ISSN: 2320-5407 Int. J. Adv. Res.

9(09), 156-164

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/13389
DOI URL: http://dx.doi.org/10.21474/IJAR01/13389

RESEARCH ARTICLE
EVALUATION OF EFFICACY OF DEMINERALIZED FREEZE DRIED BONE ALLOGRAFT WITH
AND WITHOUT PLATELET-RICH FIBRIN IN THE TREATMENT OF INTRABONY DEFECTS BY
CONE BEAM COMPUTED TOMOGRAPHY: A CLINICAL AND RADIOGRAPHIC STUDY

Dr. Sunkavilli Ravi Kiran, Dr. Mohd Aijaz Ahmed, Dr. Niharika Bammidi and Dr. Yudheera Karnam
MDS; Senior Lecturer, Dept Of Periodontics, Lenora Institute Of Dental Sciences, Rajhamundry. Andhra Pradesh,
India.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Background: Eventhough the combination of DFDBA (demineralized
Received: 10 July 2021 freeze dried bone allograft) with PRF (platelet-rich fibrin) has been
Final Accepted: 13 August 2021 attempted in periodontal practice with significant results, assessment
Published: September 2021 of the intrabony defect and defect bone fill largely done with two-
dimensional imaging modalities. Three dimentional analysis of the
Key words:-
Intrabony defect. CbctEvaluation, Defect intrabony defect and defect bone fill has not been attempted with cone
fill, DFDBA beam computer tomography (CBCT). The present study evaluated the
efficacy of DFDBA with and without PRF in the treatment ofintrabony
defects by CBCT.
Methods: 60 defects in systemically healthy patients ranging from 18
to 50 years of age will be included in the study.30 defects were treated
with PRF+DFDBA and 30 defects were treated with DFDBA alone.
The study will include the assessment of clinical parameters involving
probing depth (PD), relative attachment level(RAL), full mouth
bleeding scores(FMBS),plaque index and gingival index from baseline
to 3 , 6, 9 months. Hard tissue changes will be assessed
radiographically by evaluating defect fill and defect resolution by
CBCT at baseline& 9 months.
Results: The results of the present study are statistically significant in
both groups in terms of clinical and radiographical parameters (P <
0.001). In inter-group comparison, there was a statistically significant
greater PD reduction and attachment gain while there was not
significant reduction in terms of PI, GI, FMBS, defect fill and defect
resolution in DFDBA+ PRF group.
Conclusion: DFDBA along with PRF failed to provide additional
value in terms of defect fill and defect resolution over DFDBA alone.

Copy Right, IJAR, 2021,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
Periodontal regenerative procedures may restore lost supporting structures of the dentition such as cementum,
periodontal ligament (PDL) and bone on a previously diseased root surface. Various bone graft materials have
demonstrated regenerative potential and have been successfully used in the treatment of intrabony defects. The bone
replacement grafts may aid in providing a scaffold for the host’s resident cells or provide factors that aid in
stimulating regeneration via osteoinductive or osteoconductive pathways. 1,2

Corresponding Author:- Dr. Sunkavilli Ravi Kiran 156

Address:- MDS; Senior Lecturer, Dept Of Periodontics, Lenora Institute Of Dental Sciences,
Rajhamundry. Andhra Pradesh, India.
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For the last three decades, DFDBA has been used alone and in combination with other treatment modalities for
periodontal therapy. DFDBA has shown to be both osteoconductive and osteoinductive. The presence of Bone
Morphogenic Proteins (BMPs) within DFDBA, aids in mesenchymal cell migration, attachment and osteogenesis
when implanted into bony defects.Regeneration of the lost periodontium through the process of tissue engineering is
the greatest hallmark of recent studies in the field of periodontics. The 2nd generation platelet concentrate is called
PRF or Choukroun’s PRF after its inventor. PRF consists of an intimate assembly of platelets, growth factors,
cytokines, glycanic chains and structural glycoproteins enmeshed within a slowly polymerized fibrin network. These
biochemical components have well-known synergistic effects on healing process. 2-5

