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Vol. 95 No. 4 April 2003

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY ENDODONTICS


Editor: Larz S. W. Spnberg

Periapical and periodontal healing after osseous grafting and guided tissue regeneration treatment of apicomarginal defects in periradicular surgery: Results after 12 months
Thomas Dietrich, MD, DMD, MPH,a Petra Zunker, DMD,b Dieter Dietrich, MD, DMD,c and Jean-Pierre Bernimoulin, MD, DMD, PhD,d Berlin, Germany
, HUMBOLDT-UNIVERSITY OF BERLIN CHARITE

Objective. The aim of the present study was to evaluate the periapical and periodontal healing of apicomarginal defects 12 months after periradicular surgery and guided tissue regeneration in a series of consecutively treated patients. Study design. Patients with apicomarginal defects who were referred for periradicular surgery were included. Apicomarginal defects were grafted with Bio-Oss bone mineral and covered with a Bio-Gide membrane. Periodontal probing depths (PPDs) and relative attachment levels were measured preoperatively and 12 months postoperatively with a manual force controlled probe. Periapical healing was assessed clinically and radiographically. Results. Of the 23 defects in 22 patients for whom follow-up data were available, 19 were considered clinically and radiographically successful, 2 were doubtful, and 2 were failures. Overall, the baseline median PPD decreased from 9.0 mm to 3.0 mm, corresponding to a median relative attachment level gain of 2.8 mm. In the case of periodonticendodontic lesions, the median baseline PPD decreased from 9.8 mm to 4.0 mm, corresponding to a median relative attachment level gain of 4.2 mm. Defects that involved a proximal root surface had a signicantly higher residual PPD than did defects not involving a proximal root surface. Conclusion. Guided tissue regeneration treatment of apicomarginal defects yields good results in terms of periapical and periodontal healing after 12 months and should be considered as an adjunct to periradicular surgery in such cases. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:474-82)

Several tooth-related factors have been shown to inuence the prognosis of periradicular surgery, among them the amount and location of bone loss.1,2 Two retrospective studies indicated that the prognosis is substantially reduced in teeth with a localized total loss of marginal bone.2,3 Hirsch et al2 found complete heal-

Assistant Professor, Department of Periodontology and Synoptic Dentistry, Charite , Humboldt-University of Berlin. b Research Fellow, Department of Periodontology and Synoptic Dentistry, Charite , Humboldt-University of Berlin. c In private practice, oral and maxillofacial surgery, Berlin, Germany. d Professor and Head, Department of Periodontology and Synoptic Dentistry, Charite , Humboldt-University of Berlin. Received for publication Jul 16, 2002; returned for revision Sep 4, 2002; accepted for publication Oct 7, 2002. 2003, Mosby, Inc. All rights reserved. 1079-2104/2003/$30.00 0 doi:10.1067/moe.2003.39

ing in only 9 of 33 cases (27%), with total buccal bone loss compared to a healing rate of 50% in patients with intact buccal bone. Skoglund and Persson3 reported complete healing in only 10 of 27 cases (37%), stating that this is a considerably lower healing rate than that of historical controls. Although apicomarginal defects are relatively rare, they constitute a signicant challenge to the oral surgeon. With the introduction of guided tissue regeneration (GTR) to oral and periodontal surgery, a new treatment option became available for such defects. A number of case reports on the application of GTR techniques and periradicular surgery in teeth with apicomarginal defects report successful outcomes.4-15 A review of these case reports reveals a considerable diversity in the treated lesions with respect to etiology, pathogenesis, and morphology, in addition to the surgical techniques applied. At present, there are no stud-

