COMPARATIVE EVALUATION OF PLATELET RICH PLASMA
(PRP) + β-TRICALCIUM PHOSPHATE( β-TCP) AND PLATELET
RICH FIBRIN (PRF) + β-TRICALCIUM PHOSPHATE( β- TCP ) ON
HEALING OF PERIAPICAL LESIONS USING CONE BEAM
COMPUTED TOMOGRAPHY(CBCT) - AN INVIVO STUDY.
A dissertation submitted
in partial fulfillment of the requirements
for the degree of
MASTER OF DENTAL SURGERY
BRANCH – IV
CONSERVATIVE DENTISTRY AND ENDODONTICS
THE TAMILNADU DR. MGR MEDICAL UNIVERSITY
CHENNAI – 600 032
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation titled “
COMPARATIVE
EVALUATION OF PLATELET RICH PLASMA (PRP) +
β
-TRICALCIUM PHOSPHATE (
β
-TCP) AND PLATELET RICH
FIBRIN (PRF) +
β
-TRICALCIUM PHOSPHATE (
β
-TCP) ON
HEALING OF PERIAPICAL LESIONS USING CONE BEAM
COMPUTED TOMOGRAPHY(CBCT) - AN INVIVO STUDY
” is a
bonafide and genuine research work carried out by me under the guidance of
Dr.M.KAVITHA M.D.S., Professor and H.O.D.
Department Of
Conservative Dentistry and Endodontics, TamilNadu Government Dental
College and Hospital, Chennai -600003.
This is to certify that
Dr.R.KRISHNAVENI
Post Graduate student
(2012-2015) in the Department Of Conservative Dentistry and Endodontics,
Tamil Nadu Government Dental College and Hospital, Chennai-600003 has
done this dissertation titled “
COMPARATIVE EVALUATION OF
PLATELET RICH PLASMA (PRP) +
β
-TRICALCIUM
PHOSPHATE(
β
-TCP) AND PLATELET RICH FIBRIN (PRF) +
β
-TRICALCIUM PHOSPHATE (
β
- TCP ) ON HEALING OF
PERIAPICAL LESIONS USING CONE BEAM COMPUTED
TOMOGRAPHY(CBCT) - AN INVIVO STUDY
”, under my direct
guidance and supervision in partial fulfillment of the regulations laid down
by the TamilNadu Dr.M.G.R Medical University Chennai-600032, for
M.D.S., Conservative Dentistry and Endodontics (Branch IV) Degree
Examination .
Dr.M.KAVITHA M.D.S.,
Professor & H.O.D. GUIDEDepartment of Conservative Dentistry and Endodontics. TamilNadu Government Dental College and Hospital
HEAD OF THE INSTITUTION
This is to certify that the dissertation titled “
COMPARATIVE
EVALUATION OF PLATELET RICH PLASMA (PRP) +
β
-TRICALCIUM PHOSPHATE (
β
-TCP) AND PLATELET RICH
FIBRIN (PRF) +
β
-TRICALCIUM PHOSPHATE (
β
-TCP) ON
HEALING OF PERIAPICAL LESIONS USING CONE BEAM
COMPUTED TOMOGRAPHY(CBCT) - AN INVIVO STUDY
” is a
bonafied research work done by
Dr.R.KRISHNAVENI,
Post Graduate
student (2012-2015) in the Department Of Conservative Dentistry &
Endodontics under the guidance of
Dr.M.KAVITHA,M.D.S, Professor
and H.O.D.(Guide),
Department Of Conservative Dentistry & Endodontics,
Tamilnadu Government Dental College and Hospital, Chennai-600003.
Dr.M.KAVITHA M.D.S., Dr.S.PREMKUMAR M.D.S.,
Professor & H.O.D., Principal i/cDepartment of Conservative Dentistry & Endodontics
I wish to place on record my deep sense of gratitude to my guide, my mentor Dr. M. KAVITHA M.D.S., for the keen interest, inspiration, immense help and expert
guidance throughout the course of this study as Professor & HOD of the Department of Conservative Dentistry and Endodontics, TamilNadu Govt. Dental College and Hospital, Chennai.
It is my immense pleasure to utilize this opportunity to show my heartfelt gratitude and sincere thanks to Dr.S.JAIKAILASH M.D.S., D.N.B. and Dr. B.RAMAPRABHA M.D.S, Professors, for their constant guidance and suggestions throughout this dissertation .
I take this opportunity to convey my everlasting thanks and sincere gratitude to Dr. S.PREMKUMAR M.D.S., Principal i/c, Tamil Nadu Government Dental College and Hospital, Chennai for permitting me to utilize the available facilities in this institution.
My sincere thanks to Dr. K.AMUDHALAKSHMI M.D.S., and Dr. ARUNA RAJ M.D.S., Associate professors, for all the support and encouragement throughout this study.
My extended thanks to Dr. G.VINODH M.D.S., Dr. A.NANDHINI M.D.S., Dr.P.SHAKUNTHALA M.D.S., Dr.M.S.SHARMILA M.D.S., Dr.SUDHARSHANA RANJINI M.D.S., Dr.SMITHA M.D.S., Dr.JOTHILATHA M.D.S., and Dr.VENKATESH M.D.S., Assistant professors, for all the help and suggestions throughout this study.
I whole heartedly thank my husband Mr.S.VASANTH B.Tech, M.B.A., and my dear son S.V.HARSHITH DEV for their moral support and patience .
TITLE OF DISSERTATION
Comparative Evaluation Of Platelet Rich Plasma (PRP) +
β
-Tricalcium Phosphate( β-Tcp) And Platelet Rich Fibrin
(PRF) +β
-
Tricalcium Phosphate (β- Tcp) On Healing Of Periapical Lesions Using Cone Beam Computed Tomography(CBCT) - An Invivo Study.PLACE OF STUDY Tamil Nadu GovernmentDental College &Hospital,
Chennai – 3.
DURATION OF THE
COURSE 3 Years
NAME OF THE GUIDE Dr. M. Kavitha
HEAD OF THE DEPARTMENT
Dr. M. Kavitha
I hereby declare that no part of the dissertation will be utilized for gaining financial assistance/any promotion without obtaining prior permission of the Principal, Tamil Nadu Government Dental College & Hospital, Chennai-600003. In addition, I declare that no part of this work will be published either in print or in electronic media without the guide who has been actively involved in dissertation. The author has the right to reserve for publish of work solely with the prior permission of the Principal, Tamil Nadu Government Dental College & Hospital, Chennai-600003.
This agreement herein after the “Agreement” is entered into on this day Dec 2014 between the Tamil Nadu Government Dental College and Hospital represented by its Principal having address at Tamil Nadu Government Dental College and Hospital,Chennai - 600 003, (hereafter referred to as, ‘the college‘)
And
Mrs. Dr. M. Kavitha aged 44 years working as Professor and HOD in Department of Conservative Dentistry & Endodontics at the college, having residence address at 69/4,Mettu street, Ayanavaram, Chennai-23(herein after referred to as the Principal Investigator‘)
And
Mrs. Dr. R.Krishnaveni aged 30 years currently studying as Post Graduate student in Department of Conservtive Dentistry & Endodontics, Tamilnadu Government Dental College and Hospital, Chennai 3 (herein after referred to as the PG student and coinvestigator‘).
