|Year : 2017 | Volume
| Issue : 4 | Page : 294-300
Evaluation of effectiveness of platelet-rich fibrin for ridge preservation after atraumatic extraction: A case series
BS Shilpa, Prasad V Dhadse, Manohar L Bhongade, Sneha Puri, Jayshree Nandanwar
Department of Periodontics, Sharad Pawar Dental College, Wardha, Maharashtra, India
|Date of Web Publication||17-May-2018|
Dr. B S Shilpa
Department of Periodontics, Sharad Pawar Dental College, Sawangi (Megha), Wardha - 442 005, Maharashtra
Source of Support: None, Conflict of Interest: None
Purpose: The present study was undertaken to evaluate the effectiveness of platelet-rich fibrin (PRF) for ridge preservation after atraumatic extraction. Materials and Methods: Seven patients with a nonrestorable tooth requiring extraction followed by implant placement were treated in this study. After atraumatic extraction, the socket was filled with PRF as the sole grafting material in preparation of placing an implant after wound healing. At the time of extraction and 3 months later, vertical and horizontal socket dimensions were measured clinically and radiographically. Results: The measurements of buccolingual dimension of the socket immediately after extraction and at 3-month postsurgery were recorded. The mean buccolingual measurement of socket at baseline was 10.0 ± 1.6 mm. Postoperatively, 3 months after ridge preservation, the mean buccolingual measurement was 9.4 ± 1.6 mm showing minimal changes. The radiographic vertical bone level at baseline was 14.1 ± 1.0 mm and 3 months postoperatively 12.7 ± 0.8 mm showing minimal changes in apicocoronal dimension. Conclusion: The ridge preservation using PRF as space filler after atraumatic extraction was found to be an effective procedure for the placement of implants.
Keywords: Atraumatic extraction, dimensional change, healing, platelet-rich fibrin, ridge preservation, tooth socket
|How to cite this article:|
Shilpa B S, Dhadse PV, Bhongade ML, Puri S, Nandanwar J. Evaluation of effectiveness of platelet-rich fibrin for ridge preservation after atraumatic extraction: A case series. J Datta Meghe Inst Med Sci Univ 2017;12:294-300
|How to cite this URL:|
Shilpa B S, Dhadse PV, Bhongade ML, Puri S, Nandanwar J. Evaluation of effectiveness of platelet-rich fibrin for ridge preservation after atraumatic extraction: A case series. J Datta Meghe Inst Med Sci Univ [serial online] 2017 [cited 2019 Aug 17];12:294-300. Available from: http://www.journaldmims.com/text.asp?2017/12/4/294/232575
| Introduction|| |
One of the most important prerequisites for achieving and maintaining successful osseointegrated implant is the presence of sufficient volume of healthy bone at the recipient site. This includes not only bone of sufficient height to allow the insertion of implant of appropriate length but also a ridge of sufficient crest width. An average of 40%–60% of original height and width is expected to be lost after tooth extraction, with the greatest loss occurring within the first year. Clinical studies have shown that implants placed in a site with a missing buccal bone wall have a greater rate of soft-tissue complications and/or compromised long-term prognosis.,,,, The rate and pattern of bone resorption may be further altered if pathologic and traumatic processes have damaged one or more of the bony walls of the socket. In these circumstances, fibrous tissue will likely to occupy part of the socket, preventing normal healing and osseous regeneration. Therefore, preservation of alveolar dimensions after tooth extraction is crucial to maintain adequate bone volume for placement and stabilization of the implants and to achieve optimal esthetic and functional prosthetic results.
The rationales for alveolar ridge preservation (ARP) procedure are as follows: (a) an attempt to reduce crestal bone dehiscences or facial undercut, (b) encourage socket fill, and (c) improve bone quality before implant placement and ensuring better primary stability. With the aim of minimizing the need for tissue augmentation, several authors have proposed techniques to preserve the anatomy of the alveolar ridge after tooth extraction. These procedures have collectively been termed ARP or socket preservation. Several different ARP techniques exist, most of which include the use of foreign graft materials. Since ARP is a relatively new procedure, no long-term studies regarding the technique have been published, and even though several case reports have been presented, there is no evidence to support the superiority of one technique over the other.
