|Year : 2015 | Volume
| Issue : 1 | Page : 22-27
Treatment of periodontal intrabony defects with platelet-rich fibrin and porous hydroxyapatite bone graft: A comparative clinical and radiographic study using Dentascan
Guneet Juneja, Vipin Bharti
Department of Periodontology, Government Dental College and Hospital, Patiala, Punjab, India
|Date of Web Publication||30-Jul-2015|
Dr. Guneet Juneja
H. No 1649, Sec 39 B, Chandigarh
Source of Support: None, Conflict of Interest: None
Objective: The aim of the present study was to compare autologous platelet-rich fibrin (PRF) combined with a porous hydroxyapatite bone graft to porous hydroxyapatite bone graft alone in the treatment of periodontal intrabony defects clinically and radiographically using Dentascan.
Materials and Methods: In a split-mouth study design, 10 patients suffering from generalized chronic periodontitis, having two almost identical intrabony defects with probing pocket depth of at least 5 mm were selected for the study and randomly divided into two groups. In Group I periodontal flap surgery followed by placement of porous hydroxyapatite bone graft was done and in Group II, periodontal flap surgery followed by placement of a homogenous mixture of PRF and porous hydroxyapatite bone graft was done. All the clinical parameters were recorded at baseline, 3 and 6 months postoperatively and radiographic parameters were recorded at baseline and 6 months postoperatively.
Results: There was statistically significant reduction in probing pocket depth and gain in clinical attachment level in both groups. On comparison Group II showed statistically significant more probing pocket depth reduction than Group I at all-time intervals. There was statistically significant mean defect fill and mean defect resolution observed in both groups at all-time intervals. However, the intergroup comparison was statistically nonsignificant.
Conclusion : Within limits of the study it may be concluded that a combination of PRF with porous hydroxyapatite bone graft demonstrated better results as compared to porous hydroxyapatite bone graft alone in the treatment of periodontal intrabony defects. Spiral multislice computed tomography equipped Dentascan provides three-dimensional images of excellent quality for evaluating the morphology of the periodontal bone defects. Its use in ascertaining the various defect parameters in the periodontal treatment of intrabony defects is promising.
Keywords: Periodontal intrabony defects, periodontal regeneration, platelet-rich fibrin, porous hydroxyapatite
|How to cite this article:|
Juneja G, Bharti V. Treatment of periodontal intrabony defects with platelet-rich fibrin and porous hydroxyapatite bone graft: A comparative clinical and radiographic study using Dentascan. Saint Int Dent J 2015;1:22-7
|How to cite this URL:|
Juneja G, Bharti V. Treatment of periodontal intrabony defects with platelet-rich fibrin and porous hydroxyapatite bone graft: A comparative clinical and radiographic study using Dentascan. Saint Int Dent J [serial online] 2015 [cited 2020 Jan 27];1:22-7. Available from: http://www.sidj.org/text.asp?2015/1/1/22/161797
Regeneration of lost structures has become the primary therapeutic goal in periodontics.  Porous hydroxyapatite is calcium-phosphate based material that is biocompatible and non-immunological.  It has excellent bone conductive properties. 
Recently, platelet-rich fibrin (PRF), a second generation platelet concentrate has been introduced by Choukroun et al. in 2001.  It is an autologous leukocyte and PRF material. 
To overcome the inherent difficulties of conventional radiography, three-dimensional (3D) image analysis by computed tomography (CT) has been introduced and is widely used for 3D maxillofacial imaging in dentistry.  Dentascan, a dental CT software program, is an extension of CT technology. 
| Materials and Methods|| |
Ten patients suffering from generalized chronic periodontitis, visiting the Department of Periodontology, Government Dental College and Hospital, Patiala, Punjab were selected for the study according to split-mouth design.
Criteria for patient selection
The patients included in the study were in the age group of 30-50 years, having sufficient platelet count for PRF preparation and having two almost identical intrabony defects, one on either side of arch based on radiographic observations (intraoral periapical radiograph) with probing pocket depth of at least 5 mm. However, the patients with any systemic problem that contraindicate periodontal surgery, a history of coagulation defect or current anticoagulation treatment, a smoker or an alcoholic patient and teeth with furcation defects, endodontic treatment, Miller's Grade II or greater mobility were excluded from the study. All subjects received verbal information regarding participation, and written informed consent was obtained for participation in the study.
