# Endodontic Management of Endo-Period Lesions
## 2 Materials and Methods
### Clinical Case 2  
A healthy 30-year-old Caucasian woman presented at the clinic with a chief complaint of pain in the first maxillary right molar. **Intra-oral clinical examination**  
The tooth was restored with a composite resin restoration, there was tenderness on percussion, and a sinus tract with purulent exudate was present on the buccal surface. The periodontal pocket depth was 8-10 mm buccally, and the periodontal pocket width was 3-4 mm. **Radiographic examination**  
Preoperative CBCT imaging revealed previous root canal obturation and an extensive lesion in the fraction area, with loss of the cortical plate at the buccal surface. In addition, there was a radiolucent lesion in the apical area, and a perforation of the floor of the tooth cavity was suspected (Figure 2i). Figure 1: Clinical case 1: (**a,b**) preoperative CBCT demonstrates radiolucent lesion on the distal aspect of the second left mandibular molar; (**c**) clinical view of the access cavity, remnants of obturation material; (**d**) clinical view of the access cavity after instrumentation of the root canals; (**e**) clinical view of the access cavity after obturation of root canal treatment with GuttaFlow Bioseal; (**f,g**) postoperative CBCT demonstrates complete root canal filling; and (**h**) a follow-up CBCT (after 12 months) demonstrates healing. On periapical radiograph examination, a radiolucent area in the function was observed, which extended to the apical region of the palatal root (Figure 2a). Fragments of endodontic separated instruments were observed in the palatal and meso-buccal canals (Figure 2b). Figure 2: (**a,b**) Preoperative periapical radiographs of the first upper molar, presenting the “bone” defect as a radiolucent area with irregular contour in the apical region and in the bifurcation region. (**c,d**) Stages of removal of fragments of endodontic instruments from the buccal medial and palatal canals. (**e**) Tooth appearance after instrumentation of the root canals. (**f**) Introduction of BioDentin into the palatal canal. (**g**) Root canal obturation. (**h**) Postoperative periapical radiograph. (**i**) Diagnostic CBCT. (**j**) Follow-up CBCT 11 months later. (**k**) Follow-up CBCT 24 months later. Endodontic Diagnosis Pulpal diagnosis--previously treated Periapical diagnosis--chronic apical abscess Primary endodontic--secondary periodontal lesion Tooth perforation Periodontal Diagnosis Localized periodontitis Stage III Treatment  
After a discussion of the treatment options with the patient, a decision was made in favor of endodontic retreatment followed by periodontal treatment. Treatment under magnification using an operating microscope required two visits. At the first visit, following local anesthesia (2% lidocaine with 1:100,000 epinephrine), the tooth was isolated using a rubber dam, the old restoration was removed, and an appropriate access cavity was refined. On access, perforation was observed in the truncation area, and this was sealed with Bio-Dentin (Septodont, Figure 2c). At the second visit, 2 days later, retreatment was carried out using the Re-mover 30/07 instrument (MicroMega). The separated instruments were removed using an RT system (EMS) and abundant irrigation with 5% sodium hypochlorite solution (Figure 2d). The canals were then prepared according to the HyFlex EDM protocol, with intermediate active irrigation using 5% sodium hypochlorite solution with an endoactivator and 17% EDTA solution (Figure 2e). The buccal root canals were obturated with the GuttaFlow Bioseal cold flowing guttapercha system (Coltene, Roeko, Germany) using the single cone technique (Figure 2g). Due to significant resorption of the apical region of the palatal canal, the apical third was filled with BioDentin (Septodont, Figure 2f) [4], followed by GuttaFlow Bioseal (Coltene, Roeko, Germany). Postoperative radiographs showed complete root canal filling (Figure 2h). A temporary filling with glass-ionomer cement was applied. Periodontal therapy followed the completion of the endodontic treatment.