Several techniques have been used to evaluate hard tissue responses to regenerative therapy around periodontally
involved teeth. CBCT is used to assess the amount of bone fill following periodontal regenerative procedures. This
may be of particular significance because conventional radiographs tend to underestimate the amount of bone fill
following such procedures. CBCT may be a valuable tool for periodontal regeneration imaging and assessment, both
preoperatively and postoperatively.6,7

Even though the combination of DFDBA with PRF has been attempted in periodontal practice with significant
results, assessment of the intrabony defect (IBD) and defect bone fill largely done with two-dimensional imaging
modalities such as conventional and digital radiography. Three-dimensional analysis of the intrabony defect and
defect bone fill has not been attempted much with CBCT. Thus in the present study, the combination of DFDBA and
PRF will be studied and three-dimensional analysis of the intra bony defect and defect bone fill was done by CBCT.

Materials and Methods:-

The study sample included 60 intrabony defects in 48 patients with chronic periodontitis visiting Government Dental
College & Hospital, Vijayawada were randomly divided in to two groups of 30 each (Group I (DFDBA) or Group
II (DFDBA+PRF) ) and the study period was 9 months. Ethical clearance was obtained from the Institutional Ethics
Committee. The study was designed as a single blinded, randomized, controlled, two arm parallel study. Patients age
between 18-50years having intrabony defect depth of ≥ 3mm and should not undergone any periodontal therapy
prior to six months before initial treatment with good oral hygiene are included in the study. All the patients were
explained about the study and written informed consent was obtained before the commencement of the study. (FIG
1)

Following initial examination, at first visit (pre surgical visit) clinical parameters were recorded and impressions
were taken to prepare study casts and fabricate occlusal stents for the treatment teeth. Scaling and root planing were
performed using hand curettes and an ultrasonic device under local anesthesia. Occlusal adjustment was performed
if trauma from occlusion was diagnosed. A periodontal re-evaluation was performed after 4 weeks to confirm the
suitability of the sites for this periodontal surgical study. Patients who are suitable for the procedure are advised to
take baseline CBCT before surgery.

At the second visit (surgical visit) Periodontal assessment was done by recordingRelative attachment level (distance
from apical border of stent to base of pocket),Probing Depth (The distance from the free gingival margin to the base
of the pocket). Plaque index(Loe H et al 8) and gingival index(Loe H et al 8) FMBS ( full mouth bleeding
score)(Ainamo and Bay9)The oral hygiene maintenance of the patient was evaluated and only those patients
maintaining optimum oral hygiene (PI ≤ 1) proceeded for the surgery. The surgical area was anaesthetized by local
anaesthetic techniques using 2% lignocaine with adrenaline 1:200000 dilution. The procedure was done under
proper aseptic precautions using continuous aspiration to keep surgical site clean. Buccal and lingual sulcular
incisions were made and mucoperiosteal flaps elevated. Care was exercised to preserve as much interproximal soft
tissue as possible. Complete debridement of the defects, as well as scaling and root planing to ensure root
smoothness, were achieved with the use of an ultrasonic device and hand curettes. In the PRF–DFDBA group,
DFDBA granules (Tata Bone Graft) with particle sizes of 500-1040μ were mixed with PRF(prepared by Choukran
protocol using a research centrifuge (REMI laboratories) for 15 min at 3000 rpm ) that had been minced into pieces
about 0.5 mm × 0.5 mm at a proportion of 1:1 (v/v). The PRF+DFDBA mixture was delivered to the defect and
packed with amalgam condensers to the level of the surrounding bony walls. Care was taken not to overfill defects.
Defects in the DFDBA group were filled with DFDBA granules only.Appropriate post-operative instructions with
medication were given to the patients.

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After one week following surgery, sutures were removed. Symptoms regarding discomfort, pain, swelling, and fever
were asked and recorded. Oral hygiene instructions were reinforced. Clinical parameters including PI, GI, FMBS,
PD and RAL were recorded after 3rd, 6th, and 9th months Oral hygiene instructions were reinforced and scaling was
done if necessary.A 9 month post- operative CBCT was taken and radiographic parameters defect fill and defect
resolution were recorded.