Currently, bone graft materials and guided bone regeneration are used following tooth extraction for the preservation of the extraction socket. However, treatment with membrane and graft material often result in compromised outcomes because of the avascular and inert nature of bone graft material, movement and exposure of membrane,, mucoperiosteal flap design, and surgical and suturing technique. Recently, Choukroun et al. suggested the use of autologous platelet-rich fibrin (PRF) as a grafting material for ridge preservation. PRF is obtained by gentle centrifugation of peripheral blood and is characterized as being leukocyte and platelet-rich and fibrin dense, besides not requiring the addition of any anticlotting agent. PRF can be used directly as a filler agent or compressed into a membrane. PRF is believed to release polypeptide growth factors, such as transforming growth factor-β1, platelet-derived growth factor, vascular endothelial growth factor, and matrix glycoproteins (such as thrombospondin-1), into the surgical wound in a sustained fashion for at least 7 days. PRF looks like a fibrin network and leads to more efficient cell migration, proliferation, and thus angiogenesis. PRF was initially used in implant surgery to improve bone healing. However, little information is available on clinical evaluations of extraction sockets with PRF. Therefore, the aim of this study is to evaluate the effectiveness of PRF for ridge preservation after atraumatic extraction.
| Materials and Methods|| |
A total of 7 systemically healthy patients with age range of 20–45 years (mean = 28.57 ± 7.93) were recruited from the Outpatient Department of Periodontics, Sharad Pawar Dental College, Sawangi (Meghe), Wardha. The patients were enrolled in the study using the following criteria: (1) teeth which need immediate restoration due to root fractures, endodontic failures, internal and external resorption, teeth with open apex, over-retained deciduous teeth, nonrestorable carious lesions, and residual roots, (2) good oral hygiene defined as full-mouth plaque score ≤25%, (3) presence of opposing natural teeth, (4) presence of adjacent teeth, (5) thick gingival biotype, (6) radiographic and clinical appearance of intact alveolar bony walls, (7) presence of at least 4 mm of bone beyond the root apex, and (8) D-1, D-2, or D-3 bone quality. Patients with compromised general health conditions that would jeopardize the bone healing process, severe maxillomandibular space discrepancies, parafunctional habits (bruxism or clenching), history of alcoholism, excessive smoking or drug abuse, D-4 bone quality, width of keratinized gingiva <2 mm at implant site, and pregnant and lactating mothers were excluded from the study.
Before initiating the study, information concerning dietary status, mouth cleaning habits, systemic background, and gingival and periodontal status along with other routine clinical details were recorded in a specially designed chart. Patients were examined under good illumination with the help of mouth mirror and William's graduated periodontal probe. Before initiating this study, the purpose and design of this clinical trial were explained to the patients and written informed consent was obtained. The study protocol was approved by the Ethical Committee of Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha.
After proper examination and diagnosis, initial therapy consisting of oral hygiene instructions and supragingival and subgingival scaling were performed. Plaque control instructions were repeated until the patient achieved a plaque score of ≤1. Before the surgical phase, diagnostic cast of each patient was prepared to establish maxillomandibular relationship. The clinical photographs, periapical radiograph using long-cone paralleling technique, and orthopantomogram (OPG) were obtained for all the patients.
Clinical measurements recorded were plaque index  and papillary bleeding index. Clinical measurements at the extraction site recorded were width of keratinized gingival at extraction site, Assessment of gingival biotype  and mesiodistal and buccolingual diameter of alveolar ridge at the extraction site was measured with William's graduated probe.
Radiographic measurements recorded were as follows: on intraoral periapical: mesiodistal dimension and apicocoronal length of root were measured with William's graduated periodontal probe to confirm clinical measurements; postridge preservation, procedure was used to determine bone formation in preserved socket; and on OPG: to determine position of adjacent and opposing teeth and relation with adjacent delicate anatomic structures [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Examination and assessment of the topography and quality of the ridge were done carefully during the entire procedure, clinically and radiographically. Prophylactic antibiotics (amoxicillin 500 mg + clavulanic acid 125 mg) were used 1 day before surgery and 4-day postsurgery. Anti-inflammatory analgesics (ibuprofen, 400 mg) were given 1 h presurgery and three times daily postsurgery, as needed. Following thorough cleansing of the teeth, the patients were instructed to use 0.2% chlorhexidine as a mouth rinse. To minimize vasoconstriction, a local anesthetic (lidocaine 2%), with no or minimal epinephrine concentration, i.e., a maximum of 1:100,000 were administered in the extraction site.
