|Year : 2018 | Volume
| Issue : 2 | Page : 112-116
The Effect of Platelet-Rich Fibrin on Soft Tissue and Crestal Bone in One-Stage Implant Placement in Fresh Extraction Sockets: A Randomized Controlled Clinical Trial
Kishore K Avula1, Uma D Rayavaram1, Sravanthi Gujjula2, Siva Sai Prasad R Dandu1, Prasuna Egatela3, Ravindra R Nagireddy1
1 Department of Periodontics, CKS Theja Institute of Dental Sciences, Tirupati, Andhra Pradesh, India
2 Department of Prosthodontics, CKS Theja Institute of Dental Sciences, Tirupati, Andhra Pradesh, India
3 Department of Statistics, CKS Theja Institute of Dental Sciences, Tirupati, Andhra Pradesh, India
|Date of Web Publication||2-Jan-2019|
Dr. Kishore K Avula
Department of Periodontics, CKS Theja Institute of Dental Sciences, Tirupati, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: The goal of modern dentistry is to prevent tooth loss and provide a healthy dentition with optimal functional efficiency, structural balance, and aesthetic harmony. The placement of an implant immediately after tooth extraction helps to maintain the bone crest and leads to ideal implant positioning from a prosthetic point of view and has the potential of decreasing the total treatment time for patients. Aim and Objective: To evaluate the platelet rich fibrin with or without bone ceramic on soft issue and crestal bone in one stage implant placement in fresh extraction socket. Materials and Methods: A total of 30 patients were randomly assigned into two groups—each group comprising 15 patients based on platelet-rich fibrin with and without bone ceramic and one-stage implant placement in fresh extraction socket. All patients were prospectively evaluated clinically and radiographically. All the data were analyzed using a software statistical package for social sciences (SPSS) version 11.5 (Chicago, Illinois, USA). Results: During the 6-month interval, no implant was lost; the mean bone level at the implants increased in platelet-rich fibrin (PRF) with bone ceramic group and decreased in PRF group and papillary index increased in both the groups, whereas modified sulcus bleeding index and probing pocket depth (PPD) decreased in both the groups. Conclusion: It can be concluded that mean crestal bone levels increased in PRF with bone ceramic group, whereas decrease in PRF group and both the groups are statistically significant. When the papillary levels are compared between the two groups, there was no statistical significance, but increased papillary levels were found in both the groups. The mean PPD was decreased in both the groups, but there was no statistical significance between the two groups.
Keywords: Atraumatic extraction, bone ceramic, immediate implants, platelet-rich fibrin
|How to cite this article:|
Avula KK, Rayavaram UD, Gujjula S, Dandu SR, Egatela P, Nagireddy RR. The Effect of Platelet-Rich Fibrin on Soft Tissue and Crestal Bone in One-Stage Implant Placement in Fresh Extraction Sockets: A Randomized Controlled Clinical Trial. J Orofac Sci 2018;10:112-6
|How to cite this URL:|
Avula KK, Rayavaram UD, Gujjula S, Dandu SR, Egatela P, Nagireddy RR. The Effect of Platelet-Rich Fibrin on Soft Tissue and Crestal Bone in One-Stage Implant Placement in Fresh Extraction Sockets: A Randomized Controlled Clinical Trial. J Orofac Sci [serial online] 2018 [cited 2019 Mar 21];10:112-6. Available from: http://www.jofs.in/text.asp?2018/10/2/112/249086
| Introduction|| |
The goal of modern dentistry is to prevent tooth loss and provide a healthy dentition with optimal functional efficiency, structural balance, and aesthetic harmony. Two-stage procedures require a waiting time after implant surgery in which the implant is completely buried into the alveolar bone prior to a second abutment surgery. Dental implants for a single tooth replacement have shown to be highly predictable and clinically successful.
The timing between extraction of a tooth and placement of an implant is an important factor in determining the aesthetic and functional success of the final restoration, because it indicates the amount of bone resorption and loss of the soft tissue profile, which might have taken place within this time. The advantages claimed for the immediate implant placement protocol are the marked reduction in time taken for healing, the reduced number of surgical procedures, and the optimal availability of existing bone to allow primary stability of the implant.
