October 16, 2018
by Valentin Dabuleanu, BSc, DDS, MSc, FRCD(C); Mary Dabuleanu, DDS, MS, FRCD(C)
Periodontal regenerative medicine encompasses a spectrum of procedures that restore lost tooth-supporting hard and soft tissue, thereby reversing some of the damage caused by periodontal disease. This is in contrast with repair of periodontal tissues that was the staple of periodontal treatment for decades. Regenerative surgery involves the reflection of the gingival tissue and removal/disruption of the majority of disease-causing bacteria/biofilm. Over the past 25 years research in this field has followed two paths. On the one hand, there has been development in the types of membranes and bone grafts used, as well as the addition of tissue-stimulating factors, which encourage the body’s natural ability to regenerate periodontal tissues. On the other hand, there has also been development in novel surgical approaches that maximize treatment outcomes. 1 This progress has resulted in a shift in case analysis, such that teeth with localized severe periodontal disease, including those with combined endodontic-periodontal lesions, are no longer considered as having a hopeless therapeutic prognosis. 2
This article will review the rationale for treatment, a classification system for intrabony defects, lesion diagnosis, indications for treatment, site-specific factors such as the combined endodontic-periodontal lesion, materials used, surgical techniques, postoperative care, efficacy and effectiveness, as well as factors influencing patient selection. Clinical application will then be illustrated by five case presentations.
The goals of periodontal treatment are to eliminate infection and to resolve chronic inflammation. When this is achieved disease progression is arrested, and its recurrence is prevented. Short term clinical indicators of successful treatment are an absence of bleeding on probing as well as the presence of shallow probing depths ≤4mm. Long-term success is defined by the lack of recurrence of infection and absence of progression of periodontal destruction. Teeth with persisting pockets >5mm following non-surgical therapy are often associated with intrabony and furcation periodontal defects. These teeth are at an increased risk for disease progression and tooth loss. 3 Periodontal regeneration aims to achieve an increase in the attachment of severely compromised teeth, a decrease in pocket depths to a more maintainable depth, and a reduction in the vertical and horizontal components of both intrabony and furcation defects. 4 This treatment provides us with the possibility of changing the prognosis of a tooth from either questionable or hopeless, to fair or even good. As a result, an increased number of teeth can be maintained, and patient comfort and function are improved. 1
Classification of Periodontal Osseous Defects
When periodontal breakdown occurs around teeth, it is site-specific. The long-term prognosis of teeth is compromised by way of the formation of three different kinds of defects: suprabony (or horizontal), infrabony (or vertical), and inter-radicular (or furcation-type) (Fig. 1). In suprabony defects, the base of the pocket is coronal to the alveolar crest, whereas in infrabony defects, the base of the pocket is apical to the crest. Infrabony defects are further divided into intrabony defects and craters (Fig. 2.). Intrabony defects primarily affect one tooth. Craters are formed when the defect connects two adjacent root surfaces. 4 One-, two-, and three-wall intrabony defects are defined on the basis of the number of residual alveolar bone walls surrounding the tooth. 5 The most widely used classification system of furcation involvement by Hamp et al. 6 distributes furcations into Class I, or incipient lesions when the horizontal attachment loss does not go beyond 3mm, Class II, when there is a horizontal loss of >3mm but not encompassing the total width of the furcation area, and Class III, when there is through-and-through communication (Fig. 3.).
