|Year : 2017 | Volume
| Issue : 2 | Page : 107-113
Effect of platelet rich plasma on stability of dental implants: A prospective comparative clinical study
Anne Gopinath, Anne Ravikanth, Krishna K Kadiyala, Krishna M Thota, Prakash Manne, Muvva S Babu
Department of Prosthodontics, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India
|Date of Web Publication||13-Jun-2017|
SF-3, AGS Towers, Srinivasa Nagar Bank Colony, Vijayawada - 520 008, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: Good implant stability is the prime concern for successful prosthetic rehabilitation. Many methods and different types of implants have been used to achieve primary and secondary stability with varying success rates. The evolution continued with the use of biological materials for early osseointegration. The present study was aimed to compare and evaluate the effect of platelet rich plasma (PRP) on the early osseointegration and secondary stability of dental implants using implant stability values.
Materials and Methods: A total of 18 dental implants were randomly placed among 10 patients in the mandibular posterior region using split mouth design. In the control group, implants were placed following standard surgical protocol. In the study group, autologous PRP was used to moisten the implants before placement. Implant stability was observed and compared using Osstel Implant stability meter at 0, 30, 60, and 90 days. All the cases were followed-up over period of 18 months. Statistical analysis was carried using one-way analysis of variance and paired and unpaired t-test.
Results: Significant difference in stability values were observed in the study group following 30 days after implant placement. Control group showed no statistically significant difference at all time intervals. Implant stability values were higher in the early phase of osseointegration in the PRP group. However, at the end of the study period, both groups showed similar stability.
Conclusion: Good primary implant stability is beneficial for early loading and rehabilitation. PRP can be successfully used as an adjunct for better and early function. It is safe due to its autologous origin, thus eliminating the risk of disease transmission and immunogenic reactions.
Keywords: Implant stability, platelet rich plasma (PRP), resonance frequency analysis (RFA)
|How to cite this article:|
Gopinath A, Ravikanth A, Kadiyala KK, Thota KM, Manne P, Babu MS. Effect of platelet rich plasma on stability of dental implants: A prospective comparative clinical study. J NTR Univ Health Sci 2017;6:107-13
|How to cite this URL:|
Gopinath A, Ravikanth A, Kadiyala KK, Thota KM, Manne P, Babu MS. Effect of platelet rich plasma on stability of dental implants: A prospective comparative clinical study. J NTR Univ Health Sci [serial online] 2017 [cited 2020 Apr 3];6:107-13. Available from: http://www.jdrntruhs.org/text.asp?2017/6/2/107/208012
| Introduction|| |
Implant treatment mainly aims at the functional restoration of stomatognathic system which provides comfort and health for the patient. Although considered as the most innovative and superior prosthetic modality in dentistry, a traditional healing period of 3–6 months is considered essential for osseointegration and its maintenance during functional loading. However, changing concepts with evolution and recent technical advances to enhance the stability have changed the traditional outlook. Clinicians and researchers look at various means for reducing the healing phases, guarantying osseointegration. Advanced treatment protocols, such as early or immediate loading, are frequently used to reduce treatment time, however, these pose new demands for promising osseointegration. Many researchers published criteria for determination of factors affecting osseointegration., Several measures have been proposed to improve and accelerate osseous healing of endosseous implants, however, most of them are concerned with implant surface characteristics that are under manufacturer's control. However, a clinician, with appropriate stimulus can modify and accelerate osseointegration by inducing the regenerative capacity of surrounding tissues at bone-implant interface zone, which governs the success and longevity of the implant.
Platelet rich plasma (PRP) is one such autologous source, rich in various growth factors whose release continues for 7 days. Low pH of PRP (6.5–6.7) inhibits bacterial growth.
Implant stability plays a key role for successful osseointegration. Therefore, for clinical evaluation of implant success, implant stability can be measured by various methods of which resonance frequency analysis (RFA) can be considered to be noninvasive, reliable, and safe.
The present study was conducted to assess the effect of autologous PRP coating on the secondary stability of dental implants with the help of implant stability measurements using RFA at regular time intervals.
| Materials and Methods|| |
A comparative randomized clinical study was conducted in the Department of Prosthodontics, SIBAR Institute of Dental Sciences, Andhra Pradesh during 2012–2015 on patients requiring implant-supported prosthesis in the mandibular posterior regions. A total of 18 implants were placed among 10 healthy patients between 25 and 40 years of age and of either gender. Patients with adequate bone height and width were selected so that all the patients received standard size implants of 3.75 × 10 mm to prevent variations in surface area and the primary stability. Patients with metabolic diseases, blood dyscrasias, bruxism, habits of smoking, alcohol consumption, and other contraindications to implant surgery were excluded to prevent bias associated with healing. They were randomly divided into study group (implants coated with PRP before placement) and control group (conventional implant placement without PRP coating). All the patients were explained about the treatment protocol, and informed written consent was obtained from the patients. The study protocol was approved by institutional ethical committee.
