Comparative evaluation of the effectiveness of bioresorbable collagen membrane in combination with deproteinized bovine bone matrix xenograft (DBBM), and advanced platelet rich fibrin membrane in combination with deproteinized bovine bone matrix xenograft for periodontal regeneration

Sample size calculation

Calculation of sample size was done with the use of previous study data by Gorkhali et al. in 2020.⁷ The result of the calculation is 12 in each group, thus around 24 samples will be undertaken for the entire study.

Ratio of sample size (Group 1/Group 2) = 1:1

Total sample size 24 with each 12 per group.

Study population

The outpatient department of periodontics, Sharad Pawar dental college, Sawangi, Wardha will choose 24 systemically healthy individuals with mild to advanced chronic periodontitis based on the following inclusion criteria:

Inclusion criteria

Exclusion criteria

In a specially created chart, information about food status, oral hygiene practises, systemic history, gingival and also periodontal state, in addition to standard clinical information, will be documented.

Initial therapy

Supragingival and subgingival scaling and root planning will be done as a part of the initial therapy. If required, a coronoplasty will be carried out. Patient will receive repeated plaque control instructions until they have a plaque score of less than 1. Following the conclusion of the initial therapy, a re-evaluation will be conducted to do assessment of the patient towards therapy. If during re-evaluation test after 6 weeks, the periodontal pocket depth is more than 3 mm, plaque score is less than 1 then only we will take the patient for surgery.

Each patient will be given an explanation of the study’s goal and design prior to getting started, and their informed consent will be obtained.

The probe angulations and position will be standardised using a specially designed occlusal acrylic stent. A cast model made from an alginate impression will be used to create an occlusal stent. The occlusal stent will be stretched to encompass coronal one-third of the teeth. A reference point or slot will be created on the deepest site of affected tooth. Linear, fixed reference point will be the apical border.

Study design

After receiving initial therapy, a total of 24 systemically healthy individuals will be chosen for the study. A coin flip will be used to randomly distribute the participants, in keeping with a randomised parallel design, each of which will have 12 defects, prior to surgery (Figure 1).

Figure 1. Schematic of trial.

Clinical measurements

The clinical parameters that will be documented like Plaque index, papillary bleeding index, probing pocket depth, relative clinical attachment level, and relative gingival marginal level on the day of surgery as baseline and then after six months. Moreover, additional data will be collected including intraoral periapical radiographs, intraoral clinical pictures, and periodontal charting on a specially prepared form.

Indices

Plaque index, a measurement of the buildup of full mouth supragingival plaque, will be used in order to assess the patient’s oral hygiene health. Papillary bleeding index will be used to evaluate inflammation of gingiva. These are:

The best score will be less than 1. Worst score will be more than 1.

Probing measurements

A UNC-15 probe will be inserted into the slot of acrylic stent at the gingival margin level, with the tip positioned at that level. The measurement will be taken up to the bottom edge of the stent, will be recorded as the relative gingival margin level. A relative attachment level will then be determined. The depth of the probing pocket will be measured (PPD).

With a Periodontal Probe calibrated to UNC-15, width of keratinized gingiva will be determined. At baseline, three months, all probing measurements will be recorded.

Radiographic analysis

CBCT

Using CBCT, osseous defect sites will be examined at baseline and six months post-surgery. The lowest discontinuous point of the periodontal ligament will serve as landmark for the location of the base of defect. Root surface will be intersected by a line that runs perpendicular to the alveolar crest (AC). AC is the point of intersection along the root surface.

Surgical procedure

Rinsing the patients mouth using 0.2% chlorhexidine gluconate solution at the start of the surgical procedure is required for the patients. The condition of asepsis will be preserved during the entire process. The area undergoing for surgery will be anaesthetized using a local anaesthetic solution (2% w/v Lignocaine adrenaline solution (1:100,00) will be used. Maximum of 15 ml I.M. dosage will be given).

Flap design (incisions)

Using BP blades number 12 or 15, intracrevicular (sulcular) incisions will be made to include periodontal access flap on the buccal and lingual sides. To retain the complete interdental papillae and accomplish primary wound closure, the incisions will be carried. The flap will include a tooth mesially and distally to the tooth and is connected with the defect. If additional access is needed, divergent vertical relief incisions will be made one tooth away from the problem.

Flap reflection

A periosteal elevator will be used for reflecting a full thickness mucoperiosteal flap to expose alveolar bone inside the osseous defect. By removing granulomatous tissue, extreme care will be taken to prevent perforation of the reflected periodontal flap.

Debridement and root surface management

Hand tools (Hu-friedy Gracey curettes) and ultrasonic tools (EMS, piezo 150) will be used to remove granulation tissue from the osseous defect. It will be taken care of to ensure that the flap is not extremely thin. Plaque and calculus on the root surfaces will be removed. The root surfaces will be planed until they have smooth and firm surface.

