Tooth replacement in the early-diverging neornithischian Jeholosaurus shangyuanensis and implications for dental evolution and herbivorous adaptation in Ornithischia.

BACKGROUND: Tooth replacement patterns of early-diverging ornithischians, which are important for understanding the evolution of the highly specialized dental systems in hadrosaurid and ceratopsid dinosaurs, are poorly known. The early-diverging neornithischian Jeholosaurus, a small, bipedal herbivorous dinosaur from the Early Cretaceous Jehol Biota, is an important taxon for understanding ornithischian dental evolution, but its dental morphology was only briefly described previously and its tooth replacement is poorly known. RESULTS: CT scanning of six specimens representing different ontogenetic stages of Jeholosaurus reveals significant new information regarding the dental system of Jeholosaurus, including one or two replacement teeth in nearly all alveoli, relatively complete tooth resorption, and an increase in the numbers of alveoli and replacement teeth during ontogeny. Reconstructions of Zahnreihen indicate that the replacement pattern of the maxillary dentition is similar to that of the dentary dentition but with a cyclical difference. The maxillary tooth replacement rate in Jeholosaurus is probably 46 days, which is faster than that of most other early-diverging ornithischians. During the ontogeny of Jeholosaurus, the premaxillary tooth replacement rate slows from 25 days to 33 days with similar daily dentine formation. CONCLUSIONS: The tooth replacement rate exhibits a decreasing trend with ontogeny, as in Alligator. In a phylogenetic context, fast tooth replacement and multi-generation replacement teeth have evolved at least twice independently in Ornithopoda, and our analyses suggest that the early-diverging members of the major ornithischian clades exhibit different tooth replacement patterns as an adaption to herbivory.

Kidney capsule transplantation of chemically treated embryonic murine tooth germs.

Subcapsular transplantation of developing tissues and organs into the richly vascularized murine kidney provides the necessary trophic support, thus ensuring proper completion of their growth.1,2,3 Here, we provide a protocol for kidney capsule transplantation that allows the full differentiation of embryonic teeth previously exposed to chemicals. We describe steps for dissection and in vitro culture of embryonic teeth, followed by transplantation of tooth germs. We then detail harvesting of kidneys for further analysis. For complete details on the use and execution of this protocol, please refer to Mitsiadis et al.4.

Effect of Acellular Dermal Matrix Placement Simultaneous with Implant Placement on Vertical Soft Tissue Thickness: A Randomized Controlled Clinical Trial.

Acellular dermal matrix (ADM) is commonly used for soft tissue augmentation in root coverage, increasing the width of keratinized gingiva or vestibular depth, or filling the localized alveolar bone defects. This parallel-design randomized controlled clinical trial assessed the effect of ADM membrane placement simultaneous with implant placement on vertical soft tissue thickness. A total of 25 submerged implants were placed in 25 patients (8 men, 17 women) with vertical soft tissue thickness < 3 mm at the surgical site. Patients were randomized into two groups: The intervention group (n = 13) received ADM over the implant for soft tissue augmentation, while no augmentation was performed for the control group (n = 12). After 3 months, healing abutments were placed, and the soft tissue thickness at the surgical site was measured again with a periodontal probe in both groups. Data were analyzed using Mann-Whitney and Wilcoxon tests. All 25 patients were successfully treated. The presurgical vertical soft tissue thickness was 2 mm and 1.92 mm in the control and test groups, respectively (P > .05). These values changed to 1.83 mm and 2.69 mm, respectively, after the intervention. The mean gain in soft tissue thickness was 0.76 mm in the test group, and the difference between groups was statistically significant (P < .05). ADM membrane can be successfully used to augment vertical soft tissue thickness simultaneous with implant placement.

A novel chairside technique to assess the interocclusal clearance and abutment axial walls during tooth preparation.

The importance of a judicious and unerring abutment tooth preparation in the field of prosthodontics has always been paramount. It is not uncommon for many clinicians to face challenges during laboratory fabrication of fixed prostheses, caused due to inappropriate occlusal clearance and over axial wall taper of the abutment tooth. With evolving technologies and methods, the modus operandi for attaining such tooth preparation is varying; however, every technique has its own shortcomings. The technique mentioned in the article is cost-effective as it uses modified Heister mouth gag forceps to achieve the desired objective of evaluating the prepared abutment morphology three-dimensionally with minimum chairside time.

Radiographic Outcome of the Endodontic Treatment of 55 Fractured Canine Teeth in 43 Dogs (2013-2018).

