• Nu S-Au Găsit Rezultate

View of Evaluation of the Effect of a Hydroxyapatite-Beta Tricalcium Phosphate (βTCP) graft with Platelet Rich Fibrin Occlusive Membrane on Intrabony Defects Accessed With a Single Flap Approach –A Randomized Controlled Clinical trial

N/A
N/A
Protected

Academic year: 2022

Share "View of Evaluation of the Effect of a Hydroxyapatite-Beta Tricalcium Phosphate (βTCP) graft with Platelet Rich Fibrin Occlusive Membrane on Intrabony Defects Accessed With a Single Flap Approach –A Randomized Controlled Clinical trial"

Copied!
11
0
0

Text complet

(1)

Evaluation of the Effect of a Hydroxyapatite-Beta Tricalcium Phosphate (βTCP) graft with Platelet Rich Fibrin Occlusive Membrane on Intrabony Defects Accessed With a Single Flap Approach –A Randomized Controlled

Clinical trial.

Dr.Indhu N

1

, Dr.P.S.G Prakash

2*

,Dr.JasmineCrena M

3

, Dr.Dhayanand John Victor

4

, Dr.Sangeetha Subramanian

5

1 MDS, Private practice, Chennai

2MDS, Professor, Department of Periodontics, SRM Dental College, Ramapuram, Chennai 600089.

3 MDS, Senior Lecturer, Department of Periodontics, SRM Dental College, Ramapuram, Chennai 600089..

4 MDS, Professor and Head of the Department, Department of Periodontics, SRM Dental College, Ramapuram, Chennai 600089.

5 MDS, Reader, Department of Periodontics, SRM Dental College, Ramapuram, Chennai 600089.

*Corresponding author: [email protected]

ABSTRACT

The aim of this study was to evaluate and compare the clinical and radiographic outcomes of intrabony defects accessed with a Single Flap Approach, with an occlusive Platelet Rich Fibrin membrane, that did or did not receive an additional Hydroxyapatite - Beta Tri Calcium Phosphate composite bone graft. The study comprised 30 patients presenting with intra-bony defects who were randomly treated using Single Flap Approach with Platelet Rich Fibrin and with or without additional bone graft (Hydroxyapatite + β Tri Calcium Phosphate composite graft). Patients were recalled at 12 and 36 months to assess and compare the Full Mouth Plaque scores (FMPS%), Full mouth bleeding scores (FMBS%),Probing Pocket Depth (PPD), Relative Clinical Attachment Level (R-CAL),position of Gingival Margin at surgical site (GM), and Radiographic assessment of crestal bone level with Radiovisiography - RVG (mm). The results revealed a significant reduction in the mean FMPS%, FMBS%, & PPD within the groups (p≤0.0001),but did not reveal any statistical significance when compared between the test and the control groups at various time points (12 and 36 months). Both test and control groups showed statistically significant gain in the mean Relative Clinical Attachment Levels (R-CAL) at 12 months (p≤0.0001). The position of the gingival margin (GM) had a minimal gradual apical shift (gingival recession) till 12 months with a mild statistical significance of (p≤ 0.048) in the control group. The test group initially had a coronal shift at 12 months’ time point and then shifted apically later and became comparable at 36 months between the control and the test group but with no statistical significance(p≤0.784).RVG values revealed a statistically significant radiographic bone fill (p≤0.0001) in both, test group and the control groupat 12 months’ time point. This Bone fill significantly improved in both the groups when measured at 36 months, and the test group had a better bone fill compared to the control group with statistical significance (p≤0.023).The results of this study indicate that the sites which received PRF alone and PRF + HA - βTCP in the treatment of periodontal intraosseous defects accessed with Single Flap A were clinically effective with a substantial probing pocket depth reduction and clinical attachment gain. Although the adjunctive use of HA -βTCP graft shows a significant bone fill radiographically under the experimental conditions it offers no significant adjunctive effects on the surrogate markers.