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ies beyond case reports that have evaluated the outcome of periradicular surgery and GTR in teeth with apicomarginal defects. This clinical study investigated the application of GTR in periradicular surgery of apicomarginal defects in a series of consecutively treated patients. The aim of the present article was to evaluate the periapical and periodontal healing of such defects clinically and radiographically after 1 year and to evaluate the effects of several variables on the treatment outcome. MATERIAL AND METHODS The study population consisted of patients referred by general dentists for periradicular surgery; these patients were initially seen by an oral and maxillofacial surgeon in private practice. All patients referred for apicoectomy by general dentists were asked by the oral and maxillofacial surgeon to make appointments for examination and periradicular surgery on 2 specic weekdays when the involved investigators were present. If this arrangement was not possible and if an apicomarginal defect was suspected after the initial examination, the patient was asked for a new appointment for surgery on 1 of the 2 weekdays. The patients who were not suspected of having apicomarginal defects and who did not come on 1 of the 2 weekdays were not included, even if a defect was realized after ap reection. After a medical history, including current smoking status, was taken and after initial routine surgical exploration, all patients were informed about the aim and procedures of the treatment and gave their informed consent to the surgical treatment and procedures. Patients with any systemic disease contraindicating oral surgery were excluded, as were pregnant patients. Preoperative measurements All preoperative clinical periodontal measurements were performed by a single investigator (P.Z.). Baseline periodontal probing depths (PPDs) and baseline relative attachment levels (RALs) of the teeth to undergo surgery were measured. This was done at 6 sites on single-rooted teeth, at 8 sites on upper molars, and at 10 sites on lower molars, to the nearest 0.5 mm, by means of a manual force controlled probe (DB764R; Aesculap, Tuttlingen, Germany). RAL measurements were performed with an acrylic stent used as a reference. Furthermore, the degree of furcation involvement was assessed with a standard furcation probe (Nabers 2; Hu-Friedy, Chicago, Ill) according to the method used by Hamp et al.16 In addition, PPDs were measured at 2 proximal sites per tooth on all teeth, and a diagnosis of generalized periodontitis was made if probing depths of at least 5 mm were recorded on at least 2 teeth other

than the tooth with the apicomarginal defect and if there was evidence on a panoramic radiograph of bone loss exceeding 5 mm, measured from the cementoenamel junction, in at least 2 teeth. Surgical procedure and postoperative care All surgeries were performed by a single investigator (T.D.). With the patient under local anesthesia (Ultracain D-S forte [4% articaine epinephrine 1:100,000]; Hoechst Marion Roussel, Frankfurt/Main, Germany), full-thickness mucoperiosteal aps were raised after marginal incision with a mesial releasing incision. After ap reection and soft tissue curettage, an apicomarginal defect was diagnosed if there was a localized bony defect encompassing the total root length. Afterward, apicoectomies were performed in all teeth but 1 second lower molar, on which only an apical curettage was performed because of the limited surgical access. The defects were classied according to their pathogenetic and morphologic criteria. This classication has been described in detail in a previous article.17 Briey, periodontic-endodontic lesions consisting of a probable periodontal lesion extending to the apex are classied as Class I defects. These defects are subclassied according to their etiology (periodontal I/1, endodontic I/3, combined I/2), modied from the method used by Simon et al.18 Class II defects are defects caused by large periapical lesions, and Class III defects are defects caused by bony dehiscences. Both Class II and Class III defects present with PPDs within the normal range. Defects that do not belong to either category are classied as Class IV defects. In addition to defect class, the following defect characteristics were assessed: (1) defect type (type A, no bony bridge over defect; type B, bony bridge present); (2) defect size, dened as the number of root surfaces (mesial, buccal, distal, oral, furcation) involved at the coronal part of the defect; and (3) defect location (buccal or proximal) of the coronal part of the defect. Whenever possible, orthograde debridement with hand instruments and orthograde lling with sealer (Diaket; ESPE, Seefeld, Germany) and gutta-percha points (Roeko, Langenau, Germany) of the root canal was performed. Alternatively, retrograde cavities were prepared by using diamond-coated sonic tips (SONICex Retro; KaVo, Biberach/Riss, Germany) and were lled with Diaket sealer. The root surface was carefully scaled with sonic tips (SONICex; KaVo). Afterwards, the defect was augmented with inorganic bovine bone mineral (BioOss spongiosa 0.5-1.0 mm particles; Geistlich Biomaterials, Wolhusen, Switzerland). In the case of type B defects, in which the bony bridge offered sufcient stability for the graft, the placement of the bone mineral was restricted to the coronal part of the defect (Fig 1).