Whereas the PG student as part of her curriculum undertakes to research on “COMPARATIVE EVALUATION OF PLATELET RICH PLASMA (PRP) +
β
-TRICALCIUM PHOSPHATE( β-TCP ) AND PLATELET RICH FIBRIN (PRF) +
β
-TRICALCIUM PHOSPHATE( β- TCP ) ON HEALING OF PERIAPICAL
LESIONS USING CONE BEAM COMPUTED TOMOGRAPHY(CBCT) - AN INVIVO STUDY” for which purpose the Principal Investigator shall act as principal investigator and the college shall provide the requisite infrastructure based on availability and also provide facility to the PG student as to the extent possible as a Co-investigator. Whereas the parties, by this agreement have mutually agreed to the various issues including in particular the copyright and confidentiality issues that arise in this regard. Now this agreement witnesseth as follows
1. The parties agree that all the Research material and ownership therein shall become the vested right of the college, including in particular all the copyright in the literature including the study, research and all other related papers.
2. To the extent that the college has legal right to do so, shall grant to licence or assign the copyright so vested with it for medical and/or commercial usage of interested persons/entities subject to a reasonable terms/conditions including royalty as deemed by the college.
whatsoever and for any purpose without the express written consent of the college.
6. All expenses pertaining to the research shall be decided upon by the Principal Investigator/Co -investigator or borne solely by the PG student. (Co-investigator)
7. The college shall provide all infrastructure and access facilities within and in otherinstitutes to the extent possible. This includes patient interactions, introductory letters, recommendation letters and such other acts required in this regard.
8. The Principal Investigator shall suitably guide the Student Research right from selection of the Research Topic and Area till its completion. However the selection and conduct of research, topic an area of research by the student researcher under guidance from the Principal Investigator shall be subject to the prior approval, recommendations and comments of the Ethical Committee of the College constituted for this purpose. 9. It is agreed that as regards other aspects not covered under this agreement, but which pertain to the research undertaken by the PG student, under guidance from the Principal Investigator, the decision of the college shall be binding and final.
10. If any dispute arises as to the matters related or connected to this agreement herein, it shall be referred to arbitration in accordance with the provisions of the Arbitration and Conciliation Act 1996.
In witness whereof the parties herein above mentioned have on this day, month and year herein above mentioned set their hands to this agreement in the presence of the following two witnesses.
College represented by its Principal PG Student
Witnesses Student Guide
The aim of this study is to quantitatively evaluate and compare bone regeneration in periapical lesions using a combination of Platelet Rich Plasma + β-Tricalcium phosphate and Platelet Rich Fibrin + β –Tricalcium phosphate.
Materials And Methods:
Ten subjects with periapical lesion measuring 10-20 mm in relation to maxillary anteriors indicated for periapical surgery were selected . Pre operative bone density values at periapical region were measured in Hounsefield units using CBCT. Root canal treatment was completed appropriately in all the cases. Under adequate local anesthesia full thickness mucoperiosteal flap was raised, debridement of the periapical lesion followed by root end resection and retrograde filling was done. The 10 subjects were randomly divided into two groups. In Group I, periapical bone defect was filled with PRP + β-TCP and in Group II, with PRF + β-TCP. The mucoperiosteal flaps were repositioned and sutured. Bone density evaluation of the periapical region was done 6 months and 1 year after surgery using CBCT and the HU values were obtained.
Results:
Mean 6 months HU value obtained for group I and group II were significantly higher than the respective pre op values of both groups.Mean 1 Year HU value obtained for group I and group II were higher than the respective pre op and 6 months HU values
.
There was no statistically significant difference in bone density HU values between the two groups at 6 Months and 1 year post operatively.Conclusion:
Both the combinations PRP + β-TCP and PRF + β-TCP are equally effective in promoting bone regeneration and can be considered to be valuable options for placement in periapical bone defects.
CONTENTS
S.No. TITLE PAGENo.
1 INTRODUCTION 1
2 AIM AND OBJECTIVES 4
3 REVIEW OF LITERATURE 5
4 MATERIALS AND METHODS 22
5 RESULTS 38
6 DISCUSSION 51
7 SUMMARY 61
8 CONCLUSION 63
LIST OF TABLES
TABLE NO.
TABLE PAGE NO.
1
HOUNSEFIELD UNIT VALUES OBTAINED FOR
GROUP I
38
2
HOUNSEFIELD UNIT VALUES OBTAINED FOR
GROUP II
393
PRE-OP, 6MONTHS AND 1 YEAR HU UNIT
MEAN AND STANDARD DEVIATION OF
VALUES
39
4
WITHIN GROUP COMPARISON-
REPEATED MEASURE ANOVA
40
5
BONFERRONI POST HOC TESTS
41
LIST OF GRAPHS
S.No. GRAPH PAGE No.
1
GRAPH I COMPARISON OF HU UNITS VALUES PRE - OP , 6 MONTHS AND I YEAR -
GROUP I
43
2
GRAPH II COMPARISON OF HU UNITS VALUES PRE - OP ,6 MONTHS AND I YEAR -
GROUP II
43
3 GRAPH III INTER GROUP COMPARISON OF
ABBREVIATIONS USED
BMP Bone Morphogenic Protein
β –TCP Beta Tricalcium Phosphate
CBCT Cone Beam Computed Tomography
EGF Endothelial Growth Factor
FGF Fibroblast Growth Factor
HA Hydroxyapatite
HU Hounsefield Unit
IGF Insulin Like Growth Factor
IL Interleukin
PDAF Platelet Derived Angiogenic Factor
PDGF Platelet Derived Growth Factor
PPP Platelet Poor Plasma
PRF Platelet Rich Fibrin
PRP Platelet Rich Plasma
RCT Root Canal Treatment
TGF Transforming Growth Factor
TNF Tumor Necrosis Factor
1
INTRODUCTION
Periapical lesions are the most common sequelae of microbial infection of the
dental pulp. They generally present with acute pain and/or swelling in relation to the
affected tooth or diagnosed during routine radiographic examination. All endodontic
therapies are aimed to regain the state of health and function of the affected tooth.61 Most
periapical lesions heal satisfactorily with non-surgical endodontic intervention. However,
a few cases require periradicular surgery when symptoms and infection persist, in order
to eliminate the source of infection, and promote healing.2
Traditional surgical approaches to treat periapical defects include debridement of
apical lesions along with reshaping of the surrounding bone where healing is almost
always by repair .6 Repair is defined as the healing of a wound by tissue that does not
fully restore the architecture or the function of the lost tissue .29So attention has
shifted towards regenerative approaches that aim to restore lost tissue.
Regeneration is reproduction or reconstitution of a lost or injured part without
any scar. Various bone substitutes has been used after degranulation of the lesion, to
achieve regeneration of the bone and optimal healing.
Beta-tricalcium phosphate (β-TCP) alloplastic bone graft material is one of these
substitutes widely used to enhance new bone formation in periapical surgery. It is
osteoconductive which gets chemically resorbed with a concomitant release of bioactive
ions. However beta TCP is osteoconductive but not osteoinductive and more time is
2
The key to tissue regeneration is to simulate a cascade of healing events and
promote integrated tissue formation. This is possible only with the use of biological
modulators like the use of bone morphogenetic proteins, growth factors and extracellular
matrix because these induce regeneration by osteoinduction.12Osteoinduction is a
process where one tissue or its derivative causes another undifferentiated tissue to
differentiate into a new bone and whereby new bone is produced in an area where there
was no bone earlier.
