Menu
Back to the Journal

Bone block graft to treat an apicomarginal defect simultaneously with apical surgery of the maxillary incisors: A case report with three-year follow-up

July 4, 2016 / Categories: Digital Dentistry, Implant Dentistry

Cervera Ballester, Juan

Peñarrocha Oltra, David

Peñarrocha Diago, Maria

Maestre Ferrína, Laura

Peñarrocha Diago, Miguel

The objective of this article is to describe the successful management of an apicomarginal defect of a maxillary lateral incisor with a bone block graft performed simultaneously with apical surgery of both lateral and central incisors.

Introduction

An apicomarginal defect is defined as a localized bony defect that is characterized by the absence of alveolar bone over the entire root length.1Dietrich T, Zunker P, Dietrich D, Bernimoulin JP. Apicomarginal defects in periradicular surgery: classification and diagnostic aspects. → Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002 Aug;94(2):233–9. This type of defect significantly reduces the prognosis of periapical surgery.

Hirsch et al.2Hirsch JM, Ahlström U, Henrikson PA, Heyden G, Peterson, LE. Periapical surgery. → Clin Implant Dent Relat Res. 1979 Jun;8(3):173–85. and Skoglund and Persson3Skoglund A, Persson G. A follow-up study of apicoectomized teeth with total loss of the buccal bone plate. → Oral Surg Oral Med Oral Pathol. 1985 Jan;59(1):78–81. observed healing rates of 27% and 37%, respectively, in teeth that had undergone periapical surgery and with apicomarginal defects, substantially lower than teeth in which the vestibular cortical was intact. Current surgical techniques, supported by the use of ultrasound, amplification and magnification devices, have improved the prognosis of periapical surgery,4Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. → J Endod. 2006 Jul;32(7):601–23. also in teeth with this type of bony defect. Kim et al. observed a healing success of 77.5% in teeth with apicomarginal defects using a microsurgical technique, but still significantly lower than the 95.2% rate of teeth with lesions confined to the apical area.5Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective clinical study evaluating endodontic microsurgery outcomes for cases with lesions of endodontic origin compared with cases with lesions of combined periodontal-endodontic origin. → J Endod. 2008 May;34(5):546–51.

The reason for the poorer prognosis in teeth with apicomarginal defects has been suggested to be the formation of a long junctional epithelium over the denuded root surface, preventing bone regeneration.6Rankow HJ, Krasner PR. Endodontic applications of guided tissue regeneration in endodontic surgery. → J Endod. 1996 Jan;22(1):34–43. Experimental7Douthitt JC, Gutmann JL, Witherspoon DE. Histologic assessment of healing after the use of a bioresorbable membrane in the management of buccal bone loss concomitant with periradicular surgery. → J Endod. 2001 Jun;27(6):404–10.8Britain SK, von Arx T, Schenk RK, Buser D, Nummikoski P, Cochran DL. The use of guided tissue regeneration principles in endodontic surgery for induced chronic periodontic-endodontic lesions: a clinical, radiographic, and histologic evaluation. → J Periodontol. 2005 Mar;76(3):450–60. and clinical studies9Marín-Botero ML, Domínguez-Mejía JS, Arismendi-Echavarría JA, Mesa-Jaramillo AL, Flórez-Moreno GA, Tobón-Arroyave SI. Healing response of apicomarginal defects to two guided tissue regeneration techniques in periradicular surgery: a double-blind, randomized-clinical trial. → Int Endod J. 2006 May;39(5):368–77. have shown significantly higher success rates with the use of tissue regeneration techniques (guided tissue regeneration, GTR) in apicomarginal defects.

The purpose of this article is to describe the successful management of an apicomarginal defect of a maxillary lateral incisor with a bone block graft performed simultaneously with apical surgery of both lateral and central incisors.

Case report

A 15-year-old male patient was referred to our clinic because of a recurrent sinus tract involving the maxillary right incisors (Fig. 1). Regarding the patient’s medical history, no health problem was reported, nor was a history of allergies or the use of any medication. The patient had suffered a traumatism one year before that caused fracturing of the central incisors and the right lateral incisor. The central incisors were restored with composite and root canal fillings were performed in both central and lateral right incisors; in addition, root resection of the lateral incisor had been performed without retrograde filling. The periapical radiograph showed a radiolucent area surrounding the tooth apex (Fig. 2). Probing depth was normal around the central incisor and the lateral incisor had a 7 mm depth at the vestibular aspect.

