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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 5  |  Page : 456-460  

Preservation of alveolar ridge using graft material after tooth extraction: A clinical trial


1 Department of Dentistry, Patna Medical College and Hospital, Patna, Bihar, India
2 Department of Prosthodontics, M. A. Rangoonwala College of Dental Sciences and Research Center, Pune, Maharashtra, India
3 Department of Oral and Maxillofacial Surgery, Consultant Oral Surgeon, E-481, Kamal Nagar, Agra, Uttar Pradesh, India
4 Department of Prosthodontics, Patna Dental College and Hospital, Patna, Bihar, India
5 Nair Hospital Dental College, Mumbai, Maharashtra, India

Date of Submission27-Sep-2020
Date of Acceptance28-Sep-2020
Date of Web Publication05-Jun-2021

Correspondence Address:
Revati Singh
Department of Dentistry, Patna Medical College and Hospital, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpbs.JPBS_603_20

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   Abstract 


Background: The alveolar process is a tooth-dependent structure, and hence, removal of teeth results in the alteration of alveolar process. To alter bone remodeling after dental extraction, various techniques have been put forward for ridge preservation. Aim: The aim of this study is to evaluate and compare the changes of hard and soft tissues in postextraction socket after the application of bone graft material. Materials and Methods: Healthy patients of sample size of 40 were selected who underwent the extraction of anterior tooth irrespective of the arch, from premolar of one side to another, with the exception of incisors in mandible. Twenty patients were randomly selected as the control group and other 20 as the experimental group using an allograft bone material, i.e., beta-tricalcium phosphate to fill the socket. Cone-beam computed tomography (CBCT) was done as baseline preoperative and postoperative at 14 weeks after the extraction. CBCTs data help in recording linear and volumetric measurements which was performed by calibrated examiners to record all the measurements. After measurements, digital planning of dental implants was performed. Results: Forty participants were selected, in which 20 patients each were as the experimental and control groups. No significant difference was found at basal line at any of the cases. At follow-up of 14 weeks, statistical significance was seen in buccal and lingual plate height in the experimental group, and no significant difference was seen in the control group.(P = 0.023). Conclusions: This study clearly points out that an alveolar ridge preservation technique provides therapeutic benefit by limiting bone resorption in comparison to extraction alone.

Keywords: Beta-tricalcium phosphate, buccal-lingual dimension, cone-beam computed tomography, linear and volumetric measurements


How to cite this article:
Kumar K, Singh R, Mugal V, Dhingra N, Priyadarshni P, Bandgar S. Preservation of alveolar ridge using graft material after tooth extraction: A clinical trial. J Pharm Bioall Sci 2021;13, Suppl S1:456-60

How to cite this URL:
Kumar K, Singh R, Mugal V, Dhingra N, Priyadarshni P, Bandgar S. Preservation of alveolar ridge using graft material after tooth extraction: A clinical trial. J Pharm Bioall Sci [serial online] 2021 [cited 2021 Jun 23];13, Suppl S1:456-60. Available from: https://www.jpbsonline.org/text.asp?2021/13/5/456/317577




   Introduction Top


The periodontium comprise of gingival tissues, cementum, PDL, cortical, and cancellous bone. However, an augmentation of the existing alveolar bone is often necessary to obtain excellent functional and esthetic restorations of the implants. Nowadays, several biocompatible materials and autogenous bone are used to treat bone atrophy of the alveolar ridges, thus allowing ideal implant placement.[1] Subsequent to tooth extraction, the alveolar ridge undergoes resorption and atrophy, which cause a wide range of dimensional changes among individual patients. 8–10 after tooth extraction soft- and hard-tissue healing was studied in humans and animals by histologic and clinical evaluations.[2],[3] The healing of the extraction socket goes through the sequence of events, including the formation of a coagulum that was replaced with a provisional connective tissue matrix: After 1 month, woven bone filled the extraction socket, a cortical ridge, including woven and lamellar bone, was observed after 3 months; subsequently, the woven bone was gradually replaced with lamellar bone and marrow.[4]

Alveolar ridge preservation strategies were aimed to minimize the loss of ridge volume following tooth extraction and help to preserve buccal and lingual wall of the socket. In described method, immediately after extraction socket is filled with a biomaterial which helps in preserving ridge. This process is essential in cases where implant is planned.[5]

When extraction socket filled with the bone substitute is known as socket grafting. Nowadays, alveolar ridge preservation technique has become most popular. There are many publications regarding alveolar preservation technique.[6],[7] Literature shows that alveolar ridge preservation is lacking data. Hence, the present randomized clinical trial was carried out to eliminate the curbs of antecedent literature work.


   Materials and Methods Top


The clinical component of the study was carried out on 40 patients were included who requires the extraction of maxillary incisors, canine and premolars or mandibular canine or premolar. Mandibular incisors were excluded. At clinical examination, all patients were explained in detail about the intention and duration of study. The patient ages from 18 to 65 years who require single tooth extraction were included in the study, and informed consent was obtained before study.