Radiographic Measurement:
Before performing regenerative procedure, paralleling cone technique was used to take peri-apical radiographs with
XCP devices for screening the defect. CBCT imaging was taken to check the 3D architecture of the intrabony defect
for better treatment planning and evaluate the measurements preoperatively at baseline and postoperatively after 9
months.All the CBCT (NEW CS 9000 System®) scans were taken by a single trained technician at baseline and 9
months. The voltage (70.00KV), Current (10.00mA), Exposure time (10.8 sec) and Detection field were kept
constant for each patient at baseline and at 9 months. The reference chosen to standardize the axial and sagittal
planes was the bi-spinal line, coinciding with the vertical and horizontal planes,respectively. The reference
employed to standardize the coronal plane was the linebetween infra-orbital points, named the infra-orbital line thus
concluding the positioning of images over the three spatial planes. The sagittal and coronal sections were
reconstructed after 9 months at the same axial slicing to that of the baseline.

The linear measurements of CEJ to AC (Measured from cemento-enamel junction to alveolar crest) and CEJ to
BOD(Measured from cemento-enamel junction to base of the defect) were used to determine defect fill and defect
resolution. Defect fill was calculated by subtracting CEJ to BOD at baseline from CEJ to BOD at 9 months. Defect
resolution was calculated by the formula [(CEJ-BOD) – (CEJ-AC) at baseline] – [(CEJ-BOD) – (CEJ-AC) at
9months].

Statistical analysis
Mean and standard deviation were calculated for all the clinical and radiological parameters. The significance of
differences between intervention and control groups in terms of numerical data was evaluated via univariate analysis
using the Mann- Whitney U test. The significance of the differences within each group before and after treatment
was evaluated using the Friedman test.

Results:-
All patients showed good compliance and the healing was uneventful for both treatment groups, without infection or
complications. The mean PI, GI, FMBS decreased from baseline to 9 months with in group I & group11 with
statitistical significance. intergroup comparison was not significant (P>0.05) from baseline to 9 months.The mean
PD at baseline was 7.27 ± 0.46 mm in group I and 7.8 ± 1.08 mm in group II, the mean PD at 9 months was 4.07 ±
0.26 mm and 3.07 ± 0.26 mm respectively. The mean RAL at baseline was 10.47±0.64 mm in Group I and 11.0 ±1.0
mm in group II, the mean RAL at 9 months was 7.33±0.62 mm and 6.87±0.52 mm respectively. The difference in
PD and RAL between group I and group II (intergroup) from baseline to 9 months postoperatively was significant
(P<0.05). (Table 1)

The mean CEJ-BOD Level at baseline was 7.23± 1.13 mm in group I and 7.05 ± 1.07 mm in group II, the mean
CEJ-BOD Level at 9 months was 5.59 ± 1.24 mm and 5.08 ± 0.98 mm respectively. The mean CEJ-AC Level at
baseline was 3.447 ± 0.90 mm in group I and 3.513 ± 0.81 mm in group II, the mean CEJ-AC Level at 9 months was
3.582 ± 0.75 mm and 3.61 ± 0.58 mm respectively. The mean defect fill and defect resolution after 9 months in
group I was 1.63 ± 0.51 mm and 1.50 ± 0.52 mm, in group II was 1.97 ± 0.62 mm and 1.75± 0.54 mm respectively.
The difference in defect fill and defect resolution between group I and group II (intergroup) after 9 months
postoperatively was insignificant (p>0.05). There was a statistically significant difference for group I (P<0.05) and
group II (P<0.05) from baseline to nine months.(TABLE 2&3)

Discussion:-
The first evolutionary stage of periodontal regeneration focused on using avariety of bone graft materials. Presently,
a lot of research being carried out in evaluating the combination oftherapies that would promote maximum
resolution of the defects. Accordingly, in thisstudy we decided to combine PRF containing platelet growth factors to
DFDBA, aclinically effective periodontal regenerative therapeutic modality. 10Radiological parameters like defect fill
and defect resolution was assessed by CBCT at baseline and 9 months postoperatively. More recently, CBCT

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hasbeen used to assess head and neck structure which has ability to visualize thesestructures in three dimensions
while producing images that have high resolution andaccuracy. Grimard BA et al.6states that CBCT is an equivalent
substitution for direct surgical measurements of bony changesoccurring after bone replacement graft procedures,
especially defect fill and defectresolution.