Recent studies have shown that immediate implant placement accompanied with bone grafting reduces the horizontal resorption of the facial bone caused by tooth extraction. The peri-implant bone quantity and quality not only affects the osseointegration phase but also influences the overlying soft tissue architecture.
For successful implant therapy, preservation of peri-implant bone is one of the most important factors, and in the process of tissue repair and regeneration, the quality and quantity of peri-implant bone and soft tissue can be improved by harnessing the regenerative capacity of surrounding tissue with an appropriate stimulus. Various growth factors are expressed during different phases of tissue healing and hence could serve as therapeutic agents to enhance both peri-implant soft and hard tissue repair.Platelet concentrates are one of these various growth factors, and platelet-rich fibrin (PRF) is one of the recent innovations of various platelet concentrates. PRF contains all the constituents of blood favorable to healing and immunity.
| Materials and Methods|| |
The patients in this study included people who were found to have at least one maxillary or mandibular single tooth indicated for extraction and were willing to replace their tooth. It was made clear to the patients that their participation was voluntary; after obtaining their written consent, they were invited to participate in the study. All eligible patients were thoroughly informed of the nature, potential risks, and benefits of the study; ethical approval for this study (Ethical Committee Ref. no.: 139/IEC-CKS/Lr/17) was provided by the Ethical Committee IEC of CKS, Tirupati, on December 15, 2016. All the 30 patients were grouped under two categories: group I (PRF + bone ceramic) and group II (PRF only). Patients were selected using the following inclusion criteria—age ranges from 25 to 50 years, good oral hygiene, failing tooth, ideal soft tissue contour at the facial aspect of the failing tooth in perfect harmony with the surrounding teeth, and adequate bone height and width apical to the alveolus of the failing tooth to ensure primary implant stability, whereas patients with systemic diseases, smoking, bruxism, lack of posterior occlusion, presence of active infection, and loss of the labial crest after extraction of the failing tooth were excluded from the study.
Preoperative evaluation of the patient
After clinical examination, the prognosis of the tooth was confirmed as hopeless, and extraction of the tooth and immediate replacement with an endosseous dental implant was advised to the patient. Patients were selected on the basis of blood investigations, diagnostic cast, case history, bone mapping, and radiographic interpretation.
Single-piece, threaded, titanium, root-form endosseous implants (varying from 8 to 13 mm in length and 3.6 to 5 mm in diameter) were selected based on the available dimensions. Implants (Adin Dental Implants) were carefully placed in the prepared sites using the routine protocol with all the surgical precautions to avoid implant complications.
Phase I therapy, including scaling and root planning, was performed, oral hygiene instructions given, and a 0.2% chlorhexidine mouthwash was advised.
The PRF was prepared just before placement at the surgical site; 5 ml of whole blood was drawn by venipuncture of the antecubital vein and collected into blood collection tubes. The tubes were initially centrifuged for 10 min at the rate of 3000 rpm in a tabletop centrifuge. The PRF was easily separated from the red corpuscles base using sterile tweezers and then transferred to a sterile dappen dish.
A single dose of antibiotic was given 1 h before surgery. Patients were advised to rinse for 1 min with 0.2% chlorhexidine mouthwash. After administration of local anesthesia, a sulcular incision was made at the implant recipient site and the mesial aspects of the adjacent teeth with a Bard-Parker blade no. 15 (Apen Surgicals, Caledonia, Michigan, USA), and a full-thickness flap was elevated. Hopeless teeth were gently extracted using periotomes and extreme care was exercised to avoid fracture of the socket walls. After extraction, the site was thoroughly degranulated using curettes; the extraction socket was thoroughly irrigated with povidone–iodine and carefully examined to be certain that the socket walls were intact and most ideal position for implant placement. The length and width of the extracted root were measured with a UNC-15 probe to determine the length and diameter of the implant; the osteotomy site was prepared through sequential drilling for both the groups, with maximum use of bone apical to the extraction sockets. After the pilot drill, parallelism was checked using a paralleling pin and radiovisiography (RVG).
