Table of Contents      
CASE REPORT
Year : 2017  |  Volume : 9  |  Issue : 1  |  Page : 35-40

Platelet-rich fibrin application in immediate implant placement


1 Department of Periodontology, Adhiparasakthi Dental College and Hospital, Melmaruvathur, Chennai, Tamil Nadu, India
2 Department of Periodontology, Meenakshi Ammal Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Web Publication30-Jun-2017

Correspondence Address:
Vijayalakshmi Rajaram
Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-0754.201435

Rights and Permissions
   Abstract 

The dental rehabilitation of a patient following single-tooth extraction in the esthetic zone is often clinically challenging. The treatment option for this is implant-supported single crown which has the advantage that adjacent teeth do not have to be prepared, as in a fixed prosthesis. This article presents a case of immediate implant placement in relation to 22 and a guided bone regeneration approach with platelet-rich fibrin (PRF) and bone graft. After immediate implant placement, to compensate for the gap (jumping distance) between the implant surface and bone walls of the socket, we used bone grafts and PRF clot as well as PRF membrane to achieve guided bone regeneration. PRF, which is the second generation platelet concentrate, offers the surgeon an access to growth factors with a simple and available technology. These growth factors, which are autologous, nontoxic, and nonimmunogenic, enhance and accelerate the normal bone regeneration pathways. The case presented showed successful outcome with a 1 year follow-up period.

Keywords: Extraction socket, immediate implants, platelet concentrates, platelet rich fibrin


How to cite this article:
Rajaram V, Theyagarajan R, Mahendra J, Namachivayam A, Priyadharshini S. Platelet-rich fibrin application in immediate implant placement. J Int Clin Dent Res Organ 2017;9:35-40

How to cite this URL:
Rajaram V, Theyagarajan R, Mahendra J, Namachivayam A, Priyadharshini S. Platelet-rich fibrin application in immediate implant placement. J Int Clin Dent Res Organ [serial online] 2017 [cited 2017 Oct 23];9:35-40. Available from: http://www.jicdro.org/text.asp?2017/9/1/35/201435


   Introduction Top


Single-tooth replacement with an implant-supported crown is gaining importance in treating partially edentulous patients. In posterior sites, the primary objective of single-tooth replacement is the reestablishment of masticatory function. Esthetic considerations in these areas are less frequently of concern. In contrast, anterior sites are more closely linked to esthetic expectations and often represent a considerable challenge. Hence, immediate implant placement at the time of extraction or early implant placement following a few weeks of soft tissue healing has become a treatment of choice.

The obvious advantages of immediate implant placement are minimal number of surgical procedures and shortest possible treatment time from tooth extraction to implant restoration.


   Case Report Top


A 40-year-old female patient presented with a complication following root canal treatment (RCT) in 22. History revealed that the patient allegedly met with trauma and fractured 22, for which she underwent RCT and postcore. Even after 4 months of endodontic treatment, there was recurrent periapical infection in 22, which was confirmed with Orthopantamogram [Figure 1] and [Figure 2]. There was no relevant medical or surgical history. The treatment plan proposed was extraction of 22 and immediate implant placement.
Figure 1: preoperative view

Click here to view
Figure 2: preoperative OPG

Click here to view


She had already undergone replacement of 12 by implant prosthesis in a private dental clinic. The patient was informed about the relevant aspects of the treatment. Written consent was obtained from the patient for the same.

Preparatory phase

Preparation of the patient included scaling and root planing of the entire dentition and oral hygiene instructions.

