Assessment of the Effect of Phototherapy and PRP on the Immediate Implants: An Original Research

ABSTRACT

Immediate implants have been gaining popularity in recent times. There are many adjuvant techniques that are followed before implant placement, which have recently shown hopeful results. For this reason, the current comparative study analyzes the effectiveness of platelet-rich plasma (PRP) and photofunctionalization (PF) at a tertiary care dental hospital. In the current clinical trial, 30 subjects were grouped equally to receive immediate dental implants, with one group in which pretreatment of the extraction site was done with the auto-PRP and PF, while the control group received no pretreatment. For 12 months after the placement of the implant, the subjects were observed for alterations in the parameters. The variables analyzed were survival, esthetics, biological integration, and finally the success of the implants in each group. Values were noted and compared using the appropriate statistical tools, while keeping the level of significance at P < 0.05. For the variables of esthetics and survival, no substantial differences were observed in the PRP and PF groups. There was no difference between these experimental groups and the control group. However, there were significant differences for the biological variable as there was more marginal bone loss in the experimental groups. On the whole, the success was greater for the experimental groups than the control group, though not significant. The pretreatment protocols using PRP and PF have shown to improve some characteristics of the immediate implants in the anterior regions. However, further studies are suggested.

INTRODUCTION

Dental implants have been used for edentulous area restoration and have been shown to produce successful results.[1,2] Research has shown that after tooth extraction or tooth loss for other reasons, the alveolar process experiences volume loss and significant resorption.[3-6] The success of implants in an immediate extraction area is debatable and lacks sufficient evidence.[7-9] Premature implant failure is caused by scarce osseointegration and requires “bioactive surface treatment,” which may augment osseointegration after placement of the implant and validate an established bone-to-implant relationship.[10]

There are numerous novel therapies that support patient recovery in challenging clinical settings with anticipated success rate.[11] These therapies include ion beam–assisted deposition, sputter coating, pulsed laser deposition, electrostatic spray deposition, photofunctionalization (PF), and platelet-rich plasma (PRP).[11]

Implants are exposed to ultraviolet (UV) light during the PF process. In the previous studies, PF exposure of the implant surface was described to result in greater implant-to-bone integration. This method is economical, needs no special training and equipment, simple to learn, yet very efficient in the implant outcomes. The light treatment brings about an increase in surface energy and wettability and increases osteoconductivity, while lowering the degree of surface.[12-18] Studies reported that pretreatment of an adjuvant with the PF has shown promising results in the implants at various anatomical locations (posterior vs. anterior) and also in various situations (immediate vs. delayed).[17–20]

PRP improves socket healing through boosting blood supply in the socket area in the first 3 weeks of tooth extraction. However, there is still no agreement on the regenerative capacity of the PRP in the dental community due to differences in experimental design and controls.[21-24]

As regards the use of PF dental implants or PRP pretreatment methods for implant insertion, controlled clinical trials are absent in evidence-based dentistry. For this reason, the current comparative study analyzes the effectiveness of PRP and PF for immediate implants at a tertiary care dental hospital.

MATERIALS AND METHODS

The current randomized clinical trial study was conducted in the Department of Prosthodontics at a tertiary dental hospital. The institutional ethics clearance was obtained. The study’s design was explained to all the subjects. Verbal as well as the written consent was taken from all the subjects. “Consolidated Standards of eporting Trials (CONSORT)” reporting guideline was used to prepare the manuscript.[25]

The study subjects were selected from the patients who visited the department for restoration of the lost anterior teeth. Only male subjects who needed replacement of the central incisor (right or left) were considered for the study. The marginal bone loss of the extraction site was taken as the baseline for the selection of subjects and grouping. A mean bone loss of 2.2 ± 1.4 (1.95–3.6) mm was considered for all the selected subjects. No greater variations were allowed between the groups.

Inclusion criteria

• The central incisor tooth being extracted must have >4 mm of bone from the radicular apex.

• There must be >1.5 mm of bone between a dental implant and the teeth next to it, as well as anteriorly, and 0.5 mm of bone between the implant and the palatal side.

• Existence of healthy periodontal tissues in the lateral and mesial teeth

• Teeth that had to receive immediate implants after the extraction

• Central incisor teeth of both the right and/or left side

• Adult male participants

Exclusion criteria

• Two adjacent teeth with uncontrolled periodontal disease, caries, or radiographic or clinical symptoms of infection

• Systemic illnesses or metabolic conditions that may affect research; pregnant women or nursing mothers

• Smokes now or last gave up less than a year ago

• Nonfunctional habits

• Current radiation, chemotherapy, or medications interfering with recovery

After the selection of the subjects was finalized, a total of 30 participants were randomly divided equally into

• Group PRP,

• Group PF, and

• Control group.

