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Among the different graft materials used in dental clinics, autogenous bone is the most ideal. However, its biggest short coming is that the amount invested is limited, resorption is unavoidable and a secondary defect is generated at the donor site. Extracted tooth has been discarded as infective medical dust. So, the present study was aimed to evaluate the efficacy of autogenous tooth as graft material in the extraction socket of third molar region.
Materials and method
A split mouth study design was undertaken. 20 patients requiring extraction of bilateral mandibular third molars were included in the study. This study was carried out in third molar region. Group A: PRF membrane was placed in the third molar extraction socket. Group B: Autogenous tooth processed into bone graft was used in the third molar extraction socket, over which PRF membrane was placed. Postoperative pain and bone healing were assessed in the post-operative follow-up visits.
Results
We observed that Group B showed significantly faster bone healing as compared to Group A, in terms of overall density and trabecular pattern of bone at the end of 3 months and 6 months following extraction.
Conclusion
This study clearly indicates that autogenous tooth used as bone graft material showed improved bone healing at the third molar extraction sockets. This study emphasis on use of human dentin as graft material as it was simple, cost effective, required no special armamentarium and infrastructure for preparation and even did not require additional donor site.
Tooth extraction is one of the most widely performed procedure in dentistry, leading to inevitable dimensional changes of the alveolar ridge. With the surge of implant dentistry, augmentation of such sites with various graft materials is being carried out successfully using different graft materials.
Autogenous bone, allogenic bone, xenogenic bone, and alloplastic materials are bone graft materials that are presently used in dental clinics. According to bone healing mechanism, they can be categorized into materials that induce osteogenesis, osteoinduction and osteoconduction.
Among the many different types of bone graft materials, autogenous bone is the most ideal since it exhibits all of the above three mechanisms. Its major advantage is rapid healing time without immune rejection. However, its biggest shortcoming is that the amount harvested is limited, bone resorption after grafting is unavoidable and a second defect is generated in the donor area.
Allogenic, xenogenic and alloplastic graft materials have been used as alternatives, but they have a number of drawbacks compared with autogenous grafts, such as decreased function, the potential risk of infectious diseases, an unsatisfactory resorption pattern, a prolonged healing time and high cost.
Generally, extracted teeth have been discarded as infective medical dust. In 2003, Murata et al., first presented the idea of using human dentine as bone graft material in the same patient to regenerate new bone.
In our study we have employed clinical waste i.e, the extracted tooth as a raw material for bone graft which has greatly influenced the cost of the procedure. Traditional graft materials like hydroxyapatite, Bio-oss are expensive graft materials, whereas the graft used in our study only included graft processing as a potential cost. Hence the present study was aimed to evaluate the efficacy of autogenous tooth as bone graft material in the extraction socket of third molar region.
2. Materials & methods
A total of 20 patients who reported to the department of oral and maxillofacial surgery requiring extraction of bilateral mandibular third molars were taken up for the study. In this study split mouth method was used wherein one side was randomly taken up as the control group and the other side as the study group. As third molar region is the only region where graft material can be retained after primary closure of extraction site, third molar region was used.
n= (Zα/2 +Zβ)2Ϭ2/ (ᴫ1 - ᴫ2)2
With 5% level of significance and 80% power and mean difference between the overall density between the groups assumed as 0.4 and SD of the difference assumed as 0.6, sample size required for the study was 18. So, 20 participants were chosen as study participants (12 males and 8 females).
Study design: Prospective study (Split mouth study) was conducted for a period of two and half years.
The following criteria was considered:
Inclusion Criteria:
1.
Patients above 18 years of age.
2.
Patients indicated for trans-alveolar extraction of bilateral mandibular third molars.
Exclusion Criteria:
1.
The presence of any contraindicating systemic condition.
2.
Acute exacerbation of chronic infection like pain or swelling.
3.
Grossly decayed tooth.
4.
Patients with history of radiation therapy/chemotherapy in the 12 month period earlier to the proposed therapy.
5.
Pregnant women, children, elderly (>60 years), physically and mentally challenged, terminally and seriously ill.
6.
An unwillingness to commit to a long-term post therapy maintenance programme.
Random Blood sugar levels, Haemoglobin levels, Bleeding time, Clotting time, Preop RVG (Radio Visio Graphy) was done on study participants.
Patients were divided into the following groups:
Group A (Control group): Placement of PRF (Platelet Rich Fibrin) membrane in the third molar extraction socket followed by primary closure of the site.