Among the rich sources of autologous growth factors the various generations of
platelet concentrates are currently in use.
Whitmen developed Platelet-Rich Plasma [PRP] in 1997 the first generation
of autologous platelet concentrate.15This is a rich source of growth factors and its
application is thought to induce tissue repair and regeneration.75Marx et al., in 1998,
reported the first clinical dental results with PRP and they suggested that PRP when
added to bone grafts accelerated the rate of bone formation.47
Choukroun in the year 2001, introduced Platelet rich fibrin (PRF), the
second-generation platelet concentrate.18This promotes periapical tissue regeneration
and healing being enriched with platelets and growth factors.
PRF and PRP are now being widely used in diverse disciplines of dentistry.
Various studies4,10,43,60 have proved their potential role in promoting soft tissue and bone
3
combination with various graft materials. They are also suggested as an ideal scaffold in
revascularization of immature permanent teeth with necrotic pulps and various studies38,65
have been conducted on the same. However very few evidence is available in the
literature regarding the use of platelet concentrates in periapical bone defects .16, 54, 66
Till date no studies have been conducted on the use of PRF/PRP in combination
with β- TCP in periapical bone defects.
So in this invivo study PRF+ β-TCP and PRP+ β-TCP were used in periapical
bone defects and a comparative evaluation of healing was done using CBCT after a
4
AIM AND OBJECTIVES
AIM:
The aim of this study is to quantitatively evaluate and compare bone regeneration in
periapical lesions using a combination of PRP + β-TCP and PRF + β-TCP.
OBJECTIVES:
i. To evaluate bone density in periapical lesions using a combination of PRP and
β-TCP by CBCT after a post-operative period of 6 months and one year.
ii. To evaluate bone density in periapical lesions using a combination of PRF and
β-TCP by CBCT after a post-operative period of 6 months and one year.
5
REVIEW OF LITERATURE
REGENERATION OF TISSUE/BONE
Traditional approaches for treatment of endodontic and periodontic defects
include debridement of root surfaces or root canals non-surgically and surgical
procedures that provide better access to clean the root surfaces and apical lesions and to
reshape the surrounding bone/root apex. Bone is sometimes removed for access or to
create better physiologic contours.
The ultimate goal of any other oral reconstructive procedure is to achieve
complete wound healing and the regeneration of the tissues (periodontal ligament, bone,
cementum, and connective tissue) destroyed as a result of disease.
Melcher et al. (1976)49proposed the type specific repopulation theory, which was
further established by Gotlow et al (1984).31 The theory states that, the type of healing
that occurs after conventional endodontic and periodontal therapy is critically dependent
on the cell type that repopulates the wound first resulting in either repair or regeneration.
Typically, the cells with the fastest migration rate tend to dominate the initial healing
phase.
Trombelli et al. (2002)76in their systematic review discussed various bone
substitutes and bone grafts that have been used for regenerative purposes. They compared
results of open flap debridement alone and in combination with graft materials and
concluded implantation of graft materials provided favourable results.
Wang et al.(2006)78 described the 4 major biologic principles necessary for
6
healing, angiogenesis for adequate blood supply and undifferentiated progenitor cells,
space maintenance to provide adequate space for bone in growth, and stability of wound.
The amount and extent of regeneration achieved via various grafting modalities is
decided by these factors which play a significant role.
BETA TRICALCIUM PHOSPHATE
The use of bone replacement grafts is the most popularly used technique for
regeneration .These grafts promote bone regeneration through various mechanisms.
Grafts could be osteogenic, osteoinductive or /and osteoconductive. Osteogenic grafts
contain cells that lay down bone matrix, resulting in new bone formation. Osteoinductive
grafts release mediators that signal the host to produce native bone and growth factors.
Osteoconductive graft materials are those which form a scaffold on which host
osteogenic cells proliferate. In general, grafts can be categorized into autogenous graft,
xenograft, allograft and alloplast.
Petite et al. (2000)56 reported that autogenous bone grafts are the preferred choice
for any regenerative procedure, however patient morbidity, limited supply of suitable
bone, painful procurement, risk of infection, nerve damage and haemorrhage remain the
factors of concern.
Reynolds et al. (2003)57in their systematic review on comparing the variety of
bone replacement grafts concluded that bone grafts increase bone level and better soft
tissue healing compared to open flap debridement. Also, no differences in clinical
outcome measures were observed between particulate bone allografts, and bovine derived
7
Koepp HE et al. (2004)45 stated that beta tricalcium phosphate (β-TCP) is highly
biocompatible and possess osteoconductive properties and is the most prevalent of
alloplastic materials.
ZerboI R et al. (2004 )80 in his in vivo study histologically compared
beta-Tricalcium phosphate (β-TCP) and autologous bone for sinus floor augmentation in a
split mouth model and concluded that the historically well accepted β-TCP is a reliable
bone substitute material for bone augmentation. But however the rate of bone formation
could be somewhat delayed when compared to autologous bone, as the material is
osteoconductive, but not osteoinductive.
Horch HH et al. (2006)36 in their study evaluated the properties of
beta-tricalcium phosphate (β-TCP) at different sites of alveolar reconstruction and concluded,
because of its versatility, low complication rate and good long-term results, synthetic, β
-TCP is a suitable material for the filling of bone defects.
Jensen SS et al. (2006)39 compared quantitatively and qualitatively the bone
formation and their resorption, with autogenous bone as a control. Bone defects were
prepared in mandibular angles of 12 adult minipigs and were grafted with either,
anorganic bovine bone (ABB), autograft or synthetic β-TCP. Histomorphometric and
histologic analysis was performed at 1, 2, 4, and 8 weeks.
At 2 weeks, defects filled with autograft showed more new bone formation than
with β--TCP and ABB. After 4 weeks, there was no significant difference between
beta-TCP and the two other materials, however ABB filled defects exhibited less bone
formation than those filled with autograft. At 8 weeks, bone formation observed in
8
be demonstrated between autograft and beta-TCP over 8 weeks, beta-TCP resorbed
almost completely whereas ABB remained stable.
Bashutski et al. (2009)6 in their systematic review reported that alloplast
materials as the most commonly used bone replacement materials for periapical defects.
Positive results with respect to periodontal regeneration in periapical defects have been
reported with these materials.
Bettach R et al. (2014)7 evaluated the effectiveness of β-TCP for maxillary sinus
floor augmentation. The authors concluded β-TCP which is highly porous and resorbed
faster proved to be a valuable option for sinus augmentation, even when it is used alone.
PLATELET CONCENTRATES
Platelets are un-nucleated cells which circulate in blood for 8-10 days. Ross et al.
(1974)58 introduced their regenerative potential and discussed the role of platelets in
wound healing. They play an important role in hemostasis and are a natural source of
growth factors that are stored within platelet α-granules like the vascular endothelial
growth factor(VEGF), insulin like growth factor (IGF ),platelet derived growth factor
(PDGF), platelet derived angiogenic factor (PDAF), and transforming growth factor beta
(TGF-β). The activation of platelets triggers release of these growth factors that is
initiated by various substances or stimuli such as, calcium chloride, collagen or thrombin.
