1. ijdrd - one year follow up of an …. ijdrd - one...one year follow up of an iatrogenic root...

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ONE YEAR FOLLOW UP OF AN IATROGENIC ROOT PERFORATION TREATED

WITH MINERAL TRIOXIDE AGGERGATE (MTA) AND VERTICAL BONE LOSS

GRAFTED WITH NOVABONE BONE GRAFT PLUS PLATELET RICH PLASMA

(PRP)

SAGRIKA SHUKLA1, VIDHI GUPTA

2 & ASHI CHUG

3

1Senior lecturer, Department of Periodontics, Seema Dental College and Hospital, Rishikesh, Uttarakhand , India

2Private practice, New Delhi, India

3Assistant professor, Department of Dentistry and Oral and Maxillofacial Surgery,

All India Institute of Medical Sciences, Rishikesh, Uttarakhan , India

ABSTRACT

Aim

To evaluate 12 months post treatment results of Novabone® plus PRP in a vertical defect along with MTA

placed in an iatrogenically perforated tooth.

Case Presentation

Periodontal flap procedure in relation to 21,22 and 23 was done along with placement of Novabone® bone

graft +PRP and closure of perforation with MTA in 22 was done. Post operative recordings of Plaque index

(PI),Gingival index (GI), Clinical attachment level (CAL) and pocket depth upto 12 months with the help of acrylic stent

were taken.

Results

Results showed uneventful healing and decrease in pocket depth in relation to 22 where the bone graft + PRP

was placed.

Conclusion

Pocket depth and CAL showed a significant reduction from baseline to 12 months in site treated with

Novabone® bone graft. This means that the graft material was well tolerated by the patients and is effective in

regenerating the lost periodontal tissues. Also, MTA placed in perforated teeth provides good sealing and aids in

periodontal health.

KEYWORDS: Novabone®, Bone Graft, Vertical Defect, Periapical Radiolucency, MTA

Received: Apr 04, 2016; Accepted: Apr 19, 2016; Published: Apr 25, 2016; Paper Id.: IJDRDJUN20161

INTRODUCTION

Periodontitis is one of the most common diseases resulting in the loss of connective tissue attachment and

alveolar bone1. The permanent altered morphological features of the bone, in addition to reduced bone height can be

of various shapes, such as horizontal pattern of bone loss, craters, furcation involvement, vertical/angular bone loss

and combination defects. The treatment of periodontal intrabony defects dates back to the work of Oschsenbein

Orig

inal A

rticle International Journal of Dental Research &

Development (IJDRD)

ISSN(P): 2250-2386; ISSN(E): 2321-0117

Vol. 6, Issue 3, Jun 2016, 1-12

© TJPRC Pvt. Ltd.

2 Sagrika Shukla,Vidhi Gupta & Ashi Chug

Impact Factor (JCC): 1.9876 Index Copernicus Value (ICV): 6.1

(1986) who recommended elimination of angular defects because if remaining, they promote deeper pocket formation that

can lead to disease progression2. Surgical treatment of these types of defects frequently involves either bone grafts, or

autogenous bone from the surgical site along with the use of barrier membranes or growth factors to increase the

probability of bone regeneration in the area3-5

.

Autogenous bone is considered as the gold standard for bone regeneration procedures, however, to overcome its

clinical limitations such as, early bone re sorption at the site of bone placement, additional surgical site and limited amount

that can be obtained intraorally6, all oplastic bonegraft materials have been proposed among others for use in the treatment

of intrabony defects. Alloplastic bone graft materials are synthetic bioactive bone substitutes which are mostly

osteoconductive and act as scaffolds for bone regeneration7. One such synthetic material is a third generation bioactive

glass, calcium phosphosilicate putty (CPS putty) (Nova Bone Dental Putty, Nova Bone Products, Alachua, FL), which is

osteostimulative in addition to being osteoconductive and has enhanced handling characteristics8,9

. CPS putty is composed

of Calcium Phosphosilicate glass particles and a synthetic absorbable binder that allows it to be premixed in a putty

consistency. Recent evidence on the use of this graft in ridge regeneration procedures has shown superior clinical and

histological results of bone regeneration in comparison to osteoconductive grafts that have been attributed to its

osteostimulative properties10,11

.

