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 Table of Contents  
Year : 2014  |  Volume : 3  |  Issue : 1  |  Page : 39-42

Postextraction socket grafting using calcium phosphate cement and platelet rich fibrin

1 Department of Periodontology, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
2 Department of Oral Pathology, Sinhgad Dental College and Hospital, Pune, Maharashtra, India

Date of Web Publication6-May-2015

Correspondence Address:
Dr. Nihal Devkar
Department of Periodontology, Sinhgad Dental College and Hospital, Vadgaon Budruk, Pune - 411 041, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2277-4696.156528

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This clinical case report describes and demonstrates the successful use of calcium phosphate cement (CPC) in conjunction with platelet-rich fibrin (PRF) for postextraction socket grafting in maxillary right first premolar area. CPC can be molded to form a scaffold. It has been used previously for regeneration in intrabony defects, but very few clinical studies in humans have reported its use for socket grafting. In this report, we have presented a novel use of CPC in conjunction with PRF for ridge preservation after tooth extraction.

Keywords: Calcium phosphate cement, platelet rich fibrin, ridge preservation, socket grafting

How to cite this article:
Devkar N, Palaskar S, Meherwade V, Navale S, Ansari M. Postextraction socket grafting using calcium phosphate cement and platelet rich fibrin. J Dent Allied Sci 2014;3:39-42

How to cite this URL:
Devkar N, Palaskar S, Meherwade V, Navale S, Ansari M. Postextraction socket grafting using calcium phosphate cement and platelet rich fibrin. J Dent Allied Sci [serial online] 2014 [cited 2018 Mar 21];3:39-42. Available from: http://www.jdas.in/text.asp?2014/3/1/39/156528

  Introduction Top

After extraction, severe hard and soft tissue alteration takes place within the affected site of the alveolar ridge. [1] The three-dimensional resorption process at extraction sites results in narrower ridges and reduced vertical height and lingual/palatal shifting of their long axis. This change may lead to esthetic and functional disadvantages that compromise future implant placement particularly if the dental implant placement needs to be delayed for 6 months or longer. [2],[3]

Hence, it is crucial to preserve the dimensions and contour of the alveolar ridge after tooth extraction to achieve a predictable esthetic and functional prosthetic restoration. Some studies have documented positive socket healing responses with autogenous bone, alloplasts, and xenografts, whereas others reported poor results with bovine bone, decalcified freeze-dried bone and autogenous bone. [1],[4],[5],[6],[7],[8]

A new class of alloplast materials, namely, calcium phosphate cements (CPC) are aqueous-based cements that get converted to hydroxyapatite (HA) upon setting. The combination of biocompatibility, osteoconductivity and restorability makes it a unique material for grafting bony defects. [9]

Platelet-rich fibrin (PRF) is an autologous preparation of concentrated platelets created by centrifugation of a patient's blood. The use of PRF during the surgical procedure is a current treatment concept used to accelerate wound healing and tissue maturation. [10],[11]

Based on these positive findings of CPC and PRF, we present a case report of an extraction socket grafting for postextraction ridge preservation in the maxillary right first premolar area.

  Case Report Top

A systemically healthy 52-year-old female patient was referred to the Department of Periodontology at Sinhgad Dental College and Hospital, Pune, Maharashtra, India. The patient was undergoing a root canal treatment in Department of Conservative Dentistry. After the root canal opening, progressive increase in the tooth mobility was observed and hence the case was referred to Department of Periodontology. The Patient did not complain of any pain or swelling associated with the same tooth.

The patient was afebrile with normal vital signs. Intraoral examination revealed temporary occlusal restoration with tooth 14. There was tenderness on percussion. The clinical appearance of the soft tissue around the tooth appeared healthy [Figure 1]. An intraoral periapical radiograph (IOPA) of the same region showed a horizontal fracture in relation to the middle third of root of 14 along with residual roots of 15 [Figure 2]. There was no periapical radiolucency or pathological bone changes. Since 14 was a nonrestorable tooth, a decision was taken to extract it. The patient was explained the need for postextraction socket preservation, followed by delayed implant placement for which the patient consented. She was not willing for extraction of 15. Oral prophylaxis was done a week before the procedure. The entire procedure was explained to the patient and a verbal and written informed consent was taken from the patient. The patient gave a negative history of smoking or tobacco habit. She was not on any medications that impair hematological parameter. There was no history of the bone disorder. The laboratory tests revealed a normal hemogram. Preoperative antibiotic and analgesics were started 1-day prior to the procedure.
Figure 1: Preoperative photograph

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Figure 2: Preoperative intraoral periapical radiograph showing fracture line

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Platelet rich fibrin preparation

The preparation was done in Department of Oral Pathology according to the protocol given by Dohan et al. in 2006. [11] A 10 cc venous blood was obtained from antecubital fossa by venipuncture and collected in a sterile test tube. The collected blood sample was centrifuged immediately at 3000 rpm for 10 min. This separated the PRF from the red blood cells. This separation is stable and can remain in the tube for 1 h.

