Rajiv Gandhi University of Health Sciences s161

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA , BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

Comparison of the efficacy of a combination of platelet rich fibrin and biograft- HT® with that of platelet rich fibrin alone in healing of mandibular third molar sockets - A Prospective clinical study

DR. MD. H. SHAKEEB ULLAH. POST GRADUATE STUDENT DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY K.V.G. DENTAL COLLEGE AND HOSPITAL SULLIA, D.K. – 574327 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE – KARNATAKA

ANNEXURE – II PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1) NAME OF THE CANDIDATE DR. MD.H.SHAKEEB ULLAH AND ADDRESS POST GRADUATE STUDENT, DEPT. OF ORAL AND MAXILLOFACIAL SURGERY, K.V.G. DENTAL COLLEGE AND HOSPITAL, KURUNJIBAG, SULLIA- 574327.

2) NAME OF THE INSTITUTION K.V.G DENTAL COLLEGE AND HOSPITAL, KURUNJIBAG, SULLIA- 574327

3) COURSE OF STUDY AND MASTER OF DENTAL SURGERY SUBJECT (ORAL AND MAXILLOFACIAL SURGERY )

4) DATE OF ADMISSION TO 29-07-2013 COURSE. Comparison of the efficacy of a 5) TITLE OF THE TOPIC combination of platelet rich fibrin and biograft- HT® with that of platelet rich fibrin alone in healing of mandibular third molar sockets - A Prospective clinical study 6.) BRIEF RESUME OF THE INTENDED WORK

6.1) Need for the study:

Reconstruction of bony defects represents a challenging problem for the surgical community. Many defects in facial skeleton may significantly impair proper prosthetic and functional rehabilitation of the stomatognathic system. 1

Platelet Rich Growth Factors (PRGF) are very successful in stimulating bone regeneration and promote healing after the surgical removal of third molar tooth 2 Platelet rich fibrin (PRF) is a newer material which is referred to as a second-generation platelet concentrate. It contains all constituents of a blood sample favorable for healing and immunity on a single fibrin membrane. It is successfully used in healing of the wound2.

Platelet rich fibrin (PRF) is both healing and interpositional biomaterial. As a healing material, it accelerates wound closure and mucosal healing due to fibrin bandage and growth factor release. As interpositional material, it avoids the early invagination for undesired cells, thereby behaves as a competitive barrier between desired and undesired cells2.

Alloplastic bone graft materials are synthetic, inorganic, biocompatible, and bioactive bone substitutes that are believed to promote healing of bone defects through osteoconduction. Several calcium phosphate biomaterials have been tested since the mid-1970. They have excellent tissue compatibility and do not elicit any inflammation or foreign body response. Two types of calcium phosphate ceramics have been used, hydroxyapatite (HA) and tricalcium – phosphate2.

Biograft- HT® is a biphasic calcium phosphate consisting of hydroxyapatite (HA) and beta- tricalcium phosphate in the weight % ratio of approximately 60:40 that is biocompatible, non- toxic, resorbable, non-inflammatory, and bioactive. It causes no immunological, foreign-body, or irritating response, and has excellent osteoconductive ability. Hydroxyapatite has a stoichiometry similar to natural bone and provides an osteoconductive scaffold in the bone regenerative process6.

Socket healing is a highly co-ordinated sequence of biochemical, physiologic, cellular and molecular responses involving numerous cell types, growth factors, hormones, cytokines, and other proteins, which is directed towards restoring tissue integrity and functional capacity after injury. Third molar socket provides a very good study model to assess the role of various biomaterials in healing. There are several studies1,2,4,5 to assess the role of platelet rich fibrin (PRF) in healing sockets as well as bony defects, similarly there are studies to prove the role of alloplastic materials such as hydroxyapatite (HA) as well as biograft- HT® in healing of bony defects in the oral cavity6.