Group B (Study group): Placement of autogenous tooth as graft material in the third molar extraction socket (Fig. 1), followed by placement of PRF membrane (Fig. 2) and primary closure of the site.
In both the groups, the patients were recalled on 7th day,1st,3rd and 6th month post operatively to assess the healing of the socket clinically and radiographically.
Fig. 1After placement of bone graft in the socket.
Extraction socket examined clinically for any postoperative pain or signs of infection.
2.
Bone healing of the third molar socket assessment radiographically using standard RVG image. The criteria for bone healing and scoring system are based on a modification of the method used by Kelly et al.
Three radiographic parameters namely lamina dura, overall density and trabecular pattern were used sefor the assessment of bone healing (Table 1).
Table 1Radiographic parameters.
Lamina dura (LD)
+2: LD essentially absent, may be present in isolated areas. +1: LD substantially thinned, missing in some areas. 0: Within normal limits −1: Portions of LD thickened, milder degrees −2: Entire LD substantially thickened
Overall density
+2: Severe increase in the radiographic density +1: Mild to moderate increase in radiographic density 0: Within normal limits −1: Mild to moderate decrease in radiographic density −2: Severe decrease in radiographic density
Trabe pattern
+2: All trabeculae substantially coarser +1: Some coarser trabeculae; minor degrees 0: Within normal limits −1: Delicate finely meshed trabeculations −2: Granular, nearly homogenous patterns, individual trabeculations essentially absent.
Under all aseptic techniques, the extracted tooth was cleaned to remove all fibrous tissue and foreign materials such as fillings, calculus from the tooth with the help of a carbide bur. The mechanically cleaned tooth was then thoroughly air dried and the enamel was removed.
Multi-rooted molars were sectioned into 2–3 pieces to facilitate grinding. Further grinding of the tooth was done with the help of a Mortar and Pestle (Fig. 3). After this the grounded material was immersed in Basic Alcohol (0.5 M of NaoH and 30% Alcohol) for 10 min, in a small sterile glass container.
After decanting the basic alcohol cleanser, the particulate was washed twice, in sterile Phosphate Buffered Saline (PBS). The PBS was decanted, and the bone graft material was stored in a sealed bottle in dry form after vaporizing its liquids and drying it on hot plates at 140 °C for 5 min.
2.2 Preparation of platelet rich fibrin
Choukroun's method was adopted for preparation of PRF.
The clot formed was then squeezed between two gauge pieces and was placed in the extraction socket over the bone graft.
Patients were recalled on the 7th postoperative day for suture removal and to assess pain and examine for any signs of infection and also at 1st,3rd and 6th postoperative month to assess bone healing (Fig. 4, Fig. 5, Fig. 6, Fig. 7, Fig. 8, Fig. 9).
The study was reviewed and approved by the Ethics Committee of the Institute. Written informed consent was taken from each participant.
Statistical analysis was done using SPSS software version 20.
Results and observation: The study and control group consisted of 12 males and 8 females respectively. The mean age of the patients was 27 years. Bone healing was assessed in terms of the appearance of Lamina dura, the overall density and the trabecular pattern that were observed on the RVGs of the wound site at an interval of 7 days, 1 month, 3 months and 6 months.
Lamina dura: (Graph 1) The mean lamina dura score of Group B was higher as compared to that of Group A, though the scores were not statistically significant.
Graph 1Mean lamina dura scores among cases and controls.
Overall density: (Graph 2) The score for overall density for Group B was higher as compared to that of Group A at the end of 7th day, 1st month,3rd month, 6th month and was statistically significant. However, the density in group B decreased over time which can be attributed to the presence of dense bone graft initially which underwent resorption in subsequent visits but was still significantly higher when compared to the control group.
Graph 2Overall density scores among cases and controls.
Trabecular pattern: (Graph 3) A statistically significant difference was again noted in scores of Group B as compared to Group A. Both groups showed an improvement in scores as compared to the initial scores.
Graph 3Trabecular pattern among cases and controls.
Pain assessment: Patients were asked to record and score on sheet for next consecutive 7 days and the sheet was collected on 7th day of follow up. The assessment was done as per the Numeric Rating Scale. The mean scores were higher for Group B as compared to the mean score of Group A, though not statistically significant.
There were no reported cases with presence of pus discharge or wound dehiscence at the end of three months and six months.
