SRM Journal of Research in Dental Sciences

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 10  |  Issue : 2  |  Page : 72--77

Evaluation of treatment outcome after impacted mandibular third molar surgery with and without autologous platelet concentrates


Sauvik Singha, Rajesh B Dhirawani, Sumit Asrani, Anshalika Agrawal, Jay Taank 
 Department of Oral and Maxillofacial Surgery, Hitkarini Dental College and Hospital, Jabalpur, Madhya Pradesh, India

Correspondence Address:
Dr. Sauvik Singha
Department of Oral and Maxillofacial Surgery, Hitkarini Dental College and Hospital, Jabalpur, Madhya Pradesh
India

Abstract

Aim and Objective: The prospective study was conducted to assess the role of platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) in healing of soft tissue after the surgical extraction of mandibular-impacted third molars. The main objective of the study was to compare clinical parameters and especially the postoperative pain, swelling, interincisal distance, wound dehiscence, dry socket, soft tissue healing, and infection. Materials and Methods: 300 patients having impacted mandibular third molar were included in this study. They were selected on the OPD basis at the Department of Oral and Maxillofacial Surgery. Patients were divided into Group A treated with PRP and Group B treated with PRF. Result and Conclusion: The study indicates faster healing with no untoward reaction on PRP and PRF group. Platelet concentrates especially PRF in extracted third molar socket give excellent enhancement in wound healing with lesser postoperative complication.



How to cite this article:
Singha S, Dhirawani RB, Asrani S, Agrawal A, Taank J. Evaluation of treatment outcome after impacted mandibular third molar surgery with and without autologous platelet concentrates.SRM J Res Dent Sci 2019;10:72-77


How to cite this URL:
Singha S, Dhirawani RB, Asrani S, Agrawal A, Taank J. Evaluation of treatment outcome after impacted mandibular third molar surgery with and without autologous platelet concentrates. SRM J Res Dent Sci [serial online] 2019 [cited 2019 Jul 18 ];10:72-77
Available from: http://www.srmjrds.in/text.asp?2019/10/2/72/262376


Full Text

 Introduction



Third molar extraction is the most common minor surgery performed in oral and maxillofacial surgery department. Healing of wounds histologically proceeds generally in three phases: catabolic period, proliferative phase, and reparation and reorganization phase.[1] Platelet-derived growth factors (PDGFs) mainly have effect on proliferation phase. Regenerative potential of platelets was introduced in 1974, and Ross et al. were among the pioneers who firszt described a growth factor from platelets which have been shown to stimulate the mitogenic response in the periosteum for bone repair during normal wound healing.[2],[3],[4]

In 1997, platelet-rich plasma (PRP) was first introduced through an article entitled “platelet gel; an autologous alternative to fibrin glue with applications in oral and maxillofacial surgery.” They also assumed “through activation of the platelets within the gel and the resultant release of growth factors, enhanced wound healing should be expected.”[1],[2],[3],[4],[5]

Choukroun's platelet-rich fibrin (PRF) is a fibrin matrix in which platelet cytokines and cells are entrapped. They are released a certain time and can act as a resorbable membrane.[6] Gassling et al. and Khiste and Tari have shown that PRF is suitable to breed human periosteal cells in vitro. It can be used for bone tissue engineering applications.

This study compares the effectiveness of PRP and PRF in wound healing of extracted mandibular third molar.

 Materials and Methods



A total of 300 patients reporting to Department of Oral And Maxillofacial Surgery, Hitkarini Dental College and Hospital, Jabalpur Madhya Pradesh, who were willing for extraction of impacted mandibular third molar and who satisfied the inclusion and exclusion criteria were selected. Patients were divided into Group A treated with PRP and Group B treated with PRF.

Patient aged between 18 and 30 years of either sex, having asymptomatic impacted mandibular third molars with mild to moderate difficulty (Pederson index), without any systemic disorders, who did not have any abusive habits, and female patients who were not using oral contraceptives were included in this study. Patient with infection at the site of surgery, having substance abuse, any hematological problems or deficiency diseases, and who were not willing for extraction were excluded.

Preparation of the patient

All the patients were briefed about the surgical procedure and autologous PRP/PRF harvesting. A written informed consent was obtained from all the patients. Institutional ethical committee clearance was obtained to conduct the study.

The cases were evaluated for the following information using standardized case history recording pro forma, radiological examination using Intraoral periapical radiograph (IOPA) and orthopantomogram (OPG), type of impaction (winter's classification, Pell Gregory Classification, Pederson's difficulty index, WHARFE'S assessment) and all required lab investigations were done.