Medical records from 4 private practice veterinary dentistry specialty clinics were reviewed for a 5-year period (2013-2018) to identify dogs that had a fractured canine tooth treated by root canal therapy and returned for subsequent follow-up evaluation. Evaluation criteria included the presence of complete medical records with diagnostic quality intraoral radiographs for each procedure visit with a minimum of 6 months between visits. Forty-three dogs with a total of 55 endodontically treated canine teeth were identified and evaluated. Root canal treatment outcome was defined as successful, no evidence of failure (NEF), or failure based on radiographic findings. Patient age, time from initial treatment to follow-up, obturation material used, radiographic quality of obturation (including voids, overfill, and retention of fractured endodontic files), radiographic evidence of periapical disease and/or presence of external inflammatory root resorption (EIRR), and the presence or absence of a full coverage metal crown were evaluated. Treatment was classified as successful in 51 (92.73%) teeth, NEF in 3 (5.45%) teeth, and failure in 1 (1.82%) tooth. The results suggest that endodontic treatment of fractured canine teeth in dogs is a successful treatment option that allows for retention of this functionally important tooth.

Automated detection of posterior restorations in permanent teeth using artificial intelligence on intraoral photographs.

OBJECTIVES: Intraoral photographs might be considered the machine-readable equivalent of a clinical-based visual examination and can potentially be used to detect and categorize dental restorations. The first objective of this study was to develop a deep learning-based convolutional neural network (CNN) for automated detection and categorization of posterior composite, cement, amalgam, gold and ceramic restorations on clinical photographs. Second, this study aimed to determine the diagnostic accuracy for the developed CNN (test method) compared to that of an expert evaluation (reference standard). METHODS: The whole image set of 1761 images (483 of unrestored teeth, 570 of composite restorations, 213 of cements, 278 of amalgam restorations, 125 of gold restorations and 92 of ceramic restorations) was divided into a training set (N = 1407, 401, 447, 66, 231, 93, and 169, respectively) and a test set (N = 354, 82, 123, 26, 47, 32, and 44). The expert diagnoses served as a reference standard for cyclic training and repeated evaluation of the CNN (ResNeXt-101-32 × 8d), which was trained by using image augmentation and transfer learning. Statistical analysis included the calculation of contingency tables, areas under the receiver operating characteristic curve and saliency maps. RESULTS: After training was complete, the CNN was able to categorize restorations correctly with the following diagnostic accuracy values: 94.9% for unrestored teeth, 92.9% for composites, 98.3% for cements, 99.2% for amalgam restorations, 99.4% for gold restorations and 97.8% for ceramic restorations. CONCLUSIONS: It was possible to categorize different types of posterior restorations on intraoral photographs automatically with a good diagnostic accuracy. CLINICAL SIGNIFICANCE: Dental diagnostics might be supported by artificial intelligence-based algorithms in the future. However, further improvements are needed to increase accuracy and practicability.

Er:YAG laser-induced damage to a dental composite in simulated clinical scenarios for inadvertent irradiation: an in vitro study.

Inadvertent Er:YAG laser irradiation occurs in dentistry and may harm restorative materials in teeth. The aim of this in vitro study was to quantify Er:YAG laser-induced damage to a nanohybrid composite in simulated clinical scenarios for inadvertent direct and indirect (reflection) laser irradiation. The simulation was performed by varying the output energy (OE;direct˃indirect) reaching the specimen and the operating distance (OD;direct˂indirect). Composite specimens were irradiated by an Er:YAG laser. The ablation threshold was determined and clinically relevant parameters were applied (n = 6 for each OE/OD combination) for direct (OE: 570 mJ/OD: 10 mm, OE: 190 mJ/OD: 10 mm) and indirect irradiation (OE: 466 mJ/OD: 15 mm, OE: 57 mJ/OD: 15 mm, OE: 155 mJ/OD: 15 mm, OE: 19 mJ/OD: 15 mm). The extent of damage in the form of craters was evaluated using a laser scanning microscope (LSM) and a conventional light microscope (LM). The ablation threshold was determined to be 2.6 J/cm2. The crater diameter showed the highest value (LM: 1075 ± 18 µm/LSM: 1082 ± 17 µm) for indirect irradiation (reflectant:dental mirror) (OE: 466 mJ/OD: 15 mm). The crater depth showed the highest and comparable value for direct (OE: 570 mJ/OD: 10 mm; LSM: 89 ± 2 µm) and indirect irradiation (OE: 466 mJ/OD: 15 mm; LSM: 90 ± 4 µm). For each OD, the crater diameter, depth, and volume increased with higher laser fluence. However, the OD-and thus the laser spot diameter-also had an enlarging effect. Thus, indirect irradiation (reflectant:dental mirror) with only 47% of the laser fluence of direct irradiation led to a larger diameter and a comparable depth. The three-dimensional extent of the crater was large enough to cause roughening, which may lead to plaque accumulation and encourage caries, gingivitis, and periodontitis under clinical conditions. Clinicians should be aware that reflected irradiation can still create such craters.

