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Elsheikh HAE, Abdelsameaa SE, Elbahnasi AA, Abdel-Rahman FH. Comparison between platelet rich fibrin as space filling material versus xenograft and alloplastic bone grafting materials in immediate implant placement: a randomized clinical trial. BMC Oral Health 2023; 23:977. [PMID: 38066454 PMCID: PMC10704731 DOI: 10.1186/s12903-023-03678-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/19/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND This study aimed to compare the efficacy of different gap filling materials in immediate implant in anterior and premolar regions of maxilla. MATERIALS AND METHODS Thirty-six implants were inserted in patients seeking for replacement of non-restorable maxillary anterior and premolar teeth (esthetic zone) by immediate implant. Patients were randomly distributed into three equal groups, twelve implants in each group. Group 1 received Platelet Rich Fibrin (PRF) into the jumping distance, Group 2 received Xenograft into the jumping distance and Group 3 received Alloplastic bone grafting material into the jumping distance. Implant stability by measuring the changes in Resonance Frequency Analysis (RFA), peri-implant pocket depth, marginal bone loss and changes in buccal bone thickness were evaluated during follow up periods. All the clinical and radiographic data were subjected to statistical analysis by One Way ANOVA test and the Post Hoc Tukey test. RESULTS This study involved 19 female patients and 17 male patients who received 36 dental implants. There was no significant difference between the study groups regarding implant stability, peri-implant pocket depth and palatal bone loss, while there was a significant difference between PRF Group (Group 1) and the other Groups regarding buccal bone loss and changes in buccal bone thickness. CONCLUSION PRF can be used as a gap filling material in conjunction with immediate implant placement, but other bone grafting materials give superior result regarding buccal bone loss and changes in buccal bone thickness. TRIAL REGISTRATION The study was listed on www. CLINICALTRIALS gov with registration number (NCT05878392) on 26/05/2023. The Institutional Review Board (IRB) of the Faculty of Dentistry, Mansoura University, Mansoura, Egypt, approved the current study in compliance with the seventh revision of the Helsinki Declaration in 2013 (A0103023OS).
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Affiliation(s)
| | | | - Ahmed Adel Elbahnasi
- Fixed Prosthodontics, Faculty of Dentistry, Mansoura University, Mansoura, Egypt
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Zhang TS, Mudalal M, Ren SC, Zhou YM. Implant site development using titanium plate and platelet-rich fibrin for congenitally missed maxillary lateral incisors: A case report. World J Clin Cases 2022; 10:2015-2022. [PMID: 35317160 PMCID: PMC8891761 DOI: 10.12998/wjcc.v10.i6.2015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/29/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Bone deficiency and soft tissue atrophy in the absence of maxillary lateral incisors are among the most challenging problems for implant clinicians. Autologous bone grafting is the gold standard for bone augmentation, but not without limitations. Platelet-rich fibrin (PRF), a biodegradable autologous biomaterial, has been widely used for bone and soft tissue management. Moreover, titanium plate is an advantageous barrier due to its good space-maintaining ability. However, there is a lack of literature on implant site development using titanium plate and PRF for congenitally missing maxillary lateral incisors.
CASE SUMMARY The patient was a 19-year-old girl with a congenitally missing tooth (#12). She underwent implant placement and simultaneous autologous bone grafting with titanium plate and PRF. At the follow-up visit 15 d post-procedure, the vascularization of soft tissue was visible. There was no swelling or pain after the surgery. Six months postoperatively, bone regeneration was evident. Subsequently, the definitive restoration was placed, and the patient was satisfied with the esthetic outcomes.
CONCLUSION Implant site development using titanium plate and PRF for congenitally missing maxillary lateral incisors is a feasible procedure. In this case, the labial bone plate was displaced but remained connected to the base bone, ensuring blood supply. The titanium plate fixed the labial bone plate and maintained the osteogenic space, while the PRF provided growth factors and leukocytes for bone and soft tissue regeneration. Furthermore, the procedure reduced the surgical complexity and adverse reactions, displaying outstanding esthetic outcomes.