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no distinction was made between incomplete healing and uncertain healing. The clinical and radiographic results were combined into the following categories: (1) successful healing: clinical success and complete radiographic healing; (2) doubtful healing: clinical success and incomplete/uncertain radiographic healing; and (3) unsuccessful healing: clinically unsuccessful or unsatisfactory radiographic healing. Data analysis Data are expressed as median values and 25/75 percentiles or ranges. In the case of apicomarginal defects involving more than 1 site, the site with the deepest PPD at baseline was evaluated. The periodontal outcome variables were residual PPD after 1 year and gain in RAL (RAL gain RAL at baseline RAL at 1 year). Nonparametric statistical tests were used for univariate comparisons, with 0.05. All statistics were calculated by using the Statistical Package for the Social Sciences, version 10.0 (SPSS Inc, Chicago, Ill). RESULTS A total of 24 patients with 25 teeth having apicomarginal defects were treated. There were 16 class I defects (1 Class I/1, 3 Class I/2, and 12 Class I/3 defects) and 7 Class II defects. All teeth with Class I and Class II defects yielded negative results on thermal and electrical pulp tests preoperatively (ie, they were necrotic or had had prior endodontic treatment). We did not observe any Class III defects in our series. Two defects in 1 patient were characterized as Class IV. The patient had had an impacted canine removed alio loco approximately 10 years before, and deep periodontal defects on the palatal site of teeth 11 and 12 had subsequently developed. Both teeth yielded positive results on thermal and electrical pulp tests. Upon periodontal surgery, it became evident that the palatal surface of the roots had been cut during the rst surgery. Because of their unique nature, these defects were excluded from our inferential statistical analysis. Orthograde root canal treatment and lling was performed in 21 (84%) cases, and 4 teeth (16%) received retrograde cavity and root-end llings. Of the 9 type B defects, 6 (67%) were only coronally augmented with the grafting material (Fig 1). In 3 cases (33%), the entire defect, including the periapical defect, was augmented. The immediate postoperative healing was uneventful in all patients; in particular, no membrane exposures or any other adverse effects were clinically detectable. One patient moved and could not be reached for reevaluation (Class I/3 defect), and 1 patient had to be excluded from the analysis because of a pregnancy

Fig 1. A clinical photograph of a Class I/3 type B defect. The bony bridge offers sufcient stability for the graft.

The grafted defect was then covered with a resorbable collagen membrane (Bio-Gide; Geistlich Biomaterials) followed by wound closure (Ethibond Excel 40; Ethicon, Norderstedt, Germany). Postoperatively, a periapical radiograph was taken (Agfa Dentus M2 Comfort; Agfa-Gevaert, Mortsel, Belgium) with a lmholder in the rectangular technique (RWT-Ro ntgensystem; Kentzler-Kaschner Dental, Ellwangen, Germany). The patients were prescribed an oral analgesic (ibuprofen 400 mg) and instructed to take an oral antibiotic (clindamycin 300 mg every 6 hours) for 1 week and to rinse twice daily with chlorhexidine 0.2% mouthrinse for 1 week. Patients were seen twice during the rst postoperative week and received supragingival tooth cleaning followed by the application of chlorhexidine gel (CHX Dental Gel; Dentsply DeTrey, Konstanz, Germany). The sutures were removed 1 week postoperatively. After suture removal, the patients were sent back to the referring dentist for further treatment. Reevaluation After 12 months of healing, the patients were reevaluated. After the patients history was taken, the PPDs, RALs, and furcation involvement were measured in the same manner as preoperatively. Clinical assessments included palpation of the gingival tissues and percussion testing of the treated tooth. The treatment was deemed clinically unsuccessful if any suppuration, stulation, swelling, pain, or tenderness on palpation or percussion was present. Furthermore, periapical radiographs were taken as previously described. Radiographic healing was characterized as (1) complete healing; (2) incomplete, uncertain healing; or (3) unsatisfactory healing.19,20 The criteria originally described by Rud et al19 were slightly modied insofar as