Hopeless tooth? Prognosis and comprehensive treatment. A case report.

A hopeless tooth from a periodontal point of view, with severe bone resorption, mobility and abnormal tooth migration, is often extracted. In advanced cases, function and esthetics are impaired, and an interdisciplinary treatment is requested. Retaining or not these teeth is based on clinician judgment. A growing body of evidence claims that prognosis has great potential to be improved in a motivated patient with good oral hygiene and regular maintenance. This case report aims to present a periodontal regenerative technique combining enamel matrix protein derivatives and a particulated xenograft to treat intraosseous defects caused by periodontitis. The patient healed uneventfully, and no complications were recorded after the surgical procedure. To correct abnormal tooth migration and improve function and esthetics, orthodontic treatment was instituted. Tooth prognosis improved from hopeless to questionable. This approach extended the life span of a compromised tooth, improving periodontal support and decreasing tooth mobility. This could be an alternative to extraction and implant.

Exodontia associated bacteremia in horses characterized by next generation sequencing.

Bacteremia resulting from dental surgery is increasingly recognized as a health risk, especially in older and immunocompromised patients. Dentistry-associated bacteremia can lead to remote infections, as exemplified by valvular endocarditis. Emerging evidence points to a novel role played by oral cavity commensals in the pathogenesis of diabetes, respiratory disease, cardiovascular disease, and adverse pregnancy outcomes. Whether dental extraction, a commonly undertaken procedure in old horses, causes bacteremia has not been reported extensively. In a prospective clinical study using next generation sequencing (based on bacterial 16S rRNA), the circulating blood microbiome was characterized before and at 1 h following extraction of incisor, canine or cheek teeth from 29 adult horses with dental disease. 16S rRNA gene sequencing results from the blood microbiome were compared with those from gingival swab samples obtained prior to extraction at the location of the diseased tooth. Bacteremia associated with translocated gingival commensals was demonstrated in horses undergoing exodontia and was, in some cases, still evident one hour post-operatively.

Autogenous Tooth Bone Graft and Simvastatin Combination Effect on Bone Healing.

OBJECTIVE: Autogenous tooth bone grafts (ATGM) are materials prepared from extracted teeth and have been used for bone augmentation. These graft materials are known to have similar structures and components to bone grafts. In this sense, this study aimed to evaluate all the tooth layers mixed with simvastatin without any demineralization process effect on bone formation. METHODS: In 60 Wistar albino rats, a standardized 6.0 m-diameter critical size bone defect was created in their calvarium. The study consists of 1 control and 4 experimental groups. In the control group (12 rats), the defects were left empty. The defects were grafted only with ATGM in Group 1, with ATGM mixed with simvastatin in Group 2, autogenous bone graft mixed with simvastatin in Group 3, and with xenogenic bone graft mixed with simvastatin in Group 4. The animals were sacrificed at the 7th and 28th days after operation. RESULTS: PCR, micro CT and histological results show that bone formation was enhanced in the experimental groups in comparison to the control group. Group 1 and Group 2 had similar bone formation rate when compared to Group 3 and Group 4 at the 28th day after operation. CONCLUSION: This study concludes that mineralized teeth may be used for defect reconstruction without any demineralization process. Autogenous mineralized tooth bone graft should be mixed with simvastatin for bone regeneration like other grafts.

Laser Doppler Assessment of Microcirculation of Apical Periodontitis before Nonsurgical and during Surgical Laser Treatment.