At this point, UNC15 probe will directly assess the vertical bone defects and quantity of the bony walls present. If the vertical depth of the bone defect is less than 3 mm, the subject’s eligibility will be determined in the end. If the base of the defect doesn’t bleed enough, a half-round bur will be used to perform intra-marrow penetration. At this time, deproteinized bovine bone matrix graft will be used in combination with porcine collagen membrane to correct the test site defects.

Preparation of APRF

Venous blood (10 ml) will be drawn under aseptic conditions from antecubital fossa (10 ml venous blood will be withdrawn in 18 gauge needle) and moved to sterile test tubes before being centrifuged (REMI, (R-8C)) at 1500 rpm for the next 14 minutes to prepare A-PRF, according to Ghanaati et al.¹² In the test sites, the infrabony defect will first get a Porcine Collagen Membrane with DBBM.

Procedure for test group

It will be possible to completely isolate and hemostasize the defect. To enable quick flap closure after the implantation of the graft material, the flap will be presutured without making a knot. Deproteinized Bovine Bone Matrix bone graft will be inserted inside the osseous defect in the test site until maximal coronal level is reached of the osseous wall by raising the flap, on which Collagen membrane will be placed over the defect. Membrane will be applied so that it extends 3 mm or more. The flap will then be coronally repositioned and then sutured accordingly.

Now the reflected flap will be held in place combining vertical mattress sutures and interproximal sutures. After two minutes, saline-soaked gauze will be used to close any gaps that could allow a clot to develop and prevent reattachment. Periodontal dressing will be applied.

Procedure for control group

The surgical process on selected control site and the test site will be the same, with the exception that the osseous deficiencies at control sites will be filled with Deproteinized Bovine Bone Matrix graft and then APRF membrane will be applied on the top of the filled bone graft.

Post operative care

Antibiotics including Amoxicillin 500 mg thrice a day and analgesics with the combination of Ibuprofen 325 mg and Paracetamol 400 mg thrice a day will be prescribed post-surgical for 5 days. Patients will be instructed to rinse daily with 0.2% chlorhexidine gluconate twice for 6 weeks. Periodontal dressing and sutures will be removed after 8-10 days post-surgery. Patients will be instructed to clean the treated site with cotton pellet saturated with 0.12% chlorhexidine gluconate for additional 2-3 weeks in an apico-coronal direction and later using a soft toothbrush. After this period, patients will be again instructed to resume mechanical oral hygiene measures, use of interdental cleaning aids such as interdental brush and to discontinue chlorhexidine.

Monitoring

The study will be monitored till completion by data monitoring committee (DMC) which includes PG Guide, head of the department, research convener and chief advisor of university research cell.

The principal investigator (PI) will have access to these interim results and make the final decision to terminate the trial.

Data will be collected, assessed, and spontaneously reported during adverse events and other unintended effects of trial interventions or trial conduct.

The project management group meet will review the trial conducted every month. The trial steering group and the independent data monitoring and ethics committee meet will review and conduct the trial period till the trial is complete.

Maintenance care

Patients will be recalled back at the first, third, and sixth months after surgery. All patients will be given oral hygiene instructions together with oral prophylaxis (supragingival scaling). In the first six months following surgery, neither probing nor subgingival instrumentation will be done.

Re-examination

At six months, during follow-up visit a thorough post-operative evaluation will be carried out. Plaque index, gingival index, probing pocket depth, relative clinical attachment level, and relative gingival marginal level are the main clinical parameters that will be recorded. Radiographs and CBCT will also be required.

Expected result

After 6 months, we are expecting increase in clinical attachment level and decrease in periodontal pocket depth with radiographic bone fill in the test group.

Data analysis

The data collected from patients will be entered on Microsoft excel by PI ensuring the quality checks. Software for statistical analysis will be SPSS version 15.0, SPSS, Chicago, USA). Student’s unpaired t-test will be done.

Dissemination

The results will be published in an indexed journal.

Study status

Not yet started.

Ethical considerations

Procedures will be performed in keeping with the ethical standards of the institutional. This protocol was permitted by the Institutional Ethics Committee of Datta Meghe Institute of Higher education and Research, Sawangi, Meghe, Wardha (approval number DMIHER (DU)/IEC/2023/576) on 6^th February 2023. This trial has been registered at the Clinical trial registry of India (CTRI) (REF/2023/05/066732; registration pending).

Case histories will be taken for each patient. A unique I’d number will be provided to each case histories which will be stored in password protected folder in desktop and while sharing it will be ensured that identifying information such as age, address, IPD number and OPD number will be deleted. PI and institutional authorities will be accessible to the final trial dataset.