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32سورة البقرة آية
Clinical and Histopathological
Assessment of the Healing
Potential of Periapical Lesions
Using Different Protocols
By Doaa Gamal Abdel Mouez Basta
Under Supervision of
Prof. Dr. Hossam Mohammed Tawfik Dean faculty of dentistry, Misr International University
Professor of Endodontics
Faculty of Dentistry, Ain Shams University
Prof. Dr. Kariem Mostafa El-Batouty Vice Dean Faculty of Dentistry, Ain Shams University
Professor of Endodontics
Faculty of Dentistry, Ain Shams University
Prof. Dr. Ashraf Mohamed Abdel-Rahman Abu Seida Professor of Surgery, Anesthesiology and Radiology
Faculty of Veterinary Medicine, Cairo University
Acknowledgment
Dedication
Introduction
Periradicular surgery is an important part in modern
endodontic practice.
Introduction
Most periapical radiolucent
lesions heal with
Conventional endodontic
treatment some cases may require
periradicular surgery However
Pathologic
tissues
to remove
Micro-
oranisms Source of
irritation
Introduction
The final outcome of the nature of wound
healing after endodontic surgery can be
Repair Regeneration
Not an ideal outcome
after wound healing Regeneration approaches
Depending on:
Nature of wound.
Availability of
progenitor cells
To restore the lost tissues
(bone, PDL, cementum and
C,T) have been introduced
For optimum healing of periapical defect area after surgery.
1. Disinfection of the peri-apical area should be done by
application of combination of antibiotic drugs (metronidazole,
ciprofloxacin and doxycyclin).
2. Application of regenerative therapies like;
a) Synthetic bone graft to fill the intra bony defects with
excellent bone conducting properties.
b) Platelet rich fibrin also have been used as a barrier
membrane achieving the concept of guided tissue
regeneration by maintaining confined space for
regenerative cells for greater periapical bone.
Introduction
PRF act as healing biomaterial, as it accelerate
wound closure and mucosal healing due to fibrin
bandage, growth factor release and it act as inter
positional biomaterial which act as a barrier between
the desired and undesired cells so prevent early
invagination of the undesired cells.
Introduction
Aim of the Study
Aim of the Study
The aim of the present study was to detect
the role of Platelet Rich Fibrin, synthetic
bone graft and triple antibiotic paste in
healing and regeneration of periapical
tissues following periapical surgery. The
study included the evaluation of clinical,
radiographic and histopathologic changes.
Materials and Methods
I-Materials.
1- PRF (platelet rich fibrin) (10 mL blood (dog's blood).
2- TAP (triple antibiotic paste).
a. Ciprofloxacin 250 mg.
b. Metronidazole 500 mg.
c. Doxycycline 100 mg.
3- Synthetic bone graft G-BONE.
Materials and Methods
II- Methods
I- Selection and preoperative care for animal model
II- Classification of samples.
Materials and Methods
III- Experimental procedures:
A-Anaesthetizing animals.
B-Induction of periapical pathosis.
Materials and Methods
C-Root canal instrumentation and obturation.
Materials and Methods
Root canal instrumentation Obturation
D- Surgical procedures
1. Induction and maintenance of anesthesia.
2. Incision and reflection of soft tissues.
3. Standardization of surgically created bone defects (Osseous
cavities of about 4x4mm in diameter).
Materials and Methods
4- Augmentation of the bony defects with the different
tested materials.
According to the tested material used for filling the
osseous defects, bone defects were divided into :
o 3 experimental groups.
o 1 control group.
Materials and Methods
The four groups were as follow.
Group I. PRF with synthetic bone graft and triple antibiotic
paste.
The bony defects were filled with
1- Synthetic bone graft (G-Bone).
Materials and Methods
Synthetic hydroxyapatite
bone granules
2- Triple antibiotic paste or mix
Materials and Methods
3- Platelet rich fibrin (PRF)
Group II. PRF with synthetic bone graft without triple antibiotic
paste
The defect was filled with synthetic bone graft granules and PRF
(platelet rich fibrin) was placed as a membrane covering it as
mentioned previously but without the triple antibiotic paste.
