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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 31  |  Issue : 4  |  Page : 311-317

A Study to Evaluate the Efficacy of Platelet Rich Fibrin with Nanocrystalline Beta-Tricalcium Phosphate in the Treatment of Periodontal Intrabony Defects


1 Department of Dentistry, Oral Medicine and Radiology, IGIMS, Patna, Bihar, India
2 Department of Periodontics, Buddha Institute of Dental Sciences and Hospital, Patna, Bihar, India

Date of Submission07-Dec-2019
Date of Acceptance28-Dec-2019
Date of Web Publication03-Mar-2020

Correspondence Address:
Dr. Sneha Mayuri
Department of Periodontics, Buddha Institute of Dental Sciences and Hospital, Patna, Bihar; C/O Dr. Naresh Prasad, Ayodhya Niwas, 85-A Block, Road No-2B, Rajendra Nagar, Patna - 800 016, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_202_19

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   Abstract 


Background: Presently, there is no gold-standard regenerative material for the treatment of periodontal intrabony defects. The use of bone grafts in combination with guided tissue regeneration membrane is a predictable treatment option but is expensive. Platelet concentrates are increasingly being used due to their ease of use and cost-effectiveness. Aims: The objective of the present study is to compare clinically and also by Cone Beam Computed Tomography (CBCT), the effect of platelet-rich fibrin combined with synthetic beta-tricalcium phosphate to synthetic beta-tricalcium phosphate alone in the treatment of periodontal intrabony defects. Materials and Methods: 10 patients possessing 2 almost identical interproximal intrabony defects in either side of mandible were selected and the defects were further divided into 2 groups randomly: Control Group A (Beta-tricalcium phosphate placed) and Test Group B (Beta-tricalcium phosphate with platelet-rich fibrin placed). Regeneration of soft tissue and hard tissue (using CBCT) were evaluated after 6 months from baseline in both groups. Statistical Analysis Used: The intragroup and intergroup comparisons were done using Paired and student t-test. Results: Intragroup showed significant improvement in both soft tissue and hard tissue parameters. Mean of all parameters was better in the test group; however, the intergroup difference was not statistically significant. Conclusions: Within the limitations of the present study, the use of beta-tricalcium phosphate bone graft combined with platelet-rich fibrin and beta-tricalcium phosphate bone graft alone are both equally effective for the treatment of periodontal intrabony defects.

Keywords: Beta-tricalcium phosphate, periodontal tissue regeneration, platelet concentrates


How to cite this article:
Singh N, Mayuri S, Banerjee A, Biswas N, Singh PK, Sehgal R. A Study to Evaluate the Efficacy of Platelet Rich Fibrin with Nanocrystalline Beta-Tricalcium Phosphate in the Treatment of Periodontal Intrabony Defects. J Indian Acad Oral Med Radiol 2019;31:311-7

How to cite this URL:
Singh N, Mayuri S, Banerjee A, Biswas N, Singh PK, Sehgal R. A Study to Evaluate the Efficacy of Platelet Rich Fibrin with Nanocrystalline Beta-Tricalcium Phosphate in the Treatment of Periodontal Intrabony Defects. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2020 Apr 4];31:311-7. Available from: http://www.jiaomr.in/text.asp?2019/31/4/311/279863




   Introduction Top


The optimal periodontal treatment should aim not only for the arrest of disease but also for the regeneration of structures lost due to disease. Bone grafting is one of the most common forms of regenerative therapy and is usually essential for restoring periodontal supporting tissues.[1] In the present study, beta-tricalcium phosphate, which is a bioceramic material, with Ca/PO4 ratio similar to natural bone, has been used as a bone graft.

Growth factors have recently emerged as an important factor in periodontal regeneration and have shown promising results. Growth factors are a class of natural biologic mediators that regulate key cellular events in tissue regeneration including cell proliferation, chemotaxis, differentiation, and matrix synthesis via binding to specific cell surface receptors.[2]

Platelet-rich fibrin is a second-generation platelet-rich concentrate introduced by Choukroun et al. in 2001 which is an autologous platelet-rich fibrin (PRF) gel with growth factors and has several advantages.

