Alveolar ridge preservation with the socket-plug technique utilizing an alloplastic putty bone substitute or a particulate xenograft: a histological pilot study

Socket Preservation Using Dense Polytetrafluoroethylene Membranes and Platelet-Rich Plasma

Socket preservation (SP) is a method aimed at reducing the post-extraction resorption of the alveolar crest and promoting bone deposition in the socket. It involves procedures such as atraumatic tooth extraction, guided regeneration with barrier membranes and bone substitutes, socket sealing, and immediate implant placement. This research aims to evaluate the influence of the combination of dense polytetrafluoroethylene (d-PTFE) membranes and platelet-rich plasma (PRP) on the vertical post-extraction resorption at the premolar and molar sites. Forty participants, aged 18-65 years, who needed extraction of a premolar or molar were enrolled and randomly assigned to an experimental group (SP with d-PTFE membrane and PRP) or a control group (spontaneous socket healing). The results demonstrated that SP with non-porous PTFE membranes and PRP reduced vertical bone resorption at the premolar and molar sites. Data analysis suggested that the buccal plate width influences the amount of its vertical resorption, but not as much as the management of the post-extraction socket (SP versus spontaneous socket healing). Further longitudinal randomized controlled trials are necessary to clarify which factors influence post-extraction ridge resorption and evaluate the success of different SP techniques.

A novel porcine dentin-derived bone graft material provides effective site stability for implant placement after tooth extraction: a randomized controlled clinical trial

OBJECTIVES

Assessment of the clinical performance of a porcine dentin-derived particulate bone graft material for bone regeneration after tooth extraction with implant placement at 4 months, in comparison to a commercially available porcine bone-derived graft.

MATERIAL AND METHODS

This study was a randomized, parallel-group, semi-double-blinded clinical trial evaluating the clinical safety, tolerability, and performance of Ivory Dentin Graft™ in comparison with a commercial bone-derived material in alveolar ridge preservation following tooth extraction (registered at ClinicalTrials.gov, May 12th, 2017, Identifier NCT03150472). Extraction sites were grafted with test or comparator material and a titanium implant placed at 4 months after taking a graft site biopsy. Primary endpoints were the extent of new bone growth and bone-graft integration at 4 months.

RESULTS

The dentin graft material had statistically significantly more new bone formation (60.75% vs 42.81%, p = 0.0084, N = 20 vs 16), better bone-graft integration scores (good integration in 85% vs 40%, p = 0.0066), and higher mean radiodensity of the bone (981.5HU vs 727.7HU, p = 0.0011) at the graft site compared to the bone-derived material. The mean implant insertion torque force was similar for the dentin and bone materials (34.75 Ncm vs 34.06 Ncm). Titanium implant placement was successful in 95% of patients with the dentin graft material compared to 81.25% for the bone graft. Both materials had similar clinical safety and tolerability as determined by adverse events and local site reactions. Physician-assessed ease of grafting and ease of implant placement on a 10-point scale showed no statistical differences (8.78 vs 8.27, p = 0.2355; 8.05 vs 8.75, p = 0.1118, respectively).

CONCLUSIONS

A porcine dentin-derived bone graft material has clinical safety, tolerability, and performance for implant placement at 4 months after tooth extraction at least as good as a commercial bone-derived material.

CLINICAL RELEVANCE

The availability of porcine dentin-derived bone graft material allows wider use of dentin-derived material which has so far only been available in the form of autologous dentin from the patient's own teeth.

Bone Grafts in Dental Medicine: An Overview of Autografts, Allografts and Synthetic Materials

This review provides an overview of various materials used in dentistry and oral and maxillofacial surgeries to replace or repair bone defects. The choice of material depends on factors such as tissue viability, size, shape, and defect volume. While small bone defects can regenerate naturally, extensive defects or loss or pathological fractures require surgical intervention and the use of substitute bones. Autologous bone, taken from the patient's own body, is the gold standard for bone grafting but has drawbacks such as uncertain prognosis, surgery at the donor site, and limited availability. Other alternatives for medium and small-sized defects include allografts (from human donors), xenografts (from animals), and synthetic materials with osteoconductive properties. Allografts are carefully selected and processed human bone materials, while xenografts are derived from animals and possess similar chemical composition to human bone. Synthetic materials such as ceramics and bioactive glasses are used for small defects but may lack osteoinductivity and moldability. Calcium-phosphate-based ceramics, particularly hydroxyapatite, are extensively studied and commonly used due to their compositional similarity to natural bone. Additional components, such as growth factors, autogenous bone, and therapeutic elements, can be incorporated into synthetic or xenogeneic scaffolds to enhance their osteogenic properties. This review aims to provide a comprehensive analysis of grafting materials in dentistry, discussing their properties, advantages, and disadvantages. It also highlights the challenges of analyzing in vivo and clinical studies to select the most suitable option for specific situations.

