Rehabilitation of Anterior Region with Immediate Implants Using Platelet Rich Fibrin
K.D Dental College, Mathura, U.P, India
INTRODUCTION
Loss of tooth in the aesthetic zone is a traumatic experience with or without compromising in phonetics. Hence, in the aesthetic zone implant supported single/multiple tooth replacement is one of the most challenging situations confronting the clinician. According to traditional Protocols few months of healing period is required for the consolidation of extraction socket. Patients are required to wait for longer period upto 5-6 months or more for replacement of the tooth loss.
Attempts to shorten the overall length of treatment period have focussed on approaches like early or immediate loading following implant placement, immediate implant placement in fresh socket site and immediate implant placement and early or immediate loading.
Immediate implant placement into fresh extraction socket reduces the treatment cost, preserved the gingival aesthetics and increases the comfort of the patient. This case reports describes the procedure for immediate implant placement in fresh extraction sockets with plasma rich fibrin (PRF) membrane, bone graft, provisionalization and progressive loading of the prosthesis.
PLATELET-RICH FIBRIN(PRF)
Unlike PRP, this technique does not require anticoagulants, bovine thrombin or any other gelifying agent. The PRF clot is yielded by a natural polymerization process during centrifugation, and its natural fibrin architecture seems responsible for a slow release of growth factors and matrix glycoproteins during ≥7 days.PRF has a dense fibrin network with leukocytes, cytokines, structural glycoproteinsand also growth factors such as transforming growth factor b1, platelet-derived growth factor, vascular endothelial growth factor and glycoproteins such as thrombospondin-1 during 7 day.Leukocytes that are concentrated in PRF scaffold play an important role in growth factor release,immune regulation,anti-infectious activities, and matrix remodelling during wound healing. The slow polymerization mode of PRF and cicatricle capacity creates a physiologic architecture favourable for wound healing.
PREPARATION OF PRF
Preparation of PRF follows the protocol developed by Choukroun et al in 2001. Blood specimen is collected from the patient and centrifuged at 3000 rpm for 10 minutes or 2700 rpm for 12 minutes.
APPLICATIONS OF PRF
Oral Applications
PRF membrane in combination with bone grafts can be used for healing in lateral sinus floor elevation procedures, stabilisation of graft material, socket preservation, wall defects, recession, and filling of cystic cavity.
Extra oral Clinical Applications
PRF is used for dentinogenesis by stimulating cell proliferation and differentiation of Dental Pulp Cells, repair of Achilles tendon repair and articular cartilage, healing of non-healing lower extremity ulcers. PRF can also be used in various facial plastic surgery procedures.
Limitations of PRF
Availability of this biomaterial in larger amounts is a concern because of autologous origin and it can’t be used as allogenic material due to presence of the circulating immune cells and antigenic molecules.
CASE REPORT 1
A 47year old male patient reported to the department of prosthodontics in K.D. Dental College Mathura with chief complaint of missing tooth in relation to lower anterior region and mobility in 31,41,42 and wanted to replace his missing teeth. Complete medical and dental history was recorded radiographs and photographs were taken. No systemic disorder were told neither observed in the Investigations. Past Dental history revealed that patient underwent excision of gingiva in upper and lower region 8 years back due to inflammation. Extra oral examination revealed no facial asymmetry and patient did not have any symptoms of temporomandibular disorder.
On intraoral examination mandibular central incisor i.e. 31 were found missing, grade III mobility in 41,42,32 and there was generalised recession and periodontitis. No gross abnormality was noted in the overall soft tissue of lips, cheeks, tongue and pharynx.
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| Fig. 1: Preoperative View | Fig 2 Midcrestal and Vertical Incision for A traumatic Extraction |
PROSTHETIC TREATMENT PROPOSED INCLUDED
Extraction of 32,41,42 and fixed partial denture on 44,43,42,41,31,32,33,34 or immediate placement of implants after extraction of 32,42.
TREATMENT PROCEDURE
Patients’ blood was takenfor preparation of PRF membrane, immediate implants were placed after extraction of teeth in relation to 32,41,42 and implant site and was closed with sutures after placing PRF membrane over it. After follow up of 3 months radiographs were taken and implants were evaluated after that implants were exposed and healing abutment were placed. Final prosthesis was given after 10 days of it.
