RESEARCH ARTICLE


https://doi.org/10.5005/jp-journals-10042-1095
Journal of Health Sciences & Research
Volume 11 | Issue 2 | Year 2020

Comparison of Bioactive Glass Bone Graft (Putty) with Autologous Platelet-rich Fibrin in the Treatment of Intrabony Defects

Ashwini A Apine1, Shivaprasad Bilichodmath2, Nimmi Janardhanan3

1–3Department of Periodontics, RajaRajeswari Dental College and Hospital, Bengaluru, Karnataka, India

Corresponding Author: Shivaprasad Bilichodmath, Department of Periodontics, RajaRajeswari Dental College and Hospital, Bengaluru, Karnataka, India, Phone: +91 9901759011, e-mail: drspbmath@gmail.com

How to cite this article: Apine AA, Bilichodmath S, Janardhanan N. Comparison of Bioactive Glass Bone Graft (Putty) with Autologous Platelet-rich Fibrin in the Treatment of Intrabony Defects. J Health Sci Res 2020;11(2):42–52.

Source of support: Nil

Conflict of interest: None

Abstract

Aim and objective: This study was aimed to clinically and radiographically evaluate and compare the efficacy of bioactive glass bone graft (NovaBone® putty) and autologous platelet-rich fibrin (PRF) in the treatment of periodontal intrabony defects.

Materials and methods: A total of 30 intrabony defects were treated in 11 patients. Defects were randomly divided into group I (n = 15; NovaBone® putty) and group II (n = 15; PRF). Clinical parameters evaluated were plaque index, gingival index, probing depth (PD), clinical attachment level (CAL), gingival recession (GR), and cementoenamel junction from a fixed reference point (acrylic stent). Radiographic parameters such as radiographic defect depth, radiographic defect fill, percentage defect fill, and radiographic bone density analysis were recorded and analyzed using radiovisiography (RVG) and film grid. All the parameters were recorded at baseline, 3-, 6-, and 9-month visits.

Results: The mean PD reduction, gain in CAL, and mean GR were 4.067, 4.06, and 0.2 mm, respectively, for group I, whereas that of group II, they were 3.467, 3.00, and 0.14 mm, respectively. The mean radiographic defect depth and mean percentage defect fill were, 1.867 mm and 30.7%, respectively, in group I at 9 months. And that of group II, they were 1.466 mm and 27.5%, respectively, at 9 months. The improvement of clinical and radiographic parameters at sites treated with NovaBone® putty was better compared to that of sites treated with PRF, but the differences were statistically not significant.

Conclusion: The results of the present study emphasize that the regenerative potential of NovaBone® putty was predictable and equivalent to autologous platelet-rich fibrin. Autologous platelet-rich fibrin can be considered as a reliable periodontal regenerative material, which is inexpensive and readily available.

Key message: Autologous PRF can be considered as an inexpensive alternative to the NovaBone® putty bone graft material.

Keywords: Density analysis, Film grid, Intrabony defects, NovaBone® putty, Platelet-rich fibrin.

INTRODUCTION

Periodontitis is an infectious disease, sharing a number of similarities with other infections of the body. At the same time, it presents certain unique features, such as the spread of microorganisms from the tooth to the soft tissues and vice versa. Disease occurs at individual periodontal sites and damages the periodontium in the form of periodontal attachment and bone loss.1

Traditional surgical or nonsurgical approaches to periodontitis do not generally lead to regeneration.2 According to Melcher's hypothesis,3 the selected cell population in the periodontium can regenerate periodontal tissues, provided that cells are given opportunity to occupy the periodontal wound.

Bone graft materials can be autografts, allografts, xenografts, or alloplasts. Autogenous bone graft, which is harvested from the patient's own body, is considered ideal because of its osteoconductive and osteoinductive properties and because it contains a source of osteoprogenitor cells, while autogenous bone is still the gold standard, because of the second wound created at the donor site and the relatively limited amount of conveniently available autogenous bone and the harvest time involved in obtaining these grafts have led clinicians to utilize other bone replacement grafts. The demand for alloplastic material is generally justified by the disadvantages of autologous bone material.4

Bioactive glasses are one of the widely used alloplastic bone graft materials. Bioactive glasses are composed of calcium oxide, sodium oxide, silicon dioxide, and phosphorous pentoxide and bind to bone through the development of a surface layer of carbonated hydroxyapatite.5 When exposed to tissue fluids, bioactive glasses are covered by a double layer composed of silica gel and a calcium phosphorus-rich (apatite) layer. The calcium phosphate-rich layer promotes adsorption and concentration of proteins utilized by osteoblasts to form a mineralized extracellular matrix.6 It has been theorized that these bioactive properties guide and promote osteogenesis,7 allowing the rapid formation of bone.