Alloplastic Bone Substitutes for Periodontal and Bone Regeneration in Dentistry: Current Status and Prospects

Various bone graft products are commercially available worldwide. However, there is no clear consensus regarding the appropriate bone graft products in different clinical situations. This review is intended to summarize bone graft products, especially alloplastic bone substitutes that are available in multiple countries. It also provides dental clinicians with detailed and accurate information concerning these products. Furthermore, it discusses the prospects of alloplastic bone substitutes based on an analysis of the current market status, as well as a comparison of trends among countries. In this review, we focus on alloplastic bone substitutes approved in the United States, Japan, and Korea for use in periodontal and bone regeneration. According to the Food and Drug Administration database, 87 alloplastic bone graft products have been approved in the United States since 1996. According to the Pharmaceuticals and Medical Devices Agency database, 10 alloplastic bone graft products have been approved in Japan since 2004. According to the Ministry of Health and Welfare database, 36 alloplastic bone graft products have been approved in Korea since 1980. The approved products are mainly hydroxyapatite, β-tricalcium phosphate, and biphasic calcium phosphate. The formulations of the products differed among countries. The development of new alloplastic bone products has been remarkable. In the near future, alloplastic bone substitutes with safety and standardized quality may be the first choice instead of autologous bone; they may offer new osteoconductive and osteoinductive products with easier handling form and an adequate resorption rate, which can be used with growth factors and/or cell transplantation. Careful selection of alloplastic bone graft products is necessary to achieve predictable outcomes according to each clinical situation.

Extraction socket preservation

Extraction socket preservation (ESP) is widely performed after tooth extraction for future implant placement. For successful outcome of implants after extractions, clinicians should be acquainted with the principles and indications of ESP. It is recommended that ESP be actively implemented in cases of esthetic areas, severe bone defects, and delayed implant placement. Dental implant placement is recommended at least 4 months after ESP.

Randomized and Controlled Clinical Trial of Bone Healing After Alveolar Ridge Preservation Using Xenografts and Allografts Versus Plasma Rich in Growth Factors

The aim of this study was to compare bone regeneration in the anterior maxilla between bone substitutes and autologous platelet concentrate in alveolar ridge preservation. Forty patients requiring tooth extraction in the anterior maxilla were randomly allocated to the following 4 treatment modalities: spontaneous healing (control), natural bovine bone mineral covered with resorbable native collagen membrane (BBM/CM), freeze-dried bone allograft covered with resorbable native collagen membrane (FDBA/CM), and plasma rich in growth factors (PRGF) alone. Bone biopsies and histomorphometrical analysis were performed after 3 months of healing. The following parameters were assessed: newly formed mineralized tissue, newly formed nonmineralized tissue, and residual bone-grafting material (if applicable). Statistical analysis was performed to provide descriptive analysis and to compare the parameters of the bone regeneration between the study groups. Histomorphometrical analysis revealed the highest new mineralized tissue formation in the PRGF group. Statistically significant differences in new mineralized tissue formation were found between control/PRGF (46.4% ± 15.2% vs 75.5% ± 16.3%), control/(BBM/CM) (46.4% ± 15.2% vs 20.3% ± 21.9%), control/(FDBA/CM) (46.4% ± 15.2% vs 7.2% ± 8.6%), PRGF/(BBM/CM) (75.5% ± 16.3% vs 20.3% ± 21.9%), and PRGF/(FDBA/CM) (75.5% ± 16.3% vs 7.2% ± 8.6%) groups. The new mineralized tissue formation was in the following order: PRGF > control > BBM > FDBA. Alveolar ridge preservation in the esthetic zone with PRGF was the most effective for bone regeneration of the alveolar ridge.

Biofunctionalization with a TGFβ-1 Inhibitor Peptide in the Osseointegration of Synthetic Bone Grafts: An In Vivo Study in Beagle Dogs

