Multi-modular bone healing assessment in a randomized controlled clinical trial of root-end surgery with the use of leukocyte- and platelet-rich fibrin and an occlusive membrane.

OBJECTIVES: The aim of this study was to assess in a multi-modular manner the bone healing 1 year post root-end surgery (RES) with leukocyte- and platelet-rich fibrin (LPRF) and Bio-Gide® (BG; Geistlich Pharma North America, Inc., Princeton, USA) as an occlusive membrane. MATERIALS AND METHODS: A randomized controlled clinical trial (RCT) of RES +/- LPRF and +/- BG was performed. The follow-up until 1 year post RES was performed by means of ultrasound imaging (UI), periapical radiographs (PR), and cone-beam computed tomography (CBCT). RESULTS: From the 50 included patients, 6 dropped-out during follow-up. For the 44 assessed patients (34 with UI and 42 with PR and CBCT), there was no evidence (p > 0.05) for an effect of LRPF, neither on UI measurements nor on CBCT assessments. On the contrary, there was an indication for a better outcome with BG. UI presented significant shorter healing time for the bony crypt surface (p = 0.014) and cortical opening (p = 0.006) for the groups with BG. The qualitative CBCT assessment for the combined scores of the apical area and cortical plane was significantly higher for BG (p = 0.01 and 0.02). The quantitative CBCT measurement for bone healing after 1 year was lower with BG (p = 0.019), as well as the percentage of non-zero values (p = 0.026), irrespective of the preoperative lesion size and type. Furthermore, UI seemed to be safer for frequent follow-up during the early postoperative stage (0-3 months), whereas CBCT gave more accurate results 1 year post RES. Amongst the assessors, the qualitative PR analysis was inconsistent for a favorable outcome 1 year post RES with LPRF (p = 0.11 and p = 0.023), but consistent for BG (p = 0.024 and p = 0.023). CONCLUSIONS: There was no evidence for improvement of bone healing when RES was applied with LPRF in comparison with RES without LPRF. However, RES with BG gave evidence for a better outcome than RES without BG. CLINICAL RELEVANCE: The addition of an occlusive membrane rather than an autologous platelet concentrate improved bone regeneration 1 year post RES significantly, irrespective of the assessment device applied. The accuracy of PR assessment is questionable.

Regenerative Endodontic Procedures Posttrauma: Immunohistologic Analysis of a Retrospective Series of Failed Cases.

INTRODUCTION: Regenerative endodontic procedures (REP) are a novel treatment modality to restore the function of necrotic pulp tissue via stimulation or transplantation of stem cells into the root canal. This study aimed to investigate the immunohistologic outcome of 3 extracted teeth because of sequelae of trauma and unsatisfactory REP outcomes. METHODS: Three immature permanent maxillary central incisors of 3 female patients (6-9 years) were extracted 5.5-22 months after REP. Additionally, 1 sound permanent immature central maxillary incisor of 1 of the included patients was extracted for orthodontic reasons. The teeth were immunohistologically stained with Masson's trichrome, neurofilament (NF), pan cytokeratin, dentin sialophosphoprotein, and Gram+/-. RESULTS: The REP-teeth presented intracanalar vascularized connective/mineralized reparative tissue (RT), which was less organized than the pulp tissue of the sound tooth. Moderate to considerable calcification was observed below the Portland cement used during REP. In 1 case, the RT was NF+; in the 2 other cases, the periodontal ligament and apical granuloma/papilla were NF+. All teeth were Gram+/- negative; nevertheless, inflammatory cells were present in 2 cases. The pan cytokeratin and dentin sialophosphoprotein stainings were not specific enough for 2 cases. CONCLUSIONS: This immunohistologic study of failed REP cases resulted in bacteria-free intracanalar RT and biomaterial-induced calcification. Nevertheless, the presence of inflammatory cells revealed a persistent inflammation. Hence, the clinical and radiographic signs were decisive for tooth survival and multidisciplinary outcome determination.

Root-end surgery with leucocyte- and platelet-rich fibrin and an occlusive membrane: a randomized controlled clinical trial on patients' quality of life.

OBJECTIVES: The aim of this study was to investigate the impact of the adjunct of leukocyte- and platelet-rich fibrin (LPRF) to root-end surgery (RES) on the patients' quality of life during the first week post RES. MATERIALS AND METHODS: Patients in need of RES were recruited for an open randomized controlled clinical trial (RCT) with a 2 × 2 factorial design. They were randomly allocated to the test (+LPRF) and control (-LPRF) group. Each group was subsequently divided into two strata: with or without an occlusive membrane (Bio-Gide®, Geistlich Biomaterials, Switzerland; BG). After RES, the patients completed daily for 1 week a visual analog pain scale (VAS) and a 5-point Likert-type scale questionnaire concerning activity impairment, occurrence of symptoms, and medication use. RESULTS: Fifty patients were included, equally divided between the test and control group. Only one patient in the "-LPRF+BG-group" had to take additional antibiotics due to a persistent jaw swelling. There was no evidence (p ≤ 0.05) for a difference between the test and control group in VAS, occurrence of pain symptoms, impairment of daily activities, and medication use, over the 7 days and daily during the 7 days post RES. CONCLUSIONS: There was no statistical significant evidence for improvement of patients' quality of life during the first week post RES with LPRF in comparison with RES without LPRF. CLINICAL RELEVANCE: Although LPRF seems to be an inexpensive and autologous agent to reduce pain and swelling post RES, this RCT does not provide a statistical significant evidence for that.

Ultrasound Assessment of Bone Healing after Root-end Surgery: Echoes Back to Patient's Safety.

INTRODUCTION: The aim of this study was to present ultrasound imaging (UI) techniques as promising and safe tools for the follow-up of root-end surgery (RES) in vivo. METHODS: The study included 8 patients who underwent RES. All were followed up using UI at 1 week, 1 month, 2 months, 3 months, and 6 months (if necessary) after RES. The bony crypt was defined on the ultrasound image, and the following observations were made during follow-up: cortical bone interruption and surface area measurement of the residual echoic bony crypt image. RESULTS: In all cases, the hypoechoic image became hyperechoic, indicating gradual bone healing of the crypt. Compared with baseline, at 3 months a remaining cortical opening of 51.2% (±12.6%) and a bony crypt surface area of 24.3% (±10.8%) was detected for all patients. For 50% of the patients, the echographic follow-up ended at 3 months because the ultrasound waves could no longer enter the bony crypt. For 4 patients who attended the 6-month recall, a remaining cortical disruption of 43.2% (±9.9%) and a bony crypt surface area of 17.2% (±7%) compared with the baseline was noted. CONCLUSIONS: UI is a promising follow-up tool for RES. It helps clinicians understand the initial stages of bone healing, allows close healing monitoring, and is radiation free.

Regenerative potential of leucocyte- and platelet-rich fibrin. Part A: intra-bony defects, furcation defects and periodontal plastic surgery. A systematic review and meta-analysis.

AIM: To analyse the regenerative potential of leucocyte- and platelet-rich fibrin (L-PRF) during periodontal surgery. MATERIALS AND METHODS: An electronic and hand search were conducted in three databases. Only randomized clinical trials were selected and no follow-up limitation was applied. Pocket depth (PD), clinical attachment level (CAL), bone fill, keratinized tissue width (KTW), recession reduction and root coverage (%) were considered as outcome. When possible, meta-analysis was performed. RESULTS: Twenty-four articles fulfilled the inclusion and exclusion criteria. Three subgroups were created: intra-bony defects (IBDs), furcation defects and periodontal plastic surgery. Meta-analysis was performed in all the subgroups. Significant PD reduction (1.1 ± 0.5 mm, p < 0.001), CAL gain (1.2 ± 0.6 mm, p < 0.001) and bone fill (1.7 ± 0.7 mm, p < 0.001) were found when comparing L-PRF to open flap debridement (OFD) in IBDs. For furcation defects, significant PD reduction (1.9 ± 1.5 mm, p = 0.01), CAL gain (1.3 ± 0.4 mm, p < 0.001) and bone fill (1.5 ± 0.3 mm, p < 0.001) were reported when comparing L-PRF to OFD. When L-PRF was compared to a connective tissue graft, similar outcomes were recorded for PD reduction (0.2 ± 0.3 mm, p > 0.05), CAL gain (0.2 ± 0.5 mm, p > 0.05), KTW (0.3 ± 0.4 mm, p > 0.05) and recession reduction (0.2 ± 0.3 mm, p > 0.05). CONCLUSIONS: L-PRF enhances periodontal wound healing.

The impact of autologous platelet concentrates on endodontic healing: a systematic review.

The current literature was reviewed to determine the impact of autologous platelet concentrates (APCs) on endodontic healing. All types of clinical study designs concerning any kind of endodontic treatment involving the application of APCs were included. Two independent reviewers searched three databases (PubMed, Embase, and Cochrane Library) for studies, complemented by hand search, until 16/1/2016. From the 423 identified records, 48 articles met the inclusion criteria. Selected randomized controlled clinical trials (RCTs) underwent Cochrane Collaboration's risk-of-bias assessment and data extraction. Only two RCTs showed low risk of bias. There was considerable heterogeneity between the RCTs with regard to the type of therapy, type of APCs, assessment method, and study quality, and therefore the data could not be analyzed quantitatively. The included case reports/series and non-randomized comparative studies underwent qualitative analysis with the revised Methodological Index for Non-Randomized Studies (MINORS) and data extraction. The two comparative non-randomized studies scored qualitatively high, though the MINORS-scores of the case series and reports were dispersed. APCs were involved in five endodontic treatment modalities, namely apexification, regenerative endodontic procedures, pulpotomy, apical surgery, and treatment of endo-perio/perio-endo lesions. APCs seem to accelerate postoperative bone healing, augment the patients' postoperative quality of life, aid further root development, and support maintenance/regaining of pulp vitality. No adverse events were reported. APCs in endodontic treatments seem to contribute to the healing of soft and hard tissues, though there is a lack of long-term high quality clinical trials and standardized treatment protocols.