Till date, bioactive glass has been used in the treatment of extraction socket, sinus elevation, craniofacial procedures, and different periodontal procedures.8 NovaBone® putty is a newly introduced bioactive glass graft material. Unlike other bone graft materials, characteristic putty form of NovaBone® putty eliminates the need for a membrane to stabilize the graft material. Putty form also provides ease of handling the material.

Autologous platelet-rich fibrin (PRF) is a second-generation platelet concentrate widely used to accelerate soft and hard tissue healing.9 Studies have been conducted to evaluate the efficacy of using autologous PRF in the treatment of periodontal intraosseous,10,11 furcation defects,9 and other defects.12

PRF besides its periodontal and dental uses has been successfully used in various other treatments, including extraction socket preservation,13 facial plastic surgeries,14 tympanoplasty,15 wound healing,16 tendon surgeries,17 and as a scaffold for delivering stem cells.18 NovaBone® putty is expensive when compared to autologous PRF.

Therefore, the purpose of the present study is clinical and radiographical evaluation and comparison of the efficacy of bioactive glass bone graft (NovaBone® putty) and autologous PRF in the treatment of periodontal intrabony defects.

MATERIALS AND METHODS

Study Population

The study was approved by the institutional review board of RajaRajeswari Dental College and Hospital, Bengaluru, and the ethical clearance was issued. A total of 30 randomly selected intrabony periodontal defects in chronic periodontitis patients with age-group of 20–50 years and probing depth >6 mm were selected from the patients visiting the Department of Periodontology. Systemically healthy patients who had not taken any medication within the last 6 months, which may alter the periodontal status and with no history of allergy to materials and drugs used or prescribed, were recruited in the study. Smokers, pregnant and lactating mothers, patients who have undergone periodontal treatment within a period of 1 year, patients with plaque index >1 who did not follow oral hygiene instructions after phase I therapy, and patients who did not accept terms and conditions of the study were excluded from the study. The defect sites were randomly divided into two groups:

  • Group I: 15 intrabony defects treated using NovaBone® putty.
  • Group II: 15 intrabony defects treated using autologous platelet-rich fibrin.

A written informed consent was obtained from each subject recruited for the study. Ethical clearance for surgical periodontal intervention, blood sample collection, and evaluation of periodontal parameters was obtained from the institutional ethics committee.

Presurgical Therapy

Each patient underwent scaling and root planing, oral hygiene instructions, and occlusal adjustment where indicated. An informed consent was obtained from the patient regarding the flap surgery and use of NovaBone® putty and PRF. Prior to surgery, a customized acrylic stent was fabricated. The stent was grooved in an occlusal apical direction with a tapered bur to make a fixed reference point (FRP). Clinical examination was performed at baseline and 3, 6, and 9 months after the surgery. Measurements for clinical parameters were recorded from the fixed reference point (stent) (Fig. 1). All measurements were recorded by a single investigator. The following measurements were recorded for test and control teeth using UNC-15 probe.

Fig. 1: Acrylic stent

  • Stent to cementoenamel junction (CEJ).
  • Stent to gingival margin (GM).
  • Stent to base of the pocket (BOP).

Standardized radiographs of the defect sites were taken using radiovisiography (RVG) and film grid.

To evaluate oral hygiene, plaque index was recorded based on the criteria for plaque index by Silness and Loe19, and recordings for gingival status were based on the criteria for gingival index by Loe and Silness.20

Clinical Parameters

  • Probing depth (PD) was measured from fixed reference point to base of the pocket.
  • Clinical attachment level (CAL) was measured from CEJ to the base of the pocket (Fig. 2).
  • Gingival recession (GR) was measured from fixed reference point to gingival margin.