INTRODUCTION: Laser doppler flowmetry is a non-invasive method of measuring microcirculatory blood flow in tissue. Using laser doppler flowmetry Moor VMS-LDF1-HP and CP1T-HP probe combined with Moor VMS-PC software to evaluate the state of the periapical lesion (cyst) before nonsurgical endodontic treatment with bioceramics (Well Root SP™) and compare it to a healthy vital tooth of the same type with no periapical lesions. Later the bony crypt of the cyst was evaluated with Moor VMSLDF1-HP and VP7BS-HP probe during periapical surgery after the cyst was ablated with Er: YAG laser Lite Touch™ (Sineron, Israel) and retrogradely obturated with TheraCal LC®. Then the cyst received a bioceramic bone graft. To our knowledge, this is the first time laser doppler has been used during periapical surgery to evaluate tissue perfusion. Lesion type was confirmed with a histological examination after surgery. AIM: Evaluate tissue perfusion of a periapical lesion before nonsurgical treatment and during surgical endodontic treatment with Er:YAG laser with the help of laser doppler flowmeter. RESULTS: Laser doppler flowmetry shows that the cystic tooth has a decreased blood flow, decreased concentration, direct current, speed, and lower temperature compared to a healthy tooth of the same type. During periapical surgery, the direct laser blood flow evaluation of the surgical crypt shows different values of the flux, speed, direct current, concentration, and temperature, which could be attributed to the mechanical trauma, adrenaline in the local anaesthetic or laser irradiation of tissues. CONCLUSIONS: Laser doppler flowmetry is a valuable method to perform tissue evaluation before, during and after treatment. It allows us to follow up the healing and pathological dynamics of microcirculatory tissue changes as well as evaluate and compare different methods and materials for treatment of apical periodontitis.

Simultaneous Perio-endo Surgery with ER:YAG Laser and Bone Xenograft. A Case Report.

Periodontally affected teeth with periapical lesion indicated for periapical surgery have a poor prognosis. Using Er:YAG lasers to perform simultaneous surgery on both defects may increase their survival rate. Preparing a retrograde cavity on affected teeth and obturating it is still a matter of debate among clinicians. The purpose of this case report was to describe the simultaneous use of Erbium-doped Yttrium Aluminium Garnet Er:YAG (2,940 nm) laser in the treatment of periapical granuloma and infraossal defect and the achieved results. The Er:YAG laser was used to perform flap dissection, granulation tissue removal, osteotomy and root-end resection except for initial flap incision and reflection. The cystic cavity was filled with Bio-Oss Collagen® xenograft. Results were followed up for 18 months with the help of radiographic orthopantomographic images. The outcome of this clinical case indicates that the use of Er:YAG laser could be considered a suitable method to perform simultaneous periodontal and endodontic surgery.

The Effects of Premature Tooth Extraction and Damage on Replacement Timing in the Green Iguana.

Reptiles with continuous tooth replacement, or polyphyodonty, replace their teeth in predictable, well-timed waves in alternating tooth positions around the mouth. This process is thought to occur irrespective of tooth wear or breakage. In this study, we aimed to determine if damage to teeth and premature tooth extraction affects tooth replacement timing long-term in juvenile green iguanas (Iguana iguana). First, we examined normal tooth development histologically using a BrdU pulse-chase analysis to detect label-retaining cells in replacement teeth and dental tissues. Next, we performed tooth extraction experiments for characterization of dental tissues after functional tooth (FT) extraction, including proliferation and ß-Catenin expression, for up to 12 weeks. We then compared these results to a newly analyzed historical dataset of X-rays collected up to 7 months after FT damage and extraction in the green iguana. Results show that proliferation in the dental and successional lamina (SL) does not change after extraction of the FT, and proliferation occurs in the SL only when a tooth differentiates. Damage to an FT crown does not affect the timing of the tooth replacement cycle, however, complete extraction shifts the replacement cycle ahead by 4 weeks by removing the need for resorption of the FT. These results suggest that traumatic FT loss affects the timing of the replacement cycle at that one position, which may have implications for tooth replacement patterning around the entire mouth.

Chitosan: A natural substitute of EDTA solution for final irrigation in endodontics treatment.

BACKGROUND: The purpose of this study was to assess the quantity of the chelated calcium ions and the smear layer removal efficiency after root canal final irrigation with three different solutions. MATERIALS AND METHODS: Forty-five teeth were instrumented with rotary-files, then randomly divided into 3 equal groups (n = 15) depending on the final irrigation solution; group I: 17% ethylenediaminetetraacetic acid (EDTA), group II: 0.2% chitosan, and group III: 10% trisodium citrate. According to the time of application, every group was divided into 3 subgroups (1 min, 5 min, and 24 h). The quantification analysis of chelated calcium ions was performed by flame atomic absorption spectrometry (FAAS). Then, the presence of smear layer was examined by splitting the samples longitudinally and using scanning electron microscopy (SEM) to examine coronal, middle, and apical root canal levels. One-way analysis of variance (ANOVA) test was used for the evaluation of treatment effect. Kruskal-Wallis test was executed to detect a significant difference between groups, while Mann-Whitney U test has determined the difference between each two groups for smear layer. RESULTS: Both 17% EDTA and 0.2% chitosan had not been statistically significant difference for smear layer removal efficiency and observed calcium ion concentrations. Although, they were more efficient of 10% trisodium citrate with a significant difference (P < 0.05). CONCLUSION: The application time of the chelators' solutions must not exceed 5 min to completely remove smear layer, and 0.2% chitosan is a natural substitute for 17% EDTA with a safety application for 24 h.

