Surgical Management of Endo-Perio Lesion with Demineralised Bone Matrix in Combination of Platelet Rich Fibrin: A Case Report

Periodontal disease is an inflammatory disease leading to periodontal attachment loss and bone destruction. The objective of periodontal therapy is to regenerate the lost periodontal supporting tissues. Platelets are rich in growth factors that may contribute to an accelerated process of tissue regeneration. Demineralised Bone Matrix (DMBM) Xenograft is a bone inductive sterile bioresorbable Xenograft composed of Type I collagen. Given the unique properties of autologous Platelet Rich Fibrin (PRF) and already demonstrated regenerative capacity of commercially available bone grafts, application of a combination approach was attempted. We present here a case report with an eight month follow-up report of a combined endo-perio lesion, which was treated by means of combination of autologous PRF with bovine derived xenograft, and assessed clinically and radiographically.


Introduction
Periodontal disease is an inflammatory disease leading to periodontal attachment loss and bone destruction. The objective of periodontal therapy is to regenerate the lost periodontal supporting tissues. However, periodontal regeneration requires a sequence of biological events including cell adhesion, migration, proliferation and differentiation [1]. A combination of growth factors may more effectively stimulate formation of mineralized as well as non mineralized tissues [2]. Platelets are rich in growth factors that may contribute to an accelerated process of tissue regeneration. During the early stages of wound healing, platelets released growth factors, including platelet derived growth factor, insulin like growth factor-1 and transforming growth factor-β, initiate a cascade of cellular and molecular events that result in wound healing in a highly regulated and coordinated manner [2]. The application of these growth factors to bone and periodontal regeneration has been investigated using numerous in-vitro and in-vivo models with promising results [3][4][5][6]. Xenografts used in the treatment of infrabony defects can be both bovine bone and natural coral, these are also referred to as anorganic bone, since they are suggested to remove all cells and proteinaceous material leaving behind an inert absorbable bone scaffolding upon which revascularization, osteoblasts migration, and woven bone formation supposedly occurs [7]. Demineralised Bone Matrix (DMBM) Xenograft is a bone inductive sterile bioresorbable Xenograft composed of Type I collagen. It is prepared from bovine cortical samples, resulting in non-immunogenic flowable particles of approximately 250 µm dimensions that are completely replaced by host bone in 4-24 weeks [8]. Platelet-Rich fibrin (PRF) described by Choukroun et al. is a second-generation platelet concentrate which allows one to obtain fibrin membranes enriched with platelets and growth factors, after starting from an anticoagulant-free blood oral maxillofacial surgery [12][13][14] and in dental implantology [15][16]. Given the unique properties of autologous PRF and already demonstrated regenerative capacity of commercially available bone grafts, application of a combination approach was attempted. We present here a case report with a 12 month follow-up report of a combined endo-perio lesion, which was treated by means of combination of autologous PRF with bovine derived xenograft, and assessed clinically and radiographically.

Case Presentation
A 35 year old patient reported to the department with a chief complaint of swelling in the upper front tooth region since 2 months. The patient had reported trauma in the same region 7 years back. The nature of the pain was intermittent in nature. The patient used to take analgesics to relieve the pain. The past medical history of the patient did not reveal any significant finding and the patient was systemically healthy and was not on any medication. Patient revealed no history of smoking and alcohol and other deleterious habits. On examination, there was a swelling of about 3cm x 3cm with Ellis class IV fracture in relation to 11. The tooth appeared to be discolored ( Figure 1). The pulp vitality tests revealed that the tooth was nonvital while the radiographic examination of the concerned area in the form of an Intra-Oral Peri-Apical Radiograph (IOPAR) revealed that it had a large peri-apical radiolucency ( Figure 2). Periodontal probing revealed a deep periodontal pocket measuring about 15mm in depth. (Figure 3). The provisional diagnosis arrived-at was a combined endo-perio lesion in relation to 11 region.

Endodontic therapy
At the initial visit, immediate emergency access opening was done and the pus was drained-out. The access was kept open and only a thick cotton pledget was used to close the access for a day. Next day, the patient was recalled and the cotton pledget was removed and the canal was re-irrigated with saline. The swelling had reduced.
Patient was recalled for irrigation and dressing after 4 days till which time, the swelling had completely resolved. Working length and biomechanical preparation were completed with the tooth ( Figure  4). Calcium hydroxide dressing was given for 7 days and the access was closed with a temporary restoration ( Figure 5). A dressing was given again and the patient was recalled after 7 days for the follow-up and then, the patient was transferred to Department of Periodontics for opinion and needful. A thorough oral prophylaxis was done in the concerned region ( Figure 6) and the patient was recalled for completion of endodontic treatment (Figure 7).

Periodontal therapy
A periodontal surgery was planned after 1 month of the      Submit your Manuscript | www.austinpublishinggroup.com completion of the endodontic treatment. Routine blood investigations were advised for which the reports were found to be normal. Presurgical periodontal pocket depth was reduced to 7mm ( Figure 8). After proper isolation of the surgical field, the operative site was anaesthetized using 2% xylocaine hydrochloride with adrenaline (1:200000). A crevicular incision was given covering 12, 11, 21 region and a full thickness mucoperiosteal flap was raised (Figure 9). The infected, necrosed bone was removed and a continuous apicomarginal defect was observed along with buccal wall with dehiscence. 3mm of root was resected for apicoectomy and 3mm gutta percha was removed from the apex with the help of a heated probe ( Figure 10).

