Abstract
Background:
Autogenous particulate dentin (APD) has been used as a bone graft material for bone augmentation, but the specifics of its effect on alveolar ridge preservation (ARP) are uncertain. The aim of this study was to investigate the clinical and histomorphometric performance of APD compared with blood clot healing or other grafted materials in ARP.
Methods:
MEDLINE, Embase, Web of Science, Scopus and the Cochrane Library and citation databases were searched until August 2, 2023 to identify randomized controlled trials that employed APD for ARP. Two independent meta-analyses were performed based on the different control groups (Group I: blood clot healing; Group II: other grafted materials). Weighted or mean differences (MDs) and corresponding 95% confidence intervals (CIs) were calculated. The protocol was prospectively registered with PROSPERO (CRD42023409339).
Results:
A total of 238 records were identified, of which ten studies with 182 participants were included. The meta-analysis indicated that APD resulted in fewer changes in horizontal ridge width (Group I: MD = 1.61, 95% CI 0.76–2.46; Group II: MD = 1.28, 95% CI 1.08–1.48) and labial bone height (Group I: MD = 1.75, 95% CI 0.56–2.94; Group II: P < .05) than the control treatments. Regarding histomorphometry, APD yielded a satisfactory proportion of vital bone area (MD = 10.51, 95% CI 4.70–16.32) and residual material area (MD = −8.76, 95% CI −12.81 to −4.71) in Group II, while there was no significant difference in Group I. Moreover, none of the secondary outcomes were significantly differed between groups.
Conclusion:
Within this study limitations, APD effectively maintained the horizontal and vertical dimensions of the extraction sockets and exhibited favorable osteogenic properties and degradation capacity. Further well-designed randomized controlled trials with larger samples and longer follow-up periods are needed to evaluate whether APD is superior to other substitutes for ARP.
Keywords: Autogenous dentin, demineralization, extraction tooth, meta-analysis, socket preservation
1. Introduction
Following exodontia, the extraction socket undergoes a series of bone reconstruction processes, significantly reducing the ridge dimension.[1,2] According to a systematic review by Tan et al,[3] vertical and horizontal ridge absorption reached 11% to 22% and 29% to 63% respectively within 6 months of tooth loss. Moreover, the anatomical features of the bundle bone in the buccal/labial wall resulted in more absorption on that side than on the lingual/palatal side.[4,5] These undesirable events complicate the optimal positioning and degrade the long-term prognosis of dental implants.
To counteract post-extraction ridge resorption, alveolar ridge preservation (ARP) has been proposed and expanded in clinical practice.[6–8] As biological scaffolds, various bone-graft materials, including autografts, allografts, xenografts, and alloplasts, have shown effectiveness at minimizing the reduction in extraction socket dimensions.[9,10] However, several relevant limitations, including fast resorption, graft rejection, slow degradation, and insufficient osteogenesis, should be considered.[11,12]
Half a century ago, autogenous dentin was proposed as a substitute for autogenous bone based on its superior biocompatibility with alveolar bone.[13] Indeed, tooth-derived dentin shares similarities to alveolar bone in terms of physicochemical properties, such as calcium and phosphate concentrations as well as overall inorganic and organic composition.[14] These characteristics have driven the production of autogenous particulate dentin (APD) and gradually developed into a set of standard preparation protocols.
During the preparation of APD, extracted teeth undergo a series of critical processes, including the removal of unserviceable components (e.g., enamel, cementum, filling or restoration materials); the generation of primitive dentin particles by grinding machines; and phased cleaning, disinfection, and/or demineralization to gain APD that fulfills the application-specific standard[15,16] (Fig. 1).
Figure 1.
The process of APD for ARP. (A) Extracted tooth; (B) sectioned root; (C) the dentin transformer; (D) particulated dentin graft; (E) filling APD in the extraction socket. APD = autogenous particulate dentin, ARP = alveolar ridge preservation.
With the popularity of the procedural preparation of APD grafts, many scholars have attempted to utilize APD in ARP surgery and have yielded encouraging preliminary results in animal and human trials.[17–20] Nevertheless, to our knowledge, the clinical and histomorphological outcomes of APD in ARP have rarely been statistically evaluated in systematic reviews.
Therefore, this study aimed to comprehensively investigate the effects of APD for ARP in comparison with spontaneous healing/blood clot healing (BCH) or other grafted materials (OGM) based on the available randomized controlled trials (RCTs).
2. Materials and methods
2.1. Protocol and registration
The protocol was elaborated and registered in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42023409339. This systematic review was performed by following Preferred Reporting Items for Systematic Reviews.[21]
2.2. Focal question and eligibility criteria
The following central research question was developed: In patients with extraction sockets and a requirement for ARP, what are the clinical and histomorphometric effects of APD compared with BCH or OGM?
Eligibility criteria were applied according to the PICOS framework: population (P), systemically healthy patients needing ARP after tooth extraction; intervention (I), ARP employing an APD graft; comparison (C), ARP employing BCH or OGM; outcomes (O), primary (change in horizontal ridge width, change in labial bone height, and histomorphometry) and secondary (primary implant stability and postoperative complications) outcomes; study design (S), RCTs only.
Studies were excluded if they met at least one of the following criteria: no primary and secondary outcomes of interest. Published in a language other than English. Inappropriate study design (i.e., protocols, reviews, case [series] reports, case-control studies, non-RCTs, preclinical studies, and conference papers). Non-particulated dentin grafts for ARP. Less than 1 month follow-up time.
2.3. Search strategy
An electronic retrieval on MEDLINE (via PubMed), Embase, Web of Science, Scopus, and Cochrane Library was conducted through the specified search strategy shown in Table 1. Databases were searched from the date of their inception to August 2, 2023. Moreover, the authors independently searched the citations of critical articles to locate any potentially eligible studies.