PRF acts by releasing polypeptide growth factors, such as transforming growth factor-b1, platelet-derived growth factor, vascular endothelial growth factor (VEGF), and matrix glycoproteins into the surgical wound in a sustained fashion for at least 7 days as shown in vitro.[3]

PRF could improve the periodontal osseous defect healing, as PRF can up regulate phosphorylated extracellular signal-regulated protein kinase expression and suppress the osteoclastogenesis by promoting secretion of osteoprotegerin (OPG) in osteoblasts cultures.[4] Hence, the clinician can expect less post surgical discomfort, rapid soft tissue healing with less edema compared with other techniques.[5]

Although multiple studies have been done with beta-tricalcium phosphate and platelet-rich fibrin as regenerative materials for vertical bone defects separately,[6],[7],[8] there is a dearth of studies regarding the use of both these materials together and also regarding the interpretation of treatment outcome using cone-beam computed tomography (CBCT), by which we get more reliable data than by conventional 2D imaging techniques. This deficiency necessitated the present study.


   Aims and Objectives Top


The objective of the present study is to compare clinically and also by cone-beam computed tomography (CBCT), a three-dimensional imaging technique, the effect of platelet-rich fibrin combined with synthetic beta-tricalcium phosphate to synthetic beta-tricalcium phosphate alone in the treatment of periodontal intrabony defects.


   Materials and Methods Top


10 systemically healthy patients possessing almost 2 identical interproximal intrabony defects in either side of mandible reporting to the Outpatient Department (O.P.D) of Periodontology at Buddha Institute of Dental Sciences and Hospital, Postgraduate Institute and Research Center Patna, Bihar were selected. Ethical clearance and consent was taken for all patients.

Inclusion criteria

  1. Systemically healthy subjects.
  2. Presence of almost 2 identical interproximal intrabony 3 walled defects on either side of mandibular arch clinically assessed and assumed by radiograph.
  3. Clinical probing depth of at least 5 mm at the defect site without furcation involvement.
  4. Subjects who had not taken antibiotics 6 months prior to initial examination.
  5. No periodontal surgery performed in the areas to be treated within the last 12 months.


Exclusion criteria

  1. Patient with any systemic disease or condition that contraindicate periodontal surgery.
  2. Patients having low platelet count for PRF preparation, that is, less than 1,50,000 per microliter of circulating blood.
  3. Patient with unacceptable oral hygiene after reevaluation of phase 1 therapy.
  4. Patients using tobacco in any form.
  5. Pregnant or lactating mothers.
  6. Untreated acute infection at a surgical site.
  7. Teeth with endodontic involvement and mobility of grade III.
  8. Unwilling and noncompliant patients.
  9. Patients under medications that can affect periodontal wound healing.


For selected subjects, detailed history, clinical examination, and routine investigations were done. Sagittal cone-beam computerized tomogram (CBCT) was done for the defect parameters. Two measurements were performed for each site: the depth of the defect, measured from the CEJ to the bottom of the defect; and the width of the defect, measured from the highest point of the alveolar crest (AC) to the dental root adjacent to the defect. All subjects were treated with initial phase I–therapy and were reevaluated after 6 weeks.

Study design

The study was a split-mouth randomized controlled clinical trial where 20 sites in contralateral quadrants of 10 patients were taken. The sites were divided into 2 groups randomly [Figure 1].
Figure 1: Flowchart of Study Design

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Control Group A

Placement of synthetic nanocrystalline beta-tricalcium phosphate (600–700 micron) alone [Figure 2].
Figure 2: Beta-tricalcium phosphate placed in control site

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Test Group B

Placement of synthetic nanocrystalline beta-tricalcium phosphate (600–700 micron) with platelet-rich fibrin [Figure 3].
Figure 3: Platelet-rich fibrin and beta-tricalcium phosphate placed in test site

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Probing pocket depth, gingival recession, and clinical attachment loss of selected site were recorded using acrylic occlusal stent before surgery and again was recorded 6 months postoperatively [Figure 4]. Radiographic parameters of each defect was recorded before surgery and again after 6 months post operatively [Figure 5].
Figure 4: Comparative reevaluation of surgical sites

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Figure 5: CBCT Report (Re Evaluation After 6 Months)

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Platelet-rich fibrin preparation

Following Choukroun' s method of PRF preparation, immediately before the surgical procedure, 10 ml of blood was drawn from the subject's vein. The blood-containing tube was immediately centrifuged at a rate of 3000 rpm for 10 min. The centrifuged blood mass presented with a structured fibrin clot in the middle of the tube, between the red corpuscle layer on the bottom and the acellular plasma on top. The fibrin clot could easily be removed from the tube. In the present study, PRF was compressed between the gauge and was then mixed with beta-tricalcium phosphate to a homogenous mixture to be placed at the test site.

Surgical procedure

Six weeks after the completion of the initial therapy, all the patients were undertaken for periodontal surgery.