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Affiliation(s)
- Tian-Shou Zhang
- Department of Prosthodontics, School and Hospital of Stomatology, Jilin University, Changchun 130021, Jilin Province, China
| | - Mahmoud Mudalal
- Department of Dental Implantology, School and Hospital of Stomatology, Jilin University, Changchun 130021, Jilin Province, China
- Department of Oral and Maxillofacial Surgery and Periodontology, Faculty of Dentistry, The Arab American University, Jenin 240, Palestine
| | - Si-Cong Ren
- Department of Dental Implantology, School and Hospital of Stomatology, Jilin University, Changchun 130021, Jilin Province, China
| | - Yan-Min Zhou
- Department of Dental Implantology, School and Hospital of Stomatology, Jilin University, Changchun 130021, Jilin Province, China
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Fang J, Xin XR, Li W, Wang HC, Lv HX, Zhou YM. Immediate implant placement in combination with platelet rich-fibrin into extraction sites with periapical infection in the esthetic zone: A case report and review of literature. World J Clin Cases 2021; 9:960-969. [PMID: 33585645 PMCID: PMC7852644 DOI: 10.12998/wjcc.v9.i4.960] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/02/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In this case, platelet-rich fibrin (PRF) was added to guided tissue regeneration as a biomaterial in proper order for immediate planting in aesthetic area with periapical infection.
CASE SUMMARY With the history of endodontic failure in maxillary central incisor, a 34-year-old female patient required the extraction of maxillary anterior residual root and immediate implantation. Cone beam computed tomography and clinical observation were used to assess the regeneration of soft and bone tissue. Before operation, cone beam computed tomography showed the anterior residual root had serious periapical periodontitis with insufficient labial bone in the aesthetic zone. The patient underwent immediate implant placement and reconstruction of the bone substitution by modified guided bone regeneration. The barrier was a three-layer structure of PRF-collagen membrane-PRF that covered the mixture of PRF and Bio-Oss to promote both osteogenesis and soft tissue healing. At 6 mo postoperatively, the definitive crown was placed after accomplished finial impression. One-year follow-up showed a satisfactory aesthetic effect with no obvious absorption of the labial bone and soft tissue.
CONCLUSION The use of PRF in combination with guided bone regeneration can serve as a reliable and simple adjuvant for immediate implanting in infected socket and result in a stable osteogenic effect with good aesthetic outcome.
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Affiliation(s)
- Jiao Fang
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun 130021, Jilin Province, China
| | - Xi-Rui Xin
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun 130021, Jilin Province, China
| | - Wen Li
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun 130021, Jilin Province, China
| | - Han-Chi Wang
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun 130021, Jilin Province, China
| | - Hui-Xin Lv
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun 130021, Jilin Province, China
| | - Yan-Min Zhou
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun 130021, Jilin Province, China
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A new insight of Platelet-Rich Fibrin clots morphology and their elemental composition. Tissue Cell 2020; 65:101362. [PMID: 32746996 DOI: 10.1016/j.tice.2020.101362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 12/24/2022]
Abstract
This study analyzed the architecture of Platelet-Rich Fibrin (PRF) clots and assessed their elemental composition in order to provide new insight into this biomaterial. Five surplus PRF clots (2,700 RPM, 12 min.) donated by patients (63.6 ± 12.3 years old) were prepared for use in dental clinical procedures. The internal three-dimensional morphology of the red zones and the thirds of the yellow zones of the clots were analyzed by Variable Pressure Scanning Electron Microscope (VPSEM) after sample preparation by two methods: 1. Fixation (2.5% gluataraldehyde); and 2. Fixation with subsequent partial removal of extracellular elements (8 N, HCl). Semi-quantitative elemental analysis was performed by energy-dispersive X-ray spectrometry (EDX). VPSEM analysis showed erythrocytes in both the red zone and the yellow zone, which consisted mainly of fibrin. Removal of extracellular elements enriched the morphology of both zones; the organization of the fibrin was observed to differ in the thirds of the yellow zone, with increasing density and organization to distal. The elements that compose organic substances (C-Carbon, N-Nitrogen, O-Oxygen, Na-Sodium and P-Phosphorus) and halogens (Cl-Chloride and S-Sulfur) were detected; the highest concentrations were of C, followed by O (p < 0.05), in the proximal region of the fibrin. The results of the present study suggest organization of fibrin in the PRF clot, and also reveal the distribution of the elements present in the different regions of the clot. Improved understanding of these characteristics may favor the use of this biomaterial by increasing its efficiency and functionality.