Group III. PRF with triple antibiotic paste without bone graft
The defect was filled with PRF (platelet rich fibrin) with the
triple antibiotic paste. Without bone graft.
Group IV (Control):
The bony defect was left empty without placement of any
material.
Materials and Methods
5- Repositioning of the flap and suturing.
Materials and Methods
6- Euthanasia of animals.
3 dogs were sacrificed after one month of surgical procedure,
representing (subgroup A).
the remaining three dogs were sacrificed after 3 months of
surgical procedures representing (subgroup B).
The maxilla and mandible of each dog were removed surgically
and they were fixed in formalin solution. Blocks containing a
single tooth with its surrounding bone were obtained by
sectioning the jaws.
Materials and Methods
IV- Methods of evaluation.
A-Radiographic evaluation.
Each quadrant in every dog was radiographed several
times as follows.
i. Pre-operative.
ii. After induction of periapical lesions.
iii. Immediate post obturation.
iv. After one month of periapical surgery.
v. After three months of periapical surgery.
Materials and Methods
Radiographs were taken using conventional films which were
digitized and image analysis was performed using Digora image
analysis software to measure the periapical bone density.
Radiophotographs showing measurement of bone density using
digora software during induction period, one months and three
months
Materials and Methods
Induction period One month Three months
B- Histopathologic evaluation.
For histopathologic evaluations, the following was included.
1- Quantitative Evaluation.
i. Inflammatory cell count:
From each section, 3 microscopic fields of the periapical
region were captured at original magnification of 40X for
inflammatory cell count.
ii. Percentage of newly formed bone (bone area fraction):
For bone area fraction 2 fields at original magnification
20X were obtained for each section.
2- Qualitative Evaluation.
Materials and Methods
Results
Results
First part of the study
I-Radiographic evaluation:
A- Radiodensity of periapical bone:
a-Radiodensity of periapical bone among groups:
108.5
109
109.5
110
110.5
111
111.5
112
Group I Group II Group III Group IV
109.85
110.59
111.77
111.01
Ra
dio
de
nsity o
f b
on
e in p
eria
pic
al
are
a a
t In
du
ctio
n P
erio
d
Bar chart representing mean values of radiodensties of periapical bone
in the four groups in the induction period
- Induction period
Results
- One month and three months evaluation periods
Bar chart representing mean values of
radiodensties of periapical bone in the
four groups in the one month
evaluation period
0
20
40
60
80
100
120
140
160
Group I Group II Group III Group IV
115.82
141.89
104.1
119.69
Radio
density o
f bone in
peria
pic
al are
a a
t 1 m
onth
Bar chart representing mean values of
radiodensities of periapical bone in the
four groups in the three months
evaluation period
0
50
100
150
200
250
Group I Group II Group III Group IV
119.02
204.94
105.8447 123.43
Radio
density o
f bone in
peria
pic
al are
a a
t 3 m
onth
Results
104
106
108
110
112
114
116
118
120
Induction 1 month 3 months
109.85
115.82
119.02
Rad
iod
en
sity o
f b
on
e in
pe
ria
pic
al a
rea
Group I
b- Radiodensity of periapical bone among subgroups in all groups:
0
50
100
150
200
250
Induction 1 month 3 months
110.59
141.89
204.94
Rad
iod
en
sity o
f b
on
e in
pe
ria
pic
al a
rea
Group II
100
102
104
106
108
110
112
Induction 1 month 3 months
111.77
104.1
105.85
Rad
iod
en
sity o
f b
on
e in
pe
ria
pic
al a
rea
Group III
104
106
108
110
112
114
116
118
120
122
124
Induction 1 month 3 months
111.01
119.69
123.43
Rad
iod
en
sity o
f b
on
e in
pe
ria
pic
al a
rea
Group IV
Bar chart representing mean values of difference in radiodensties of periapical