Figs 2A to C: Clinical measurements made using acrylic stent: (A) Stent to cementoenamel junction; (B) Stent to gingival margin; (C) Stent to base of the pocket

The following calculations were made from the radiographs:

  • Amount of defect fill = Initial defect depth − defect depth at recalled time interval.
  • Percentage (%) of defect fill = Amount of defect fill/baseline defect depth × 100.
  • Radiographic density changes in the defects were assessed using Kodak Densitometric Software.

Procurement of Platelet-rich Fibrin (PRF)

The PRF was prepared in accordance with the protocol developed by Choukroun et al.21 Just prior to surgery, intravenous blood (by venipuncturing of the cubital vein) was collected using syringe. Blood was then transferred in two 5-mL sterile tubes without anticoagulant and immediately centrifuged in centrifugation machine at 3,000 rotations 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) at the top. PRF was easily separated from red corpuscles base (preserving a small red blood cell (RBC) layer) using a sterile tweezers/curette and scissors (Fig. 3).

Figs 3A and B: (A) Platelet-rich fibrin formed; (B) Platelet-rich fibrin

Surgical Procedure

The surgical procedure was performed under local anesthesia of 2% lignocaine containing adrenaline at a concentration of 1:80,000. Buccal and lingual/palatal sulcular incisions were placed using Bard Parker handle with no. 12 surgical blade and interdental incisions were placed using no. 15 surgical blade, and the mucoperiosteal flap was reflected. Care was exercised to preserve as much interproximal soft tissue as possible. After reflection of flap and exposure of osseous defect, a thorough surgical degranulation of the infected tissue from the osseous defect and thorough root planing were done with curettes. The defects were randomly assigned to group I or group II and treated with NovaBone® putty (Figs 4 and 5) or PRF, respectively (Fig. 6).

Fig. 4: NovaBone® putty bone graft material

Figs 5A to F: Intrabony defect treated using platelet-rich fibrin: (A) Clinical parameters recorded using acrylic stent; (B) Incision placed; (C) Flap reflected; (D) PRF placed in the intrabony defect after debridement; (E) Sutures placed, (F) Coe pack placed

Figs 6A to F: Intrabony defect treated using NovaBone® putty graft material: (A) Incision placed; (B) Flap reflected; (C) NovaBone® putty bone graft material; (D) NovaBone® putty placed in the defect after debridement; (E) Sutures placed; (F) Coe pack placed

Antibiotics (Amoxicillin 500 mg, every 8 hours for 5 days), analgesics (Imol/Diclomol every 8 hours for 3 days), and 0.2% chlorhexidine gluconate rinses (every 12 hours for 2 weeks) were prescribed. Postsurgical instructions were given to the patients.

Postsurgical Procedures

One week following surgery, the periodontal dressing and sutures were removed and the area was irrigated thoroughly with normal saline. Any signs of swelling, infection, flap displacement, hematoma, and necrosis were noted, and if needed, periodontal dressing was re-applied for another week. Symptoms regarding discomfort, pain, and sensitivity were asked to the patient. Patients were recalled 3, 6, and 9 months postsurgery, and at each visit, oral hygiene instructions were re-enforced and scaling was done if necessary. Postoperative patient's evaluation was done clinically and radiographically at 3, 6, and 9 months (Fig. 7).

Figs 7A to C: (A) 3-month postoperative probing; (B) 6-month postoperative probing; (C) 9-month postoperative probing

STATISTICAL ANALYSIS

Clinical parameters were recorded at baseline, 3, 6, and 9 months postsurgically, and suitable statistical analysis was performed to compare parameters. Data were entered in Microsoft Excel and analyzed using SPSS (Statistical Package for Social Science, Ver.10.0.5) package.

The results were averaged (mean + standard deviation) for continuous data, and the number and percentage for dichotomous data are presented in table and figure. Normality of data was tested using Shapiro–Wilk test. If data are normal, then the parametric test was carried out; otherwise, nonparametric test was carried out.

Proportions were compared using chi-square (χ2) test of significance. The Student's “t”-test was used for intergroup comparison of clinical parameters, if the data are normal. Mann–Whitney U test is used as a nonparametric test for intergroup comparison of clinical parameters.

RESULTS

In the present study, the mean age of subjects in group I and group II was 34.00 + 7.081 and 36.33 + 5.589 years, respectively (Table 1, Fig. 8). Eleven defects were treated in males and 4 defects were treated in females in group I, whereas 4 defects were treated in males and 11 defects were treated in females in group II.

