Takayoshi Nagahara

Background: Distal furcation‐associated intrabony defects in mandibular molars are difficult to manage because of limited surgical access, restricted visibility, and complex root anatomy. This case report describes the regenerative management of a distal furcation‐associated intrabony defect in a mandibular first molar using recombinant human fibroblast growth factor‐2 (rhFGF‐2) with a double‐sided entire papilla preservation technique‐based approach (DEPPT‐BA). Methods: A 56‐year‐old systemically healthy woman presented with stage III, grade B periodontitis and Hamp Class II distal furcation involvement of the mandibular left first molar, with a maximum probing pocket depth (PPD) of 8 mm. After initial periodontal and endodontic therapy, periodontal regenerative surgery was performed using the DEPPT‐BA to obtain buccal and lingual access while preserving the interdental papilla. rhFGF‐2 was applied to the defect without adjunctive bone graft material. Results: Healing progressed without major complications. At 12 months postoperatively, PPDs were ≤2 mm at all sites, bleeding on probing was absent, and the distal furcation involvement was clinically resolved without gingival recession. Cone‐beam computed tomography demonstrated substantial bone fill within the intrabony defect and clinical resolution of the distal furcation involvement. Conclusions: Within the limitations of a single case report, this application of DEPPT‐BA combined with rhFGF‐2 may improve buccal and lingual access while maintaining interdental soft‐tissue stability in distal furcation‐associated intrabony defects with buccolingual extension in mandibular molars. Key points: Distal furcation‐associated intrabony defects in mandibular molars pose considerable regenerative challenges, given limited access, restricted visibility, and complex root anatomy. DEPPT‐BA provided buccal and lingual access to the distal furcation defect while preserving the interdental papilla and maintaining wound stability. Favorable 12‐month clinical and radiographic outcomes were achieved using rhFGF‐2 without adjunctive bone grafting material. Plain language summary: This case report describes the treatment of a difficult periodontal defect affecting the distal furcation area of a mandibular molar using DEPPT with rhFGF‐2. The technique improved surgical access while maintaining soft‐tissue stability, resulting in favorable clinical healing and substantial bone fill at 12 months.

Background/Objectives: Endodontic–periodontal lesions (EPLs) represent complex pathological conditions arising from interactions between endodontic and periodontal infections. Existing classification systems primarily describe the etiology or periodontal tissue destruction but provide limited support for clinical interpretation, particularly pulp preservation and the sequencing of endodontic and periodontal management. This review aimed to propose a biologically informed conceptual framework intended to organize clinical reasoning considerations in EPL management. Methods: This narrative review integrates current knowledge regarding pulp vitality, pathways of infection, periodontal healing, and treatment sequencing reported in the endodontic and periodontal literature. Based on this synthesis, a conceptual framework was constructed using two clinical dimensions: the extent of remaining vital pulp and the presence or absence of coronal-originating infection (IC), defined as a potential coronal pathway of bacterial ingress that may contribute to lesion development. Results: The framework categorizes EPLs into four principal groups according to pulp vitality (vital/non-vital) and IC status (present/absent), with additional grading to describe the potential feasibility of pulp preservation and structural reassessment during initial management. Rather than prescribing specific therapies, the model organizes clinical interpretation related to pulp-preserving considerations, the timing of periodontal intervention, and evaluation of surgical management following nonsurgical treatment. Conclusions: This framework provides a biologically oriented conceptual model for understanding EPLs and structuring clinical reasoning. It is intended as a hypothesis-guided interpretive framework rather than a clinical practice guideline and is designed to support case interpretation, not to determine mandatory treatment decisions; thus, its clinical applicability requires further validation, and prospective multicenter studies are necessary before routine clinical implementation.

Background: Cemental tear, representing separation of cementum from the root surface, is a rare but challenging condition often mimicking vertical root fracture or endodontic–periodontal lesions. Despite advances in regenerative therapy, a predictable treatment protocol for cemental tears with non‐contained bone defects remains lacking. Minimally invasive regenerative surgical techniques, such as the entire papilla preservation technique (EPPT) and connective tissue graft (CTG) wall technique, may optimize wound stability and enhance clinical outcomes when combined with biologic agents. Methods: A 73‐year‐old male patient presenting with gingival swelling and suppuration in #8 was diagnosed with a two‐wall bone defect associated with a cemental tear (Class 3/Stage B) using cone‐beam computed tomography (CBCT). Regenerative therapy was performed using recombinant human fibroblast growth factor‐2 (rhFGF‐2), carbonate apatite (CO ₃ Ap), and a CTG applied via the EPPT. Clinical parameters and radiographic findings were evaluated at baseline and 1, 3, 6, and 12 months postoperatively. Results: Healing progressed without postoperative complications such as gingival recession or graft exposure. The probing pocket depth was reduced from 10 to ≤3 mm, and clinical attachment gain of 7 mm was achieved at 12 months. CBCT demonstrated complete radiographic bone fill and reformation of the proximal and labial bone walls. Conclusion: Combination regenerative therapy using rhFGF‐2, CO ₃ Ap, and CTG with the EPPT achieved stable soft and hard tissue regeneration in an elderly patient with a cemental tear–associated two‐wall bone defect. This multidisciplinary, minimally invasive approach shows promise for managing complex non‐contained intrabony defects while maintaining gingival aesthetics. Key points: A multidisciplinary regenerative approach combining rhFGF‐2, CO ₃ Ap, and CTG with EPPT resulted in favorable clinical and radiographic outcomes for a cemental tear–associated two‐wall bone defect. The CTG wall technique functioned as a protective barrier, minimized gingival recession, and promoted soft tissue stability. Cone‐beam computed tomography aided in the accurate diagnosis of cemental tear morphology and postoperative evaluation of bone regeneration. This case underscores the importance of flap design and biologic integration in achieving optimal periodontal and aesthetic results. Plain Language Summary: This case report describes a new treatment method for repairing bone loss around a tooth caused by a “cemental tear,” a type of root surface damage that can lead to gum swelling and bone destruction. A 73‐year‐old male patient was treated with a combination of a growth factor (rhFGF‐2), a synthetic bone substitute (CO ₃ Ap), and a small piece of gum tissue (CTG) using a minimally invasive surgical technique that preserves the entire gum papilla. Over 12 months, the treatment resulted in significant healing of both bone and gum tissues without recession. This approach may offer a reliable option for saving teeth with similar severe bone defects.

