Management of failed periodontal surgical intervention for a furcal lesion with a nonsurgical endodontic approach
A 42-year-old female, complaining of a painful swelling beside her right first mandibular molar, demanded a dental visit. She had normal hygiene and mentioned regular dental visits. On tooth #46, a class 1 composite filling with stained margins was evident. On the buccal gingival tissue just below the gingival margin, an inflamed swelling was present that revealed pain upon palpation. On probing assessment of the furcation, a non-through-and-through furcation lesion could be penetrated. Orthoradial periapical radiography () revealed that a root canal treatment had been performed on this tooth 5 years earlier following severe nocturnal pain. The radiographic quality of root canal therapy (RCT) was not good, and a large furcation lucency extending to the inter-radicular apical region was evident. It also seemed that a periapical lesion existed around the mesial root that had combined with the furcal lucency. The patient mentioned a visit to a periodontist a year before with the same chief complaint. He had diagnosed the problem to be periodontal in origin and performed an alloplastic operation on the furcation of the tooth. The graft was still visible in our radiography, and not only had the healing not occurred, but also, as mentioned before, the symptoms had started to recur.\nConsidering the furcation lucency that was not responsive to periodontal surgery, the poor quality of RCT, and the presence of the periapical lucency around the mesial root, a diagnosis of the primary endodontic, secondary periodontal lesion was made, and this lesion could be handled with endodontic intervention. The treatment plan was root canal retreatment, permanent restoration of the tooth, and patient follow-up. We also considered that further periodontal intervention might be required if the healing process was assumed to be insufficient during the follow-up.\nAfter local anesthesia with 2% lidocaine containing epinephrine 1 : 80,000 (Darou Pakhsh, Tehran, Iran), the composite filling of the crown was removed. The filling had severe marginal discoloration and upon removal with a high-speed bur, was assumed to be debonded in some areas. The chamber floor was covered with a layer of gutta-percha, which was removed. The orifices of the canals filled with gutta-percha were detected, and then, the tooth was isolated with a rubber dam. Then, the filling material in the coronal portion of the three canals (distal, mesiobuccal, and mesiolingual) was removed with No. 1 - 4 Gates-Glidden drills (Mani, Inc., Tochigi, Japan) and then, subsequent to using a drop of chloroform, the rest of the canal filling was removed with a D-RaCe retreatment file, DR2 (RaCe, FKG Dentaire SA, La Chaux de Fonds, Switzerland) at 900 rpm until the canal was totally cleaned. After the determination of the working length with radiography, the canals were completely shaped to #35/0.04 of the RaCe system, with simultaneous 5.25% NaOCl irrigation. Thereafter, canal obturation and restoration of the access cavity was completed (). After two weeks, the clinical signs/symptoms faded away.\nThe patient was put on a follow-up schedule with 3-month intervals. shows the 12-month follow-up periapical radiography. Bone healing in the furcation area around the previously inserted graft is evident, and the periapical lucency of the mesial root has healed.