Keywords

Intrabony defects, PRF, HA -βTCP, single flap approach, periodontal flap, bone fill

Introduction

The ultimate goal of periodontal therapy remains the predictable three-dimensional repair of an intact and functional periodontal attachment apparatus that replicates its pre diseased structure. Most techniques that are purported to regulate lost periodontal tissues are either unpredictable or have an inherent capacity to heal, by repair of the periodontal tissues, rather than periodontal regeneration.1

(2)

Over the years, minimally invasive periodontal surgical techniques are being developed with the intent to lessen surgical trauma, while providing limited, although adequate, surgical access, so that the tissues following manipulation may be primarily secured, thereby enabling periodontal wound stability.2,3 Towards this end, the Single Flap Approach was developed which allows for minimization of soft tissue trauma and the removal of granulation tissue from periodontal defects using a much smaller surgical incision, that ensures wound and clot stability.4,5,6 Regenerative techniques that have emerged over the last few decades have rested on two basic tenets; the use of bone grafts, to regenerate the lost alveolar bone, and the use of Guided Tissue Regeneration (GTR) membranes to selectively repopulate the period with cells that arise from the periodontal ligament, to ensure the formation of a connective tissue attachment, on a previously diseased root surface.7

Recent publications have extrapolated the effects of PRF when used along with open flap debridement.8 These studies have found that the additive use of PRF, increases Probing Pocket depth reduction and Clinical Attachment gain. The Single Flap Approach and the Platelet Rich Fibrin Matrix, both have the potential to positively alter periodontal wound healing.9,10,11

In the present study, we proposed to place an occlusive PRF membrane over a hydroxyapatite plus beta tricalcium phosphate composite graft into an intrabony defect that is accessed by a Single Flap Approach.We hypothesize that the concomitant use of these treatment strategies would have a synergistic effect on periodontal tissue regeneration.

There are no earlier published studies with this design and this study is proposed to evaluate, the potential of this technique to promote optimal periodontal tissue regeneration.

Materials and Methods

Ethical clearance:

Institutional Scientific and Ethical Review Board granted the ethical clearance(IRB Approval no - SRMDC/IRB/2014/MDS/No.503).Surgical procedures including the possible risk, benefits and complications were explained and both verbal and written informed consent was obtained.

Subject recruitment & allotment:

Thirty six subjects with two/three walled infrabony defects were recruited into the study and underwent Phase 1 therapy. Six weeks later thirtytwosubjects reported for review, four subjects were lost to follow up. All the clinical parameters were to be assessed by a single calibrated examiner. Blood investigations and intra oral periapical radiograph using RVG were performed and final recruitment was done when they fulfilled the other selection criteria after phase I therapy.

Phase I Therapy:

Oral hygiene instructions and motivation of the patients.Non-surgical periodontal therapy was done by means of conventional scaling and root planing, using curettes and ultrasonic instruments.Treatment of carious lesions.Anatomic factors considered (e.g. correction of over - hanging restoration, malposed teeth).

Inclusion Criteria

:

Systemically healthy patients with Probing pocket depth ≥5 mm and Clinical attachment loss of ≥ 3 mm after phase I therapy, Patients with 2 wall or 3 wall defect that are non - circumferential andpresence of FMPS ≤ 20%& FMBS ≤ 20%.However, Patients requiring antibiotic prophylaxis before the periodontal examination or under immunosuppressive drugs, diagnosed with malocclusion, Female patients with hormonal imbalance, currentsmokers and pan chewers were excluded.Allocation of the treatment option for each patient was on a random basis, patients under Group A received SFA with PRF and Group B received SFA with PRF and HA--TCP composite graft.

Patients were reviewed 6 weeks after phase I therapy and the following clinical parameters were assessed -

(3)

1. Full Mouth Plaque scores. (O’Leary 1972) - FMPS%

2. Full Mouth Bleeding scores. (Ainamo and Bay 1975) – FMBS%

3. Assessment of Probing Pocket Depth at the surgical site. – PPD(mm)

4. Assessment of Relative Clinical Attachment Level at the surgical site – RCAL (mm) 5. Assessment of Relative Gingival Position at the surgical site – GM(mm)

6. Assessment of Radiographic Crestal Bone Level with RVG- RVG(mm)

Radiographic evaluation:

Digital radiographic assessment involved placement of the photo - stimulable phosphor plates on an x - ray positioning and holding device.The X-ray positioning and holding device was provided with a bite plane where the patients occlusal relationship was recorded with poly -vinyl siloxane material (heavy body impression material). A guiding arm attached to the X -ray positioning and holding device facilitated reproduction of the position of the tube head, with the same horizontal and vertical angulation, thereby standardizing the radiographic image. The PSP plates were mounted on the X -ray positioning and holding device and radiographs obtained.The PSP plates were scanned using DIGORA software and digital images were obtained.Crestal bone levels were measured at baseline and six month time points using SOPRO IMAGING software.Initially a horizontal line was created along the highest crestal bone level in the surgical site. Thereafter a vertical line drawn from the most deep crestal bone level perpendicular to meet the previously drawn horizontal line.The dimension of the vertical line was used to measure the crestal bone level at baseline and six months and compared.

