The Present Study Was Performed to Evaluate the Efficacy of Lyophilized-PRF in Treatment of Periodontal Intra-bony Defects (Lyo-PRF -IBDs)

The Efficacy of Lyophilized Platelet-Rich Fibrin in Treatment of Periodontal Intra-Bony Defects (A Comparative Clinical, Radiographic and Biochemical Study)

The present study will be performed to evaluate the efficacy of lyophilized platelet-rich fibrin alone and combined with nanocrystalline hydroxyapatite in treatment of periodontal intra-bony defects through:

1. Primary outcomes:

   • The clinical parameters including: Probing pocket depth (PPD) reduction and clinical attachment level (CAL) gain.
   • The radiographic parameters including: Marginal bone level (MBL), bone-defect fill.
2. Secondary outcome: The level of BMP-2 in Gingival crevicular fluid (GCF).

Study Overview

• Status: Active, not recruiting
• Conditions: Treatment of Periodontal Intra-bony Defects
• Intervention / Treatment: Biological: open flap debridement

Detailed Description

Periodontitis is a multi-factorial inflammatory process affecting the periodontal tissues. Among the characteristic signs of periodontal disease is loss of alveolar bone support. The risk of further alveolar bone loss and the probability of tooth loss increases with the presence of intra-bony defects.

Periodontal intra-bony defects (IBDs) are osseous defects with specific morphology, the bottom of these defects is located more apically than the alveolar crest and they are surrounded by bony walls on 1-, 2-, or 3- sides, with the tooth root forming the additional wall. The prevalence of these defects is significantly lower than supra-crestal periodontal defects.

Among the main goals of periodontal therapy is to regenerate the lost periodontal tissues after arresting the progress of the disease. Surgical management of periodontally affected sites includes conventional and regenerative procedures. The conventional modality of surgical debridement allows for reliable access to root surfaces leading only to healing by repair. While the regenerative treatment options allow for the regeneration of destroyed periodontal ligament and bone. Guided tissue regeneration (GTR), placement of bone grafting materials, the addition of biologic mediators and a combination of such techniques are the different forms of periodontal regenerative techniques.

Bone grafts (BGs) and substitutes are classified into autogenic, allogenic, xenogenic and synthetic bone grafts. Synthetic nanocrystalline hydroxyapatite (NCHA) has been extensively applied as bone graft replacement material and characterized by its osteoconductive properties and improved osseointegrative features. The size of the particle was found to be around 18 nm, allowing for quicker vital bone substitution. It has been proved that NCHA can enhance the adhesion of the bone formative cells (osteoblasts) more than micromaterials. Furthermore, the nano-sized particles provide special properties to NCHA such as ahydrated surface layer, a large surface/volume ratio, this layer is actively involved in the homeostasis process, ionic exchange and other techniques involved in the osteogenesis regulation. NCHA is osteoconductive but has inferior osteoinductive properties; therefore, one of the efforts to increase the ability of this material is to combine it with other bioactive materials such as platelet-rich fibrin (PRF).

Platelet-rich fibrin is a second-generation platelet concentrate that has been widely used in the treatment of bone deficiency and its main action is derived from its high content of platelets that release many growth factors (GFs) and cytokines. However, freshly prepared PRF must be used immediately in order to retain the bioactivity of growth factors. In addition, the bio-degradation rate of PRF is fast and irregular, along with the rapid release of growth factors, and then enzymatically hydrolyzed.

The lyophilization of PRF by vacuum freeze dryer was found to provide a dense three-dimensional fibrin network, better storage stability with a longer half-life and preservation of GFs. Lyophilized platelet-rich fibrin (Ly-PRF) showed adaptability as a viable biomaterial for application as a craniofacial bio-scaffold due to, the advantage of lowering the difficulty in application, providing a newly grown tissue with straightforward access to multiple GFs as well as, sustained release GFs presenting a better tissue regeneration process and bone tissue reconstruction.

It was proven that, Ly-PRF significantly improve the osteogenic differentiation of bone marrow mesenchymal stem cell (BMSC) in vitro through the upregulation of osteogenic markers: collagen type I, osteopontin (OPN), osteocalcin (OCN), and bone morphogenetic protein 2 (BMP-2). BMP-2 is described as being osteoinductive, which is capable of inducing and enhancing bone growth and formation, and it also promotes cell chemotaxis, proliferation and differentiation towards the osteogenic pathway.