The implantation was done using the Touareg-OS (ADIN Dental Implant System, Afula, Israel). Pretreatment with the PF and PRP was done for the extraction sites of the experimental groups. Following the manufacturer’s instructions, the implants were loaded immediately after extraction. The preoperative and post-op radiographs were procured. All the measurements regarding the bone conditions and the height were measured using the digital Intra Oral Periapical images (IOPA) images. Prophylactic antibiotics were given for all the subjects, considering specific antibiotic drug allergies of the subjects.

For PF, implants were placed right away in the extraction socket after 20 min of chairside exposure to UV radiation with a wavelength of 255 nm in an UV chamber.[12,13]

About 30 ml of the subject’s venous blood was taken and centrifuged for 10 min at 3500 rpm in a vacutainer for the PRP graft procedure. This caused PRP to separate at the vacutainer’s bottom. When PRP was created, 10% calcium chloride was used to activate it. After the implant had been thoroughly hydrated with the PRP solution, it was inserted into the osteotomy site.

Subjects were given postoperative instructions that included using an ice pack, diet restrictions, and twice-daily mouthwash rinses with 0.2% chlorhexidine gluconate. The prosthesis was loaded after 6 months.

The methodology used in the study of Shah et al.[1] was followed in this study for calibration of the four different parameters. Results were measured during the follow-up process at predetermined intervals of 1, 3, 6, and 12 months. The researchers were blinded to the calibration of the parameters considered in this study. The parameters assessed were

• Bone loss (marginal),

• Implant stability,

• At 6 months, pink and white esthetic scores (esthetics),[26] and

• At 1 year, survival and success of the implants.

Descriptive statistics were used to assess the findings and make comparisons between the groups. Quantitative data were summarized as mean ± standard deviation, while categorical data were presented as proportions and percentage. One-way analysis of variance (ANOVA) was used to examine marginal bone loss, implant stability, and esthetic outcomes; repeated-measures ANOVA was used to analyze intragroup changes over time with baseline and after. IBM Corporation’s Statistical Package for Social Sciences (SPSS) was used to conduct statistical analysis (version 25.0 of IBM SPSS Statistics for Windows; IBM Corp., Armonk, NY, USA). The chosen level of significance was P < 0.05.

RESULTS

• Demographics:

The observed mean age of the subjects in the present study was 21 ± 6.9 years. All men had the central incisor to be replaced with immediate implants. The various parameters observed in the present study are presented in Tables 1 and 2.

Table 1.

Comparison of stability, marginal bone loss, and esthetics among the groups

	PF	Control	PRP	P
Marginal bone loss
1 month	1.21±0.20	0.85±0.01	0.85±0.18	<0.001
3 months	1.27±0.22	1.13±0.03	1.13±0.01	0.006
6 months	1.49±0.02	1.43±0.19	1.39±0.22	0.116
12 months	1.68±0.23	1.66±0.19	1.65±0.02	0.562
P (within the group)	<0.001	<0.001	<0.001
Stability
1 month	53.47±3.11	48.55±2.78	51.35±1.52	<0.001
3 months	65.05±2.69	53.73±2.6	61.85±1.92	<0.001
6 months	69.73±1.37	61.19±1.48	68.05±1.34	<0.001
12 months	72.18±1.48	65.19±1.86	71.07±1.24	<0.001
P (within the group)	<0.001	<0.001	<0.001
Esthetics (at 6 m)	13.35±0.77	13.28±0.85	13.18±0.80	0.785

PF=photofunctionalization, PRP=platelet-rich plasma

Table 2.

Comparison of implant survival and success among the subjects

	PF	Control	PRP
Success	9	9	10
Failure	1	1	0
Percentage	90	90	100

PF=photofunctionalization, PRP=platelet-rich plasma

• Marginal bone loss:

At 1 month, but not at 3, 6, or 12 months, the subjects demonstrated a statistically substantial alteration in the mean marginal bone loss among the PF group, the control group, and the PRP group. The bone loss was greater for the PF group compared to others. Each follow-up significantly increased the mean marginal bone loss in each group. The range of 1.75–1.78 mm in the mean marginal bone loss is not clinically significant [Table 1].