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Table I. Characteristics of all patients with follow-up data


Total no. of patients (n 22) 43.5 (17-65) 7/22 (32%) 15/22 (68%) 7/22 (32%) 15/22 (68%) 12/22 (54%) 10/22 (46%) Class I Total (n 15) 47.0 (17-65) 3/15 (20%) 12/15 (80%) 3/15 (20%) 12/15 (80%) 11/15 (73%) 4/15 (27%) I/1 (n 1)* 65 1/1 (100%) 1/1 (100%) 1/1 (100%) I/2 (n 3) 52.0 (34-64) 3/3 (100%) 1/3 (33%) 2/3 (67%) 3/3 (100%) I/3 (n 11) 46.0 (17-60) 3/11 (27%) 8/11 (73%) 2/11 (18%) 9/11 (82%) 6/11 (54%) 5/11 (46%) Class II (n 6) 39.0 (32-47) 4/6 (67%) 2/6 (33%) 4/6 (67%) 2/6 (33%) 2/6 (33%) 4/6 (67%) Class IV (n 1) 38 1/1 (100%) 1/1 (100%) 1/1 (100%)

Variable Age, ymedian (range) Sex female frequency (%) male frequency (%) Smoking yes frequency (%) no frequency (%) Periodontitis yes frequency (%) no frequency (%)
*

Includes the treatment that failed after 6 months.

(Class II). After 6 months, 1 patient with a Class I/1 defect presented with suppuration and mild tenderness on tooth palpation. This treatment was deemed unsuccessful, and the tooth was extracted. Thus, a total of 22 patients (range, 17-65 years old) with 23 defects provided follow-up information (Tables I and II), and 22 defects were followed for 1 year. Of the latter, 1 patient reported occasional discomfort and slight tenderness on percussion and palpation. All other treatments were clinically successful. The radiographic evaluation revealed complete healing in 20 of 22 cases (91%) and uncertain/incomplete healing in 2 cases (9%). By combining the clinical and radiographic criteria for all patients with follow-up data (including the patient whose treatment was unsuccessful after 6 months), we determined that successful healing occurred in 19 of 23 patients (83%), doubtful healing occurred in 2 patients (9%), and unsuccessful healing occurred in 2 patients (9%). For the total group, baseline median PPD (25/75 percentile) decreased from 9.0 (4.0/12.1) mm to 3.0 (2.4/4.1) mm, corresponding to an RAL gain of 2.8 (0.0/7.1) mm. These changes were highly signicant (Table III). The 2 Class IV defects in 1 patient showed marked reductions in the PPDs (5.0 mm and 16.5) and RAL gains (3.0 mm and 15.0 mm). The Class II defects exhibited a slight median PPD reduction from 3.2 to 2.8 mm (P .025, Wilcoxon signed rank test) and no change in probing RAL. In Class I defects, a marked median reduction of PPD from 9.8 mm to 4.0 mm was observed, corresponding to an RAL gain of 4.2 mm (Table II). These changes were statistically signicant (P .001, Wilcoxon signed rank test). However, in 1 Class I/3 defect, a PPD of 7 mm persisted and no RAL gain could be observed. Seven defects involved molar furcations. One degree III defect and 2 degree II