The surgical treatment combined two procedures: endodontic surgery of both maxillary right incisors and a bone autograft to regenerate the buccal bone plate of the lateral incisor. The surgery was carried out under local anesthesia with 4% articaine and 1:100,000 epinephrine (Inibsa, Lliçà de Vall, Spain). After elevation of a full-thickness mucoperiosteal flap, the pathological tissue around the apex of the lateral incisor was debrided. Afterward, a bone block was harvested from the apical area of the central incisor with ultrasound tips to gain access to the root end (Fig. 3); the block was kept submerged in saline solution. The root of the central incisor was then resected approximately 3 mm from the apex; the lateral incisor root had been resected in a previous periapical surgery (Fig. 4). Hemostasis of the bony crypt was achieved with aluminum chloride (Expasyl, Produits Dentaires Pierre Rolland, Merignac, France).10Von Arx T, Jensen SS, Hänni S, Schenk RK. Haemostatic agents used in periradicular surgery: an experimental study of their efficacy and tissue reactions. → Int Endod J. 2006 Oct;39(10):800–8. The root ends were inspected using a rigid endoscope (Möller-Wedel, Munich, Germany; Figs. 5 & 6). The root-end cavities were prepared with sonic-driven microtips (Piezon Master 400, EMS Electro Medical Systems, Nyon, Switzerland; Fig. 7) and were retrofilled with mineral trioxide aggregate (MTA; DENTSPLY Tulsa Dental Specialties, Tulsa, Okla., U.S.; Fig. 8). The quality of the retrograde fillings was inspected with the endoscope (Fig. 9). The bone block graft was fixed with an osteosynthesis screw to regenerate the buccal wall of the lateral incisor (Fig. 10). The bony defect at the donor area and the apical area of tooth #12 were covered with textured bovine collagen (Lyostypt, B. Braun Melsungen, Tuttlingen, Germany). After cleaning the wound area, primary wound closure was accomplished with multiple interrupted sutures.

The patient was prescribed amoxicillin (500 mg/8 h) preoperatively (two days before surgery) for suppurative abscess and five days after intervention owing to the bone block graft procedure, ibuprofen (400 mg/8 h for four days), a 0.12% chlorhexidine rinse (t.i.d. for seven days) and paracetamol (500 mg on demand) in the event of intense pain. The sutures were removed after one week.

At the follow-up visit after three years, the teeth were asymptomatic, no gingival recession had occurred and normal periodontal probing depths were recorded around both teeth (Fig. 11). The periapical radiograph showed complete bone regeneration around the apexes (Fig. 12).

Discussion

Complete healing of periapical tissue after periapical surgery includes regeneration of the alveolar bone, periodontal ligament and cementum.11Lin L, Chen MY, Ricucci D, Rosenberg PA. Guided tissue regeneration in periapical surgery. → J Endod. 2010 Apr;36(4):618–25. Several studies have shown that GTR applied with periapical surgery promotes healing of apical lesions and improves the prognosis of the treatment.12Taschieri S, del Fabbro M, Testori T, Weinstein R. Efficacy of xenogeneic bone grafting with guided tissue regeneration in the management of bone defects after surgical endodontics. → J Oral Maxillofac Surg. 2007 Jun;65(6):1121–7.13Taschieri S, Del Fabbro M, Testori T, Saita M, Weinstein R. Efficacy of guided tissue regeneration in the management of through-and-through lesions following surgical endodontics: a preliminary study. → Int J Periodontics Restorative Dent. 2008 Jun;28(3):265–71.14Pecora G, De Leonardis D, Ibrahim N, Bovi M, Cornelini R. The use of calcium sulphate in the surgical treatment of a ‘through and through’ periradicular lesion. → Int Endod J. 2001 Apr;34(3):189–97. In a recent meta-analysis, Tsesis et al. observed that GTR improved the success rate of periapical surgery, particularly in large and through-and-through lesions, although the differences were not statistically significant.15Tsesis I, Rosen E, Tamse A, Taschieri S, Del Fabbro M. Effect of guided tissue regeneration on the outcome of surgical endodontic treatment: a systematic review and meta-analysis. → J Endod. 2011 Aug;37(8):1039–45. However, none of the studies included evaluated the prognosis of teeth with apicomarginal defects. Tissue regeneration in teeth with apicomarginal defects is not as predictable and there is no verified treatment option.16Von Arx T, AlSaeed M. The use of regenerative techniques in apical surgery: a literature review. → Saudi Dent J. 2011 Jul;23(3):113–27. Only four clinical trials, none of them with control groups, were found in which the prognosis of periapical surgery in teeth with apicomarginal lesions was studied. Dietrich et al. grafted the defects with inorganic bovine bone material and a collagen membrane.17Dietrich T, Zunker P, Dietrich D, Bernimoul in JP. Periapical and periodontal healing after osseous grafting and guided tissue regeneration treatment of apicomarginal defects in periradicular surgery: results after 12 months.→ Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Apr;95(4):474–82. After one year, the clinical and radiographic assessment demonstrated a success rate of 82.6% and the median probing pocket depth decreased from 9 mm to 3 mm. Three years later, Marín-Botero et al. found similar results in two study groups.18Marín-Botero ML, Domínguez-Mejía JS, Arismendi-Echavarría JA, Mesa-Jaramillo AL, Flórez-Moreno GA, Tobón-Arroyave SI. Healing response of apicomarginal defects to two guided tissue regeneration techniques in periradicular surgery: a double-blind, randomized-clinical trial. → Int Endod J. 2006 May;39(5):368–77. In one group, a polyglactin 910 membrane was placed over the apicomarginal defect (n = 15), and in the other group, a sliding periosteal graft was used to cover the defect (n = 15). Identical success rates of 87% were observed in both groups.