Table 1.
The search strategy used for each database.
| Database | Search strategy | Records |
|---|---|---|
| MEDLINE | ((Extraction socket[MeSH Terms]) OR (((((socket preservation[Title/Abstract]) OR (socket preservation[Title/Abstract])) OR (ridge augmentation[Title/Abstract])) OR (bone regeneration[Title/Abstract])) OR (ridge reconstruction[Title/Abstract]))) AND ((extraction socket[MeSH Terms]) OR (((((autogenous tooth[Title/Abstract]) OR (autogenous dentin[Title/Abstract])) OR (autogenous root[Title/Abstract])) OR (autogenous root graft[Title/Abstract])) OR (autogenous dentin matrix[Title/Abstract]))) Filters: Randomized Controlled Trial, Humans | 35 |
| Embase | (“Autogenous tooth” OR “autogenous dentin” OR “autogenous root” OR “autogenous root graft” OR “autogenous dentin matrix”) AND (“socket preservation” OR “bone augmentation”/exp OR “bone augmentation” OR “ridge augmentation” OR “bone regeneration”/exp OR “bone regeneration” OR “ridge reconstruction”) AND (“clinical trial”/exp OR “clinical trial” OR “human”/exp OR “human”) | 53 |
| Web of Science | (“Autogenous tooth” OR “autogenous dentin” OR “autogenous root” OR “autogenous root graft” OR “autogenous dentin matrix”) AND (“socket preservation” OR “bone augmentation” OR “ridge augmentation” OR “bone regeneration” OR “ridge reconstruction”) AND (“clinical trial” OR “human”) | 65 |
| Scopus | “Autogenous tooth” OR “autogenous dentin” OR “autogenous root” OR “autogenous root graft” OR “autogenous dentin matrix” AND “socket preservation” OR “bone augmentation” OR “ridge augmentation” OR “bone regeneration” OR “ridge reconstruction” AND “clinical trial” OR “human” | 61 |
| Cochrane Library | (“Autogenous tooth” OR “autogenous dentin” OR “autogenous root” OR “autogenous root graft” OR “autogenous dentin matrix”) AND (“socket preservation” OR “bone augmentation” OR “ridge augmentation” OR “bone regeneration” OR “ridge reconstruction”) in Title Abstract Keyword | 24 |
2.4. Study selection and data extraction
After the initial publications were retrieved, 2 independent reviewers (Z.R.M and L.J.X) performed sequential screening and deleted repeated studies, read the title and abstract, reviewed the full text, and determined their eligibility for inclusion. During the title and abstract screening phase, GraphPad (https://www.graphpad.com/quickcalcs/kappa1.cfm) was used online to assess the decision homogeneity, yielding satisfying agreement between reviews (Cohen kappa = 0.83).
The following data were recorded: author(s), year of publication, study design, number of patients/sockets, male/female, age, grafted sites, grafted materials, number of implants, reentry period, follow-up, and outcomes. After that, unmatched information was cross-checked and verified to exclude literature that did not meet inclusion criteria.
2.5. Risk of bias for the included studies
Two adjudicators (Y.Z.F and X.X) independently assessed the risk of bias for RCTs through the Cochrane Collaboration tool,[22] which consists of 7 domains (sequence generation, allocation concealment, blinding of participants, and investigators, blinding of outcome assessment, incomplete data outcome, selective outcome reporting, and potential sources of bias). These areas are graded as “high risk,” “low risk” or “unclear.” Inconsistent results were resolved by reexamining the full texts.
2.6. Statistical analysis
The relevant results were analyzed, and forest plots were drawn using Review Manager 5.4. For continuous variables, the mean and standard deviation of each indicator were pooled and analyzed with mean differences (MDs). The 95% confidence intervals (CIs) were calculated, and a P value < .05 was considered to indicate statistical significance. The levels of heterogeneity among studies were classified as follows: I2 < 50%, 50% to 75%, and > 75% represented low, moderate, and high heterogeneity, respectively.
2.7. Variables
For the comparability of results, several outcome variables were defined as follows:
Change in horizontal ridge width: The buccal-lingual radiological widths near the alveolar crest immediately after tooth extraction were defined as the baseline. Radiological widths were measured in the same way during the follow-up period after ARP. The difference between the baseline value and the final value was defined as the change in horizontal ridge width.
Change in labial bone height: Buccal/labial height was measured as the vertical distance from the buccal/labial ridge to the apical level. The change in this distance over the follow-up period was defined as the change in labial bone height.
Histomorphometry: Vital bone, residual grafts, and connective tissue areas were identified from multiple histological specimens to calculate the proportion of each tissue.
Primary implant stability: The implant stability quotient (ISQ), measured by an Osstell Mentor Resonance Frequency Analyzer, was used to assess the primary stability of implant placement (averaged between the buccolingual and mesiodistal directions) during reentry.
2.8. Subgroup analysis and parallel analysis
Considering the impact of the reentry time and type of OGM, a subgroup analysis was carried out. Following the above statistical strategies, 2 groups of parallel meta-analyses were performed based on the type of intervention:
Group I: The control group underwent BCH for extraction sockets. The intervention group received APD for extraction sockets.
Group II: The control group underwent OGM for extraction sockets. The intervention group received APD for extraction sockets.
2.9. Sensitivity analysis and assessment of the quality of evidence
The sensitivity analysis was conducted for each outcome measure by assessing the significance of the changes in results upon removing individual studies.
Based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach,[23] the evidence of outcomes from RCTs was initially considered to be high-quality. Once events of risk of bias, inconsistency, indirectness, imprecision, and publication bias were identified, the quality of evidence was progressively degraded to moderate, low, or very low.