defects were reduced to a degree I; 1 degree II defect persisted; and, in 3 teeth with degree II defects, no horizontal furcation involvement could be found after 6 months. As can be seen from Table IV, Class I lesions exhibited signicantly more RAL gain (P .001) and a trend toward higher residual PPDs (P .09) compared with Class II defects. Table IV further shows median PPD at 6 months and RAL gain values stratied by several patient- and defect-related variables. Defects that involved only the buccal root surface showed signicantly lower residual PPDs (P .01). There were no signicant differences in the outcome variables between smokers and nonsmokers, patients with or without generalized periodontitis, defects with or without bony bridges (ie, type A or type B defects), or defects involving 1 or more than 1 root surface. Furthermore, there were no signicant correlations between any of the outcome variables and age (Spearman rank correlation, P .05). DISCUSSION Apicomarginal defects represent a heterogeneous group of lesions with respect to their pathogenesis and morphology. Several case reports have shown that GTR techniques can be applied to successfully correct such defects. The rst animal study on the healing of apicomarginal defects has only recently been published by Douthitt et al.21 In this study, buccal apicomarginal defects 3 mm wide were surgically created in 9 beagle dogs who were randomized to receive either apicoectomy alone (control group) or apicoectomy and GTR treatment with a resorbable membrane (Guidor, test group). All teeth received endodontic treatment before apicoectomies. Healing was evaluated histologically and histomorphometrically after 9 and 27 weeks. The

478 Dietrich et al Table II. Defect characteristics

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Class I Variable Tooth type Maxillary incisorsfrequency (%) Maxillary premolarsfrequency (%) Maxillary molarsfrequency (%) Mandibular incisorsfrequency (%) Mandibular premolarsfrequency (%) Mandibular molarsfrequency (%) Defect type Type Afrequency (%) Type Bfrequency (%) Debridement/root lling Orthogradefrequency (%) Retrogradefrequency (%) Defect size 1 surfacefrequency (%) 2 surfacesfrequency (%) 3 surfacesfrequency (%) Defect localization Buccalfrequency (%) Otherfrequency (%)
*

Total no. of defects (n 23) 4 (17%) 3 (13%) 2 (9%) 2 (9%) 1 (4%) 11 (48%) 14 (61%) 9 (39%) 19 (83%) 4 (17%) 14 (61%) 6 (26%) 3 (13%) 14 (61%) 9 (39%)

I/1 (n 1)* 1 (100%) 1 (100%) 1 (100%) 1 (100%) 1 (100%)

I/2 (n 3) 1 (33%) 2 (67%) 3 (100%) 3 (100%) 1 (33%) 1 (33%) 1 (33%) 3 (100%)

I/3 (n 11) 2 (18%) 2 (18%) 1 (9%) 6 (54%) 3 (27%) 8 (73%) 8 (73%) 3 (27%) 8 (73%) 2 (18%) 1 (9%) 8 (73%) 3 (27%)

Class II (n 6) 2 (33%) 1 (17%) 3 (50%) 5 (83%) 1 (17%) 5 (83%) 1 (17%) 5 (83%) 1 (17%) 6 (100%)

Class IV (n 2) 2 (100%) 2 (100%) 2 (100%) 2 (100%) 2 (100%)

Includes the treatment that failed after 6 months.

Table III. PPDs at baseline and 1 year and RAL gain


Total no. of patients (n 22) 9.0* (4.0/12.1) 3.0* (2.4/4.1) 2.8 (0.0/7.1)

Class I Total (n 14) 9.8 (8.4/12.6) 4.0 (2.8/5.1) 4.2 (2.4/7.5)


Defect characteristics PPD/BLmedian (25/75 percentile) PPD/12Mmedian (25/75 Percentile) RAL gainmedian (25/75 percentile)

I/2 (n 3) 12.0 (6.5/12.5) 5.0 (3.0/5.5) 4.5 (2.0/5.5)

I/3 (n 11) 9.5 (9.0/13.0) 4.0 (3.0/4.5) 4.0 (2.5/7.5)


Class II (n 6) 3.2** (3.0/4.0) 2.8** (2.0/3.0) 0.0 (0.1/0.0)

Class IV (n 2) 14.0 (8.0/20.0) 3.2 (3.0/3.5) 9.0 (3.0/15.0)

PPD, Periodontal probing depth; RAL, relative attachment level; PPD / BL , PPD at baseline; PPD/12 M, PPD at 12 months. Same superscript symbols represent statistically signicant differences between pretreatment and posttreatment values (Wilcoxon signed rank test). * P .001. , , P .001. P .003. P .005. ** P .025. P .317.