Sidexis software (Sirona Dental Systems GmbH, Germany) was used to measure preoperative bone height from crest of the ridge to the superior border of inferior alveolar nerve canal using digital panoramic radiograph [Figure 1]. Diagnostic casts were used to prepare template for ridge mapping [Figure 2] and preparation of surgical stent. Ridge mapping was performed in the presurgical visit to assess the thickness of soft tissue over the crest and to assess the exact width of bone present [Figure 3]. Patients with adequate bone height and width were included in the study. The observers were blinded for the study protocol and follow-up duration to prevent observer bias. Kappa correlation was taken into consideration to assess the degree of observer agreement for assessment.
|Figure 2: (a) Diagnostic cast sectioned at desired implant site (b) measuring thickness of Thermoplastic template for ridge mapping|
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|Figure 3: (a) Thermoplastic template adapted in mouth. (b) Measuring soft tissue thickness (c) Transfer of measurements onto cast (d) outline of available alveolar bone|
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Preparation of platelet rich plasma
Standard aseptic precautions were followed to draw 5 ml of venous blood from antecubital fossa. The blood was transferred to a sterile vacutainer (CML Biotech Ltd, Hyderabad, India.) containing 0.5 ml of 3.2% sodium citrate which acts as an anticoagulant. After titration, it was subjected to first centrifugation at 2400 rpm for 10 minutes, which separated plasma and platelets from the remaining whole blood. Thus obtained plasma was subjected to second centrifugation at 3600 rpm for 15 minutes to concentrate platelets into the plasma. This separated the plasma into platelet poor plasma (PPP) and platelet rich plasma (PRP), which was collected at the bottom of the vacutainer. PRP was carefully drawn. Just prior to implant placement, the PRP was activated with equal volume of 10% CaCl2 [Figure 4] to precipitate the citrate in the anticoagulant. This also initiated release of growth factors and thrombin formation.
|Figure 4: (a) platelets and plasma seperated from whole blood (b) PRP at the bottom of the vaccutainer (c) addition of 10% calcium chloride to PRP (d) circumferential moistening of implant with activated PRP|
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Preparation of surgical site and placement of an implant
The standard operating procedures were followed for the preparation of surgical site before placement of implant under local anesthesia using Lignocaine hydrochloride (2% lignocaine with adrenaline 1:80.000). Surgical stent were adopted at predetermined positions [Figure 5].
Mid crestal incisions along with adjacent sulcular incision were made at the implant recipient site and a full thickness mucoperiosteal flap was elevated [Figure 6]. Using a surgical guide template, a mark was placed with no-5 round bur with initial entry. The pilot drilling was performed until the required depth. The osteotomy preparation was then completed using drills of sequential sizes using surgical kit (Adin Israel). The implant of 3.75 × 10 mm (Touraeg-S; ADIN implant systems Ltd, Israel) [Figure 7] was then placed into the osteotomy site [Figure 8]. Implant stability was checked with torque wrench and Osstell implant stability meter (Osstell S/N 4101, Osstell AB, Sweden) [Figure 9] to measure the RFA [Figure 10]. Cover screw was placed; flap was approximated and sutured using interrupted sutures. In the study group, the implants were circumferentially moistened with a mixture of platelet rich plasma and 10% calcium chloride in equal volumes before placing into the osteotomy sites [Figure 11]. Post surgically, antibiotics and analgesics were advised and patients were critically followed-up for thorough oral prophylaxis and use of chlorhexidine gluconate mouthwash thrice daily till the observation period. The implants were loaded with prostheses after initial healing period and followed-up for 90 days.
Postoperative evaluation and follow up
A total of 18 dental implants were randomly placed among 10 patients in the mandibular posterior region using split mouth design. Hence, 9 implants served as the study group and 9 as the control group. All the patients were subjected to RFA in two planes, i.e., buccal, lingual, mesial, distal, and occlusal surfaces at regular intervals of 0, 30, 60, and 90 days. A mean of the Implant Stability Quotient index (ISQi) values for each patient were calculated. The results obtained were subjected to statistical analysis using analysis of variance (ANOVA) and paired and unpaired t-tests.
| Results|| |
No implant was lost during the follow-up period. Comparison of mean RFA values in the control group showed no statistically significant difference at 0–30, 0–60, 0–90, and 30–60 days intervals. However, significant difference was observed at 30–90 and 60–90 days intervals [Graph 1]. In the study group, statistically significant difference was observed at 0–30, 30–90, and 60–90 days. However, no significant difference was found at 0–60, 0–90, and 30–60 days intervals [Graph 2]. When a mean comparison was done between the study and control groups at all time intervals, no statistically significant difference was observed [Graph 3].
| Discussion|| |
To promote early osseointegration with qualitative bone formation, researchers have proposed various implant surface modifications., These surface modified implants have been used with varying rate of success. The advent of various biologicals changed the face of bone regeneration and osseointegration, resulting in enhanced clinical performance and implant survival rates. One among such modifications includes the application of growth factors. PRP is a portion of the plasma fraction of autologous blood having a platelet concentration above baseline. PRP also has been referred to as platelet-enriched plasma, platelet rich concentrate, platelet releasate, and autologous platelet gel. It has being used to treat extensive wounds since a long time. Extensive literature regarding PRP is available elsewhere in the published literature.
