Dr. Nida Sultana Thesis
Dr. Nida Sultana Thesis
Dr. Nida Sultana Thesis
Batch 2018-2021
Acknowledgement
ACKNOWLEDGEMENT
Post Graduate Student, during my thesis tenure people were instrumental directly
ALLAH the savior, for giving me energy, perseverance and the will, to finish this
work successfully.
Rungta College of Dental Sciences and Research for being my support pillar in this
vast knowledge and attention to detail, hard work is an example I hope to match
IV
Acknowledgement
someday. His unprecedented calm and patient persona, an unfailing caring and
understanding demeanor made each endeavor easier. His own zeal for perfection,
show my gratitude towards him, it always will be infinitely small and thereby I
Dental Sciences and Research and Dean Dr. SUDHIR PAWAR for providing an
efficient and able platform for me to gain knowledge through this effective and
former H.O.D in Rungta College of Dental Sciences and Research, for introducing
me to the world of research. It was only due to their valuable guidance, cheerful
enthusiasm, and ever friendly nature that gave me boosts to start my work.
College of Dental Sciences and Research. Her personified excellence, not only
through deep insight into the field of periodontology, but also through the unique
V
Acknowledgement
art, to exhume from her students the strings of an inquisitive mind and dedication
College of Dental Sciences and Research who had always been there for me for
unravelling the hitches of my course, giving constant advices to tackle glitches and
for his meticulous statistical data analysis, without which this dissertation would
Centre for Treatment, Research & Education in Cancer, Navi Mumbai. for providing
I extend my heartfelt thanks to my revered seniors Dr. TEH CHAI LIU and
Dr. NIKITA AGRAWAL for constant support and guidance, who have always been
there for me for unraveling the hitches of my course, giving constant advices to
tackle glitches and also for their constant guidance, infinite patience and
VI
Acknowledgement
for his continued and unfailing love, and understanding during my pursuit of post-
graduation that made the completion of thesis possible. who was always around
in perspective. I greatly value his contribution and deeply appreciate his belief in
me. Words would never say how grateful I am to him. I consider myself the
luckiest in the world to have such a caring husband standing beside me with his
those very dreaded days, you both made my life easier. Thanks for supporting me
VII
Acknowledgement
NAZIYA HASAN, Dr. ASHIDA SARA BLESSON, Dr. SASWATI MOHANTY and
Dr. KRITIKA KEJRIWAL for their valuable help and support in all possible aspects.
No words could ever express the love and appreciation that I hold for my
loving PARENTS AND FAMILY, for their unconditional love, constant prayers,
support and sacrifice that they have made and also for instilling in me those
I would like to pay high regards and deep sense of gratitude to my parents
Mr. JAMAL KHAN, Mrs. NAJMA SULTANA, my in Laws Mr. SHAHABUDDIN and
Mrs. SHAMIM BANO, for their sincere encouragement and inspiration throughout
my work and lifting me uphill in this phase of life. I hope I have made them
SEDRA SULTANA, my brother in laws MINHAJ AHMAD and Dr. MOHD SHAHID
and my sister in laws ALFIYA BANO and SANIYA NASEEM for their kind co-
VIII
Acknowledgement
operation and support. Their faith in me gave me the strength to carry out the
work successfully.
all the patients who co-operated with me, they deserve maximum credit for the
Besides this, I want to thank all the people that have knowingly and
IX
List of abbreviations
LIST OF ABBREVIATIONS
AM Amnion Membrane
BP Bard Parker
CM Chorion Membrane
X
List of abbreviations
GI Gingival Index
GR Gingival Recession
HA Hydroxyapatite
HCL Hydrochloride
HS Highly Significant
XI
List of abbreviations
IL Interleukin
mm Millimeter
NS Non-Significant
OPG Orthopantomogram
PI Plaque Index
PTFE Polytetrafluoroethylene
RVG Radiovisiography
XII
List of abbreviations
S Significant
XIII
Table of contents
TABLE OF CONTENTS
1. INTRODUCTION 1-4
6. DISCUSSION 119-131
8. BIBLIOGRAPHY 134-153
9. ANNEXURES 154-164
XIV
List of tables
LIST OF TABLES
XV
List of tables
XVI
List of tables
day in group I
interval
day in group II
intervals
XVII
List of tables
group I
group II
XVIII
List of figures
LIST OF FIGURES
walls present
anatomy
a periodontal pocket
XIX
List of figures
(DFDBA)
XX
List of figures
XXI
List of figures
XXII
List of graphs
LIST OF GRAPHS
180th day
180th day
XXIII
List of graphs
180th day
XXIV
List of annexures
LIST OF ANNEXURES
approval
XXV
Abstract
ABSTRACT
Perhaps the most obvious shift has been from resective periodontal surgical procedures
periodontium.
Objectives: To compare the efficacy of Amnion Membrane (AM) allograft barrier with
periodontitis patients.
Methods: A total of 40 sites (20 in each group) with clinical and radiographical
evidence of intrabony defects were selected from the Out-Patient Department, Rungta
College of Dental Sciences and Research, Bhilai, Chhattisgarh. The selected sites were
randomly divided into group I (Open flap debridement with DFDBA) and group II
(Open flap debridement with DFDBA+ AM). The clinical parameter evaluated were
Plaque index (PI), Gingival index (GI), Probing pocket depth (PPD), and Relative
attachment level (RAL), at baseline, 90th day and 180th day postoperatively.
Radiographic parameters recorded vertical osseous defect depth, amount of defect fill
and percentage of defect fill at baseline and 180th day. All clinical and radiographic data
were subjected to statistical analysis using appropriate tests for within group
the study period. The plaque and gingival index showed significant reduction from
baseline (Group I: 2.07±0.18, Group II: 2.05±0.25 and Group I: 2.14±0.24, Group II:
XXVI
Abstract
2.28±0.21 respectively) to 180th day (Group I: 0.57±0.10, Group II: 0.61±0.13 and
Group I: 0.69±0.12, Group II: 0.66±0.15 respectively). Both the group showed
reduction in mean PPD and RAL which was statistically significant when comparing
baseline (Group I: 6.95±0.94, Group II: 7.30±0.92 and Group I: 12.05±1.39, Group II:
12.95±1.93 respectively) to 180th day (Group I: 4.10±0.78, Group II: 3.45±0.60 and
reduction in PPD (p= 0.005) and improvement in RAL (p= 0.048) than group I. There
was significant reduction in defect depth (Group I: 2.11± 0.57 and Group II: 1.85±0.55)
parameters.
XXVII
INTRODUCTION
Introduction
INTRODUCTION
teeth. It results from pathogenic bacterial infection, which produces factors that
destroy collagenous support of the tooth, as well as loss of alveolar bone. 1 Loss of
disease and is generally considered to represent the anatomical sequela to the apical
spread of periodontitis.2
The main goals of periodontal treatment are the elimination of infection and
prevent its recurrence. Persistent probing depths following treatment are often related
to the presence of intrabony (angular) periodontal defects, thus worsening the long-
term prognosis for teeth. The rationale behind the treatment of intrabony defects is
therefore to reduce residual probing depths to improve tooth prognosis. During the
have been employed for the treatment of intrabony defects and have achieved variable
success.3
including formation of new cementum with inserting periodontal ligament, bone and
1
Introduction
Although bone tissue exhibits a large regeneration potential and may restore
its original structure and function completely, bony defects may often fail to heal with
bone tissue. In order to facilitate and/or promote healing, bone grafting materials can
be placed into bony defects. It is generally accepted that the biologic mechanisms
forming the basis for bone grafting include three basic processes: osteogenesis,
bone graft,10 guided tissue regeneration,11 growth factors,12 enamel matrix derivative,8
stem cells13 have been quite successful for treating the more challenging intrabony
lesions, particularly as the size and complexity of the lesion increases. 14 Typically
these efforts have included a bone replacement graft that has been covered by an
periodontal regeneration with GTR it is noted that the GTR and bone substitutes
osteoinductive properties and eliminates the need for a second surgical site. DFDBA
socket.16 DFDBA has the potential for osteoinduction with more expression of bone
substitutes for the purpose of restoring, maintaining or improving tissue function and
requires the application of principles and methods from engineering and life
2
Introduction
sciences.21 Stem cells represent an excellent source for use in TE. Recently Amniotic
The placental based amniotic membranes have been used for tissue
feeder layer for stem cells, skin reconstruction, endothelial cell cultivation,21 local
properties that actively promote wound healing in lieu of simply providing an occlusal
barrier for selective cell population and also promotes bone induction.24,25
epithelial layer, thick basement membrane and avascular stroma. AM has anti-
source for scaffolding material, as it creates an almost a native scaffold for self-
seeding in tissue engineering as the epithelium might retain reservoir of stem cells. 21
treated with conventional open flap debridement and bone substitutes. However, the
periodontal regeneration.
3
Introduction
4
AIM &
OBJECTIVES
Aim and objectives
AIM
The aim of this study was to evaluate clinically and radiographically the efficacy
of Amnion Membrane (AM) allograft barrier with DFDBA and DFDBA alone in
OBJECTIVES
probing pocket depth, gain in the clinical attachment level and reduction in
gingival recession.
5
REVIEW OF
LITERATURE
Review of literature
REVIEW OF LITERATURE
attachment loss, and bone loss.”27 The clinical feature that distinguishes periodontitis
inflammatory destruction of the periodontal ligament and alveolar bone. This loss is
often accompanied by periodontal pocket formation and changes in the density and
DEFINITIONS
function of lost tissues are completely restored. With periodontal regeneration this
would mean regeneration of the lost supporting tissues of the tooth including new
alveolar bone, a new periodontal ligament and gingival structures. New connective
tissue attachment is defined as the reunion of connective tissue to a root surface that
connective tissue to a root surface exposed by incision or injury. Bone fill is defined
as clinical restoration of bone tissue in a treated periodontal defect. Bone fill does not
6
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OSSEOUS DEFECTS:
trough in the bone alongside the root. The base of the defect is located apical to
alveolar crest and it forms when junctional epithelium is apical to alveolar crest. 34 An
one, two or three bony walls or a combination of these’. 29 Periodontal disease alters
the morphologic features of the bone in addition to reducing bone height and result in
OSSEOUS DEFECTS
COMBINED DEFECT
7
Review of literature
8
Review of literature
Infrabony defects are usually classified according to their morphology i.e. the
number of walls present and their topographic extension around the tooth: 31,32
1) one-wall defects: defects limited by one osseous wall and the tooth surface;
2) two-wall defects: defects limited by two osseous walls and the tooth surface; and
The number of bony walls in the apical portion of the defect may be greater
than in its coronal portion i.e. three wall defect in most apical portion of the defect
outcome of the regenerative procedures. The deeper the defect, greater is the amount
of clinical improvement and the wider the defect the lower the clinical attachment and
bone gain.36
9
Review of literature
thick have the greatest chances to result in consistent amounts of clinical attachment
and bone gains, irrespective of the number of residual bony walls. The thickness of
DEFECT ANATOMY
Shallow (≤ 3 mm) Deep (>3 mm) Shallow (≤ 3 mm) Deep (>3 mm)
Increasing Predictability
or supporting tissues and includes formation of new alveolar bone, new cementum,
10
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perivascular region of alveolar bone after tooth development and their synchronized
differentiation, and maturation to form new alveolar bone, PDL and cementum in a
sequence that these three individual tissues are integrated to function as a new
normal conditions, new cells and tissues are constantly being formed to replace those
that mature and die; this is termed wear and tear repair.41
It is manifested by:
1. Mitotic activity in the epithelium of the gingiva and the connective tissue
processes and as such are healing lesions. However, bacteria and bacterial products
that perpetuate the disease process, along with the resulting inflammatory exudate, are
injurious to the regenerating cells and tissues, thus preventing completion of the
healing process. By removing bacterial plaque and creating the conditions to prevent
its new formation, periodontal treatment removes the obstacles to regeneration and
enables the patient to benefit from the inherent regenerative capacity of the tissues. A
11
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Repair
Repair simply restores the continuity of the diseased marginal gingiva and
reestablishes a normal gingival sulcus at the same level on the root as the base of the
preexisting periodontal pocket. This process, called “healing by scar” arrests bone
destruction but does not result in gain of gingival attachment or bone height. 42 This
of epithelial and connective tissue cells into the damaged area and increased local
12
Review of literature
partially) their level on the root, therapy must include special materials and
techniques. If these are not used or are not successful, tissues undergo repair only,
which involves regeneration of tissue to remodel the attachment apparatus but does
not include regaining attachment level or new bone height. For this reason, we prefer
to use the term reconstruction of the periodontium to refer to the crucial therapeutic
techniques that seek to rebuild the periodontium and result in a significant gain of
New Attachment
New attachment is the embedding of new periodontal ligament fibers into new
cementum and the attachment of the gingival epithelium to a tooth surface previously
denuded by disease. The critical phrase in this definition is “tooth surface previously
areas of the tooth from which they have been removed in the course of treatment (or
of the periodontium, not new attachment. The term reattachment refers to repair in
areas of the root not previously exposed to the pocket such as after surgical
13
Review of literature
apposition of the gingival epithelium to the tooth surface, with no gain in height of
gingival fiber attachment. The pocket is not completely obliterated, although it may
cells and fibers and remodeling of the lost periodontal structures that results in-
14
Review of literature
A technique to attain these ideal results has been a constant but elusive goal of
periodontal therapy for centuries.45 Since the 1970s, renewed laboratory and clinical
research efforts have resulted in new concepts and techniques that have moved us
much closer to attaining this ideal result of therapy. Melcher pointed out that the
because it “provides continuity between the alveolar bone and the cementum and also
because it contains cells that can synthesize and remodel the three connective tissues
During the healing stages of a periodontal pocket, the area is invaded by cells
from four different sources: oral epithelium, gingival connective tissue, bone, and
periodontal ligament.
15
Review of literature
events during the healing stages.46 If the epithelium proliferates along the tooth
surface before the other tissues reach the area, the result will be a long junctional
epithelium. If the cells from the gingival connective tissue are the first to populate the
area, the result will be fibers parallel to the tooth surface and remodeling of the
alveolar bone with no attachment to the cementum. If bone cells arrive first, root
resorption and ankylosis may occur. Finally, only when cells from the periodontal
ligament.46
Bone replacement grafts are widely used to promote bone formation and
periodontal regeneration. The use of bone grafts for reconstructing osseous defects
produced by periodontal disease dates back to Hegedus in 192347 and was reviewed
transplanted with the grafting material into the defects, where they may establish
centers of bone formation. Autogenous iliac bone and marrow grafts are examples of
for the ingrowth of precursor osteoblasts into the defect. Autogenous cortical bone or
properties.
16
Review of literature
uncommitted connective tissue cells into bone-forming cells under the influence of
Bone grafting material function, in part as structural scaffolds and matrices for
donor site.
17
Review of literature
The use of bone grafting or replacement materials is based on the assumption that
these materials may facilitate formation of alveolar bone, periodontal ligament and
root cementum.47
HUMAN BONE
Autogenous grafts (autografts)
Extraoral
Intraoral
Allogeneic grafts (allografts)
Fresh frozen bone
Freeze-dried bone allografts
Demineralized freeze-dried bone allografts
BONE SUBSTITUTES
Xenogeneic grafts (xenografts)
Bovine-derived hydroxyapatite
Coralline calcium carbonate
Alloplastic grafts (alloplasts)
Polymers
Bioceramics
Tricalcium phosphate
Hydroxyapatite
dense, nonporous, nonresorbable
18
Review of literature
transferred from one position to a new position in the same individual. Autogenous
bone is often referred to as the “gold standard” grafting material since it contains both
osteoprogenitor cells and scaffolding. They can be obtained either from intraoral sites
at the time of surgery led to the development of several types of bone allografts. The
allografts are obtained from other individuals of the same species but different
genotype. Two types of bone allografts in routine use are mineralized freeze-dried
bone allograft and demineralized freeze-dried bone allograft. They come in different
forms like particulate, gel and putty. They provide a source of type-I collagen, which
there are two available sources of xenografts used as bone replacement grafts in
periodontics: bovine bone and natural coral. Both sources, through different
19
Review of literature
similar to human bone. They are osteoconductive with the advantage of being free of
materials are used simply as volume expanders, such as when there is insufficient
volume of autogenous bone. Other times, they are used as biocompatible space fillers,
such as to occlude the gap between a dental implant and an extraction socket wall.
source for new bone formation. Used alone as a single graft material, these materials
can result clinically in improved bone density and can lead to more complete bone fill
polymers.49
same species. Urist and Strates (1965) stated that demineralizing and freeze drying
the bone greatly enhances the osteogenic potential. HCL demineralization exposes the
bone morphogenic proteins that are composed of acidic polypeptides. The bone
morphogenic proteins are located in the bone matrix and therefore are abundant in
20
Review of literature
DFDBA was first used in dentistry and medicine in 1965 and in 1975 for the
first time it was used for the treatment of periodontal defects in humans. 55 DFDBA
formation when implanted in tissues that would otherwise not form bone. DFDBA
contains bone morphogenic proteins (BMPs) such as BMP 2, 4, and 7 which help
stimulate osteoinduction.56
influence cell behavior in vivo. BMPs produce multiple effects on bone by: acting as
the expression of the osteoblast phenotype bone cells, and acting as chemo attractants
for mesenchymal cells and monocytes as well as binding to extracellular matrix type
IV collagen.57
Predictable results
Host incompatibility
21
Review of literature
Processing Sequence:59
2. Then the bone is fragmented into 0.5 to 1mm particles and decalcified in 0.6 N
HCL and immersed in 100% ethyl alcohol for 1 hour to remove fat and to
inactivate virus.
3. After which, bone is frozen at -80֯C for 1-2 week to interrupt the degradation
process, further decreasing the risk of disease transfer. Freeze drying removes
4. The bone is grounded to a particle size of 250-800μm. This particle size range
5. This graft material is again immersed in ethyl alcohol and washed repeatedly
6. Then it is decalcified with 0.6 N HCL which removes Ca ++ leaving the bone
7. Then washed with Na phosphate buffer to remove the residual acid and stored.
bone. Although the precise origin of these progenitor cells remains unknown, it is
clear that they have the capacity to migrate and differentiate into synthetically
22
Review of literature
the range of 125 to 1000 μm possess a higher osteogenic potential than do particles
below125 microns.61 Optimal particle size appears to be between 100 to 300 μm. This
may be due to a combined effect of surface area and packing density. Very small
DFDBA particles elicit a macrophage response and are rapidly resorbed with little or
no new bone formation. Tissue banks providing DFDBA for dental use usually have
this graft material in various particle sizes, and the range from 250 to 750 μm is the
AMNION MEMBRANE
fibronectin derived from the inner lining of the human placenta. It is composed of
8 layers of cells. It is tough and lacks blood vessels, lymphatic system and nerves.
The amnion withstands tensile forces better than the chorionic membrane because
23
Review of literature
EMBRYOLOGY
the chorion, the outer layer of membranes surrounding the fetus. The innermost
trophoblastic cells, the so called amniogenic cells, form the amniotic membrane
with fluid, expands gradually and adheres to the inner surface of the chorion; the
chorionic cavity disappears but the two layers do not fuse histologically and
remain separable. The amnion is thick and hard but a flexible sheet of tissue at
full term. 65
The Amnion and Chorion are multiple layers of collagen and are hydrophilic
Human amniotic membrane is totally free of smooth muscle cells, nerve fibers
I and II.
tractional resistance such as bone and tendon, but in other tissues, collagen III is
known as the main factor of integrity and firmness. 65 Elastin exists in small
amounts in the amniotic membrane and its elasticity is mainly due to collagen
type III. Owing to the presence of interstitial collagens, one of the important
24
Review of literature
and cytokines. 66
PROPERTIES
Promotion of Epithelialization
epidermal growth factor (EGF), keratocyte growth factor (KGF) which can
25
Review of literature
26
Review of literature
Inhibition of Fibrosis
Fibroblasts are naturally responsible for scar formation during wound healing and are
27
Review of literature
membrane. 64
Lack of Immunogenicity
Studies showed that both amniotic epithelial and mesenchymal cells and fibroblasts
express all HLA class I molecules including class Ia (HLA-A, B, C, DR) and class
amnion epithelial cells. INFγ and other immunologic factors have been
epithelial cells, amniotic membrane may induce immunologic reactions. One study
epithelial cells.
28
Review of literature
dead space formation and serous discharge accumulation thereby reducing bacterial
Other Properties
owing to adhesion to the wound surface and coverage of dermal nerve endings. It
29
Review of literature
cesarean section after a full -term pregnancy. The donor is initially evaluated for
and by performing physical examination specifically for tattoos and needle marks.
After obtaining written consent, serum samples of the potential donor are tested for
anti-hepatitis C virus antibody, and rapid plasma reagin test for syphilis. The
infections in the window period of the previous tests. Until confirmation of the
There are several methods of tissue preparation and preservation which are
described hereunder.
In this method, the tissues are dried overnight in an oven at 40±2°C. It is then
sterilized using gamma irradiation. In this method, the membrane loses many of its
biologic properties due to the high temperature employed and serves as a biologic
30
Review of literature
After separating and washing, the amniotic membrane is flattened under a lamellar
flow hood and exposed to the air overnight to get dried. Packing and sterilization
applied in this method, some properties of the amnion are lost or altered
In this method, placental membrane is cut into pieces and rapidly frozen at -50ºC
to -80ºC. Thereafter it is dried under high vacuum using a freeze drier device.
10%. At the end, packing and sterilization using gamma irradiation is performed.
and the product can be stored at room temperature. The technique is complex and
more expensive than the previous two methods. This preparation is mainly used
Glycerol has been used as a cryoprotective agent for a long time. Due to its high
osmotic pressure it extracts interstitial water from the amniotic membrane. In this
method, 80% glycerol is used for drying the amniotic membrane which can
31
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thereafter be preserved at 4ºC for a long time, although it loses some of its biologic
properties. This type of preserved amnion is used for dressing burn wounds. 63,73
Under sterile conditions, the placenta is washed free of blood clots with isotonic
solutions. Next, the amniotic membrane is separated from the chorion and washed
then flattened onto a nitrocellulose paper & then cut into desired sizes and placed
The vial containing the amniotic membrane and the solution is frozen at -
80ºC.
The tissue is packed within two layers of polycarbonate and aluminum foil
properties compared to other methods. It seems that the viability of amniotic epithelial
cells has little effect on the biologic properties of the membrane; these properties are
32
Review of literature
wound surface.74
Human amnion has a long history of clinical applications. It was reported for
the first time as a biological dressing to heal skin wounds a century ago. In the
management of open wounds, the major goal is to obtain a clean and closed wound in
the shortest time possible, thereby preventing fluid, heat, and nutrient loss as well as
Amniotic membranes are efficiently used as allografts for treating skin burns;
open and nonhealing ulcers; pressure sores; and surgical, infected, and traumatic
wounds. An alternative treatment to manage wounds in the oral cavity, such as the
tongue, buccal mucosa, vestibule, palatal mucosa, and floor of the mouth; in the
and so forth. Its adhesive and tight contact with the injured surface promotes
hemostasis and good pain relief due to exposition of nerve fibers. Good
33
Review of literature
shown decreased necrosis and rapid healing of ulcers with herpes simplex virus
(HSV), varicella zoster virus infected tissues, erythema multiforme major (Stevens–
Johnson syndrome), and cervical necrotizing fasciitis. AM has been tried in the
used as a carrier for local delivery of various drugs such as antibiotic netilmycin and
antiviral drugs such as acyclovir and trifluridine. Amnion has been tried as a graft
A novel allograft composed of amnion tissue has recently been introduced for
periodontal plastic surgery. Collected data and subjective observation by the authors
indicate that the use of processed dehydrated allograft amnion provides good results
in terms of root coverage, increased tissue thickness, and increased attached gingival
in terms of texture and color match without postoperative discomfort and adverse
reactions. The allograft has been reported to treat Grade II furcation defects with
34
Review of literature
REVIEW OF LITERATURE
Animal Studies:
women undergoing cesarean sections, whereas PDL tissue was obtained from human
maxillary third molars. The harvested PDL cells were maintained in explant culture
for three or four passages, following which they were cultured on AM. After 3 weeks
of culture, the PDL cells had grown well on AM. Immunofluorescence showed that
these cells were capable of proliferating and potentially maintaining their PDL-like
tight junctions, were shown to be present between cells. Electron microscopy images
showed that the cultured PDL cells had differentiated and proliferated on AM with
suitable substrate for culturing PDL cells and that PDL cells cultured on AM show
sheet formation.
are transplanted for periodontal tissue regeneration, and the PDL is regenerated using
a cultured cell sheet. This cultured cell sheet is prepared using PDL-derived cells,
growth factors, and AM. Dental pulp-derived cells can be easily obtained from
extracted wisdom teeth, proliferate rapidly, and are less susceptible to bacterial
infection than PDL-derived cells. Thus, to prepare a novel cell sheet, DP-derived cells
35
Review of literature
Wisdom teeth extracted from three adults were cut along the cement-enamel border.
DP tissue was collected, minced, and primarily cultured. After three or four passage
layered structure. Cells positive for vimentin, Ki-67, ZO-1, desmoplakin, CD29, 44,
105 or 146, STRO-1, collagen IV or VII or laminin 5 or α5 chain were localized. DP-
derived cells proliferated on AM, while retaining the properties of DP, which allowed
the cultured cell sheet to be prepared. In addition, the cultured cell sheet contained
transferred onto amniotic membranes using a glass substrate treated with polyethylene
such as cell surface marker expression (CD90, CD44, CD73, CD105, CD146, and
STRO-1) and trilineage differentiation ability (i.e., into osteoblasts, adipocytes, and
membrane and stability of the sheet even with movement and deformation caused by
36
Review of literature
Human Studies:
(CM) with BBM in GTR for the treatment of intrabony periodontal defects. Ten
were randomly divided into two groups. The test group was treated with AM+BBM,
and the control group was managed with CM+BBM. Periodontal clinical parameters
were recorded at baseline and at 6 months after treatment. PPD, clinical attachment
level (CAL), and probing bone (PB) showed significant improvements after 6 months
in both the test and control groups. Gingival recession showed a significant increase
in the control group but not in the test group. The changes in mean PPD, PB, and
CAL preoperatively and postoperatively between the groups were not significant.
There was no significant relationship between the depth of the baseline bony defect
and CAL gain. Both AM and CM in conjunction with BBM provided improvement of
clinical periodontal parameters. AM did not induce significant gingival recession and
amnion chorion membrane (ACM) with demineralized bone matrix (DBM) in a putty
severe chronic periodontitis and intrabony defects were randomly assigned in two
37
Review of literature
equal parallel groups. Each group was treated with open flap debridement (OFD) and
ACM or OFD and DBM putty. Plaque index, gingival index, PD, CAL and
and 6 months postoperatively. Both ACM and DBM putty demonstrated significant
baseline values. However, no significant difference was observed between the two
postoperatively, ACM showed PD reduction and CAL gain, while DBM putty
revealed PD reduction and CAL gain. Radiographic assessment showed that mean
baseline BDA for ACM group, which significantly reduced after 6 months. Mean
BDA mm2 in DBM putty group also significantly improved after 6 months, when
compared to baseline values. Both ACM barrier and DBM putty allograft provided
significant differences were noticed between them. This trial implied that both
defects.
STUDIES ON DFDBA
Animal studies:
milligrams of bone from each of the bank was implanted into the hindquarter muscles
of athymic mice. Two samples from each of the banks were compared with samples
from the other banks. A total of 16 implants were grafted into 8 mice. Two additional
38
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cortical bone matrix (DBM). The other mouse received an implant of human bone
demineralized human cortical bone (positive control). At 21 days the mice were
killed, the hindquarters were photographed, and the tissues were prepared for
histologic evaluation. There was no radiographic evidence of bone formation for the
DFDBA implanted mice or the DBM implants. Small bone ossicles were scarcely
visible in the hindquarters of the mouse which received the hBMP/NCP infused bone.
The result of this exploratory study questions the continued use of commercially
available DFDBA for bone induction in periodontal defects and adjacent to dental
implants. One potential cause might be that bone induction proteins are not present in
the bone inductive components of DFDBA are present but in an inactive form.
for assessing the induction ability of DFDBA in vitro. They characterized the
response of 2T9 cells, an immature osteoprogenitor cell line derived from the
calvariae of transgenic mice containing the SV40 T-antigen driven by the mouse bone
alkaline phosphates specific activity. They also tested the hypothesis that the radio
opacity of tissue following implantation of DFDBA in vivo correlated with the ability
of human DFDBA to induce new bone. DFDBA from 9 different donors, stratified by
age, were implanted subcutaneously in the thorax of 18 nude mice. Tissue was
for calcium and phosphorous uptake. In conclusion the calcium and phosphorous
39
Review of literature
uptake by DFDBA implanted, tissue correlated with the age dependent decrease in
bone induction. These data showed that early x-rays might actually detect
Human studies:
periodontal defects treated with a decalcified, lyophilized bone allograft. Two patients
received grafts of cancellous bone and one patient received a cortical bone graft. The
patients were observed up to 2 years following implantation. The results showed that
the implantation of decalcified, lyophilized bone allograft of both the cortical and
cancellous bone types resulted in new bone formation and a gain in attachment level
selected for the study, out of which 16 defects were randomly selected for grafting
attachment with the allografting procedure but not with the control procedure, which
treatment of human periodontal osseous defects over a 6-month period. Cortical bone
obtained under sterile conditions from a human donor within 24 hours after death, was
decalcified, freeze dried and grounded to particle size of 250-500 microns. 27 osseous
defects with one, two and wide three wall morphology were treated. Clinical
40
Review of literature
measurements were made before surgery, at the time of surgery and re-entry. The
results showed a combined mean osseous regeneration for all defects was 2.4mm.
been used to treat advanced intrabony defect and where new bone formation had
occurred. A total of 20 defects were treated, and at the nine-month evaluation, the six
cases presented in this report had minimal probing depth and showed radiographic
evidence of substantial bone fill. The amount of repair ranged from 75% to 95% of
the original defect. Bone fill was achieved on both vital and non-vital teeth and in
some cases, there was a radiographic evidence of a lamina dura and a discernable
periodontal ligament space. Furthermore, the teeth that were initially mobile showed a
decrease in mobility.
resolution by using two different particle size of DFDBA. Cortical bone of final
particle sizes of 250μ to 500μ or 850μ to 1000μ were obtained. Paired interproximal
intrabony periodontal defects in 11 patients were grafted with DFDBA. Soft and hard
tissue measurements were made using an electronic constant force probe at the initial
significant difference in bony fill between defects grafted with the different particle
defects after either osseous surgery or open flap debridement in combination with
grafting procedures with DFDBA. Pre- and post-surgical computer digitized images
41
Review of literature
patients were treated with osseous surgery and had received flap procedures with
bone fill for osseous surgery sites and 0.5 mm for DFDBA sites.