To enhance the results of graft placement many authors have also recommended the addition of either

recombinant or autologous growth factors in the surgical treatment of intrabony defects12,13

showing clinically comparable

results to those of guided tissue regeneration procedures with barrier membranes. Platelet rich plasma (PRP) is one such

autologous growth factor that is prepared from the centrifugation of autologous whole blood and results in concentration of

the platelet count in the PRP by 338% in comparison to the total platelet count6. Thus when PRP is used, it releases growth

factors, helps in hemostasis and contributes rapid healing of the surgical site14

. PRP contains proinflammatory cytokines

which play an important role in the early responses of bone repair, it contains growth factors, which help the regeneration

of tissues with low healing potential, potentially restoring biomechanical properties similar to normal bone15

. There are

angiogenesis factors, which promote angiogenesis rapidly in the bone graft in the early stage and other factors are also

found such as serotonin, histamine, dopamine, calcium, and adenosine which have fundamental effects on the biologic

aspects of wound healing15

. Mixing PRP with bone alloplastic bone substitutes has been shown to be a safe treatment

modality16

.

To the best of our knowledge, this is the first case study to have included both MTA as a sealing agent and

Novabone®

as a bone graft material in combination for treatment of a tooth with iatrogenic perforation and vertical bone

loss.

METHODS AND. MATERIALS

A male patient aged 47 years old reported to the dental office with pain in the upper front tooth region. Pain was

continuous, mild and non radiating. Upon taking the history the patient revealed that he had undergone root canal treatment

at a private clinic a month before, however even after multiple visits for root canal treatment he did not get relief from pain

and his treatment was not completed and consequently reported to our dental office for further treatment. Patient was

healthy and did not have any adverse habits such as smoking or tobacco chewing. Intraorally, patient had generalized

horizontal bone loss, generalized grade I mobility and missing 16,17,27,28,37,38,47. At baseline, in relation to (irt) 21 and

One Year Follow Up of an Iatrogenic Root Perforation Treated With Mineral Trioxide Aggergate 3

(MTA) and Vertical Bone Loss Grafted with Novabone Bone Graft Plus Platelet Rich Plasma (PRP)


22 pocket depth was 5 mm and clinical attachment level was 6 mm (figure 1.) with positive TOP and periapical

radiolucency irt 22. On radiographic evaluation with the help of files a perforation was noticed in middle one third irt 22,

which was further confirmed on a CBCT (figure 2).

Observing poor periodontal condition, full mouth periodontal flap surgery was planned along with placement of

bone graft +PRP irt 21 and 22 and closure of perforation with MTA in relation to 22. In between full mouth complete

scaling appointments, retreatment irt 22 was initiated. Study model was made for fabrication of customized acrylic occlusal

stent. The stent was made17

using self cured pink acrylic which covered the occlusal as well as the coronal 1/ 3rd of the

labial and lingual surfaces of the tooth involved and one tooth mesial and distal to the involved area. Vertical grooves were

made to guide the placement of the probe in the same plane and direction repeatedly during measurements to avoid any

variation (figure 1.).

At 4 weeks, before starting with the surgical procedure, PRP was prepared where 10 ml of blood was drawn from

the patient, mixed with anticoagulant EDTA and centrifuged for 15 minutes at 2000 rpm. The centrifugation consisted of

separation spin and concentration spin. After the first spin 3 distinct layers were obtained (figure 3.) out of which first two

layers were pipetted out and placed in another plastic vacutainer blood collection tube without the anticoagulant and was

centrifuged at 3,000 rpm for 15 minutes. After the second spin two distinct layers were obtained, from which the bottom

layer was pipetted out (figure 4.). The time taken for PRP preparation was in accordance to the machine used and was

calculated according to the following formula:

g = (1.118 × 10-5

) R S2

Where g is the relative centrifugal force, R is the radius of the rotor in centimeters, and S is the speed of the

centrifuge in revolutions per minute. This prepared PRP without activation with calcium chloride and thrombin can be

stored upto 8 hours.

Just prior to the commencement of the surgical procedure, the patient was asked to rinse the mouth with 10 ml of

0.2% chlorhexidine digluconate solution. Perioral surface of the patient was swabbed with 5% povidone iodine solution.

