Endo-periodontal lesion: the benefit of the chorionic membrane in regeneration

The clinical challenge of endo-periodontal lesions

The management of endo-periodontal lesions represents one of the most complex challenges in general practice and periodontology. This pathology, illustrated here by the case of a 40-year-old patient presenting a lesion on the upper right central incisor (11), results from a close communication between the root canal system and the periodontium. In this case report, the practitioner faces a non-vital tooth associated with clinical suppuration, probing depths reaching 9 mm mesially, and significant radiographic bone loss, classifying the pathology as a primary endodontic lesion with secondary periodontal involvement.

Study objective and therapeutic strategy

The central objective of this work is to document the effectiveness of a sequential multidisciplinary protocol to save a tooth with a guarded prognosis. The strategy is based on the elimination of endodontic infection through root canal treatment, followed by a surgical intervention aimed at neutralizing tension factors (labial frenectomy) and regenerating periodontal structures. The study precisely evaluates the contribution of a guided tissue regeneration (GTR) technique using G-Graft (hydroxyapatite and collagen) combined with a chorionic membrane.

Hypothesis: the chorionic membrane as a biological barrier

The authors hypothesize that the chorionic membrane, thanks to its anti-inflammatory properties and its ability to promote cell proliferation, constitutes an effective biological barrier for treating a two-walled bone defect (9 mm deep by 12 mm wide). The challenge is to confirm whether this approach allows for a drastic reduction in pocket depth and appreciable bone filling, thus offering a viable alternative to conventional membranes in the treatment of complex periodontal defects.

Therapeutic Approach and Experimental Protocol

This case report documents the multidisciplinary management of a 40-year-old patient presenting with a primary endo-periodontal lesion with secondary periodontal involvement on the upper right central incisor (11). Initial diagnosis revealed pulp non-vitality, probing depths up to 9 mm mesially and a radiolucent infra-bony defect.

The treatment protocol was sequenced as follows:

• Initial phase: Completion of root canal endodontic treatment, followed by scaling and root planing and a maxillary labial frenectomy to eliminate mechanical tension and plaque accumulation.
• Surgical phase (GTR): Elevation of a full-thickness flap via sulcular and papilla preservation incisions. Debridement exposed a two-wall defect 9 mm deep and 12 mm wide.
• Biomaterials: Filling of the defect with a synthetic bone graft (G-Graft, crystalline hydroxyapatite and collagen) and application of a chorion membrane (2 x 2 cm). The membrane was positioned to extend beyond the defect margins by 3 to 4 mm apically and 2 to 3 mm laterally.
• Post-operative follow-up: Antibiotic therapy (Amoxicillin 500 mg) and analgesics (Brufen 600 mg) for 5 days, supplemented by 0.2% chlorhexidine rinses for 4 weeks.

L'évaluation des résultats a reposé sur des mesures cliniques de la profondeur de sondage (sonde UNC-15) et des examens radiographiques rétro-alvéolaires (IOPA) effectués à 1, 3 et 6 mois post-intervention.

Results: Marked periodontal regeneration at 6 months

Surgical exploration of tooth 11 revealed a two-walled infra-bony defect, measuring 9 mm in depth and 12 mm in width. Following the application of the protocol combining endodontics, frenectomy, and guided tissue regeneration (GTR), primary healing was achieved without complication. The 4-0 silk sutures were removed at 10 days postoperatively, confirming healthy mucosal closure.

Evolution of clinical parameters

The 6-month clinical follow-up shows a significant reduction in probing pocket depths (PPD). Initially measured at deep pathological levels, the values have stabilized at a physiological level of 3 mm across all surfaces of tooth 11.

Measurement site (Tooth 11)	Baseline (Preoperative)	6-month follow-up
Mesial Face	9 mm	3 mm
Mid-buccal aspect (mid-buccal)	8 mm	3 mm
Distal Face	4 mm	3 mm

Radiographic and qualitative observations

Analysis of the 6-month intraoral periapical radiographs (IOPA) confirms the success of the regenerative strategy:

• Bone grafting: A clinically appreciable radio-opacity is visible at the mesial defect, indicating effective bone filling.
• Periodontal ligament space: A resolution of the initially observed widening of the periodontal ligament space is noted.
• Peri-apical integrity: The disappearance of mesial radiolucency and apical stability validate the effectiveness of intracanalar infection elimination.

The favorable clinical outcome of this case, treating a primary endo-periodontal lesion with secondary periodontal involvement, highlights the effectiveness of the association between crystalline hydroxyapatite (G-Graft) and the chorionic membrane as a biological barrier.

A therapeutic synergy validated by the numbers

The results of this clinical case highlight the effectiveness of rigorous sequencing in treating a primary endo-periodontal lesion with secondary involvement. In the practice, the reduction in probing pocket depth (PPD) from 9 mm mesially and 8 mm buccally to only 3 mm at 6 months post-operatively demonstrates the power of guided tissue regeneration (GTR) when the endodontic infection is previously controlled.

The originality of the approach lies in the use of a chorionic membrane (Tata Memorial Hospital) combined with G-Graft (crystalline hydroxyapatite and collagen). Beyond its function as a physical barrier preventing the apical migration of epithelial cells, this placenta-derived membrane acts as a bioactive scaffold. It releases growth factors and possesses intrinsic anti-inflammatory properties that optimize selective cellular repopulation within the 9 mm deep bone defect.

The elimination of gingival tension through labial frenectomy was also a determining factor, facilitating plaque control and flap stability. Although the results are promising and corroborate literature data on placental biomaterials, it should be noted that this single case report (n=1) with a 6-month follow-up requires larger-scale longitudinal studies to confirm the long-term stability of this bone grafting.

Summary of results

The sequential treatment of a primary endo-periodontal lesion with secondary involvement in a 40-year-old patient (tooth 11) resulted in a reduction of pocket depth from 9 mm to 3 mm within 6 months. The combined approach, associating initial endodontics and guided tissue regeneration (GTR) with crystalline hydroxyapatite (G-Graft) under a chorionic membrane, generated significant radiological bone fill of the 12 mm wide infra-bony defect.

Concretely, for the practitioner:

• Strictly respect the therapeutic chronology: the sanitization of the root canal system must imperatively precede periodontology surgery in order to eliminate the infectious reservoir responsible for the inflammation of the ligament.
• Eliminate tension co-factors: do not underestimate the impact of a short labial frenum or a high insertion; a prior frenectomy is a prerequisite here to ensure flap stability and prevent plaque accumulation on the grafted site.
• Consider the chorionic membrane: beyond its role as a mechanical barrier, its biological properties (low immunogenicity and release of growth factors) promote rapid tissue healing, particularly useful in complex combined defects.

The management of endo-periodontal lesions represents a major clinical challenge due to the anatomical interconnection between the pulp and the periodontium. This case report documents the treatment of a primary endodontic lesion with secondary periodontal involvement in a 40-year-old patient.

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