SUBSCRIBE TO OUR NEWSLETTER

Subscribe to our newsletter to receive the latest articles and DTScience opportunities.

Recently, the outcome of modern endodontic microsurgery was evaluated by Kim et al. in a prospective study.19Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective clinical study evaluating endodontic microsurgery outcomes for cases with lesions of endodontic origin compared with cases with lesions of combined periodontal-endodontic origin. → J Endod. 2008 May;34(5):546–51. They studied healing according to the type of lesion and observed a healing success rate of 73.7% for teeth with apicomarginal defects treated with calcium sulfate placed into the periradicular bony defect and a collagen membrane covering the denuded buccal surface. Goyal et al. evaluated the use of platelet-rich plasma (PRP) for the treatment of apicomarginal defects.20Goyal B, Tewari S, Duhan J, Sehgal PK. Comparative evaluation of platelet-rich plasma and guided tissue regeneration membrane in the healing of apicomarginal defects: a clinical study. → J Endod. 2011 Jun;37(6):773–80. They conducted a study with three groups: In the first group, the defect was covered with a collagen membrane (n = 10); in the second group, a PRP preparation was placed over the defect (n = 10); and in the last group, PRP was packed into the defect and a collagen sponge was used to cover it (n = 10). The overall rate of healed cases was 80.76%, with differences that were not statistically significant between the groups.

Currently, the use of ultrasound, amplification and magnification devices has improved the prognosis of periapical surgery.21Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. → J Endod. 2006 Jul;32(7):601–23. In this case report, these advances allowed treatment of an apicomarginal defect with a bone block graft after periapical surgery of two maxillary incisors. There are no studies in the literature on the use of a block graft to treat this type of lesion simultaneously with apical surgery. Bone block grafts are used in implantology owing to osteogenic, osteoinductive and osteoconductive potential. Thus, although there are currently very few studies that provide scientific evidence sufficient to determine the ideal treatment of apicomarginal defects, we believe that the procedure proposed in this article can be an alternative for the treatment of these defects.

One of the main problems with this type of graft is management of the soft tissue, since in order to minimize the risk of dehiscence, it is necessary to achieve a tension-less wound closure.22Felice P, Pellegrino G, Checchi L, Pistilli R, Esposito M. Vertical augmentation with interpositional blocks of anorganic bovine bone vs. 7-mm-long implants in posterior mandibles: 1-year results of a randomized clinical trial. → Clin Oral Implants Res. 2010 Dec;21(12):1394–403. The stabilization and intimate contact between the block graft and the recipient bed have been considered crucial to a successful outcome.23De Carvalho PS, Vasconcellos LW, Pi J. Influence of bed preparation on the incorporation of autogenous bone grafts: a study in dogs. → Int J Oral Maxillofac Implants. 2000 Jul-Aug;15(4):565–70. This can be achieved with the use of osteosynthesis screws.24Buser D, Dula K, Hirt HP, Schenk RK. Lateral ridge augmentation using autografts and barrier membranes: a clinical study with 40 partially edentulous patients. → J Oral Maxillofac Surg. 1996 Apr;54(4):420–32.

Conclusion

The use of a bone block graft to treat an apicomarginal defect in conjunction with apical surgery achieved complete healing of the periradicular tissue in this case.

Competing interests

The authors declare that they have no competing interests.