Extraction of teeth
The surgical protocol was followed with complete asepsis and infection control. Briefly after induction of local anesthesia, sulcular incision was performed on the buccal and lingual aspects of the teeth to be removed. Two vertical releasing incisions were placed on the mesiobuccal and distobuccal aspects of the papillae, adjacent to the teeth to be extracted extending 3–5 mm apically beyond the mucogingival junction. Full-thickness buccal or buccal and lingual mucoperiosteal flaps were reflected.
Every attempt was made to minimize trauma to the alveolus during extraction and minimum socket expansion. The initial incision was made with a microsurgical blade (15 C) to separate the periodontal ligament fibers at the mesial and distal aspect of the root piece/tooth indicated for extraction. To preserve the buccal plate, the periodontal ligament fibers were further separated with the use of periotomes. The tooth was carefully removed with the extraction forceps. Small elevators were used, but luxation was performed in the mesiodistal direction with extreme care to avoid fracture of the socket walls. The root fragments were extracted carefully without placing pressure on the alveolus preserving all remaining interradicular bone of the multirooted teeth.
Once the tooth was extracted, the sockets were examined for any fracture of the walls of the socket. The fresh socket was debrided thoroughly of granulation tissue and residual periodontal ligament fibers followed by a thorough evaluation of the remaining bony housing. The socket bony walls were decorticated further in their apical part (except for the labial wall) to increase the participation of endosteal bone-forming cells in the wound. The extraction socket was irrigated with normal saline and then packed with gauze soaked in normal saline, which was left in situ for 5 min.
Alveolar ridge preservation using grafting material
The objective of this technique is to maintain the postextraction alveolar dimensions during the initial healing phase in order to allow for the placement of an implant in the shortest possible time frame. To obtain PRF, venous blood was drawn and was collected in a test tube. The test tube was placed in a centrifuge and spun at 1100 ×g for 6 min. The patented gel separates the plasma and platelets in the supernate from the red blood cells at the bottom of the tube. The extraction sockets were filled with PRF. Flap advancement for primary soft-tissue closure to ensure complete coverage of graft placed.
The patients were instructed to follow the prescribed presurgery medication protocol, and a chlorhexidine mouthwash was prescribed for a 3-week duration postsurgically. No toothbrushing or mechanical cleansing was allowed at the surgical area. Only a soft diet was advised for the first 2 weeks of the healing process. Sutures were removed 7 days postsurgery [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12].
|Figure 10: Placement of plasma-rich fibrin in extraction socket after presuturing|
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|Figure 12: Intraoral periapical radiograph 6 months after ridge preservation|
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The mean and standard deviations (mean ± standard deviation) values were calculated for all clinical parameters including plaque index, papillary bleeding index, probing pocket depth, clinical attachment level, width of keratinized gingiva, PH, PIS, and radiographic marginal bone level. The mean data were analyzed for the statistical significance by standard statistical method to compare data from baseline to those at 3 months for all the patients.
| Results|| |
Seven systemically healthy patients (5 females, 2 males) in the age group of 25–35 years (mean age 28.57 ± 7.93 years) received ridge preservation using PRF in 7 extraction sockets. Out of 7 implants, 6 were placed in the maxilla and 1 placed in the mandible. The reasons for tooth removal included one site due to crown-root fracture and 6 sites due to unrestorable carious lesion. The implants of length of 11–13 mm and diameter 3.8–5.7 mm were placed in the recipient site.
There was no clinical evidence of infection of the extraction site or graft at the surgical site. None of the selected patients had dropped out before the termination of the study. The mean full-mouth plaque index and full-mouth papilla bleeding index scores at baseline and at 3-month follow-up period remained low (<1) in all patients. This could be due to the reinforcement of oral hygiene instructions. After atraumatic extraction, the labial/buccal cortical plate was intact at all the 7 extraction sites.
