Combination of hydroxyapatite, platelet rich fibrin and amnion membrane as a novel therapeutic option in regenerative periapical endodontic surgery: Case series

The impact of bone grafting with/without barrier membrane placement on the outcome of apical surgery: A systematic review and meta-analysis

BACKGROUND

Regenerative techniques are increasingly being advocated in endodontic apical surgery (AS) to enhance the healing of periapical lesions. Various grafting and membrane materials are employed as adjuncts to modern AS.

OBJECTIVES

This systematic review aimed to answer the following PICO question: In patients with apical periodontitis (P) what is the impact of bone grafting with/without barrier membrane materials (I) compared with surgery without grafting materials (C) on the outcome of AS evaluated clinically and radiographically (O).

METHODS

A systematic search was conducted in four databases (Embase, Web of Science, PubMed and Cochrane Central Register of Controlled Trials) until 1 August 2023. Google Scholar was also manually searched. Studies with a prospective randomized design were included. Cochrane risk-of-bias (RoB) tool 2.0 assessed bias. Two independent reviewers performed the study selection, data extraction and appraisal of studies. Meta-analysis was performed using R3.5.1 software.

RESULTS

From the identified 2582 studies, eight randomized clinical trials were included for meta-analysis. Two studies had low RoB, while six had some concerns. Analysis revealed significantly better outcomes when surgery involved bone regeneration techniques than conventional surgery (OR = 2.18, 95% CI: 1.32-4.31, p = .004). Subgroup analyses on individual grafts (OR = 0.22, 95% CI: -0.99 to 1.44, p = .720) (OR = -0.09, 95% CI: -1.42 to 1.23, p = .885) and membranes (OR = -1.09, 95% CI: -2.94 to 0.76, p = .247) and their combinations (OR = 0.03, 95% CI: -1.50 to 1.55, p = .970) did not yield any significant results. The type of membrane used did not significantly impact the outcome (OR = -1.09, 95% CI: -2.94 to 0.76, p = .247) nor did altering the combination of graft/membrane.

DISCUSSION

This systematic review examined the effects of bone grafting with/without membrane placement on the outcome of AS. It highlights the potential advantages of regenerative techniques and the need for further research in this area.

CONCLUSIONS

Based on current evidence, bone grafting with/without barrier membrane placement significantly improves healing after AS. Subgroup analysis of resorbable membranes or grafting did not significantly influence the outcome. The combination of membrane and graft was also not significant. Future well-designed, randomized controlled trials in this area are essential before these materials can be recommended for routine use to enhance healing outcomes in AS.

REGISTRATION

PROSPERO (CRD42021255171).

Fabrication and characterization of a novel injectable human amniotic membrane hydrogel for dentin-pulp complex regeneration

OBJECTIVE

Injectable biomaterials that can completely fill the root canals and provide an appropriate environment will have potential application for pulp regeneration in endodontics. This study aimed to fabricate and characterize a novel injectable human amniotic membrane (HAM) hydrogel scaffold crosslinked with genipin, enabling the proliferation of Dental Pulp Stem Cells (DPSCs) and optimizing pulp regeneration.

METHODS

HAM extracellular matrix (ECM) hydrogels (15, 22.5, and 30 mg/ml) crosslinked with different genipin concentrations (0, 0.1, 0.5, 1, 5, and 10 mM) were evaluated for mechanical properties, tooth discoloration, cell viability, and proliferation of DPSCs. The hydrogels were subcutaneously injected in rats to assess their immunogenicity. The hydrogels were applied in a root canal model and subcutaneously implanted in rats to determine their regenerative potential for eight weeks, and histological and immunostaining analyses were performed.

RESULTS

Hydrogels crosslinked with low genipin concentration demonstrated low tooth discoloration, but 0.1 mM genipin crosslinked hydrogels were excluded due to their unfavourable mechanical properties. The degradation ratio was lower in hydrogels crosslinked with 0.5 mM genipin. The 30 mg/ml-0.5 mM crosslinked hydrogel exhibited a microporous structure, and the modulus of elasticity was 1200 PA. In vitro, cell culture showed maximum viability and proliferation in 30 mg/ml-0.5 mM crosslinked hydrogel. All groups elicited minimum immunological responses, and highly vascularized pulp-like tissue was formed in human tooth roots in both groups with/without DPSCs.