However there is no single study that compares the efficacy of platelet rich fibrin (PRF) with that of a combination of platelet rich fibrin (PRF) with biograft- HT® in healing sockets. We believe there is a need to continuously look for newer biomaterials or combinations of existing alloplastic materials with autografts to find out any additional advantages and superiority in terms of healing. This study is an attempt in that direction. Hence we feel there is a need for a study comparing the efficacy of a combination of platelet rich fibrin and biograft- HT® with that of Platelet rich fibrin alone in mandibular third molar sockets.

6.2) Review of literature:

Choukroun et al1 evaluated the potential of PRF in combination with Freeze-dried bone allograft (FDBA) to enhance bone regeneration in sinus floor elevation. This study was a case of 9 sinus elevations with FDBA with or without PRF. Bone fragments were analyzed. Preliminary analysis highlight mineralized trabecular bone rich in osteocytes with important osteoid borders in contact with dense cellular osteoblast fronts. Hence they concluded PRF membranes have potential to treat sinus membrane perforation

Sunitha and Munirathnam2, elaborated the method of preparation of the platelet rich plasma (PRP) and platelet rich fibrin(PRF). PRP is a platelet concentrate and has been used widely to accelerate soft- tissue and hard-tissue healing. Platelet rich fibrin (PRF) was first discovered by Choukroun et al. in France. In their review article they have described the evolution of this novel platelet concentrate which is referred to as PRF.

Olufemi et al 3, conducted A prospective randomized comparative clinical study was undertaken over a 2-year period. Patients requiring surgical extraction of a single impacted third molar and who fell within the inclusion criteria and indicated willingness to return for recall visits were recruited. The predictor variable was application of PRP gel to the socket of the third molar in the test group, whereas the control group had no PRP. The outcome variables were pain, swelling, and maximum mouth opening, which were measured using a 10-point visual analog scale, tape, and millimeter caliper, respectively. Socket healing was assessed radiographically by allocating scores for lamina dura, overall density, and trabecular pattern. Sixty patients aged 19 to 35 years (mean: 24.7 _ 3.6 years) were divided into both test and control groups of 30 patients each. The mean postoperative pain score (visual analog scale) was lower for the PRP group at all time points and this was statistically significant (P _ .05). Although the figures for swelling and interincisal mouth opening were lower in the test group, this difference was not statistically significant. Similarly, the scores for lamina dura, trabecular pattern, and bone density were better among patients in the PRP group. This difference was also not statistically significant.

Shepherd et al4 conducted a prospective Randomised Controlled Trial where fibrin sealant (human) is used in 10 consecutive patients undergoing lateral osteotomy in Rhinoplasty. Fibrin sealant was used on either the right or the left side with the contralateral side acting as the control. The observers evaluated all photographs and completed a grading scale to define bruising and swelling on each side. Then after seeing the results they declared that Fibrin sealant applied to a lateral osteotomy site significantly reduced bruising and swelling.

Michael et al5 did a prospective study on 110 patients where 138 implants were placed using osteotome-mediated sinus floor elevation (OMSFE) with PRF. The mean increase in the height of implant sites by OMSFE/PRF was 3.4mm. 138 implants that had been placed, 97 have been restored and in function for an average loading time of 5.2 months. Then in the end they concluded that OMSFE/PRF technique presented for localized sinus floor elevation and implant placement demonstrates a high degree of safety and success at sites with 5mm to 8mm residual sub-antral bone height.

Chandrashekhar and Saxena6, diagnosed twenty patients with generalized chronic periodontitis having two or more vertical defects were selected for this study.Radiographic evaluation included the depth of the bone defect and the percentage of bone defect fill and was carried out for both the groups at baseline, three months and six months.After recording clinical parameters and administering phase-1 therapy, the sites were randomly treated either with biograft- HT® or open flap debridement only. After the study they concluded that biograft- HT® improves healing outcomes, leads to a reduction of probing depth, a resolution of osseous defects and a gain in clinical attachment, compared with open flap debridement by itself.