3. Results
3.1. Study selection
The electronic search yielded a total of 238 publications. After 48 duplicates, 9 non-English publications, and 12 protocols were excluded, the remaining titles and abstracts were scrutinized, eliminating another 161 publications. Finally, 8 publications from the initial search and 5 publications identified by searching their citations were reviewed in full-text format. Three were excluded due to inappropriate control groups,[24–26] leaving 10 articles[27–36] eligible for inclusion in this systematic review (Fig. 2).
Figure 2.
PRISMA flowchart of the search process. PRISMA = Preferred Reporting Items for Systematic Reviews.
3.2. Study characteristics
Of the 10 RCTs included, 6 studies[27,28,30–33] belonged to Group I, and 3 studies[34–36] belonged to Group II. Only the study by Joshi et al,[29] which was designed with 3 comparison groups, belonging to both Group I and Group II (Table 2). In Group I, 79 patients with 180 extraction sockets underwent ARP and were followed up from 2 to 19 months. In Group II, 92 patients with 115 extraction sockets underwent ARP and were followed up from 4 to 18 months. A total of 5 studies[28,33–36] reported implant procedures, but only 3[28,35,36] reported implant numbers in detail.
Table 2.
Characteristics of the included studies.
| Author/yr of publication | Study design | No. patients/sockets | Male/female | Age (yr) | Grafted sites (number) | Grafted materials | No. implants | Reentry (mo) | Follow-up (mo) |
|---|---|---|---|---|---|---|---|---|---|
| Group I: APD versus BCH | |||||||||
| del Canto-Díaz et al 2019 | Split-mouth RCT | 6/12 | 3/3 | 47.6 ± 9.04 | NR | APD: Filled with 300–1200 µm mineralized APD, covering 15*20 mm collagen membrane | 2, 4 | ||
| BCH: Covered 15*20 mm collagen membrane | |||||||||
| Isola et al 2022 | Split-mouth RCT | 14/28 | 6/8 | 48.2 (37–62) | Maxillary anterior region | APD: Filled with mineralized APD, covering free gingival graft | APD: 14 | 4 | 19 |
| BCH: Covered free gingival graft | BCH: 14 | ||||||||
| Joshi et al 2016 | Split-mouth RCT | 15/45 | 9/6 | 35.6 ± 5.7 (28–45) | APD: Upper (10), lower (5) | APD: Filled with 300–500 µm partially demineralized APD, covering chorion membrane (Tissue Bank, India) | 4 | ||
| OGM: Upper (8), lower (7) | OGM: Filled with β-TCP alloplast (SyboGraf-T Plug, India), covering chorion membrane (Tissue Bank, India) | ||||||||
| BCH: Upper (8), lower (7) | BCH: Covered chorion membrane (Tissue Bank, India) | ||||||||
| Kuperschlag et al 2020 | Split-mouth RCT | 13/24 (APD: 13 sites; BCH: 11 sites) | 3/10 | 22.61 (18–27) | Third molar | APD: Filled with demineralized APD, absorbable hemostatic gelatin sponge | 3, 12 | ||
| BCH: Absorbable hemostatic gelatin sponge | |||||||||
| Mazzucchi et al 2022 | Split-mouth RCT | 10/20 | 4/6 | 32.7 ± 9.8 | Third molar | APD: Filled with 300–1200 µm demineralized APD | 3, 6 | ||
| BCH: No graft | |||||||||
| Sánchez-Labrador et al 2020 | Split-mouth RCT | 15/30 | 4/11 | 21.86 | Third molar | APD: Filled with 300–1200 µm demineralized APD, fibrin sponge (Gelatamp, Germany) | m | 3, 6 | |
| BCH: No graft | |||||||||
| Yüceer-Cetiner et al 2021 | RCT | APD: 3/20 | 4/5 | 31–62 | NR | APD: Filled with 300–1200 µm demineralized APD, covering resorbable membrane (Bio-Gide, Geistlich, Switzerland) | NR | 3 | |
| BCH: 3/16 | BCH: No graft | ||||||||
| Group II: APD versus OGM | |||||||||
| Jung et al 2018 | RCT | APD: 8/8 | APD: 4/4 | APD: 46.63 ± 18.12 | APD: Molar (7) | APD: Filled with demineralized APD, covering absorbable atelocollagen plug (Rapiplug, Korea) | NR | 4 | |
| OGM: 8/8 | OGM: 5/3 | OGM: 49.75 ± 17.21 | OGM: Premolar (3), molar (5) | OGM: Filled with Bio-Oss Collagen, covering absorbable atelocollagen plug (Rapiplug, Korea) | |||||
| Pang et al 2017 | RCT | APD: 15/21 | APD: 8/7 | APD: 58.53 ± 7.66 | APD: Maxilla (14), mandible (7) | APD: Filled with 300–800 µm demineralized APD | APD: 15 | 6 | |
| OGM: 9/12 | OGM: 3/6 | OGM: 60.56 ± 10.49 | OGM: Maxilla (7), mandible (5) | OGM: Filled with Bio-Oss (Geistlich, Switzerland) | OGM: 9 | ||||
| Santos et al 2021 | RCT | APD: 26/34 | APD: 15/11 | APD: 56.8 ± 12.3 | APD: Anterior (12), posterior (22) | APD: Filled with 250–1200 µm mineralized APD, covering resorbable barrier membrane (Bio-Gide, Geistlich, Switzerland) and free gingival graft | APD: 34 | 6 | 12, 18 |
