Journal of Pharmacy And Bioallied Sciences

ORIGINAL ARTICLE
Year
: 2017  |  Volume : 9  |  Issue : 5  |  Page : 96--102

Comparison of marginal periosteal pedicle graft and bioactive glass with platelet-rich fibrin and bioactive glass in the treatment of intrabony defects – A clinicoradiographic study


MS Yasaswini1, KV Prabhakara Rao2, P Tanuja2, Narendra Reddy Motakatla3,  
1 P.G. Student, Gitam Dental College and Hospital, Gitam Dental College and Hospital, Vishakhapatnam, Andhra Pradesh, India
2 Department of Periodontics, Gitam Dental College and Hospital, Vishakhapatnam, Andhra Pradesh, India
3 Department of Periodontics, Best Dental College and Hospital, Madurai, Tamil Nadu, India

Correspondence Address:
Narendra Reddy Motakatla
Department of Periodontics, Best Dental Science College and Hospital, Ultra Nagar, Vowalthottam Post, Melur Highway, Madurai - 625 020, Tamil Nadu
India

Abstract

Introduction and Objectives: The objective of the study was to compare clinically and radiographically the regenerative potential of marginal periosteal pedicle graft (MPPG) or platelet-rich fibrin (PRF) with a bioactive glass in the treatment of two- and three-wall intrabony defects. Methods: A total of 28 sites (bilateral or contralateral infrabony defects) from 14 patient were treated with MPPG (Experimental site A) and the other site was treated with PRF (Experimental site B). The clinical parameters, such as full-mouth plaque index (PI) and site PI, were recorded at baseline, 3, 6, and 9 months' postsurgery while sulcus bleeding index (SBI), probing pocket depth (PD), clinical attachment level (CAL), and gingival recession were recorded at baseline, 6, and 9 months. Radiographic evaluation was carried out to evaluate the defect fill, change in alveolar crest height, and percent defect fill at 6 and 9 months. Results: Results showed that both the experimental groups showed clinically and statistically significant reduction in mean PI, SBI, PD, radiographic defect depth, and gain in CAL. The percentage of defect fill at 6 months (70.55 ± 15.99 vs. 55.30 ± 11.87) and 9 months (84.55 ± 11.74 vs. 72.2 ± 9.91) was significantly greater in Site A compared to Site B. Conclusions: Within the limitations of this study, it can be concluded that both the treatment modalities showed the potential of enhancing bone regeneration. However, the use of marginal periosteal pedicle flap showed better improvement in clinical and radiographic parameters.



How to cite this article:
Yasaswini M S, Prabhakara Rao K V, Tanuja P, Motakatla NR. Comparison of marginal periosteal pedicle graft and bioactive glass with platelet-rich fibrin and bioactive glass in the treatment of intrabony defects – A clinicoradiographic study.J Pharm Bioall Sci 2017;9:96-102


How to cite this URL:
Yasaswini M S, Prabhakara Rao K V, Tanuja P, Motakatla NR. Comparison of marginal periosteal pedicle graft and bioactive glass with platelet-rich fibrin and bioactive glass in the treatment of intrabony defects – A clinicoradiographic study. J Pharm Bioall Sci [serial online] 2017 [cited 2022 Aug 9 ];9:96-102
Available from: https://www.jpbsonline.org/text.asp?2017/9/5/96/219310


Full Text



 Introduction



One of the most important factors that limit the achievement of predictable regeneration is the downgrowth of the junctional epithelium along the denuded root surface. A number of resorbable and nonresorbable guided tissue regeneration (GTR) materials have been proposed to delay epithelial downgrowth during healing. The use of bioresorbable barriers eliminates the need for second surgery to remove the membrane and decrease the associated disturbances of newly formed osteoid that may result in bone resorption.[1]

Oral cavity comprises tissues which are complex in nature harboring distinctive progenitor cell colonies residing in the form of extracellular matrix framework. Complex natural scaffolds allow repopulation of own cells, thereby producing an autologous tissue-engineered organ. Periosteum and platelet-rich fibrin (PRF) are two natural scaffolds suited for tissue regeneration.