Background: Recombinant human fibroblast growth factor‐2 (rhFGF‐2) has been shown to effectively promote the formation of new periodontal tissues, and its efficacy has been demonstrated in clinical settings. Moreover, the clinical and radiographic outcomes in the treatment of periodontal infrabony defects can be improved by using rhFGF‐2 in combination with a bone substitute. Here, we present a case of four‐wall bone defect in a tooth treated by combination regenerative therapy using rhFGF‐2 and beta‐tricalcium phosphate (βo‐TCP). Methods: A 43‐year‐old male with a four‐wall bone defect in tooth #28 was subjected to combination therapy with rhFGF‐2 and β‐TCP. Periodontal clinical parameters and radiographic images were evaluated at the first visit, after the initial periodontal treatment, and after 4 months and 4 years postoperation. Results: Although gingival recession and nonvital pulp were observed postoperation, improvements in the periodontal parameters and radiographic outcomes were subsequently recorded. Conclusion: Periodontal regenerative therapy with a combination of rhFGF‐2 and β‐TCP showed great potential in the treatment of four‐wall bone defects of teeth. Key points: Periodontal regenerative therapy using recombinant human fibroblast growth factor‐2 (rhFGF‐2) and beta‐tricalcium phosphate (β‐TCP) showed immense potential in the treatment of four‐wall bone defect in teeth. In addition to using computed tomography for assessing bone defects and root morphologies, an evaluation of root canal morphology and pulp diagnosis is essential for understanding the internal and external aspects of the defect, which would aid in tooth preservation. Appropriate periodontal and endodontic treatments enabled tooth preservation following apical periodontitis after periodontal regenerative therapy. Plain language summary: This case report focuses on a new approach for the treatment of a four‐wall bone defect, a significant dental issue in which the bone around the tooth is damaged, thereby decreasing the stability of the tooth. We treated a 43‐year‐old male patient with a combination of two key components: the growth factor rhFGF‐2, which helps promote the growth of new tissues, and the synthetic bone graft substitute β‐TCP, which acts as a substitute for the missing bone. Over the course of 4 years, we monitored the patient's progress using dental exams and X‐ray photos. Despite some minor side effects, such as gum recession and the loss of tooth vitality, the overall condition of the tooth and surrounding bone showed significant improvement. This combination therapy shows promise in repairing similar bone defects, which would help save teeth that might otherwise be lost.

Key Clinical Message: Endodontists should be aware that some maxillary second molars can have more than three roots. If any unusual anatomical features are detected during dental radiography or endodontic procedures, it is necessary to conduct cone‐beam computed tomography (CBCT) scanning to prevent procedural mishaps. CBCT can provide three‐dimensional reconstructed images of the root canal system. With the help of CBCT, variations in tooth root number and root canal morphology, such as extra canals, apical ramifications, apical deltas, and lateral canals, can be identified. Knowledge of the variations is very important for the success of endodontic treatment. This report suggests that endodontists must not assume that a MSM has only three tooth roots, which is the most prevalent number.

Cone‐beam computed tomography and clinical examinations including pulp vital testing and pocket probing depth showed a cemental tear with a severe labial alveolar bony defect, but no endodontic lesions, in #25, which had a sinus tract at the labial site, in a 75‐year‐old woman.

Cone-beam computed tomography and clinical examinations including pulp vital testing and pocket probing depth showed a cemental tear with a severe labial alveolar bony defect, but no endodontic lesions in #25, which had a sinus tract at the labial site, in a 75-year-old woman.

The present case report describes the clinical detection and root canal management of a rare middle mesial canal of a Japanese mandibular second molar by troughing preparation using an operating microscope and cone‐beam computed tomography.

Key Clinical Message: Dental radiography and cone‐beam computed tomography revealed the left mandibular first molar in a 68‐year‐old female patient with Heithersay Class 3 invasive cervical resorption ( ICR ). The inhibition of ICR progression and environmental improvement in and around the affected tooth through combined endodontic and periodontal treatments led to a favorable clinical outcome.