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Nguyen VT, Nardini M, Ruggiu A, Cancedda R, Descalzi F, Mastrogiacomo M. Platelet Lysate Induces in Human Osteoblasts Resumption of Cell Proliferation and Activation of Pathways Relevant for Revascularization and Regeneration of Damaged Bone. Int J Mol Sci 2020; 21:ijms21145123. [PMID: 32698534 PMCID: PMC7403959 DOI: 10.3390/ijms21145123] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/13/2020] [Accepted: 07/16/2020] [Indexed: 12/17/2022] Open
Abstract
To understand the regenerative effect of platelet-released molecules in bone repair one should investigate the cascade of events involving the resident osteoblast population during the reconstructive process. Here the in vitro response of human osteoblasts to a platelet lysate (PL) stimulus is reported. Quiescent or very slow dividing osteoblasts showed a burst of proliferation after PL stimulation and returned to a none or very slow dividing condition when the PL was removed. PL stimulated osteoblasts maintained a differentiation capability in vitro and in vivo when tested in absence of PL. Since angiogenesis plays a crucial role in the bone healing process, we investigated in PL stimulated osteoblasts the activation of hypoxia-inducible factor 1-alpha (HIF-1α) and signal transducer and activator of transcription 3 (STAT3) pathways, involved in both angiogenesis and bone regeneration. We observed phosphorylation of STAT3 and a strong induction, nuclear translocation and DNA binding of HIF-1α. In agreement with the induction of HIF-1α an enhanced secretion of vascular endothelial growth factor (VEGF) occurred. The double effect of the PL on quiescent osteoblasts, i.e., resumption of proliferation and activation of pathways promoting both angiogenesis and bone formation, provides a rationale to the application of PL as therapeutic agent in post-traumatic bone repair.
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Affiliation(s)
- Van Thi Nguyen
- Department of Experimental Medicine (DIMES), University of Genova, 16132 Genova, Italy; (V.T.N.); (A.R.); (F.D.)
| | - Marta Nardini
- Department of Internal Medicine (DIMI), University of Genova, 16132 Genova, Italy;
- Biotherapy Unit, Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Alessandra Ruggiu
- Department of Experimental Medicine (DIMES), University of Genova, 16132 Genova, Italy; (V.T.N.); (A.R.); (F.D.)
| | | | - Fiorella Descalzi
- Department of Experimental Medicine (DIMES), University of Genova, 16132 Genova, Italy; (V.T.N.); (A.R.); (F.D.)
| | - Maddalena Mastrogiacomo
- Department of Internal Medicine (DIMI), University of Genova, 16132 Genova, Italy;
- Biotherapy Unit, Ospedale Policlinico San Martino, 16132 Genova, Italy
- Center for Biomedical Research (CEBR), University of Genova, 16132 Genova, Italy
- Correspondence: ; Tel.: +39-010-555-8203
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Tabrizi R, Mirmohammad Sadeghi H, Bakhshaei P, Ozkan BT. Does platelet-rich fibrin increase stability of the maxilla following Le Fort I osteotomy? A single-blind clinical trial study. J Craniomaxillofac Surg 2020; 48:531-535. [PMID: 32402496 DOI: 10.1016/j.jcms.2020.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/20/2020] [Accepted: 04/18/2020] [Indexed: 01/15/2023] Open
Abstract
This single-blind clinical trial study aimed to assess the efficacy of platelet-rich fibrin (PRF) in increasing stability following Le Fort I osteotomy for maxillary advancement. Patients who underwent Le Fort I osteotomy for maxillary advancement were assigned randomly into two groups: in group 1 (the study group, n = 22) PRF was placed in the osteotomy sites following fixation, while no PRF was used in group 2 (the control group, n = 22). Lateral cephalograms obtained preoperatively (T0), immediately after surgery (T1), and 1 year after surgery (T2) were compared between the two groups, and the amount of relapse was determined. The amount of maxillary change (relapse) at the A point in relation to the x-axis was 0.45 ± 0.67 mm in group 1 and 1.86 ± 0.56 mm in group 2. There was a significant difference in mean relapse in relation to the x-axis between the two groups 12 months after osteotomy (p < 0.001). The mean maxillary change (relapse) in relation to the y-axis was 0.77 ± 1.15 mm in group 1 and 2.25 ± 1.22 mm in group 2. Analysis of the data demonstrated a significant difference in mean relapse in relation to the y-axis between the two groups (p < 0.001). PRF may enhance the stability of the maxilla following Le Fort I osteotomy. Based on the results of this study the administration of PRF should be considered whenever possible.