PRF preparation
Blood sample of the patient was drawn in 10mL test tubes without an anti-coagulant and centrifuged immediately. Blood was centrifuged using a tabletop centrifuge (REMY Laboratories, Chennai, Tamilnadu, India) for 12 min at 3000 rpm. The resultant product consisted of the following three layers (Figure 11).
• The upper layer of acellular PPP (Platelet-Poor Plasma); • PRF clot in the middle; and • Red blood cells at the bottom.
Platelet rich fibrin was then separated by cutting with a sterile surgical scissor and collected using a dappen dish. (Figure 12). PRF clot was placed inside the periapical defect ( Figure 13). A Demineralised Bone Matrix (DBM) xenograft was then placed over the peri-apical defect and also, the entire root length devoid of bone ( Figure 14). A Collagen membrane was finally placed over the defect. The Collagen membrane was cut according to requirement and then placed over the defect using 4-0 vicryl resorbable suture ( Figure  15). The flap was sutured with 3-0 black braided silk ( Figure 16). A perio pack was then mixed and placed over the sutured area so that the repositioned flap be immobile till healing ensued ( Figure 17). Immediate Post-Operative Radiograph (IOPAR) was advised ( Figure   Figure 9: Showing crevicular incision given in relation to 12, 11, 21 region with raised full thickness mucoperiosteal flap.          18). Antibiotics and analgesics were prescribed for one week. After 15 days, the pack was removed. The sutures were removed and the healing was found to be uneventful. The crown preparation with 11 was done ( Figure 19) and elastomeric impression was recorded ( Figure 20). All Ceramic Emax crown was fabricated and cemented ( Figure 21). The patient was asked for regular follow-up visits and the 12 months post-operative radiograph was taken which revealed apparent bone fill with resolution of the osseous defect ( Figure  22). Clinical evaluation of the periodontal pocket depth revealed a successful outcome of the procedure with a considerable reduction in pocket depth that got reduced from 15mm to 3mm depth (Figure 23).

Discussion
The treatment of combined endo-perio lesions requires both endodontic therapy and periodontal regenerative procedures, as discussed in the above case report. The goal of peri-radicular surgery is to remove all necrotic tissues from the surgical site to completely seal the entire root canal system, and to facilitate the regeneration of hard and soft tissues including the formation of a new attachment apparatus [17]. It is interesting to note that there was no radiographic or clinical evidence of a pre-existing deep decay in the tooth, and no cracks were evident. The most common clinical/ radiographic features of these endo-perio lesions reported were the periapical radiolucency and deep pocket depths with a nonvital pulp status. Traditional approaches to treat endo-perio defects include non-surgical debridement of root surfaces or root canals, as well as surgical approaches that provide better access to clean the root surfaces and apical lesions and to reshape the surrounding bone/root apex. Bone loss caused by pulpal disease is reversible, whereas advanced bone loss caused by periodontal disease is usually irreversible [18]. The necessity of periodontal surgical therapy most likely was because the periodontal bone loss was more advanced and    was less likely to resolve after non surgical root canal therapy alone [19]. Generally, partial apical root resection has been suggested for all endodontic surgeries advised for extensive involvements [20]. In this case report, we had planned a regeneration therapy for bone as well as the periodontal ligament as it would lead to a better prognosis. Hence, here we performed root canal debridement with subsequent retrograde filling and removal of granulation tissue around the root and apex. Apicoectomy was done to prevent recurrence of infection as the maximum number of canal variations and complexities are seen in the apical third [21]. PRF i.e. Platelet Rich Fibrin, is in the form of a platelet gel and can be used in conjunction with bone grafts, which offers several advantages including promoting wound healing, bone growth and maturation, graft stabilization, wound sealing and hemostasis, and improving the handling properties of graft materials. It is saturated with growth factors which expediates the regenerative process during healing [12]. Also here, using the Guided Tissue Regeneration (GTR) membrane technique, combined with bone graft, the result was clinically successful after a 1-year follow-up period. The role of bone graft in the above case was for space-making and also for inducing bone formation and attachment gain. The rationale for using GTR barrier membranes in above case with bone grafting materials is to encourage the growth of key surrounding tissues, while excluding unwanted cell types such as epithelial cells [22]. GTR therapy has been implemented in the endodontic surgeries as a concomitant treatment during the management of the combined endo-perio lesions. However, from clinical and radiographic findings, the result of this combined technique was quite impressive, resulting in a significant reduction of probing depth and bone fill. Although traditional non-surgical periodontal therapy and regular endodontic therapy can be predictably used to arrest mild to moderate periodontal bone defects in combined endo-perio lesions, it might be inadequate for the treatment of disease characterized by deep pockets or apicomarginal defects. Currently, regenerative techniques are widely available in terms of their predictability to regenerate the lost tissue/ bone in all types of defects or for all situations.

Conclusion
A careful pre-operative diagnosis, appropriate case selection and knowledge of the factors that can negatively affect regeneration outcomes can help to optimize successful regenerative attempts. Treatment strategies used in this case report suggests that combined endo-perio lesions can be successfully managed with multiple regenerative procedures.