Materials used in the study
Porous hydroxyapatite bone graft (OsteoGen (HA Resorb))
It is a synthetic, resorbable, osteoconductive, nonceramic form of hydroxyapatite manufactured by Impladent, Ltd. It is supplied sterile in a crystalline form (300-400 μ). Controlled manufacturing produces bone grafting crystals of nearly perfectly-formed clusters bound to a single nucleus and relatively hexagonal-shaped crystals. These clusters intertwine to each other for greater porosity to form a 360° lattice mechanism for the host cell proliferation and integration.
Prior to the surgical procedure, informed consent was taken from each patient for taking a blood sample for the preparation of PRF. A 10 ml peripheral blood sample was collected from the subjects in a test tube without anticoagulant and centrifuged immediately at 3000 rpm for 10 min. The resultant product consisted of the following three layers [Figure 1]:
- Top most layer consisting of acellular platelet poor plasma
- Platelet-rich fibrin clot in the middle
- RBCs at the bottom.
The PRF clot was recovered and cut into few millimeter fragments and mixed with 0.5 mg of porous hydroxyapatite bone graft to form an easy to use homogenous graft material [Figure 2].
|Figure 2: Homogenous mixture of platelet-rich fibrin with porous hydroxyapatite bone graft|
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| Methodology|| |
A general assessment of selected subjects was made through their history, clinical examination, and routine investigations. All subjects were treated with Phase I therapy involving proper oral hygiene instructions, full mouth scaling and root planning. Following Phase I therapy the subjects were re-evaluated after 6 weeks and those who still fulfilled the selection criteria were finally taken up for the study. The clinical parameters recorded from the selected sites of these subjects included probing pocket depth, clinical attachment level, Gingival marginal position, site-specific plaque index, and site-specific sulcus bleeding index. The radiographic parameters included defect fill, Alveolar crest resorption, and defect resolution.
Immediately before surgery, selected sites in each subject were randomly divided by the toss of a coin into two groups according to split-mouth study design. In Group I, - Periodontal flap surgery followed by placement of porous hydroxyapatite bone graft was done and in Group II, - Periodontal flap surgery followed by placement of a homogenous mixture of PRF and porous hydroxyapatite bone graft was done.
Amoxycillin 500 mg thrice a day was prescribed for 5 days. Ibuprofen 400 mg thrice daily and Vitamin-B complex, 1 capsule daily was also prescribed for 5 days. The subjects were instructed not to brush the operated area for 1-week and to rinse the oral cavity twice a day with chlorhexidine (0.12%) mouthwash daily. Periodontal dressing and sutures were removed after 10 days postoperatively.
Clinical parameters were again recorded at 3 months and at 6 months postoperatively and radiographic parameters were again recorded at 6 months postoperatively [Figure 3], [Figure 4], [Figure 5], [Figure 6]. The data thus recorded were compiled, tabulated, and statistically analyzed to arrive at the results.
|Figure 3: Dentascan reformatted spiral computed tomography image at baseline (before surgery) in Group I|
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|Figure 4: Dentascan reformatted spiral computed tomography image at 6 months (after surgery) in Group I|
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|Figure 5: Dentascan reformatted spiral computed tomography image at baseline (before surgery) in Group II|
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|Figure 6: Dentascan reformatted spiral computed tomography image at 6 months (after surgery) in Group II|
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| Results|| |
There was statistically significant probing pocket depth reduction found in both groups from baseline to 3 months, baseline to 6 months and between 3 months to 6 months. On comparison, Group II showed statistically significant more probing pocket depth reduction than Group I at all-time intervals [Table 1].
Statistically nonsignificant change in gingival marginal position from baseline to 3 months, baseline to 6 months and between 3 months and 6 months was found on both intragroup and intergroup comparison.
|Table 1: Comparison of mean probing pocket depth reduction (in mm) of groups I and II at different time intervals |
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There was statistically significant clinical attachment level gain observed in both groups from baseline to 3 months, baseline to 6 months and between 3 months to 6 months. On comparison, Group II showed statistically significant more clinical attachment level gain than Group I at all-time intervals [Table 2].
|Table 2: Comparison of mean clinical attachment level gain (in mm) of groups I and II at different time intervals |
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Reductions in the site-specific plaque index score and site-specific sulcus bleeding index score were observed in both groups from baseline to 3 months, baseline to 6 months and between 3 months and 6 months, but they were statistically nonsignificant. On comparison, the difference between the two groups was also statistically nonsignificant at all-time intervals.
There was statistically significant mean defect fill observed in both groups from baseline to 6 months. On comparison, more mean defect fill was observed in Group II at all-time intervals. However, the difference in mean defect fill between the two groups was statistically nonsignificant [Table 3].