PRF Preparation:

The PRF was prepared following the protocol developed by Choukroun et al.8Just prior to surgery, intravenous blood (by venipuncture of theantecubital vein) was collected in three 10-ml sterile tubes without anticoagulant and immediately centrifuged in centrifugation machineat 3,000 revolutions (approximately 400 g) per minute for 10 minutes. Blood centrifugation immediately after collection allows the composition of a structured fibrin clot in the middle of the tube, just between the red corpuscles at the bottom and acellular plasma (Platelet-poor plasma [PPP]) at the top. PRF was easily separated from red corpuscles base [preserving a small red blood cell (RBC) layer] using a sterile tweezerand scissors just after removal of PPP and then transferred onto a sterile compress. A stable fibrin membrane was obtained by squeezing serum out of the PRF clot.

Surgical Procedure:

Intra-oral antisepsis was performed with 0.12% chlorhexidine digluconate rinse and iodine solution was used to carry out extraoral antisepsis. Following administration of local anaesthesia, the single flap access was performed in the selected sites. Meticulous defect debridement and root planing were carried out using ultrasonic instrumentsand area specific curettes. No osseous recontouring was carried out. In the control group, an occlusive PRF matrix was grafted into the defect and in test group,the graft [A commercially available synthetic bone graft substitute/ regenerative material composed of HA-β-TCP composite graft (Ossifi™ ) of particle size 0.25-1 mm and 0.5 cc granules] is gently pushed into the intrabony defects followed by the occlusive PRF membrane.Care was taken not to overfill defects. Wound closure was obtained using vertical internal matrix sutures with vicryl -0 and the surgical area was protected and covered with periodontal dressing(COE – PAK).

(4)

Post-surgical instructions:

Sutures were removed two weeks after surgery.The patients were instructed to abstain from mechanical oral hygiene procedures in the surgical area for 4 weeks. 0.2% chlorhexidine mouth rinse was used to support plaque control.

professional plaque removal was performed for every 2 weeks, up to the sixth week.Each patient was to report thereafter for a monthly maintenance regime for six months.Each recall visit included reinforcement of oral hygiene procedure, supragingival plaque and calculus removal if necessary.

Statistical Analysis

The data was analyzed statistically using SPSS software version.22to find the mean, standard deviation, and test of significance. Intra group analysis was done bypaired t tests and the Inter group analysis was done with Levene’s test for equality of variances. p value of (p≤0.05) was considered statistically significant.

Results

The healing process went without complications. The flap closure was completeand no flap dehiscence was observed,thus providing primary healing process. Table 1 shows the descriptive details of the control and test subjects at baseline,12 months, and 36 months. Pre-operative Clinical Parameters were similar for the both the SFA+PRF+HA -βTCP (test) group and SFA+PRF (control) group.

A.SINGLE FLAP ACCESS PERFORMED B.PREPARATION OF PRF MATRIX

C.WOUND CLOSURE USING VERTICAL INTERNAL MATRIX SUTURES

(5)

Table 1. Descriptive Statistics

Clinical Parameters

N Baseline 12 Months 36 Months

Control Test Control Test Control Test

FMPS% 15 17.2 ± 1.32

16.4 ± 1.96

12.03±1.24 12.3±1.48 11.3±1.11 11.5±1.04 FMBS% 15 18±1.06 18.3±1.28 12.4±1.31 12.3±1.13 11.7±1.16 11.6±0.98 PPD (mm) 15 6.8±0.77 7.06±1.39 2.6±0.51 2.53±0.52 2.6±0.51 2.8±0.56 RCAL

(mm)

15 10.2±0.82 10.5±1.38 6.4±3.9 6.06±0.78 6.4±0.46 6.4±0.53 GM (mm) 15 3.43±0.68 3.4±0.58 3.8±0.61 3.5±0.61 3.5±0.76 3.3±0.37 RVG (mm) 15 3.7±0.94 3.7±0.92 2.23±0.66** 1.4±0.47** 1.38±0.62 0.92±0.39

Post -surgical measurements at 12 months and 36 months revealed a significant reduction in the mean FMPS%, FMBS%, & PPD within the groups (p≤0.0001), but they did not reveal any statisticalsignificance when compared between the test and the control groups at various time points. (Table 2 &3)

Table 2. Intra group assessment of Clinical and Radiographic parameters

Parameters Groups Baseline - 12 Months 12 Months - 36 Months Baseline - 36 Months Mean ± SD P value Mean ± SD P value Mean ± SD P value FMPS Control 17.2 ± 1.32 0.0001 12.03±1.24 0.002 17.2 ± 1.32 0.0001

