An innovative approach for the treatment of combined lesion: a case report.
Abstract: Interdisciplinary approaches for endo-perio combined lesion give us a successful outcome. Patient with non-vital tooth with massive bone loss and gingival recession defect have traditionally been located with various procedure. Recently guided tissue regeneration with collagen membrane has shown promising results particularly when demineralized freeze dried bone graft with collagen material used for new attachment procedure. Several properties make collagen attractive candidates for use as barriers membrane as well as a component for bone graft materials use in guided-tissue regeneration based root coverage procedure. Free mucosal graft also applied for to avoid the exposure of bone graft and collagen membrane. This case is presented to illustrate the principal and innovative surgical technique by interdisciplinary approach for promotion of new connective tissue attachment.
Article Type: Report
Subject: Collagen implants (Usage)
Collagen implants (Properties)
Artificial bones (Usage)
Artificial bones (Properties)
Periodontal disease (Diagnosis)
Periodontal disease (Care and treatment)
Bone regeneration (Research)
Authors: Biswas, Chhanda
Adhya, Pampa
Pub Date: 10/01/2011
Publication: Name: Trends in Biomaterials and Artificial Organs Publisher: Society for Biomaterials and Artificial Organs Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Society for Biomaterials and Artificial Organs ISSN: 0971-1198
Issue: Date: Oct, 2011 Source Volume: 25 Source Issue: 4
Topic: Event Code: 310 Science & research
Product: SIC Code: 2836 Biological products exc. diagnostic
Geographic: Geographic Scope: India Geographic Code: 9INDI India
Accession Number: 304842728
Full Text: Introduction

The tooth, its pulp and its supporting structures must be viewed as a biologic unit. The inter-relationship among these structure influences each other during health, function and diseases.

The indications for endo-perio combined treatment procedures are multiple. But in a nutshell it can be said that any lesion that after performing endodontic treatment results in irreversible reactions in the attachment apparatus and requires periodontic treatment. Similarly the lesion after periodontal treatment results in irreversible reaction in pulp tissue also requires endodontic treatment.

Gingival recession defects are often associated with sensitivity, esthetic concern, marginal tissue irritation and probable increased susceptibility to root caries. Various surgical techniques have been developed for connection of such defect. Among them guided tissue regeneration technique with free gingival graft to treat such defect has recently been attempted with promising clinical and histological results (1,2). Most of the earlier investigations utilized non-absorbable barrier materials as membranes (3). Despite their proven efficacy, non absorbable membranes require a second surgical procedure for retrieval of the membranes. The use of absorbable membranes, including collagen membrane, for GTR procedures has recently enabled clinician to reduce exposure of membranes and infection along with reduce need for second surgical procedure.

Collagen membranes have been shown in animal studies and human clinical trial to be as effective as other GTR membranes in inhibiting epithelial migration and promoting new connective tissue attachment (4,5).

Collagen is the predominant protein in alveolar bone and periodontal connective tissues. Among the positive properties of collagen when used for GTR-based root coverage procedures is its haemostatic function, achieved though its ability to aggregate platelets.

These properties may facilitate early clot formation and wound stabilization (6). In addition, collagen possesses a chemo tactic function for fibroblasts, which many aid in cellular migration to promote primary wound closure (7) which is essential component of successful GTR procedure. It may also provide a collagenous scaffold for tissue repair as well as augment the gingival tissue thickness (8,9). In addition, collagen possesses a semipermeable structure that permits gas exchange and allows passage of nutrients to ensure healthier flap healing.

Recently encouraging results were achieved when demineralized freeze dried bone allograft (DPDBA) was added during guided tissue regeneration to create and maintain the space that is needed for regeneration. Many studies show the utilization of bone graft for enhancement of a GTR-based root coverage procedure.

The purpose of this case study to evaluate the treatment of endo-periodontal lesion with root canal treatment and guided tissue regeneration with bone graft membrane and free mucosal graft.

Case Report

A 16 years old adolescent patient came with the chief complaint of pain and gap of gums with discharging pus in right side of the lower anterior teeth. On examination, there was a gingival defect in between canine and lateral incisor. Gingival is bright red in colour, soft and edematous, tender in percussion with 15 mm pocket depth. Intra oral periapical radiograph (I.O.P.A) shows periapical radiolucency and massive bone loss in between canine and lateral incisors with both the teeth are non-vital. Preopertive radiographs and photographs were taken (figs 1 & 2).



Treatment Plan

Inter-disciplinary approach was taken for treatment of the patient. First phase-I therapy was done. Scaling and root planning (SRP) was done for improvement of the overall gingival health in the department of periodontia. At the same time root canal treatment was done in the department of conservative and endodontics. After preparing access cavity, the canal is flared to give a funnel shape for better debridement. Intra canal calcium hydroxide dressing given to provide a basic pH so that all viable bacteria become inactive and body immune mechanism can produce healing of the apical periodontal attachment apparatus. Now the canal filled with gutta percha by lateral condensation technique (Fig. 3). After obturation of canine lateral and central incisor teeth, we go for the phase II therapy (Fig. 4).

Surgical Procedure

After 4 months of obturation of the canine, lateral and central incisors we go for GTR (guided tissue regeneration) with collagen membrane, bone graft and free mucosal graft surgery.