Fig. 8: Age distribution of the study groups

Table 1: Mean and standard deviation of age of subjects in different groups
N Mean age SD Min. Max. “t” value “p” value
Group I 15 34.00 7.081 20 48 1.004 0.325
Group II 15 36.33 5.589 20 40

The difference in mean gingival index at different time intervals was not statistically significant between group I and group II except at 6-month interval (p = 0.001) (Table 2, Fig. 9). Both the groups showed reduction in probing depth at 3, 6, and 9 months.

Fig. 9: Comparison of mean gingival index between study groups at different time intervals

Table 2: Comparison of gingival index between two groups from baseline to 3, 6, and 9 months
N Mean SD Median Min. Max Mann–Whitney U “p” value
Baseline Group I 15 0.443 0.157 0.500 0.25 0.70 112.500 1.000
Group II 15 0.443 0.157 0.500 0.25 0.70
3 months Group I 15 0–5433 0.1613 0.5000 0.25 1.00 80.500 0.122
Group II 15 0.4433 0.1568 0.5000 0.25 0.70
6 months Group I 15 0.613 0.146 0.500 0.50 1.00 35.000 0.001
Group II 15 0.380 0.152 0.250 0.25 0.70
9 months Group I 15 0.490 0.148 0.500 0.25 0.70 72.000 0.069
Group II 15 0.397 0.222 0.250 0.25 1.00
*, Kruskal–Wallis test

Within group I, the difference in probing depth reduction at various time intervals was statistically significant (p < 0.001) and the same results were observed in group II (Table 3, Fig. 10). Difference in probing depth reduction between group I and group II was statistically not significant. However, within group I, the difference in clinical attachment level gain at various time intervals was statistically significant (p < 0.001) and the same results were observed in group II (Table 4, Fig. 11). The difference in gingival recession was not statistically significant in intergroup and intragroup comparison. The comparison of the radiographic defect fill between the two groups at various time intervals was statistically insignificant. Within group I and group II, the difference in radiographic bone fill was statistically significant for various time intervals (Table 5, Fig. 12). The difference in radiographic bone density was statistically significant between group I and group II at various time intervals except at 3 months (Table 6, Fig. 13). Intragroup bone density changes at different time intervals were statistically not significant.

Fig. 10: Comparison of mean probing depth between time intervals in study groups

Fig. 11: Comparison of mean clinical attachment level between time intervals in study groups

Fig. 12: Comparison of mean radiographic defect fill between time intervals in study groups

Fig. 13: Comparison of mean radiographic bone density between study groups at different time intervals

Table 3: Comparison of probing depth within each group from baseline to 3, 6, and 9 months
N Mean SD Min. Max “t” value “p” value
Group I Baseline 15 11.00 1–927 9 15 16.761 <0.001
3 months 15 8.53 1.807 6 13
6 months 15 7.33 1.799 5 11
9 Months 15 6.93 1.335 5 10
Group II Baseline 15 10.13 1.457 8 13 19.123 <0.001
3 months 15 8.07 1.486 6 11
6 months 15 7.13 1.302 5 10
9 months 15 6.67 1.175 5 9
Table 4: Comparison of clinical attachment level within each group from baseline to 3, 6, and 9 months
N Mean SD Median Min. Max. Chi-square* “p” value
Group I Baseline 15 5.53 2.066 5.00 2 10 26.162 <0.00l
3 months 15 3.20 1.821 2.00 1 7
5 months 15 2.07 1.668 2.00 0 6
9 months 15 1.47 1.506 1.00 0 5
Group II Baseline 15 4.93 1.831 5.00 3 10 27.612 <0.00l
3 months 15 3.00 1.648 2.00 1 7
6 months 15 1.93 1.534 1.00 0 6
9 months 15 1.47 1.598 1.00 0 6
*, Kruskal–Wallis test
Table 5: Comparison of radiographic defect fill within each group from baseline to 3, 6, and 9 months
N SD Median Min. Max. Chi-square* “p” value
Group I Baseline 15 0.000 0 000 0.000 0.0 0.0 30.722 <0.001
3 months 15 1.000 0.756 1.000 0.0 2.0
6 months 15 1.333 0.976 1.000 0.0 3.0
9 months 15 1.867 0 896 2.000 1.0 4.0
Group II Baseline 15 0.000 0 000 0.000 0.0 0.0 29.915 <0.001
3 months 15 1.000 0.655 1.000 0.0 2.0
6 months 15 1.467 1.407 1.000 0.0 6.0
9 months 15 1.467 0.915 1.000 0.0 4.0
*, Kruskal–Wallis test
Table 6: Comparison of radiographic bone density between two groups from baseline to 3, 6, and 9 months
N Mean SD Min Max. “t” value “p” value
Baseline Group I 15 63 49 14.144 30.2 86.4 1.962 0.172
Group II 15 56.21 14.319 37.8 82 6
3 months Group I 15 71.68 13.272 430 95.0 6.334 0.014
Group II 15 59 96 11.194 43.0 772
6 months Group I 15 71.49 15.312 45.0 95.8 3.105 0.089
Group II 15 62.39 12.891 40.6 81.0
9 months Group I 15 74.08 15.741 43.6 99.4 0.873 0.358
Group II 15 69.08 13.474 45.0 89.6