12.03±1.24 11.3±1.11 11.3±1.11

Test 16.4 ± 1.96 0.0001 12.3±1.48 0.005 16.4 ± 1.96 0.0001

12.3±1.48 11.5±1.04 11.5±1.04

FMBS Control 18±1.06 0.0001 12.4±1.31 0.001 18±1.06 0.0001

12.4±1.31 11.7±1.16 11.7±1.16

Test 18.3±1.28 0.0001 12.3±1.13 0.001 18.3±1.28 0.0001

12.3±1.13 11.6±0.98 11.6±0.98

PPD Control 6.8±0.77 0.0001 2.6±0.51 1.000 6.8±0.77 0.0001

2.6±0.51 2.6±0.51 2.6±0.51

Test 7.06±1.39 0.0001 2.53±0.52 0.057 7.06±1.39 0.0001

2.53±0.52 2.8±0.56 2.8±0.56

GM Control 3.43±0.68 0.048 3.8±0.61 0.060 3.43±0.68 0.788

3.8±0.61 3.5±0.76 3.5±0.76

Test 3.4±0.58 0.784 3.5±0.61 0.094 3.4±0.58 0.388

3.5±0.61 3.3±0.37 3.3±0.37

RCAL Control 10.2±0.82 0.0001 6.4±3.9 0.085 10.2±0.82 0.0001

6.4±3.9 6.4±0.46 6.4±0.46

Test 10.5±1.38 0.0001 6.06±0.78 0.685 10.5±1.38 0.0001

6.06±0.78 6.4±0.53 6.4±0.53

RVG Control 3.7±0.94 0.0001 2.23±0.66 0.0001 3.7±0.94 0.0001

2.23±0.66 1.38±0.62 1.38±0.62

(6)

Test 3.7±0.92 0.0001 1.4±0.47 0.0001 2.78±0.87** 0.0001

1.4±0.47 0.92±0.39 0.92±0.39

Table 3. Inter group assessment of Clinical and Radiographic parameters

Both test and control treatments resulted in a statistically significant gain in the mean Relative Clinical Attachment Levels (R-CAL) of 4.467±1.2mm 3.767±.942mm at six months (p≤0.0001). Differences in R-CAL gain between the two treatment modalities were comparable between both the groups at all time points. (Table 2 &3)

The position of the gingival margin (GM) had a continual gradual apical shift (gingival recession) till 12 months which averaged to -0.433±.77 mm with a mild statistical significance of (p≤ 0.048) in the control group. The test group initially had a coronal shift in the 12monthstime point and then shifted apically later and became comparable at 36 months between the control and the test group with no statistical significance(p≤0.784). (Table 2 &3)

Additionally RVG values revealed a statistically significant bone fill (p≤0.0001) in both, test group (2.30 ± 0.79mm) and the control group (1.47±0.49mm) at 12 months, this radiographic bone fill was greater and statistically significant in the test group when compared with the control at the 12months . (p≤0.0001). (Table 2 &3)

when the difference in the bone fill was measured at 36 months between test (2.30 ±0.58 mm) and control (2.78

±0.87mm) the difference was almost comparable between the groups at this time point with minimal significance.(p≤0.023). (Table 2 &3)

Discussion

The clinical procedure of choice for intrabony defects is the guided tissue regeneration (GTR) approach with a barrier membrane aiming clot and periodontal wound stability with the bone graft filling the defect.This study sought to assess the ability of a third tenet that has become louder over the last decade.Clinical studies arising from

Parameters N Groups Baseline 12 Months 36 Months

Mean ± SD P value Mean ± SD P value Mean ± SD P value

FMPS 15 Control 17.2 ± 1.32 0.2 12.03±1.24 0.598 11.3±1.11 0.506

15 Test 16.4 ± 1.96 12.3±1.48 11.5±1.04

FMBS 15 Control 18±1.06 0.403 12.4±1.31 0.825 11.7±1.16 0.674

15 Test 18.3±1.28 12.3±1.13 11.6±0.98

PPD 15 Control 6.8±0.77 0.521 2.6±0.51 0.724 2.6±0.51 0.240

15 Test 7.06±1.39 2.53±0.52 2.8±0.56

RCAL 15 Control 10.2±0.82 0.476 6.4±3.9 0.087 6.03±0.69 0.678

15 Test 10.5±1.38 6.06±0.78 6.13±0.61

GM 15 Control 3.43±0.68 0.886 3.8±0.61 0.147 3.5±0.76 0.365

15 Test 3.4±0.58 3.5±0.61 3.3±0.37

RVG 15 Control 3.7±0.94 0.974 2.23±0.66 0.0001 1.38±0.62 0.023

15 Test 3.7±0.92 1.4±0.47 0.92±0.39

(7)