Vasundara et al7, did a prospective study on 45 year old male patient with the swelling in the upper front teeth region and large inflammatory periapical bony defect radiologically. The surgical defect was filled with with a combination of PRF and hydroxyapatite bone graft crystals The defect was covered by PRF membrane and sutured. Clinical examination revealed uneventful healing. Radiologically the HA crystals have been completely replaced by new bone at the end of 2 years. In the end of the study they concluded that the use of PRF in combination with the hydroxyapatite crystals might have accelerated the resorption of the graft crystals and would have induced rapid rate of bone formation.

Sculean et al8, in the study concluded the that the combination of barrier membrane and grafting materials may result in histological evidence of periodontal regeneration, predominantly bone repair.

Gassling et al9, proved in their study that PRF membranes are suitable for cultivation of periosteal cells for bone tissue engineering.

Pradeep et al10, in the study concluded that when hydroxyapetite is combined with PRF, it increases the regenerative effects observed with PRF in the treatment of human three wall periodontal intrabony defects.

6.3) Aim and objectives:

To compare the efficacy of a combination of platelet rich fibrin and biograft- HT® with that of platelet rich fibrin alone in healing of mandibular third molar sockets.

Objectives:  To compare the postoperative pain using a standard scale.  To compare the postoperative swelling using standard measurements.  To compare the postoperative trismus at various time intervals.  To compare the periodontal health distal to mandibular second molar using periodontal probe at various time intervals.  To compare the quality of bone healing and the formation of the new bone at the mandibular third molar socket using Intraoral periapical radiograph (IOPA) at various time intervals.

7) Materials and methods:

Pre-operatively :

 IOPA films (Kodak E- films).

 X- ray machine (Planmeca intra).

 Betadine solution and normal saline.

 Perioguard mouthwash (Colgate Palmolive INDIA LTD)

 Syringe of 10ml and 2.5ml (Dispo van).

 Centrifugal vials.

 Lignocaine hydrochloride with adrenaline (1:80000)

 Centrifugation machine.

Intra-operatively :

 Standard armamentarium for surgical removal of mandibular third molar.

 Guaze piece.

 Platelet rich fibrin (PRF).

 Biograft- HT® (An Alloplast material)

 Suturing needle and 3-0 Black braided silk (lifecare) Postoperatively :

 Cap Mox (Amoxicillin) 500 mg thrice daily for 5 days

 Tab Voveron 50 mg (Diclofenac sodium) twice daily for 5 days

To record pain, swelling, trismus, periodontal health and bone healing and bone formation.  Visual analog scale

 Thread

 Vernier calliper

 Williams probe

 IOPA radiograph (tracing equipments )

7.1) Source of data: 15 patients of both genders with age group 18-35 years who will report to the Department of Oral and Maxillofacial Surgery, K.V.G. Dental College, Sullia, for surgical removal of bilateral similarly impacted mandibular third molars.

7.2) Methods of data collection:

I. Definition of study subject:

15 patients between age group ranging 18-35 years, with bilateral similarly impacted mandibular lower third molar surgery will be the study subjects. Informed consent will be taken from the subjects prior to treatment.

Surgical technique

 Written informed consent will be obtained from all the patient.  The area of the anticubital region will be prepared with the cotton and spirit.  For the preparation of PRF, the blood will be transferred into the vial which doesn’t contain citrate phosphate dextrose (anticoagulant).  Patient is asked to gargle with Perioguard mouthwash 10 minutes before starting the procedure.  As the preparation requires 15- 20 minutes, in the meantime the extraction procedure is started.  Surgical procedure will be done after draping and painting the surgical area with betadine solution.  All the patients will be treated using 2% lignocaine Hydrochloride with adrenaline in 1:80000 concentrations  Both right & left impacted molars will be treated by the same surgeon with a time interval of minimum 30 days.  Incision will be given with B.P. blade no.15 and envelope flap will be used.  After the flap reflection, bone removal will be done with straight fissure bur ( No. 702 S.S White). If required tooth sectioning will be performed.  Once tooth is removed smoothening of bone margins, irrigation of socket with normal saline will be done. Hemostasis will be achieved.  Platelet Rich Fibrin (PRF) and Biograft- HT® (in case of group A) or Platelet Rich Fibrin (PRF) alone (in case of group B) will be placed into the socket with the help of tweezers.  3 Sutures will be given with 3-0 black silk (Lifeline) after surgery.  Immediate post-operative x- ray (IOPA) of the extraction socket will be taken.  Post extraction instructions are given and patients are recalled for follow-up on 1st, 3rd, 7th, 14th post-operative day and also after 8th and 16th week.  All the patients are instructed to take the following medication : o Cap Mox (Amoxicillin) 500mg thrice daily for 5 days o (Tab Clindamycin 600mg twice daily for 5 days in case of allergy to Penicillins) o Tab Voveron (diclofenac sodium) 50 mg thrice daily for 5 days. Tab Rantac 150mg (Ranitidine ) twice daily is prescribed if patient has a history of gastric irritation. Methods of Preparation:

Method of Preparation of Platelet Rich Fibrin: The 10ml blood is drawn into test tubes without an anticoagulant and centrifuged immediately. Blood is centrifuged using a tabletop centrifuge for 12 minutes at 2,700 rpm. The resultant product consists of the following three layers:

• Top most layer consisting of acellular plasma • PRF clot in the middle • Red Blood Cells at the bottom The top most layer consisting of acellular plasma is discarded with the help of pipette, because of the absence of an anticoagulant, the blood begins to coagulate as soon as it comes in contact with the glass surface. Therefore, for successful preparation of PRF, speedy blood collection and immediate centrifugation, before the clotting cascade is initiated is absolutely essential.

Method of Preparation of a combination of platelet rich fibrin and biograft- HT®

Biograft- HT® is available in two forms i.e. granules and blocks 0.5cc granular form of biograft- HT® is applied on to the socket and platelet rich fibrin (PRF) is added up to fill the socket. The porous structure promotes colonization of osteogenic cells from the patient’s blood.

II. Inclusion and exclusion criteria.

Inclusion criteria:  Patients with bilateral similarly impacted mandibular 3rd molar requiring similar surgical methods for their removal.  Patients free of significant systemic diseases.  Patients between 18 – 35 years of age.  Surgical site free of active infection or acute pericoronitis.

Exclusion Criteria:  Patients with periodontally compromised 2nd molar.  Medically compromised patients that may affect healing.  Impacted molars with pathology & periapical infection.  Patients with pre-existing calcium metabolic disorder like hypercalcemia.  Patients who are with immuno deficient syndromes.  Patients who are smokers.  Pregnant patients.

III. Study design. This is a Split-mouth study where un-erupted lower third molars on either side will be divided in to two groups-

GROUP (A) – Those in which platelet rich fibrin in combination with biograft- HT® will be placed in the extraction socket GROUP (B) -. Those in which platelet rich fibrin will be placed into the extraction socket.

In every patient, one side will belong to Group A and the other will be Group B. In every odd patient platelet rich fibrin (PRF) in combination with biograft- HT® is placed in the left socket and platelet rich fibrin (PRF) is placed in the right socket. In every even patient platelet rich fibrin in combination with biograft- HT® is placed in the right socket and PRF is placed in the left socket.

Clinical Parameters:

Various preoperative, intraoperative and postoperative parameters will be used to evaluate the study subjects. They are –

 Preoperative assessment : . Maximum mouth opening with Vernier’s caliper (Inter-incisal distance). . Facial measurement with thread. ( from tragus to corner of mouth and lateral canthus of eye to angle of the mandible.) . Periodontal health by measuring pocket depth distal to mandibular 2nd molar using William's periodontal probe.  IOPA will be taken.  Intraoperative assessment: Immediately after the procedure, details of the procedure will be documented including the duration of the surgery in minutes (from first incision to the last suture), intra-operative complications if any.

 Post operative assessment : Post-operatively patient will be evaluated for- . Pain - 1st, 3rd, 7th and 14th postoperative day. . Trismus - 1st, 3rd, 7th and 14th postoperative day. . Swelling - 1st, 3rd, 7th and 14th postoperative day. . Periodontal health - on 8th and 16th week. . Bone healing - on 8th and 16th week.