Intragroup comparison of PI and GI and FBS showed statistically significant results (P<0.001) while intergroup
comparison was not significant (P>0.05). These results are similar to studies of Agarwal A et al. 11Piemontese M et
al.12, Markou N et al.13The significant mean change of PI, GI, FMBS in both the groups could be due toregular and
frequent recall visits in which the patient underwent regular supragingivalscaling and also because of careful patient
selection who were able to maintainacceptable oral hygiene. Numerous reports have indicated that good oral
hygiene, as reflected by low plaque scores, is associated with better regenerative response 14,15

PD and RAL from baseline to nine months in intra group and inter group comparison showed statistically significant
reduction (p<0.05). PD reduction is not only a desirable outcome of periodontal regenerative procedures but may
also be the most important parameter in patient care for the clinician because it directly impacts one’s ability to
instrument a treated area during maintenance appointments. The present study showed a mean PD reduction of
3.2±0.56 mm in group I and 4.73 ±0.96 mm in group II from baseline to 9 months postoperatively. A mean
attachment gain in group II (4.13±0.83) was higher compared to group I (3.13±0.74) in the present study. These are
similar to studies done by Parashis A etal. 16, Mellonig JT et al.17 Bansal C et al.10, Demonstration of better results
(attachment gain and PD reduction) in DFDBA + PRF group in the present study may be explained by the additional
biologic effects of PRF. unlike other platelet concentrate, it is able to progressively release cytokines during fibrin
matrix remodeling.4PRF organizes as a dense fibrin scaffold with a high number of leukocytes concentrated in one
part of the clot. Leukocytes seem to have a strong influence on growth factor release, immune regulation, anti-
infectious activity, and matrix remodeling during healing. It is an optimal matrix for migration of endothelial cells
and fibroblasts. It permits a rapid angiogenesis and an easier remodeling of fibrin in a more resistant connective
tissue. Such a mechanism might explain the clinically observed soft tissue healing properties of PRF. 18,10It can also
be speculated that because BMPs are members of the TGF super family, their effect, if BMPs exist in DFDBA and
are active will add to the effects of the growth factors within the platelets, ensuring a synergetic impact on the cell
population of the wound.12These observations revealed that DFDBA when used along with PRF results in good
healing compared to use of DFDBA alone. 19

There is a statistically significant mean defect fill of 1.63± 0.51 mm in group I from baseline to 9 months and 1.97 ±
0.62 mm in group II respectively. Mean defect resolution also showed significance in group I (1.50 ± 0.52 mm) and
group II (1.75 ± 0.54 mm) from baseline to 9 months. Inter group comparison was not significant (p>0.05) for both
defect fill and defect resolution after 9 months. Defect fill in group I is due to osteogenic potential of DFDBA that is
due to presence of bone morphogenic protein which elicits mesenchymal cell migration, attachment and
osteogenesis when implanted in well vascularized bone. 20When mixed with the graft, PRF fragments serve as a
biological connector between bone particles. Moreover, the gradual release of cytokines plays a significant role in
the self regulation of inflammatory and infectious phenomena within the grafted material. 10Even though the results
are significant in both the groups, defect fill and defect resolution is less in the present study compared to several
similar studies.10,11,21Thereason for this may be due to random selection of the intrabony defect with remaining bony
walls and also due to less intrabony defect depth. 22 In clinical practice, pure two orthree wall angular defects are
uncommon, whereas the majority of the defects are present in combinations. Intrabony Defects treated in this study
were two wall, threewall or a combination of two and three wall defects. Regenerative potential of verticaldefects
depends on the defect topography11and percentage osseous repair is directly proportional to the number of bony
walls lining the defect 23,24

The uniqueness of the present study is using a three dimensional approach (CBCT) for evaluating defect fill and
defect resolution inintrabony defects treated with DFDBA and DFDBA+PRF. As per now there are very few studies
regarding this context in literature.

Currently, there is sparse evidence to support the adjunctive use of PRF with bone graft in the management of
periodontal osseous defects. Studies using larger samples and additional long term documentation with
standardization of the study design, surgical technique and other variables are needed to assess the efficacy of
adding PRF to bone graft materials and to allow for more valid and meaningful comparisons between studies.