Active proteins thus bind to transmembrane receptors of the target cells and activate
intracellular signalling proteins and thereby expression of a gene sequence which directs
9
from growth factors (GFs), platelets also release various other substances
e.g., fibronectin, sphingosine 1-phosphate, vitronectin etc. that aid in wound healing.
Gruber et al. (2002)33 demonstrated the beneficial effects of platelets and their
ability to accelerate bone regeneration by stimulating the osteoblastic proliferation. They
determined the mitogenic response of trabecular bone-derived cells to platelets and
platelet-released supernatant. They showed an average of 50-fold increase in DNA
synthesis of bone cells that were cultured in the presence of PRS or human platelets and
thereby concluded their grafting applications could contribute to the mineralised tissue
regeneration. Concentrating the blood components by centrifugation provides an
opportunity to amplify the advantageous and rich components of patients’ own blood.
Platelet rich plasma and platelet rich fibrin are two such platelet concentrates. These are
basically fibrin matrices enmeshed with morphogenic proteins (growth factors) and
leukocytes.
Fabbro et al. (2011)25 summarised the ideal role of platelet concentrates as,
augmentation of tissue healing by increasing proliferation of connective
tissue progenitor cells that stimulate fibroblastic and osteoblastic activity and enhancing
osteogenesis, anti-microbial activity against a variety of bacterial species that are
involved in oral infection and modification of host defence mechanism by delivering the
signalling peptides that would attract macrophage cells and modification of immune
10
PLATELET RICH PLASMA
Platelet rich plasma (PRP), the first generation of platelet concentrate, is an
increased concentration of autologous platelets suspended in a small amount of plasma
after centrifugation.
Marx et al. (1998) 47 compared bone density in grafts with and without PRP and
histomorphometric assessment value showed greater bone density (74.0% +/- 11%) in
grafts in which PRP was added than in grafts in which PRP was not added (55.1% +/-
8%; p = 0.005). They also observed 1.62 to 2.16 times greater maturation rate
radiographically in the PRP group than that of grafts without PRP.
Carlson NE et al. (2002) 9 in their systematic review explained since PRP
contains Growth factors namely PDGF, and TGF-beta, VEGF, etc. that are capable to
increase fibroblast cell differentiation by stimulating osteogenesis, using PRP to
accelerate hard and soft tissue healing has been proposed. Researches have also shown
that PRP and such analogous products minimize micro-movement and improve graft
adhesion providing the most advantageous environment for graft acceptance.
Sánchez AR et al. (2003)62 in their systemic review discussed the regenerative
potential of Platelet rich plasma. As the osseous regeneration with various
osteoconductive grafting materials is not predictable they suggested improvement in the
osteoinductive properties where PRP is a valuable option in such cases. PRP being a rich
source of various growth factors is believed to increase the rate and quality of bone
11
Hanna R et al. (2004)34 compared the clinical outcomes obtained by the
combination of platelet rich plasma and a bovine derived xenograft to those obtained
from the use of the bone replacement graft alone, in a 9 months clinical trial in
periodontal bone defects. They stated addition of autologous platelet concentrates to a
bovine derived xenograft to treat intrabony defects significantly improved their clinical
response.
Kassolis JD et al. (2005)42 compared bone formation after subantral maxillary
sinus augmentation with an allograft plus resorbable membrane versus the allograft plus
PRP and concluded that PRP, an autogenous sources of bioactive mediators, offers the
potential to enhance the biological activity of bone replacement graft.
Fernández-Barbero JE et al. (2006)26examined and provided an ultra-structural
and flow cytometric characterization of PRP gel. PRP gel specimens were prepared for
scanning and transmission electron microscopy examination of their morphological
ultrastructure. Flow cytometry with human-platelet-specific antigen CD41 recognizing
CD41-PE monoclonal antibody was used to detect human platelet cells. The results
showed that PRP gel contains two components: a cellular component that contains
platelet cells and a fibrillar material similar to fibrin filaments. Both techniques indicated
that no morphological elements were bound between the fibrillar material and the cellular
component. From these findings, they were on an impression that this unique structure
may act as a vehicle for cells that promote hard and soft tissue regeneration.
Sunitha et al .( 2008 )73 stated 5% platelets are present in normal human blood
12
contain growth factors such as PDGF and TGF – β etc. that may influence the
regeneration .
In-vitro studies by Creeper et al. (2009)14have reported proliferation of
osteoblastic and periodontal ligament cells under the influence of PRP. Although PRP
contains growth factors, their release in wound site tends to be rapid and for a short
duration of time.
Parimala et al. (2010)54 performed a comparative evaluation of bovine porous
bone mineral with and without platelet rich plasma. Significant results in both soft and
hard tissue regeneration were observed with both treatment modalities. Although the
mean difference between two groups was statistically non-significant, more favourable
results were observed with combination therapy.
Parikh B et al. (2011)53described a case report with the use of PRP unilaterally in
a bilateral periapical defect in the same patient. Periapical bone regeneration was
evaluated quantitatively using CT scan. As early as 8 weeks PRP treated site showed
better healing than the other site. The CT scan measures the density of bone at various
sections in Hounsfield Unit (HU). The normal bone density was averaged to 750 HU.
After 1 year the bone density at the periapex of PRP treated side was 559 HU and the
opposite side was 398 HU suggesting the positive role of PRP in accelerating bone
formation.
Vaishnavi et al. (2011)77 compared bone regeneration in endodontically induced
periapical lesions using, Platelet-Rich Plasma (PRP), Hydroxyapatite (HA) and a
13
I — bone defect replaced with Hydroxyapatite, Group II — PRP, Group III — PRP and
Hydroxyapatite, and Group IV — Control group with no substitute .On radiographic
evaluation, in Group I patients complete regeneration of bone with evidence of
trabecular pattern, was seen after 1 year, at the end of 9 months in Group II , at the end of
6 months in Group III, and Group IV patients showed no satisfactory bone regeneration,
even after 1 year .So they concluded PRP and HA combination achieved better and faster
regeneration of bone when compared to PRP alone.
Durmu Şlar MC et al . (2014 ) 23 evaluated clinically and radiographically the
efficacy of PRP when combined with bovine derived hydroxyapatite bone grafting
materials and resorbable collagen membranes for the treatment of intra-bony defects in
post extraction sockets . Post-operative assessment was done at 1, 3 and 6 months. Digital
panoramic radiographic assessment showed no significant difference in bone formation
among groups after 1st and 6th month, while in the 3 months post-operative group the
radiographic density at the PRP side was significantly higher. This led to a conclusion
that combined use of PRP and bone graft materials might be an appropriate approach
when providing earlier bone regeneration is the main goal.
Tae-Hoon Kim et al. (2014) 74comparatively evaluated the effect of platelet-rich
plasma, platelet-rich fibrin, and concentrated growth factor on bone healing, on skull
bone defects in rabbits. Microscopic computed tomographic (micro-CT) and
histomorphometric analysis of the bone volume and bone mineral density were made at
the 6th and 12th week. Bone volume and bone density were greater at both 6th and 12th
14
They reported that the addition of PRP and PRF significantly increased bone formation at
the 6th week.
