
initiated, is absolutely essential.
• PRF can be obtained in the form of a membrane
by squeezing out the fluids in the fibrin clot.
• After debridement, bone graft (Periobone-G, Top-Notch,
Health Care Products, Kerala, India) was mixed with the PRF
gel derivative in a sterile dappen dish to a paste-like
consistency (Fig 10).

• This was placed into the periodontal defects to the level of

thesurrounding bony walls, taking care not to overfill (Fig
11).
• It has been suggested that under-filling or
overfilling may be counter productive because it
may preclude proper flap closure, thereby
retarding healing and possibly resulting in loss of
the graft material.
• This was followed by placement of a GTR
membrane over the defect (Fig 12).
• The mucoperiosteal flap was replaced and
primary wound closure was achieved by means
of black silk 4-0 sutures (Fig 13) and Coe-PakTM
(GC America, Alsip, IL, USA) was placed (Fig 14).
• After a period of 7 to 10 days the sutures were
removed.

Placement of sutures. Placement of Coe-Pak

 Post operative care
• Following surgery, the patient was instructed to avoid
chewing in the surgical area during the first post
operative day.
• Systemic antibiotics (amoxicillin 500 mg, 3 times a
day for 5 days) and analgesics (ibuprofen 400 mg, 3
times a day for 3 days) were prescribed.
Healing
• After 10 days, the sutures were removed and healing
was found to be adequate.
• Re-evaluation of the patient after 9 and 12 months
revealed satisfactory bone fill and complete soft
tissue healing.
• Periapical radiographs taken at the 9- and 12-
month follow up appointments indicated
radiographic bone fill in relation to tooth 36 and
healing of the periapical lesion (Fig 15).
• The probing depth reduced from 8 mm to 3 mm
(Fig 16).

Twelve-month post-operative
Twelve-month follow-up radiograph view showing reduced
pocket depth
 Discussion
• Periodontal–endodontic lesions develop by either
periodontal destruction combining apically with an
existing periapical lesion, or an endodontic lesion
combining with an existing periodontal lesion.
• It has long been recognised that an intimate
relationship exists between the pulp of a tooth and
its surrounding periodontium.
• Seltzer et al12 concluded that an established
endodontic lesion could progress through the main
or accessory canals to produce periodontal
breakdown.
• The regeneration of a new attachment apparatus is
one of the most challenging aspects of periodontal
therapy.
• Periodontal regeneration is now understood in the
treatment of many periodontal defects, and is at the
forefront of periodontal research.
• The goal is to regenerate the components of the
periodontium that have been lost through
periodontitis. The use of bone grafts and bone
substitutes, guided tissue regeneration and, more
recently, the application of polypeptide growth
factors to the surgical wound are some commonly
used techniques to promote periodontal
regeneration.
• The case presented was more amenable to
regenerative therapy than root resection as there
was complete bone support on the buccal side
when the flap was raised.
• Clinically, the tooth showed no mobility. Anderegg
et al18 showed that the vertical component of the
defect can predict the extent of osseous repair
following regenerative surgery.
• Although the vertical component in this case was
extensive, the lack of mobility and the presence of
good bone support on the buccal side were factors
that favoured the use of regenerative procedures
instead of root resection.
• Diagnosis of primary endodontic disease and
primary periodontal disease usually presents no
clinical difficulty.
• In primary endodontic disease the pulp is
infected and non-vital.
• In primary periodontal disease the pulp is vital
and responds to sensitivity testing.
• Treatment results should be evaluated in 2 to 3
months and only then should periodontal
treatment be considered.
• Within the limit of the present report, a
combination of bone graft with PRF gel and GTR
led to a favourable clinical improvement in
periodontal intrabony defects.
• Further studies are necessary to assess the long-
term effectiveness of this combined therapy in
the treatment of intrabony defects.
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