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Journal of Oral Science & Rehabilitation Volume 2 | Issue 2/2016 37 B o n e b l o c k g r a f t t o t r e a t a p i c o m a r g i n a l d e f e c t Introduction An apicomarginal defect is defined as a localized bony defect that is characterized bythe absence of alveolar bone overthe entire root length.1 This typeofdefectsignificantlyreducestheprognosis of periapical surgery. Hirsch et al.2 and Skoglund and Persson3 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 surgi- cal techniques, supported by the use of ultra- sound, amplification and magnification devices, have improved the prognosis of periapical sur- gery,4 also in teeth with this type of bony defect. Kim et al. observed a healing success of77.5% in teeth with apicomarginal defects using a micro- surgical technique, but still significantly lower than the 95.2% rate of teeth with lesions con- fined to the apical area.5 The reason for the poorer prognosis in teeth with apicomarginal defects has been suggested to be the formation of a long junctional epithe- lium over the denuded root surface, preventing bone regeneration.6 Experimental7, 8 and clinical studies9 have shown significantlyhighersuccess 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 apicalsurgeryofbothlateralandcentralincisors. Case report A 15-year-old male patient was referred to our clinic because ofa recurrent sinustract involving the maxillaryright incisors (Fig.1). Regardingthe patient’s medicalhistory, no health problemwas reported, norwas a historyofallergies orthe use of any medication. The patient had suffered a traumatism oneyearbeforethat causedfractur- ing of the central incisors and the right lateral incisor. The central incisors were restored with compositeandrootcanalfillingswereperformed in both central and lateral right incisors; in addi- tion, root resection ofthe lateralincisorhad been performed without retrograde filling. The peri- apicalradiograph showed a radiolucent area sur- rounding the tooth apex (Fig. 2). Probing depth was normal around the central incisor and the lateral incisorhad a 7mm depth atthevestibular aspect. The surgicaltreatment combinedtwo proce- dures: endodontic surgeryofboth maxillaryright 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 patholo- gical tissue around the apex of the lateral incisor was debrided. Afterward, a bone block was har- vested 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 salinesolution.Therootofthecentralincisorwas thenresectedapproximately3mmfromtheapex; 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).10 The root endswere inspectedusingarigidendoscope(Möller-Wedel, Munich, Germany; Figs.5&6). The root-end ca- vitieswere preparedwith sonic-driven microtips (Piezon Master 400, EMS Electro Medical Sys- tems, Nyon, Switzerland; Fig. 7) and were retro- filled with mineral trioxide aggregate (MTA; DENTSPLYTulsa Dental Specialties,Tulsa, Okla., U.S.; Fig.8).The qualityofthe retrograde fillings was inspected with the endoscope (Fig. 9). The bone block graft was fixed with an osteosynthe- sis screw to regenerate the buccal wall of the lateral incisor (Fig. 10). The bony defect at the donor area and the apical area oftooth #12 were coveredwithtextured bovine collagen (Lyostypt, B. Braun Melsungen,Tuttlingen, Germany).After cleaning the wound area, primary wound closu- re 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 (400mg/8hforfourdays), a 0.12% chlorhexidine rinse (t.i.d. for seven days) and paracetamol (500 mg on demand) in the event ofintense pain.The sutureswere 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 depthswererecordedaroundbothteeth(Fig.11). Theperiapicalradiographshowedcompletebone regeneration around the apexes (Fig. 12). Volume 2 | Issue 2/201637