Cortellini and also from Trombelli,have shown that their MIST & SFA technique have been able to generate significant periodontal tissue regeneration.14,15,16,17,18,19

Present study was a comparative evaluation of SFA+PRF & SFA+PRF+β-TCP in the treatment of the intrabonydefects present in the 30 patients. Periodic oral prophylaxis was performed so as to avoid formation of plaque, calculus deposits & debris on the surgicalsite as they could hamper the final out come.The highly significant gingival and plaque scores and bleeding scores in both the groups are in agreement with the previous studies demonstrating that oral hygiene and also the potential effects of PRF in the uneventfullhealing process.The most important surrogate marker of periodontal disease is that of probing pocket depth and is one of the primary objectives of the study. In our study there was a marked reduction in the Probing pocket depth with both test and control groups from baseline to various time points which were also a significant find in other studies by Trombelli et al14and Hanna et al16

The primary reason for reduction in depth after treatment can be attributed to the minimally accessed surgical technique (Single Flap Approach). The design of this surgical approach allows both access to root surface instrumentation and minimization of flap elevation through the elevation of the buccal flap alone. This further enhances wound stability during early wound healing and prevents the collapse of the papilla into the defect: at the end of the procedure, the buccal flap is repositioned and sutured to the interdental supracrestal soft tissues, still anchored with their fibres to the root cement. The improved stability of the soft tissues could play a positive role in increasing the stability of the blood clot, a key factor in regenerative therapy.1In addition, the potential prevention of the interdental soft tissue collapse could preserve more space for the regeneration to occur. The PRF also has been shown in earlier studies to promote the proliferation of periodontal ligament fibroblasts as well as gingival fibroblasts. Recently, studies have demonstrated that PRF has a very significant slow sustained release of growth factors such as PDGF and (TGF)-β for atleast 1 week and upto 28 days and this enhancement of the optimal healing period by PRF, ofthe periodontal wound creates greater opportunity for the regeneration of the lost periodontal tissues.18The PPD reduction although had progressive rate of reduction in both the groups, remained similar between the two groups suggesting that both treatment procedures ensure conditions for primary intention healing supporting adequate wound stability allowing uneventful tissue formation and maturation.20,21Most importantly the highly significant decrease in the probing pocket depth scores at all the evaluation time points, can occur due to combination of gain in clinical attachment as well as post treatment gingival margin shift to apical position in our study, that was seen in the control and test sites all of which showed continual progressive gain.22,23

The gain in clinical attachment level also reflected in the positive outcome to the position of the gingiva. The position of the gingival margin had a continual apical shift in the control group and was statistically significant when compared at baseline to12 months. (p ≤ 0.05). On the other hand although the test group had an initial coronal shift in the position of the gingival margin at the time point of month, this level shifted apically in the 36thmonth and showed no statistical difference. These positions of the gingival margins at the surgical sites when compared between the test and the control groups were similar at all evaluation time points.

These clinical outcomes were further reflected in the gain in bone at the crest of the interproximal region,that was assessed through individually standardized digital radiographs. Both the control and the test groups had a significant gain in the crestal bone levels with a very highstatistical significance (p<0.0001).The Intergroup comparison further indicated the improvement to the bone levels, which showed a highly significant, formation of alveolar bone in the test group(2.23±.66mm),(1.38±0.62), in comparison to the controls(1.4±.47mm), (0.92±0.39) at 12 and 36 month time points (p<0.0001).In the standardized radiographs, 12 months after treatment with the composite graft, the filling of radiographic defects with bone -like radio opaque tissue, was observed and indistinguishable from native bone. The gain in the bone levels in the test group could have been due to the application of HA -βTCP as a bone replacement graft which has demonstrated its osseointegrative properties in other studies. It is accepted that the suitable biomaterials used for bone regeneration should be resorbable and gradually replaced by the newly formed bone. β -TCP has a low degradation rate and takes a longer period to be replaced by new bone tissue. Previous

(8)

histologic studieshave shown that β –TCP particles are resorbed in 12 -24 months and replaced with the newly generated bone in 36 months. Wiltfang et al.24 compared the graft materials with PRP in pigs and they observed β – TCP particles remaining in the bone defects at 12th week. At the end of the 12th week of the study by Yilmaz et al25, β-TCP particles were observed histologically in the cavities that contained β –TCP alone, but no β -TCP particles were observed in the bone marrow when β -TCP and PRF has been used in combination. As a result, it can be stated that PRF increases the transformation of β -TCP particles into bone. Adding PRF to β–TCP was observed to significantly reduce the time required to promote graft consolidation, maturation, and improved trabecular bone density. Nery et al.26 studied the tissue response to BCP ceramic with different ratios of HA/βTCP in periodontal osseous defects. They found that among the seven “active” treatment groups, two (65/35 and 85/15) had significantly higher gain in probing attachment levels than those in three group (50/50, 100/0, and 0/100) (p< 0.05).