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Affiliation(s)
- Reza Tabrizi
- Oral and Maxillofacial Surgery, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hassan Mirmohammad Sadeghi
- Oral and Maxillofacial Surgery, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pedram Bakhshaei
- Oral and Maxillofacial Surgery, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Birkan Taha Ozkan
- Oral and Maxillofacial Surgery, Toros University, Institute of Health Science, Toros, Turkey
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Dias FJ, Arias A, Borie E, Fuentes R. Platelet-rich fibrin and collagen membrane in the preservation of the alveolar bone: Feasibility of the elemental inorganic composition and scanning electron microscopy analysis. Microsc Res Tech 2019; 82:1993-1999. [PMID: 31441994 DOI: 10.1002/jemt.23368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/05/2019] [Accepted: 08/06/2019] [Indexed: 12/13/2022]
Abstract
The success of dental implants is related to the amount, quality, and composition of the alveolar bone. The placement of platelet-rich fibrin (PRF) clot associated with a resorbable collagen membrane (RCM) in a postextraction alveolus is a technique used for ridge preservation. This case report study analyzed the ultrastructural characteristics of cross-sectioned alveolar bone that received PRF and RCM using scanning electron microscopy and the inorganic composition using "energy dispersive X-ray spectrometry," in order to explore the feasibility of this method to clinical studies. Three alveolar bone samples from two male patients (37 and 58 years old), obtained in the procedure of placing the dental implant, were analyzed. Two bone samples previously received PRF and RCM (M37 and M58), the third sample represented a physiological bone formation without treatment (M37-control). The bone sample M37 showed irregularly shaped islets of calcified material intermingled with connective tissue. The other samples, from the 58-year-old patient with PRF and RCM (M58); and the other untreated bone sample from the same 37-year-old patient (M37-control) showed similar ultrastructural morphology with trabecular conformation without islets agglomerations. The inorganic composition analysis showed higher concentrations of calcium and phosphorus in both samples treated with PRF and RCM in comparison to the untreated bone sample. The Ca/P ratio was higher in the M37 sample compared to the others samples. The results showed morphology and inorganic composition differences among the treatments used, suggesting that this method is feasible to analyze parameters of the alveolar bone tissue.
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Affiliation(s)
- Fernando José Dias
- Department of Integral Dentistry, Dental School, Universidad de La Frontera, Temuco, Chile.,Research Centre for Dental Sciences CICO, Dental School, Universidad de La Frontera, Temuco, Chile
| | - Alain Arias
- Department of Integral Dentistry, Dental School, Universidad de La Frontera, Temuco, Chile.,Research Centre for Dental Sciences CICO, Dental School, Universidad de La Frontera, Temuco, Chile.,Universidad Adventista de Chile, Chillán, Chile
| | - Eduardo Borie
- Department of Integral Dentistry, Dental School, Universidad de La Frontera, Temuco, Chile.,Research Centre for Dental Sciences CICO, Dental School, Universidad de La Frontera, Temuco, Chile
| | - Ramón Fuentes
- Department of Integral Dentistry, Dental School, Universidad de La Frontera, Temuco, Chile.,Research Centre for Dental Sciences CICO, Dental School, Universidad de La Frontera, Temuco, Chile
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Engler-Pinto A, Siéssere S, Calefi A, Oliveira L, Ervolino E, de Souza S, Furlaneto F, Messora MR. Effects of leukocyte- and platelet-rich fibrin associated or not with bovine bone graft on the healing of bone defects in rats with osteoporosis induced by ovariectomy. Clin Oral Implants Res 2019; 30:962-976. [PMID: 31287918 DOI: 10.1111/clr.13503] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 06/03/2019] [Accepted: 06/18/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the healing of critical size defects (CSDs) in calvaria of rats with osteoporosis induced by ovariectomy and treated with leukocyte- and platelet-rich fibrin (L-PRF) associated or not with bovine bone graft (XENO). MATERIAL