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| Fig.3 Extraction of Teeth prior to immediate implant | Fig.4 Extraction Sockets | Fig.5 Subsequent placement of immediate implants |
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| Fig.6 Preparation of PRF membrane | Fig.7 Placement of Platelet Rich Fibrin |
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| Fig 8 Radiographic Analysis | Fig. 9 Post Three Month Healing |
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| Fig. 10 & 11: Post 3 Months of Implants and abutments Placement for Impression | |
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| Fig 12 & 13: Permanent Implant Supported Prosthesis | |
CASE REPORT 2
A 25year old male patient reported to the department of prosthodontics in K.D. Dental College Mathura with chief complaint of fractured tooth in upper front region since 6 months. Complete medical and dental history was recorded radiographs and photographs were taken. No systemic disorder were told neither observed in the Investigations.Extraoral examination revealed no facial asymmetry and patient did not have any symptoms of temporomandibular disorder.
On Intra-oral examination, maxillary central incisor i.e 11 had Ellis class III fracture with generalised gingivitis.. No gross abnormality was noted in the overall soft tissue of lips, cheeks, tongue and pharynx.
PROSTHETIC TREATMENT PROPOSED INCLUDED
Atramatic Extraction of the central incisor 11 followed by immediate implant. Or Fixed Partial denture on 21,11,12 tooth.
Treatment Procedure:
Patients blood was taken for preparation of PRF membrane, immediate implant were placed after atraumatic extraction of central incisor i.e 11 tooth.Plasma rich fibrin with bio-oss bone graft placed after the implant placement. Sutures were given for 7 days. Provisional Prosthesis using fractured segment of tooth was made by altering the cast created before extraction.Natural tooth was placed on the cast and deficient fractured portion was build with composite resin.Then, the provisional prosthesis was splinted with the adjacent tooth with 0.7 gauge wire creating slots in adjacent tooth and bonding it with flowable composite resin.
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| Fig.1 Pre-Operative View | Fig.2: Atraumatic Extraction |
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| Fig. 3 & 4 Immediate Implant Placement i.r.t 11 region | Fig. 4 Radiographic analysis | |
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| Fig 5 & 6 Preperation of the PRF | Fig.7 Bio-oss bone graft with PRF membrane | |
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| Fig.8 Interrupted sutures i.r.t 11 | Fig. 9 & 10 Provisionalization using fractured segment of tooth; altering the cast created before extraction | |
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| Fig 11 Slots On Adjacent Tooth For Retention | Fig.12 Placing The Fractured Tooth Portion On The Cast | Fig.13 Provisional Restoration Bonded With Composite Resin |
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| Fig.14 Provisional Restoration 11 Tooth | Fig.15: Placement Of Prepared Abutment Irt 11 | Fig.16: Radiograph After 3 Months Of Implant Placement |
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| Fig 18. Post Operative View |
DISCUSSION
The biologic advantage of immediate implant is the contention that the implant will prevent postsurgical bone resorption seen following tooth extraction as a normal part of the socket healing. It also eliminates the waiting period for socket consolidation, has fewer surgical sessions, a shorter total treatment time, reduced over-all costs.
Membranes either resorbable or non-resorbable with or without bone grafting have been used for many years in guided tissue regeneration (GTR) to heal periodontal defects and to regenerateperi-implant defects in GBR. Because the membrane is generally expensive and has a possibility of disease transmission, a product from the patient’s own blood has gained much popularity as a supplement to procedures of tissue regeneration.
PRF is autogenous and do not cause any immune reactions or infections.Its gelatinous consistency enhances clot and graft stability. Platelets release cytokines, such as platelet-derived growth factor (PDGF), insulin-like growth factor (IGF), and vascular endothelial growth factor (VEGF). PDGF and IGF are well known osteogenic cytokines. PRF is known to release growth factors for at least ≥7 days.
PRF allows to avoid the use of membranes and barriers, thus reducing the risk of possible exposure to the oral cavity and of the consequences that the bacterial contamination may have on the regenerative process.
CONCLUSION
This case reports demonstrates that it is possible to achieve greater efficiency in our efforts to give patient sound,timely and economical treatement.It is clear that with continued innovation in the prosthetic capabilities of implants system we should be able to enhance the service and treatnment offered to our patients in regard to our treatment time,patient comfort ,cost and aesthetics.
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References are available on request
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How to cite this article
Dr. Rahul Nagrath, Dr. Arjun Jawahar Sharma, Dr. Amit Gupta Department of Prosthodontics. Rehabilitation of Anterior Region with Immediate Implants Using Platelet Rich Fibrin. Guident. 2016 Jan;9(2). Available from: https://guident.in/articles/implantology/rehabilitation-of-anterior-region-with-immediate-implants-using-platelet-rich-fibrin.html