Histologically, higher HA ratio (but not 100% HA) showed accelerated new bone formation and new attachment levels. Based on histological results, the 85 HA/15 β-TCP ratio appears to demonstrate greater gain in attachment level and bone regeneration in the treatment of periodontal osseous defects. However human histologic studies indicate that dense HA and β-TCP does not induce new attachment or bone formation, that pocket reduction is primarily through fibrous encapsulation of the graft particles in the intraosseous defect, and that pocket closure is through long junctional epithelium and connective tissue adhesion. In our study accessed with SFA, when the PRF+HA/β-TCP combination group was compared with the PRF group, more radiographic bone fill was observed. It is thought that PRF accelerates the healing effect by keeping the particles of HA/β-TCP together via its adhesive property and adapting them tightly to the walls of the cavity. Although different studies have shown that there is complete biodegradation and new bone formation only histologic analysis can provide evidence on stimulated new bone formation.

Although different studies27,28have shown that there is complete biodegradation and new bone formation only histologic analysis can provide evidence on stimulated new bone formation.The different distribution of patients observed in control and test groups according to defect morphology may represent a potential source of bias since it has been reported that defect morphology is associated with varying regenerative potential.29 The test group had 66.6% of two walls and 33.3% of three walls and there is also a possibility that variations in this supracrestal and osseous defect characteristics might have influenced our treatment outcome. The presence of a three - wall component conceptually is one determinant for the outcome of a reconstructive procedure because it may safeguard the stability of the fibrin clot and positively influence the osteogenic potential of the site. 30

Conclusion

To the best of our knowledge, clinical data demonstrating an improved prognosis for three -wall versus one-or two- wall intraosseous defects after surgical debridement alone clearly segregating the depth of the intrabonycomponents are not available for comparison. However, when intraosseous defects are treated using a graft biomaterial or barrier membrane, defect configuration does not seem to significantly affect the amount of CAL gain. Despite these limitations, this study has proved in principle that PlateletRich Fibrin when grafted to a periodontal defect, which is approached through a minimal access periodontal surgical technique, has a high potential to favorably modulate the healing periodontal wound with or without an additional graft material.

References

[1] Wikesjö, U. M., &Nilvéus, R. (1990). Periodontal repair in dogs: effect of wound stabilization on healing. Journal of periodontology, 61(12), 719–724. https://doi.org/10.1902/jop.1990.61.12.719

(9)

[2] Cortellini, P., &Tonetti, M. S. (2007). A minimally invasive surgical technique with an enamel matrix derivative in the regenerative treatment of intra-bony defects: a novel approach to limit morbidity. Journal of clinical periodontology, 34(1), 87–93. https://doi.org/10.1111/j.1600-051X.2006.01020.x

[3] Cortellini, P., Prato, G. P., &Tonetti, M. S. (1995). The modified papilla preservation technique. A new surgical approach for interproximal regenerative procedures. Journal of periodontology, 66(4), 261–266.

https://doi.org/10.1902/jop.1995.66.4.261

[4] Simonelli, A., Minenna, L., Trombelli, L. et al. Single flap approach with or without enamel matrix derivative in the treatment of severe supraosseous defects: a retrospective study. Clin Oral Invest (2021).

https://doi.org/10.1007/s00784-021-03941-5

[5] Mathala VL, Konathala SV, Gottumukkala NV, Pasupuleti MK, Bypalli V, Korukonda R. Single-flap versus double-flap approach for periodontal pocket reduction in supraosseous defects: a comparative study. J Periodontal Implant Sci. 2021;51:e10. https://doi.org/10.5051/jpis.2004200210

[6] Trombelli, L., Farina, R., Franceschetti, G., &Calura, G. (2009). Single-flap approach with buccal access in periodontal reconstructive procedures. Journal of periodontology, 80(2), 353–360.

https://doi.org/10.1902/jop.2009.080420

[7] Tonettims, cortellini p, suvan je, adriaens p, baldi c, dubravec d, et al. Generalizability of the added benefits of guided tissue regeneration in the treatment of deep intrabony defects: evaluation in a multi-center randomized controlled clinical trial. Journal periodontol 69, (1998):1183–92.