Surgical technique

The first treatment step was the careful extraction of 22 under Local anaesthesia – 1.8 ml of 2% lignocaine [Figure 3] and antibiotic coverage (capsule amoxicillin 500 mg TDS, tablet aceclofenac 100 mg, and paracetamol 500 mg combination BD after food). This was carried out by luxating with periotome and removing with an appropriate pair of forceps, taking care to preserve the buccal plate of bone. The extraction socket was adequately debrided, and all the infected granulation tissue was removed. Implant bed preparation was completed according to the standard protocol using sharp round burs and spiral drills of increasing diameter and copious cooling with chilled saline. The surgical guidelines for immediate implant placement were met. The implant (4.2 mm × 10 mm) was positioned in such a way that in the coronoapical direction, it penetrated halfway to two-thirds of the way down the extraction site into the remaining lingual apical bone for rigid fixation.[1] The platform of implant was positioned approximately 3–4 mm apical to the anticipated mid-facial mucosal margin of the future implant crown.[2] In addition, in the orofacial direction, the implant was intentionally positioned about 1 mm palatal of the prosthetic point of emergence. The implant achieved excellent primary stability. A 4 mm healing cap was placed [Figure 4]. After placement of implant, a gap was observed between the implant and bony wall, which was proposed to be filled with bone graft and platelet-rich fibrin (PRF).
Figure 3: extraction of 22

Click here to view
Figure 4: immediate implant placed in relation to 22

Click here to view


Preparation of platelet-rich fibrin

The patient's blood samples were taken in the operating room during the surgery. Immediately after the blood draw, the dried monovettes (without anticoagulant) were centrifuged at 2700 rpm for 12 min in a table top centrifuge (Remy ® Laboratories).

The PRF clots were recovered and used in two ways as follows:[3]

  1. Some were placed in sterile cups and cut in few millimeter fragments. Then, they were mixed with demineralized bone matrix (DMBM), which is an allograft material. The mixture obtained constituted an easy-to-use homogeneous graft material which was placed in the gap between the implant surface and the extraction socket [Figure 5]
  2. The left half of PRF clot was packed tightly in two sterile compresses to obtain resistant fibrin membranes, which was placed over the implant surface before wound closure [Figure 6] and [Figure 7].
Figure 5: bone grafts were placed in relation to 22

Click here to view
Figure 6: PRF membrane placed in relation to 22

Click here to view
Figure 7: flap sutured in relation to 22soft

Click here to view


Ideal angulation and placement of implant was verified with an intraoral periapical radiograph [Figure 8].{Figure 8}

The patient was asked to continue the antibiotics (amoxicillin 500 mg tid for 5 days) and analgesics (combination of ibuprofen 200 mg and paracetamol 500 mg twice daily for 3 days) and postoperative instructions were given. Chlorhexidine (0.2%) mouth rinse was prescribed for 4 weeks after surgery.

Postoperative healing

The sutures were removed 10 days after the procedure. The surgical site was examined for uneventful healing. There were no postoperative complications and healing was satisfactory.

The implant was uncovered and a healing abutment was connected to allow emergence of the implant through the soft tissues, thus facilitating access to the implant from the oral cavity and provisional restoration was placed in infraocclusion [Figure 9]. During the next few weeks, the peri-implant soft tissues were observed to adapt nicely to the shape of the crown.
Figure 9: abutment placed in relation to 22

Click here to view


The provisional crown remained in place for 6 months postloading [Figure 10]. The 6 months follow-up examination demonstrated clinically healthy peri-implant soft tissues and a well-integrated implant, with adequate bone formation as confirmed with a periapical radiograph.
Figure 10: provisional restoration in relation to 22

Click here to view


Subsequently, the provisional crown was replaced by porcelain fused metal crown [Figure 11].
Figure 11: final restoration in relation to 22

Click here to view



   Discussion Top


The implants placed at the time of tooth extraction are called immediate implants (Schwartz 2000).[4] There are several advantages of immediate implants, namely, maintenance of soft tissue profile, prevention of bone loss in both vertical and horizontal directions, reduced postextraction healing period, better angulation, and improved surgical orientation.[5] In the anterior maxilla, the facial bone wall of extraction sockets is most often thin as a result of the facial position of the teeth. In addition, the facial bone can often be missing because of chronic infections. Both clinical situations require bone augmentation at implant placement if an esthetic outcome is to be accomplished. Iasella et al. 2003 compared normal socket healing and augmented sockets and concluded that unaugmented sockets decreased in width by an average of 1.7 mm while grafted sites decreased by 1.2 mm.[6] Furthermore, Nevins et al. 2006 confirmed in a clinical study using computerized tomographic scans that the ridges of nongrafted extraction sockets showed more than 20% loss of crest height.[7]

Even in patients with an intact facial wall at implant placement, horizontal bone resorption still takes place and leads to a flattening of the facial contour.[8] Thus, contour augmentation is beneficial even in these clinically favorable situations if the esthetic outcome is to be optimized.