total of six patients were selected for the study. Soft and hard tissue measurements
were taken at baseline and 6 months re-entry. There was no significant difference in
any of the soft tissue measurements when DFDBA and HA were compared. There
was a defect fill of 61% for DFDBA and 53% for HA which was not statistically
significant.
point and osseous measurements at the time of surgery. At reentry after 6 months a
mean osseous repair of 59% occurred with DFDBA and 66% with FDBA. Findings
material for the treatment of periodontal osseous defects. Paired osseous defects in 11
42
Review of literature
patients were randomized to receive ABM or DFDBA. Soft tissue and hard tissue
similar density changes with each graft. These results demonstrated that both the
treatments were effective and that ABM may be a useful graft material in the
15 patients with three osseous defects each were selected for the study. Each site in
each subject was randomly assigned to one of the following groups: 1) DFDBA +
surgery, at 6months and 1 year. Radiographs were taken at baseline and 1 year and
were evaluated by CADIA. Osseous defect measurements were taken at baseline and
and attachment level at 1 year. Although the grafted groups showed greater bone fill
and defect resolution there was no statistically significant difference in any of the
clinical parameters between the treatment groups. There is no significant benefit from
years on the surgical treatment of intrabony defects. The treatments included open
flap debridement, open flap debridement with DFDBA, FDBA or autogenous bone
and GTR. The review included only those studies that presented baseline and final
data on probing depths, intrabony defect depth as measured during surgery, clinical
attachment level gain and or bone fill. Result of meta-analysis showed that open flap
debridement alone resulted in limited pocket reduction, clinical attachment level gain
43
Review of literature
averaged 1.5mm and bone fill 1.1mm. Open flap debridement plus bone graft resulted
in limited pocket reduction; clinical attachment level gain and bone fill averaged
polylactic acid softened with citric acid ester barrier and commercially available
DFDBA in the treatment of 2 and 3 wall intrabony defects. 12 patients, each with one
treated defect comprised each group. Soft tissue measurements and hard tissue
measurements were taken and were comparable in both the groups at baseline. They
between the 2 groups; only the exception was in the radiographic resolution of defect,
controls, and histological cores of the treatment sites were obtained. Results
concluded that although the differences in percent vital bone were not statistically
significant among the 3-treatment group, bioactive glass material was observed to act
months post extraction. Residual implant material was significantly higher in DFDBA
44
Review of literature
osseous defects compared to surgical debridement alone. The therapeutic end points
examined included changes in bone level, clinical attachment level, probing depth,
gingival recession and crestal resorption with respect to the treatment if intrabony
defect, the results of meta-analysis supported the following conclusions; 1). Bone
grafts increased bone level, reduced crestal resorption, increased clinical attachment
level, and reduce probing depth compared to OFD procedures 2). Bone grafts in
combination with barrier membranes increased clinical attachment level and reduced
probing depth compared to graft alone 3). Histologically DFDBA supported the
alone in the treatment of human periodontal osseous defects. 40 patients with a total
of 67 sites were selected for the study; each subject received either enamel matrix
derivative alone, (34 sites) or enamel matrix derivative in combination with DFDBA
(33sites). Both soft tissue and hard tissue measurements were taken at baseline and
6months. Results showed significant improvements in soft tissue parameters for both
significant difference in hard tissue fill of intrabony defects following treatment with
defects were selected for the study. Soft tissue and hard tissue measurements were
45
Review of literature
recorded at baseline and 6 months. Defects were randomly treated with either a
barrier or with DFDBA and fitted with an ePTFE barrier. Results of this study
indicated that calcium sulphate, when used as a binder and barrier in combination
DBX paste and putty compared to DFDBA in the treatment of human intraosseous
periodontal defects. Sixty systemically healthy individuals between the ages of 31 and
radiographic evidence of at least 40% to 50% vertical bone loss were accrued.
receive either DBX paste, DBX putty, or DFDBA (control). Baseline and 6-month
reentry soft and hard tissue parameter measurements were made. Results showed that
Probing depth reductions and attachment level gains were significantly improved in
all treatment groups. Bone fill was similar between all groups with DBX paste, putty,
and DFDBA control groups demonstrating 2.0 mm, 2.4 mm, and 2.2 mm,
respectively.
alone for the treatment of infrabony defects and to examine the influence of
infrabony defects were treated with DFDBA/PRP combination or PRP alone. Clinical
46
Review of literature
months. The results showed more favorable gains in both clinical and radiographic
existed between defect angle, defect depth, and clinical/radiographic outcomes for the
defects treated with DFDBA/PRP. The narrow defects presented more favorable CAL
gain, probing pocket depth (PPD) reduction and defect resolution than wide defects in
derivative (EMD) and DFDBA with DFDBA alone for the treatment of human
defects in 56 periodontitis patients were randomly assigned to the test group (DFDBA
+ EMD) or the control group (DFDBA) for periodontal treatment. Clinical and
radiographic measurements were made at the baseline and after 12 months. Compared
to baseline, the 12-month results indicated that both treatment modalities resulted in
PD, CAL, gingival recession and radiographic parameters (hard tissue fill (HTF) and
the test group compared to the control group in PD reduction, CAL gain, and HTF.
from moderate to severe chronic periodontitis, aged 35-60 years, were randomly
divided for bone graft, alone (control) and with doxycycline (test) for the study. At
baseline, after 3 months and after 6 months of post-operative period, PPD, CAL,
radiological bone fill (RBF) and alveolar height reduction were recorded. The results
47
Review of literature
showed no added benefits of local doxycycline, as compared with bone graft alone,
efficacy of autologous PRF combined with DFDBA to DFDBA alone in the treatment
defects with clinical probing depth of at least 6 mm were selected for the study.
Selected sites were randomly divided into two groups. In Group I, mucoperiosteal flap
PRF with DFDBA was done. Clinical and radiographic parameters were recorded at
baseline and at 6 months post‑operatively. Results showed both treatment groups had
a significant probing pocket depth reduction, clinical attachment gain, defect fill, and
defect resolution 6 months after surgery compared to baseline. However, there was a
significantly greater probing pocket depth reduction and clinical attachment gain
months. Ten systemically healthy patients diagnosed with chronic periodontitis, with
included in this study. Defect on one side was treated with DFDBA and the other side
with bioactive glass. Clinical and radiographic measurements were made at baseline 6
month and 12 months after the surgery. Compared to baseline, the 12-month results
indicated that both treatment modalities resulted in significant changes in all clinical
parameters (gingival index, probing depth, CAL and radiographic parameters (bone
48
Review of literature
fill), however, sites treated with DFDBA exhibited statistically significantly more
changes compared to the bioactive glass in probing depth reduction and CAL gain.
systemically healthy patients with 20 periodontal infrabony defects were selected for
the study. Baseline measurements included plaque index, papillary bleeding index,
PPD, gingival recession, clinical attachment level and radiographic defect depth
(DD). At the time of surgery, the defects were randomly assigned to either the test
group (collagen membrane plus DFDBA) or the control group (collagen membrane
only). At the 6-month examination, result showed PPD reduction was significantly
greater in the test group compared with the GTR group. Radiographic DD reduction
was greater in the test group compared with the GTR group.
comparable bilateral intrabony defects. Each pair of defects was randomly treated
with DFDBA+PRP (test) or DFDBA alone (control). CAL, intrabony defect depth
(IDD), distance from the stent to the alveolar crest and PD as well as radiographic
parameters including the radiographic defect depth, width and angulation were
measured at baseline and six months post-operatively. This study showed that both
treatments resulted in significant PD reduction, CAL gain and IDD reduction. Also,
of PRF with a DFDBA in the treatment of human intrabony periodontal defects. Sixty
49
Review of literature
DFDBA/saline. Clinical [PD, CAL and gingival recession (REC)] and radiographic
(bone fill, defect resolution and alveolar crest resorption) measurements were made at
indicated that both treatment modalities resulted in significant changes in all clinical
significantly greater changes compared with the DFDBA/saline group in PD, CAL,
REC, bone fill and defect resolution. Observations indicate that a combination of
PRF and DFDBA is more effective than DFDBA with saline for the treatment of
clinical attachment level and bone fill of periodontal intrabony defects treated with
completed the study protocol. Each patient contributed a single intrabony defect,
which was randomized to receive either DFDBA or PRF. Clinical and standardized
radiographic data were collected at baseline and 6 months after treatment. Primary
outcomes measures included radiographic bone fill as measured from the CEJ to base
of bony defect, and change in CAL. Both treatment groups had significant gains in
CAL as well as bone fill, with no significant differences in outcomes between groups.
gain in CAL as well as bone fill after 6 months of healing, with no significant
infrabony defects. Thirty infrabony defects were treated with either autologous PRP
with OFD or autologous PRP + DFDBA with OFD or OFD alone. Clinical parameters
recorded were gingival index, plaque index, PD, CAL, and REC. Radiographic
50
Review of literature
parameters included defect depth reduction, defect resolution, and crestal bone level.
All the parameters were recorded at baseline and 12 months postoperatively. Mean
PD reduction and CAL gain were greater in PRP + DFDBA and PRP groups than the
control group. Within the limits of the study, all the three groups showed significant
amount of defect depth reduction and defect resolution treated with PRP alone group
were significantly <PRP + DFDBA. The results pertaining to these parameters were
surgery. Eighteen intra-bony defects (9 intra patient pairs) in 9 patients with chronic
radiographic (RVG) measurements were made at base line and 12 months. Data
plaque and gingival indices with reduction in the mobility, probing pocket depth and
gain in clinical attachment. Radiographs showed significant bone fill and increased
bone density However, group 1 (FDBA) showed increase in the bone density which
was statistically significant. The use of the FDBA and DFDBA block allografts
defects.
51
Review of literature
intrabony defects were randomly assigned into three groups: (Group I ‐ Open flap
debridement, Group II ‐ DFDBA alone, and Group III‐ DFDBA + PRF). Parameters
such as PPD, relative attachment level (RAL), and radiographic bone fill were
measured at baseline, 3 months, and 6 months. Reduction in the PPD and greater
difference in RAL was observed over the study period in all the three groups with
depths was observed over the study period in all the three groups with the greatest
was reported by DFDBA versus DFDBA + PRF group. Combination of DFDBA and
PRF improved the clinical and radiographic parameters compared to PRF and
DFDBA alone. PRF was combined with DFDBA to produce a synergistic effect for
52
MATERIALS &
METHOD
Materials and method
were selected for this study from the Outpatient Department of Periodontology,
Study Design:
The study was double blinded, randomized controlled clinical trial. Patients diagnosed
the 1999 International World Workshop were selected for the study. 111 A total of 40
sites were selected for this clinical study, and Phase I therapy was performed in all the
performed to confirm the suitability of the sites for the study. The selected sites were
randomly divided into Group I and Group II according to the type of treatment
rendered to them.