Free mucosal graft surgery : The procedure describing by Miller was used. The recipient site was prepared by marking an intra sulcular incision connected by two vertical releasing incision (Fig. 5) in the apical direction into the alveolar mucosa. A full thickness flap was raised. At the donar site, a free gingival autograft was dissected with a No. 11 blade (Fig. 6) and care was taken to obtain a uniform thickness of 1.5 mm-2 mm. Then graft was placed and suture was placed for immobilization of the graft.

Guided tissue regeneration technique: Then crevicular incision was given two teeth distal and mesial to elevate a envelop flap. Then roots were planned with hand curates to obtained smooth surfaces end then treated by root conditioning. An type I collagen membrane for the lateral proximal site of the tooth was trimmed to desire shape to cover the entire defect. It was extending 3 mm apically over the alveolar crest in the defect. Then membrane were fixed with a suture (Fig. 7) (Chromic cat gut) used in a sling technique. After placement of osteoinductive bone material (Fig. 8) (made of type I collagen and calcium-sulphate hemihydrate) flap was positioned coronally with suture to cover the membrane entirely (Fig. 9). Special care was taken not to displace or compress the membrane. Then periodontal dressing was applied (Fig. 10).






Post Operative Care : The patient were prescribed Amoxicillin 500 mg. 3 times a day for 8 days and metronidazole 400 mg and instructed to rinse twice daily with 0.2% Chlorhexidine solution twice daily for 4 weeks to prevent post surgical infection. An analgesic, paracetamol 650 mg twice a day for 5 days were prescribed for relief of pain. Suture was removed after 15 days of surgery and patient were instructed to brush the teeth with soft brush.

Reentry procedure was not needed because the membrane is made of bio-absorbable material.


Preoperative (Fig. 1, 2) and post operative (Fig. 11, 12) radiograph and photograph was taken after 6 months of surgery.


The goal of this treatment to resolve the esthetic problem treat dentinal hypersensitivity and prevent root caries along with that regeneration of attachment apparatus like bone and periodontal ligament to restore complete health of the teeth.

Although most previous report have indicated that human facial gingival recession can treat successfully through use of GTR procedure with expanded polytetra fluoroethylene (e-PTFE) membrane (12-14). In this case use of modified type I collagen membrane along with the osseoinductive bone graft material having type-I collagen with calcium sulphate hemihydrate to cover the bone graft and membrane we taken free mucosal graft from the palate.

Collagen seems to be more promising for its physical and biological properties (15). Collagen membrane and GTR-based root coverage technique yielded results similar to those achieved by traditional root coverage (16). This may be largely due to collagen's biologic activities such as (1) being physically absorbable through enzymatic degradation, (2) the chemotactic ability to promote primary wound coverage and reduce the incidence of membrane exposure and bacterial contamination, and (3) the haemostatic capacity to facilitate initial clot formation and wound stability, hence a membrane made of type I collagen is an appropriate biomaterial to be used in guided tissue regeneration (GTR).

Creation and maintenance of space between the root surface and overlying GTR barrier is essential to the success of GTR. This space is necessary to provide a channel for the migration of progenitor cells towards and onto the detoxified root surface hence differentiation of cementoblast, formation of new cementum and periodontal ligament is desired (17, 18).

Compromised results after GTR may be obtained in case of membrane collapses into the defect, thereby reducing space. In case of resorbable membrane placed in a wide one wall defect involves the risk of membrane collapse. The collapse may be prevented by implantation of biomaterial into the defect to support the membrane so that it preserves its original position.

Encouraging results were achieved when demineralized freez-dried bone allo-graft was added during guided tissue regeneration to create and maintain the space that is needed for tissue regeneration (23).

In this study we used bone graft material Osseomold is consisted of (type I collagen) demineralized bone matrix xenograft with calcium sulphate hemihydrate that has been used in both animal and human studies to determine its osteoinductivity. It has specific bone stimulatory activity. It is specially prepared from bovine cortical bone samples resulting in non-immunogenic flowable particles of approximately 250 micron size. It is a bone inductive, sterile, bioabsorbable and moldable bone graft material.

In this present case, collagen membrane along with demineralized freeze dried bone graft (xenograft) with free mucosal autograft to achieved bone fill with root coverage. Similar result achieved by demineralized freeze dried bone graft (DFDBA) during guided tissue regeneration based root coverage by Kimle et al 2000 (24). The term bone fill is used purposefully instead of new attachment (new bone, new cementum, new periodontal ligament and new connective tissue) because only histological examination will confirm, whether there is new attachment occur or not.


Interdisciplinary approach for treatment of a complicated case particularly when collagen membrane and bone graft use for guided tissue regeneration base therapy with free mucosal graft use, they help not only new attachment formation but also causes root coverage. Furthermore, the addition of demineralized freeze dried bone graft showed a tendency toward improving the percentage of root coverage and reduces membrane collapse. The author's experiences with collagen membrane suggest that it can safely be used for GTR based root coverage procedure.


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Chhanda Biswas * and Pampa Adhya

Department of Periodontia, Department of Conservative Dentistry and Endodontics Dr. R. Ahmed Dental College & Hospital, A.J.C. Bose Road, Kolkatta 14

* Corresponding author, ( Dr. Chhanda Biswas

Received 12 October 2010; Accepted 27 April 2011; Available online 8 September 2011
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