Tentative diagnosis of suprabony, infrabony, and inter-radicular defects requires a combination of periodontal probing, periapical radiographs, and bone sounding under local anaesthesia, although the true morphology of the defect is usually not identified until it is visualized surgically. An accurate diagnosis can then be made, and this leads to a more evidenced based prognosis and site/defect specific treatment. 7
Regenerative periodontal therapy is indicated in three clinical situations. First, it can be applied in deep and narrow intrabony defects. Three-wall intrabony sites are well contained and thus preferred. However, two- and even one-wall sites can be successfully treated when the correct combination of surgical technique and regenerative materials are chosen (Fig 4.). 1 Second, it can be applied in Class II buccal furcations of both maxillary and mandibular molars. Regeneration is less predictable at mandibular lingual furcations. Regeneration is unpredictable at maxillary interproximal Class II and at all Class III furcations (Fig. 5). 7 Third, it can be applied in deep intrabony defects of ≥7mm in esthetic areas, as this treatment will maximize attachment gain while at the same time limit postoperative recession. 8 Regenerative treatment is preferred over traditional osseous resection in the esthetic zone (Fig. 6.).4
Site-Specific Factors: The Combined Endodontic-Periodontal Lesion
Endodontic pathology that affects the surrounding periodontium can mimic the combined endodontic-periodontal lesion, however full recovery of the periodontium is expected with prompt proper root canal treatment or retreatment. 9 When endodontic pathology affecting the periodontium is left untreated, sub-gingival calculus inevitably forms, and the resulting periodontal defect will not spontaneously recover. This combined lesion, specifically: primary endodontic-secondary periodontal, may occur with a long-standing necrotic pulp, inadequate root canal treatment or the iatrogenic lateral strip and furcal perforation. In these situations, the endodontic pathology must first be addressed with root canal treatment, retreatment and/or perforation repair. If the periodontal pathology is an intrabony defect, then regenerative surgery may only commence once the endodontic (re)treatment is considered successful. Teeth with severe uncontrolled mobility, Miller grade II or higher 10, may impair regenerative success. These teeth should receive pre-operative splinting. 1
Usually a period of ≥3-month healing after endodontic (re)treatment is allowed for periodontal recovery and to allow for partial improvement of the combined lesion. 1 Recent research, however, suggests that periodontal surgery should not be delayed as parameters such as improvements in probing depths, relative attachment level, bleeding on probing and mobility are statistically comparable. 11-12
Barrier Membranes: Barrier membranes are used in guided tissue regeneration (GTR) with the intention of blocking and physically excluding epithelial down-growth into the regenerative zone. They provide wound stability for the blood clot and space provision to allow the up-growth of periodontal ligament cells along the root surface (Fig. 7.). Earlier barrier membranes were non-resorbable, and included cellulose acetate (Millipore©), expanded polytetrafluoroethylene (PTFE ) (GoreTex©) as well as dense PTFE (Cytoplast™) membranes (e-PTFE, d-PTFE respectively). These membranes were successful but necessitated removal in a second surgery. 1,4 More current techniques involve the use of natural or synthetic bioabsorbable membranes (Fig. 8.).
Bone graft: All bone grafts used in periodontal regenerative surgery provide space provision, blood clot stabilization and an osteoconductive platform to allow bone regeneration to take place (Fig. 9.). 1 Intraoral and extraoral autogenous grafts were the first type of bone graft used. Autogenous bone had the potential to provide osteogenesis. Human histology confirmed that true regeneration occurred with this graft. Treatment was not predictable, however, and carried with it the risk of transference of osteoclasts to the recipient site, which resulted in ankylosis and root resorption. 4
Allografts were the first natural substitute used for autogenous grafts. Two types of allografts are available: mineralized freeze-dried bone allograft (FDBA) (MinerOss®, Raptos® among others), and decalcified freeze-dried bone allograft (DFDBA) (Dynagraft® among others). DFDBA by way of demineralization exposes bone morphogenetic proteins (BMPs) which have the ability to induce host cells to differentiate into osteoblasts. Research has shown variability in the osteoinductive potential of DFDBA, however. 4
Xenograft was the second natural substitute used for autogenous grafts. Deproteinized bovine bone mineral may serve as a non-organic osteoconductive scaffold. Alloplastic materials are synthetic, inorganic, and biocompatible bone graft substitutes which may also provide osteoconduction. The four most common kinds of alloplasts used are hydroxyapatite, beta-tricalcium phosphate (β-TCP), polymers, and bioactive glasses. 4
Wound Healing Modifiers: Wound healing modifiers are used to accelerate the process of matrix formation and cell differentiation. Two preparations are available (Fig. 10.). The first, enamel matrix derivative (EMD), is supported by human histological studies, case report studies, meta-analyses of randomized controlled trials, and large multicenter trials. EMD is derived from the enamel layer of developing porcine teeth. When applied in the wound, EMD promotes both hard and soft tissue regeneration. It decreases the expression of cytokines interleukin (IL)-1β and IL-8, increases the expression of hormone-like prostaglandin PGE 2 and cytokine receptor osteoprotegerin (OPG), and it decreases the expression of receptor activator of nuclear factor kappa-B ligand (RANKL). This results in diminished osteoclast activity. EMD increases the proliferation of T-lymphocytes, which enables tissue debridement. EMD promotes the formation of osteoblasts, it improves periodontal ligament (PDL) cell regeneration, and it improves angiogenesis. Furthermore, EMD lowers bacterial numbers, resulting in reduced local inflammation. 13 EMD in a gel form is available for use in Canada as Straumann® Emdogain.