(DFDBA).
Duration of study:
Study was carried out for 6 months with clinical evaluation at baseline, 90th day and
53
Materials and method
Sample Size:
40 sites (20 sites in each group) with intrabony defects were included in the study.
The minimum sample required was calculated taking into consideration the following:
2(1.96+1.26)2 𝑆𝐷2
Minimum sample size is N = =2(10.36) (0.346)/ (0.86)2
𝐷2
= 10 minimum sites
Appling Boneferroni correction for missing data management, a total of 40 sites (20
sites in each group) with intrabony defects was selected for this study.
Sampling Technique-
INCLUSION CRITRIA
54
Materials and method
the defect.
EXCLUSION CRITERIA
wound healing.
5. Subjects showing poor oral hygiene maintenance after initial phase I therapy.
The proposed study was carried out on patients with chronic periodontal disease as
assessed by clinical and radiographical findings. Patient’s verbal and written informed
consent was obtained from all the patients before the commencement of the study. A
brief history of each patient was recorded on a case history proforma. Four weeks
55
Materials and method
CLINICAL PARAMETERS
The clinical parameters used for assessment before and after surgical procedures
were:
Radiographic evaluation:
1. Orthopantomogram (OPG)
at baseline. At 90th day follow-up all the clinical parameters were evaluated. At 180th
day follow-up the clinical parameters as well as the radiographical parameters were
evaluated.
Plaque Index (Silness and Loe, 1964) and Gingival Index (Loe and Silness, 1963) of
56
Materials and method
Plaque Index was evaluated on the cervical third of the tooth with no attention
to the plaque that extended to the middle or incisal thirds. The explorer was passed
across the tooth surface in the cervical third near the entrance of the sulcus.
Score Criteria
1 A film of plaque adhering to the free gingival margin and adjacent area of
the tooth. The plaque may only be recognized by running a probe across
the tooth surface.
The evaluation of scored was done at four areas i.e. the distal-facial, facial,
mesial-facial and lingual surface in the cervical third of the tooth. The scored around
57
Materials and method
each tooth was added and divided by four, the plaque index score for the tooth was
obtained.
Table 3- Suggested Nominal Scale for Patient Evaluation for Plaque Index
Rating Scores
Excellent 0
Good 0.1-0.9
Fair 1.0-1.9
Poor 2.0.3.0
The severity of gingivitis is scored on all surfaces of teeth as done for bleeding
on probing. A blunt instrument, such as a periodontal probe was used to assess the
Score Criteria
58
Materials and method
provoked on probing.
For scoring purpose, the tissues surrounding each tooth were divided into four
gingival scoring units: distal-facial papilla, facial margin, mesial-facial papilla and the
entire lingual gingival margin. The scores around each tooth was added and divided
Table 5- Suggested Nominal Scale for Patient Evaluation for Gingival Index
59
Materials and method
An occlusal stent was fabricated with self-cure acrylic resin on a dental stone cast
(University of North Carolina No. 15 Probe, Hu-Friedy, USA). The occlusal stent was
made to cover the occlusal surfaces of the teeth being treated and were extended on
the buccal and lingual surfaces to cover the coronal third of the teeth involved. A
groove was made in the inter-dental regions, such that the position and angulation of
the probe remained the same for all pre- and post-operative measurements. An
imaginary line was drawn on the bucco-occlusal line angle of the teeth using a black
permanent marker. Using the groove as a guide, the periodontal probe was inserted
into the periodontal pocket until resistance was encountered and PPD (using the
gingival margin as reference), and RAL (using the marking in the stent as reference)
were recorded.
GR was measured from fixed reference point (marking in the stent) to the
PPD, RAL & GR were recorded at baseline i.e. after the completion of phase I
Radiographic Measurements:8
Digital intraoral periapical radiographs were taken for all the sites at baseline and
180th day. The radiographs were standardized by using long cone paralleling
60
Materials and method
exposure time of 0.8 seconds. The radiographic linear bone growth/defect fill were
distance (in mm) measured with the following formula at baseline and at 180th day
follow-up.
At baseline: -
AC = Alveolar crest
At 180th day: -
Amount of defect fill (ADF) = Initial defect depth – defect depth at 180th day
61
Materials and method
CEJ
AC
BD
62
Materials and method
ARMAMENTARIUM
1. Mouth mirror
2. Straight probe
3. Explorer
4. Tweezer
USA)
6. Disposable gloves
8. Disposable syringes
63
Materials and method
28. Amnion membrane (Tissue bank, TATA Memorial Hospital & Research
Center, Mumbai)
29. DFDBA bone granules (Tissue bank, TATA Memorial Hospital & Research
Center, Mumbai)
31. Suture material (Mersilk, No. 3-0, Ethicon, Johnson & Johnson, India)
TREATMENT PROTOCOL
1. Presurgical Procedure:
Initial therapy consisting of full mouth supragingival and subgingival scaling and
root planning was carried out. Detailed instruction regarding self-performed plaque
After four weeks, study subjects were recalled and only those maintaining
optimum oral hygiene were further subjected to the surgical procedure. The PPD,
RAL and GR were recorded for each selected site in all patients.
64
Materials and method
2. Surgical Procedure:
Prior to the surgical procedure, the patients were instructed to rinse with 0.2%
The operative site was anaesthetized with 2% lignocaine HCL with adrenaline
(extending one tooth on either side of the tooth of interest) on the facial and lingual
sides reaching the tip of the interdental papilla using B.P knife with blade no. 11 and
an interdental incision with blade no. 12. A full thickness mucoperiosteal flap was
reflected using the periosteal elevator, taking care that the interdental papillary tissue
root planing was performed using hand instruments and area-specific curettes. No
osseous recontouring was performed. Suture was passed through the elevated flaps as
per the relevant technique prior to performing the regenerative procedure. In Group I,
the intrabony defects was treated with DFDBA allograft and material was filled up to
the level of alveolar crest. In Group II, the intrabony defects was treated with
DFDBA allograft and covered with dry AM. Prior to the regenerative material
placement an aluminum foil template was cut in to the desired amount according to
the osseous defect. Then the AM was trimmed with the help of curved scissors as the
template. After coming in contact with blood dry AM quickly became supple by
hydration and was adapted with hand instruments to cover DFDBA allograft. The AM
was extended ≥ to 3mm beyond defect border and was allowed to touch adjacent root
surfaces. If the AM barrier folded on itself, no attempt was made to unfurl the barrier.
65
Materials and method
After placement of AM, the mucoperiosteal flaps was repositioned and secured in
place using 3-0 non-absorbable black braided silk surgical suture. Direct loop sutures
were placed at the defect site and figure of eight in the adjacent sites. The surgical
area was protected and covered with non-eugenol periodontal dressing. Pressure was
applied to the surgical sites for 1minute with the moistened gauze.
Post-operative care:
periodontal dressing and the sutures. Symptoms regarding discomfort, pain and
displacement, hematoma and necrosis were noted and dressing was replaced for
another one week, if necessary. Recall appointments were given at 90th day and 180th
day post-surgery and the relevant clinical and radiographic parameters were recorded
during these visits. At each visit, oral hygiene instructions were reinforced.
66
Materials and method
STATISTICAL ANALYSIS
Statistical software: The Statistical software namely SPSS v.16.0, was used for the
analysis of the data and Microsoft office and Excel programs used to generate graphs,
tables etc.
Statistical Methods: Descriptive statistical analysis was carried out in the present
Assumptions:
2. Samples drawn from the population should be random, Cases of the samples should
be independent.
Independent t-test:
Independent student t test was used for the comparison of mean Plaque index, Gingival
index, PPD, RAL, Radiographic Defect Depth and Amount of Defect Fill.
It is applied to a data of observation for same variables between two samples. It can
also be applied to paired data of observations from one sample only when each
67
Materials and method
i. Find the difference in each set of observation for the same variables or paired
iii. Calculate the standard deviation (SD) of difference (SD of d’s) and standard
iv. Calculate the ‘t’ value by substituting the above values in the formula:
In its simplest form ANOVA provides a statistical test of whether or not the
means of several groups are all equal, and therefore generalizes t-test to more than two
committing a type I error. For this reason, ANOVAs are useful in comparing two, three
or more means.
The basic principle of ANOVA is to test the difference among the mean of
populations examining the amount of variation within each if these samples, relative to
the amount of variation between the samples. In terms of variation between the given
population, it is assumed that the observation differ from the mean of this population
only because of random effective i.e. there are influence which are unexplainable,
68
Materials and method
whereas in examining the difference in between the population we assume that the
difference between the mean of the jth population and grand mean is attributable to what
is called a specific factor or what is technically described as treatment effect. Thus while
using ANOVA, we assumed that each of the sample was drawn from a normal
population and that each of these population had the same variance, we also assumed
that all factors other than one being tested are effectively controlled, this in other words
means that we assumed the absence of many factors that might affect the conclusion.
ANOVA was used to determine the mean difference between the different time
FORMULA:
Significant figures
KRUSKAL-WALLIS H TEST:
parametric method for testing whether samples originate from the same distribution. It
is used for comparing two or more independent samples of equal or different sample
sizes. It extends the Mann–Whitney U test when there are only two groups. The
69
Materials and method
(ANOVA).
stochastically dominates one other sample. The test does not identify where this
stochastic dominance occurs or for how many pairs of groups stochastic dominance
obtains. For analyzing the specific sample pairs for stochastic dominance in post hoc
testing, Dunn's test, pairwise Mann-Whitney tests without Bonferroni correction, or the
normal distribution of the residuals, unlike the analogous one-way analysis of variance.
If the researcher can make the less stringent assumptions of an identically shaped and
scaled distribution for all groups, except for any difference in medians, then the null
hypothesis is that the medians of all groups are equal, and the alternative hypothesis is
that at least one population median of one group is different from the population median
70
Materials and method
MANN-WHITNEY U TEST:
independent groups is the Mann Whitney U test. The Mann Whitney U test,
sometimes called the Mann Whitney Wilcoxon Test or the Wilcoxon Rank Sum
Test, is used to test whether two samples are likely to derive from the same
population (i.e., that the two populations have the same shape). Some
investigators interpret this test as comparing the medians between the two
populations. Recall that the parametric test compares the means (H0: μ1=μ2)
This test is often performed as a two-sided test and, thus, the research
hypothesis indicates that the populations are not equal as opposed to specifying
The procedure for the test involves pooling the observations from the two
samples into one combined sample, keeping track of which sample each
71
Materials and method
observation comes from, and then ranking lowest to highest from 1 to n1+n2,
respectively.