PLATELET RICH FIBRIN
Platelet rich fibrin is a second generation platelet concentrate, developed in
France by Choukroun (2001), is an autologous reservoir of growth factors which
accumulates platelets and cytokines in a physiologic fibrin clot. PRF clot concentrates 97
% of platelets and >50 % of leukocytes in a specific three dimensional distribution. It
consists of intimate assembly of glycanic chains, cytokines and structural glycoproteins
enmeshed within a slowly polymerized fibrin network.
Dohan et al. (2006a) 18 showed that slow and natural polymerization of PRF in
the presence of physiologic thrombin gives it the crucial three dimensional organization
of fibrin network. This characteristic fibrin network provides it with great elasticity, thus
forming a very strong PRF membrane. Waiting for more than a minute or two may cause
the fibrin to polymerize in a diffuse way, leaving behind only a small poorly formed clot
in the test tube.
Histological analysis by Dohan et al. (2006b)19 explained the platelet distribution
within the various layers of the blood after centrifuge. The platelets accumulate in the
lowest part of the fibrin clot, at the junction between the red thrombus and the PRF clot
itself. From observation it is evident that the red extremity of PRF would be of maximum
15
Dohan et al. (2006c) 20 in their systematic review about the leukocyte activation
of PRF, discussed about the activation of PRF. Activation and degranulation of platelets
is essential to initiate coagulation and support their aggregation at the site of healing. In
the absence of anticoagulant, platelets are activated when they come in contact with silica
of glass tube walls and this initiates the coagulation cascade. Fibrin is formed from
fibrinogen in the presence of physiologic thrombin. After centrifugation platelets are
massively concentrated and fibrin is obtained in the middle of the tube. Activation of
platelets, thus releases the cytokines (Interleukin-1 β, interleukin-6, TNF-α) and growth
factors namely, PDGF, VEGF, TGF- β1, EGF that stimulate migration and proliferation
of cells within the fibrin matrix and initiates healing.
Connell (2007) 13raised concerns regarding the safety issue of methodology used
in the preparation of PRF. He mentioned about the types of tubes to be used to produce
PRF and the hazards that might be possible with the silica containing glass tubes.
However, Dohan et al.( 2007) 21 conducted an analysis on the cytotoxicity of
PRF on a wide range of human cells and concluded that the silica micro particles coating
these glass tubes are not cytotoxic for the human cells tested. They also reported
improvement in mitotic proliferation and suggested silica being a clot activator, contact
with silica is necessary to start the process of polymerization. Thus, to produce PRF
either glass coated plastic tubes or dried glass tubes must be used.
According to a study by Su et al. (2009) 72, platelet rich fibrin allows continuous
16
be used immediately after preparing. The progressive release of cytokines and leukocytes
continues for a period of 7-11 days, as the fibrin network disintegrates.
Kanakamadela et al. (2009) 41reported combined use of platelet rich fibrin and
bone graft for combined periodontic – endodontic furcation defect. They reported
beneficial results with the combination therapy.
Mazor Z et al. (2009) 48used PRF as the sole agent in simultaneous sinus lift and
implant placement. They demonstrated stabilization of high volume of natural
regenerated bone in the sub-sinus cavity when reviewed after 6 months.
Chang et al. (2010)11reported in their in-vitro study that platelet rich fibrin can
modulate the expression of extracellular signal-regulated protein kinase and osteprotegrin
in human osteoblasts, suggesting potential role in bone regeneration. PRF increased
osteoblast proliferation during incubation period of 5 days.
Sharma A et al. (2011)64 explored the clinical and radiographic effectiveness of
autologous PRF in the treatment of intrabony defects in patients with chronic
periodontitis. Fifty-six intrabony defects were treated with either open-flap debridement
and autologous PRF or open-flap debridement alone. The defect fill at baseline and 9
months was calculated by using image-analysis software on standardized radiographs. A
significantly higher percentage of mean bone fill was noted in the test group (48.26% ±
5.72%) compared to the control group (1.80% ± 1.56%). However the authors suggested
a long-term, multicentered randomized clinical trial to confirm the clinical and
17
Bambal D et al. (2012)5 evaluated and compared the healing ability of
bilateral periapical lesions treated with and without the use of
platelet-rich fibrin. Platelet-platelet-rich fibrin (PRF) being a platelet concentrate platelet-rich in various growth
factors widely used to promote tissue healing and bone induction when used in periapical
lesions showed better healing and this was confirmed with a 3-D X-ray.
Smita Singh et al. (2013)69 discussed PRF applications in surgical management
of periapical lesions. They stated that PRF improves maturation of bone, early wound
closure, and the final aesthetic result of the periodontal soft tissues. It normally requires
around 1 year for healing to occur completely after the periapical surgery. PRF when
used, healing is accelerated and complete regeneration of bone occurs as early as 6
months and suggested production of PRF on high-speed centrifugation that is dense,
cross-linked, and physically robust, rich in intact platelets and fibrin and without an
exogenous thrombin, is an ideal scaffold for use in tissue regeneration.
Shivashankar et al. (2013) 66 evaluated the effectiveness of using the
combination of HA, PRF and PRF membrane in the management of large periapical
lesion. On observation uneventful wound healing clinically and radiologically,
replacement of HA crystals completely by new bone was seen at the end of 2 years. From
the results obtained, they hypothesized that the use of PRF might have accelerated the
resorption of the HA crystals and induced the rate of bone formation.
Saurav Panda et al. (2014) 63 evaluated the combination of PRF with an
alloplastic graft material. It has been reported though PRF is a firmer and denser agent it
18
combination of a rigid mineralized bone mineral with PRF to enhance the clinical
outcome of intrabony defects by maintaining the space for regeneration to occur.
PRF/PRP + β-TCP
Demiralp B et al. (2004) 16 in his case report discussed the use of platelet rich
plasma in combination with beta TCP graft material in periapical bone defect after
curettage and reported the results after an observation period of one year.
Radiographically TCP particles have almost been totally resorbed at the end of 12 months
and replaced with new bone. They concluded the use of PRP in combination with beta
TCP accelerates the resorption of the graft and induces bone formation. However they
suggested histological evaluation to confirm their result.
Meyer et al. (2009)50advocated that the long-term reliability of β-TCP associated
to growth factors (PRP or PRF) without any bone graft, in massive sinus-lift procedures
induce fewer complications, and the implant success as well as resorption rate is
comparable to the one obtained by using autologous bone grafts.
Park JK et al. (2011) 55evaluated the efficacy of PRF and PRP when used in
combination with beta-TCP on bone regeneration in rabbits. Artificial bone defects were
filled with beta-TCP +PRP or beta-TCP + PRF or beta-TCP alone. After four and eight
weeks, histology , histomorphometric analysis demonstrated more new bone formation in
beta-TCP + PRF and in beta-TCP only groups and it was significant statistically. There
was no significant difference between beta-TCP + PRP and nothing apply groups in the
19
Saini N et al. (2011) 60 compared the efficacy of autologous PRP + β-TCP versus
β-TCP alone in the treatment of infrabony defects. Radiographic evaluation of the defect
depth done 36 weeks postoperatively showed significantly more linear bone fill in
PRP+β-TCP filled group than the β-TCP alone group suggesting the combination of PRP
and β-TCP for favourable clinical outcome in intrabony defects.