The present clinical trial will be performed to clarify and shed some light on Ly-PRF in periodontal regeneration

• Study Type: Interventional
• Enrollment (Estimated): 36
• Phase: Early Phase 1

Contacts and Locations

Study Locations

• Egypt
  • Assuit ., Egypt
    • Faculty of Dental Medicine, Al- Azhar University,

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• All periodontitis patients to be included in this study should be diagnosed as having stage III periodontitis with probing pocket depth (PPD) ≥ 6 mm, and clinical attachment loss (CAL) ≥ 5mm.
• 2- or 3-wall intra-bony interproximal defect with depth ≥3 mm, a width of ≥3 mm at its most coronal part and 45-55-degree angulation will be selected in order to reduce defect variability.
• All patients will be free from any systemic diseases according to the American Dental Academy general guidelines for referring dental patients to specialists and other care settings

Exclusion Criteria:

• Any patients with any systemic condition that contraindicate any surgical intervention.
• Pregnant or lactating females, smokers, or alcoholic patients.
• Patients with intra-bony defects received drugs that affect bone turnover such as (chemotherapy and radiotherapy).
• History of periodontal therapy and antibiotic administration in the last 6 months.
• Patients taking any medicine which may affect the function of platelet (i.e., aspirin) in the previous 3 months.
• Miller grade II or greater mobility, furcation involvement as well as one-wall defects and interdental craters.
• Patients with unacceptable oral hygiene after the re-evaluation of phase I therapy.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Placebo Comparator: open flap debridement; Immediately before surgery, patients rinsed with 0.12% chlorhexidine digluconate and povidone iodine solution was used to perform extra-oral antisepsis. The surgical site was anaesthetized. A mucoperiosteal flap was elevated and reflected followed by thorough debridement of all inflammatory granulation tissue from IBD until a sound, healthy bone surface was obtained. Root surface debridement was also performed. Copious irrigation with normal saline solution. The flap was repositioned and sutured.	Biological: open flap debridement; does lyophilized platelet rich fibrin combined with open flap debridement or combination of open flap debridement, lyophilized platelet rich fibrin and nano-crystalline hydroxyapatite bone substitute can add benefits to open flap debridement alone or not; Other Names: lyophilized platelet rich fibrin combined with open flap debridement; combination of lyophilized platelet rich fibrin and nano-crystalline hydroxyapatite bone substitute
Active Comparator: lyophilized platelet rich fibrin; Immediately before surgery, patients rinsed with 0.12% chlorhexidine digluconate and povidone iodine solution was used to perform extra-oral antisepsis. The surgical site was anaesthetized. A mucoperiosteal flap was elevated and reflected followed by thorough debridement of all inflammatory granulation tissue from IBD until a sound, healthy bone surface was obtained. Root surface debridement was also performed. Copious irrigation with normal saline solution. The lyophilized-PRF granules was hydrated with a few drops of normal saline then, it was applied and packed to fill defect. The flap was repositioned and sutured.	Biological: open flap debridement; does lyophilized platelet rich fibrin combined with open flap debridement or combination of open flap debridement, lyophilized platelet rich fibrin and nano-crystalline hydroxyapatite bone substitute can add benefits to open flap debridement alone or not; Other Names: lyophilized platelet rich fibrin combined with open flap debridement; combination of lyophilized platelet rich fibrin and nano-crystalline hydroxyapatite bone substitute
Active Comparator: lyo-PRF and nanocrystalline hydroxyapatite bone graft; Immediately before surgery, patients rinsed with 0.12% chlorhexidine digluconate and povidone iodine solution was used to perform extra-oral antisepsis. The surgical site was anaesthetized. A mucoperiosteal flap was elevated and reflected followed by thorough debridement of all inflammatory granulation tissue from IBD until a sound, healthy bone surface was obtained. Root surface debridement was also performed. Copious irrigation with normal saline solution. A mixture of Ly-PRF and n-HA (1:1by weight) was hydrated with a few drops of normal saline then, it was applied and packed to fill the defect. The flap was repositioned and sutured.	Biological: open flap debridement; does lyophilized platelet rich fibrin combined with open flap debridement or combination of open flap debridement, lyophilized platelet rich fibrin and nano-crystalline hydroxyapatite bone substitute can add benefits to open flap debridement alone or not; Other Names: lyophilized platelet rich fibrin combined with open flap debridement; combination of lyophilized platelet rich fibrin and nano-crystalline hydroxyapatite bone substitute