DISCUSSION

In the present study, the efficacy of bioactive glass bone graft (NovaBone® putty) and autologous PRF in the treatment of periodontal intrabony defects was evaluated and compared clinically and radiographically.

Bioactive glasses are one of the widely used alloplastic bone graft materials. When exposed to tissue fluids, bioactive glasses are covered by a double layer composed of silica gel and a calcium phosphorus-rich (apatite) layer. The calcium phosphate-rich layer promotes adsorption and concentration of proteins utilized by osteoblasts to form a mineralized extracellular matrix.6 It has been theorized that these bioactive properties guide and promote osteogenesis, allowing the rapid formation of bone.

The difference in the mean plaque index in group I and group II at various time intervals was not statistically significant. This variable is totally dependent on the patient's compliance and efficacy to maintain oral hygiene. As the subjects were on periodic recall, constant motivation, education, and oral hygiene instructions’ revision have led to almost similar plaque scores at all the periods of observation, which have reduced the possibility of effect of this variable on regeneration. Similarly, nonsignificant changes in plaque index scores have also been reported by Mengel et al.,22 Sculean et al.,23 Grover et al.,24 and Ong et al.,25 in relation to the use of bioactive glass. These results are also in accordance with the study conducted by Thorat et al.,10 at 9-month postsurgical follow-up in relation to platelet-rich fibrin.

In group I, the difference in the mean gingival index at baseline to 6-month interval and 6- to 9-month interval was statistically significant. These changes could be attributed to the unresolved inflammatory process because of innate healing response to the regenerative material26 in spite of good oral hygiene maintenance by the patient as shown by decrease in the plaque index. These findings are in contrast to the observations by Park et al.,27 Sculean et al.,23 and Grover et al.,24 who reported statistically insignificant changes in gingival index scores at the sites, treated using bioactive glass.

Mean clinical attachment level gain of 3.46 and 4.06 mm was statistically significant from baseline to 6 months and baseline to 9 months, respectively in group I. This gain in clinical attachment level can be attributed to long junctional epithelium formation,28 periodontal regeneration, and/or soft tissue healing at the base of the pocket.29 These findings are in accordance with the study conducted by Grover et al.,24 who had reported 2.71 + 1.139 mm attachment level gain in the sites treated using NovaBone® putty. Froum et al.,8 Sculean et al.,23 and Mengel et al.22 also reported a mean attachment level gain of 2.96, 6.71 + 1.89, and 2.8 + 1.9 mm, respectively, at 12 months in the sites treated with bioactive glass. Park et al.27 and Kaur et al.11 also reported that the sites treated with bioactive glass have shown statistically significant gain of attachment levels 6 months postsurgery.

A statistically significant mean probing depth reduction of 4.07 mm was observed from baseline to 9 months in group I. This reduction in probing depth can be accredited to soft and hard tissue improvements following the resolution of inflammation and to the osteogenic potential of the bone graft material used in the study.24These findings are in accordance with the study conducted by Grover et al.,24 who had reported 4.21 + 1.8 mm mean probing depth reduction in the sites treated using NovaBone® putty. These results are also in agreement with the previous studies of Froum et al.8 and Mengel et al.,22who had reported 4.26, 3.8 reduction in probing pocket depth, respectively, over a period of 12 months in sites treated with bioactive glass. Other studies by Ong et al.25 and Park et al.27 have also demonstrated statistically significant reductions in probing pocket depth over a period of 6 months in bioactive glass-treated sites.

