Journal of Advanced Biochemistry

Use of PRP in severe bone defects and immediate loading implantology

Maurizio Serafini1*ORCID ID, Sara Di Teodoro2, Luisa Romondio2

1Private Practitioner. Chieti Italy.

2Collaborators, School Of Medicine, University Of “Aldo Moro”Bari-Italy,- Via Caduti Sul Lavoro, 37 66100 CHIETI, Abruzzo, Italy

*Corresponding Author: Serafini M, Via Caduti sul Lavoro, 37-66100 CHIETI-Italy. E-mail: [email protected].

Citation: Serafini M, Teodoro Di S, Romondio L. Use of PRP in severe bone defects and immediate loading implantology. Journal of Advanced Biochemistry. 2021;1(1):1-11.

Copyright: © 2021 Serafini M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received On: January 26th,2021     Accepted On: February 23rd,2021    Published On: March 8th,2021

Abstract

Aim of the study is to demonstrate the influence of using growth factors such as Platelet Derived Growth Factor (PDGF) in bone regeneration when treating advanced implantology cases. In this case report a difficult case of maxillary and mandibular bone loss was successfully rehabilitated using Platelet-Rich- Plasma (PRP) mixed with alloplastic material.

Keywords: Computerized implant Software, growth factors, dental implants, oral rehabilitation, platelet rich plasma, Biologic Membrane, Scaffold, One to one implant.

Case report

A 41-years-old female patient in good health and good clinical records presented for restorative consultation regarding her failing dentition. The patient complaint was lack of comfort and self-confidence and unwillingness to smile. Clinical examination during the first visit revealed signs of chronic periodontal disease, due to long-term accumulation of bacterial plaque and calculus in both arches, swollen and bloody gums, dehiscence and grade 3 dental mobility with incongruous prosthesis, missing teeth and residual root elements Figures 1-5.SNI-JAB-21-01-F1.jpgSNI-JAB-21-01-F2.jpg

          Figure 1: Chronic periodontal disease                      Figure 2: Clinical examination


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Figure 3: Residual root elements                                                                                          Figure 4: Plaque and calculus accumulation

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Figure 5: Poor oral hygiene                                                                                              Figure 6: orthopantomography

Orthopantomography and dental scan Figures 6-10 show severe vertical and horizontal bone resorption. The upper right posterior elements are extruded from the alveoli, dental elements 2.4-2.5-2.6 are missing.

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Figure 7: Dental scan                                                                                                                                        Figure 8: Dental scan

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Figure 9: Dental scan                                                                                                                                               Figure 10: Dental scan

Surgical phase

Surgery was performed in two phases, firstly the upper arch and after two months, the lower one. Before surgery, sessions of professional dental cleanings were scheduled to restore periodontal health.

Upper arch

The patient was premedicated with Clavulanic Acid and Amoxicillin (1 gr. one every 12 hours for a week) and an oral antibacterial rinse (2% chlorhexidine mouthwash three times a day for 30 seconds). All dental elements were extracted and a bilateral crestal sinus lift was performed, in addiction on the left side was also necessary a split-crest because of reduced bone thickness. During the procedure, eight 3.5 ml venous blood samples were collected and centrifuged at 1000 rpm for 20  minutes, approximately 1.5-2 ml of PRP was obtained from each tube Figure 11, 12.

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      Figure 11: Blood samples                                                                                                                                    Figure 12: PRP

On the left side, upon avulsion of the dental elements, the post extraction surgical sites highlight the large horizontal bone loss and a large dehiscence in region 2.3 about 13 mm Figure 13, 14.

        SNI-JAB-21-01-F13.jpgSNI-JAB-21-01-F14.jpg

                       Figure 13: Region 2.3                                                                                                                                                 Figure 14: Large bone resorption

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Figure 15: Implants positioned                                        Figure 16: Implants positioned

The insertion of 3 implants in sites 2.1-2.2-2.6 with the immediate loading and split-Crest with crestal sinus lift and two additional submerged implants are shown in Figure 15, 16. Sinus lift was performed with endosinusal injection of liquid PRP and fibrin sponges, and the large dehiscence in region 2.3 was filled with PRP mixed with Calcium Gluconate, which induces platelet degranulation, in order to obtain Plasma-Rich in fibrin (PRF) mixed with animal bone Figures 17-19.

SNI-JAB-21-01-F17.jpgSNI-JAB-21-01-F18.jpg

         Figure 17:  Animal bone mixed with PRP                                                Figure 18: PRP mixed with calcium gluconate

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Figure 19: PRP mixed with animal bone in region 2.3                      Figure 20: Post extractive space grafted

On the right side, all dental and root elements were removed and post – extraction implants loaded immediately were placed. The alveolar spaces were grafted with bone graft mixed with PRP Figure 20. Suture and temporary prosthesis and X-Ray control are shown in Figures 21-23.

SNI-JAB-21-01-F21.jpgSNI-JAB-21-01-F22.jpg

Figure 21: Sutures                                                                                                                                                                        Figure 22: Temporary prosthesis

SNI-JAB-21-01-F23.jpg

           Figure 23: Post surgery x-ray

Lower arch

Two months later the second phase surgery was performed on the jaw. Extraction of 6 hopeless dental elements and 6 post- extractive implants with immediate load were completed and provisional prosthesis was inserted Figures 24-31.