Periosteum, a structure rich in osteoprogenitor cells, has been as having regenerative potential. Periosteal grafts provide the wound area with additional osteoprogenitor cells which compensate for the deficiency of cells available in the periodontal defect.[2] Gamal and Mailhot introduced a novel marginal pedicle periosteum (MPP) flap as a biologic guided tissue membrane in the management of deep angular two- and three-wall intrabony periodontal defects. They reported that the use of vascularized MPP graft as a barrier membrane significantly improved clinical and radiographic parameters of deep intrabony defects and proved superior to open-flap debridement alone.[3],[4]

PRF is a second-generation platelet concentrate introduced by Choukroun et al. It is an autologous leukocyte and PRF biomaterial which is made up of an intimate assembly of cytokines and structural glycoproteins enmeshed within a slowly polymerizing fibrin network.[5] PRF also induces the proliferation of various cells in vitro with strongest induction effect on osteoblasts.[6]

A collapse of the mucoperiosteal flap may limit the area available for the regenerative process and may thus affect the result. To avoid these disadvantages, combination therapies of bone substitutes and GTR have been recommended.

Therefore, the aim of the study was to compare the effectiveness of autogenous marginal periosteal pedicle graft (MPPG) and bioactive glass with autogenous PRF membrane and bioactive glass in the treatment of intrabony defects.

 Materials and Methods



The study undertaken was a single-blind, active, prospective, split-mouth clinical trial. Patients were recruited from outpatient center of the Department of Periodontics, GITAM dental college, Visakhapatnam, India. The study protocol pro forma was submitted and approved by the Ethical Committee of the institution. Systemically healthy individuals, in the age group of 20–60 years, with the presence of at least two periodontal pockets with probing depth ≥6 mm and radiographic evidence of two intrabony defects on bilateral or contralateral sides with one site showing a 4–5 mm band of keratinized gingiva were included in the study. Patients with poor oral hygiene, users of tobacco in any form, pregnant and lactating women, patients with the study tooth mobility, and patients with a history of drug intake known to affect the periodontium were excluded from the study. Informed consent was obtained from all the patients.

Following initial examination and treatment planning, the selected patients underwent Phase I periodontal therapy. Customized acrylic stents with grooves were prepared on the study model of the patients.

Clinical parameters

The clinical parameters, including full-mouth plaque index (PI) and site PI (Silness and Loe 1964), were recorded at baseline, 3, 6, and 9 months, while the full-mouth sulcus bleeding index (SBI) and site SBI (Muhlemann and Son 1971) were recorded baseline, 6, and 9 months. Probing depth (PD), clinical attachment level, and gingival recession (GR) were recorded to the nearest millimeter with a UNC-15 probe at baseline, 6, and 9 months.

Radiographic parameters

Intraoral periapical (IOPA) radiographs were taken for each site at baseline (patient's initial visit) and at 6 and 9 months postoperatively using long cone paralleling technique. The IOPA radiographs were digitalized and the measurements from the cementoenamel junction (CEJ) to the base of the defect (A) and CEJ to the crest of the alveolar bone (B) were done using Image J software. Based on these measurements, the amount of defect fill, percentage of defect fill, and change in alveolar crest height at 6 and 9 months were calculated.

Surgical procedure

The operative sites A and B were anesthetized with 2% xylocaine in hydrochloric acid with adrenaline (1:80,000) using block and infiltration techniques. The surgical procedure for the study groups was performed by a single operator.

Site A

As described in detail by Gamal and Mailhot, the procedure consisted of facial and lingual intrasulcular incisions extending to two teeth adjacent to the defect that possessed wider attached gingiva. Subsequently, one facial vertical releasing incision extending into the alveolar mucosa was given, and a facial split-thickness flap reflection was done that would permit free movement of a 3-to 4-mm wide periosteal pedicle strip. Full-thickness mucoperiosteal flaps were raised lingually. A marginal periosteal strip was obtained from the facial periosteum adjacent to the defect using one vertical incision starting from 4 mm apical to the alveolar crest and one horizontal incision parallel to the gingival margin. The periosteum was elevated with a periosteal elevator from the underlying bone and the separation extended laterally keeping the base attached for use as a pedicle biological carrier membrane. Debridement of all inflammatory granulation tissues from the intrabony defect was performed until a sound, healthy bone surface was obtained using the appropriate scalers and Gracey curettes. The surgical site was thoroughly irrigated with 0.9% normal saline, and an alloplastic graft bioactive glass material (Perioglas) was used to fill the defect. The periosteal flap material was rotated to cover the interproximal defect without suturing since the flap adheres well to the bony surfaces. Finally, the soft-tissue flap was repositioned and secured to the original position with interproximal and sling sutures using black silk (3-0) [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7].{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}