1) Pain:

It will be evaluated using 10 point Visual Analog Scale3, with a score of “0” equals “no pain” and “10” equals “very severe pain” Pain will be evaluated on 1st, 3rd, 7th and 14th postoperative day.

2) Swelling:

Swelling will be calculated using a modification of the method of Schultze-Mosgau et al3 and this requires measuring the distances from tragus to the oral commissure and tragus to the pogonion. The arithmetic sum of the 2 measurement will be used to determine the facial swelling at the time point. The percentage facial swelling will be calculated from the difference of the measurements made in the preoperative and postoperative periods and multiplied by 100.

(Swelling Postoperatively – Swelling Preoperatively) /Swelling Preoperatively X 100

Swelling will be evaluated on 1st, 3rd, 7th and 14th postoperative day.

3) Trismus: Opening of mouth after removal of impacted third molar will be evaluated by measuring the distance between incisal edges of upper & lower central incisors using Vernier’s caliper. Trismus is expressed as a percentage and is calculated from the difference of the mouth opening measurements in the preoperative and postoperative periods divided by the value obtained in the preoperative periods and multiplied by 100. (Mouthopening Preoperatively – Mouthopening Postoperatively) / Mouthopening Postoperatively X 100

Trismus will be evaluated on 1st, 3rd, 7th and 14th postoperative day.

4) Periodontal health:

It will be checked with William’s periodontal probe, with millimeter marking by measuring pocket depth. It will be checked from free gingival margin to bottom of pocket on distobuccal, distolingual & mid-distal aspect of second molar. It will be compared with preoperative pocket depth. Postoperatively it will evaluated on 8th week and 16th week.

5) Bone healing and the bone formation:

The bone healing and the bone formation of the third molar socket is assessed using IOPA radiographs. Unlabelled films developed, fixed and rinsed under standard conditions are independently evaluated using image view box with magnification viewer. The criteria of bone healing and scoring system are based on modification of method used by Kelley et al3. Three parameters namely: Lamina Dura Score, Density Score, Trabaculae Pattern Score will be assessed. Radiographs will be taken immediately after the procedure and on 8th and 16th weeks postoperatively.

Lamina dura Score :

+2 - Lamina dura essentially absent, may be present in isolated areas

+1 - Lamina dura substantially thinned, missing in some areas

0 - Within normal limits -1 - Portions of lamina dura thickened, milder degrees

-2 - Entire lamina dura substantially thickened

Overall density Score:

+2 - Severe increase in radiographic density

+1 - Mild to moderate increase in radiographic density

0 - Within normal limits

-1 - Mild to moderate decrease in radiographic density

-2 - Severe decrease in radiographic density

Trabecular pattern Score:

+2 - All trabeculae substantially coarser

+1 - Some coarser trabeculae; milder degrees

1 - Within normal limits

-1 - Delicate finely meshed trabaculations

-2 - Granular, nearly homogenous patterns; individual trabaculations essentially absent

Bone healing and the bone formation on IOPA radiograph will be evaluated after 8th and 16th week.

IV Statistical analysis: • It will be done with the - Paired ‘t’ test ANOVA test

7.3. Does the study require any investigation or interventions to be conducted on patients or other humans or animals? If so please describe briefly.

Yes, The study requires the following investigation and intervention Four IOPA radiographs at after various time intervals (i.e. before the procedure, immediately after the procedure and on 8th and 16th week) 10ml of intravenous blood drawing from the patients for preparation of PRF, Surgical removal of mandibular 3rd molars under Local Anesthesia.

7.4 Has the ethical clearance been obtained from your institution in case of (7.3)?

Yes, Institutional ethics committee clearance copy enclosed.