Objectives: The aim of this research was to determine the osseointegration of two presentations of biphasic calcium phosphate (BCP) biomaterial—one untreated and another submitted to biofunctionalization with a TGF-β1 inhibitor peptide, P144, on dental alveolus. Materials and Methods: A synthetic bone graft was used, namely, (i) Maxresorb^® (Botiss Klockner) (n = 12), and (ii) Maxresorb^® (Botiss Klockner) biofunctionalized with P144 peptide (n = 12). Both bone grafts were implanted in the two hemimandibles of six beagle dogs in the same surgical time, immediately after tooth extraction. Two dogs were sacrificed 2, 4, and 8 weeks post implant insertion, respectively. The samples were submitted to histomorphometrical and histological analyses. For each sample, we quantified the new bone growth and the new bone formed around the biomaterial’s granules. After optical microscopic histological evaluation, selected samples were studied using backscattered scanning electron microscopy (BS-SEM). Results: The biofunctionalization of the biomaterial’s granules maintains a stable membranous bone formation throughout the experiment timeline, benefitting from the constant presence of vascular structures in the alveolar space, in a more active manner that in the control samples. Better results in the experimental groups were proven both by quantitative and qualitative analysis. Conclusions: Synthetic bone graft biofunctionalization results in slightly better quantitative parameters of the implant’s osseointegration. The qualitative histological and ultramicroscopic analysis shows that biofunctionalization may shorten the healing period of dental biomaterials.

Alveolar Ridge Preservation after Tooth Extraction Using Different Bone Graft Materials and Autologous Platelet Concentrates: a Systematic Review

Objectives

To review and assess the efficiency of different post extraction socket preservation techniques.

Material and Methods

An electronic literature search was performed on the MEDLINE and Embase databases. The review included human studies published between from January 1^st, 2007 to January 1^st, 2018, in English. Outcome measures included dimensional changes and/or histological evaluation of alveolar bone.

Results

Twenty-six full text articles were reviewed, 16 of which met the inclusion criteria and were selected for the study. Autogenous tooth graft prevented vertical resorption the most: -0.28 (SD 0.13) mm, observation period (OP): 4 months, while the least effective approach was beta tri-calcium phosphate (β-TCP): -1.72 (SD 0.56) mm, OP: 4 months. Estimating horizontal resorption, the most effective technique was biphasic calcium sulphate (BCS) with β-TCP and hydroxyapatite (HA) - BCS + TCP + HA: 0.03 (SD 2.32) mm, OP: 4 months, while β-TCP was the least efficient: -1.45 (SD 0.4) mm, OP: 4 months. Evaluating residual graft particles (RG) and newly formed bone (NFB) ratio the best results were achieved with demineralized freeze-dried bone allograft: RG: 8.88%, NFB: 38.42%, OP: 5 months, whereas magnesium-enriched hydroxyapatite was least effective: RG: 40.82%, NFB: 31.85%, OP: 4 months.

Conclusions

This review revealed that even though there are numerous types of biomaterials for socket preservation none of them can completely stop alveolar bone loss after tooth extraction. Furthermore, lack of information about qualitative evaluation of bone was noticed indicating that further studies regarding this topic are needed.

Comparative Evaluation of Bioactive Glass (Putty) and Platelet Rich Fibrin in Treating Furcation Defects

The aim of this study was to compare a second-generation bioactive glass putty biomaterial against platelet rich fibrin in treating grade II furcation defects. Subjects were 15 systemically healthy patients (10 males and 5 females, ages 20-50 with a mean age of 38.33) with 20 mandibular molar class II furcation defects according to Glickman's classification. The 20 mandibular molar furcation defects were randomly allocated as follows: Group I, 10 furcation defects were treated using bioactive glass (NovaBone) bone graft putty material; Group II, 10 furcation defects were treated using platelet rich fibrin (PRF). Customized acrylic stents were fabricated on study casts and trimmed to the height contour of the teeth to serve as a fixed reference point for measurements. The following measurements were collected: gingival index, plaque index, vertical probing depth (from gingival margin to base of the pocket), clinical attachment level (CEJ to the base of the pocket), and horizontal probing depth of furcation involvement (using stent). Results showed that both groups had improvement in gingival index (GI) and plaque index (PI) at the recall intervals. There was an overall reduction in both vertical and horizontal probing depth in both groups; however, the Putty group (Group I) showed consistently more vertical probing depth reduction than the PRF group (Group II) at the end of third month (P-value = 0.0004), sixth month (P-value = 0.00001), and ninth month (P-value = 0.0004). Our conclusion was that use of bioactive glass osteostimulative biomaterial yields superior clinical results, including increased pocket depth reduction of class II furcation defects as compared to an autologous platelet concentrate. The clinical significance of our findings include the ease of use and superior biologic performance of second-generation putty bioglass biomaterials in furcation defects.