Jayalakshmi et al. (2012) 37 described a case of bone augmentation using
PRF+β-TCP in treatment of chronic periapical cyst. At regular follow ups after 3, 6, 9,
and 12 months significant, predictable and progressive clinical and radiographic bone
healing was evident.
Goyal (2014) 32 evaluated the clinical effectiveness of platelet rich fibrin in
combination with β-TCP as opposed to using these materials alone. They stated though
the healing of an endodontic lesion is predictable, the repair or regeneration of the
associated periodontal tissues is questionable. The success rate of the combined
endodontic periodontal lesion range from 27 to 37% without a concomitant regenerative
procedure suggesting the need of surgical intervention. The use of autologous platelet
concentrate PRF optimizes tissue remodeling, angiogenesis and wound healing by the
local delivery of growth factors and proteins. They concluded that this combination of
PRF + β-TCP enables the clinicians to gainfully harvest the full regenerative potential.
El Backly RM et al .(2014)24 evaluated histologically the bone regeneration
augmenting property of PRP when combined with hydroxyapatite-β-tricalcium phosphate
bone graft material in rabbit calvarial defects and observed high cellularity with regular
20
that PRP enhanced recruitment of osteoprogenitor cells and influenced the
microenvironment of local tissue in a favourable manner.
PRP VS PRF
Gassling VLet al . (2009) 28 examined the growth factor release from PRP and
PRF in vitro. PRP or PRF preparations were added for ten days to cell culture containing
human fibroblasts (F), Human osteoblasts (O) and human osteoblast-derived
osteosarcoma cells (Saos-2). Cells were cultivated, and the quantities of growth factors
(PDGF isomers AB and BB, ILGF I and TGF isomers (beta1 and beta2) were analyzed
by ELISA. In Saos-2 and osteoblast cell cultures, significantly higher cytokine
concentrations were for PRP than for PRF demonstrating higher levels of growth factors
when PRP was applied in cell cultures than PRF application.
He Let al. (2009) 35 evaluated the biologic characteristics of PRP and PRF on
proliferation and differentiation of rat osteoblasts. They observed that PRP released
higher amounts of PDGF-AB and TGF-beta1 at the first day, which decreased at later
time points. PRF released highest amount of PDGF-AB at day 7 and the highest amount
of TGF-β1 at day 14. They reported PRF released growth factors gradually thus
expressing more durable and stronger effect on rat osteoblasts proliferation and
differentiation than PRP in vitro.
Bajaj P et al. (2013) 4 conducted a study to compare the effectiveness of PRF
and PRP in the treatment of mandibular degree II furcation defects with open flap
21
showed statistically significant improvement at both the test sites, PRF with OFD and
PRP with OFD, compared to those with OFD alone stating that PRF or PRP were both
22
MATERIALS AND METHODS
The study was carried out in the Department of Conservative Dentistry and
Endodontics, Tamil Nadu Government Dental College and Hospital, Chennai, India.
Inclusion criteria
Patients with age group 20-40 years of either gender
Periapical lesions involving maxillary incisors of strictly endodontic origin.
The diameter of the bone defect of 10 -20 mm
Patients willing for voluntary participation & have signed informed consent.
Patients with good oral hygiene.
Systemically healthy subjects
Exclusion criteria
Periodontally compromised teeth with poor prognosis
Tooth with pathosis associated with vertical root fracture.
Patients with bleeding disorders.
Platelet count <1, 50, 000/mm3.
Patients showing unacceptable oral hygiene maintenance.
Patients with use of tobacco or tobacco related products
Pregnant / Lactating patients
Patients with known systemic diseases
Patients with any known allergies
23 ARMAMENTARIUM
For Root Canal Procedure
Mouth Mirror, Explorer, Tweezer
Sterile cotton, sterile gauze
Disposable Gloves, facemask and headcap
Rubber dam kit (GDC Marketing)
High speed airotorhandpiece (NSK , Germany)
Round diamond bur ( BR 31 ,Mani corporation, Japan)
Endo access diamond bur ( # 2 size, Maillefer, Switzerland)
Safe ended bur ( EX 24 ,TC Endo Z bur, Maillefer, Switzerland)
Plastic instrument
Disposable suction tube
Root canal instruments (Broaches, Reamers, K Files etc. MANI PRIME
DENTAL PVT .LTD.)
AH plus jetsealer(DentsplyMaillefer)
Cavit (3M ESPE Germany)
Glass Ionomer Cement (GC FUJI II)
Endoblock
Sodiumhypochlorite 3% solution (Hyposol, PrevestDenpro Ltd,India)
EDTA (Pulpdent corporation USA)
Normal saline
24
Absorbent Paper Points (DentsplyMaillefer, India)
Guttapercha points ( DentsplyMaillefer, India)
Calcium hydroxide (Metapex, Meta biomed Co.Ltd., Korea)
Glass slab & spatula
Spirit lamp
For surgical procedure
Mouth mirror
Dental tweezers
Surgical gloves, Head cap, Disposable mouth mask
Lidocaine 2% (Indoco remedies Ltd.)
Bard parker blade no 15 and handle
Periosteal elevator
Austin retractor
Straight and Curved scissors
Curette
Bone file
Saline and irrigation syringe
Glass ionomer cement (GC Fuji IX)
Cement spatula and Glass slab
β –TCP bone graft material (Sybograf-T, Eucare pharmaceuticals (P) Ltd.)
PRF and PRP
25
Suture material – 3-0 black silk
Needle holder
For preparation of PRF
Sterile cotton and surgical spirit.
Disposable syringe (10 ml)
Tourniquet
Sterile glass test tube
Centrifuge ( Remi, India)
Dental tweezers and scissors
For preparation of PRP
In addition to the above mentioned armamentarium for PRF,
EDTA (Qualigens chem)
Calcium chloride (Thermo Fisher Scientific India Pvt. Ltd.)
Bovine thrombin (Uniplastin, Tulip diagnostics (P) Ltd.)
For CBCT
Planmeca Promax 3D Imaging System (Planmeca Helsinki, Finland)
STUDY DESIGN
Ethical clearance was obtained from the Institution’s Ethical Committee. Ten
subjects who fulfilled the above mentioned criteria were selected for the study, with no
26
treatment procedure was explained to the patients (Annexure 1) and a written informed
consent was obtained from all the patients selected for the study (Annexure 2).
The 10 subjects were randomly divided into two groups:
Group I : (n=5) peri apical bone defect filled with PRP+β TCP
Group II : (n=5) peri apical bone defect filled with PRF+β TCP
STUDY PROTOCOL
1. Institutional ethical committee approval.
2. Pre-operative clinical, radiographic and CBCT evaluation of the patients.
3. Root canal treatment completed appropriately.
4. Surgical procedure (periapical curettage and graft placement).
5. Post –operative care and follow up.
6. Radiographic and CBCT evaluation after 6 months and 1 year.
METHODOLOGY
Pre-op evaluation of the patients
For all the patients selected for the study, medical and dental history was
recorded. Intra oral examination was done to assess the nature of the presenting illness,
the oral hygiene status, periodontal status and restorability of the involved tooth
27
Intra oral periapical radiograph was obtained using paralleling technique with
XCP film holding instruments. Electric pulp testing was performed to assess the vitality
of the teeth. Routine blood investigations were carried out for all the patients.