results revealed great variability in both groups; however, the bony healing of both the periapical and buccal defects was more consistent in the test group. Histomorphometrically, defects in the test group exhibited signicantly better healing with respect to all measured parameters (connective tissue attachment, 4.15 mm [test] vs 1.81 mm [control]; height of regenerated bone, 2.49 vs 0.66 mm; and junctional epithelium, 0.96 vs 2.03 mm). The authors concluded that the application

of GTR with a resorbable membrane enhances both the periapical bony regeneration and the regeneration of the alveolar bone and connective tissue attachment in the apicomarginal defect. However, it can only be speculated to what extent these results can be generalized to the clinical situation in human beings. In particular, the defects were surgically created, and the root surface had not been pathologically exposed. The regenerative materials used in the present study

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Table IV. Median PPDs and RAL gain


Variables Defect class Class I Class II Smoking No Yes Periodontitis No Yes Defect size 1 surface 1 surface Defect type Type A Type B Defect localization Buccal Proximal multisite
*

n 14 6 13 7 11 9 14 6 11 9 14 6

PPD/12M, median (25/75 percentile) 4.0 (2.8/5.1) 2.8 (2.0/3.0) 3.0 (2.0/4.2) 3.0 (2.5/5.5) 3.0 (2.2/4.2) 4.0 (2.0/4.5) 3.0 (2.0/4.2) 3.5 (2.2/4.8) 3.0 (2.5/4.0) 4.0 (2.0/5.0) 3.0 (2.0/3.2) 4.8 (3.8/5.5)

P value* P .09 P .54 P .66 P .84 P .60 P .01

RAL gain, median (25/75 percentile) 4.2 (2.4/7.5) 0.0 (0.1/0.0) 4.0 (1.0/7.5) 0.0 (0.0/4.0) 2.5 (0.0/7.2) 2.5 (0.0/5.5) 2.2 (0.0/5.2) 4.0 (1.5/7.6) 2.0 (0.0/4.5) 4.0 (1.2/8.2) 1.0 (0.0/7.1) 4.2 (2.4/6.5)

P value* P .001 P .10 P .77 P .35 P .13 P .15

Univariate comparisons between groups (Mann-Whitney U test).

have been shown to yield favorable results in various clinical situations.22 In fact, in a human case report in which this material combination was used, successful regeneration of cementum, periodontal ligament, and bone occurred.23 The radiographic criteria used to assess periapical healing have been validated for periradicular surgery without the use of bone substitutes.18 Therefore, the radiographic assessment as performed in this study has to be cautiously interpreted. In particular, the bone substitute used in this study is radiopaque and its resorption under different clinical conditions is still a matter of controversy.24-32 In many cases with complete radiographic healing, a hyperdense periapical area could be found (Fig 2, B). The periapical areas that were not grafted with Bio-Oss bone mineral underwent complete radiographic healing in all 6 type B defects. The radiographic criteria uncertain healing and incomplete healing were combined because of the radiopacity of the bone substitute and because the differentiation of these 2 states was not feasible. One study reported a high frequency of failures with the use of Bio-Oss bone mineral in periradicular surgery33; however, the reasons for this high failure rate remain elusive in view of the results of the present study. Overall, we obtained good results in terms of periapical healing. For example, only 1 tooth had to be extracted after 6 months. In this Class I/1 case, severe periodontitis had caused retrograde pulpal involvement and total loss of palatal bone. All other teeth were functioning well after 12 months. The