Exclusion criteria

If the patient was allergic or hypersensitive to any of material used in study or patient with hematological disorder, organ failure, any cancer, with habit history of smoking, and pregnant women were excluded from the study.

After initial screening, site-specific intra-oral pictures and X-ray were recorded. The patients were randomly assigned and divided into two groups. 20 as control group and 20 as experimental group for which allograft was used beta-tricalcium phosphate.

Just before extraction, a cone-beam computed tomography (CBCT) was obtained. All procedures were done under local anesthesia. Following extraction, integrity of alveolar wall was confirmed using unc-15 periodontal probe[Figure 1].
Figure 1: Atlas: (a) Pre-operative, (b) Intra-operative, (c) Post-operative

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For control site, socket was left as it is to heal by natural phenomenon. After this, alveolar preservation procedure was done in the experimental group. Beta tricalcium phosphate was placed into the socket till the level of crystal bone. A horizontal suture was done to maintain the integrity of material.

At follow-up appointment of 1st week sutures was removed, and oral hygiene was reinforced. At 14th week post-operative visit: Before clinical assessment 2nd CBCT was repeated all final measurements were done and after recording alveolar ridge height patient were further appointed for the next treatment plan.

Frame of each CBCT scan was adjusted for the linear measurements for buccal and lingual cortical height in a cross-sectional frame. While for mesial and distal cortical height, measurements were done in a tangential frame. Moreover, vertical measurements were done from the most coronal aspect of cortical bone to the fixed anatomical point apically. Preoperative and postoperative values were calculated by the amount of crystal bone loss. Descriptive statistics were used for volumetric analysis and lineal and basal line measuring. Statistical significance level was kept at value of P at < 0.05. The values of mean and standard deviation were assessed, and difference between two groups was analyzed by Wilcoxon rank sum test.


   Results Top


A total of 40 participants were recruited for the study and were randomly distributed into two groups. Dimensional changes were calculated by comparing the CBCT scans taken immediately after grafting procedure 1st day and 14th week postoperatively.

Demographic variables are explained in [Table 1]. Basal line parameters are explained in [Table 2].
Table 1: Demographic parameters of the study subjects

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Table 2: Clinical parameters at baseline (in millimeter [mm])

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[Table 3] depicts the clinical measurements, and [Table 4] showed volumetric changes of basal line to 14th week follow-up. [Table 5] shows the correlation of basal line clinical parameter with residual ridge reduction. The results were significant for both the groups (group with graft and the control group).
Table 3: Clinical Parameters at 14th week

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Table 4: B-L plates (radiographic assessment of the height)

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Table 5: Correlation between ridge loss parameters at basal line

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   Discussion Top


The present clinical study was carried out to if the technique of the socket grafting can reduce the alveolar bone resorption postextraction radiographically and clinically. Furthermore, if postgraft placement the changes in radiographic and clinical measurements are affected by the span of buccal plate. However, other authors showed that nonresorbable membrane use can lead to unpredictable outcomes added with the complications.[8]

In the recent literature, there documented the foreseeable results can be obtained with the scaffold membranes use with very low incidence of complications. Achieving these results greatly depends on the adequate selection of patients and proper supervision postoperatively as to minimize the complications.[9] Recently, newer techniques have been reinforced in the socket shielding techniques, including the use of free gingival grafts, incorporation of bone grafts, and collagen plug infusion. All these graft materials have depicted favorable results yielding.[10] With all these favorable and supporting studies, betatricalcium phosphate membrane was chosen for the present study, and this membrane use showed no postoperative complication in any of the patients of the two study groups.

Usually, resorption and healing of β-TCP particles are expected in 3–6 months after its placement as evident in literature.[11] Most of the β-TCP gets biodegraded by both osteoclastic activities and/or chemical dissolution of the molecule in the calcium and phosphate components followed by replacement with healthy bone.[10],[11],[12]

Literature has provided evidence in support to the fact that ridge preservation procedures reduce the bone dimensional changes compared with the extraction without ridge preservation procedures.[12] However, as per a systemic review, although, there are various evidences which depicts that there exists the preservation of alveolar ridge, complete obliteration of bone resorption (horizontal and vertical) postextraction cannot be avoided completely.[13] The results of this study are in accordance with these findings as there was some loss of ridge span and height in both the experimental groups even after performing ridge preservation technique. Thus, ridge preservation procedures do not result in complete dimensional stability but are designed to reduce the loss of ridge dimension compared to sites left to heal naturally after tooth extraction.