SNI-JAB-21-01-F24.jpgSNI-JAB-21-01-F25.jpg

          Figure 24: Dental scan                                                                                                                                                 Figure 25: Dental scan

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Figure 26: Dental scan                                                                                                                                                      Figure 27: Lower arch

SNI-JAB-21-01-F2.pngSNI-JAB-21-01-F29.png

Figure 28: Implants positioned                                                                                                                               Figure 29: Implants positioned

SNI-JAB-21-01-F30.pngSNI-JAB-21-01-F31.png

Figure 30: Post-operative x-ray                                                                                                                            Figure 31: Provisional prosthesis

Six Months after the first surgery and after CT check Figure 32 one-piece implant was inserted in region 2.3. Venous blood sample was collected and centrifuged to obtain PRP Figure 33, a mucoperiosteal flap was raised and the implant was inserted and covered with PRP. With the flap detachment we noticed that a few spires of implant positioned in region 2.4 were uncovered Figure 34 so we grafted it with PRP mixed with animal bone Figure 35. Structure Figure 36 and post-surgical x-ray control Figure 37 followed.

SNI-JAB-21-01-F32.pngSNI-JAB-21-01-F33.png

Figure 32: Dental scan                                                                                                                                                                               Figure33: Blood sample

SNI-JAB-21-01-F34.pngSNI-JAB-21-01-F35.png

Figure 34: Implant 2.4                                                                                                                                    Figure 35: Graft

SNI-JAB-21-01-F36.pngSNI-JAB-21-01-F37.png

Figure 36: Suture                                                                                                                                                                  Figure 37: Post-surgical x-ray

After diagnostic wax-up, a few adjustments were completed and final prosthesis was cemented on the lower arch Figure 36, 37.

SNI-JAB-21-01-F38.pngSNI-JAB-21-01-F39.jpg

          Figure 38: Diagnostic wax-up                                                                                                                                       Figure 39: Oral view of diagnostic wax-up

SNI-JAB-21-01-F41.jpgSNI-JAB-21-01-F40.jpg

Figure 40: Final Lower arch Prosthesis                                        Figure 41: Healing of upper arch soft tissue

Diagnostic wax-up Figure 39 was then made for the upper arch and then definitive prosthesis in zirconia- ceramic Figures 42-48.

SNI-JAB-21-01-F42.jpgSNI-JAB-21-01-F43.png

           Figure 42: Diagnostic wax-up                                                                                                                                  Figure 43: Definitive prosthesis in zirconia-ceramic

SNI-JAB-21-01-F44.pngSNI-JAB-21-01-F45.jpg

Figure 44: Definitive prosthesis cemented                                           Figure 45: Definitive prosthesis cemented

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  Figure 46-47: Lateral view

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Figure 48: Seven-year radiographic control

Discussion

Modern dentistry raises complex clinical challenges that can be solved through advanced implantology, such as those cases once not suitable for implant rehabilitation, and allows patients to get rid of discomfort due to a removable partial or total denture or prosthesis screwed on few implants. The term ‘advanced implantology’ indicates surgical procedures performed according to well-defined protocols, in order to solve anatomical situations that, due to lack of bone, reabsorption caused by atrophy, inflammatory noxae, etc., do not allow implants placement and constitute a contraindication [1-7]. Thanks to CT scan and its derived programs, a 3D model can be elaborate to reproduce all the fundamental parameters such as thickness, height and bone density. This allows the clinician to visually understand bone loss and deal with complex cases in the best way with competence and modern regeneration techniques, using growth factors in combination with alloplastic materials or auto-homo-heterologous bone grafting, reducing healing time with high and durable success rate. In-vitro and in-vivo studies have proven that the use of PRP and PRF, allows a faster healing and mineralization of the graft thanks to growth factors such as PDGF secreted by platelets trough a degranulation process [2-4], which is a great autologous adjuvant for both the clinician and the patient. Since the first introduction of the use of PRP in augmentation techniques [5,6], the benefits shown in bone regeneration have been proved. Further studies need to be complete to fully understand growth factors use and their application in modern dentistry.

References

  1. Shah R, Thomas R, Mehta DS. An Update on the Protocols and Biologic Actions of Platelet Rich Fibrin in Dentistry. The European journal of prosthodontics and restorative dentistry. 2017 Jun 1;25(2):64-72.
  2. Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: Growth factor enhancement for bone grafts. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 1998 Jun 1;85(6):638-46.
  3. Kim J, Ha Y, Kang NH. Effects of growth factors from platelet-rich fibrin on the bone regeneration. Journal of Craniofacial Surgery. 2017 Jun 1;28(4):860-5.
  4. Roberts AB, Sporn MB, Assoian RK, Smith JM, Roche NS, Wakefield LM, Heine UI, Liotta LA, Falanga V, Kehrl JH. Transforming growth factor type beta: rapid induction of fibrosis and angiogenesis in vivo and stimulation of collagen formation in vitro. Proceedings of the National Academy of Sciences. 1986 Jun 1;83(12):4167-71.
  5. Marx RE. Platelet-rich plasma: evidence to support its use. Journal of oral and maxillofacial surgery. 2004 Apr 1;62(4):489-96.
  6. Marx RE, Garg AK. Dental and craniofacial applications of platelet-rich plasma.
  7. Agrawal AA. Evolution, current status and advances in application of platelet concentrate in periodontics and implantology. World journal of clinical cases. 2017 May 16;5(5):159. 

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