CBCT scan was taken (90 kV, 10mA, FOV-50 mm) and the pre-op bone density
values were recorded in Hounsefield Units (HU) using Romexis software. HU values
were obtained from saggital section at the mid root level of the involved tooth calculating
an average of 10 values at various points within the lesion.
Oral prophylaxis was done before commencement of the treatment.
Root canal treatment
Root canal therapy was completed in cases where the patients were asymptomatic
and in others obturation was done on the day of surgery.
Under rubber dam isolation, straight line access cavity was made using
high-speed airotor hand piece and sterile burs. Canals were negotiated using K-files. Working
length was determined and chemo mechanical preparation was completed using
standardized technique and appropriate size K-files. Canals were irrigated using saline
and 3% sodium hypochlorite, 17% EDTA was used as lubricant. Canals were dried with
paper points. Calcium hydroxide intracanal medicament was placed for 2 weeks for two
consecutive times in cases where the symptoms were persistent. Subsequently obturation
was completed using Gutta Percha and AH plus jet sealer by lateral condensation
28
Surgical procedure
Extra oral antisepsis and intra-oral antisepsis was performed with 5% povidone
iodine solution and 0.2% chlorhexidine digluconate rinse respectively. The operative site
was anaesthetized with 2% Lignocaine HCl with adrenaline (1:80,000) using Infra
Orbital nerve block and infiltration techniques. Crevicular incisions were made on the
labial surfaces, extending on teeth on each side of the involved tooth using the Bard
Parker blade No.15.A full thickness mucoperiosteal flap was reflected using the
periosteal elevator. Care was taken to preserve interdental papillary tissue. After
reflection of the flap and exposure of osseous defect, a thorough surgical debridement of
soft and hard tissue was done using soft tissue and bone curette. Osseous margins were
smoothened. Debridement was followed by copious irrigation with 0.9% normal saline.
Root end was resected and retrograde filling was done with Glass Ionomer Cement.
PRP preparation
Platelet rich plasma (PRP) was prepared prior to the surgical procedure in
accordance with the protocol developed by Sonnleitner et al .7110 ml of venous blood
was drawn from the patient’s antecubital vein and transferred into test tube containing
EDTA as an anticoagulant. The tube was centrifuged at 5000rpm for 15 minutes to
separate the PRP and the platelet-poor plasma (PPP) from the red blood cells (Fig 12).
The supernatant plasma was then aspirated with a micropipette and transferred to a sterile
test tube without an anticoagulant. This was subjected to a second centrifugation at
29
bottom (Fig 13), while the surface Platelet Poor Plasma was discarded using a
micropipette. The PRP was transferred to a dappen dish and stored at room temperature
until its placement in the bone defect.
PRF preparation
PRF was prepared after periapical curettage, just before its placement in the
defect, in accordance with the protocol developed by Choukroun18. 10 ml of venous
blood was drawn from the patient’s antecubital vein and transferred into a test tube
without an anticoagulant. The tube was immediately centrifuged at 3000 rpm for 10
minutes. A structured fibrin clot was formed in the middle of the tube, just between
acellular plasma (platelet-poor plasma) at the top and the red corpuscles at the bottom
(Fig 22). PRF was separated from red corpuscles base (preserving a small RBC layer)
(Fig 23) using sterile tweezers just after removal of PPP (platelet-poor plasma) and then
30
In group I, the defect was filled with a combination of PRP and β- TCP (Fig 9).
PRP fluid obtained after centrifugation was activated using 2 drops of the solution
containing 5ml of 10% calcium chloride and 5000 units of bovine thrombin, just prior to
its placement in the defect to form a gel 71(Fig 14). Following light squeezing between
two sterile gauze pieces, it was cut into small pieces and mixed with β-TCP bone graft
material (Fig 15), and placed in the defect.
In group II, the defect was filled with a combination of PRF and β-TCP (Fig 19).
Freshly prepared PRF gel was immediately used. Following squeezing between two
sterile gauze pieces (Fig 24), it was cut into small pieces and mixed with β-TCP bone
graft material (Fig 25). The mixture was then placed into the osseous defect.
The mucoperiosteal flaps were repositioned and sutured using 3-0 black silk. All
patients were prescribed systemic antibiotics (Amoxicillin 500mg thrice daily,
Metronidazole,400mg twice daily) , analgesics (Ibuprofen 400 mg thrice daily) and
31
Post-operative instructions were given to all the patients. Re-evaluation for any
acute signs of inflammation or infection was done at 24 hours post surgically. 7 days
following surgery, the sutures were removed and surgical site was irrigated with normal
saline. Access cavity was restored with conventional GIC. Patients were observed for any
signs or symptoms of post-operative complications.
POST OPERATIVE FOLLOW UP
The patients were reviewed at regular intervals of one, three, six, nine, and twelve
months. These follow-up visits included routine intraoral examinations and professional
plaque control (Annexure 3).
IOPA radiographic evaluation and bone density evaluation of the periapical
region was done 6 months and 1 year after surgery using CBCT and the HU values were
32
PROCEDURAL FLOW CHART
10 patients (20-40 yrs of age) with periapical lesion measuring
10-20 mm in relation to maxillary anteriors indicated for periapical
surgery
RCT was completed if asymptomatic or on the day of surgery
if symptomatic
Under local anesthesia full thickness mucoperiosteal flap
raised , debridement of the periapical lesion and retrograde
filling done
Group I (n=5) Bone
defect was filled with PRP +β TCP
Group II (n=5) Bone
defect was filled with PRF +β TCP
Flap repositioned and sutured. Sutures
removed after one week
Bone density evaluation -6 months and 1 year
postoperatively using CBCT
Pre-operative bone density values at periapical region
33
[image:48.612.336.525.120.245.2]ARMAMENTARIUM
FIG.1 SURGICAL INSTRUMENTS FIG.2 β-TCP BONE GRAFT
MATERIAL
FIG.3. CBCT DEVICE
34
GROUP I - SURGICAL PROCEDURE
PLACEMENT OF
FIG.6 INCISION PLACEMENT FIG.7 FLAP ELEVATION
[image:49.612.238.411.304.426.2]
FIG.8 PERIAPICAL CURETTAGE AND ROOT END MANAGEMENT
FIG.9 PRP+ β-TCP BONE GRAFT FIG.10 FLAP REPOSITIONED
[image:49.612.115.294.491.613.2]35
PRP PREPARATION AND MIXING WITH β-TCP
[image:50.612.103.536.77.734.2]
FIG .11 BLOOD IMMEDIATELY FIG.12 AFTER FIRST SPIN OF BEFORE CENTRIFUGATION CENTRIFUGATION
FIG.13 AFTER SECOND SPIN OF
CENTRIFUGATION
[image:50.612.109.207.118.283.2]
FIG.14 PRP GEL AFTER ADDING, BOVINE FIG.15 PRP MIXED
THROMBIN+CALCIUM CHLORIDE WITH β-TCP Plasma
Red Blood Cells
Platelet Poor Plasma (PPP)
36
GROUP II - SURGICAL PROCEDURE
FIG.16 PLACEMENT OF INCISION FIG.17 FLAP ELEVATION
FIG.18 PERIAPICAL CURETTAGE AND
ROOT END MANAGEMENT
[image:51.612.234.409.312.434.2]
FIG.19 PRF + β-TCP BONE GRAFT FIG.20 FLAP REPOSITIONED
37
PRF PREPARATION AND MIXING WITH β- TCP
[image:52.612.98.571.113.713.2][image:52.612.347.564.127.283.2]
FIG.21 PROCURING BLOOD FROM THE PATIENT
FIG.22 BLOOD AFTER SINGLE SPIN OF CENTRIFUGATION
FIG.23 PRF GEL OBTAINED
[image:52.612.360.498.530.674.2]
FIG.24 PRF AFTER SQUEEZING FIG.25 PRF MIXED WITH β- TCP
Platelet Poor Plasma
(PPP)
Platelet Rich Fibrin (PRF)
[image:52.612.109.251.534.682.2]38
RESULTS
No apparent adverse events were seen throughout the observation period.