Slight alveolar crest resorption was observed in both groups from baseline to 6 months, but it was statistically nonsignificant. On comparison, the difference in alveolar crest resorption between the two groups was statistically nonsignificant.
There was statistically significant mean defect resolution observed in both groups from baseline to 6 months. On comparison, more mean defect resolution was observed in Group II at all-time intervals. However, the difference in mean defect resolution between the two groups was statistically nonsignificant [Table 4].
|Table 4: Comparison of mean defect resolution (in mm) of group I and Group II |
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| Discussion|| |
Periodontal disease is among the most prevalent diseases worldwide and is characterized by the presence of gingival inflammation, periodontal pocket formation, loss of periodontal attachment and loss of alveolar bone around the affected teeth. , The goal of periodontal therapy includes not only the arrest of periodontal disease progression, but also the regeneration of structures lost due to disease.  Bone grafting is one of the most common forms of regenerative therapy and is usually essential for restoring periodontal supporting tissue.  Regeneration of cementum, bone, and functionally oriented periodontal ligament fibers has been seen at sites treated by bone grafting (Hiatt et al. 1978).  A wide range of bone grafting materials, including bone grafts and bone graft substitutes, have been applied and evaluated clinically, including autografts, allografts, xenografts, and alloplasts (synthetic/semisynthetic materials). 
Autografts are ideal but have certain limitations like paucity of suitable donor tissue and requirement of additional surgery for harvesting the graft that preclude their widespread use. , Allografts on the other hand, are available in considerable quantity but they are immunogenic and the problems of disease transmission are well documented.  To overcome these issues, alloplastic materials, which are synthetic, inorganic, biocompatible bone graft substitutes, represent a possible alternative in the treatment of periodontal intrabony defects.  For decades, various types of synthetic artificial bone substitutes have been utilized for regenerative periodontal treatment in intrabony defects. Among these synthetic materials, porous hydroxyapatite has been widely used. 
Porous hydroxyapatite is calcium-phosphate - based material.  It has been used to fill periodontal intrabony defects, which has resulted in clinically acceptable responses. It has been shown that porous hydroxyapatite bone grafts have excellent bone-conductive properties which permit outgrowth of osteogenic cells from existing bone surfaces into adjacent bone graft material. Since there are no organic components, this bone graft material does not induce any allergic reaction and is clinically very well tolerated.  It is capable of inducing migration, adhesion, and proliferation of osteoblasts inside the pore network. The architecture effectively promotes angiogenesis inside the pore system and interconnections, and blood vessels are able to carry cells and soluble signals promoting bone formation and finally bone regeneration (Mangano et al. 2006). 
Desirable results with porous hydroxyapatite bone graft have been shown by studies of Sunitha and Manjunath  and Corsair  who used it in the treatment of periodontal intrabony defects. It was found to be well tolerated with no immunologic complication, graft rejection or infection.
A different approach to periodontal regeneration is the use of polypeptide growth factors. Among the known polypeptide growth factors, platelet-derived growth factor and transforming growth factor-ß have been studied most extensively.  Platelet-rich plasma (PRP) is an autologous concentration of platelets in plasma and Platelet-rich plasma-enhanced grafts produce a more mature and dense bone than do grafts alone. , However, there are potential risks associated with the use of Platelet-rich plasma. The preparation of Platelet-rich plasma involves the use of calcium chloride and bovine thrombin. It has been discovered that the use of bovine thrombin may be associated with the development of antibodies to the factor V, XI, and thrombin, resulting in life-threatening coagulopathies. 
Recently, PRF, a second generation platelet concentrate has been introduced by Choukroun et al. in 2001 that has several advantages over Platelet-rich plasma. It requires neither anticoagulant nor bovine thrombin.  The affinity of osteoblasts to PRF membrane appeared to be superior. The conversion of fibrinogen into fibrin takes place slowly with small quantities of physiologically available thrombin present in the blood sample itself. Thus, a physiological architecture that is very favorable to the healing process is obtained with PRF.  The presence of leukocytes and cytokines in the fibrin network play a significant role in the self-regulation of inflammatory and infectious phenomena within the grafted material. 
Hence, a combination of PRF and porous hydroxyapatite bone graft can be more beneficial in treating periodontal intrabony defects. This is based on the fact that two distinct healing processes, may take place together and this may probably results in their synergistic effect. Favorable results have been obtained by Choukroun et al.,  Diss et al.  Simonpieri et al.  who used PRF in combination with bone graft in sinus augmentation procedures.