A sequential drilling was carried with a speed ranging from 500 to 1200 rpm under copious irrigation. The drill was extended 3 to 4 mm beyond the apex of the socket. It was of great importance to drill gently, in a straight, precise, up and down motion with low pressure and low speed with sufficient internal irrigation, to avoid overheating and thus necrosis of the alveolar bone. The socket was thoroughly irrigated with sterile saline solution.
The single-stage implant was then placed into the prepared socket with the implant mount, with the implant head parallel to the incisal edge of the adjacent tooth. When the implant was stable in the site, the mount (implant holder) was pulled out and the fixture insertion tool was engaged to the implant; with gentle pressure (40–55 N cm) by hand or using a Hex ratchet (Hi-Tec Implants Ltd, Herzlia Industrial Area, Israel), the implant was tightly screwed into the bone until the threaded portion of the implant disappeared into the alveolar bone and the collar of the implant came into alignment with the crest of the alveolar bone. RVG was obtained to confirm the complete placement of the implant and check its parallelism with the adjacent teeth. The residual gap between the socket wall and implant threads was grafted with SyboGraf T (Eucare Pharmaceuticals Ltd, Chennai, India) beta tricalcium phosphate bone graft and PRF in the patients placed under group I and PRF alone in patients falling under category of group II; the flap was repositioned, suturing was done, and a surgical Coe-Pak (Coe Laboratories Inc., Chicago, IL, USA) was applied.
The patients were prescribed amoxicillin (500 mg three times daily for 5 days) and diclofenac potassium (5 days). Patients were recalled after 14 days for suture removal, and oral hygiene was reinforced. The patients were checked at regular intervals. The final metal–ceramic crowns were made at 3 months after surgery.
Clinical and radiographic assessment
The soft and hard tissue changes were evaluated at baseline 1, 3, and 6 months after implant placement. RVG was obtained by using a paralleling technique for measurement of bone level on mesial and distal surfaces of the implant.
All the data were analyzed using a software statistical package for social sciences (SPSS) version 11.5 (Chicago, Illinois, USA). A sample size of 30 was taken, which was found to be adequate to achieve more than 80% power at 0.1 level of significance. A test for the validity of normality assumption using standardized range statistics was carried out, and it was found that the assumption was valid.
The mean, standard deviation (SD), and standard error of mean were calculated and subjected to statistical analysis by Student’s t-test for quantitative data and Pearson’s Chi-square test for qualitative data. Data were presented as mean ± SD, and statistical significance was set at P < 0.05.
| Results|| |
During the 6-month interval, no implant was lost in either group. The papillary index significantly increased from baseline to 6 months in the PRF with bone ceramic group (group I; 1.533 ± 0.640 to 2.600 ± 0.507) and the PRF group (group II; 1.933 ± 0.704 to 2.667 ± 0.488); when compared, there was no statistical significance between the two groups. The modified sulcus bleeding index (mSBI) and probing pocket depth (PPD) decreased significantly from baseline to 6 months in group I (2.200 ± 0.414–0.000 ± 0.000 for mSBI) and in group II (2.267 ± 0.458 to 0.000 ± 0.000 for mSBI); when comparing the two surgical techniques, there was no statistical difference. Crestal bone changes increased from baseline to 6 months in group I (1.999 ± 1.658 to 2.056 ± 1.489) and decreased in group II (2.025 ± 1.696 to 1.102 ± 0.792). However, when compared between the two groups, crestal bone changes increased significantly from baseline to 6 months in group I [Table 1].
| Discussion|| |
Teeth replacement using dental implants has proven to be a successful and predictable treatment procedure. With the ever-increasing success rates of dental implants, clinicians have turned their approach toward making the duration of treatment shorter and more comfortable for the patient. The benefits of immediate implant insertion after tooth extraction are the elimination of the postextraction healing period, and the prevention of postsurgical bone resorption seen following tooth extraction as a normal part of the socket healing. It also eliminates the waiting period for socket consolidation, involves fewer surgical sessions, a shorter total treatment time, and reduced overall costs.