The pre-op, 6 months post op and 1year post-op HU values obtained for Group I are
presented in Table 1.
The pre-op, 6 months post op and 1year post-op HU values obtained for Group II are
presented in Table 2.
[image:53.612.114.506.355.601.2] The Mean and Standard deviation for each group is presented in Table 3.
TABLE 1- HOUNSEFIELD UNIT VALUES OBTAINED FOR GROUP I
NO OF PATIENTS PRE-OP
(HU)
6 MONTHS
POST –OP (HU)
I YEAR
POST –OP(HU)
1 20 635 1013
2 5 542 907
3 22 567 920
4 60 725 1012
39
TABLE 2- HOUNSEFIELD UNIT VALUES OBTAINED FOR GROUP II
NO OF PATIENTS PRE-OP
(HU)
6 MONTHS
POST –OP (HU)
I YEAR
POST –OP (HU)
1 33 622 1051
2 66 749 962
3 38 596 892
4 93 819 1008
[image:54.612.108.505.127.364.2]5 13 583 920
TABLE 3 –MEAN AND STANDARD DEVIATION
GROUPS PRE-OP 6 MONTHS I YEAR
GROUP I MEAN 29 626.60 967.80
STD.DEVIATION 20.905 73.928 50.860
GROUPII MEAN 48.60 673.80 966.60
40 STATISTICAL ANALYSIS
The data obtained were analysed using statistical software SPSS 20.0 version. The
dependant variable in our study was the bone healing outcome. The independent
variables analysed were two different materials and at various intervals of time.
Intra Group Comparison
Intra group comparison between the pre op, 6 months post op and 1 year post op
HU values at various intervals of time, was done for each group using
One way Repeated measure ANOVA (Table 4)
[image:55.612.115.528.496.643.2] Post Hoc tests-Bonferroni (Table 5)
TABLE 4 - WITHIN GROUP COMPARISON
Repeated Measure ANOVA
GROUPS EFFECT WILKS'
LAMBDA
VALUE
F PARTIAL
ETA
SQUARED
SIG.(P
VALUE)
GROUP I
TIME
0.001 1264.844 0.999 0.000
41 TABLE 5- BONFERRONI POST HOC TESTS
GROUPS (I) Time (J)
Time
Mean
Difference
(I-J)
Std. Error Sig.b 95% Confidence Interval
for Differenceb
Lower Bound Upper Bound GROUP I 1
2 -597.600* 24.588 .000 -694.987 -500.213
3 -938.800* 17.656 .000 -1008.732 -868.868
2
1 597.600* 24.588 .000 500.213 694.987
3 -341.200* 16.323 .000 -405.852 -276.548
3
1 938.800* 17.656 .000 868.868 1008.732
2 341.200* 16.323 .000 276.548 405.852
GROUP II 1
2 -625.200* 33.448 .000 -757.679 -492.721
3 -918.000* 27.120 .000 -1025.417 -810.583
2
1 625.200* 33.448 .000 492.721 757.679
3 -292.800* 43.392 .008 -464.665 -120.935
3
1 918.000* 27.120 .000 810.583 1025.417
2 292.800* 43.392 .008 120.935 464.665
Based on estimated marginal means
*.The mean difference is significant at the .05 level.
42
Inter Group Comparison
As the data obtained was quantitative inter group comparison of HU values
[image:57.612.114.525.268.555.2]between Group I and Group II was done using Independent Sample T –Test (Table 6)
TABLE 6 - COMPARISON BETWEEN GROUPS
Independent Sample T Test
TIME Sig.(p value) Sig-(2-tailed) 95% confidence
interval of the
difference
LOWER UPPER
PRE OP 0.313 0.277
0.282
-58.342
-59.342
19.142
20.142
POST OP 6 MONTHS 0.212 0.434
0.436
-179.248
-181.845
84.848
87.445
POST OP 1YEAR 0.670 0.975
0.975
-83.437
-84.236
85.837
43
GRAPH I COMPARISON OF HU UNITS VALUES PRE - OP,
6 MONTHS AND 1 YEAR - GROUP I
GRAPH II COMPARISON OF HU UNITS VALUES PRE - OP,
44
GRAPH III INTER GROUP COMPARISON OF HU VALUES PRE-OP,
6 MONTHS AND 1 YEAR
0 100 200 300 400 500 600 700 800 900 1000
PRE-OP 6MONTHS 1 YEAR
H
OU
N
SE
FI
ELD
UNIT
S
45 INFERENCE
Inter Group Comparison
Pre-Op Observation
Mean pre op HU value obtained for group I was similar to the mean value
obtained for group II (Table 3). There was no statistically significant difference between
the two groups pre operatively (p=0.277).
6 Months Post-op observation
Mean 6 months HU value obtained for group I and group II were higher than the
respective pre op values of both groups (Table 3).There was no statistically significant
difference in bone density HU values between the two groups after 6 months, post
operatively (p=0.434).
1 Year Post-op observation
Mean 1 Year HU value obtained for group I and group II were higher than the
respective pre op and 6 months HU values (Table 3).There was no statistically significant
difference in the HU values obtained between the two groups after 1year (p=0.975).
Intra Group Comparison
Group I
There was a significant increase in bone density HU values during pre-op <
46
(p=0.000, Wilk’s lambda value=0.001, partial η 2=0.999) Table4. Pairwise comparison
using Bonferroni Post Hoc Tests also showed a highly significant difference between the
pre op, 6 months and 1year values( p=0.000) Table5.
Group II
There was a significant increase in bone density HU values during pre-op <
6 months < 1 year post op periods. The results also showed a significant time effect
(p=0.000, Wilk’s lambda value=0.003, partial η 2=0.997) Table4. Pairwise comparison
using Bonferroni Post Hoc Tests also showed a highly significant difference between the
47
CBCT IMAGES
GROUP I (PRP + β-TCP)
PRE -OP 6 MONTHS 1 YEAR
48
GROUP I (PRP + β-TCP)
49
CBCT IMAGES
GROUP II (PRF + β-TCP)