The second wound healing modifier, recombinant human platelet-derived growth factor-BB (rhPDGF-BB), is supported by significant pre-clinical research, as well as multicentre clinical studies. When applied in the wound, rhPDGF-BB triggers an increased production of osteoblast-like cells. 14 Clinical studies are not consistent, however, in demonstrating a significant difference in clinical attachment level gain when compared with control treatment. 1 rhPDGF-BB is not available in Canada. It is available in the United States as GEM 21S®, and comes in a solution, paired with β-TCP alloplast graft. The two are mixed together before being applied into the intrabony defect.
Novel research on chemoattractants, such as recombinant human stromal cell-derived factor-1α (SDF-1α) are currently being investigated using animal studies, to assess their ability to recruit the body’s own stem cells and stimulate regeneration of alveolar bone as well as periodontal ligament. 15 Research is also underway in preparing a decellularized tissue engineered construct, a bioactive scaffold, from healthy human PDL tissue, and assessing its regenerative capacity to recruit the body’s own stem cells, using the animal model. 16
Incision: When the interdental space width is >2mm, the defect-associated papilla should be incised according to the modified papilla preservation technique (MPPT) (Fig. 11.). When the space is ≤2mm, the simplified papilla preservation flap (SPPF) is used, which has an oblique interdental incision. These designs are intended such that space is created for regeneration in the interdental area. 1
Flap Design: The flap design should be selected based on the anticipated perimeter of the intraosseous defect (Fig. 12.). When involving only one third of the root perimeter, and if cleansable from the buccal aspect, a modified minimally invasive surgical technique should be used (M-MIST). This involves minimal elevation of the buccal flap. The defect-associated interdental papilla and lingual flap are left untouched. If the defect requires both buccal and lingual access, then both papillae are reflected. This is known as the minimally invasive surgical technique (MIST). If the defect is extensive and involves greater than three quarters of the root perimeter, the flap is extended. 1
Use of Materials: Very well contained intrabony defects that are appropriate for the M-MIST surgical access technique require either no regenerative material at all, or the application of EMD only. As long as primary wound closure is achieved 14, space is created for the formation of a blood clot at the interface between the flap and the root surface (Fig. 7.), and the blood clot remains stabilized and continuous against the root surface, the invasion of long junctional epithelium is prevented and regeneration can occur. 1,3 As defects become larger and non-containing, graft material should be employed, with the addition of a barrier membrane for even larger defects.
Suturing: A zone of inflammatory infiltrate extends up to 3 mm from the incision line. To help maintain primary wound closure, vertical or horizontal mattress holding sutures should be placed outside of this inflammatory zone. Simple interrupted closing sutures can then be placed within the inflammatory zone. 17
A one-week course of systemic antibiotics, combined with a two-week course of 0.12% chlorhexidine mouth rinse, will help reduce the incidence of post-operative infection. Local brushing and flossing should be avoided, and a soft diet should be adhered to until full soft tissue wound closure is achieved. Subgingival root planing and restorative dentistry should be avoided for 9 months. 1
Efficacy and Effectiveness
Both the clinical efficacy, the added treatment benefit as assessed under the ideal conditions of a highly controlled research centre, and clinical effectiveness, the benefit that can be achieved in a regular clinical setting, have been thoroughly researched for over 25 years with respect to periodontal regeneration. 1
Graziani et al. in 2011 performed a systematic review and meta-analysis of 27 randomized control trials (RCTs) including 647 patients and 734 sites treated with conservative surgery (CS) alone, with a minimum of 12-month follow-up. CS included a variety of different surgical techniques that all involved direct access to the root surface, removal of residual plaque and calculus, and site closure with no active resection of bone or soft tissue. In some cases, the intention was to achieve primary wound closure over a stable blood clot. In others, regenerative materials were applied within the bony defect. They found a 12-month post-operative statistically significant clinical attachment level gain of 1.65mm. 18
A Cochrane systematic review and meta-analysis of 9 RCTs, including 371 patients, with study durations of ≥12 months, directly compared the effectiveness of treatment with enamel matrix derivative (EMD), versus guided tissue regeneration (GTR), and procedures involving bone grafting (BG) within intrabony defects. They found that EMD treated sites showed statistically significant probing attachment level gains of 1.1mm, when compared with open flap debridement alone. EMD treated sites showed similar clinical results to GTR, but showed statistically significantly fewer cases of postoperative flap dehiscences and infection then GTR. 19 The studies indicate that clinical improvements beyond those of traditional flap surgery can be obtained by treating intrabony defects with regenerative therapies, but a great variability in clinical outcomes must be noted. An appropriately trained surgeon who controls for local and systemic conditions can predictably expect regeneration, an advanced healing event, to occur. 1
The identification and control of several local, behavioural and systemic factors will help to ensure a successful outcome with periodontal regenerative surgery. Patients with good plaque control habits, and who are compliant with prescribed post-operative care are good candidates. Non-smokers have a lower risk for postsurgical infection, and are more likely to have treatment success than those who smoke.