[8] Choukroun, J., Diss, A., Simonpieri, A., Girard, M. O., Schoeffler, C., Dohan, S. L., Dohan, A. J., Mouhyi, J., &

Dohan, D. M. (2006). Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part V: histologic evaluations of PRF effects on bone allograft maturation in sinus lift. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics, 101(3), 299–303. https://doi.org/10.1016/j.tripleo.2005.07.012

[9] Trombelli, L., Simonelli, A., Pramstraller, M., Wikesjö, U. M., & Farina, R. (2010). Single flap approach with and without guided tissue regeneration and a hydroxyapatite biomaterial in the management of intraosseous periodontal defects. Journal of periodontology, 81(9), 1256–1263. https://doi.org/10.1902/jop.2010.100113 [10] Schincaglia, G. P., Hebert, E., Farina, R., Simonelli, A., &Trombelli, L. (2015). Single versus double flap

approach in periodontal regenerative treatment. Journal of clinical periodontology, 42(6), 557–566.

https://doi.org/10.1111/jcpe.12409

[11] Naik, B., Karunakar, P., Jayadev, M., & Marshal, V. R. (2013). Role of Platelet rich fibrin in wound healing: A critical review. Journal of conservative dentistry : JCD, 16(4), 284–293. https://doi.org/10.4103/0972- 0707.114344

[12] O'Leary, T. J., Drake, R. B., & Naylor, J. E. (1972). The plaque control record. Journal ofperiodontology, 43(1),38. https://doi.org10.1902/jop.1972.43.1.38

[13] Ainamo, J.; Bay, I. Problems and proposals for recording gingivitis and plaque. International Dental Journal, Vol.

25, No. 4 (December 1975), pp.229-235, ISSN 1875-595X

[14] Trombelli, L., Simonelli, A., Schincaglia, G. P., Cucchi, A., & Farina, R. (2012). Single-flap approach for surgical debridement of deep intraosseous defects: a randomized controlled trial. Journal of

(10)

periodontology, 83(1), 27–35. https://doi.org/10.1902/jop.2011.110045

[15] Farina, R., Simonelli, A., Rizzi, A., Pramstraller, M., Cucchi, A., &Trombelli, L. (2013). Early postoperative healing following buccal single flap approach to access intraosseous periodontal defects. Clinical oral investigations, 17(6), 1573–1583. https://doi.org/10.1007/s00784-012-0838-6

[16] Hanna, R., Trejo, P. M., &Weltman, R. L. (2004). Treatment of intrabony defects with bovine-derived xenograft alone and in combination with platelet-rich plasma: a randomized clinical trial. Journal of periodontology, 75(12), 1668–1677. https://doi.org/10.1902/jop.2004.75.12.1668

[17] Cortellini, P., Prato, G. P., &Tonetti, M. S. (1995). The modified papilla preservation technique. A new surgical approach for interproximal regenerative procedures. Journal of periodontology, 66(4), 261–266.

https://doi.org/10.1902/jop.1995.66.4.261

[18] Cortellini, P., Pini Prato, G., &Tonetti, M. S. (1995). Periodontal regeneration of human intrabony defects with titanium reinforced membranes. A controlled clinical trial. Journal of periodontology, 66(9), 797–803.

https://doi.org/10.1902/jop.1995.66.9.797

[19] Cortellini, P., Tonetti, M. S., Lang, N. P., Suvan, J. E., Zucchelli, G., Vangsted, T., Silvestri, M., Rossi, R., McClain, P., Fonzar, A., Dubravec, D., &Adriaens, P. (2001). The simplified papilla preservation flap in the regenerative treatment of deep intrabony defects: clinical outcomes and postoperative morbidity. Journal of periodontology, 72(12), 1702–1712. https://doi.org/10.1902/jop.2001.72.12.1702

[20] Tonetti, M. S., Fourmousis, I., Suvan, J., Cortellini, P., Brägger, U., Lang, N. P., & European Research Group on Periodontology (ERGOPERIO) (2004). Healing, post-operative morbidity and patient perception of outcomes following regenerative therapy of deep intrabony defects. Journal of clinical periodontology, 31(12), 1092–1098.

https://doi.org/10.1111/j.1600-051X.2004.00615.x

[21] Schincaglia, G. P., Hebert, E., Farina, R., Simonelli, A., &Trombelli, L. (2015). Single versus double flap approach in periodontal regenerative treatment. Journal of clinical periodontology, 42(6), 557–566.

https://doi.org/10.1111/jcpe.12409

[22] Lekovic, V., Milinkovic, I., Aleksic, Z., Jankovic, S., Stankovic, P., Kenney, E. B., & Camargo, P. M. (2012).