| OGM: 26/32 | OGM: 16/10 | OGM: 61.5 ± 13.1 | OGM: Anterior (19), posterior (13) | OGM: Filled with Bio-Oss, covering resorbable barrier membrane (Bio-Gide, Geistlich, Switzerland) and free gingival graft | OGM: 32 | ||||
| Author/yr of publication | Primary outcomes | Secondary outcomes | |||||||
| Change in horizontal ridge width (mm) | Change in labial bone height (mm) | Histomorphometry (%) | Primary implant stability | Postoperative complications | |||||
| Group I: APD versus BCH | |||||||||
| del Canto-Díaz et al 2019 | APD: 2 mo: −0.17 ± 0.55; 4 mo: −0.46 ± 0.56 | APD: 2 mo: −0.14 ± 0.75; 4 mo: −0.16 ± 0.78 | NR | ||||||
| BCH: 2 mo: −1.11 ± 0.98; 4 mo: −1.91 ± 1.43 | BCH: 2 mo: −0.29 ± 2.24; 4 mo: −2.22 ± 2.07 | ||||||||
| Isola et al 2022 | APD: Vital bone: 34.23 ± 13.56; residual grafts: 30.22 ± 14.48; connective tissue: 27.36 ± 9.65 | NR | 0 | ||||||
| BCH: Vital bone: 30.22 ± 14.48; connective tissue: 29.23 ± 10.16 | |||||||||
| Joshi et al 2016 | APD: −0.15 ± 0.08 | APD: −0.28 ± 0.13 | 0 | ||||||
| OGM: −1.45 ± 0.40 | OGM: −1.72 ± 0.56 | ||||||||
| BCH: −2.29 ± 0.40 | BCH: −2.60 ± 0.88 | ||||||||
| Kuperschlag et al 2020 | 0 | ||||||||
| Mazzucchi et al 2022 | 0 | ||||||||
| Sánchez-Labrador et al 2020 | APD: 2 (1 abscess, 1 wound dehiscence) | ||||||||
| 3 (1 abscess, 1 wound dehiscence, 1 hematoma) | |||||||||
| Yüceer-Cetiner et al 2021 | APD: Vital bone: 19.32 ± 1.91; vessel: 14.76 ± 0.94; connective tissue: 41.57 ± 3.63 | 0 | |||||||
| BCH: Vital bone: 18.68 ± 1.18; vessel: 16.92 ± 0.66; connective tissue: 27.34 ± 2.06 | |||||||||
| Group II: APD versus OGM | |||||||||
| Jung et al 2018 | APD: −0.78 ± 0.41 | APD: Vital bone: 32.88 ± 14.48; residual grafts: 10.72 ± 9.83; connective tissue:56.40 ± 8.58 | APD: 2 (pain) | ||||||
| OGM: −1.68 ± 1.11 | OGM: Vital bone: 22.00 ± 11.01; residual grafts: 13.20 ± 9.79; connective tissue:64.80 ± 10.11 | OGM: 1 (swelling and pain) | |||||||
| Pang et al 2017 | APD: Vital bone: 31.24 ± 13.87; residual grafts: 8.95 ± 6.15; connective tissue:59.81 ± 15.50 | APD: 72.80 ± 10.81 | 0 | ||||||
| OGM: Vital bone: 35.00 ± 19.33; residual grafts: 17.08 ± 16.57; connective tissue:47.93 ± 24.46 | OGM: 70.0 ± 12.86 | ||||||||
| Santos et al 2021 | APD: Vital bone: 47.3 ± 14.8; residual grafts: 12.2 ± 7.7; connective tissue:40.5 ± 17.6 | APD: 77.1 ± 6.9 | 0 | ||||||
| OGM: Vital bone: 34.9 ± 13.2; residual grafts: 22.1 ± 10.9; connective tissue:42.9 ± 9.6 | OGM: 77.0 ± 5.9 | ||||||||
β-TCP = beta-tricalcium phosphate, APD = autogenous particulated dentin group, BCH = blood clot healing group, NR = not report, OGM = other grafted materials group, RCT = randomized controlled trial.
3.3. Quality assessment of the included studies
Among the 10 RCTs, those of Kuperschlag et al,[30] Sanchez-Labrador et al,[32] and Mazzucchi et al[31] did not provide information on the blinding of patients, and Santos et al[36] had difficulty with blinding during the intervention and follow-up period. These studies were therefore assessed as having a high risk of “performance bias” (Fig. 3).
Figure 3.
Results of risk of bias assessment for randomized controlled trials.
3.4. The outcomes of Group I
3.4.1. Change in horizontal ridge width.
Three datasets from 2 studies[27,29] were pooled and analyzed, with time ranges of 2 and 4 months after surgery. Data for this outcome were also reported by Isola et al[28]; however, the measurement method was not radiologically based and was therefore not pooled for analysis. The subgroup analysis indicated that the application of an APD graft in ARP mitigated the horizontal ridge width reduction compared to BCH (MD = 1.61; 95% CI 0.76–2.46; P = .0002, random-effect model) (Fig. 4A).
Figure 4.
Diagrams of meta-analysis for Group I (APD vs BCH). (A) Forest plot of horizontal ridge width change; (B) forest plot of labial bone height change; (C) forest plot of the proportion of vital bone area; (D) forest plot of the proportion of connective tissue area. APD = autogenous particulate dentin, BCH = blood clot healing.
3.4.2. Change in labial bone height.
Three datasets from 2 studies[27,29] were pooled. Subgroup analysis based on follow-up time showed that compared to BCH, APD contributed to the maintenance of labial bone height (MD = 1.75; 95% CI 0.56–2.94; P = .004, random-effect model). Moderate heterogeneity was detected (Chi square = 4.82, df = 2 [P = .09]; I2 = 58%) (Fig. 4B).
3.4.3. Histomorphometry.
The histomorphometric variables in the meta-analysis included the vital bone area and connective tissue area. Two studies[27,29] obtained tissue sections at 3 and 4 months, and the results of the meta-analysis showed that there was no significant difference between the 2 groups in the proportion of vital bone area (MD = 0.67; 95% CI −0.34 to 1.68; P = .19, fixed-effect model; Fig. 4C) or connective tissue area (MD = 6.59; 95% CI −9.17 to 22.34; P = .41, random-effect model; Fig. 4D).
3.4.4. Postoperative complications.
The presence or absence of postoperative complications was reported in 6 studies,[28–33] of which only the study by Sanchez-Labrador et al[32] observed complications: wound dehiscence and abscesses at the grafted sites in 2 patients and hematoma in 1 patient with BCH.
3.5. The outcomes of Group II
3.5.1. Change in horizontal ridge width.
Two studies[29,34] reported changes in ridge width after APD grafts compared with deproteinized bovine bone mineral (DBBM) or beta-tricalcium phosphate (β-TCP) grafts 4 months after surgery. Subgroup analysis based on the graft type showed that the APD grafts resulted in less ridge width absorption than the DBBM and β-TCP grafts (MD = 1.28; 95% CI 1.08–1.48; P < .00001, fixed-effect model). Heterogeneity was not detected (Chi square = 0.86, df = 1 [P = .35]; I2 = 0%) (Fig. 5A).
Figure 5.
Diagrams of meta-analysis for Group II (APD vs OGM). (A) Forest plot of horizontal ridge width change; (B) forest plot of the proportion of vital bone area; (C) forest plot of the proportion of residual grafted materials; (D) forest plot of the proportion of connective tissue area. (E) Forest plot of the primary implant stability. APD = autogenous particulate dentin, OGM = other grafted materials.
3.5.2. Change in labial bone height.
Only Joshi et al[29] reported changes in labial bone height between APD and β-TCP grafts. Descriptive analysis showed that the APD grafts resulted in less resorption of labial bone height than the β-TCP grafts (P < .05).
3.5.3. Histomorphometry.
Three studies[34–36] compared APD and DBBM grafts in terms of the percentages of tissue area occupied by vital bone, residual grafts, and connective tissue. In a subgroup analysis by reentry time, APD grafts resulted in the more vital bone area (MD = 10.51; 95% CI 4.70–16.32; P = .0004, fixed-effect model; Fig. 5B), less residual graft area (MD = −8.76; 95% CI −12.81 to −4.71; P < .0001, fixed-effect model; Fig. 5C), and similar connective tissue area (MD = −3.59; 95% CI −8.90 to 1.71; P = .18, fixed-effect model; Fig. 5D) compared with DBBM. Low heterogeneity was detected in vital bone (Chi square = 2.66, df = 2 [P = .26]; I2 = 25%) and connective tissue (Chi square = 3.02, df = 2 [P = .22]; I2 = 34%).
3.5.4. Primary implant stability.
Pang et al[35] and Santos et al[36] evaluated the primary implant stability through ISQ 6 months after surgery and found no significant difference between APD and DBBM (MD = 0.33; 95% CI −2.62 to 3.29; P = .82, fixed-effect model). Heterogeneity was not detected (Chi square = 0.25, df = 1 [P = .61]; I2 = 0%) (Fig. 5E).
3.5.5. Postoperative complications.
All 4 studies[29,34–36] reported on the presence or absence of postoperative complications. The only observed postoperative complications consisted of pain in 2 patients with APD and swelling and pain in 1 patient with DBBM, all in the study by Jung et al.[34]
3.6. Sensitivity analysis and quality of the evidence
The sensitivity analysis revealed no statistically significant difference, thereby indicating the robustness and stability of the obtained results.
In Groups I and II, moderate to high certainty values were received by GRADEpro assessment of changes in horizontal ridge width, labial ridge height, histomorphometry, and ISQ. The reason for the downgrade evidence is inconsistencies in the study design (Tables 3–5).
Table 3.
The quality of evidence for APD for ARP.
| Quality assessment | No of patients | Effect | Quality | Importance | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No of studies | Design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | APD graft | CBH | Relative (95% CI) | Absolute | ||
| Change in horizontal ridge width (follow-up 2–4 mo; measured with: Radiography; Better indicated by lower values) | ||||||||||||
| 2 | Randomized trials | No serious risk of bias | Serious* | No serious indirectness | No serious imprecision | None | 27 | 27 | – | MD 1.61 higher (0.76–2.46 higher) | ÅÅÅO MODERATE |
CRITICAL |
| Change in horizontal ridge width—2 mo (follow-up mean 2 mo; measured with: Radiography; Better indicated by lower values) | ||||||||||||
| 1 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 6 | 6 | – | MD 0.94 higher (0.04–1.84 higher) | ÅÅÅÅ HIGH |
CRITICAL |
| Change in horizontal ridge width—4 mo (follow-up mean 4 mo; measured with: Radiography; Better indicated by lower values) | ||||||||||||
| 2 | Randomized trials | No serious risk of bias | Serious† | No serious indirectness | No serious imprecision | None | 21 | 21 | – | MD 2.07 higher (1.67–2.48 higher) | ÅÅÅO MODERATE |
CRITICAL |
| Change in labial bone height (follow-up 2–4 mo; measured with: Radiography; Better indicated by lower values) | ||||||||||||
| 2 | Randomized trials | No serious risk of bias | Serious* | No serious indirectness | No serious imprecision | None | 27 | 27 | – | MD 1.75 higher (0.56–2.94 higher) | ÅÅÅO MODERATE |
CRITICAL |
| Change in labial bone height—2 mo (follow-up mean 2 mo; measured with: Radiography; Better indicated by lower values) | ||||||||||||
| 1 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 6 | 6 | – | MD 0.15 higher (1.74 lower to 2.04 higher) | ÅÅÅÅ HIGH |
CRITICAL |
| Change in labial bone height—4 mo (follow-up mean 4 mo; measured with: Radiography; Better indicated by lower values) | ||||||||||||
| 2 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 21 | 21 | – | MD 2.3 higher (1.87–2.74 higher) | ÅÅÅÅ HIGH |
CRITICAL |
| Vital bone (follow-up 2–4 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 2 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | Serious* | None | 34 | 30 | – | MD 0.67 higher (0.34 lower to 1.68 higher) | ÅÅÅO MODERATE |
CRITICAL |
| Vital bone—3 mo (follow-up mean 2 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 1 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision§ | None | 20 | 16 | – | MD 0.64 higher (0.38 lower to 1.66 higher) | ÅÅÅÅ HIGH |
CRITICAL |
| Vital bone—4 mo (follow-up mean 4 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 1 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | Serious§ | None | 14 | 14 | – | MD 4.01 higher (6.38 lower to 14.4 higher) | ÅÅÅO MODERATE |
CRITICAL |
| Connective tissue (follow-up 2–4 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 2 | Randomized trials | No serious risk of bias | Serious‡ | No serious indirectness | No serious imprecision | None | 34 | 30 | – | MD 6.59 higher (9.17 lower to 22.34 higher) | ÅÅÅO MODERATE |
CRITICAL |
| Connective tissue—3 mo (follow-up mean 2 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 1 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 20 | 16 | – | MD 14.23 higher (12.35–16.11 higher) | ÅÅÅÅ HIGH |
CRITICAL |
| Connective tissue—4 mo (follow-up mean 4 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 1 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 14 | 14 | – | MD 1.87 lower (9.21 lower to 5.47 higher) | ÅÅÅÅ HIGH |
CRITICAL |
Moderate heterogeneity.
Low heterogeneity.
High heterogeneity.
Wide confidence interval.
APD = autogenous particulate dentin, ARP = alveolar ridge preservation, CI = confidence intervals, MD = mean differences.
Table 5.
The quality of evidence for APD versus DBBM for ARP.
| Quality assessment | No of patients | Effect | Quality | Importance | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No of studies | Design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | APD | DBBM | Relative (95% CI) | Absolute | ||
| Vital bone (follow-up 4–6 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 3 | Randomized trials | No serious risk of bias | Serious* | No serious indirectness | No serious imprecision | None | 48 | 44 | – | MD 10.51 higher (4.7–16.32 higher) | ÅÅÅO MODERATE |
CRITICAL |
| Vital bone—4 mo (follow-up mean 4 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 1 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 6 | 6 | – | MD 10.88 higher (3.68 lower to 25.44 higher) | ÅÅÅÅ HIGH |
CRITICAL |
| Vital bone—6 mo (follow-up mean 6 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 2 | Randomized trials | No serious risk of bias | Serious* | No serious indirectness | No serious imprecision | None | 42 | 38 | – | MD 10.44 higher (4.11–16.78 higher) | ÅÅÅO MODERATE |
CRITICAL |
| Residual grafts (follow-up 4–6 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 3 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 48 | 44 | – | MD 8.76 lower (12.81–4.71 lower) | ÅÅÅÅ HIGH |
CRITICAL |
| Residual grafts—4 mo (follow-up mean 4 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 1 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 6 | 6 | – | MD 2.48 lower (13.58 lower to 8.62 higher) | ÅÅÅÅ HIGH |
CRITICAL |
| Residual grafts—6 mo (follow-up mean 6 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 2 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 42 | 38 | – | MD 9.73 lower (14.08–5.38 lower) | ÅÅÅÅ HIGH |
CRITICAL |
| Connective tissue (follow-up 4–6 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 3 | Randomized trials | No serious risk of bias | Serious* | No serious indirectness | No serious imprecision | None | 50 | 46 | – | MD 3.59 lower (8.9 lower to 1.71 higher) | ÅÅÅO MODERATE |
CRITICAL |
| Connective tissue—4 mo (follow-up mean 4 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 1 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 8 | 8 | – | MD 8.4 lower (17.59 lower to 0.79 higher) | ÅÅÅÅ HIGH |
CRITICAL |
| Connective tissue—6 mo (follow-up mean 6 mo; measured with: Histomorphometry; Better indicated by lower values) | ||||||||||||
| 2 | Randomized trials | No serious risk of bias | Serious* | No serious indirectness | No serious imprecision | None | 42 | 38 | – | MD 1.19 lower (7.69 lower to 5.3 higher) | ÅÅÅO MODERATE |
CRITICAL |
| Primary implant stability (follow-up mean 6 mo; measured with: Implant stability quotient; Better indicated by lower values) | ||||||||||||
| 2 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 49 | 41 | – | MD 0.33 higher (2.62 lower to 3.29 higher) | ÅÅÅÅ HIGH |
IMPORTANT |
Low heterogeneity.
APD = autogenous particulate dentin, ARP = alveolar ridge preservation, CI = confidence intervals, DBBM = deproteinized bovine bone mineral, MD = mean differences.
4. Discussion
Extraction sockets heal in 3 successive stages: inflammation, proliferation, and modeling/remodeling.[4] Without intervention, the extraction socket is eventually filled with newly formed bone, but the surrounding region is subject to undesirable bone loss.[1,4] In this context, various graft materials utilized for ARP could compensate for the volume of the collapsed sockets, serving as a space-maintain scaffold, but none of them achieve the ideal performance.[37]
The role of APD as a bone substitute has been gradually revealed since Morris et al[38] observed surprising bone remodeling phenomena in the subcutaneous transplantation of human-derived teeth in rats. APD is obtained from autogenous non-reserved teeth, with favorable cost-effectiveness and acceptability (no need for a second surgery for harvesting) while eliminating the risk of cross-infection and immunogenicity.[39]
Clinically, the preferred original teeth for filling the sockets were used, and the useless third molar was used if unavailable. In the latter case, few surgeons perform ARP surgery on the third molar area but allow it to heal spontaneously. Such a disadvantage is that the second molar may cause distal periodontal defect and even mobility due to bone loss after tooth extraction.[30] The study by Kugelberg et al[40] 43.3% of patients reported more than 7 mm intrabony defects at the distal aspect of the second molar 2 years after the mandibular third molar extraction. Some biological materials have been used to decrease intrabony defects in the third molar region,[41–43] but they all require additional costs. Conversely, transplanting APD from the third molar into the original extraction socket is a more meaningful and valuable study.
The advantages of APD have contributed to an avalanche of clinical practice on the subject of APD for ARP.[44–46] To derive robust findings, our meta-analysis compiled available RCTs and investigated multiple critical indicators of changes in ridge width and labial bone height, histomorphometry, primary implant stability, and postoperative complications.
In a recent systematic review,[47] horizontal reduction ranged from −0.15 ± 0.08 mm to −1.54 ± 0.74 mm, and vertical reduction ranged from −0.28 ± 0.13 mm to −0.97 ± 0.39 mm 4 to 6 months after employing APD in ARP surgery. Our data provided similar results, with reduction averages ranging from −0.15 to −0.78 mm horizontally and −0.14 to −0.28 mm vertically. In contrast, spontaneous healing of extractions ranged from −1.11 ± 0.98 to −2.29 ± 0.4 mm horizontally and from −2.29 ± 2.24 to −2.6 ± 0.88 vertically 2 to 4 months after ARP. These radiological changes in ridge dimension include anterior and posterior regions, indicating the broad applicability of APD in maintaining soft and hard tissue envelopes.
None of the studies on ARP in the third molar region did assess the change in socket dimension. Instead, the distal probing depth of the second molar was used to reflect the repair of the intrabony defects.[30,31] As expected, probing depth was significantly reduced when APD was applied compared to BCH.
DBBM and β-TCP were the only OGM for comparison with APD in the included studies. It has been well established in the literature that DBBM and β-TCP grafts can effectively preserve alveolar ridge dimensions and contours due to their osteoconductive properties.[4] Nonetheless, our results revealed that APD had superior performance in reducing alveolar ridge contraction, attributed to the unique physicochemical composition of APD, which is critical for its osteogenic properties.[48,49] The inorganic (mainly hydroxyapatite) and organic components (90% type I collagen) of the dentin not only provide a carrier for new bone and cells but also facilitate mineral deposition and bone calcification.[19,50] Moreover, various growth factors (e.g., transforming growth factor, fibroblast growth factor, insulin-like growth factor, and platelet-derived growth factor) promote new bone induction and remodeling.[51,52] In particular, bone morphogenetic protein-2 released from APD induces the differentiation of undifferentiated mesenchymal cells into osteoblasts, which have the potential to stimulate bone formation.[52]
The histomorphometric results further supported the current clinical findings. Regarding the percentage of vital bone area, the APD grafts averaged 19.32% to 47.3%; these results are comparable to those of spontaneous healing and significantly higher than those of DBBM or β-TCP grafts. Regarding the percentage of residual material area, the APD grafts (ranging from 8.95%–30.22% on average) had a smaller percentage than the DBBM or β-TCP grafts. In other words, APD may have more outstanding bone remodeling capacity than OGM and even closer to BCH (without intervention).
A recent histologic study designed by Minetti et al,[53] including 96 subjects who underwent APD grafting for ARP, which is consistent with our findings. The results showed that the proportions of the vital bone area in the maxilla and mandible were 37.9% ± 21.9% and 38.0% ± 22.0%, while residual material accounted for 7.7% ± 12.2% and 7.0% ± 11.1%, respectively. Histologically, some distinctive signs were observed: the residual APD was closely surrounded by newly formed mature trabeculae without fibrous tissue interference or inflammation. Most of the new bone was already composed of mature lamellar bone with osteoid bone on the outer surface.[53,54] These desirable features enable the primary stabilization and osseointegration of an implant.[39]
Primary implant stabilization is of great significance for osseointegration and implant loading. Two studies[35,36] used ISQ values to indirectly assess the efficacy of APD integration into the alveolar ridge 6 months after grafting. The meta-analysis showed that APD and DBBM grafts achieved comparable, excellent implant stability. Otherwise, Li et al[55] used APD as a material for guided bone regeneration for immediate implant placement in areas with severe periodontitis (probe depth > 6 mm). Notwithstanding, the ISQ increased from 53.6 ± 11.9 initially to 77.6 ± 7.9 at 6 months without incident. Based on the reliable biological stability and superior osteogenic efficiency of APD over DBBM, a more valuable investigation would be to clarify the optimal maturation time of APD in ARP to guide early implantation and shorten the treatment period.
A systematic review[47] reported that APD had a complication rate of 2.32% in ARP. Our result is analogous to the findings of that study, with an overall rate of 2.6% for APD (four postoperative complications occurred, including 2 cases of pain, 1 case of abscess formation, and 1 case of wound dehiscence). Notably, these complications also occur with spontaneous healing and DBBM grafts. Given the favorable healing reported in other studies,[35,36] the occurrence of complications may be related to factors such as the operating techniques of different surgeons and the characteristics of the individual patients. Conceivably, all the shortcomings of conventional graft materials could be avoided reasonably well using APD, and there are no contraindications on the basis of patients’ religious beliefs.[39]
The articles analyzed in this review described different preparation protocols of APD, which varied in aspects, including the size of the dentin particles (250 µm to 1200 µm) and the demineralization degree (undemineralization,[27,28,36] partial demineralization,[29] or complete demineralization[30–35]). Unfortunately, no further subgroup analysis was possible due to the limited number of available RCTs in this field. Some scholars[24,39,56,57] have suggested that APD grafts with different sizes and degrees of demineralization may exhibit different cell adhesion, metabolic activity, and osteogenic properties during alveolar socket healing. There is still no conclusion regarding the optimal size and degree of demineralization, so it would be essential to compare various preparation protocols to investigate whether they form different histomorphometric and clinical consequences.
The strengths of this systematic review lay in its prior registration of the protocol in PROSPERO, comprehensive literature retrieval, explicit group investigation, transparent provision of analytical data, and utilization of the GRADE tool to assess the quality of evidence. In this context, the exceptional performance demonstrated by APD grafts provides compelling evidence to support the implementation of ARP surgery in clinical practice, while also indicating the potential for widespread application of APD in other bone augmentation procedures.
Although our study adhered to strict reporting practices, several potential limitations should be considered. First, the indicators for statistical analysis were limited to the observation period of 6 months, resulting in the evaluation of the long-term effect of the APD graft complex. Second, uncertainties in blinding and interstudy heterogeneity among some of the included RCTs lowered the quality of evidence, increasing the potential bias of the results. Third, different preparation protocols were applied, different measurement methods were used, and limited grafted materials were compared between studies, thus, a unified protocol would achieve more reliable results.
5. Conclusion
Within the limitations of this study, APD can be used as a good and cost-effective graft material in ARP surgery if there are useless teeth. Two parallel meta-analyses yielded encouraging results on ridge dimension changes and histomorphometry. APD grafts effectively maintained the width and height of the alveolar ridge compared with spontaneous healing. Furthermore, APD results in better bone regeneration and more efficient degradation than DBBM or β-TCP. Further well-designed RCTs with adequate protocols, larger samples, and longer follow-up periods are needed to investigate the clinical behavior of APD in comparisons with different substitutes.
Table 4.
The quality of evidence for APD versus OGM for ARP.
| Quality assessment ([APD] versus [OGM] for [ARP]) | No of patients | Effect | Quality | Importance | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No of studies | Design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | APD | OGM | Relative (95% CI) | Absolute | ||
| Change in horizontal ridge width (follow-up mean 4 mo; measured with: Radiography; Better indicated by lower values) | ||||||||||||
| 2 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 23 | 23 | – | MD 1.28 higher (1.08–1.48 higher) | ÅÅÅÅ HIGH |
CRITICAL |
| Change in horizontal ridge width—ADD versus β-TCP (follow-up mean 4 mo; measured with: Radiography; Better indicated by lower values) | ||||||||||||
| 1 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 15 | 15 | – | MD 1.3 higher (1.09–1.51 higher) | ÅÅÅÅ HIGH |
CRITICAL |
| Change in horizontal ridge width—ADD versus DBBM (follow-up mean 4 mo; measured with: Radiography; Better indicated by lower values) | ||||||||||||
| 1 | Randomized trials | No serious risk of bias | No serious inconsistency | No serious indirectness | No serious imprecision | None | 8 | 8 | – | MD 0.9 higher (0.08–1.72 higher) | ÅÅÅÅ HIGH |
CRITICAL |
β-TCP = beta-tricalcium phosphate, APD = autogenous particulate dentin, ARP = alveolar ridge preservation, CI = confidence intervals, DBBM = deproteinized bovine bone mineral, MD = mean differences, OGM = other grafted materials.
Acknowledgments
Authors are thankful to Mr. Lang Xin for his help with the assessment of evidence quality.
Author contributions
Conceptualization: Jiaming Gong.
Data curation: Jianxue Li, Zhenfei Yuan.
Formal analysis: Ruiming Zhao, Jianxue Li, Zhenfei Yuan.
Funding acquisition: Jianxue Li.
Methodology: Yuxia Feng, Ruiming Zhao.
Project administration: Jiaming Gong.
Supervision: Jiaming Gong.
Validation: Xu Xu.
Visualization: Xu Xu.
Writing – original draft: Yuxia Feng, Ruiming Zhao.
Writing – review & editing: Jiaming Gong.
Abbreviations:
- APD
- autogenous particulate dentin
- ARP
- alveolar ridge preservation
- BCH
- blood clot healing
- CI
- confidence intervals
- DBBM
- deproteinized bovine bone mineral
- ISQ
- implant stability quotient
- MD
- mean difference
- OGM
- other grafted materials
- RCTs
- randomized controlled trials
- β-TCP
- beta-tricalcium phosphate
This study was supported by the Natural Science Foundation of Gansu Province (grant numbers 23JRRA530 and 21JR11RA006).
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Informed consent was obtained from all participants in the included studies. Formal consent was not required in this study.
How to cite this article: Feng Y, Zhao R, Li J, Yuan Z, Xu X, Gong J. Efficacy of autogenous particulated dentin graft for alveolar ridge preservation: A systematic review and meta-analysis of randomized controlled trials. Medicine 2023;102:48(e36391).
Contributor Information
Yuxia Feng, Email: Fengyuxia_dentist@outlook.com.
Ruimin Zhao, Email: zhaorm19@lzu.edu.cn.
Jianxue Li, Email: 370816151@qq.com.
Zhenfei Yuan, Email: zhenfei3737@163.com.
Xu Xu, Email: cook10102@163.com.
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