Case 1: Patient Profile, Concerns, Diagnosis
A healthy 40-year-old male with generalized aggressive periodontal disease presented for comprehensive periodontal treatment (Fig. 13). His first round of treatment was non-surgical and included full-mouth debridement combined with a one-week course of systemic antibiotics and a two-week course of 0.12% chlorhexidine mouth rinse. Tooth 13 remained with a 9 mm mesial pocket. A narrow 3-wall intrabony defect, as well as trapped subgingival calculus was suspected at tooth 13 mesial (Fig. 14). The patient was concerned that he had already lost several of his teeth due to periodontal disease. He wanted to maintain the rest of his teeth for as long as possible.
The patient was advised that regenerative surgery was indicated to maximize attachment gain while at the same time limit postoperative recession. The reduction, but not complete elimination, of periodontal attachment loss was put in perspective and discussed. He was also made aware that some post-operative gingival recession was an unavoidable consequence of the surgery. Informed consent was obtained.
A full-thickness flap was reflected at teeth 13, 12 buccal. A vertical releasing incision was made at tooth 13 distal. Granulation tissue and trapped calculus were curetted. A narrow 4 mm 3-wall intrabony defect was confirmed. The pedicle at 13 distal was mesially positioned and co-apted with chromic gut absorbable sutures. Straumann® PrefGel was applied to the root surface for two minutes, and then washed with sterile saline (Fig. 15). Straumann® Emdogain was applied to the root surface. The site was co-apted further, and Cyanoacrylate oral adhesive (PeriAcryl® – Citagenix) was placed along the distal releasing incision (Fig. 16).
The patient was seen for one-week and one-month post-operative checks. At 10-months the site showed good epithelial maturation and blending with the adjacent tissue. Some scar tissue was evident. A comparison of the initial clinical site and 10-month postoperative follow-up shows a slight increase in recession. A comparison of PA radiographs reveals significant resolution of the intrabony component of the defect (Fig. 17).
Case 2: Patient Profile, Concerns, Diagnosis
A healthy 70-year-old male with a healthy reduced periodontium, but localized severe periodontal disease at tooth 43, presented for periodontal treatment (Fig. 18). An 8 mm distal pocket was measured at tooth 43. Tooth 44 was necrotic. The radiograph revealed a narrow intrabony defect at tooth 43 distal, as well as well as a periapical lesion apical to tooth 44 (Fig. 19). The lower canines and first premolars served as removable dental prosthesis abutments. The localized severe periodontal disease may initially have been caused by a lateral strip perforation on the disto-lateral aspect of tooth 43, which had been repaired with MTA a number of years prior. Nevertheless, a primary endodontic-secondary periodontal lesion was suspected on tooth 43.
The patient was advised that root canal retreatment of tooth 44, along with regenerative surgery at tooth 43 were indicated. This would preserve both teeth 43 and 44, as well as maximize attachment gain, and decrease the pocket depth to a more maintainable range at tooth 43. The reduction, but not complete elimination, of periodontal attachment loss was put in perspective and discussed. Informed consent was obtained.
Tooth 44 received root canal treatment three months prior to surgery. A full-thickness flap was reflected at teeth 43, 44 lingual. The flap was extended crestally both on the mesial and distal to increase access. Granulation tissue was curetted. A narrow 5 mm 2-wall intrabony defect was confirmed. Straumann® PrefGel was applied to the root surface for two minutes, and then washed with sterile saline. Straumann® Emdogain, mixed with particulate bone (Bio-Oss® – Geistlich) was applied to the root surface (Fig. 20). The site was co-apted with monofilament poly-tetra-fluoroethylene non-absorbable sutures (Cytoplast™ – Osteogenics) (Fig. 21).
The patient was seen for one-week and one-month post-operative checks. At six-months the site showed good epithelial maturation and blending with the adjacent tissue. A comparison of PA radiographs reveals significant resolution of the intrabony component of the defect at tooth 43, as well as resolution of the endodontic lesion at tooth 44 (Fig. 22).
Case 3: Patient Profile, Concerns, Diagnosis
A healthy 35-year-old female with a healthy periodontium presented with localized severe periodontal disease at tooth 46. This tooth had a 9 mm buccal pocket. The radiograph revealed that the draining buccal fistula originated from the furcation lesion and a suspected strip perforation (Fig. 23). A primary endodontic- secondary periodontal lesion, containing a buccal Class II inter-radicular (furcation) defect was suspected at tooth 46 (Fig. 24). A Cone Beam CT (CBCT) scan was taken to confirm the suspicion of the strip perforation and its localization to the furcational aspect of the distal root. The CBCT scan also confirmed the absence of un-filled canals and periapical pathology.
The patient wanted to keep her tooth at all costs. It was decided along with the patient, that the perforation would be addressed non-surgically and that the canal system would not be retreated. She was advised that periodontal regenerative surgery at tooth 46 would be required after non-surgical repair of the strip perforation in order to preserve the tooth, maximize attachment gain, and decrease the pocket depth to a more maintainable range. The patient was informed that the furcational aspect of the distal root surface of tooth 46 would be thoroughly inspected under a microscope during the regenerative surgery, to confirm that the strip perforation was fully repaired. The reduction, but not complete elimination, of periodontal attachment loss was put in perspective and discussed. Informed consent was obtained.
Perforation repair was done non-surgically with mineral trioxide aggregate cement (ProRoot® MTA Root Repair Material – Dentsply Sirona). Retreatment was not performed in this case.
A full-thickness flap was reflected at teeth 44-47 buccal. A buccal cortical fenestration overlying the furcation at tooth 46 was visualized. A Class II furcation defect was confirmed. A crestal dehiscence of the buccal plate was found to communicate with the apical fenestration. A firm mass of suspected chronic inflammatory tissue was excised and sent for histologic analysis. The root strip perforation was inspected under a microscope and was determined to have been well sealed initially during non-surgical repair. The site was rinsed with a slurry containing tetracycline in sterile saline, and then again with sterile saline. Straumann® PrefGel was applied to the root surface for two minutes, and then washed with sterile saline (Fig. 25). Straumann® Emdogain, mixed with particulate bone (Bio-Oss® – Geistlich) was applied into the furcation. This mixture was also used to fill the crestal dehiscence. A bioabsorbable membrane (Bio-Gide® – Geistlich) was draped over the defect using chromic gut absorbable sutures (Fig. 26). The site was co-apted with monofilament poly-tetra-fluoroethylene non-absorbable sutures (Cytoplast™ – Osteogenics). The fistula was excised (Fig. 26).
The patient was seen for one-week and one-month post-operative checks. Histologic analysis confirmed a radicular cyst. At seven-months the site showed good epithelial maturation and blending with the adjacent tissue (Fig. 27). A comparison of BW radiographs reveals full resolution of the furcation defect (Fig. 28).
Case 4: Patient Profile, Concerns, Diagnosis
A healthy 50-year-old male with a healthy periodontium and localized severe periodontal disease at tooth 37 presented for treatment (Fig. 29). The tooth was vital and asymptomatic. 9 mm buccal and distal pockets were measured at tooth 37. Purulence was detected and there was acutely inflamed, hypertrophic and erythematous tissue at the buccal gingival margin. The radiograph revealed a deep narrow distal intrabony defect as well as a furcation defect at tooth 37. A periodontal abscess was suspected. The defect was suspected to contain both a 3-wall intrabony as well as Class II furcation component (Fig. 30).
The patient was advised that periodontal regenerative surgery at tooth 37 was indicated to maximize attachment gain and decrease the pocket depth to a more maintainable range. The reduction, but not complete elimination, of periodontal attachment loss was put in perspective and discussed. Informed consent was obtained.
The site was root planed under local anesthetic. The patient was instructed to perform daily subgingival irrigation at tooth 37 buccal using Chlorhexidine 0.12% mouth rinse and a syringe for one week. The abscess resolved. One month later, a full-thickness flap was reflected at teeth 35-38 buccal. Granulation tissue was curetted. A 6 mm distal 3-wall intrabony defect and a buccal Class II furcation defect were confirmed. The site was rinsed with a slurry containing tetracycline in sterile saline, and then again with sterile saline (Fig. 31). Straumann® PrefGel was applied to the root surface for two minutes, and then washed with sterile saline. Straumann® Emdogain, mixed with particulate bone (Bio-Oss® – Geistlich) was applied to the site. The site was co-apted with monofilament poly-tetra-fluoroethylene non-absorbable sutures (Cytoplast™ – Osteogenics) and cyanoacrylate oral adhesive (PeriAcryl® – Citagenix) (Fig. 32). The patient received an intra-coronal periodontal splint two-weeks later.