Platelet-rich fibrin and bovine porous bone mineral vs. platelet-rich fibrin in the treatment of intrabony periodontal defects. Journal of periodontal research, 47(4), 409–417. https://doi.org/10.1111/j.1600- 0765.2011.01446.x

[23]Trombelli, L., Farina, R., Franceschetti, G., &Calura, G. (2009). Single-flap approach with buccal access in periodontal reconstructive procedures. Journal of periodontology, 80(2), 353–360.

https://doi.org/10.1902/jop.2009.080420

[24] Wiltfang, J., Kloss, F. R., Kessler, P., Nkenke, E., Schultze-Mosgau, S., Zimmermann, R., & Schlegel, K. A.

(2004). Effects of platelet-rich plasma on bone healing in combination with autogenous bone and bone substitutes in critical-size defects. An animal experiment. Clinical oral implants research, 15(2), 187–193.

https://doi.org/10.1111/j.1600-0501.2004.00980.x

(11)

[25]Yilmaz, D., Dogan, N., Ozkan, A., Sencimen, M., Ora, B. E., &Mutlu, I. (2014). Effect of platelet rich fibrin and beta tricalcium phosphate on bone healing. A histological study in pigs. Acta cirurgicabrasileira, 29(1), 59–65.

https://doi.org/10.1590/S0102-86502014000100009

[26] Nery, E. B., LeGeros, R. Z., Lynch, K. L., & Lee, K. (1992). Tissue response to biphasic calcium phosphate ceramic with different ratios of HA/beta TCP in periodontal osseous defects. Journal of periodontology, 63(9), 729–735. https://doi.org/10.1902/jop.1992.63.9.729

[27] Thorat, M., Pradeep, A. R., & Pallavi, B. (2011). Clinical effect of autologous platelet-rich fibrin in the treatment of intra-bony defects: a controlled clinical trial. Journal of clinical periodontology, 38(10), 925–932.

https://doi.org/10.1111/j.1600-051X.2011.01760.x

[28] S, Shruthi &Gujjari, Sheela & Gaekwad, Shivali& Shah, Mishal. (2013). The potential use of platelet rich fibrin versus an alloplast in the regeneration of intrabony defect and furcation involvement – A case report..

International Journal of Basic and Applied Medical Sciences. 3. 205-209.

[29] Kaushick, B. T., Jayakumar, N. D., Padmalatha, O., & Varghese, S. (2011). Treatment of human periodontal infrabony defects with hydroxyapatite + β tricalcium phosphate bone graft alone and in combination with platelet rich plasma: a randomized clinical trial. Indian journal of dental research : official publication of Indian Society for Dental Research, 22(4), 505–510. https://doi.org/10.4103/0970-9290.90278

[30] Selvig, K. A., Kersten, B. G., Chamberlain, A. D., Wikesjö, U. M., &Nilvéus, R. E. (1992). Regenerative surgery of intrabony periodontal defects using ePTFE barrier membranes: scanning electron microscopic evaluation of retrieved membranes versus clinical healing. Journal of periodontology, 63(12), 974–978.

https://doi.org/10.1902/jop.1992.63.12.974

Referințe

DOCUMENTE SIMILARE

Background and aim: In the present study, tried to obtain strong evidence by comparing Platelet- rich fibrin in the treatment of both intrabony defects with other treatment

Key words: Greta Thunberg, Public Appearance, Protestant Ethics, Martin Luther, Self- Restraint, Public Responsibility, Cultural Patterns, Modern and Postmodern

The distinction between first order truth claims and second order grammatical reflection stems from the application of the linguistic metaphor to religion and from allowing

Recently, the use of tricalcium phosphate and bioactive glass 45S5 particles as alloplastic bone graft materials for alveolar ridge augmentation and sinus fl oor elevation

De¸si ˆın ambele cazuri de mai sus (S ¸si S ′ ) algoritmul Perceptron g˘ ase¸ste un separator liniar pentru datele de intrare, acest fapt nu este garantat ˆın gazul general,

Thus, if Don Quixote is the idealist, Casanova the adventurous seducer, Werther the suicidal hero, Wilhelm Meister the apprentice, Jesus Christ will be, in the audacious and

The finding of insignificant changes in the plasma malondialdehyde levels of control group when compared with the treated groups (groups that received sodium

The number of vacancies for the doctoral field of Medicine, Dental Medicine and Pharmacy for the academic year 2022/2023, financed from the state budget, are distributed to