• Stability:

Insignificant variance in implant stability was seen in the first few weeks of placement. At 1, 3, 6, and 12 months, PF and PRP groups presented significantly improved implant stability in comparison to the controls (P < 0.001), and this improvement was also statistically significant when compared within groups (P < 0.001). Maximum stability was exhibited by the PF group [Table 1].

• Esthetics :

The difference in esthetic score at the end of 6 months among groups was statistically not significant [Table 1].

• Success and survival:

The control group and the PRP group had a better success and survival rate (100%) than the PF group. The failed implant may have been due to the greater bone loss that was associated with PF [Table 2].

DISCUSSION

In this study, participants with implants treated with PF or PRP graft had considerably higher implant stability than the subjects without any pretreatment. Between these two adjuvant techniques, there was comparable bone loss to that of controls in the long term. In PF, titanium dioxide is modified on the surface, resulting in bioactivity and osseointegration. Although UV-treated titanium surfaces are superhydrophilic and electropositive, which results in increased bone-to-implant contact,[13,14,16] this study observed no variance between the PF or PRP group and the control group in terms of mean marginal bone loss. Also, the marginal bone loss was within the set range.

Compared to the control group, there was lower marginal bone loss in the PRP group. Similar observations were made in the study of Thor et al.,[27] where they observed that PRP helped in reduction of loss of the bone. This property of PRP can be attributed to its capacity to enhance the local bone deposition as it carries the growth factors like vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), and transforming growth factor (TGF). These growth factors bring about migration of the cells that deposit the bone.

In the study of Kitajima and Ogawa,[28] it was found that pretreatment of implants with PF is contributes to the greater success of the implants as they exhibit better stability than those implants that have no phototherapy. This pretreatment will allow the implant to achieve a good stability in the first few weeks of implant placement. This initial stability has been associated with a long-term success.[26-30] No significant change in stability of the implants that are phototreated are also available.[31,32]

In the study of Marx et al.,[33] the application of PRP enhanced the deposition of the bone at the site of the implant. As described above, the PRP brings chemicals which attract the cells that deposit bone, while preventing bone loss at the same time. In previous studies, the PRP has shown success for the endosseous implants.[32]

When PRP was applied to implant sites in the front maxilla, implant stability was found to be much higher than when PRP was not applied, according to Thor et al.,[27] but there were no differences for implants placed in the posterior areas. They came to the conclusion that while variations could not be linked to PRP, they might be the result of the various types of bone used as a graft.

The other parameter considered for this study was esthetics. Quantification of this parameter is objective. This parameter depends on the volume of the gingiva. No significant variance was seen for the groups considered at the end of 6 months as well as at the end of a year. In previous studies, the papillary index was used; however, in this study, the pink and white esthetic scores were used. Thus, the present study differs from the previous studies. This is easy to quantify and has less objective bias.

The development of a superhydrophilic (contact angle <5°) surface following PF treatment, which leads to higher bone-to-implant contact (2–3 times) compared to untreated implants, is thought to be the cause of PF’s success. In comparison to surfaces without any preparation, this superhydrophilic surface causes a higher adhesion of osteogenic cells to implants. Different growth factors are thought to be responsible for the success and survival rates of PRP grafts. The protein stratum, which covers the implant surface and enables initial communication of the neighboring tissues with the implant, is made up of a fibrin mesh and growth factors. Additionally, it improves bone matrix deposition, cellular proliferation, attachment, and differentiation.[22] However, we did not find a higher survival rate in adjuvant therapy participants. The only failure may have been due to the patient-related factors, which have to be evaluated at further follow-up.

A null hypothesis was rejected since the parameters showed a significant variation compared to the control group and the treated groups performed better than the untreated implant group.

Small sample size, lesser follow-up period, and inability to measure lingual and buccal bone due to limitations of radiography technology used to access the bone loss are some of the study’s weaknesses. Additionally, the PES/WSE index is employed in relation to facial esthetics. Therefore, in patients with a low lip line, this indicator is far less important. Future research with a large sample size, a longer follow-up period, and the use of advanced imaging may be able to address the restrictions of the current research and aid in generalization of the results.

CONCLUSION

In comparison to standard tapered root implants without any preparation, commercial dental implants with PF and PRP surface treatments may exhibit improved statistically significant results when placed immediately in the anterior maxillary region, although clinical significance is lacking. Furthermore, the advantages of these methods are that these are economical and can be performed chairside.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.