The patient was seen for one-week and one-month post-operative checks. A comparison of pre-operative and seven-month post-operative BW radio–graphs reveals full resolution of the defect (Fig. 33).
Case 5: Patient Profile, Concerns, Diagnosis
A healthy 40-year-old female with a healthy periodontium and localized severe periodontal disease at tooth 45 presented for treatment (Fig. 34). The tooth was vital and asymptomatic. 9 mm disto-lingual and 7mm mid-lingual pockets were measured at tooth 45. The radiograph revealed a deep narrow distal intrabony defect and trapped subgingival calculus at tooth 45. An incidental finding was short endodontic fill at tooth 46. A 2-wall intrabony defect was suspected at tooth 45 (Fig. 35).
The patient was advised that periodontal regenerative surgery at tooth 45 was indicated to maximize attachment gain and decrease the pocket depth to a more maintainable range. The reduction, but not complete elimination, of periodontal attachment loss was put in perspective and discussed. Informed consent was obtained.
A full-thickness flap was reflected at teeth 43-46 lingual, and 45-46 buccal. Granulation tissue was curetted. A 6 mm distal 2-wall intrabony defect was confirmed. The buccal plate was intact (Fig. 36). Straumann® PrefGel was applied to the root surface for two minutes, and then washed with sterile saline. Straumann® Emdogain, mixed with particulate bone (MinerOss® – BioHorizons) was applied to the site (Fig. 37). A bioabsorbable membrane (Bio-Gide® – Geistlich) was draped over the defect using chromic gut absorbable sutures. The site was co-apted with monofilament poly-tetra-fluoroethylene non-absorbable sutures (Cytoplast™ – Osteogenics). Occlusion was relieved on tooth 45 (Fig. 38). The patient received an extra-coronal bonded composite resin periodontal splint two-weeks later.
The patient was seen for one-week and one-month post-operative checks. At seven-months the site showed good epithelial maturation and blending with the adjacent tissue (Fig. 39). A comparison of pre-operative and seven-month post-operative BW radiographs reveals full resolution of the defect (Fig. 40).
This article reviewed the literature to provide a basis for surgical regenerative treatment. Five cases were utilized to demonstrate variations in the management of periodontal intrabony and furcation defects. Periodontal regeneration is predictable when it is based on sound diagnostic criteria, and when factors influencing the outcome are identified and controlled. This treatment may reduce the need to replace teeth with dental implants, conventional fixed bridgework, or with removable dentures, resulting in a significant cost benefit. Treatment of the combined lesion, specifically: primary endodontic-secondary periodontal, can be predictable, if the periodontal defect is determined pre-operatively to be amenable to regeneration, and if the endodontic (re)treatment is successfully performed. This article highlights the benefit of a combined collaborative approach between the endodontist and periodontist in order to assure long term successful treatment of teeth with combined endodontic-periodontal pathology. Selecting the right procedure and discussing all aspects of it with the patient will ensure a healthy balance between likely outcomes and patient expectations. OH
Oral Health welcomes this original article.
About the Authors
Dr. Valentin Dabuleanu and Dr. Mary Dabuleanu maintain a private practice in Toronto limited to periodontics and implant surgery, and endodontics, in a combined periodontal, endodontic, and orthodontic practice with Dr. Natoosha Nargaski, Orthodontist and alongside the family practices of Dr. Tudor Dabuleanu and Dr. Emilia Nicola, General Dentists. Valentin is a Fellow of the Royal College of Dentists of Canada in Periodontology. He obtained his DDS from the University of Toronto in 2010, and subsequently completed a general practice residency at Vancouver General Hospital. Valentin completed his MSc degree and speciality training in Periodontology at the University of British Columbia in 2014. He can be reached at email@example.com. Mary is a Fellow of the Royal College of Dentists of Canada in Endodontics. She obtained her DDS from the University of Toronto in 2002 and subsequently completed a general practice residency at the Royal Victoria Hospital in Montreal, Quebec. Mary completed her Master of Science degree and certificate in Endodontics from the University of Detroit Mercy, Detroit, Michigan in 2007. She can be reached at firstname.lastname@example.org.