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Conclusion:-
Within the limits of the study it can be concluded that the use of DFDBA along with PRF failed to provide
additional value in terms of defect fill and defect resolution over DFDBA alone. However further studies with large
samples and long follow up are needed to clarify and confirm results.

References:-
1. Reynolds MA, Aichelman-reidy ME, Mays GLB, Gunsolley JC. The efficacy of bone replacement grafts in the
treatment of periodontal osseous defects: A Systematic review. Ann Periodontol2003;8:227-265.
2. A.L. Dumitrescu. Chemicals in Surgical Periodontal Therapy, chapter 2, Bone Grafts and Bone Graft Substitute
in Periodontal Therapy.
3. Neil Blumenthal and June Steinberg. The Use of Collagen Membrane Barriers in Conjunction With Combined
Demineralized Bone-Collagen Gel Implants in Human Infrabony Defects. J Periodontol1990;61:319–327.
4. Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J et al. Plateletrich fibrin (PRF): A second-
generation platelet concentrate. Part II: plateletrelated biologic features. Oral Surg Oral Med Oral Pathol Oral
RadiolEndod 2006;10:e45-50.
5. Mellonig JT. Autogenous and allogeneic bone grafts in periodontal therapy. Crit Rev Oral Biol Med
1992;3:333-352.
6. 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 Periodontol2009;80:48–55
7. du Bois AH, Kardachi B, Bartold PM. Is there a role for the use of volumetric cone beam computed tomography
in periodontics? Aust Dent J 2012;57:s103-108.
8. Löe H. The Gingival Index, the Plaque Index and the Retention Index Systems. J Periodontol 1967;38:s610-6.
9. Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25:229-35
10. Bansal C, Bharti V. Evaluation of efficacy of autologous platelet rich fibrin with demineralized freeze dried
bone allograft in the treatment of periodontal intrabony defects. J Indian Soc Periodontol2013;17:361-366.
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treatment of human intrabony periodontal defects: a randomized split mouth clinical trail. Acta
OdontolScand2016;74:36-43.
12. Piemontese M, Aspriello SD, Rubini C, Ferrante L, Procaccini M. Treatment of Periodontal Intrabony Defects
With Demineralized Freeze-Dried Bone Allograft in Combination With Platelet-Rich Plasma: A Comparative
Clinical Trial. J Periodontol2008;79:802-810.
13. Markou N, Pepelassi E, Vavouraki H, Stamatakis HC, Nikolopoulos G, Vrotsos I, Tsiklakis K. Treatment of
periodontal endosseous defects with platelet-rich plasma alone or in combination with demineralized freeze-
dried bone allograft: a comparative clinical trial. J Periodontol2009;80:1911-1919.
14. Newman MG. The role of infection and anti-infection treatment in regenerative therapy. J Periodontol
1993;64:s1166-70.
15. Machtei EE, Cho MI, Dunford R, Norderyd J, Zambon JJ, Genco RJ. Clinical, microbiological, and histological
factors which influence the success of regenerative periodontal therapy. J Periodontol1994;65:154-61.
16. Parashis A, Andronikaki-Faldami A, Tsiklakis K. Comparison of 2 regenerative procedures--guided tissue
regeneration and demineralized freeze-dried bone allograft--in the treatment of intrabony defects: a clinical and
radiographic study. J Periodontol1998;69:751-8.
17. Mellonig JT. Decalcified freeze-dried bone allograft as an implant material in human periodontal defects. Int J
Periodontics Restorative Dent 1984;4:40-55.
18. Sharma A, Pradeep AR. Autologous platelet-rich fibrin in the treatment of mandibular degree II furcation
defects: A randomized clinical trial. J Periodontol 2011; 82:1396-1403.
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J Clin Periodontol1993;20:528-36.

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22. Rummelhart JM, Mellonig JT, Gray JL, Towle HJ. A comparison of freezedried bone allograft and
demineralized freezedried bone allograft in human periodontal osseous defects. J Periodontol1989;60:655-663.
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dried bone allografts in periodontal osseous defects. J Periodontol1982;53:726-30.
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Table 1:- Clinical Parametres Of Both Group I (Dfdba)And Groupii(DFDBA+PRF).