The operative site was anaesthetized with 2% Lignocaine HCI with adrenaline (1:80,000) using block and infiltration

techniques. The crevicular incision was given on the facial and lingual/palatal surfaces and interdental incision was given

using the Bard Parker handle No. 3 with blade No.12 and No.11 respectively. A full thickness mucoperiosteal flap was

reflected using the periosteal elevator taking care that the interdental papillary tissue was retained as far as possible. After

reflection of the flap, exposure of osseous defect, thorough surgical debridement of soft and hard tissue with area specific

Gracey curettes (company) and castroveijo scissors and irrigation with copious amount of normal saline the vertical defect

and the perforation could be seen irt 22 (figure 5&6.). Perforation was sealed with the help of MTA -sterile saline paste

(ProRoot MTA, Dental Tulsa; Dentsply, DeTrey Konstanz, Germany) mixed in a 3:1 proportion (figure 7.) after which

obturation with gutta percha points (Dentsply, DeTrey Konstanz, Germany) was completed and was coronally sealed with

Glass Ionomer Cement.

To fill the vertical defect, the PRP thus formed was activated by calcium chloride (figure 8) and patient’s own

blood instead of using bovine thrombin (figure 9). Within a few seconds, the PRP preparation assumed a sticky gel

consistency, which was mixed with calcium phosphosilicate putty (NovabonePutty, Novabone, Alachua, FL) to be put into

the bony defect (figure 10 & 11). Surgical flaps were repositioned to the pre-surgical level using 3-0 silk suture (figure 12).



Care was taken not to displace the graft + PRP during suturing, for the very same reason sutures were passed before

placement of the graft material and knot was tied after the graft + PRP placement. A periodontal dressing was placed on

the surgical site.

Routine post operative instructions were given to the patient. He was instructed to abstain from brushing and

flossing around the surgical area until suture removal and to consume only soft food during the first week. He was

prescribed one Cap. Amoxicillin 500 mg TDS (ter die sumendum or three times a day) in the morning, afternoon and at

night after meals for 5 days and was instructed to use Chlorhexidine rinse 0.12 % twice daily in the morning and at night

for a month. Tab. Ibuprofen 400 mg one tablet as per need was prescribed to control pain. Sutures and periodontal dressing

was removed 10 days post surgery. Post operative measurements were made at 1, 3, 6, 9 and 12 months, with the stent in

place to record probing pocket depth and CAL. GI and PI were also recorded.

RESULTS

The patient’s periodontal health was monitored over a period of 12 months, during which it was observed that the

patient was positively motivated and took good care in maintaining oral hygiene which was reflected by the plaque index

and gingival index scores. There was a reduction in pocket depth (5mm at baseline) to 2mm at the end of 12 months (figure

13 & 14). The CAL also showed a reduction (6mm at baseline) to 2mm at the end of 12 months. Table 1 shows month wise

measurements of CAL and probing pocket depth (PPD).

DISCUSSIONS

Periodontitis, resulting in bone loss forms different types of defects, out of which three walled defects have the

most predictable treatment outcome. Bone lost due to periodontal disease affects the overall health of the patient, thus for

functional and esthetic outcomes, patient’s health and long-term survival of teeth, a sufficient amount of healthy bone is

required. Autogenous bone is the ideal bone graft, however due to aforementioned clinical limitations other types of bone

grafts have been used widely, such as xenografts and allografts. However controversy exists with respect to the

osteoinductive potential of these materials6. It has been shown that inductive capacity varies from bone bank to bone bank

and also from different batches of the same bone bank. The bioactivity also depends upon the age of the donor, the younger

the donor, the more osteoinductive the graft material will be6,18

. Also there are chances of disease transmission19

. Due to

these limitations, the use of alloplastic materials has become popular.

The advantage of alloplastic bone substitute is that, because of their completely synthetic nature, they bear no risk

of disease transmission20

. The other main reason why alloplasts have gained increasing scientific and clinical attention over

the past several years is the theoretical possibility of designing every single material characteristic individually for a

specific clinical indication20

. Novabone® putty or 45S5, a third generation bioactive glass has been developed to show such

advantages. Novabone® is being designed to activate genes that stimulate regeneration of living tissues

21. Xynos et al

22,23

reported that the ionic products of the glass dissolution affect gene-expression profile and cause up-regulation of seven

families of genes including cell cycle regulators, growth related gene and apoptosis regulators. Beilby et al24,25

showed

similar bioactive induction of the transcription of extracellular matrix components and their secretion and self-organisation

into a mineralised matrix which may be responsible for the rapid formation and growth of bone nodules and differentiation

of the mature osteocyte phenotype in the presence of bioactive materials such as 45S5 Bioglass®. This also activates

several families of genes such as CD44, IGF2, MMP2, 60S ribosomal protein L626

and induces release of chemicals in the




form of ionic dissolution products, or growth factors such as bone morphogenetic protein (BMP), at controlled rates, by

diffusion or network breakdown that activates the cells in contact with the stimuli21

.