Site B

Facial and lingual sulcular incisions were made, and full-thickness mucoperiosteal flaps were reflected. Care was taken to preserve as much interproximal soft tissue as possible. Meticulous debridement of all granulation tissues from the defect was performed with the help of scalers and Gracey curettes [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15].{Figure 8}{Figure 9}{Figure 10}{Figure 11}{Figure 12}{Figure 13}{Figure 14}{Figure 15}

Platelet-rich fibrin preparation

PRF was prepared by the technique described by Choukroun et al. Just before surgery, intravenous blood was collected by venipuncture of the antecubital vein. The blood that was collected was transferred to a 10-ml sterile tube without anticoagulant and immediately centrifuged in a centrifugation machine (R-4C REM1 laboratory instruments) at 3000 revolutions per minute (i e., 400 g) for 12 min. The PRF was transferred onto a sterile compress to obtain a stable fibrin membrane by squeezing serum out of the PRF clot. PRF of required size was used as a membrane barrier, to cover the defect filled with bioactive glass. The mucoperiosteal flaps were repositioned and secured in place using 3-0 nonabsorbable silk surgical suture. Interrupted or sling sutures were given.

The surgical areas were covered with a periodontal dressing. Antibiotics (500 mg amoxicillin three times daily) and analgesics (100 mg aceclofenac twice daily) were prescribed for 5 days postoperatively. Patients were instructed to rinse with 10 ml of 0.2% chlorhexidine mouthwash twice daily for a week. One week after surgery, the dressing and the sutures were removed. Oral hygiene instructions were reinforced.

Statistical analysis

All the analyses were done using SPSS,1804, Westlands Road, Quarry Bay, Hong Kong. P < 0.05 was considered statistically significant. Repeated measures ANOVA with post hoc Bonferroni correction was done to compare parameters from baseline through 9-month follow-up. Paired t-test was used to compare differences in the follow-up between Site A and B.

 Results



During the course of the study, all the patients showed good compliance, with uneventful postoperative healing in both the experimental sites. A total of 28 (bilateral) defects in 14 patients were treated with MPP + Perioglas or PRF + Perioglas. There was a statistically significant reduction in mean plaque score from baseline to subsequent follow-up periods. There was a statistically significant change in mean plaque score from 3 to 9 months (P < 0.001). There was a statistically significant reduction in mean SBI from baseline to 6 and 9 months and from 6 to 9 months (P < 0.001). Comparison of site plaque and SBI scores between the treatment groups showed no statistically significant difference at different time intervals [Graph 1],[Graph 2] and [Table 1], [Table 2].[INLINE:1][INLINE:2]{Table 1}{Table 2}

At baseline, the various clinical and radiographic parameters did not show a significant difference between the sites (P > 0.05). Both the groups showed a significant reduction in pocket depth (PD) and gain in CAL at 6 and 9 months. Site A showed a significantly greater reduction in mean probing PD of 6.22 ± 1.03 mm from baseline to 9 months than Site B (5.5 ± 1.01 mm). At baseline, 6, and 9 months, the mean CAL did not show a significant difference between the sites. In the present study, there was a slight increase in GR in site B from baseline which was not statistically significant.

Statistically significant differences in the amount of defect fill and percentage of defect fill were recorded for both the test groups. The mean defect fill did not show a significant difference between Site A and Site B at time intervals, but the percentage of defect fill was significantly higher in Site A (84.55 ± 11.74%) than Site B (72.2 ± 9.91%). Site B (0.52 ± 0.03 mm) showed a significant loss in alveolar crest height as compared to Site A (0.21 ± 0.44) at 9 months.

 Discussion



The purpose of this study was to compare and evaluate the clinical and radiographic treatment outcomes of MPPG or PRF biomaterial when used along with a bone graft in the treatment of intrabony defects. In the present study, both the sites showed a significant reduction in mean PD, CAL gain, defect fill, and percentage of defect fill.

The results of the present study are in accordance with Gamal et al. who reported probing depth reduction of 5.6 ± 1.5 mm, CAL gain of 4.3 ± 1.9 mm, and a defect fill of 3.2 mm[6] at 9-month follow-up which suggests that more gain in CAL, bone fill, and probing depth reduction can be obtained using pedicled periosteal flaps. Autogenous free periosteum is less vascularized and may have less number of viable cells when compared to pedicled periosteum.