The test statistic for the Mann Whitney U Test is denoted U and is
where R1 = sum of the ranks for group 1 and R2 = sum of the ranks for group 2.
CHI-SQUARE TEST
simultaneously, with the intersections of the categories of the variables appearing in the
two variables by comparing the observed pattern of responses in the cells to the pattern
that would be expected if the variables were truly independent of each other.
72
Materials and method
from the Chi-Square distribution allows the researcher to assess whether the observed
cell counts are significantly different from the expected cell counts.
intuitive:
2 (𝑓0 − 𝑓𝑒 )2
𝜒 =∑
𝑓𝑒
As depicted in the formula, the Chi-Square statistic was based on the difference
between what was actually observed in the data and what would be expected if there
73
Materials & method
74
Materials & method
75
Materials & method
76
Materials & method
77
Materials & method
Figure 21- Osseous defect between right mandibular first molar and second molar
after debridement
78
Materials & method
79
Materials & method
80
Materials & method
81
Materials & method
82
Materials & method
83
Materials & method
84
Materials & method
Figure 34- Osseous defect between right mandibular second premolar and first
molar after debridement
85
Materials & method
86
Materials & method
87
Materials & method
88
Materials & method
89
OBSERVATION
& RESULTS
Obsevation & Results
years, with moderate to severe chronic periodontitis were included in the study.
Following parameters were recorded at baseline, 90th day and 180th day post
surgically for both group I (DFDBA) and group II (DFDBA and AM):
day:
During the six months period, the wound healing was uneventful, no bone graft
and membrane was exposed, nor were any of the sites eliminated from the study. None
of the selected patients dropped out before the termination of the study.
90
Obsevation & Results
Table 6 - Intragroup comparison of mean Plaque Index at Baseline, 90th day and
interval
time interval:
Statistical test: Tukey’s post-hoc test; (p<0.05- significant, CI=95%), H.S- Highly
Significant
91
Obsevation & Results
Table 8 - Intragroup comparison of mean Plaque Index at Baseline, 90th day and
interval
time interval:
Statistical test: Tukey’s post-hoc test; (p<0.05- significant, CI=95%), H.S - Highly
Significant
92
Obsevation & Results
Table 10: Intergroup comparison of mean Plaque Index between various time
intervals:
Non-Significant
93
Obsevation & Results
The mean PI scores at baseline, 90th day and 180th day for group I (DFDBA)
was 2.07±0.18, 1.02±0.30 and 0.57±0.10 respectively. When the mean PI score was
compared using ANOVA, the difference was found to be statistically highly significant
mean difference of 1.045 and 1.500 from baseline to 90th day and baseline to 180th day
difference between 90th day and 180th day was found to be 0.455 which was also found
The mean PI scores at baseline, 90th day and 180th day for group II (DFDBA +
AM) was 2.05±0.25, 0.96±0.22 and 0.61±0.13 respectively. When the mean PI score
was compared using ANOVA, the difference was found to be statistically highly
showed a mean difference of 1.095 and 1.440 from baseline to 90th day and baseline to
180th day respectively, which was found to be statistically highly significant (P-0.001).
The difference between 90th day and 180th day was 0.345 which was also found to be
94
Obsevation & Results
interval
time interval:
Statistical test: Tukey’s post-hoc test; (p<0.05- significant, CI=95%), H.S. - Highly
Significant
95
Obsevation & Results
interval
time interval:
Statistical test: Tukey’s post-hoc test; (p<0.05- significant, CI=95%), H.S- Highly
Significant
96
Obsevation & Results
Table 15: Intergroup comparison of mean Gingival Index between various time
intervals:
interval difference
DFDBA
20 2.28 0.21
+AM
97
Obsevation & Results
GINGIVAL INDEX (GI) (Table- 10, 11, 12, 13, 14 & Graph-2)
The mean GI scores at baseline, 90th day and 180th day for group I (DFDBA) was
2.14±0.24, 1.39±0.20 and 0.69±0.12 respectively. When the mean GI score was
compared using ANOVA, the difference was found to be statistically highly significant
(P-0.001). (Table – 10) Intragroup comparison using Tukey’s post-hoc test showed a
mean difference of 0.750 and 1.450 from baseline to 90th day and baseline to 180th day
difference between 90th day and 180th day was found to be 0.700 which was also found
The mean GI scores at baseline, 90th day and 180th day for group II (DFDBA +
AM) was 2.28±0.21, 1.45±0.19 and 0.66±0.15 respectively. When the mean GI score
was compared using ANOVA, the difference was found to be statistically highly
significant (P=0.001). (Table – 12) Intragroup comparison using Tukey’s post-hoc test
showed a mean difference of 0.945 and 1.740 from baseline to 90th day and baseline to
180th day respectively, which was found to be statistically highly significant (P-0.001).
The difference between 90th day and 180th day was 0.795 which was also found to be
98
Obsevation & Results
interval
99
Obsevation & Results
interval
100
Obsevation & Results
interval difference
+AM
+AM
101
Obsevation & Results
PROBING POCKET DEPTH (PPD) (Table- 15, 16, 17, 18, 19 & Graph- 3)
The mean PPD at baseline, 90th day and 180th day for group I (DFDBA) was
6.95±0.94, 5.15±0.744 and 4.10±0.78, respectively. When the mean PPD was
compared using ANOVA, the difference was found to be statistically highly significant
(P-0.001). (Table – 15) Intragroup comparison using Tukey’s post-hoc test showed a
mean difference of 1.800 and 2.850 from baseline to 90th day and baseline to 180th day
difference between 90th day and 180th day was found to be 1.050 which was also found
The mean PPD at baseline, 90th day and 180th day for group II (DFDBA + AM)
was 7.30±0.92, 4.60±0.85 and 3.45±0.60 respectively. When the mean PPD was
compared using ANOVA, the difference was found to be statistically highly significant
(P=0.001). (Table – 17) Intragroup comparison using Tukey’s post-hoc test showed a
mean difference of 2.20 and 3.85 from baseline to 90th day and baseline to 180th day
difference between 90th day and 180th day was 1.65 which was also found to be
groups at 90th day and 180th day (Table – 19, Graph – 3), Group II (DFDBA+AM)
102
Obsevation & Results
interval
103
Obsevation & Results
interval
104
Obsevation & Results
+AM
+AM
+AM
105
Obsevation & Results
RELATIVE ATTACHMENT LEVEL (Table- 20, 21, 22, 23, 24 & Graph- 4)
baseline to 10.350±1.78517 at 90th day and 9.300±1.86660 at 180th day. When mean
RAL was compared using ANOVA, the difference was found to be statistically highly
significant (P-0.001) (Table – 20). Intragroup comparison using Tukey’s post-hoc test
showed a mean difference of 1.700 from baseline to 90th day which was found to be
statistically significant (P-0.007) and a mean difference of 2.750 from baseline to 180th
day which was found to be statistically highly significant (P-0.001). However, mean
difference in RAL from 90th day to 180th day was 1.050 which was found to be
at baseline to 9.070±2.1788 at 90th day and 8.043±2.0519 at 180th day. When mean
RAL was compared using ANOVA, the difference was found to be statistically highly
significant (P-0.001) (Table – 22). Intragroup comparison using Tukey’s post-hoc test
showed a change of 2.250 and 3.950 from baseline to 90th day and 180th day
mean difference in RAL from 90th day to 180th day was 1.700 which was found to be
significant showing a P value of 0.099 and comparison of RAL p value was 0.49 and
0.048 at 90th day and 180th day respectively which was found to statistically significant.
106
Obsevation & Results
interval
interval
107
Obsevation & Results
time intervals:
interval difference
+AM
+AM
+AM
108
Obsevation & Results
1.00±0.56 at 90th day and 1.05±0.68 at 180th day. When mean RAL was compared using
baseline to 0.80±0.61 at 90th day and 0.55±0.60 at 180th day. When mean GR was
compared using Kruskal-Wallis H test the difference was found to be statistically non-
and 0.369 at 90th day. However, GR 180th day was found to be statistically significant
109
Obsevation & Results
110
Obsevation & Results
interval difference
+AM
+AM
111
Obsevation & Results
at baseline. At 180th day, the mean radiographic defect depth was 2.1150±0.5742. The
difference in depth was 2.8400 which was statistically highly significant (P-0.001).
(Table – 28)
4.7750±0.4961 at baseline. At 180th day, the mean radiographic defect depth was
1.8550±0.5520. The difference in depth was 2.9200 which was statistically highly
baseline. Comparison of the defect depth using independent sample t test was also
112
Obsevation & Results
Table 32: Intergroup comparison of mean Amount of Defect Fill at 180th day:
interval difference
+AM
Comparison of the amount of defect fill using independent sample t test was
113
Obsevation & Results
DFDBA 20
180 days 23.70 0.04 (S)
DFDBA +AM 20
showed statistically significant difference at 180th day (P-0.04). (Table –32, Graph- 8)
114
Obsevation & Results
DFDBA
2.5
DFDBA+AM
2.07 2.05
2
1.5
MEAN
1.02 0.96
1
0.57 0.61
0.5
0
BASELINE 90TH DAY 180TH DAY
TIME INTERVAL
Graph- 1. Comparison of mean Plaque Score Index between group I and group II
at baseline, 90th day and 180th day
DFDBA
2.5
2.28 DFDBA+AM
2.14
2
1
0.69 0.66
0.5
0
BASELINE 90TH DAY 180TH DAY
TIME INTERVAL
Graph- 2. Comparison of mean Gingival Score Index between group I and group II
at baseline, 90th day and 180th day
115
Obsevation & Results
DFDBA
8 DFDBA+AM
7.3
7 6.95
6
5.15
5 4.6
4.1
MEAN
4 3.45
0
BASELINE 90TH DAY 180TH DAY
TIME INTERVAL
Graph- 3. Comparison of mean Probing Pocket Depth between group I and group
II at baseline, 90th day and 180th day
DFDBA
14
12.9 DFDBA+AM
12 12
10.3
10 9.07 9.3
8.04
8
MEAN
0
BASELINE 90TH DAY 180TH DAY
TIME INTERVAL
116
Obsevation & Results
DFDBA
1.2 DFDBA+AM
1.05
1
1
0.8
0.8 0.7
0.65
MEAN
0.6 0.55
0.4
0.2
0
BASELINE 90TH DAY 180TH DAY
TIME INTERVAL
BASELINE
5 4.955 180TH DAY
4.775
3
MEAN
2.115
1.855
2
0
DFDBA DFDBA+AM
GROUP
117
Obsevation & Results
180TH DAY
2.92 2.92
2.9
2.88
MEAN
2.86
2.84
2.84
2.82
2.8
DFDBA DFDBA+AM
GROUP
Graph- 7. Comparison of mean Amount of Defect Fill between group I and group
II at 180th day
118
DISCUSSION
Discussion
DISCUSSION
predictable regeneration of bone and connective tissue attachment, which has been
and results are not predictable. Healing following conventional therapy is most likely
a more coronal position than before treatment, allowing cells from periodontal ligament
and bone to repopulate the root surface and to form a new periodontal attachment. 118
Alveolar bone and cementum have good potential of regeneration provided that
the necessary cell types and cell signals are present. The same is true for periodontal
ligament, but for this to form a functional attachment, the collagen fibers must become
enclosed by newly formed bone on one surface and cementum on the other. This
requires the regeneration of the three tissues to be finally integrated. Also, for any new
cells, signals, scaffolds, blood supply, mechanical loading and pathogen control. Cells
provide the machinery for new tissue growth and differentiation, whereas growth
factors and other molecules modulate the cellular activity and provide stimuli for cells
is provided by scaffolds to support and facilitate these processes that are critical for
the nutritional base for tissue growth and homeostasis, whereas appropriate mechanical
119
Discussion
loading is essential for the development of highly organized, functional PDL fibers.