A statistically significant mean probing depth reduction of 3.467 mm at 9 months was observed in group II. This reduction in probing depth can be accredited to the healing potential of the PRF, which accelerates soft and hard tissue healing by the release of many growth factors.21 These findings are in agreement with the study conducted by Thorat et al.,10 who had reported 4.69 + 1.45 mm mean probing depth reduction in the sites treated using PRF.

An increase in mean gingival recession of 0.2 mm was observed at 9 months in group I. This finding may be attributed to the shrinkage of gingival tissues with the resolution of inflammation.26 These findings are in consistency with Froum et al.,8 Mengel et al.,22 Sculean et al.,23 and Ong et al.,25 who reported an increase of 1.29, 1.20, 1.28, and 0.7 mm in gingival recession, respectively, after 12 months of the implantation of graft material. Park et al.27 and Grover et al.24 also reported the similar results.

Although the increase in mean gingival recession was statistically not significant, an increase of 0.14 mm in mean gingival recession was observed from baseline to 9 months in group II. These results are in accordance with the study conducted by Thorat et al.,10 where an increase of 0.81 + 0.75 mm in gingival recession was observed at 9 months.

The improved clinical and radiographic outcomes at the grafted sites may be a function of the healing potential of the materials. These results signify that both the materials, NovaBone® putty and PRF, have comparable regenerative potential when used in the treatment of periodontal intrabony defect.

In the present study, it was observed that the distance between acrylic stent and cementoenamel junction remained constant throughout the study. The difference in the measurements at different time intervals was not statistically significant. The results of this study demonstrate that treatment of intrabony periodontal osseous defects with NovaBone® dental putty (a bioactive glass synthetic graft) and PRF has led to statistically significant probing depth reduction, relative attachment level gain, and radiographic osseous defect fill.

Bioactive glass bone graft materials are one of the widely used alloplastic bone graft materials. NovaBone® putty is a recently introduced bioactive glass graft material. When the bioactive glass material comes in contact with body fluids, a unique surface reaction occurs within minutes of implantation. Initially, there is an ionic exchange whereby the cations are leached from the surface of the material in exchange for hydronium or hydrogen ions forming silanol groups (SiOH).30 Silanol groups bond to adjacent silanol group through a polycondensation reaction forming a silica-rich gel layer on the particular surface. Silica plays a key role in developing the bone bonding of bioactive glass. The silica-rich gel creates a site for the redeposition of calcium and phosphorus from the graft material and the blood.31 Within hours, a calcium phosphorus layer forms on the top of the silica gel layer. With time as the layer builds up in thickness and size, it becomes a crystalline hydroxycarbonate apatite (HCA) layer, which is identical to bone material. This apatite layer provides the basis for the bonding of bone and this material.32 The primary advantage of bioactive glasses is their rapid rate of surface reaction, which leads to the fast tissue bonding. The silica rich layer has a negatively charged surface. This increases the electrostatic charges enough so that water is absorbed quickly. Hydrogen bonding occurs between water molecules and the hydroxyl groups of the silanol, which gives bioactive glass cohesiveness. The negatively charged surface of the HCA layer attracts proteins, such as growth factors and fibrin, which act like an organic glue attracting osteoblastic stem cells to the layer, which differentiate into osteoblasts and produce bone.33 Collagen attaches to the surface and embeds into HCA layer. Apical migration of the junctional epithelium is indirectly inhibited by the extension of the collagen up to the junctional epithelium. Bioactive glass can promote cementum repair.34

Platelet-rich fibrin (PRF) is an inexpensive, autologous biomaterial with significant slow release of growth factors.21 Because of the absence of an anticoagulant, blood begins to coagulate as soon as it comes in contact with glass surface. Therefore, for successful preparation of PRF, speedy blood collection and immediate centrifugation, before the clotting cascade is initiated, are absolutely essential.21 All of the known clinical applications of PRF highlight an accelerated tissue cicatrization due to the development of effective neovascularization, accelerated wound closing with fast cicatricial tissue remodeling, and nearly total absence of infectious events. It features all the necessary parameters permitting optimal healing.35

CONCLUSION

Within the limitations of the study, it can be concluded that both groups showed improvement in all the clinical parameters by the end of the study. The improvement of clinical and radiographic parameters at sites treated with NovaBone® putty was better compared to that of sites treated with PRF, but the differences were statistically not significant. The results of the present study emphasize that the regenerative potential of NovaBone® putty is predictable and equivalent to autologous platelet-rich fibrin. Autologous PRF can be considered as an inexpensive alternative to the NovaBone® putty bone graft material.

