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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

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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

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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.

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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. GUIDE

Department of Conservative Dentistry and Endodontics. TamilNadu Government Dental College and Hospital

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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/c

Department of Conservative Dentistry & Endodontics

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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.

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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 .

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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.

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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.

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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

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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.

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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

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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

39

3

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

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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

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

(30)

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

(31)

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

(32)

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

(33)

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

(34)

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

(35)

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

(36)

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

(37)

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

(38)

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

(39)

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

(40)

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

(41)

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

(42)

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

(43)

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

(44)

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

(45)

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

(46)

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

(47)

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

(48)

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

(49)

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]
(50)

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)

(51)

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

(52)

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]
(53)

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

(54)

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

(55)

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

(56)

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.

(57)

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

(58)

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,

(59)

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

(60)

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 <

(61)

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

(62)

47

CBCT IMAGES

GROUP I (PRP + β-TCP)

PRE -OP 6 MONTHS 1 YEAR

(63)

48

GROUP I (PRP + β-TCP)

(64)

49

CBCT IMAGES

GROUP II (PRF + β-TCP)

Figure

FIG.1 SURGICAL INSTRUMENTS                 FIG.2 β-TCP BONE GRAFT
FIG.8 PERIAPICAL CURETTAGE AND ROOT END MANAGEMENT
FIG .11 BLOOD IMMEDIATELY               FIG.12 AFTER FIRST SPIN OF   BEFORE CENTRIFUGATION                           CENTRIFUGATION
FIG.19 PRF + β-TCP BONE GRAFT                     FIG.20 FLAP REPOSITIONED
+6

References

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