7.5 Abbreviations used:

PRP- Platelet rich plasma PRF- Platelet rich fibrin HA- Hydroxyapatite Biograft-HT® - Biograft hydroxyapatite with tri calcium phosphate OMSFE- osteotome-mediated sinus floor elevation IOPA- Intraoral periapical radiograph.

(8) List of references:

1) Joseph Choukroun, Antoine Diss, Alain Simonpieri, Marie-Odile Girard, Christian Schoeffler, Steve Dohan “Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part IV: Clinical effects on tissue healing”. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 101: 56-60

2) Sunitha RV, Munirathnam N E “Platelet-rich fibrin: Evolution of a second generation platelet concentrate”. Indian 2008; 19: 42-46

3) Olufemi K, Ogundipe, Vincent I Ugboko, Folusho J Owotade “Can Autologous Platelet Rich Plasma Gel Enhance Healing after Surgical Extraction of Mandibular Third Molars?” J Oral Maxillofac Surg 2011; 69: 2305-2310

4) Shephered G, Jonathan S, Travis T “Efficacy of Platelet rich fibrin sealant (Human) (Evicel) in Rhinoplasty”. Arch Facial Plast Surg 2008; 10: 339-344

5) Michael T, Nicholas Toscano, and Dan H. “Osteotome-Mediated Sinus Floor Elevation Using Only Platelet-Rich Fibrin: An Early Report on 110 Patients”. Implant dentist 2010; 19: 447-453

6) K. T Chandrashekhar, Chhavi Saxena “Biograft-HT® as a bone graft material in the treatment of periodontal vertical defects and its clinical and radiological evaluation: Clinical study”. J Indian Soc Periodontol 2009; 13(3): 138-14

7) Vasundara Yayathi Shivshankar, Dextom Antony Johns, Vidyanath S, George Sam “Combination of Platelet Rich Fibrin, Hydroxyapetite and PRF membrane in the management of large inflammatory peripical lesion”. Journal of Conservative Dentistry.2013; 16: 261-4

8) Sculean A, Nikolidakis D, Schwarz F. “Regeneration of periodontal tissues: Combinations of barrier membranes and grafting materials-biological foundation and preclinical evidence: A systematic review”. J Clin Periodontol 2008; 35: 106-16. 9) Gassling V, Douglas T, Warnke PH, Açil Y, Wiltfang J, Becker ST “Platelet-rich fibrin membranes as scaffolds for periosteal tissue engineering”. Clinical Oral Implants Res 2010; 21: 543-9.

10) Pradeep AR, Bajaj P, Rao NS, Agarwal E, Naik SB “Platelet-rich fibrin combined with a porous hydroxyapatite graft for the treatment of three-wall intrabony defects in chronic periodontitis: A randomized controlled clinical trial”. J Periodontol 2012; 83: 1499- 1507. 9) SIGNATURE OF THE CANDIDATE

10) REMARKS OF THE GUIDE

11) NAME AND DESIGNATION OF: (IN BLOCK LETTERS) DR. PRASANNA KUMAR. MDS 11.1) GUIDE: PROFESSOR DEPT OF ORAL AND MAXILLOFACIAL SURGERY K.V.G DENTAL COLLEGE,SULLIA, DK, KARNATAKA- 574327

11.2) SIGNATURE

11.3) CO-GUIDE: (IF ANY) DR. RAMARAJ P.N. MDS

PROFESSOR DEPT OF ORAL AND MAXILLOFACIAL SURGERY K.V.G DENTAL COLLEGE,SULLIA, DK, KARNATAKA- 574327

11.4) SIGNATURE

11.5) HEAD OF DEPARTMENT DR. MANJUNATH RAI. MDS

PROFESSOR AND HEAD DEPT OF ORAL AND MAXILLOFACIAL SURGERY K.V.G DENTAL COLLEGE,SULLIA, DK, KARNATAKA- 574327

11.6) SIGNATURE:

12) REMARKS OF THE PRINCIPAL

13) SIGNATURE AND OFFICIAL SEAL K. V. G. DENTAL COLLEGE & HOSPITAL

KURUNJIBAG - 574 327, SULLlA, D. K., KARNATAKA, INDIA SPONSORED BY ACADEMY OF LIBERAL EDUCATION (REGD.) SULLIA

DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY

CONSENT FORM

Name of the Participant: ______

Name of the Investigator: ______

Name of the Institution: ______

INFORMED CONSENT FOR PARTICIPATION IN RESEARCH

I Dr. MD.H. SHAKEEB ULLAH in Department of Oral and Maxillofacial Surgery conducting a dissertation work for an award of M.D.S degree in Oral and Maxillofacial Surgery. The topic for the study is comparison of the efficacy of a combination of platelet rich fibrin and biograft- HT® with that of platelet rich fibrin alone in healing of mandibular third molar sockets - A Prospective clinical study

Aims and objectives of the study:

Aim: To Compare the efficacy of a combination of platelet rich fibrin and biograft- HT® with that of platelet rich fibrin alone in healing of mandibular third molar sockets.

Objectives:

 To compare the postoperative pain using a standard scale.  To compare the postoperative swelling using standard measurements.  To compare the postoperative trismus at various time intervals.  To compare the periodontal health distal to mandibular second molar using periodontal probing at various time intervals.  To compare the quality of bone healing and the formation of the new bone at the mandibular third molar socket using Intraoral periapical radiograph (IOPA) at various time intervals.

MR/MS______, we are requesting you to enroll yourself In the study conducted by Dr. Md.H. Shakeeb ullah, post Graduate Student in Department of Oral and Maxillofacial Surgery under the guidance of Dr. Prasanna Kumar, Professor, at. K.V. G. Dental College & hospital, Sullia D.K.

You have been requested to participate. During the study you will be asked some questions and you are supposed to answer to the best of your knowledge. Your participation in research is voluntary. Your decision whether to participate will not affect your relationship with K. V. G. Dental College & hospital. If you decide not to participate you are free to withdraw at any time. The purpose of research is to compare the efficacy of healing in mandibular third molar sockets using the combination of platelet rich fibrin and biograft- HT® with that of platelet rich fibrin alone.

PROCEDURE INVOLVED: If you agree to participate in this research study we would want to draw 10 ml of blood from you to prepare platelet rich fibrin (PRF) and the same or the same with biograft-HT® will be placed in your extraction socket.

RISK AND BENEFITS: This procedure do not cause any harm to you.

ALTERNATIVES: Even if you decline in participation, you will get the routine line of management.

PRIVACY AND CONFIDENTIALITY: The only people to know that you are a research subject are members of the research team. No information about you or provided by you during the research will be disclosed to others without your written permission except: 1. in emergency to protect your rights and welfare. 2. If required by law.

AUTHORIZATION TO PUBLISH RESULTS: When the results of the research are published or discussed, in a conference, no information will be displayed that would disclose your identity. Any information that is obtained in a connection with this study and that can be identified with you will remain confidential.

FINANCIAL INCENTIVES FOR PARTICIPATION: You will not be paid/offered any free gifts for participating in the research. You will not be reimbursed for expenses. I have been told in a language that I understand ( ) about the study. I have been told that this is for a research procedure, that my participation is voluntary and I/he/she reserve the full right to withdrawn from the study at my own initiative at any time, without having to give any reason, and that right to participate or withdraw from study at any stage will not prejudice my/his/her, rights and welfare. Confidentiality will be maintained and only be shared for academic purposes. I hereby give consent to participate in the above study. I am also aware that I can withdraw this consent at any later date, if I wish to. This consent form being signed voluntarily indicating my agreement to participate in the study, until I decide otherwise. I understood that I will receive a signed and dated copy of this form. If I have any doubts/questions pertaining to the above study, I have been asked to contact Dr. Md.H. Shakeeb ullah Mobile no: 9538365497. Signature of the research subject: Date : Place: Signature of the witness: Date: Place: I hereby state that the study procedures in details were explained and all questions were fully and clearly answered to the above mentioned participant/his/her relative. Investigators signature: Date: Place :

Contact address: