Perio Contest 2018/ 10 April 2018/

Case 27 | Perio Contest 2018 | India

Dr Safat Sadiq

Dr. Preethesh Shetty

TREATMENT OF INTRABONY DEFECT USING PLATELET RICH FIBRIN COMBINED WITH BIOACTIVE GLASS – A CASE REPORT USING CBCT ANALYSIS

This case report includes the management of an intrabony osseous defect in relation to #21 with a combination of Platelet Rich Fibrin & bioactive glass (calcium phosphosilicate alloplast) with the clinical and radiographic evaluations using cone beam computed tomography (CBCT) for a 9 months follow up period.

CASE REPORT

A 46 year old female reported to the Department of Periodontics, with a chief complaint of mild pain in relation to the upper left front tooth for the past one week, with a recent episode of swelling & pus discharge that subsided after medication.She gave a history of a fish bone being stuck inside her gums 10 days back. She did not give any relevant medical history and was reported to be in a systemically healthy condition.

On Intraoral examination, the buccal aspect of left maxillary central incisor (#21) revealed a probing pocket depth (PPD) of 10mm, with a clinical attachment level (CAL) of 11 mm (Figure 1). No mobility was detected. Intraoral Periapical Radiograph and Computed cone beam tomography (CBCT) revealed loss of buccal cortical plate upto the apical third of #21 (Figure 2). Fremitus was found to be negative precluding the possibility of trauma from occlusion. Endodontic evaluation was done to test the vitality of #21. The tooth #21 was nonresponsive to vitality tests.

Hence, a diagnosis of Primary Periodontal lesion with secondary endodontic involvement in relation to #21 was made.
The treatment plan included:

Oral hygiene instructions and motivation of the patient in performing effective oral hygiene measures.
Routine blood investigations were found to be in the normal range.

Non-surgical periodontal therapy by means of conventional scaling and root planing using ultrasonic instrument and curettes. Antibiotics and analgesics were administered for 5 days.
Root canal therapy was done in relation to #21, owing to the non – vital response explicated (Figure 3).
The patient was recalled after every week for four weeks. Re-examination after four weeks revealed no changes in PPD and CAL. Hence, periodontal surgical therapy was planned.
Supportive Periodontal Maintenance
Preparation of PRF
Blood sample was taken on the day of the surgery according to the PRF protocol with a REMI 3000 centrifuge and collection kits. Briefly, 6 ml blood sample was taken from the patient without an anti-coagulant in 10 ml glass test tubes and immediately centrifuged at 3000 rpm for 12 minutes. The resultant product consisted of three layers:
1. Topmost layer of acellular platelet poor plasma (PPP)
2. PRF clot in the middle
3. Red blood cells (RBCs) at the bottom.
The fibrin clot was easily separated from the lower part of the centrifuged blood (Figure 4).
The PRF clot was gently pressed between the two sterile dry gauges to obtain a membrane (Figure 5).
Surgical Procedure
Intra-oral antisepsis was performed with 0.2% chlorhexidine digluconate rinse and iodine solution was used to carry out extraoral antisepsis. Following administration of local anaesthesia, sulcular incisions were made and mucoperiosteal flaps were reflected in relation to #11,21 and 22 (Figure 6).The inner surface of the flaps were curetted to remove the epithelium and granulation tissue. The root surfaces were thoroughly planed using curettes and ultrasonic scaler. The left maxillary central incisor revealed a combined intrabony defect (Figure 7). The root surfaces adjacent to the defect were conditioned for two minutes with 15% Ethylenediaminetetraacetic acid(EDTA) gel (pH 6.7) (Figure 8). The intrabony defect was filled with calcium phosphosilicate alloplast (NovaBone Dental Putty®) (Figure 9). PRF membrane of the required size was then placed on the graft (Figure 10). The flaps were repositioned to their pre-surgical

levels and sutured with non – resorbable3-0 black silk surgical suture (Figure 11). The surgical area was protected and covered with a periodontal dressing.
Post – operative care
After the surgery, post – surgical instructions were given and she was prescribed systemic antibiotics (amoxicillin 500mg, tid , 5 days), non – steroidal anti- inflammatory drugs (ibuprofen 200mg, bid , 5 days) and 0.2% chlorhexidine mouthrinse (twice a day for 2 weeks). Sutures were removed after 7 days. Clinical healing was normal, with neither infectious episodes nor untoward clinical symptoms. The patient was seen at 1st week, 2nd week, 1st month, 3rd month and 6th month after surgery (Figure 12, 13). Re-examination at 9 months after the periodontal surgery revealed reduction in PPD (from 10mm to 2mm) and CAL (from 11mm to 3mm) with no signs of bleeding on probing (Figure 14) and significant radiographic bone fill in the periodontal intrabony defect.

CBCT Measurements
In the case of vertical defects, the defect depth is measured as the distance between CEJ and the base of the defect.21The measurements were done with the help of Planmeca Romexis (Planmeca USA, Inc.,) viewer software to the accuracy of 0.2mm.
Pre – operatively the defect depth on the mesial and distal aspect of 21 was recorded as 8.6mm and 6.6mm (11.6 – 5mm) respectively (Fig.15). At the end of 9 months post – operatively, the CBCT measurements showed a significant gain in radiographic bone fill by 6.6 mm on both mesial (8.6 – 2 mm) and distal aspects of 21(Fig. 16).