Many studies have been published favoring the use of PRP for bone regeneration in bony cavities. immediate implant placements,, and animal studies,, however, scanty literature is available with placement of implant in posterior mandible. The late implant placement studies using blood products for enhancement of osseointegration are necessary for the establishment of early implant stability through early bone regeneration. Few studies with PRP in immediate implant placement have shown beneficial results.,,, Animal studies clearly showed beneficial effect of the use of blood products in bone regeneration.,, However, the mechanism involved in humans with functional loading may be one of the factors for varying opinion in published results., Many studies are case series involving small groups of patients. Though the stability and success of implant is multifactorial, our study assessed the use of PRP after functional loading in small group of patients using standardized implant size, with age and gender-matched random blind study design and standard implant placement and clinical follow-up.
Application of autologous growth factors is one of the factors to improve and accelerate osseous healing by increasing bone implant contact. PRP has been suggested to enhance the healing of bone grafts and to enhance the osseointegration of implants as activated platelets release autogenous growth factors (GFs) into the wound healing site. It serves as GF agonist and has both mitogenic and chemotactic properties. It contains a high level of platelets and a full complement of clotting and growth factors. PRP contains α granules of degranulated platelets containing various synthesized and pre-packaged growth factors such as transforming growth factor (TGF1 and 2), platelet derived growth factor (PDGF), basic fibroblast growth factor, vascular endothelial growth factor (VEGF), epithelial growth factors (EGF), and platelet activating factor (PAF). These factors when released into the wound site enhance vascular healing and bone deposition., PRP by its virtue of low pH acts as bacteriostatic. Enhanced bone regeneration is attributed due to increased angiogenesis, chemotaxis, mitosis, and stem cell proliferation after use of PRP.,
In the present study, secondary stability was compared between implants placed with and without PRP treatment. A total of 18 implants were included in the group for statistical analysis. None of the implant failed during the observation period. All the implants osseointegrated well. The study group showed a significant difference during 0–30 days interval. When comparison was made among the groups, significant difference was observed during 60–90 days and 30–90 days for both study and control groups [Graph 3]. It can be assumed that ISQ value increases from 0 to 30 days in the study group due to release of growth factors from the PRP treated implant surface, which continues for a period of 1 week. However, at the end of study period both the groups showed similar observations, hence no statistically significant difference was observed among the control and study groups at all time intervals.
Implant stability is the capacity of the implant to withstand loading in axial, lateral, and rotational directions. Total stability is a sum of the primary and secondary stabilities. Primary stability is achieved by implant dimensions, precision of drills, pitch, and design; whereas secondary stability is the result of the biologic healing process, which is therefore not under the direct control of the clinician. Therefore, to prevent bias in implant selection and implant attributes relating to the structure of implant fixture, implant dimensions were standardized to 3.75 × 10 mm. The confounding bias factors were minimized by age and gender matching with randomized blind protocol.
Achievement of secondary stability is subject to numerous variables, the most significant of all being the speed of the osseointegration process. A delay in the healing process leads to a marked decrease in the total stability of the implant between weeks 2 and 4, making this “stability dip” a critical time in the osseointegration process. The goal of PRP use is to achieve secondary stability sooner by accelerating the osseointegration process, as well as by promoting faster osseointegration and early secondary stability. PRP manages to “shift” the stability dip and allows the clinician to commence the prosthetic phase earlier than otherwise. However, in the present study, stability values at 90 days were similar for both the groups. This can be explained that regenerative potential of PRP will be useful in the early phases of bone regeneration as in the long run the normal bone physiology takes over growth modifications.
The study results were in accordance with published literature,,, however, it was not possible to compare the results as the study protocol differs with the published literature and very few similar studies were found for comparison. The immediate implant placement using PRP in the literature showed beneficial and similar results like the present study.,, The results were in favor of the use of PRP during implant placement for early secondary stability.
Scope for further study
- Densitometric analysis can be done to evaluate the quality of periimplant bone
- Cone beam computed tomography can be performed for evaluating marginal bone lossPeriodontal indices can be evaluated for soft tissue response.
| Conclusion|| |
Achieving early implant stability is beneficial for early loading and rehabilitation. Good secondary stability is attained by dense bone formation, which increases the longevity of the implant. In the present study, stability values in PRP-treated implants showed significant difference after 30 days. Initial burst of growth factors and their effect on healing and bone formation can be assumed to be the cause for significant raise in stability values. Hence, PRP can be successfully used as an adjunct with implant for better and early function. It is safe due to its autologous origin as there is no risk of immunogenic reaction or transmission of diseases.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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