bone in the four groups in the period between induction and one month
Results
5.52
28.69
-7.67
7.95
-10
-5
0
5
10
15
20
25
30
35
Group I Group II Group III Group IV
Diffe
rence in R
adio
density o
f bone in p
eriapic
al
are
a f
rom
induction t
o 1
month
B- Percentage of (difference) of radiodensity of periapical bone in two evaluation
periods between (induction, one month) and between (one month, three months)
a- Percentage of difference in radiodensity among groups:
-Difference in radiodensity from(induction to one month) among groups
Bar chart representing mean values of difference in radiodensties of
periapical bone in the four groups in the period between one month
and three months
Results
2.94
44.95
1.74 3.12
0
5
10
15
20
25
30
35
40
45
50
Group I Group II Group III Group IV
Diffe
rence in R
adio
density o
f bone in p
eriapic
al
are
a f
rom
1 m
onth
to 3
month
s
- Difference in radiodensity from (one month to three months)
Bar chart representing mean values of
percentage of difference of radiodensities
of periapical bone(from induction to one
month) and (from one month to three
months) evaluation periods in group I
Results
0
1
2
3
4
5
6
Between induction and 1 month Between 1month and 3 months
5.52
2.94
Diffe
rence in
radio
density
Group I
b- Percentage of difference in radiodensity among subgroups
Bar chart representing mean values of
percentage of difference of radiodensities
of periapical bone (from induction to one
month)and (from one month to three
months) evaluation periods in group IV
0
1
2
3
4
5
6
7
8
Between induction and 1month
Between 1month and 3months
7.95
3.12 D
iffe
ren
ce in
rad
iod
en
sit
y
Group IV
Bar chart representing mean values
of percentage of difference of
radiodensities of periapical bone
(from induction to one month) and
(from one month to three months)
evaluation periods in group II
Results
0
5
10
15
20
25
30
35
40
45
Between induction and 1month
Between 1month and 3months
28.69
44.95
Diffe
rence in
radio
density
Group II
Bar chart representing mean values
of percentage of difference of
radiodensities of periapical bone
(from induction to one month) and
(from one month to three months)
evaluation periods in group III
-7.67
1.74
-10
-8
-6
-4
-2
0
2
4
Between induction and 1 month Between 1month and 3 months
Diffe
rence in
radio
density
Group III
Bar chart representing mean
values of inflammatory cell
count for the four groups at
one month evaluation period
Results
0
50
100
150
200
250
300
350
400
450
500
Group I Group II Group III Group IV
290.8
41.2
485.13
211.53
Infla
mm
ato
ry c
ell
count at
1 m
onth
Second part of the study
II- Histopathologic evaluation:
1- Quantitative evaluation:
(i) Inflammatory cell count
a- Effect of material (procedure) in each evaluation period:
Bar chart representing mean
values of inflammatory cell
count for the four groups at
three months evaluation period
0
50
100
150
200
250
300
350
400
Group I Group II Group III Group IV
204.27
20.2
367.67
153.13
Infla
mm
ato
ry c
ell
count at
3 m
onth
Results
0
50
100
150
200
250
300
1 month 3 months
290.8
204.27
Infla
mm
ato
ry c
ell
count
Group I
b- Effect of time (evaluation periods):
0
5
10
15
20
25
30
35
40
45
1 month 3 months
41.2
20.2
Infla
mm
ato
ry c
ell
count
Group II
0
50
100
150
200
250
300
350
400
450
500
1 month 3 months
485.13
367.67
Infla
mm
ato
ry c
ell
count
Group III
0
50
100
150
200
250
1 month 3 months
211.53
153.13 In
fla
mm
ato
ry c
ell
count
Group IV
Bar chart representing mean values
of percentage of newly formed bone
in one month evaluation period in
the four groups
Results
0
5
10
15
20
25
Group I Group II Group III Group IV
5.97
23.93
3.56
9.41
Pe
rce
nta
ge
of
ne
wly
fo
rme
d b
on
e %
at 1
m
on
th
(ii) Percentage of newly formed bone (measurement of bone area fraction):