The rationale for reflecting full thickness flap in this case was threefold. First, it facilitates tooth removal which can be quite delicate, especially when the tooth is fractured or in case of root resorption. Second, the flap allows the clinician to inspect the buccal socket wall properly for fenestration and dehiscence. Third, flapless surgery increases the risk of perforation. This is in accordance with Misch who reported that the full thickness flap allows preservation of delicate soft tissue from laceration and subsequent infection.[9]

Evidence suggests that implants can be placed into sites with periapical and periodontal infections. The sites must be thoroughly debrided before placement.[10]

In the case presented here, immediate implant was an ideal treatment option because it reduced the emotional trauma associated with loss of anterior tooth. When an implant is placed in a fresh extraction socket, a gap (jumping distance) between the implant surface and bone walls of the socket may occur.[11] The presence or size of the gap is both influenced by the configuration of the alveolus and by the design and width of the implant. To compensate this problem, guided bone regeneration using bone grafts, barrier membranes, or combination therapy can be used.

Recent clinical and histologic findings suggest that the use of platelet concentrates have technical benefits and may enhance bone regeneration when used in conjunction with bone grafts. The amplification of platelet-derived growth factor and transforming growth factor is seen as an available and practical tool for enhancing the rate of bone formation and the final quality of bone formed.[12]

PRF has many advantages over platelet-rich plasma (PRP). It eliminates the redundant process of adding anticoagulant as well as the need to neutralize it. It has been shown from literature that it increases the rate of clinical graft consolidation, and PRF-enhanced grafts produce more mature and dense bone than do grafts without PRF. PRF is in the form of a platelet gel and can be used in conjunction with bone grafts, which offers several advantages including promoting wound healing, bone growth and maturation, graft stabilization, wound sealing and hemostasis and improving the handling properties of graft materials. In an experimental study which used osteoblast cell cultures to investigate the influence of PRP and PRF on proliferation and differentiation of osteoblasts, it was found that PRF had a superior influence over PRP.[13] In addition, bone augmentation grafts may act as space-maintaining devices to allow coronal migration of periodontal progenitor cells. PRF fragments when used along with bone grafts acts as a biological connector and forms a matrix that supports neoangiogenesis, migration of osteoprogenitor cells to the center of graft. The technique of applying biomaterials to support bioresorbable membranes avoids the risks associated with harvesting autogenic bone.[14]

The development of biomaterials, ideally coupled with the incorporation of bone growth factors and bioactive peptides, represents an important line of research in this direction. Cortelini et al. 2004 concluded that the use of DMBM as a membrane support at immediately placed implants may offer an advantage in areas with high esthetic demands in terms of soft tissue support.[15] Recent systematic reviews regarding the survival rate of implants into sites with regenerated/augmented bone using barrier membranes varied between 79% and 100% with the majority of studies indicating more than 90% after at least 1 year of function.[16]

Although PRF is not a substitute to GBR, owing to the exuberant growth factors released, its healing potential and nonimmunogeneic nature, it was chosen. This was in accordance with the study done by Hafez et al., 2015.[17]

The 6 months follow-up examination of 22 region revealed clinically healthy peri-implant soft tissues, no signs of complications such as peri-implant infection or mucosal recession, and an overall pleasing esthetic treatment outcome. The periapical radiograph showed stable bone crest levels, with signs of minor bone remodeling at the alveolar crest.


   Conclusion Top


The use of combined technique of PRF and immediate implant placement potentially improves implant bed preparation and motivates osseointegration. PRF membranes represent a new technology for stimulation and acceleration of bone regeneration. PRF membrane is autologous in nature, thus eliminating chances of immunogenicity and disease transmission through blood. However, long-term studies are needed to confirm the application of PRF in GBR.