A Novel HA/β-TCP-Collagen Composite Enhanced New Bone Formation for Dental Extraction Socket Preservation in Beagle Dogs

Past studies in humans have demonstrated horizontal and vertical bone loss after six months following tooth extraction. Many biomaterials have been developed to preserve bone volume after tooth extraction. Type I collagen serves as an excellent delivery system for growth factors and promotes angiogenesis. Calcium phosphate ceramics have also been investigated because their mineral chemistry resembles human bone. The aim of this study was to compare the performance of a novel bioresorbable purified fibrillar collagen and hydroxyapatite/β-tricalcium phosphate (HA/β-TCP) ceramic composite versus collagen alone and a bovine xenograft-collagen composite in beagles. Collagen plugs, bovine graft-collagen composite and HA/β-TCP-collagen composite were implanted into the left and right first, second and third mandibular premolars, and the fourth molar was left empty for natural healing. In total, 20 male beagle dogs were used, and quantitative and histological analyses of the extraction ridge was done. The smallest width reduction was 19.09% ± 8.81% with the HA/β-TCP-collagen composite at Week 8, accompanied by new bone formation at Weeks 4 and 8. The HA/β-TCP-collagen composite performed well, as a new osteoconductive and biomimetic composite biomaterial, for socket bone preservation after tooth extraction.

Effect of Addition of Platelet-rich Plasma to Calcium Phosphosilicate Putty on Healing at 9 Months in Periodontal Intrabony Defects

BACKGROUND AND OBJECTIVE

Combination of platelet-rich plasma (PRP) and bone substitutes for the surgical treatment of periodontal intrabony defects is based on a sound biologic rationale; however, the clinical results indicative of the synergistic effect of PRP remain ambiguous. The objective of the present study was to clinically and radiographically evaluate the use of calcium phosphosilicate (CPS) putty alone and in combination with PRP in the treatment of periodontal intrabony defects.

MATERIALS AND METHODS

The study was performed at an outpatient facility at a teaching dental institute in north India. A split-mouth design was employed to assess the clinical parameters and radiographic bone fill following the use of CPS putty with and without PRP in patients scheduled for surgical periodontal treatment of intrabony osseous defects. Each defect was randomized to receive treatment with open flap debridement, with CPS putty alone (Group PUT), or open flap debridement with CPS putty and PRP (Group PRp). Probing pocket depth (PPD), plaque index (PI), gingival index (GI), and clinical attachment levels (CALs) were recorded at the investigated sites utilizing custom-made reference guides for measurement reproducibility. Standardized periapical radiographs were also obtained to evaluate defect fill at the surgical sites.

RESULTS

Twenty patients each with at least two defects located in different quadrants were enrolled. The reduction in PPD from baseline to 1st, 3rd, 6th, and 9th month was found to be significant (p < 0.05). The percent reduction in PPD among PUT group was 57.18 ± 10.71% and among PRP group was 51.39 ± 12.60%. No statistically significant difference was observed in the percent reduction in PPD among two groups at 9 months (p = 0.48). Sites in both groups exhibited statistically significant reductions in PI and GI that were maintained throughout the study period. Similar results were seen while measuring CAL.

CONCLUSION

Calcium phosphosilicate Putty alone provides significant improvement in outcomes for the treatment of periodontal intraosseous defects. The addition of PRP to CPS putty does not seem to provide any additive benefit to treatment and the additional surgical time and trauma can be avoided.

A simplified approach to the minimally invasive antral membrane elevation technique utilizing a viscoelastic medium for hydraulic sinus floor elevation

PURPOSE

Maxillary sinus augmentation surgery is frequently employed to provide adequate vertical bony dimensions in posterior maxillary sites. When significant gain in bone height is sought for, an invasive lateral-window approach is routinely used to achieve sinus floor elevation. The minimally invasive antral membrane elevation technique was initially conceived as a surgical improvisation that has been shown to lead to up to, or exceeding, 10 mm of bone height, while enhancing the safety profile of the transalveolar sinus augmentation technique. This approach is based on the use of hydraulic pressure that is applied to the schneiderian membrane via a saline-inflatable balloon. Even though this technique has been shown to be a safe and efficacious treatment modality, the need for specialized equipment, training, and corresponding costs may hinder its widespread application. The purpose of this clinical paper is to introduce a simplified approach to the minimally invasive antral membrane elevation technique.

METHODS

The simplified minimally invasive antral membrane elevation technique is based on the application of hydraulic pressure by a viscous bone graft that acts as an incompressible fluid. The specific clinical steps of this technique will be demonstrated to illustrate how grafting of the maxillary sinus is achieved simultaneously with the atraumatic elevation of the schneiderian membrane, thus resulting in even less operative time.

CONCLUSIONS

This simplified technique may make the minimally invasive antral membrane elevation technique more accessible to implant surgeons as it eliminates the need for purchase of specialized equipment and aids in further decrease of intra-operative time accomplished with the original technique.