In literature, many authors have mixed PRP with bone graft materials and have shown that there was an increased

rate of osteogenesis and enhanced bone formation.27-29

. PRP releases significant quantities of growth factors, which

promote neovascularization and osseous regeneration27,30

, based on this concept Novabone and PRP were mixed. Lucarelli

et al31

investigated mesenchymal stem cell proliferation in culture media supplemented with PRP and verified that the use

of 10% PRP was sufficient to accelerate mineralization in vitro. Carlson and Roach32

showed that PRP and its growth

factors are promising for surgical wound healing. In vitro investigations have identified that the PDGF, a subcomponent of

the PRP, has a significant effect on cell proliferation33,34.

Thus when PRP is used, it releases growth factors, helps in

hemostasis and contributes rapid healing of the surgical site14

, improves esthetics, shortens duration of treatment and

reduces postoperative symptoms. Mixing PRP with bone graft material can be applied to any class of bone graft, material.

However the regeneration would not have been possible without sealing of the perforation.

There was primary endodontic component involved without the communication present between the periapical

abscess and the vertical defect, however during the previous root canal treatment there was a perforation which made the

communication possible, affecting the prognosis of tooth and resulting in loss of integrity of the root with further

destruction of the adjacent periodontal tissues35,36

. Thus it becomes important to close the artificial channel which was

created. The main goal of sealing a perforation is to re-establish periodontal health35

, with a suitable perforation repair

material, which is a key element in successful sealing and maintaining the seal. An ideal material should adhere to the root

canal wall, should be biocompatible or bioactive35

. In the past years, amalgam, composite resin, and glass ionomer cements

have been used for sealing furcal perforation36

. The advantage of GIC is that it facilitates fibroblast adhesion37,38

. However,

for cemental repair a material which enables regeneration of cementum should be used and studies have shown that MTA

enables cemental repair. studies have also shown that MTA is apparently superior to these materials with respect to

marginal adaptation39-41

, bacterial leakage39-42

and cytotoxicity39,43

. Main et al44

concluded that MTA provides an effective

seal of root perforations and can be considered a potential repair material enhancing the prognosis of perforated teeth that

would otherwise be compromised.

MTA enables cell adherence and growth, increased levels of alkaline phosphatase and osteocalcin, interleukin

production (IL-6, IL-8), periodontal ligament attachment, cementum growth, and dentinal bridge formation45-48

. It is non

irritating to the soft and hard tissues and has excellent biocompatibility.Of all ions released, Ca is the most dominant which

leads to the precipitation of Hydroxyapatite (HA). Presence of HA on its surface that is in proximity to calcified tissues

forms a chemical bond with the latter49-51.

And this is the basis for two of the most important properties of MTA that is

sealing ability and biocompatibility. Keeping these advantages of MTA, it was used for sealing of the root perforation.

Pocket depth was 5 mm which could have been maintained with the help of curettage and good oral maintance by

the patient, however, flap had to be raised for the correction of the perforation, which also made the clinicians to take

measures in treating the vertical defect. The defect was not very pronounced but it required intervention and since the flap

had to be raised, placement of bone graft + PRP was planned. Another reason for bonegraft + PRP placement was that

since perforation had taken place approximately 1 month back which would have seriously affected periodontal health and

prognosis of the treatment, clinicians decided to take extra measures in preventing any such possibility.



CONCLUSIONS

The improvement in the periodontal health of the patient over the period of 12 months indicated that the graft

material was well tolerated by the patient and was effective in regenerating the lost periodontal tissues, MTA placed in the

perforation provided for a good seal and aided in the periodontal healing. To the best of our knowledge, this is the first case

study to have included both MTA as a sealing agent and Novabone®

as a bone graft material in combination for treatment

of a tooth with iatrogenic perforation and vertical bone loss.