The extraction site was anesthetized with an appropriate local anesthesia. Atraumatic extraction of the tooth was done using periotomes and elevators without raising a full thickness mucoperiosteal flap [Figure 3]. After extraction, careful debridement was done, and the socket integrity was examined using a periodontal probe. The socket was found to have 4 wall architectures, and the alveolar bone was not damaged. The CPC graft containing powder and liquid were prepared according to the manufacturer's instructions. The PRF layer was removed from the tube and compressed between saline soaked sterile gauze to form a PRF membrane to be sutured. The socket was filled up with CPC till the bone crest and PRF membrane sutured at the soft tissue level using 5-0 resorbable suture [Figure 4]. Postoperative instructions were given. Antibiotics and analgesics were continued for 5 days. After the procedure, special care was taken to avoid trauma to the grafted site.
Figure 3: Atraumatic tooth extraction shows horizontal fracture

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Figure 4: Socket grafting with calcium phosphate cement and platelet rich fibrin

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The patient was kept on the routine maintenance phase of 1-week, 15 days, 1-month and 3 months. There were no postoperative complaints like pain, swelling or suppuration associated with the grafted area. Clinical examination was done after 4 months showed a well healed extraction socket. There was not much loss of alveolar ridge height or width [Figure 5]. An IOPA radiograph taken after 4 months revealed bone formation in the grafted area. The density of bone at extraction site was found to be comparable with the normal surrounding bone [Figure 6].
Figure 5: Healing after 4 months

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Figure 6: Four months postoperative intraoral periapical radiograph

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  Discussion Top

Earlier investigations have revealed that significant alveolar bone volume will be lost because of resorption after tooth extraction. Up to 50% of the alveolar ridge can be lost over 12 months, and approximately two-thirds of this reduction occurs within the first 3 months. Moreover, the loss in the width of the alveolar ridge is reported to be greater than the loss in height. [1],[4]

Although there has been increasing interest in immediate implant placement, it has been reported that such placement may be adversely affected by the presence of infection, lack of soft tissue closure and defects between the bone and implants. Therefore, delayed implant placement is still one of the main options for clinicians. When postextraction bone resorption has occurred, it may be difficult to place an implant in an anatomically appropriate location or to achieve a satisfactory esthetic outcome and long-term functional stability of the implant-supported restoration. Fresh extraction socket grafting has been investigated for alveolar ridge preservation. [1],[4] To avoid the need for a second surgical site, the efficacy of bone substitutes such as allografts, xenografts, and synthetic graft materials have been investigated. [1],[4],[5],[6] Some studies have also reported sealing extraction sockets with connective tissue.

Calcium phosphate biomaterials, such as HA ceramic, calcium phosphate ceramics and CPC have been widely used as bone substitute materials in clinical applications due to their good biocompatibility and osteoconduction. CPC can be molded or injected to form a scaffold that intimately conforms to the shape of complex bone defects. In 1986, a typical CPC composed of a powdered mixture of tetracalcium phosphate and dicalcium phosphate anhydrous was first reported by Brown and Chow.

The CPC powder can be mixed with aqueous liquid to form a paste that would set in situ and form HA a final product, as the main constituent part of the mineral phase of bone. Due to its high biocompatibility, osteoconduction and bone replacement capabilities, CPC was approved in 1996 by the Food and Drug Administration to repair craniofacial defects. Since then, several other CPC and injectable cements have been developed. CPC has been extensively used to treat intrabony defects. However, very few studies report the use of CPC in socket grafting.

The present novel case report was conducted to test a synthetic graft material, CPC, in combination with PRF for postextraction socket grafting with the intention of delayed dental implant placement. The PRF was used as a membrane with the sole intention of improving the soft tissue contour. Furthermore, this case report focused solely on the soft tissue and radiographic changes after the socket grafting. Further studies are needed to measure the exact dimensional changes and evaluate the histological changes associated with the procedure. Studies can also be undertaken to compare the effectiveness of different bone substitutes with CPC.

  Conclusion Top

The present case report demonstrates that CPC could be used along with PRF as a synthetic biomaterial for postextraction ridge preservation. CPC does not interfere with clinical healing process when used in fresh extraction socket with the intact bony wall. Use of PRF membrane helps to achieve primary closure of extraction socket that prevents dislodgement of CPC from the extraction socket. Use of PRF membrane also provides necessary growth factors, which is beneficial for the healing process. However, further studies are needed to evaluate the efficacy of CPC in comparison to other bone graft materials in postextraction ridge preservation.

  References Top

Vittorini Orgeas G, Clementini M, De Risi V, de Sanctis M. Surgical techniques for alveolar socket preservation: A systematic review. Int J Oral Maxillofac Implants 2013;28:1049-61.  Back to cited text no. 1
Aimetti M, Romano F, Griga FB, Godio L. Clinical and histologic healing of human extraction sockets filled with calcium sulfate. Int J Oral Maxillofac Implants 2009;24:902-9.  Back to cited text no. 2
Shakibaie MB. Comparison of the effectiveness of two different bone substitute materials for socket preservation after tooth extraction: A controlled clinical study. Int J Periodontics Restorative Dent 2013;33:223-8.  Back to cited text no. 3
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
Horowitz R, Holtzclaw D, Rosen PS. A review on alveolar ridge preservation following tooth extraction. J Evid Based Dent Pract 2012;12:149-60.  Back to cited text no. 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. 6
Jung RE, Philipp A, Annen BM, Signorelli L, Thoma DS, Hämmerle CH, et al. Radiographic evaluation of different techniques for ridge preservation after tooth extraction: A randomized controlled clinical trial. J Clin Periodontol 2013;40:90-8.  Back to cited text no. 7
Clozza E, Biasotto M, Cavalli F, Moimas L, Di Lenarda R. Three-dimensional evaluation of bone changes following ridge preservation procedures. Int J Oral Maxillofac Implants 2012;27:770-5.  Back to cited text no. 8
Rajesh JB, Nandakumar K, Varma HK, Komath M. Calcium phosphate cement as a "barrier-graft" for the treatment of human periodontal intraosseous defects. Indian J Dent Res 2009;20:471-9.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
Simon BI, Gupta P, Tajbakhsh S. Quantitative evaluation of extraction socket healing following the use of autologous platelet-rich fibrin matrix in humans. Int J Periodontics Restorative Dent 2011;31:285-95.  Back to cited text no. 10
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part III: Leucocyte activation: A new feature for platelet concentrates? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e51-5.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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