design of the present study does not allow a direct comparison with surgical well treatment of such defects without osseous grafting or GTR. However, the overall success rate of 83% is comparable with recently published results of periradicular surgery in teeth without apicomarginal defects.34-36 Furthermore, the results compare favorably with previously published success rates in apicomarginal defects without grafting and GTR (27%2 and 37%3). However, the latter studies clearly showed that the treatment of apicomarginal defects without osseous grafting and GTR can be successful in selected cases. Therefore, future studies should aim at identifying specic defects that benet from GTR procedures. In the present series, good results were observed in terms of periodontal healing. All Class II defects had PPDs within the normal range after 12 months, and changes in RALs were within the measurement error.37 In Class I defects, a marked reduction in PPDs and RAL gain can occur; however, our results were more variable. This variability is in part attributable to the specic characteristics of apicomarginal defects. Preoperative PPD and RAL and RAL gain do not just represent a loss of the periodontal ligament, but in the case of apicomarginal defects, it will also vary with the different root lengths and the size of the concomitant periapical defect. The difference in RAL gain between Class I and Class II defects represents the different preoperative PPDs characterizing these defect classes. Several factors have been shown to inuence the results of regenerative periodontal therapies: defect

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Fig 2. A, A clinical photograph of a Class I/3 type A defect. Both the periapical and the buccal part of the defect have to be grafted to support the membrane. B, Radiographic appearance 12 months after surgery. Note the hyperdense periapical area.

size and morphology,38,39 smoking,40 and the control of local and general infection.41,42 In the present investigation, the variables of age, sex, smoking status, general periodontitis, defect size, and defect type did not appear to have any inuence on the treatment result in terms of residual PPD and clinical RAL. In light of the heterogeneity of the defects and the variability of the clinical RALs, this series lacks sufcient statistical power to reveal any such differences. However, defects with a proximal location showed signicantly higher residual PPDs after 12 months than did defects that were located solely on the buccal root surface. It is generally believed that the prognosis for patients with periodontic-endodontic lesions caused by periodontal breakdown is inferior to that for patients with lesions caused by endodontic infection.43 In the present investigation, only

4 defects were classied as being caused, at least in part, by periodontal infection, and treatment for 1 of these teeth had failed after 6 months. Defect location is only one of a number of criteria that help us determine the subclassication of Class I defects, with proximal defects being more likely to have a periodontal etiology. However, the differential diagnosis of the different subclasses of periodontic-endodontic lesions is difcult and cannot always be accomplished unequivocally.18,44 Therefore, the inuence of defect location as found in this study may in fact represent the misclassication of some of the defects. Besides low statistical power, this case series has some other important limitations. All patients with apicomarginal defects and preoperative periodontal data were included in this case series. However, this series is subject to selection biases of different kinds. Class II defects in particular are likely to be underrepresented, given that they are frequently not detected preoperatively. Furthermore, Class I/1 and Class I/2 defects may be underrepresented because referring dentists are more likely to deem cases hopeless in patients with severe periodontal disease. The majority of defects were found in lower molars. Previous studies on periodonticendodontic lesions have also revealed a predominance in lower molars45; nevertheless, general dentists are more likely to refer patients with lower molar lesions to more experienced surgeons. It is generally accepted that lesions of endodontic origin may resolve after conventional endodontic therapy alone.46 However, there is a surprising scarcity of scientic data on this subject. The only available study, published as a conference proceeding, reported a signicant PPD reduction and the resolution of 10 of 15 furcation involvements in molar teeth after nonsurgical endodontic therapy alone.45 Therefore, it seems reasonable to restrict surgery to patients in whom nonsurgical therapy has failed or is considered impractical. Our case series shows that GTR of apicomarginal defects yields satisfactory results in terms of periapical and periodontal healing after 1 year. Future studies should identify specic defects that benet from GTR procedures. CONCLUSIONS Despite the limitations of this study, it can be concluded that the application of GTR of apicomarginal defects with inorganic bovine bone mineral and a bioresorbable collagen membrane yields good results in terms of periodontal healing after 12 months. This regenerative approach should be considered as an adjunct to periradicular surgery if conventional endodontic therapy has failed or is considered impractical. The

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treatment of defects involving a proximal root surface seems to result in higher residual probing depths.
We would like to thank Geistlich Biomaterials for supplying biomaterials. We also thank Mrs. N. Jobb, A. Haake, M. Mittelstedt, J. Nast, and B. Stieler for their help and Dan Fishel for his assistance during the preparation of the manuscript. REFERENCES
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