Two-stage procedures require a waiting time and second abutment surgery. A one-piece design with no separate abutment screw for the implant was used in the present study as the advantage of this design is increased strength, elimination of the risk of abutment screw loosening, and reduced crestal bone loss due to the nonexistence of a microgap between the abutment and the implant.
For successful implant therapy, the quality and quantity of peri-implant bone and soft tissue can be improved by harnessing the regenerative capacity of surrounding tissue with the appropriate stimuli. PRF is in the form of a platelet gel and can be used in conjunction with the bone grafts, which offers several advantages including promoting wound healing, bone growth and maturation, graft stabilization, and hemostasis, and improving the handling properties of graft materials. It also increases the healing rate of the grafted bone; the clinical trials suggest that the combination of bone grafts and growth factors contained in PRF may be suitable to enhance bone density.
Various studies have been conducted on PRF and its clinical application in various disciplines of dentistry.,,,,,, All these studies showed that PRF is a healing biomaterial for both soft and hard tissue because of the presence of various growth factors. To the best of our knowledge, there is no study that has shown the effect of PRF with and without bone ceramic on soft tissue and crestal bone in one-stage implant placement in fresh extraction sockets.
The results of the present study have shown that the mean mesial papillary index increased from baseline to 6 months for group I and group II, but there were no significant statistical differences (P > 0.05). The mean distal papillary index increased from baseline to 6 months for group I and group II, but there were no significant statistical differences (P > 0.05).
The results of the present study are in accordance with Juodzbalys and Wang as in this study, the analysis of the aesthetic result of immediate implant showed, at 1-year follow-up, that 63% and 35.7% of papilla had a score of 2 and 3, respectively.
The mSBI were recorded using the index described by Mombelli et al. The results of our study have shown that there was a significant reduction in bleeding on probing (BOP) from baseline to 6 months in 100% of both the groups. But there were no significant statistical differences (P > 0.05) in mSBI between the two groups from baseline to 6 months.
The results of our study are in accordance with Boora et al. According to them, BOP is a common occurrence and approximately 50% of both test group and control group showed positive findings at 1 and 3 months, and both test and control group showed only 20% and 30% of positive findings.
The mean PPD was evaluated for both the groups, which shows a significant reduction from baseline to 6 months (for group I, 5.932 to 0.810; for group II, 6.266 to 0.777). On comparing both the groups, there was no significant difference in the mean PPD from baseline to 6 months (P > 0.05). The results of this study are in accordance with the study conducted by Boora et al., as for this reference, the mean decrease in probing depth was on the mesial and distal side of the dental implant in both the groups at 3 months: for group I, 5.0 to 3.05, and for group II, 5.3 to 3.1. Intergroup comparison for mean probing depth at 1 and 3 months was statistically not significant.
The results of the present study demonstrate the crestal bone changes: the mesial crestal bone (MCB) change for group I was increased, and for group II, it was decreased from baseline to 6 months; but there was no statistical significance in either of the group on comparison. The mean MCB change was significant up to 6 months (P < 0.05). The mean distal crestal bone (DCB) change for group I was increased and for group II was decreased from baseline to 6 months, but there was no statistical significance in either of the group (P > 0.05). When compared between two groups, the mean DCB change was significant up to 6 months (P < 0.05). There was a significant increase in crestal bone change in PRF with the bone graft group (i.e., group I) when compared to the PRF group (i.e., group II). In the PRF group, the bone loss that occurred may be a result of natural bone remodeling around the implant as a sequel for the placement of the final prosthesis, which may be associated with increased load and, in turn, increased transferred stress on the bone implant interface.The results of our study are in accordance with the study conducted by Mohamed et al., with regard to the efficacy of PRF with demineralized bone matrix (DBM) in immediate implant placement; they showed the significant increase in marginal bone level from baseline to 12 months (0.8 to 1.1 mm; P < 0.05).
The authors thank Dr. Krishnaiah for his help in the statistical analyses.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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