SIGNIFICANCE

Genipin crosslinking improved the biodegradability of injectable HAM hydrogels and conferred higher biocompatibility. Hydrogels encapsulated with DPSCs can support stem cell viability and proliferation. In addition, highly vascularized pulp-like tissue formation by this biomaterial displayed potential for pulp regeneration.

Application of platelet-rich fibrin and freeze-dried bone allograft following apicoectomy: A comparative assessment of radiographic healing

Background

Apicoectomy conceptualizes surgically maintaining a tooth with an endodontic lesion that cannot be resolved by conventional endodontic (re-) treatment. To achieve this, continuous improvement in surgical techniques, materials and instruments is being done to enhance the outcome of periapical endodontic surgeries. The purpose of this study was to compare, radiographically, the healing kinetics of platelet-rich fibrin (PRF) and mineralized freeze-dried bone allograft (FDBA) in patients undergoing apicoectomy.

Materials and Methods

Nineteen patients (aged 18-40 years) were included in the study and randomly assigned to groups A or B, where they received PRF or FDBA, respectively. Following apicoectomy, PRF gel and FDBA graft were prepared and placed in the osseous defect followed by placement of PRF membrane for graft stabilization and flap closure. Radiographic follow-up was done at the 1^st, 3^rd, 6^th and 12^th months for evaluation of healing using Molven's criteria. Statistical analysis was done with Pearson's and McNemar's Chi-square tests.

Results

A highly significant difference (P = 0.002) in radiographic healing was observed at 6 months. Complete healing was observed in 50% of cases in Group A whereas in Group B, none of the cases presented with complete radiographic healing. However, at the end of 12 months, complete radiographic healing was observed in both groups.

Conclusion

Our data suggest that PRF accelerates bone healing as compared to FDBA and is both time and cost-efficient.

Effect of amniotic membrane and platelet-rich fibrin membrane on bone healing post endodontic surgery: An ultrasonographic, randomized controlled study

The use of membrane barriers and bone grafting materials in endodontic surgery promotes healing by regeneration rather than repair by scar tissue. Due to its valuable regenerative and therapeutic properties, the human amniotic membrane can support ideal periapical rehabilitation and promote better healing after surgery. The current trial aimed to evaluate the amniotic membrane's healing potential and compare it with platelet-rich fibrin using color doppler sonography. The current study is a randomized, double-blinded, parallel-group, single-center study. Thirty-four systematically healthy individuals requiring endodontic surgery who fulfilled all inclusion and exclusion criteria were selected and randomly placed in two groups. Surgical curettage of the bony lesion was performed and filled with hydroxyapatite graft. Amniotic membrane (Group 1) and platelet-rich fibrin (Group 2) were placed over the bony crypt, and the flap was sutured back. The lesion's surface area and vascularity were the parameters assessed with ultrasound and color doppler. and observations: The groups found a significant difference in mean vascularity at 1 month and mean vascularity change from baseline to 1 month (p < 0.05). Mean surface area had no statistically significant difference between the groups. However, in terms of the percentage change in surface area, a significant difference was found from baseline to 6 months (p < 0.05). Amniotic membrane was a significantly better promoter of angiogenesis than platelet-rich fibrin in the current trial. The osteogenic potential of both materials was similar. However, the clinical application, availability, and cost-effectiveness of amniotic membrane support it as a promising therapeutic alternative in clinical translation. Further large-scale trials and histologic studies are warranted.

