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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 45-48

Interdisciplinary management of root perforation along with regeneration of bony fenestrations and dehiscence


1 Department of Periodontics, ITS Dental College, Hospital and Research Centre, Greater Noida, Uttar Pradesh, India
2 Department of Pedodontics, ITS Dental College, Hospital and Research Centre, Greater Noida, Uttar Pradesh, India

Date of Submission13-Feb-2019
Date of Acceptance10-Oct-2019
Date of Web Publication27-Jan-2020

Correspondence Address:
Aakriti Sharma
Department of Periodontics, ITS Dental College, Hospital and Research Centre, Greater Noida, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_16_19

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  Abstract 


A surface alveolar bony defect communicating with the root canal perforation can be either endodontic or periodontal origin. Breach in the continuity of the cortical plate may lead to the development of dehiscence and fenestration alveolar defects. This case report discusses the regeneration of periodontal tissues in fenestration and dehiscence defects that had developed around traumatized incisors, using a type I collagen membrane and bone graft along with root perforation repair emphasizing the requirement of an interdisciplinary approach for the management of endodontic-periodontal lesions. The alveolar defects such as fenestration and dehiscences profoundly affect the prognosis of both periodontal and endodontic treatment outcomes; therefore, it should be carefully diagnosed and managed.

Keywords: Dehiscence, endodontic-periodontal lesion, fenestration, guided tissue regeneration, root perforation


How to cite this article:
Sharma A, Chhina S, Goswami M, Arora SA. Interdisciplinary management of root perforation along with regeneration of bony fenestrations and dehiscence. Indian J Dent Sci 2020;12:45-8

How to cite this URL:
Sharma A, Chhina S, Goswami M, Arora SA. Interdisciplinary management of root perforation along with regeneration of bony fenestrations and dehiscence. Indian J Dent Sci [serial online] 2020 [cited 2020 Aug 13];12:45-8. Available from: http://www.ijds.in/text.asp?2020/12/1/45/276883




  Introduction Top


The Latin word “Fenestra,” a window gave rise to the term “fenestration,” which refers to the secluded part of the denuded root, where the marginal bone is intact, and the surface is blanketed by the periosteum and gingiva. When the facial bone overlying the root is very thin, this denudation extends through the marginal bone, and the defect is called a dehiscence.[1] Following case report discusses the regeneration of periodontal tissues around fenestration and dehiscence defects that had developed around traumatized incisors, using type I collagen membrane and bone graft along with root perforation repair.


  Case Report Top


A 15-year-old female patient reported to the department of pedodontics with a history of two distinct swellings on gum in the right upper front tooth region which did not subside with systemic antibiotics [Figure 1]. The patient gave a history of trauma in 11,12; one year back for which she was endodontically treated with a definitive prosthesis of zirconia crowns. On radiological examination, sectional obturation in relation to 12 from apical-third to middle-third of the root with the absence of interradicular post was placed, and midroot radiolucency suggestive of angular bone loss was seen in between 11 and 12,12 and 13 [Figure 2]. No periapical radiolucency was evident in relation to both the teeth; however, two sinus tracts could be traced on inserting Gutta-percha points. Teeth were sensitive to vertical percussion, and thorough examination revealed pus discharge from its buccal sulcus. Sequential probing revealed sulcus depth of 4–5 mm around 11 and 12. Periodontal evaluation includes bone sounding (transgingival probing) under local anesthetic infiltration, revealed a fenestration defect on the radicular surface of tooth 12. The condition was diagnosed as a primary endodontic-periodontal lesion with fenestration defect. The treatment plan consisted of a periodontal surgery along with bone grafting and type I collagen membrane placement for the regeneration of lost periodontal tissue. The entire procedure was explained to the patient, and informed consent was obtained.
Figure 1: Preoperative swellings on gum in relation to 11 and 12

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Figure 2: Preoperative radiograph

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Local anesthesia was administered using 2% lignocaine hydrochloride with 1:80,000 adrenaline. A crevicular incision was given to raise a full-thickness mucoperiosteal flap from distal margin of 11 extending up to distal margin of 13 with a vertical releasing incision. Complete debridement of the surgical site indicated a dehiscence defect in relation to 11 and fenestration in relation to 12 [Figure 3]. On examining the mesial side of the root carefully with an explorer, there was a conspicuous perforation in the middle-third of the root of 12 communicating with distal aspect of the root causing bone loss along both the surfaces of the root. Sites were thoroughly cleaned to receive mineral trioxide aggregate (MTA) (ProRoot MTA, Dentsply) for the closure of the perforated site, thereby cutting off the communication between the tooth root and bone.
Figure 3: Full-thickness flap raised showing dehiscence defect in 11 and fenestration in 12