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
radiographic parameters	The radiographic parameters including: Bone-defect fill in mm.	baseline, 3, 6, and 9 months after treatment
clinical parameters	The clinical parameters including: Clinical attachment level (CAL) gain in mm.	baseline, 3, 6, and 9 months after treatment.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
biochemical evaluation	The level of BMP-2 (Pg/ml) in Gingival crevicular fluid (GCF).	baseline, 1, 4 and 12 weeks after surgery

Collaborators and Investigators

• Sponsor: Al-Azhar University

Publications and helpful links

General Publications

• Anoixiadou S, Parashis A, Vouros I. Minimally Invasive Non-Surgical Technique in the Treatment of Intrabony Defects-A Narrative Review. Dent J (Basel). 2023 Jan 11;11(1):25. doi: 10.3390/dj11010025.
• Tavelli L, Chen CJ, Barootchi S, Kim DM. Efficacy of biologics for the treatment of periodontal infrabony defects: An American Academy of Periodontology best evidence systematic review and network meta-analysis. J Periodontol. 2022 Dec;93(12):1803-1826. doi: 10.1002/JPER.22-0120. Epub 2022 Oct 24.
• Zhao R, Yang R, Cooper PR, Khurshid Z, Shavandi A, Ratnayake J. Bone Grafts and Substitutes in Dentistry: A Review of Current Trends and Developments. Molecules. 2021 May 18;26(10):3007. doi: 10.3390/molecules26103007.
• Shaikh MS, Zafar MS, Alnazzawi A, Javed F. Nanocrystalline hydroxyapatite in regeneration of periodontal intrabony defects: A systematic review and meta-analysis. Ann Anat. 2022 Feb;240:151877. doi: 10.1016/j.aanat.2021.151877. Epub 2021 Dec 2.
• Liu X, Yin M, Li Y, Wang J, Da J, Liu Z, Zhang K, Liu L, Zhang W, Wang P, Jin H, Zhang B. Genipin modified lyophilized platelet-rich fibrin scaffold for sustained release of growth factors to promote bone regeneration. Front Physiol. 2022 Sep 30;13:1007692. doi: 10.3389/fphys.2022.1007692. eCollection 2022.
• Wang Z, Han L, Sun T, Wang W, Li X, Wu B. Preparation and effect of lyophilized platelet-rich fibrin on the osteogenic potential of bone marrow mesenchymal stem cells in vitro and in vivo. Heliyon. 2019 Nov 1;5(10):e02739. doi: 10.1016/j.heliyon.2019.e02739. eCollection 2019 Oct.
• Ngah NA, Dias GJ, Tong DC, Mohd Noor SNF, Ratnayake J, Cooper PR, Hussaini HM. Lyophilised Platelet-Rich Fibrin: Physical and Biological Characterisation. Molecules. 2021 Nov 25;26(23):7131. doi: 10.3390/molecules26237131.
• Zhu L, Liu Y, Wang A, Zhu Z, Li Y, Zhu C, Che Z, Liu T, Liu H, Huang L. Application of BMP in Bone Tissue Engineering. Front Bioeng Biotechnol. 2022 Mar 31;10:810880. doi: 10.3389/fbioe.2022.810880. eCollection 2022.
• Tsoromokos N, Parinussa S, Claessen F, Moin DA, Loos BG. Estimation of Alveolar Bone Loss in Periodontitis Using Machine Learning. Int Dent J. 2022 Oct;72(5):621-627. doi: 10.1016/j.identj.2022.02.009. Epub 2022 May 13.

Helpful Links

• Combination of Nanocrystalline Hydroxyapatite and Injectable Platelet-Rich Fibrin on Bone Graft Materials for Alveolar Bone Preservation

Study record dates

Study Major Dates

• Study Start (Actual): November 19, 2023
• Primary Completion (Estimated): May 1, 2025
• Study Completion (Estimated): May 1, 2025

Study Registration Dates

• First Submitted: September 26, 2024
• First Submitted That Met QC Criteria: October 1, 2024
• First Posted (Actual): October 3, 2024

Study Record Updates

• Last Update Posted (Actual): October 15, 2024
• Last Update Submitted That Met QC Criteria: October 10, 2024
• Last Verified: October 1, 2024

More Information

Terms related to this study

• Keywords: periodontitis; lyophilized-PRF; Periodontal intra-Bony Defects; Periodontal angular bone defect
• Additional Relevant MeSH Terms: Stomatognathic Diseases; Periodontal Diseases; Mouth Diseases; Periodontitis
• Other Study ID Numbers: periodontal treatments

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No