a- Effect of material (procedure) in each evaluation period:
- One month and three months evaluation periods:
Bar chart representing mean values
of percentage of newly formed bone
in one month evaluation period in
the four groups
0
10
20
30
40
50
60
Group I Group II Group III Group IV
9.15
53.58
7.9 12.47
Perc
enta
ge o
f new
ly f
orm
ed b
one %
at
3
month
Results
0
1
2
3
4
5
6
7
8
9
10
1 month 3 months
5.97
9.15
Perc
enta
ge o
f new
ly f
orm
ed b
one %
Group I
b- Effect of time (evaluation period):
0
10
20
30
40
50
60
1 month 3 months
23.93
53.58
Perc
enta
ge o
f new
ly f
orm
ed b
one %
Group II
0
1
2
3
4
5
6
7
8
1 month 3 months
3.56
7.9
Perc
enta
ge o
f new
ly f
orm
ed b
one %
Group III
0
2
4
6
8
10
12
14
1 month 3 months
9.41
12.47
Perc
enta
ge o
f new
ly f
orm
ed b
one %
Group IV
At one month
Photomicrograph for sample from
group I at one month evaluation
period. (H & E,400X)
Results
At three months
Photomicrograph for sample from
group I at three months evaluation
period..(H & E,400X)
2- Qualitative Evaluation: Group I:
Inflammatory cells:
At one month
Photomicrograph for sample from
group I at one month evaluation
period.(H &E,200X)
Results
at three months
Photomicrograph for sample from
group I at three months evaluation
period(H &E,200X)
Group I:
Bone:
Inflammatory cells
Photomicrograph for sample from
group II at one month evaluation
period,(H &E,400X)
Results
Group II:
At one month:
Bone
Photomicrograph for sample from
group II at one month evaluation
period(H & E,200X)
Results
Bone
Photomicrograph for sample from
group II at three months
evaluation period.(H &E,200X)
Inflammatory cells
Photomicrograph for sample from
group II at three months
evaluation period(H &E,400X)
Group II:
At three months:
At one month
Photomicrograph for sample from
group III after one month
evaluation period (H&E,400X)
Results
At three months
Photomicrograph for sample from
group III after three month
evaluation period,(H &E,400X).
Group III:
Inflammatory cells:
At one month
Photomicrograph for sample from
group III at one month evaluation
period.(H&E,200X)
Results
At three months
Photomicrograph for sample from
group III at three months
evaluation period,(H &E,200X)
Group III:
Bone:
Inflammatory cells
Photomicrograph for sample from
group IV at one month evaluation
period. (H &E,400X)
Results
Bone
Photomicrograph for sample from
group IV at one month evaluation
period(H &E, 200X)
Group IV:
At one month:
Results
Bone
Photomicrograph for sample from
group IV at three months
evaluation period(H &E,200X)
Inflammatory cells
Photomicrograph for sample from
group IV at three months
evaluation period(H&E,400X)
Group IV:
At three month:
Conclusions
Within the limitation of this study it can be concluded that.
1. Regeneration techniques using platelet rich fibrin and
synthetic bone graft provide better healing potential than
normal healing process to the periapical bony defects.
2. Placement of triple antibiotic powder directly in the wound
with the clinically used concentration (1000 mg/ml) may be
toxic to the cells and so impair the regeneration potential of
the tissues.
Conclusion
Clinical Relevance and
Recommendations
Clinical relevance
Clinically the use of regenerative materials
like platelet rich fibrin and synthetic bone
grafts provides better healing and efficient
bone and tissue regeneration.
Recommendations
Recommendations
1. Using triple antibiotic powder or paste with lower
concentrations (0.1 mg/ml) (diluted mix).
2. Investigating the healing potential of regeneration
techniques in larger periapical bony defects than
used in the current study.
3. Using the regenerative techniques or materials
which were used in this study on humans.
Clinical Relevance and Recommendations
Thank you
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