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One Year Follow Up of an Iatrogenic Root Perforation Treated With Mineral Trioxide Aggergate


www.tjprc.org

APPENDICES

Figure Legends

Figure 1: Pre-operative image showing pocket of 5 mm

Figure 2: CBCT showing root perforation

Figure 3: PRP obtained after first spin

Figure 4: PRP obtained after second spin

Figure 5: Vertical defect after complete debridement.

Figure 6: Root perforation shown with a plugger. To prevent dessication of tissues, wet cotton ball placed in

the interdental region of 22 and 23

Figure 7: Perforation sealed with MTA

Figure 8: Activation of PRP with calcium chloride.

Figure 9: Activation of PRP with patient’s own blood.

Figure 10: PRP + Novabone®

Figure 11: PRP + Novabone®

Figure 12: Suturing done.

Figure 13: 12 months post op showin

Figure 14: RVG post-op at 12 months.

Table 1: Month Wise Decrease in Clinical Attachment Levels and Probing Pocket Depth

Figures

Figure 1: Pre-Operative Image Showing Pocket of 5 Mm

Iatrogenic Root Perforation Treated With Mineral Trioxide Aggergate

Vertical Bone Loss Grafted with Novabone Bone Graft Plus Platelet Rich Plasma (PRP)

age showing pocket of 5 mm

CBCT showing root perforation

after first spin

PRP obtained after second spin

ter complete debridement.

Root perforation shown with a plugger. To prevent dessication of tissues, wet cotton ball placed in

Perforation sealed with MTA

Activation of PRP with calcium chloride.

Activation of PRP with patient’s own blood.

® bone graft

® bone graft placed in the vertical defect

12 months post op showing reduction in probing depth

op at 12 months.

Wise Decrease in Clinical Attachment Levels and Probing Pocket Depth

Operative Image Showing Pocket of 5 Mm Figure 2: CBCT Showing Root Perforation

Iatrogenic Root Perforation Treated With Mineral Trioxide Aggergate 9

[email protected]

Root perforation shown with a plugger. To prevent dessication of tissues, wet cotton ball placed in

Wise Decrease in Clinical Attachment Levels and Probing Pocket Depth

CBCT Showing Root Perforation

10

Impact Factor (JCC): 1.9876

Figure 3: PRP Obtained

Figure 5: Vertical Defect after Complete Debridement

Sagrika Shukla,Vidhi Gupta


PRP Obtained after First Spin Figure 4: PRP Obtained After Second Spin

Vertical Defect after Complete Debridement Figure 6: Root Perforation Shown With a Pl

Prevent Dessication of Tissues, Wet Cotton Ball

Placed in the Interdental Region of 22 and 23.

Figure 7: Perforation Sealed With MTA.

Sagrika Shukla,Vidhi Gupta & Ashi Chug

Index Copernicus Value (ICV): 6.1

Obtained After Second Spin

Perforation Shown With a Plugger. to

Prevent Dessication of Tissues, Wet Cotton Ball

Interdental Region of 22 and 23.

One Year Follow Up of an Iatrogenic Root Perforation Treated With Mineral Trioxide Aggergate


www.tjprc.org

Figure 8: Activation of PRP with Calcium Chloride

Figure 11: PRP + Novabone

Placed in the Vertical Defect

Iatrogenic Root Perforation Treated With Mineral Trioxide Aggergate

Vertical Bone Loss Grafted with Novabone Bone Graft Plus Platelet Rich Plasma (PRP)

Activation of PRP with Calcium Chloride Figure 9: Activation of PRP with Patient’s

Figure 10: PRP + Novabone® Bone Graft

PRP + Novabone® Bone Graft Figure 12: Suturing Done

in the Vertical Defect

Iatrogenic Root Perforation Treated With Mineral Trioxide Aggergate 11

[email protected]

with Patient’s Own Blood

Done

12

Impact Factor (JCC): 1.9876

Figure 13: 12 Months Post Op Showing

Reduction in Probing Depth

Sagrika Shukla,Vidhi Gupta


12 Months Post Op Showing Figure 14: RVG Post-Op at

Reduction in Probing Depth

Sagrika Shukla,Vidhi Gupta & Ashi Chug

Index Copernicus Value (ICV): 6.1

Op at 12 Months

1. ijdrd - one year follow up of an …. ijdrd - one...one year follow up of an iatrogenic root...

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