REFERENCES

1. Socransky SS, Haffajee AD. The nature of periodontal diseases. Ann Periodontol 1997;2(1):3–10. DOI: 10.1902/annals.1997.2.1.3.

2. Caton J, Nyman S, Zander H. Histometric evaluation of periodontal surgery. II. Connective tissue attachment levels after four regenerative procedures. J Clin Periodontol 1980;7(3):224–231. DOI: 10.1111/j.1600-051x.1980.tb01965.x.

3. Melcher AH. On the repair potential of periodontal tissues. J Periodontol 1976;47(5):256–260. DOI: 10.1902/jop.1976.47.5.256.

4. Newmann MG, Takei HH, Klokkevold PR, et al. Clinical Periodontology, 10th ed. Noida: Elsevier; 2006. pp. 968–985.

5. Hench LL, Paschal1 HA. Direct chemical bond of bioactive glass-ceramic materials to bone and muscle. J Biomed Mater Res 1973;7(3):25–42. DOI: 10.1002/jbm.820070304.

6. El-Ghannam A, Ducheyne D, Shapiro IM. Formation of surface reaction products on bioactive glass and their effects on the expression of the osteoblastic phenotype and the deposition of mineralized extracellular matrix. Biomaterials 1997;18(4):295–303. DOI: 10.1016/s0142-9612(96)00059-2.

7. Kenney EB, Lekovic V, SaFerreira JC, et al. Bone formation within porous hydroxylapatite implants in human periodontal defects. J Periodontol 1986:57(2):76–83. DOI: 10.1902/jop.1986.57.2.76.

8. Froum SJ, Mea AW, Dennis T. Comparison of bioactive glass synthetic bone graft particles and open debridement in the treatment of human periodontal defects. A clinical study. J Periodontol 1998;69(6):698–709. DOI: 10.1902/jop.1998.69.6.698.

9. 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(10):1396–1403. DOI: 10.1902/jop.2011.100731.

10. Thorat MK, Pradeep AR, Pallavi B. Clinical effects of autologous platelet-rich fibrin in the treatment of intra-bony defects: a controlled clinical trial. J Clin Periodontol 2011;38(10):925–932. DOI: 10.1111/j.1600-051X.2011.01760.x.

11. Kaur M, Ramakrishnan T, Amblavanan N, et al. Effect of platelet-rich plasma and bioactive glass in the treatment of intrabony defects—a split-mouth study in humans. Braz J Oral Sci 2010;9(2):108–114.

12. Mazor Z, Horowitz RA, Del Corso M, et al. Sinus floor augmentation with simultaneous implant placement using Choukroun's platelet rich fibrin as the sole grafting material: a radiologic and histologic study at 6 months. J Periodontol 2009;80(12):2056–2064. DOI: 10.1902/jop.2009.090252.

13. Simon BI, Zatcoff AL, Kong JJ, et al. Clinical and histological comparison of extraction socket healing following the use of autologous platelet-rich fibrin matrix (PRFM) to ridge preservation procedures employing demineralized freeze dried bone allograft material and membrane. Open Dent J 2009;3:92–99. DOI: 10.2174/1874210600903010092.

14. Sclafani AP, Saman M. Platelet-rich fibrin matrix for facial plastic surgery. Facial Plast Surg Clin North Am 2012;20(2):177–186. DOI: 10.1016/j.fsc.2012.02.004.

15. Choukroun JI, Braccini F, Diss A, et al. Influence of platelet rich fibrin (PRF) on proliferation of human preadipocytes and tympanic keratinocytes: a new opportunity in facial lipostructure (Coleman's technique) and tympanoplasty? Rev Laryngol Otol Rhinol (Bord) 2007;128(1–2):27–32.

16. Khiste SV, Tari RN. Platelet-rich fibrin as a biofuel for tissue regeneration. ISRN Biomater 2013;Article ID 627367:1–6. DOI: 10.5402/2013/627367.