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The PerioGlas (Calcium Phospho-Silicate Bioactive Glass, Bioglass®; average particle size: 90–710 μm; Perioglas, Novabone) was filled in the osseous defect. Thereafter, the GTR membrane (HEALIGUIDE) was positioned over the surgical site, and reflected tissue was coronally advanced by splitting the flap and leaving the periosteum intact (to increase its mobility) readapted and sutured [Figure 4]. Coe-Pak (GC America Inc., Alsip, IL, USA) was applied on the operative area.
Figure 4: Placement of bone graft and membrane after placing mineral trioxide aggregate at midroot perforation

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Written postoperative instructions were given to the patient, and analgesic (ibuprofen 400 mg thrice daily) was prescribed for 3 days. Chlorhexidine 0.2% mouth rinse was instructed for 1 week, with caution to avoid it for the first 24 h. Sutures were removed after 7 days [Figure 5]. The patient was recalled after 6 months [Figure 6] and was found asymptomatic clinically with the average probing depth of 3 mm around the tooth. Radiograph obtained depicted slight bone gain at the mesial and distal aspect of 12, with MTA plug also evident on the distal aspect of the tooth root in relation to 12 at follow-up appointment [Figure 7].
Figure 5: Postoperative after 1 week

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Figure 6: Postoperative after 6 months

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Figure 7: Postoperative radiograph after 6 months

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  Discussion Top


This case addresses the regenerative management of fenestration and dehiscence defects developed around traumatized incisors having root canal perforation at the middle-third of the root. Root canal perforation not only depicts direct damage to the root structure with mechanical weakening of the tooth but also this trauma insults the periosteum, thereby potentiating entry of microorganism and providing a passageway.[2] Root perforation poses a significant therapeutic challenge, because if untreated, breakdown of periodontal tissue may lead to the formation of a periodontal pocket, thus becoming a predisposing factor for these alveolar defects. Studies have shown that dehiscence is the bone resorption pattern associated with vertical root fractures in maxillary molars/premolars and the mesial root of mandibular molars and involves the buccal plate in 90% of the cases examined. Furthermore, it results in a fenestration defect along with the coronal and apical bone being intact.[3] A case reported by Saxena et al.[4] also highlighted the role of perforation of the middle one-third of root acting as an etiology for bone defect around maxillary central incisors with a communication at mesial and distal sides of the tooth causing bone loss at both the sides.

Concurrent use of bone graft and GTR for managing combined endodontic-periodontal lesions have been reported along with MTA and other calcium silicate-based cement for orthograde and surgical repair of root perforations.[5],[6] It is the biomaterial of choice to seal such type of perforations due to its unique properties of hard setting in the presence of moisture.[7] Bains et al.[8] treated a case of pulpal floor perforation leading to an endodontic-periodontal lesion, using MTA as a perforation repair material and second-generation platelet concentrates (platelet-rich fibrin) as a membrane for osseous defect regeneration and found initial bone healing within 3 months on follow-up.[9] Following the similar rationale, sites were cleaned to receive MTA for the closure of the root canal perforation, cutting off the communication between the tooth root and bone along with placement of type I collagen barrier membrane with bone graft along the alveolar defects.


  Conclusion Top


In the present case report, fenestration and dehiscence defects were successfully treated with combined endodontic-periodontal approach with no recurrence of periodontal disease at 6-month follow-ups.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Singh S, Panwar M, Arora V. Management of mucosal fenestration by multidisciplinary approach: A rare case report. Med J Armed Forces India 2013;69:86-9.  Back to cited text no. 1
    
2.
Beavers RA, Bergenholtz G, Cox CF. Periodontal wound healing following intentional root perforations in permanent teeth of macaca mulatta. Int Endod J 1986;19:36-44.  Back to cited text no. 2
    
3.
Tamse A. Vertical root fractures in endodontically treated teeth: Diagnostic signs and clinical management. Endod Topics 2006;13:84-94.  Back to cited text no. 3
    
4.
Saxena RM, Divya S, Shashikumar P, Gujjari SK, Anoop M. Management of horizontal radicular fracture – An interdisciplinary approach. J Surg 2013;2:29-31.  Back to cited text no. 4
    
5.
Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations. J Endod 1993;19:541-4.  Back to cited text no. 5
    
6.
Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197-205.  Back to cited text no. 6
    
7.
Torabinejad M, Higa RK, McKendry DJ, Pitt Ford TR. Dye leakage of four root end filling materials: Effects of blood contamination. J Endod 1994;20:159-63.  Back to cited text no. 7
    
8.
Bains R, Bains VK, Loomba K, Verma K, Nasir A. Management of pulpal floor perforation and grade II furcation involvement using mineral trioxide aggregate and platelet rich fibrin: A clinical report. Contemp Clin Dent 2012;3:S223-7.  Back to cited text no. 8
    
9.
Sarkar NK, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. Physicochemical basis of the biologic properties of mineral trioxide aggregate. J Endod 2005;31:97-100.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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