The response surface methodology for optimization of Halomonas sp. C2SS100 lipase immobilization onto CaCO3 for treatment of tuna wash processing wastewater

An immobilized enzyme could exhibit selectively modified physicochemical properties, and it might offer a better environment for the enzyme activity. In this study, the immobilization yield of crude Halomonas sp. lipase was optimized to improve its stability. Thanks to its high adsorption capacity, CaCO₃ has been chosen as support for the immobilization process. Furthermore, response surface methodology (RSM) was used to determine optimal conditions for the immobilization of the bacterial lipase. Five tested factors (enzyme solution, support amount, time, temperature, and acetone volume) were optimized applying a central composite design of RSM. The maximum yield of lipase immobilization was improved to 96%. Furthermore, a biochemical characterization proved a significant improvement of the immobilized lipase stability. The immobilized enzyme is more stable at extreme pH values and high temperatures than the free one. We also tested the reusability of the immobilized lipase by evaluating the recovery of the support using simple filtration. Thanks to its high stability, the immobilized lipase was invested in an effective treatment of tuna wash processing wastewater. The oil biodegradation efficiency was established at 81.5% and was confirmed by Fourier transformation infrared spectrometry. Likewise, the biological oxygen demand values were reduced which makes a possible reduction of the wastewater pollution degree.

Platelet-rich fibrin/anorganic bovine bone mineral complex as grafting materials in endodontic microsurgery with a large lesion size: study protocol for a randomised controlled trial

INTRODUCTION

Endodontic microsurgery is a treatment of last resort for preserving natural teeth. According to radiographic evaluation, the percentage of complete healing after endodontic microsurgery is only 74.3%. The use of regenerative techniques in endodontic microsurgery for large lesions (>10 mm diameter) is therefore recommended. The most frequently used bone graft in endodontic microsurgery is anorganic bovine bone mineral (ABBM) but this only has an osteoconductive effect. Thus, when platelet-rich fibrin (PRF), a reservoir of growth factors, is used together with ABBM, it increases the regenerative effect. This study is devoted to comparing the clinical outcomes of PRF with/without ABBM as grafting biomaterials in endodontic microsurgery cases with large lesion size to provide some valuable reference data for dentists.

METHODS AND ANALYSIS

Sixteen patients who are in need of endodontic microsurgery will be recruited. The patients will be randomly assigned to one of two groups: an experimental group, treated with PRF/ABBM complex and collagen membrane, and a control group, treated with ABBM and collagen membrane. Clinical examination including percussion, mobility testing and presence/absence of sinus will be recorded at 7 days, and at 3, 6 and 12 months after endodontic microsurgery. A Visual Analogue Scale will be used by the patients to evaluate pain at 1, 3 and 7 days after endodontic microsurgery. Routine paralleling radiographs will be obtained before and at 3, 6 and 12 months follow-up after endodontic microsurgery. Cone-beam CT (CBCT) scans will be obtained at the 12-month follow-up. Bone formation will be evaluated according to CBCT and paralleling radiographs. The study execute time including follow-ups last from 1 June 2021 to 31 December 2024.

ETHICS AND DISSEMINATION

This study received approval from the Ethics Committee of Peking University School and Hospital of Stomatology. The results will be disseminated through scientific journals.

TRIAL REGISTRATION NUMBER

Research data will be registered with the International Clinical Trials Registry Platform (ICTRP), ID: ChiCTR2100046684.

Synergistic impact of platelet rich plasma-heparin sulfate with hydroxyapatite/zirconia on the osteoblast differentiation potential of adipose-derived mesenchymal stem cells

3D porous hydroxyapatite (HA) has been reinforced by zirconia (ZrO₂) coating and impregnation with a combination of platelet rich plasma (PRP) as a source of growth factors (GFs) and Heparin sulfate (HS) to sustain the release of GFs. Adipose mesenchymal stem cells (ADMSCs) were characterized by flow cytometry for CD (cluster of differentiation) 44, CD105, CD106, CD34 and CD144, along with checking the multipotency by differentiation into the adipocytes and osteoblasts. Then, they were cultured on the scaffold treated with and without osteogenic media on days 7, 14 and 21. Electron micrograph and PKH staining show that the ADMSCs have a fusiform phenotype in the absence of osteogenic induction. Cell viability assay shows a higher number of the viable cells on the PRP-containing scaffolds than PRP-free scaffolds on day 7. Colorimetric evaluation, quantitative RT-PCR and immunocytochemistry demonstrate that PRP and HS significantly elevate the alkaline phosphatase enzyme activity and also accelerate the production of both early and mid-osteogenic markers, including collagen I and osteopontin expression with and without osteogenic conditions. The PRP-HS also accelerates the expression of the late osteogenic marker, osteocalcin, in both mRNA and protein level expression with a peak on day 21. In conclusion, supplementation of HA/ZrO₂ with PRP/HS has a synergistic impact on the ADMSCs, even in the absence of chemical induction. It seems that HA/ZrO₂/PRP/HS scaffold provides a higher osteoconductive microenvironment for stem cell differentiation to osteoblasts.

Human amniotic membrane as therapeutic agent in pulpotomy of permanent molars

A 22-year-old woman reported with a cariously exposed mandibular molar. Pulpotomy was planned rather than routine root canal treatment, which was otherwise indicated. Amniotic membrane (AM) that has been extensively researched in different fields of medicine was used as the pulpotomy agent. After gaining coronal access to the root orifices, bleeding was arrested and activated AM was placed over the root stumps. Glass ionomer cement(GIC) was placed over the membrane and temporary restoration was done. One week later, permanent restoration with composite resin was done. The patient's symptoms resolved, and the tooth started responding normally to vitality tests at subsequent follow-ups. The present case report is an attempt to use human AM as a natural pulpotomy agent for treating irreversible pulpitis in permanent teeth. Understanding of innumerable beneficial properties of the AM and its application in preserving vitality of permanent teeth is the main learning objective.

Plasma Rich in Growth Factors in the Treatment of Endodontic Periapical Lesions in Adult Patients: A Narrative Review

Platelet concentrates have been widely used in regenerative medicine, including endodontics. The aim of this manuscript was to assess critically the efficacy of PRF in the treatment of endodontic periapical lesions in adult patients on the basis of the literature. The PICO approach was used to properly develop literature search strategies. The PubMed database was analyzed with the keywords: "((PRP) OR (PRF) OR (PRGF) OR (CGF)) AND (endodontic) AND ((treatment) OR (therapy))". After screening of 155 results, 14 articles were included in this review. Different types of platelet concentrates are able to stimulate the processes of proliferation and differentiation of mesenchymal stem cells. Platelet rich fibrin (PRF) releases growth factors for at least 7 days at the application site. Growth factors and released cytokines stimulate the activity of osteoblasts. Moreover, the release of growth factors accelerates tissue regeneration by increasing the migration of fibroblasts. It was not possible to assess the efficacy of PRF supplementation in the treatment of endodontic periapical lesions in permanent, mature teeth with closed apexes, due to the lack of well-designed scientific research. Further studies are needed to analyze the effect of PRF on the healing processes in the periapical region.

Applications of Human Amniotic Membrane for Tissue Engineering

An important component of tissue engineering (TE) is the supporting matrix upon which cells and tissues grow, also known as the scaffold. Scaffolds must easily integrate with host tissue and provide an excellent environment for cell growth and differentiation. Human amniotic membrane (hAM) is considered as a surgical waste without ethical issue, so it is a highly abundant, cost-effective, and readily available biomaterial. It has biocompatibility, low immunogenicity, adequate mechanical properties (permeability, stability, elasticity, flexibility, resorbability), and good cell adhesion. It exerts anti-inflammatory, antifibrotic, and antimutagenic properties and pain-relieving effects. It is also a source of growth factors, cytokines, and hAM cells with stem cell properties. This important source for scaffolding material has been widely studied and used in various areas of tissue repair: corneal repair, chronic wound treatment, genital reconstruction, tendon repair, microvascular reconstruction, nerve repair, and intraoral reconstruction. Depending on the targeted application, hAM has been used as a simple scaffold or seeded with various types of cells that are able to grow and differentiate. Thus, this natural biomaterial offers a wide range of applications in TE applications. Here, we review hAM properties as a biocompatible and degradable scaffold. Its use strategies (i.e., alone or combined with cells, cell seeding) and its degradation rate are also presented.

Impact of different regenerative techniques and materials on the healing outcome of endodontic surgery: a systematic review and meta-analysis

BACKGROUND

Regenerative techniques are increasingly applied in endodontic surgery, but different materials used in regenerative techniques may have varying impacts on wound healing.

OBJECTIVES

This study evaluated the effects of different regenerative techniques and materials on the outcome of endodontic surgery.

PARTICIPANTS

patients with persistent periapical lesions, treated with root-end surgery.

CONTROL

endodontic surgery without the use of regenerative techniques/materials.

INTERVENTION

endodontic surgery with the use of regenerative techniques/materials.

OUTCOME

combined clinical and radiographic results.

METHODS

PubMed, Web of Science, Embase, SinoMed and the CENTRAL Cochrane were searched up to 10th July 2020, followed by a manual search. Detailed eligibility criteria were applied. Cochrane's risk-of-bias tool 2.0 was used to assess the risk of bias of the eligible studies. Meta-analysis was conducted using RevMan software. Subgroup analyses were performed based on the regenerative materials used in endodontic surgery.

RESULTS

Eleven eligible randomized controlled trials (RCTs) were included in the meta-analysis: two had a low risk of overall bias, and nine had some concerns of overall bias. Generally, the use of regenerative techniques significantly improved the outcome of endodontic surgery (risk ratio [RR]: 0.42; 95% confidence interval [CI], 0.26-0.68; P < 0.001). On subgroup analysis, the use of expanded polytetrafluoroethylene (e-PTFE) membranes alone had no added benefits (RR: 2.00; 95% CI, 0.22-18.33; P = 0.54). The application of collagen membranes or autologous platelet concentrates (APCs) alone was associated with a trend for better outcomes (RR: 0.51; 95% CI, 0.20-1.25; P = 0.14) (RR: 0.55; 95% CI, 0.18-1.71; P = 0.30). The combined use of collagen membranes and bovine-derived hydroxyapatite significantly improved the outcome (RR: 0.35; 95% CI, 0.17-0.75; P = 0.007).

DISCUSSION

This systematic review evaluated the effects of collagen membranes, e-PTFE membranes, APCs and bone grafting materials, providing detailed information about the risks and benefits of using each regenerative technique/material or its combination in endodontic surgery.

CONCLUSIONS

Regenerative techniques improve periapical lesion healing after endodontic surgery. The combined use of collagen membranes and bovine-derived hydroxyapatite may be beneficial as an adjunct to endodontic surgery. In contrast, the positive efficacy of e-PTFE membranes or APCs alone remains doubtful.

Assessment of fresh and preserved amniotic membrane for guided bone regeneration in mice

Thanks to its biological properties, the human amniotic membrane (HAM) can be used as a barrier membrane for guided bone regeneration (GBR). However, no study has assessed the influence of the preservation method of HAM for this application. This study aimed to establish the most suitable preservation method of HAM for GBR. Fresh (F), cryopreserved (C) lyophilized (L), and decellularized and lyophilized (DL) HAM were compared. The impact of preservation methods on collagen and glycosaminoglycans (GAG) content was evaluated using Masson's trichrome and alcian blue staining. Their suture retention strengths were assessed. In vitro, the osteogenic potential of human bone marrow mesenchymal stromal cells (hBMSCs) cultured on the four HAMs was evaluated using alkaline phosphatase staining and alizarin red quantification assay. In vivo, the effectiveness of fresh and preserved HAMs for GBR was assessed in a mice diaphyseal bone defect after 1 week or 1 month healing. Micro-CT and histomorphometric analysis were performed. The major structural components of HAM (collagen and GAG) were preserved whatever the preservation method used. The tearing strength of DL-HAM was significantly higher. In vitro, hBMSCs seeded on DL-HAM displayed a stronger ALP staining, and alizarin red staining quantification was significantly higher at Day 14. In vivo, L-HAM and DL-HAM significantly enhanced early bone regeneration. One month after the surgery, only DL-HAM slightly promoted bone regeneration. Several preserving methods of HAM have been studied for bone regeneration. Here, we have demonstrated that DL-HAM achieved the most promising results for GBR.