17. Sanchez M, Anitua E, Azofra J, et al. Comparison of surgically repaired achilles tendon tears using platelet-rich fibrin matrices. Am J Sports Med 2007;35(2):245–251. DOI: 10.1177/0363546506294078.

18. Haleem AM, Singergy AA, Sabry D, et al. The clinical use of human culture–expanded autologous bone marrow mesenchymal stem cells transplanted on platelet-rich fibrin glue in the treatment of articular cartilage defects: a pilot study and preliminary results. Cartilage 2010;1(4):253–261. DOI: 10.1177/1947603510366027.

19. Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964;22:121–135. DOI: 10.3109/00016356408993968.

20. Loe H, Silness J. Periodontal disease in pregnancy. I. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964;22:533–521.

21. Choukroun J, Adda F, Schoeffler C, et al. Une opportunite' en paro-implantologie: Le PRF. Implantodontie 2000;42:55–62. French.

22. Mengel R, Soffner M, Jacoby LF. Bioabsorbable membrane and bioactive glass in the treatment of intrabony defects in patients with generalized aggressive periodontitis: results of a 12-month clinical and radiological study. J Periodontol 2003;74(6):899–908. DOI: 10.1902/jop.2003.74.6.899.

23. Sculean A, Giovanni B, Giovanni C, et al. Clinical evaluation of an enamel matrix protein derivative combined with a bioactive glass for the treatment of intrabony periodontal defects in humans. J Periodontol 2002;73(4):401–408. DOI: 10.1902/jop.2002.73.4.401.

24. Grover V, Kapoor A, Malhotra R, et al. Evaluation of the efficacy of a bioactive synthetic graft material in the treatment of intrabony periodontal defects. J Indian Soc Periodontol 2013;17(1):104–110. DOI: 10.4103/0972-124X.107484.

25. Ong MM, Eber RM, Korsnes MI. Evaluation of a bioactive glass alloplast in treating periodontal intrabony defects. J Periodontol 1998;69(12):1346–1354. DOI: 10.1902/jop.1998.69.12.1346.

26. Polimeni G, Xiropaidis AV, Wikesjo UM. Biology and principles of periodontal wound healing/regeneration. Periodontol 2000 2006;41:30–47. DOI: 10.1111/j.1600-0757.2006.00157.x.

27. Park JS, Suh JJ, Choi SH, et al. Effects of pretreatment clinical parameters on bioactive glass implantation in intrabony periodontal defects. J Periodontol 2001;72(6):730–740. DOI: 10.1902/jop.2001.72.6.730.

28. Garret S, Gary B. Periodontal regeneration: a review of flap management. Periodontol 2000 1993;1(1):100–108.

29. Bowers GM, Chadroff B, Carnevale R, et al. Histologic evaluation of new attachment apparatus formation in humans. Part I. J Periodontol 1989;60(12):664–674. DOI: 10.1902/jop.1989.60.12.664.

30. Ducheyne P, Brown S, Blumenthal N, et al. Bioactive glasses, aluminum oxide and titanium. Ion transport phenomenon and surface analysis. Ann N Y Acad Sci 1988;523:257–261. DOI: 10.1111/j.1749-6632.1988.tb38517.x.

31. Kitsugi T, Nakamara T, Oka M, et al. Bone-bonding behavior of three heat-treated silica gels implanted in mature rabbit bone. Calcif Tissue Int 1995;57(2):155–160. DOI: 10.1007/BF00298437.

32. Greenspan DC, Zhong JP, La Torre GP. The evaluation of surface structure of bioactive glasses in-vitro. In: Wilson J, Hench LL, Greenspan D, editors. Proceedings of the eight international symposium on ceramics in medicine. Bioceramics, vol. 8. London: Pergamon Press; 1995. pp. 477–482.

33. Hench LL. Bioactive ceramics. Ann N Y Acad Sci 1988;523:54–71. DOI: 10.1111/j.1749-6632.1988.tb38500.x.

34. Wilson J, Low SB. Bioactive ceramics for periodontal treatment: comparative studies in the Patus monkey. J Appl Biomater 1992;3(2):123–129. DOI: 10.1002/jab.770030208.

35. Choukroun J, Diss A, Simonpieri A. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part IV: clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101(3):e56–60. DOI: 10.1016/j.tripleo.2005.07.011.

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