  • There are rarely any reports on PRF application in immediate implants; this report is one of a kind in that regard
  • Bone loss in extraction sockets is prevented by immediate implant placement; this report reinforces the advantage of immediate implant placement
  • The orientation of immediate anterior implant has been clearly described.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: Anatomic and surgical considerations. Int J Oral Maxillofac Implants 2004;19:43-61.  Back to cited text no. 1
    
2.
Lazzara RJ. Immediate implant placement into extraction sites: Surgical and restorative advantages. Int J Periodontics Restorative Dent 1989;9:332-43.  Back to cited text no. 2
[PUBMED]    
3.
Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part V: Histologic evaluations of PRF effects on bone allograft maturation in sinus lift. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:299-303.  Back to cited text no. 3
    
4.
Schwartz, Grossman Y, Chadshunt G. The clinical effectiveness of implants placed immediately into fresh extraction sites of molar teeth. Journal of Periodontology 2000;71:839-44.  Back to cited text no. 4
    
5.
Giri D, Kundapur PP, Singh VP. Immediate implants in dentistry: A Review. Pak Oral Dent J 2013;33:449-54.  Back to cited text no. 5
    
6.
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;3:168-77.  Back to cited text no. 6
    
7.
Nevins M, Camelo M, De Paoli S, Friedland B, Schenk RK, Parma-Benfenati S, et al. A study of the fate of the buccal wall of extraction sockets of teeth with prominent roots. Int J Periodontics Restorative Dent 2006;26:19-29.  Back to cited text no. 7
    
8.
Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations following immediate implant placement in extraction sites. J Clin Periodontol 2004;31:820-8.  Back to cited text no. 8
[PUBMED]    
9.
Misch C. Contemporary Implant Dentistry. 2nd ed. St. Louis: Mosby Co.; 1999. p. 390-1.  Back to cited text no. 9
    
10.
Waasdorp JA, Evian CI, Mandracchia M. Immediate placement of implants into infected sites: A systematic review of the literature. J Periodontol 2010;81:801-8.  Back to cited text no. 10
[PUBMED]    
11.
Schropp L, Kostopoulos L, Wenzel A. Bone healing following immediate versus delayed placement of titanium implants into extraction sockets: A prospective clinical study. Int J Oral Maxillofac Implants 2003;18:189-99.  Back to cited text no. 11
[PUBMED]    
12.
Devescovi V, Leonardi E, Ciapetti G, Cenni E. Growth factors in bone repair. Chir Organi Mov 2008;92:161-8.  Back to cited text no. 12
[PUBMED]    
13.
Su CY, Kuo YP, Tseng YH, Su CH, Burnouf T.In vitro release of growth factors from platelet-rich fibrin (PRF): A proposal to optimize the clinical applications of PRF. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:56-61.  Back to cited text no. 13
[PUBMED]    
14.
Toffler M, Toscano N, Corso MD. Introducing Choukroun's platelet rich fibrin (PRF) to the reconstructive surgery milieu. J Implant Adv Clin Dent 2009;1:21-30.  Back to cited text no. 14
    
15.
Cortelini R, Cangini F, Martuscelli G, Wennstrom J. Deproteinized bovine bone and biodegradable barrier membranes to support healing following immediate placement of trans-mucosal implants: A short-term controlled clinical trial. Int J Periodontics Restorative Dent 2004;24:555-63.  Back to cited text no. 15
    
16.
Chen ST, Buser D. Esthetic outcomes following immediate and early implant placement in the anterior maxilla – A systematic review. Int J Oral Maxillofac Implants 2014;29:186-215.  Back to cited text no. 16
    
17.
Hafez WK, Seif SA, Shawky H, Hakam MM. Platelet rich fibrin as a membrane for coverage of immediate implants: Case-series study on eight patients. Tanta Dent J 2015;12:203-10.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure8 8], [Figure 9], [Figure 10], [Figure 11]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed539    
    Printed46    
    Emailed0    
    PDF Downloaded79    
    Comments [Add]    

Recommend this journal