Finally, because of the microbial load at the periodontal lesion, strategies to control
infection and host response are required to optimize periodontal regeneration. 120
growth factors and cells during wound healing. In bone regeneration, osteoblasts
proliferate and produce ECM components and local growth factors which play key roles
with bone or bone substitute, stimulation of cells with growth factors, hormones or
extracellular matrix proteins and cell occlusive barrier membrane have all been
repopulation has been an accepted treatment modality for nearly 30 years. In 1976,
the clinical application of this concept was first demonstrated by Nyman et al.124 then
in 1986, Gottlow et al. coined the term guided tissue regeneration (GTR) to describe
this treatment modality, which allows for the formation of bone, cementum, and
GTR therapy has evolved and changed. Initially, non-resorbable occlusive barriers were
used to simply isolate degranulated periodontal intrabony defects. Over the years, bone
or bone substitutes were used to fill these defects, and when covered by a barrier, the
120
Discussion
term combination GTR was used. Non-resorbable barriers were eventually replaced
with bioabsorbable barriers and, more recently, biologic growth factors have been used
properties that actively promote wound healing in lieu of simply providing an occlusive
of achieving defect fill and defect resolution. The autogenous bone graft is considered
as ‘gold standard’ but limited amount of intraoral donor bone, need for second surgical
site for graft procurement and potential risk for root ankylosis and resorption with iliac
crest graft was its drawback. Alloplasts as graft materials have an unlimited supply and
provide greater defect fill and less crestal resorption than debridement alone.
from a tissue bank in the form of FDBA or DFDBA. The use of allografts in the
treatment of periodontal defects has become popular since studies have reported defect
fill of greater than 50% in the majority of treated sites. Histologically, when placed in
significantly more new cementum, new connective tissue, and bone formation in
providing appropriate stiffness for the treatment site. Bone graft material commonly
used for these procedures are DFDBA and FDBA. The osteoinductive properties of
121
Discussion
DFDBA have made it the grafting material of choice as compared to FDBA, xenografts
and alloplasts. The use of DFDBA has seen successfully proven in a histologic study
wherein 80% of test sites showed complete regeneration. The demineralization process
the lost periodontium and specifically the regeneration of alveolar bone. Bone healing
the term “osteoinduction” implies bone formation through the active recruitment of less
differentiated host cells by bioactive diffusible mediators and their eventual expression
eliciting osteogenesis from precursor cell populations has been termed “Bone
matrix is required. Both these elements are made available through the demineralization
defects were selected. Patients with good systemic health and no contraindication to
periodontal surgery were selected, since patients suffering from systemic diseases like
Variation in the assessment of pocket depths and attachment levels may occur
if the probing site and the direction of the probe insertion differ from one measurement
used as a fixed reference point. CEJ is frequently used as a fixed reference point is often
difficult to identify. To eliminate these problems acrylic occlusal stent with groove and
122
Discussion
reference marking was used to provide a landmark for accurate and reproducible
Clinical parameters including plaque index and gingival index were recorded
and probing pocket depth, relative attachment level and gingival recession were
measured from the selected patients at baseline, 90th day and 180th day post-operatively.
All those patients maintaining efficient oral hygiene in recall appointments during
phase I therapy, were considered for the study because of local and behavioral factors
Radiographic evaluation was done at baseline prior to surgery and at 180th day
standardized with long cone paralleling technique with 70 KVp, 10 mA and exposure
manageability of tissues, the selected sites were randomly treated with DFDBA (Group
I) and DFDBA with AM (Group II). All patients in the study showed good compliance
and the healing period was uneventful for both test and control group.
The study did not have non-graft site as control group because numerous studies
have been reported statistically significant results in favor of bone replacement grafts
To the best of our knowledge there are no clinical studies reported using
DFDBA with AM in the treatment of intrabony defects, the present study was done to
evaluate and compare the clinical efficacy of Amnion Membrane with DFDBA bone
parameters.
123
Discussion
All patients participating in the study demonstrated good oral hygiene level and
a healthy gingival condition throughout the study period as indicated by plaque index
(PI) and gingival index (GI) scores. The reduction in PI & GI score was statistically
highly significant in both the groups. This improvement in PI and GI was attributed to
the maintenance of optimum oral hygiene by the patient and regular supportive
periodontal care program. The results obtained in this study were similar with previous
the resolution of inflammation and return of the gingival tissues from a diseased to
health state. Numerous reports based on short term and long-term data indicate that
good oral hygiene reflected by low plaque scores, was associated with enhanced
On comparison between the two groups at 90th day and 180th day post-surgery,
mean plaque index and gingival index was statistically non-significant. Similar findings
Mean change in gingival margin position was not statistically significant for the
Group I (DFDBA) from baseline to 180th day post-surgery. Mean change in gingival
margin position was not statistically significant for the Group II (DFDBA+ AM) from
gingival margin position was statistically not significant and at 180 th day post-surgery
mean change in gingival margin position was statistically significant. Results of this
124
Discussion
directly affects the ability of a clinician to maintain a treated site. In this study, mean
reduction in probing pocket depth was statistically highly significant for the Group I
(DFDBA) from baseline to 180th day. The results of this study are similar to the findings
reduction in pocket depth was also statistically highly significant 180 th day post-
The primary reason for reduction in probing pocket depth after treatment can be
attributed to the reduction in inflammation, shrinkage of the pocket wall and gain in
attachment level. As well as reattachment of collagen fibers and bone fill also impede
penetration of probe.
On comparison between the two groups at 90th day and 180th day post-surgery,
levels due to its fixed reference point (FRP) provides better information relating to gain
or loss of attachment to the root surface and in assessing the disease progression as
have certain inherent shortcomings like its high level of tactile sensitivity and time
status.143
125
Discussion
In this study, mean relative attachment level was statistically highly significant
for the Group I (DFDBA) from baseline to 180th day. The results of this study are
relative attachment level was also statistically highly significant at 180th day post-
surgery. The results of this study are similar to the findings of Camargo et al.141 and
Kher et al.144 who demonstrated notable improvement in the gain in attachment level.
On comparison between the two groups at 90th day and 180th day post-surgery, mean
relative attachment level was statistically significant. Results of this study are similar
The results of the study with respect to mean defect fill for Group I and Group
II were quite similar. Though the value was higher in Group II than in Group I
mathematically, there was no statistically significant difference found between the two
groups. In accordance the present study, some other similar type of clinical trials also
shows no statistically significant difference between combination and bone graft alone
type of therapy.147-149 These studies were in agreement with our study which records no
additional benefit of GTR membrane together with bone graft alone. However, there
are certain studies which favor the combination therapy with respect to bone
fill.145,150,151
biocompatibility of AM. Despite the lack of histologic clues and with respect to
clinical healing, it can be claimed that, cellular adhesion to the membrane surface,
blood clot stabilization, and integration of the membrane with the proliferating
connective tissue of the gingiva occurred. To date, there are no published data on the
use of AM in conjunction with DFDBA for the treatment of intrabony defects. Also,
126
Discussion
there are several variations that make it difficult to compare the results of this clinical
study with those of other studies that examined other biodegradable membranes.
observed. In both groups, uneventful healing and subsequent integrity of soft tissue
were noted.
Since its introduction there have been immense alterations in the processing
of AM, which have resulted in improved clinical outcomes. The lyophilized (freeze-
ligament fibroblasts and can serve as fibrillar scaffolds for early vascular ingrowth. AM
wound protection, and epithelialization effects, that make it different from routinely
It has been shown that AM, through adhesion to the wound surface, can act as
an antibacterial barrier and reduce bacterial infiltration. 154 Thus, it has been speculated
that AM, because of its antibacterial properties, could decrease the risk of infection and,
based on the presence of growth factors, promote healing. AM contains growth factors
that hasten formation of granulation tissue by stimulating the growth of fibroblasts. 155
bioactive matrix that facilitates cell migration. 157 Hence, it can be speculated that the
127
Discussion
tissue in the defects and promote cell migration and wound healing.