All MPPG grafts performed in the present study were placed against residual periodontal pocket bony walls. In terms of viability, a vascularized MPP graft provides a more adequate vascular supply to the graft. The osteogenic capacity of a vascularized periosteum is less affected by the environment of the recipient site compared to free periosteum. Frost described a situation referred to as ''regional acceleratory phenomenon.” It denotes that there is a local exuberant response to noxious stimuli, which accelerates the normal healing process.[7] Mesenchymal stem cells are normally quiescent. Relevantly, elevation and relocation of the periosteum performed in MPPG surgery can be considered a noxious stimulus.[8] Application of this concept is being used in MPPG surgery as a method to initiate local tissue release of osteoprogenitor cells and osteoinductive agents.

The results of the study are in accordance to the study performed by A. Pradeep et al. who reported a 63.39 ± 16.52 percentage of defect fill at the end of 9 months when PRF was used along with hydroxyapatite. The combination of fibrins and cytokines within PRF becomes a powerful bioscaffold with an integrated reservoir of growth factors TGF-β1, VEGF, and MPO in the first 7 days and IGF1, PDGF-AB, and platelet activity (PF4-CXCL4) in the first 8 h, followed by a decrease to close to zero at 28 days.[9] Qi Li et al. found a stronger effect of PRF on alveolar bone cells and dental follicle cells than on PDL progenitors, and the PRF induces the elevation of proliferation of alveolar bone progenitors. PRF can upregulate p-ERK expression in human osteoblasts and enhance the cell proliferation through p-ERK signal transduction pathway.

There was a slight increase in GR and alveolar crest loss in Site B from baseline and 9 months, and this may be attributed to reduced vascular supply to the overlying flap due to the placement of a barrier that creates two avascular surfaces – the root surface and the barrier membrane.[10] Although the PRF acts as a good scaffold and is enriched with growth factors, it does not contain viable cells. The greater increase in percentage of defect fill in Site A demonstrates that periosteum has more osteogenic potential than the PRF owing to the presence of viable osteoprogenitor cells in the defect.

 Conclusion



Thus, the present study demonstrates that both the treatment modalities have predictable outcomes and were successful in showing promising results in the treatment of periodontal intrabony defects. Treatment of two- or three-wall defects with MPPG and bone graft has slightly more clinical and radiographic gains.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Aichelmann-Reidy ME, Reynolds MA. Predictability of clinical outcomes following regenerative therapy in intrabony defects. J Periodontol 2008;79:387-93.
2Augustin G, Antabak A, Davila S. The periosteum. Part 1: Anatomy, histology and molecular biology. Injury 2007;38:1115-30.
3Sharma A, Pradeep AR. Treatment of 3-wall intrabony defects in patients with chronic periodontitis with autologous platelet-rich fibrin: A randomized controlled clinical trial. J Periodontol 2011;82:1705-12.
4Thorat M, Pradeep AR, Pallavi B. Clinical effect of autologous platelet-rich fibrin in the treatment of intra-bony defects: A controlled clinical trial. J Clin Periodontol 2011;38:925-32.
5Gamal AY, Mailhot JM. A novel marginal periosteal pedicle graft as an autogenous guided tissue membrane for the treatment of intrabony periodontal defects. J Int Acad Periodontol 2008;10:106-17.
6Gamal AY, Mohamed G, Osama SE, Mohamed MK, Mahmoud AE, Mailhot J. Clinical re-entry and histologic evaluation of periodontal intrabony defects following the use of marginal periosteal pedicle graft as an autogenous guided tissue membrane. J Int Acad Periodontol 2010;12:76-89.
7Singhal R, Nandlal, Kumar A, Rastogi P. Role of space provision in regeneration of localized two-wall intrabony defects using periosteal pedicle graft as an autogenous guided tissue membrane. J Periodontol 2013;84:316-24.
8Steiner GG, Kallet MP, Steiner DM, Roulet DN. The inverted periosteal pedicle graft. Compendium 2007;28;154-61.
9Zumstein MA, Berger S, Schober M, Boileau P, Nyffeler RW, Horn M, et al. Leukocyte- and platelet-rich fibrin (L-PRF) for long-term delivery of growth factor in rotator cuff repair: Review, preliminary results and future directions. Curr Pharm Biotechnol 2012;13:1196-206.
10Aukhil I, Pettersson E, Suggs C. Guided tissue regeneration. An experimental procedure in beagle dogs. J Periodontol 1986;57:727-34.