The measurements of buccolingual dimension of the socket immediately after extraction and at 3-month postsurgery were recorded. The mean buccolingual measurement of socket at baseline was 10.0 ± 1.6 mm. Postoperatively, 3 months after ridge preservation, the mean buccolingual measurement was 9.4 ± 1.6 mm showing minimal changes. The radiographic vertical bone level at baseline was 14.1 ± 1.0 mm and 3 months postoperatively 12.7 ± 0.8 mm showing minimal changes in apicocoronal dimension [Table 1], [Table 2], [Table 3], [Table 4].
|Table 4: Radiographic vertical bone level at baseline and 3 months postsurgery|
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| Discussion|| |
Healthy osseous structure of the alveolar ridge maintains the esthetic soft-tissue appearance around natural dentition and also provides a framework for peri-implant soft-tissue contour. Lack of alveolar bone due to postextraction bone resorption can result in functional and esthetic problems that necessitate the use of augmenting procedures to reestablish the missing original dimensions. PRF is a viable and biocompatible autologous biologic material that can be used alone to maintain ridge dimension during preservation procedures, while at the same time, stimulating rapid osseous fill of the socket. Therefore, the aim of this study was to evaluate the effectiveness of PRF for ridge preservation after atraumatic extraction followed by delayed implant placement.
Preservation of integrity of the labial cortical plate is critical for the success of implants. Atraumatic tooth extraction is of key importance for preservation of buccal cortical bone before implant placement. Therefore, in the present study, all teeth were extracted with minimal trauma by first luxating them with a periotome. This was a useful technique, resulting in preservation of intact labial wall of all extraction sockets, which was required for eventual healing and soft-tissue framing.
An important debate topic is the choice of grafting material for the ridge preservation procedures. These graft materials include autografts, allografts, xenografts, alloplasts, bioactive agents, or a combination (composite) of grafts. As compared to the mentioned grafting material, it would appear that the net loss of alveolar bone width and height measured when PRF alone was used as a graft for ridge preservation was less than that noted when membranes alone or membrane and grafts were used. The favorable bone and soft-tissue response undoubtedly exhibit because PRF possesses the ability to accelerate tissue regeneration by stimulating the normal physiology. Therefore, in the present study, PRF was used for grafting the fresh extraction socket.
Traditional methods of tooth extraction often result in loss of the labial plate of the alveolar bone. In the present study, the buccolingual dimension of the socket showed a mean dimension of 10.0 ± 1.6 mm preoperatively, whereas 3 months postoperatively, it was 9.4 ± 1.6 mm showing minimal changes in buccolingual dimension at 3 months. Gupta et al. reported mean dimension loss of 1.68 mm in the control group (atraumatic extraction only) and 1.07 mm in the test groups where the extraction socket was treated with bovine bone graft, collagen plug, and collagen membrane following atraumatic extraction. A similar postextraction alveolar ridge resorption was observed  where extraction sockets were treated with either a porcine xenograft and a collagen barrier or freeze-dried bone and a collagen membrane and compared with the healing of “empty” untreated extraction sockets. This may occur due to the constriction of the blood clot as well as the presence of bundle bone at the crestal region. The pattern of bone rearrangement could be induced by new bone apposition, at the same time by buccal and lingual bone resorption leading to a buccolingual width reduction of the alveolar ridge.
In the present study, apicocoronal dimension of 14.1 ± 1.0 mm and 3 months postoperatively 12.7 ± 0.8 mm showed minimal changes, indicating that PRF was useful for bone formation. Brownfield et al. reported a vertical bone loss of 0.2–1.7 mm when the extraction socket was treated with osteoinductive graft. Barone et al. reported a mean 0.7 mm vertical resorption at the buccal sites of preserved sockets.
| Conclusion|| |
From the analysis of the result and within the limitations of the present study, the following conclusions were drawn:
- The use of PRF was successful in preserving the alveolar ridge by limiting the amount of bone resorption after tooth extraction resulting in horizontal alveolar bone crest resorption of 0.6 ± 0.2 mm and vertical bone loss of 1.4 ± 0.6 mm, respectively
- Clinical and radiographic data after 3 months after ridge preservation showed adequate bone fill.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1], [Table 2], [Table 3], [Table 4]