PLAQUE GINGIVAL FMBS PD CAL

INDEX INDEX

GROU GROU GROU GROU GROU GROU GROU GROU GROU GROU

PI PII PI PII PI PII PI PII PI PII

MEAN MEAN MEAN MEAN MEA MEAN MEAN MEAN MEAN MEAN

±SD ±SD ±SD ±SD N± SD ±SD ±SD ±SD ±SD ±SD

baselin 0.73±0 0.72±0 0.74±0 0.75±0 19.9±1 20.2±1 7.27±0 7.80±1 10.47± 11.00±

e .05 .05 .06 .06 .39 .39 .46 .08 0.64 1.00

3mont 0.66±0 0.65±0 0.65±0 0.67±0 17.87± 18.2±1 4.67±0 4.27±0 8.40±0 8.00±0

hs .06 .06 .07 .07 1.35 .35 .49 .70 .74 .93

6mont 0.57±0 0.58±0 0.54±0 0.54±0 15.93± 16.2±2 4.07±0 3.00±0 7.47±0 7.00±0

hs .09 .09 .09 .09 2.23 .23 .26 .00 .64 .63

9 0.55± 0.53±0 0.59±0 0.59±0 14.5±1 14.5±1 4.07±0 3.07±0 7.33±0 6.87±0

months 0.07 .07 .08 .08 .95 .95 .26 .26 .62 .52

Baselin 0.05±0 0.05±0 0.05±0 0.04±0 1.66±1 1.66±1 2.60±0 3.53±0 - -

e- .03 .03 .04 .04 .17 .17 .51 .64 2.07±0 3.00±0
3mont .70 .65
hs
Baselin 0.12±0 0.12±0 0.13±0 0.14±0 3.68±1 3.68±1 3.20±0 4.80±1 - -
e- .04 .04 .04 .04 .50 .50 .56 .08 3.00±0 4.00±0
6mont .65 .65
hs
Baselin 0.19±0 0.19±0 0.21±0 0.22±0 5.71±1 5.71±1 3.20±0 4.73±0 - -
e- .06 .06 .07 .07 .93 .93 .56 .96 3.13±0 4.13±0

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9mont .74 .83

hs
P- P=<0.0 P=<0.0 P=<0.0 P=<0.0 P=<0. P=<0.0 P=<0.0 P=<0.0 P=<0.0 P=<0.0
VALU 1 HS 1 HS 1 HS 1 HS 01 1 HS 1 HS 1 HS 1 HS 1
E HS HS
(Intrag
roup)
P- P=1.00 NS P=1.00 NS P=1.00 NS P=<0.01 HS P=<0.01 HS
VALU
E
(Interg
roup)

Table 2:- Radiological Parametres Of Both Group I (DFDBA)And Groupii(DFDBA+PRF) At Baseline And 9
Months.
CEJ TO BOD CEJ TO AC

GROUP I GROUPII GROUP I GROUPII

MEAN±SD MEAN±SD MEAN±SD MEAN±SD

baseline 7.22±1.13 7.05±1.07 3.44±0.91 3.51±0.75

9months 5.59±1.23 5.08±0.98 3.58±0.80 3.61±0.58

P=<0.01 HS P=<0.01 HS P=<0.05 S P=<0.01 HS

Table 3:- Radiological Parametres Of Both Group I (DFDBA)And Groupii(DFDBA+PRF) From Baseline - 9
Months.
Baseline -9months

GROUP I GROUPII

MEAN± SD MEAN±SD p-value

CEJ TO BOD -1.63±0.51 -1.97±0.62 0.18 NS

CEJ TO AC 0.13±0.39 0.10±0.47 ˃0.05 NS

Defect fill 1.63±0.51 1.97±0.62 0.18NS

Defect resolution 1.50±0.52 1.75±0.54 0.88 NS

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Fig 1:- Flow Chart Of Study Design.

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Fig 2:- Radiographic Measurement By Cbct At Baseline.

Fig 3:- Radiographic Measurement By Cbct At 9 Months.

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