The evaluation of hard tissue changes after regeneration therapy can be done either by surgical re-entry procedure or by radiographic assessment. However, re-entry procedures require a second surgical intervention which is usually not acceptable to the patient. Furthermore, it may cause a disturbance of the new connective tissue attachment. Radiographic assessment, however, provides a noninvasive method for evaluating the hard tissue changes. ,
Conventional radiographs have been used as a surrogate technique to evaluate regenerative outcomes in vivo.  However, radiographs are a two-dimensional mapping of 3D periodontal structures and their limitations have been well described. They underestimate the true amount of bone loss. Many complicated anatomic structures, such as cortical plates or teeth, may superimpose the region of interest. Moreover, foreshortening or elongation of radiographic images caused by cone indication, and variations in the contrast and density caused by poor control of film processing, may prevent the accurate detection of osseous changes by the clinician. 
To overcome the difficulties caused by the nature of conventional radiography, 3D image analysis using CT has been introduced which enables the clinician to have access to 3D images of the selected areas of interest. , The use of CT as an effective method to assess the bone defect morphology and outcome of regenerative therapy have been shown by Naito et al.,  Ito et al.  and Pradeep et al.  They concluded that the use of CT in ascertaining the various defect parameters in the periodontal treatment of intrabony defects appears promising.
Recently, Spiral multislice tomography has replaced conventional CT. Spiral CT has been shown to be diagnostically superior in terms of reducing artifacts and blurred images. 
Dentascan, a dental computed tomographic software program, is an extension of CT technology. Dentascan reformats standard axial CT scan which improves specificity and sensitivity over standard imaging. 
Therefore, in the present study radiographic parameters were taken and assessed using Spiral multislice CT equipped with a 3D image reconstruction software package, Dentascan.
Hence, the present study was undertaken to compare autologous PRF combined with a porous hydroxyapatite bone graft to porous hydroxyapatite bone graft alone in the treatment of periodontal intrabony defects clinically and radiographically using Dentascan.
| Conclusion|| |
Within limits of the study it may be concluded that a combination of PRF with porous hydroxyapatite bone graft demonstrated better results in probing pocket depth reduction and clinical attachment level gain as compared to porous hydroxyapatite bone graft alone in the treatment of periodontal intrabony defects. However, histological studies are needed to establish the exact nature of this clinical attachment gain. Spiral multislice CT equipped Dentascan provides 3D images of excellent quality for evaluating the morphology of the periodontal bone defects. Its use in ascertaining the various defect parameters in the periodontal treatment of intrabony defects is promising and could be of greater clinical relevance if a longer observational period is envisaged. Future long term studies with a large sample size should be carried out to further explore the role of PRF in the management of periodontal intrabony defects and to verify the results of in vitro studies in a clinical study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Choukroun J, Diss S, Dohan SL, Dohan AJ, Mouhyi J, Gogly B, et al
. PRF: A second generation platelet concentrate. Part IV: Clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;1:56-60.
Mangano C, Scarano A, Iezzi G, Orsini G, Perrotti V, Mangano F, et al.
Maxillary sinus augmentation using an engineered porous hydroxyapatite: A clinical, histological, and transmission electron microscopy study in man. J Oral Implantol 2006;32:122-31.
Okuda K, Tai H, Tanabe K, Suzuki H, Sato T, Kawase T, et al.
Platelet-rich plasma combined with a porous hydroxyapatite graft for the treatment of intrabony periodontal defects in humans: A comparative controlled clinical study. J Periodontol 2005;76:890-8.
Sharma A, Pradeep AR. Autologous platelet-rich fibrin in the treatment of mandibular degree II furcation defects: A randomized clinical trial. J Periodontol 2011;82:1396-403.
Ito K, Yoshinuma N, Goke E, Arai Y, Shinoda K. Clinical application of a new compact computed tomography system for evaluating the outcome of regenerative therapy: A case report. J Periodontol 2001;72:696-702.
Brockenbrough JM, Petruzzelli GJ, Lomasney L. DentaScan as an accurate method of predicting mandibular invasion in patients with squamous cell carcinoma of the oral cavity. Arch Otolaryngol Head Neck Surg 2003;129:113-7.
Carranza FA, Klokkevold PR, Takei HH, Newman MG. Carranza′s Clinical Periodontology. 10 th
ed. Elsevier 2006 . p. 506.
Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL. Regeneration of periodontal tissue: Bone replacement grafts. Dent Clin North Am 2010;54:55-71.