Preparation of placental tissue transplants and their application in skin wound healing and chosen skin bullous diseases - Stevens-Johnson syndrome and toxic epidermal necrolysis treatment

Unique properties of amniotic membrane make it a promising source for tissue engineering and a clinically useful alternative for patients suffering from chronic wounds including, for example, ulcers, burns, ocular surface damages and wounds occurring in the course of bullous diseases like stevens-johnson syndrome and toxic epidermal necrolysis. Its use has many advantages over standard wound care, as it contains pluripotent cells, nutrients, anti-fibrotic and anti-inflammatory cytokines, growth factors and extracellular matrix (ECM) proteins. Placental tissues can be prepared as a medical component, an advanced therapy medicinal product or a tissue graft. In addition to basic preparation procedures such as washing, rinsing, cutting, drying and sterilisation, there are many optional steps such as perforation, crosslinking and decellularisation. Finally, transplants should be properly stored-in cryopreserved or dehydrated form. In recent years, many studies including basic science and clinical trials have proven the potential to expand the use of amniotic membrane and amnion-derived cells to the fields of orthopaedics, dentistry, surgery, urology, vascular tissue engineering and even oncology. In this review, we discuss the role of placental tissues in skin wound healing and in the treatment of various diseases, with particular emphasis on bullous diseases. We also describe some patented procedures for placental tissue grafts preparation.

Apical periodontitis associated with a calculus-like deposit: A case report of a rare fan-shaped manifestation

Introduction

Bacterial biofilms can be calcified. Granulomas or cystic lesions are the most commonly found entities in endodontics. Surprisingly, this case report presents a rare radiopaque image, in a fan shape, of a calculus-like deposit in the periapical region of the maxillary left central incisor.

Case presentation

A 34-year-old male, with a history of trauma, presented with apical periodontitis associated with an uncommon image, similar to a calculus-like deposit adhered to the apical region of the maxillary left central incisor. Nonsurgical endodontic intervention was performed, followed by apicoectomy and histopathological analysis of the collected material. The results of the biopsy were not compatible with a cyst or granuloma but showed fibrous connective tissue with calcified areas.

Discussion

Correct diagnosis in endodontics is possible with a well-conducted anamnesis, complementary imaging exams and, in some cases, histopathological analysis. The periapical calculus-like deposit, associated with a periapical radiolucent lesion, was a result of the body's fight for healing, producing unusual radiopacity.

Conclusion

The presence of the calculus-like deposit in a fan shape at the root surface represented dystrophic calcification as a manifestation of the attempt to heal. In the present case, apicoectomy and tissue biopsy for histological evaluation were fundamental for the correct diagnosis.

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Root canal is critical area for biofilm development.

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Extraradicular biofilm on the surface of the root may cause persistent periapical lesions.

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Uncommon radiopaque image association with endodontic periapical lesions was related.

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Persistent periapical lesions associate with extraradicular biofilm represents a challenge for Endodontic treatment.

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Only surgical resection was capable to repair the injury.

Efficacy of Adjunctive Bioactive Materials in the Treatment of Periodontal Intrabony Defects: A Systematic Review and Meta-Analysis

Objectives

Lots of bioactive materials have been additionally applied for the treatment of periodontal intrabony defect. However, there is dearth of studies to systematically evaluate the supplementary role of them in periodontal regeneration. The goal of this meta-analysis is to evaluate the adjunctive effects of bioactive materials such as platelet-rich plasma (PRP), platelet-rich fibrin (PRF), enamel matrix derivative (EMD), and amnion membrane (AM) on the outcomes of bone grafting treatment for periodontal intrabony defects.

Methods

Articles published before December 2017 were searched electronically in three databases (PubMed, Embase, and Cochrane Central), with no date or language limits. Randomized controlled trials (RCTs) on the assessment of effectiveness of the four biomaterials in conjunction with demineralized freeze-dried bone allografts (DFDBA) in the treatment of periodontal intrabony defects were enrolled in this meta-analysis. Data were analyzed with STATA 12.

Results

Nine studies were included. PRF and PRP significantly improved pocket depth (PD) reduction and clinical attachment loss (CAL) gain. Only PRF exhibited a positive result in recession reduction (RecRed). Only PRP showed a statistically significant increase in bone fill. AM merely gained more CAL. EMD did not improve any clinical outcome.

Conclusion

Our data suggest that PRF/PRP could be taken as a preferred adjunct to facilitate periodontal regeneration of intrabony defects.