3. Discussion
Healing of an extraction socket after tooth removal involves retention of the blood clot followed by a sequence of events that lead to changes in the alveolar process in a three dimensional fashion.
During the first three months following extraction, bone loss seen is significant and may result in both hard and soft tissue deformity affecting the ability to restore the site with acceptable aesthetics.
Procedures that reduce the resorptive process have the potential to eliminate secondary surgery for site preservation and hence aid in dental implant placement or fabrication of fixed or removable prosthesis. The key element is prior planning by the dentist to act at the time of extraction to prevent ridge collapse due to loss of alveolus.
Several techniques have been employed as ridge preservation procedures involving the use of bone grafts or barrier membranes to provide a better restorative outcome. A number of grafting materials like autografts, allografts, xenografts have been introduced for socket preservation.
Human dentin has been proposed as a potential autograft material for a similar purpose. Although, it has been known that tooth dentin has the same properties and contents as that of cortical bone, it has not been employed routinely as a bone graft material in humans.
There are many studies which propose that non-functional teeth or periodontally compromised teeth, indicated for extraction should be considered as patient's own graft material.
In this study we have evaluated the efficacy of autogenous tooth as graft material in the mandibular third molar extraction sockets and have also assessed the potential use of this material as an alternative for autologous bone and other graft materials. Hard tissue healing potential of this material was also evaluated.
Kim et al, recently studied the safety and efficacy of autogenous dentin bone graft material as compared to other grafting biomaterials used in clinical dentistry. They concluded that autogenous tooth used as graft material have the structure and physicochemical characteristics that are almost similar to those of autogenous cortical bone.
In our study with a follow up period of 6 months, no adverse effects like wound dehiscence or presence of pus discharge were observed. Postoperative pain was compared between two groups which did not show any significant change, suggesting that the choice of bone graft material did not affect postoperative pain or swelling.
Bone healing was evaluated by assessing the lamina dura, overall density and trabecular pattern on digital RVG images using healing index by Kelly et al.
We compared the 7th day post-operative RVG image to those taken at the end of 1st, 3rd and 6th month.
Autogenous tooth used as bone graft material along with PRF membrane showed better bone healing as compared to the control group which only had PRF packed in the extraction socket silmilar to case report.
, a comparison of PRF and PRP as graft materials in extraction sockets.They concluded that PRF showed better results in terms of soft tissue and bone healing as compared to PRP and the control group, where no graft material was placed.
Histological analysis was carried out by Kim et al
the results of which concluded that autogenous teeth underwent gradual resorption and was replaced by new bone of excellent quality in just 3 months.
In our study we had employed clinical waste i.e, the extracted tooth as a raw material for bone graft which greatly influenced the cost of the procedure. Traditional graft materials like hydroxyapatite, Bio-oss* are expensive graft materials, whereas the graft used in our study only included graft processing as a potential cost. Similarly in a systematic review it is shown that tooth derived bone graft material is an efficient and affordable bone graft substitute, hence more acceptable and applicable.
Autogenous grafting procedures, although are single appointment procedures like our study but present with certain limitations like prolonged intraoperative time, additional donor site morbidity such as pain and trauma to the patient.
This study clearly indicates that autogenous tooth used as bone graft material showed improved bone healing at the third molar extraction sockets.
•
This study emphasis on use of human dentin as graft material as it was simple, cost effective, required no special armamentarium and infrastructure for preparation and even did not require additional donor site.
Limitations
i)
Smart Dentin Grinder could not be used as it was not cost-effective.
ii)
Rather we have used mortar and pestle to mechanically grind the tooth, thus the uniformity of the obtained dentin particles could not be determined.
iii)
The time taken to prepare the graft material was also longer, which was 40–45 min as compared to 20 min taken by grinding through Smart Dentin Grinder.
Recommendations
i)
Due to very slow replacement of dentin, a follow up period of more than 6 months would be more appropriate for evaluation of stability of autogenous tooth as graft material.
ii)
Histological analysis can also be recommended to arrive at a better conclusion.
iii)
Same methodology could be adopted in other surgical sites of extraction as well.
Conflict of interest
None declared.
Source of funding
None.
Acknowledgement
Authors would like to thank the study participants for their cooperation. We would also like to thank the institution for granting the permission to conduct the study.
Autogenous demineralized dental matrix for maxillary sinus augmentation in human.
in: The first clinical report. 81th International Association for Dental Research Geteburg,
Sweden2003, June ([Online].[cited January 15]: Available from;)
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