Murata reported the first clinical case of sinus augmentation using auto-dentin as a bone graft material. Interestingly, dentin and bone are almost similar with respect to composition. They consist of body fluid (10%), collagen (18%), noncollagenous proteins (2%), and hydroxyapatite (HA) (70%) in weight volume. According to Urist in 1965, demineralized dentin matrix and demineralized bone matrix contain mainly type-I collagen with growth factors such as bone morphogenetic proteins 2 and fibroblast growth factors. These bioactive molecules are thought to contribute to osteoinduction and osteoconductive property of human tooth as a graft material.[13],[14] Mineral content wise, tooth consists of low -crystalline HA and possibly other calcium phosphate minerals such as β-TCP, amorphous calcium phosphate, and octacalcium phosphate which is quite similar to human bone tissues.[14]


   Conclusions Top


This study reveals that alveolar ridge preservation for socket grafting provides an additional effect by maintaining the integrity of bone volume. This leads no further grafting at the implant site. This study evaluate that if the bone density of the buccal plate is <1 mm, then ridge preservation is not done while if it is >10% alveolar ridge reduction seen postextraction, it suggests that in future this reduction will continue with the thinning of the buccal cortical plate.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Lekovic V, Kenney EB, Weinlaender M, Han T, Klokkevold P, Nedic M, et al. A bone regenerative approach to alveolar ridge maintenance following tooth extraction. Report of 10 cases. J Periodontol 1997;68:563-70.  Back to cited text no. 1
    
2.
Lekovic V, Camargo PM, Klokkevold PR, Weinlaender M, Kenney EB, Dimitrijevic B, et al. Preservation of alveolar bone in extraction sockets using bioabsorbable membranes. J Periodontol 1998;69:1044-9.  Back to cited text no. 2
    
3.
Cardaropoli G, Araújo M, Lindhe J. Dynamics of bone tissue formation in tooth extraction sites. An experimental study in dogs. J Clin Periodontol 2003;30:809-18.  Back to cited text no. 3
    
4.
Darby I, Chen ST, Buser D. Ridge preservation techniques for implant therapy. Int J Oral Maxillofac Implants 2009;24 Suppl: 260-71.  Back to cited text no. 4
    
5.
Ten Heggeler JM, Slot DE, Van der Weijden GA. Effect of socket preservation therapies following tooth extraction in non-molar regions in humans: A systematic review. Clin Oral Implants Res 2011;22:779-88.  Back to cited text no. 5
    
6.
Simion M, Baldoni M, Rossi P, Zaffe D. A comparative study of the effectiveness of e-PTFE membranes with and without early exposure during the healing period. Int J Periodontics Restorative Dent 1994;14:166-80.  Back to cited text no. 6
    
7.
Fotek PD, Neiva RF, Wang HL. Comparison of dermal matrix and polytetra fluoro ethylene membrane for socket bone augmentation: A clinical and histologic study. J Periodontol 2009;80:776-85.  Back to cited text no. 7
    
8.
Iasella JM, Greenwell H, Miller RL, Hill M, Drisko C, Bohra AA, et al. Ridge preservation with freeze-dried bone allograft and a collagen membrane compared to extraction alone for implant site development: A clinical and histologic study in humans. J Periodontol 2003;74:990-9.  Back to cited text no. 8
    
9.
Artzi Z, Weinreb M, Givol N, Rohrer MD, Nemcovsky CE, Prasad HS, et al. Biomaterial resorption rate and healing site morphology of inorganic bovine bone and betatricalcium phosphate in the canine: A 24month longitudinal histologic study and morphometric analysis. Int J Oral Maxillofac Implants 2004;19:357-68.  Back to cited text no. 9
    
10.
Lu JX, Gallur A, Flautre B, Anselme K, Descamps M, Thierry B, et al. Comparative study of tissue reactions to calcium phosphate ceramics among cancellous, cortical, and medullar bone sites in rabbits. J Biomed Mater Res 1998;42:357-67.  Back to cited text no. 10
    
11.
Trisi P, Rao W, Rebaudi A, Fiore P. Histologic effect of purephasebetatricalcium phosphate on bone regeneration in human artificial jaw bone defects. Int J Periodontics Restorative Dent 2003;23:69-77.  Back to cited text no. 11
    
12.
Kwong CH, Burns WB, Cheung HS. Solubilization of hydroxyapatite crystals by murine bone cells, macrophages and fibroblasts. Biomaterials 1989;10:579-84.  Back to cited text no. 12
    
13.
Nampo T, Watahiki J, Enomoto A, Taguchi T, Ono M, Nakano H, et al. A new method for alveolar bone repair using extracted teeth for the graft material. J Periodontol 2010;81:1264-72.  Back to cited text no. 13
    
14.
Kim YK, Kim SG, Oh JS, Jin SC, Son JS, Kim SY, et al. Analysis of the inorganic component of autogenous tooth bone graft material. J Nanosci Nano technol 2011;11:7442-5.  Back to cited text no. 14
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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