Three-dimensional evaluation of skeletal and dental changes in patients with skeletal class III malocclusion and facial asymmetry after surgical-orthodontic treatment.

OBJECTIVE: To evaluate skeletal and dental changes in patients with skeletal Class III malocclusion and facial asymmetry after surgical-orthodontic treatment using cone-beam computerized tomography (CBCT). METHODS: This study included forty adult patients diagnosed with skeletal Class III malocclusion and asymmetry who underwent either isolated mandibular surgery or bimaxillary surgery. CBCT scans were taken before treatment (T0), at the completion of presurgical orthodontic treatment (T1) and after treatment (T2). Mimics 17.0 and 3-Matics 7.0 were used to measure skeletal and dental parameters. Skeletal and dental changes within each group from pretreatment to posttreatment were assessed, and Pearson correlation analysis was used to analyze the correlations among skeletal changes. RESULTS: The three-dimensional changes in condylar position were insignificant after surgical-orthodontic treatment in either group (P > 0.05). However, in the one-jaw surgery group, there were significant backward rotations of the condyle and ramus on the nondeviated side (P < 0.05), and the condyle on the deviated side rotated inward and forward significantly in the two-jaw surgery group (P < 0.05) at T2. There were no significant differences in the changes in the total alveolar bone thickness of bilateral first molars during dental decompensation (P > 0.05). The ratio between the buccal and the total bone thickness around the maxillary first molar on the deviated side decreased significantly at T1, as did those around the mandibular first molar on the nondeviated side (P < 0.05). CONCLUSIONS: Condylar angulations were less stable after treatment (7 to 9 months after surgery) in both the one-jaw and the two-jaw surgery groups, while condylar displacements were insignificant. In addition, orthodontists should keep a watchful eye to the relative position of the root in the alveolar bone during tooth decompensation.

Orthognathic surgery with two-segment le fort i and sagittal split ramus osteotomies of open bite deformity in an amelogenesis imperfecta patient via virtual planning: A case report.

Amelogenesis imperfecta (AI) is an enamel defect and is often associated with the anterior open bite (AOB) and transverse maxillary deficiency. It is known that in such cases when AI and AOB appeared together, posterior maxillary impaction with or without bilateral mandibular ramus osteotomies is a frequently preferred treatment option. Virtual planning is more reliable rather than the conventional model surgery planning, especially for complicated cases. Usage area of virtual 3D anatomical models reconstructed from Cone Beam Computed Tomography (CBCT) data is expanding day by day for both diagnosis and surgical planning. The aim of this study is to present a patient with AI and AOB and transverse maxillary deficiency and management of this case with virtually planned two-segment Le fort I and sagittal split ramus osteotomies followed by prosthetic rehabilitation.

Apical periodontitis healing and postoperative pain following endodontic treatment with a reciprocating single-file, single-cone approach: A randomized controlled pragmatic clinical trial.

This trial assessed post-operative pain and healing of apical periodontitis following endodontic therapy with a reciprocating system compared to a crown-down technique with hand files and lateral compaction filling. One-hundred and twenty nonvital anterior teeth with apical periodontitis were randomly treated using either a reciprocating single file followed by matching-taper single-cone filling or a hand file and lateral compaction filling. Postoperative pain was assessed during the 7 days after the treatment, using a visual analogue scale and a verbal rating scale. Apical healing was assessed using the periapical index score after a 12-month follow-up. The hypothesis tested was that both protocols were equivalent and present similar effectiveness in healing periapical lesions. Data were analyzed through two one-sided tests, t-tests, as well as Mann-Whitney and Chi-squared tests (α = 0.05). Logistic regression was used to investigate the association of clinical and demographic factors with the success of treatment. Regardless of the assessment time, no difference in incidence (38%-43% at first 24h), intensity of postoperative pain, and incidence of flare-up (≈ 3%) was observed between the two endodontic protocols. Both protocols resulted in a similar healing rate of apical periodontitis. After 12 months, the success rate ranged from 73% to 78% and the difference between the treatments fell within the pre-established equivalence margin (-0.1; -0.41 to 0.2). Endodontic treatment combining a reciprocating single file with matching-taper single cone showed similar clinical effectiveness to the treatment using hand-file instrumentation and the lateral compaction filling.

Dental and Skeletal Changes after Transpalatal Distraction.

Maxillary constriction is a common skeletal craniofacial abnormality, and transverse maxillary deficiency affects 30% of patients receiving orthodontic and surgical treatment. The aim of the study was to analyse craniofacial skeletal changes in adults with maxillary constriction after transpalatal distraction. The study group consisted of 36 patients (16 women) aged 17 to 42 years (M = 27.1; SD = 7.8) with a known complete skeletal crossbite and who underwent transpalatal distraction procedure. The measurements were obtained on diagnostic models, and cephalometric PA radiograms were obtained at time points, i.e., before treatment (T1) and after the completion of active distraction (T2). The analysis of diagnostic models involving the arch width measurement at different levels demonstrated a significant increase in L1, L2, L3, L4, L5, and L6 dimensions after transpalatal distraction. The largest width increase (9.5 mm) was observed for the L3 dimension (the intercanine distance). The analysis of frontal cephalograms displayed a significant increase in W1, W2, and W3 dimensions after transpalatal distraction. The largest width increase (4.9 mm) was observed for the W1 dimension at the level of the alveolar process of the maxilla. Transpalatal distraction is an effective treatment for transverse maxillary deficiency after the end of bone growth. The expansion observed on diagnostic models is close to a parallel segment shift mechanism, with a mild tendency towards a larger opening anteriorly. The maxillary segment rotation pattern analysed based on the frontal cephalograms is close to a hand fan unfolding with the rotation point at the frontonasal suture.

Biomechanical effects of corticotomy facilitated orthodontic anterior retraction: a 3-dimensional finite element analysis.

The objective of this study was to assess the biomechanical effects of different corticotomy designs used for orthodontic anterior retraction through finite element analysis. MATERIALS AND METHODS: A basic finite element model simulating retraction of anterior teeth was built reversely from CBCT films of an adult patient with protruded maxillary anterior teeth. Another thirteen FE models were created according to different corticotomy designs varied with site width and the extent of incision. The initial displacement, Von Mises stress and pressure stress of dento-alveolar structures was computerized and analyzed. RESULTS: Corticotomy can increase the initial displacement of anterior segment including teeth and surrounding alveolar bone, change the distribution of Von Mises stress in cancellous bone and the pressure stress in periodontal ligament of anterior teeth. When the incision was near the periphery of apical, the anterior segment showed the greatest displacement, the cancellous bone at either sockets or incision region showed the maximum stress. Bilateral incision combined with palatal incision showed approximate initial displacement and stress distribution with circumscribing incision. While the incision width increased, the biomechanical effects of corticotomy amplified. CONCLUSIONS: Varied corticotomy designs can change the biomechanical effects on dento-alveolar structures. The incision near the periphery of apical and bilateral incision combined with palatal incision may be the optimized design used for retraction of anterior teeth.

A Multidisciplinary Approach of an Endo-Perio Lesion in a Severely Compromised Tooth: An 18-Year Follow-up Case Report.

This case report describes the diagnosis, multidisciplinary treatment, and long-term follow-up of a severely compromised tooth in a patient who was referred for assessing a gingival recession. Clinical evaluation of the left maxillary canine showed 12 mm of mid-buccal gingival recession, probing depth of 14 mm on the mesial-buccal aspect, and grade III mobility. A periapical radiograph revealed extensive periapical and lateral radiolucency. The first step of the treatment was to carry out oral hygiene instructions and full-mouth debridement. After that, endodontic treatment was performed immediately. Periodontal reevaluation four months after endodontic therapy revealed that probing depths of all sites were within 3 mm and periapical radiograph showed a slight decrease in periapical and lateral radiolucency. It was subsequently decided to perform root coverage with a laterally positioned flap and subepithelial connective tissue graft. Six months after surgery, the root surface showed 1 mm recession, representing root coverage of 91.7% and a gain of attachment of 13 mm. The patient was enrolled in a 6-month supportive periodontal therapy. Treatment outcomes were evaluated over 18 years, with successful radiographic and clinical results throughout the follow-up period. The successful management of endo-periodontal lesions requires an accurate diagnosis, which is imperative to provide proper therapy in the correct treatment sequence.