Anesthesia

Area subjected to surgery was anesthetized by nerve block-infiltration depending on the surgical site. 2% lignocaine hydrochloride was used as the local anesthetic.

Incision

Sulcular incision was made using Bard-Parker scalpel with surgical blade no. 15 to the level of alveolar bone. The incision was extended one tooth mesially and one tooth distally to the involved tooth.

Flap reflection and debridement

A full-thickness mucoperiosteal flap was raised using periosteal elevator on both facial and lingual sides until the bony defect was exposed. The granulation tissue was removed from the bony walls and the associated root surfaces using area-specific Gracey curettes to expose the root surface and the alveolar bone. The inner surface of the flap was carefully curetted to remove the lining pocket epithelium and granulation tissue. Then, the defect area was confirmed clinically.

In Group A or control group, beta-tricalcium phosphate (600–700 μg) was packed into the defect [Figure 2].

In Group B or test group, PRF was prepared and mixed with beta-tricalcium phosphate (600–700 μg) to get a homogeneous mass. The prepared mixture was properly condensed in the defect to the level of surrounding bony walls [Figure 3].

The flap was adapted back to its original position and suturing was done using nonresorbable silk thread (3-0). Periodontal dressing was placed.

Postsurgical care

The patients were prescribed 500 mg amoxicillin and 400 mg ibuprofen to be taken thrice daily for 5 days. The subjects were instructed not to brush the operated area until sutures removed and to use 0.2% Chlorhexidine rinses twice daily for ten days. Periodontal dressing and sutures were removed after 10 days postoperatively.

Clinical parameters including probing pocket depth, gingival recession, and clinical attachment loss were evaluated at 6 months postoperatively [Figure 4].

Radiological parameters for the defect site were evaluated with the help of sagittal cone beam computerized tomography after 6 months postoperatively [Figure 5]. The clinical and radiographical parameters were recorded in data collection sheet and the data was subjected to statistical analysis.


   Results Top


Statistical analysis

Data was entered in Microsoft excel and Paired and student t-test applied for comparison between two groups using statistical analysis software Graph pad Prism (Version 5). “P” value of less than 0.05 was accepted as indicating significance.

[Table 1], [Graph 1] denote intragroup comparison of PPD, GR, and CAL measurements in Control Group A at baseline and 6 months. It reveals significant decrease in probing pocket depth (PPD) after 6 months with respect to the baseline (P-value < 0.001), a nonsignificant increase in gingival recession after 6 months (P-value = 0.1039), and a significant decrease in clinical attachment loss (CAL) after 6 months (P-value <.001).
Table 1: Intra-group comparison of PPD, GR and CALin Group A

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[Table 2], [Graph 2] show comparison of radiographic measurement (CBCT) at baseline and after 6 months in Control Group A. It reveals a significant decrease of defect height after 6 months, (P-value < 0.001) and a significant decrease of defect width after 6 months, (P-value < 0.001).
Table 2: Intra-group comparison of radiographic measurements in Group A

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[Table 3], [Graph 3] show a comparison of PPD, GR, and CAL in Test Group B at baseline and 6 months. It reveals significant decrease in probing pocket depth (PPD) after 6 months with respect to baseline (P-value < 0.001), a nonsignificant increase in gingival recession (GR) after 6 months (P-value =0.3434), and a significant decrease in clinical attachment loss (CAL) after 6 months (P-value < 0.001).
Table 3: Intra-group comparison of PPD, GR and CAL in Group B

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[Table 4], [Graph 4] show comparison of radiographic measurement (CBCT) at baseline and after 6 months in Test Group B. It reveals a significant decrease of defect height after 6 months (P-value < 0.001) and a significant decrease of defect width after 6 months (P-value < 0.001).
Table 4: Intra-group comparison of radiographic measurements in Group B

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[Table 5], [Graph 5] show comparison of difference after 6 months follow-up for PPD, GR, and CAL measurements between Control Group A and Test Group B. It reveals more probing pocket depth reduction and clinical attachment loss reduction in Group B than Group A and more gingival recession in Group A than Group B after 6 months. However, the values were not statistically significant.
Table 5 : Comparison of difference after sixth month follow up for the PPD, GR and CAL between Group A and Group B

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[Table 6], [Graph 6] show comparison of difference after 6-month follow-up for the radiographic measurement (CBCT) between Group A and Group B. It reveals decrease in defect height more in Group B as compared to Group A and greater decrease in defect width in Group B as compared to Group A, but the values were not statistically significant.
Table 6 : Comparison of difference after sixth month follow up for the radiographic measurement (CBCT) between Group A and Group B

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   Discussion Top


Regeneration of soft tissue and hard tissue (using CBCT) was evaluated after 6 months from baseline in both Control Group A and Test Group B which showed significant improvement in both soft tissue and hard tissue parameters. Mean of all parameters was better in the test group; however, the intergroup difference was not statistically significant.

All patients enrolled for this study completed the study uneventfully, validating the fact that the usage of the alloplastic regenerative material beta-tricalcium phosphate and growth factor containing platelet-rich fibrin had been well accepted in the treatment of intraosseous defects in periodontal disease.

Platelets can play a crucial role in periodontal regeneration as they are reservoirs of growth factors and cytokines which are key factors for regeneration of the bone and maturation of the soft tissue. PRF is an autologous platelet concentrate prepared from patient's own blood. Recent studies are being focused on the development of therapeutic materials which are easy to prepare, biocompatible to living tissues, and economically cheap that might result in the local release of growth factors accelerating hard and soft tissue healing.[9] PRF seems to be an ideal material which might fulfill all the above criteria. Thus, presently there is a surge in studies regarding the role of PRF in periodontal regeneration. Numerous in vitro studies have shown a beneficial effect of PRF on bone healing, like its effect on proliferation and differentiation on osteoblasts.[10],[11]

A study conducted by Bansal and Bharti[2] in 2013 using PRF and DFDBA in test sites and DFDBA alone in control sites has been found to have identical results with the present study.

A study by Ashawan and Zade[12] in 2016 using bioactive glass and PRF as the test site and bioactive glass alone in the control site revealed exactly similar results. Other studies by Demir et al.[13] (2007) and Lucarelli et al.[14] (2010) had also come up with comparable results. In all the above studies, there was statistically significant soft tissue and hard tissue changes in both the test and control groups at 6 months, but the intergroup comparison was not statistically significant.

On the other hand, a study by Agarwal[15] in 2017 using calcium phospho silicate putty alone and in combination with PRF in the treatment of intrabony defects gave significantly better soft tissue and hard tissue parameters at the end of 6 months in sites where the putty and PRF were put together. Comparable results were obtained by Naqvi et al.[16] using bioactive glass putty and PRF at the end of 9 months.

However, a study by Pinipe et al. in 2014, with β-tri calcium phosphate alone and in combination with platelet-rich plasma (PRP) for treatment of intrabony defects in chronic periodontitis patients yielded results similar to the present study.[17]

The safety and efficacy of β-TCP for the treatment of periodontal intraosseous defects have been demonstrated by a number of studies.[1],[7],[18] It has been shown by examining biopsy material after implantation of TCP in human intrabony pockets that this material is actively resorbed before promoting bone formation and degraded slowly at a later stage.[1] β-TCP has been shown to have osteogenic potential.[1] Therefore, it has been used as an active control in this study as well as in the test site along with PRF.

In the present study, the radiographic assessment was carried out using CBCT technique. Thus, the findings of the present study can be assumed to have greater accuracy since two-dimensional techniques significantly underestimate treatment outcomes. It has been postulated that CBCT is an equivalent substitution for direct surgical measurement of bony changes occurring after bone replacement graft procedures.[19]

The present study suffers from a number of limitations. It does not provide surgical reentry data and histological evaluation of the treated periodontal intrabony defect sites was also not done. The biodegradation of β-TCP has been shown to be an extremely slow process in humans.[1] Thus, long-term studies would be more favorable for demonstrating bone formation and integration of the material after grafting in contrast to the present study, which had a postoperative follow-up of 6 months. The small sample size of the study was another limiting factor for it.

Thus, further studies need to be designed with larger sample size and longer postoperative follow-up periods. The studies should also be designed with options for reentry surgery and histological evaluation.


   Conclusion Top


The present study showed significant improvements in clinical and the radiographic parameters in both test (β-TCP + PRF) and control (β-TCP) groups. All the soft tissue and hard tissue parameters were better in the test group; however, no statistically significant difference was found between the test and control groups. Thus, it can be concluded that the use of beta-tricalcium phosphate bone graft combined with platelet-rich fibrin and beta-tricalcium phosphate bone graft alone are both equally effective for the treatment of periodontal intrabony defects in humans. The findings of the present study will be useful in decision making during regenerative procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Saffar JL, Colombier ML. Bone formation in tricalcium phosphate filled periodontal intrabony lesions. Histological observations in humans. J Periodontol 1990;61:209-16.  Back to cited text no. 1
    
2.
Bansal C, Bharti V. Evaluation of efficacy of autologous platelet rich fibrin with demineralised freeze dried bone allograft in the treatment of periodontal intrabony defects. J Indian Soc Periodontol 2013;17:361-6.  Back to cited text no. 2
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Panda S, Jayakumar ND, Sankari M, Sheeja S, Sivakumar D. Platelet rich fibrin and xenograft in treatment of intrabony defect. Contemp Clin Dent 2014;5:550-4.  Back to cited text no. 4
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Shah M, Deshpande N, Bharwani A, Nadig P, Doshi V, Dave D. Effectiveness of autologous platelet rich fibrin in the treatment of intrabony defects. A systematic review and meta- analysis. J Indian Soc Periodontol 2014;18:698-703.  Back to cited text no. 5
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Jayakumar A, Rajababu P, Rohini S, Butchibabu K, Naveen A, Vidyasagar S. Multicenter randomized clinical trial of efficacy and safety of recombinant human platelet derived growth factor with beta tricalcium phosphate in human intraosseous periodontal defects. J Clin Periodontol 2011;38:163-72.  Back to cited text no. 7
    
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Calisir M, Akpinar A, Alpan AL. Platelet rich fibrin membrane combined with Biphasic Calcium Phosphate bone graft in the treatment of intrabony defect. A three year case report. Oral Surj Oral Med Oral Pathol Oral Radiol Endod 2014;5:21-5.  Back to cited text no. 8
    
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Chandran P, Sivadas A. Platelet-rich fibrin: Its role in periodontal regeneration. Saudi J Dent Res 2014;5:117-22.  Back to cited text no. 9
    
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Dohan Ehrenfest DM, Diss A, Odin G, Doglioli P, Hippolyte MP, Charrier JB. In vito effects of Choukroun's PRF on human gingival fibroblasts, dental prekeratinocytes, preadepocytes and maxillofacial osteoblasts in primary cultures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:341-52.  Back to cited text no. 10
    
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He L, Lin Y, Hu X, Zhang Y, Wu H. A comparative study of PRF and PRP on effect of proliferation and differentiation at rat osteoblasts in vitro. Oral Surg Ora Med Oral Pathol Oral Radiol Endod 2009;108:707-13.  Back to cited text no. 11
    
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Ashawan PJ, Zade RM. Comparative evaluation of bioactive glass bone graft material with platelet rich fibrin and bioactive glass bone graft material alone for the treatment of periodontal intrabony defects: A clinical and radiographic study. Int J Res Med Sci 2016;4:3288-94.  Back to cited text no. 12
    
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Demir B, Sengun D, Berberoglu A. Clinical evaluation of platelet-rich plasma and bioactive glass in the treatment of intra-bony defects. J Clin Periodontol 2007;34:709-15.  Back to cited text no. 13
    
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Lucarelli E, Beretta R, Dozza B, Tazzari P, Connell S, Ricci F, et al. A recently developed bifacial platelet-rich fibrin matrix. Eur Cell Mater 2010;20:724-32.  Back to cited text no. 14
    
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Agarwal I, Chandran S, Nadig P. Comparative evaluation of the efficacy of platelet-rich fibrin and calcium phosphosilicate putty alone and in combination in the treatment of intrabony defects: A randomized clinical and radiographic study. Contemp Clin Dent 2017;8:205-10.  Back to cited text no. 15
    
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Naqvi A, Gopalakrishnan D, Bhasin MT, Sharma N, Haider K, Martande S. Comparative evaluation of bioactive glass putty and platelet rich fibrin in the treatment of human periodontal intrabony defects. J Clin Diagn Res 2017;11:9-13.  Back to cited text no. 16
    
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Pinipe J, Mandalapu NB, Manchala SR, Mannem S, Gottumukkala NV, Koneru S. Comparative evaluation of clinical efficacy of β-tricalcium phosphate (Septodont-RTR) TM alone and in combination with platelet rich plasma for treatment of intrabony defects in chronic periodontitis. J Indian Soc Periodontol 2014;18:346-51.  Back to cited text no. 17
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Ridgway H, Mellonig J. Human histologic and clinical evaluation of recombinant human platelet derived growth factor with beta tricalcium phosphate in human intraosseous periodontal defects. Int J Periodontics Restorative Dent 2008;28:171-9.  Back to cited text no. 18
    
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Grimard BA, Hoidal MJ, Mills MP, Mellonig JT, Nummikoski PV, Mealey BL. Comparison of clinical, periapical radiograph, and cone-beam volume tomography measurement techniques for assessing bone level changes following regenerative periodontal therapy. J Periodontol. 2009;80:48-55.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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