References   [ + ]

1. Dietrich T, Zunker P, Dietrich D, Bernimoulin JP. Apicomarginal defects in periradicular surgery: classification and diagnostic aspects. → Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002 Aug;94(2):233–9.
2. Hirsch JM, Ahlström U, Henrikson PA, Heyden G, Peterson, LE. Periapical surgery. → Clin Implant Dent Relat Res. 1979 Jun;8(3):173–85.
3. Skoglund A, Persson G. A follow-up study of apicoectomized teeth with total loss of the buccal bone plate. → Oral Surg Oral Med Oral Pathol. 1985 Jan;59(1):78–81.
4, 21. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. → J Endod. 2006 Jul;32(7):601–23.
5, 19. Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective clinical study evaluating endodontic microsurgery outcomes for cases with lesions of endodontic origin compared with cases with lesions of combined periodontal-endodontic origin. → J Endod. 2008 May;34(5):546–51.
6. Rankow HJ, Krasner PR. Endodontic applications of guided tissue regeneration in endodontic surgery. → J Endod. 1996 Jan;22(1):34–43.
7. Douthitt JC, Gutmann JL, Witherspoon DE. Histologic assessment of healing after the use of a bioresorbable membrane in the management of buccal bone loss concomitant with periradicular surgery. → J Endod. 2001 Jun;27(6):404–10.
8. Britain SK, von Arx T, Schenk RK, Buser D, Nummikoski P, Cochran DL. The use of guided tissue regeneration principles in endodontic surgery for induced chronic periodontic-endodontic lesions: a clinical, radiographic, and histologic evaluation. → J Periodontol. 2005 Mar;76(3):450–60.
9, 18. Marín-Botero ML, Domínguez-Mejía JS, Arismendi-Echavarría JA, Mesa-Jaramillo AL, Flórez-Moreno GA, Tobón-Arroyave SI. Healing response of apicomarginal defects to two guided tissue regeneration techniques in periradicular surgery: a double-blind, randomized-clinical trial. → Int Endod J. 2006 May;39(5):368–77.
10. Von Arx T, Jensen SS, Hänni S, Schenk RK. Haemostatic agents used in periradicular surgery: an experimental study of their efficacy and tissue reactions. → Int Endod J. 2006 Oct;39(10):800–8.
11. Lin L, Chen MY, Ricucci D, Rosenberg PA. Guided tissue regeneration in periapical surgery. → J Endod. 2010 Apr;36(4):618–25.
12. Taschieri S, del Fabbro M, Testori T, Weinstein R. Efficacy of xenogeneic bone grafting with guided tissue regeneration in the management of bone defects after surgical endodontics. → J Oral Maxillofac Surg. 2007 Jun;65(6):1121–7.
13. Taschieri S, Del Fabbro M, Testori T, Saita M, Weinstein R. Efficacy of guided tissue regeneration in the management of through-and-through lesions following surgical endodontics: a preliminary study. → Int J Periodontics Restorative Dent. 2008 Jun;28(3):265–71.
14. Pecora G, De Leonardis D, Ibrahim N, Bovi M, Cornelini R. The use of calcium sulphate in the surgical treatment of a ‘through and through’ periradicular lesion. → Int Endod J. 2001 Apr;34(3):189–97.
15. Tsesis I, Rosen E, Tamse A, Taschieri S, Del Fabbro M. Effect of guided tissue regeneration on the outcome of surgical endodontic treatment: a systematic review and meta-analysis. → J Endod. 2011 Aug;37(8):1039–45.
16. Von Arx T, AlSaeed M. The use of regenerative techniques in apical surgery: a literature review. → Saudi Dent J. 2011 Jul;23(3):113–27.
17. Dietrich T, Zunker P, Dietrich D, Bernimoul in JP. Periapical and periodontal healing after osseous grafting and guided tissue regeneration treatment of apicomarginal defects in periradicular surgery: results after 12 months.→ Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Apr;95(4):474–82.
20. Goyal B, Tewari S, Duhan J, Sehgal PK. Comparative evaluation of platelet-rich plasma and guided tissue regeneration membrane in the healing of apicomarginal defects: a clinical study. → J Endod. 2011 Jun;37(6):773–80.
22. Felice P, Pellegrino G, Checchi L, Pistilli R, Esposito M. Vertical augmentation with interpositional blocks of anorganic bovine bone vs. 7-mm-long implants in posterior mandibles: 1-year results of a randomized clinical trial. → Clin Oral Implants Res. 2010 Dec;21(12):1394–403.
23. De Carvalho PS, Vasconcellos LW, Pi J. Influence of bed preparation on the incorporation of autogenous bone grafts: a study in dogs. → Int J Oral Maxillofac Implants. 2000 Jul-Aug;15(4):565–70.
24. Buser D, Dula K, Hirt HP, Schenk RK. Lateral ridge augmentation using autografts and barrier membranes: a clinical study with 40 partially edentulous patients. → J Oral Maxillofac Surg. 1996 Apr;54(4):420–32.

Open / Download PDF

Open the PDF Download the PDF

Categorised in:

Leave a Reply

Be the First to Comment!


 

DT Science is supported by