Rosenberg E, Rose LF. Biologic and clinical considerations for autografts and allografts in periodontal regeneration therapy. Dent Clin North Am 1998;42:467-90.
Hiatt WH, Schallhorn RG, Aaronian AJ. The induction of new bone and cementum formation. IV. Microscopic examination of the periodontium following human bone and marrow allograft, autograft and nongraft periodontal regenerative procedures. J Periodontol 1978;49:495-512.
Kenney EB, Lekovic V, Han T, Carranza FA Jr, Dimitrijevic B. The use of a porous hydroxylapatite implant in periodontal defects. I. Clinical results after six months. J Periodontol 1985;56:82-8.
Kumar PG, Kumar JA, Anumala N, Reddy KP, Avula H, Hussain SN. Volumetric analysis of intrabony defects in aggressive periodontitis patients following use of a novel composite alloplast: A pilot study. Quintessence Int 2011;42:375-84.
Sopyan I, Mel M, Ramesh S, Khalid KA. Porous hydroxyapatite for artificial bone applications. Sci Technol Adv Mater 2007;8:116-23.
Kasaj A, Röhrig B, Zafiropoulos GG, Willershausen B. Clinical evaluation of nanocrystalline hydroxyapatite paste in the treatment of human periodontal bony defects - A randomized controlled clinical trial: 6-month results. J Periodontol 2008;79:394-400.
Sunitha J, Manjunath K. A combination of platelet rich plasma and hydroxylapatite (osteogen) bone graft in the treatment of intrabony defects - A case report: A preliminary study. J Clin Diagn Res 2010;4:2984-8.
Corsair A. A clinical evaluation of resorbable hydroxylapatite for the repair of human intra-osseous defects. J Oral Implantol 1990;16:125-8.
Pradeep AR, Shetty SK, Garg G, Pai S. Clinical effectiveness of autologous platelet-rich plasma and Peptide-enhanced bone graft in the treatment of intrabony defects. J Periodontol 2009;80:62-71.
Ouyang XY, Qiao J. Effect of platelet-rich plasma in the treatment of periodontal intrabony defects in humans. Chin Med J (Engl) 2006;119:1511-21.
Sunitha Raja V, Munirathnam Naidu E. Platelet-rich fibrin: Evolution of a second-generation platelet concentrate. Indian J Dent Res 2008;19:42-6.
Toffler M, Toscano N, Holtzcaw D. Introducing Choukron′s PRF to the reconstructive surgery milieu. J Implant Adv Clin Dent 2009;1:21-3.
Choukroun J, Diss S, Dohan SL, Dohan AJ, Mouhyi J, Gogly B, et al
. PRF: A second generation platelet concentrate. Part V: Histologic evaluations of PRF effects on bone allograft maturation on sinus lift. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;3:299-303.
Diss A, Dohan DM, Mouhyi J, Mahler P. Osteotome sinus floor elevation using Choukroun′s platelet-rich fibrin as grafting material: A 1-year prospective pilot study with microthreaded implants. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:572-9.
Simonpieri A, Choukroun J, Del Corso M, Sammartino G, Dohan Ehrenfest DM. Simultaneous sinus-lift and implantation using microthreaded implants and leukocyte-and platelet-rich fibrin as sole grafting material: A six-year experience. Implant Dent 2011;20:2-12.
Bender SA, Rogalski JB, Mills MP, Arnold RM, Cochran DL, Mellonig JT. Evaluation of demineralized bone matrix paste and putty in periodontal intraosseous defects. J Periodontol 2005;76:768-77.
Saini N, Sikri P, Gupta H. Evaluation of the relative efficacy of autologous platelet-rich plasma in combination with ß-tricalcium phosphate alloplast versus an alloplast alone in the treatment of human periodontal infrabony defects: A clinical and radiological study. Indian J Dent Res 2011;22:107-15.
Grimard BA, Hoidal MJ, Mills MP, Mellonig JT, Nummikoski PV, Mealey BL. Comparison of clinical, periapical radiograph, and cone-beam volume tomography measurement techniques for assessing bone level changes following regenerative periodontal therapy. J Periodontol 2009;80:48-55.
Naito T, Hosokawa R, Yokota M. Three-dimensional alveolar bone morphology analysis using computed tomography. J Periodontol 1998;69:584-9.
Dixon DR, Morgan R, Hollender LG, Roberts FA, O′Neal RB. Clinical application of spiral tomography in anterior implant placement: Case report. J Periodontol 2002;73:1202-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4]