AND METHODS A total of 32 rats underwent a bilateral ovariectomy procedure. After 3 months, one 5 mm in diameter CSD was created in the middle of the calvaria of each animal. In group C, defect was filled with blood clot only. In PRF, XENO, and PRF-XENO groups, defects were filled with 0.1 ml of L-PRF, 0.1 ml of XENO, and a mixture of 0.1 ml of L-PRF plus 0.1 ml of XENO, respectively. L-PRF compressed clots were used to cover the defects in PRF and PRF-XENO groups. Animals were submitted to euthanasia at 30 postoperative days. Histomorphometric, microtomographic, and immunohistochemical analyses were performed. RESULTS PRF-XENO group presented greater amount of neoformed bone (NB) when compared with XENO group, as well as higher expression of vascular endothelial growth factor (VEGF), osteocalcin (OCN), and bone morphogenetic protein (BMP-2/4) (p < .05). PRF group presented increased amount of NB and higher expression of VEGF, OCN, BMP-2/4, and Runt-related transcription factor 2 (RUNX-2) when compared with group C (p < .05). CONCLUSIONS (a) The isolated use of L-PRF clot can improve bone neoformation in CSDs in rats with osteoporosis induced by ovariectomy, but seems to lead to decreased amount of bone neoformation when compared to the isolated use of XENO; (b) L-PRF potentiates the healing of XENO in rats with osteoporosis induced by ovariectomy.
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Affiliation(s)
- Ana Engler-Pinto
- Department of Morphology, Physiology and Basic Pathology - DMFPB, School of Dentistry, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Selma Siéssere
- Department of Morphology, Physiology and Basic Pathology - DMFPB, School of Dentistry, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Ana Calefi
- Department of Morphology, Physiology and Basic Pathology - DMFPB, School of Dentistry, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Luiz Oliveira
- Department of Oral and Maxillofacial Surgery and Periodontology - DCTBMF, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Edilson Ervolino
- Department of Basic Sciences, School of Dentistry, São Paulo State University, Araçatuba, SP, Brazil
| | - Sérgio de Souza
- Department of Oral and Maxillofacial Surgery and Periodontology - DCTBMF, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Flávia Furlaneto
- Department of Oral and Maxillofacial Surgery and Periodontology - DCTBMF, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Michel Reis Messora
- Department of Oral and Maxillofacial Surgery and Periodontology - DCTBMF, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
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Soni R, Priya A, Yadav H, Mishra N, Kumar L. Bone augmentation with sticky bone and platelet-rich fibrin by ridge-split technique and nasal floor engagement for immediate loading of dental implant after extracting impacted canine. Natl J Maxillofac Surg 2019; 10:98-101. [PMID: 31205397 PMCID: PMC6563640 DOI: 10.4103/njms.njms_37_18] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Nowadays, dental implants are the best treatment option for tooth loss, but implant placement requires sufficient bone volume. In defect area of alveolar ridge, augmentation is done by various available methods. Utilizing the growth factors such as platelet-rich fibrin (PRF) derived from patient's blood platelets improve treatment outcome. PRF accelerates the wound healing, enhances osteogenic activity as well as regulates the inflammation. Bone grafting, guided bone regeneration, and ridge-split technique promote new bone formation. The aim of this case report is to demonstrate an efficient method of bone augmentation using sticky bone along with PRF membrane, followed by ridge-split technique and engagement of nasal floor to place implant.
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Affiliation(s)
- Romesh Soni
- Department of Prosthodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Aditi Priya
- Department of Prosthodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Himanshi Yadav
- Department of Prosthodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Nitesh Mishra
- Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Lakshya Kumar
- Department of Prosthodontics, Crowns and Bridges, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
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