The presence of laminin-5 in high concentrations throughout AM, with its high
affinity for gingival epithelial cells, could accelerate healing and integration of the
membrane with gingival tissue.156,158 In other words, it has been claimed that AM has
the ability to form an early physiologic “seal” with the host tissue. This precludes
gingiva may account for the smaller amount of REC observed in the Group II
(DFDBA+ AM). For confirmation of this hypothesis, further studies with histologic
It can also be claimed that the presence of various growth factors in AM, such as
platelet-derived growth factors alpha and beta and transforming growth factor beta, is
likely to induce faster sealing of the defects and limited loss of the grafting material in
layers of cells.161 One of the major advantages of AM, in comparison to other bio-
degradable membranes, is its thinness (320 μm) and good adaptability. The significant
lack of GR observed in the Group II (DFDBA+ AM) might be a result of the thinness
of the AM, which resulted in better adaptation of the membrane over the bony defect
and consequently better coverage of gingiva over the membrane. AM is suggested for
use in areas with limited thickness and height of gingiva, as full coverage of membrane
readily available membrane. Its unique physical nature permits the clinician to ignore
many of the recognized guiding principles for the application of customary barrier
membranes. From a clinical and practical viewpoint, the ease of handling, trimming,
128
Discussion
membrane. The AM used in this study, after being hydrated, needs less defined
trimming and adapts tightly to the underlying grafting material, bony margin, and tooth
noted that this physical property of AM does not afford any space maintenance
capabilities, because of a lack of stiffness. Thus, after becoming dampened by the tissue
fluid, it adapts to the surgical field. Therefore, some kind of space-saving grafting
In an attempt to further improve the clinical outcomes of GTR, this study was
designed to employ a combined periodontal regenerative technique. 162 It means that the
study did not include a nongrafted group. There was no defect selection according to
the number of walls or configuration of the defect in the protocol of the study, so it was
expected that unfavorable and large defects might be encountered during surgery.
According to the rationale for combined periodontal regenerative therapy, the bone
material that is used in conjunction with membranes enhances the stability of the
prevents collapse of the membranes onto the root surface or into the defects during
wound healing, thereby preserving the space necessary for regeneration. Reduced or
space for tissue ingrowth.163 In this study, it was assumed that DFDBA would
enhance and facilitate the proliferation of osteogenic cells through its osteoinductive
quality.
membranes allows the flaps to be sutured over the defects without exerting pressure
on the membranes or displacing them. Owing to the pliability and fragility of AM,
129
Discussion
the presence of DFDBA as a graft material in the defect provided good support for
One of the important factors in the outcome of GTR is the speed at which the
In fact, it is difficult to determine how long the barrier effect of the AM lasts. It has
been claimed that the protective function of AM, acting as a skeletal substructure,
prevention of exposure to the oral cavity might lead to longer degradation time. The
gains in RAL and reductions in PPD in this study make it safe to speculate that the
considered. Although acrylic resin guides were used to confirm the reproducibility of
a smaller margin of error. Reentry was not considered in this study, so the changes
in crestal bone levels and bony defect depths could not be measured directly.
Certainly, the nature of the attachment between the newly regenerated tissue and the
root surface cannot be determined without biopsy of the treated teeth. Histologic
studies are needed to claim true periodontal regeneration. Because none of the teeth
included in this study were candidates for extraction, a histologic study was not
performed. Further studies with a larger sample size over a longer postoperative
membrane.
130
Discussion
addition to its various biologic properties, AM is easy to use as it could be folded and
compressed into narrow spaces between the roots. AM, with its diverse characteristics,
131
SUMMARY &
CONCLUSION
Summary & conclusion
The present study was undertaken with the aim of this study is to evaluate
barrier with DFDBA and DFDBA alone in treatment of periodontal intrabony defect in
chronic periodontitis patients and observing the findings at baseline, 90th day and 180th
day postoperatively.
Clinical parameters:
There was reduction in the mean plaque and gingival indices scores from
In both the groups there was a reduction in mean PPD and gain in RAL which
Group II.
When reduction in PPD and gain in RAL was compared between both the
I.
Radiographic Evaluation:
In both the groups there was decrease in mean defect depth and increase in
significant.
132
Summary & conclusion
From the analysis of the clinical and radiographic results the following conclusions
were drawn:
intrabony defects.
II. However, better results were observed with Group II (DFDBA + AM) in clinical
infrabony defects. Future studies with more critically designed protocols, larger sample
133
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153
ANNEXURES
Annexures
154
Annexures
155
Annexures
DEPARTMENT OF PERIODONTOLOGY
OPD No.:
156
Annexures
Name: Date:
Age: OPD No:
Sex: Case No:
Occupation: Telephone No:
Address:
Chief Complaint:
Personal History:
157
Annexures
AT BASELINE:
DATE:
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
PI SCORE:
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
GI SCORE:
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
158
Annexures
PI SCORE:
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
GI SCORE:
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
PI SCORE:
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
GI SCORE:
159
Annexures
Group II:
Clinical measurements:
Probing
Pocket
Depth
(PPD)
Relative
Attachment
Level
(RAL)
Gingival
recession
(GR)
Radiographic measurements:
160
Annexures
Percentage of
Defect Fill
(area of defect)
3) PROVISIONAL DIAGNOSIS:
4) INVESTIGATIONS:
Complete blood count:
Blood sugar:
Orthopantomograph (OPG):
Radiovisiography (RVG):
Study models:
5) FINAL DIAGNOSIS:
STAFF SIGNATURE
161
Annexures
MASTER TABLE 1
Name Age/ Plaque Index Gingival Index Name Age/ Plaque Index Gingival Index
Sex Baseline th
90 day th
180 day Baseline th
90 day th
180 day Sex Baseline th
90 day th
180 day Baseline 90th day 180th day
Pankaj Patil 31/M 2.1 1.4 0.7 1.8 0.2 0.5 Pankaj Patil 31/M 2.2 1.2 0.6 2.3 1.3 0.8
Bharti Sahu 36/F 2.2 1.5 0.9 2.3 1.1 0.7 I Sunil 26/M 2.4 1.5 0.7 1.9 1.1 0.7
Shailendri Dhahariya 38/F 2.5 1.8 0.8 1.9 0.8 0.5 I Sunil 26/M 2.1 1.2 0.5 2.2 1.2 0.7
Pankaj Patil 31/M 2.2 1.6 0.7 2.1 1.2 0.6 Bharti Sahu 36/F 2.2 1.6 0.8 2.1 1.3 0.6
Rituraj Goswami 40/M 2.4 1.4 0.5 2.3 1.1 0.6 Shailendri Dhahariya 38/F 2.6 1.8 0.8 2.3 1.1 0.5
D Vamsi 25/M 2.3 1.1 0.6 1.9 0.9 0.5 Shailendri Dhahariya 38/F 2.5 1.5 0.6 1.3 0.7 0.4
Rituraj Goswami 40/M 2.4 1.7 0.8 2.1 1.2 0.7 T Anita 31/F 2.8 1.7 0.7 2.3 1.1 0.6
D Vamsi 25/M 2.2 1.2 0.6 1.9 0.8 0.5 Pramila Banjare 35/F 2.5 1.4 0.6 2.1 0.9 0.6
Mohini Sahu 48/F 2.4 1.3 0.7 1.9 0.7 0.5 Bharti Chandrakar 26/F 2.2 1.6 0.6 2.1 1.1 0.7
Shiv Kumari 29/F 1.9 1.2 0.5 1.8 0.8 0.4 Mohini Sahu 48/F 2.3 1.2 0.6 1.9 0.7 0.5
Shiv Kumari 29/F 2.3 1.6 0.9 2.2 1.1 0.8 Shiv Kumari 29/F 2.5 1.5 0.8 1.8 0.8 0.5
Chandana Rao 40/F 1.8 1.1 0.6 1.9 0.9 0.6 Bharti Chandrakar 26/F 2.3 1.2 0.7 1.9 0.7 0.4
Usha Chaubey 42/F 1.8 1.1 0.6 1.8 0.7 0.5 Chandana Rao 40/F 2.5 1.6 0.8 2.1 0.7 0.6
Ganga Das 32/M 2.1 1.3 0.8 2.2 1.2 0.5 Ganga Das 32/M 2.8 1.4 0.9 2.2 0.8 0.5
V Uma 34/F 2.2 1.6 0.9 2.3 1.2 0.7 Dhanesh Ku. Sahu 27/M 2.2 1.3 0.6 1.6 0.7 0.6
Usha Chaubey 42/F 2.5 1.5 0.7 2.2 1.1 0.6 Beena Yadav 31/F 2.6 1.5 0.8 2.2 1.1 0.8
Nandlal Kalet 46/M 1.9 1.4 0.7 2.2 1.2 0.4 Dhanesh Ku. Sahu 27/M 2.4 1.4 0.6 2.2 0.9 0.6
Usha Chaubey 42/F 1.8 1.2 0.5 2.2 1.6 0.7 K Saibabu 54/M 2.6 1.7 0.8 2.2 0.8 0.7
Dhanesh Ku. Sahu 27/M 1.9 1.5 0.6 2.2 1.4 0.6 Vijay Badge 51/M 2.1 1.2 0.5 2.2 0.9 0.6
Bhagraji Yadav 55/F 1.9 1.3 0.7 2.2 1.3 0.5 Vijay Badge 51/M 2.2 1.6 0.2 2.2 1.3 0.9
162
Annexures
MASTER TABLE 2
4 6 4 3 13 11 10 0 1 1 7 4 3 15 12 11 1 1 1
5 6 5 4 13 12 11 1 1 2 8 5 3 14 11 9 1 0 0
6 6 5 4 15 14 13 0 1 1 9 7 4 16 14 11 1 0 0
7 7 6 5 11 10 9 1 2 2 8 5 4 10 7 6 2 1 1
8 6 4 3 10 8 7 1 1 1 7 4 3 10 7 6 2 1 1
9 7 5 4 10 8 7 2 1 1 6 5 4 13 12 11 0 1 1
10 8 6 4 12 10 8 0 2 1 7 5 3 11 9 7 0 1 0
11 7 5 5 11 9 9 0 1 1 6 4 3 12 10 9 1 1 1
12 6 6 4 11 11 9 1 1 2 6 5 4 11 9 7 1 1 0
13 8 6 5 12 10 9 2 1 1 7 7 5 12 12 10 0 0 0
14 7 5 3 12 10 8 0 1 2 8 5 3 12 9 7 1 2 2
15 6 5 4 11 10 9 0 0 0 7 5 4 13 11 10 0 1 0
16 8 6 5 13 11 10 1 1 0 6 5 3 15 14 12 0 1 1
17 6 6 5 15 15 14 1 1 2 7 4 3 14 11 10 0 0 0
18 8 6 5 12 10 9 0 0 1 8 5 3 16 13 11 1 1 0
19 7 5 3 11 9 7 0 1 0 9 5 3 12 8 6 1 1 1
20 6 5 4 12 11 10 0 0 1 8 6 4 11 9 7 2 2 1
163
Annexures
MASTER TABLE 3
5 8 3 5 62.5 5 2 3 60
6 5 1.5 3.5 70 4 1.2 2.8 70
7 6 3 3 50 4.2 2.5 1.7 40.4
8 4.5 2.2 2.3 51.1 5 1.5 3.5 70
9 4.1 1.5 2.6 63.4 5 2 3 60
164