Preparation of platelet-rich plasma

Under aseptic techniques, 10 ml of intravenous blood was drawn from the antecubital region using 10 ml disposable syringe and blood was transferred to acid citrate dextrose tubes. Then, the blood was centrifuged using a “soft” spin (2400 rpm for 10 min). After that, another sterile tube (without anticoagulant) is taken, and the supernatant plasma containing platelets was transferred. Then, the tube was centrifuged using a “hard” spin (3600 rpm for 10 min) to get the platelet concentrate. The upper 2/3 is platelet-poor plasma (PPP) and lower 1/3 is PRP. Platelet pellets are formed at the bottom of the tube. PPP was removed, and the platelet pellets were suspended in a 2–4 mL of plasma by gently shaking the tube.

Preparation of platelet-rich fibrin

The tube with 10 ml of whole blood was kept in the centrifuge machine and centrifuged at 3000 rpm for 15 min. Out of the three layers formed after centrifugation, the middle layer (PRF) was extracted. The others two layers (PRP and red blood cell) were discarded.

Surgical technique

Patients were asked to gargle with chlorhexidine mouthwash 1 min before starting the procedure. Draping and painting of the surgical area is done. The nerve blocks given were inferior alveolar nerve block, lingual nerve block, and long buccal nerve block. 2% lignocaine hydrochloride with 1:1:80000 adrenaline is used as an anesthetic agent. Average 3 ml solutions were used. The ward's incision was made in all the cases with blade no 15, full thickness mucoperiosteal flap raised for adequate exposure. Guttering of bone was done at 10,000 rpm to 30,000 rpm with stainless steel round (No-8) and straight fissure bur (No-712) under constant copious saline irrigation. Sectioning of the tooth was done if required. Elevators and forceps were used to remove the tooth. The surrounding bone was smoothened using bone file and the wound was irrigated with 20 ml of normal saline. Then, the obtained PRP gel was placed into the Group A extraction socket and PRF gel into Group B extraction socket and then socket was sutured using 3-0 mersilk simple interrupted suture.

Postoperative assessment

Done on postoperative day 1, 3, and 7.

Pain

Pain was assessed using 10 cm visual analog scale (VAS), by asking the patient about the pain experienced by them, where “0” equals “no pain” and “10” equals “worst possible pain.”

Facial measurements

Facial measurements were made based on the method described by Gabka and Matsumara. It required surface soft tissue marking of 5 points on the ipsilateral side: Lateral canthus of eye, Corner of the mouth, Pogonion, Angle of the mandible, and Tragus.

Three arbitrary lines were constructed using these points as references [Figure 1]:{Figure 1}

Line joining tragus to angle of the mouthLine joining lateral canthus of eye to angle of the mandibleLine joining tragus to soft tissue pogonion.

The arithmetic sum of the 3 measurements was used to determine the facial swelling at any point of time.

[INLINE:1]

Mouth opening

Mouth opening before and after the surgical procedure was measured as the interincisal distance using a metallic ruler.

Dry socket

Dry socket is a very painful condition caused by loss or necrosis of the blood clot formed at the extraction site within 24–72 h after extraction thus exposing the underlying bone. The presence or absence of dry socket was evaluated clinically on day 3.

Infection

Clinical evaluation was done to rule out the presence (+) of infection at every visit during the study period.

Wound dehiscence

Wound dehiscence is a surgical complication in which the wound ruptures along the surgical sutures. Dehiscence was assessed clinically as absent (−) or present (+) on postoperative day 3 and 7.

Soft tissue healing

Healing index of Landry, Turnbull and Howley - the soft tissue healing of the extraction wound was assessed on postoperative day 7 by evaluating 5 parameters – tissue color, presence or absence of bleeding on palpation, presence or absence of granulation tissue, epithelialization of incision margin, and presence or absence of suppuration. The healing index ranged from 1 to 5, 1 being very poor healing and 5 being excellent healing.

 Results



kruskal wallis test results showed significant difference between the groups for VAS scores (χ2 = 13.358, df = 2, P < 0.01 on 1st day; χ2 = 12.149, df = 2, P < 0.01 on 3rd day; χ2 = 13.422, df = 2, P < 0.01 on 7th day). After this, Mann–Whitney U-test was applied for pairwise comparison, which showed VAS scores for pain in control group were significantly higher than PRP and PRF groups. There was no significant difference between PRP and PRF groups [Graph 1].[INLINE:2]

Preoperatively, mean ± standard deviation (SD) of swelling in control, PRP, and PRF groups were 36.38 ± 2.10 mm, 36.35 ± 2.12 mm, and 36.25 ± 2.21 mm, respectively. One-way ANOVA showed no significant difference between the groups for swelling (F = 0.010, P > 0.05). Postoperatively, one-way ANOVA showed significant difference between the groups for swelling (F = 6.974, P < 0.01 on 1st day; F = 5.780, P < 0.01 on 3rd day; F = 1.898, P > 0.05 on 7th day). After this, least significant difference (LSD) post hoc test was applied for pairwise comparison, which showed swelling in control group was significantly higher than PRP and PRF groups. Moreover, there was no significant difference between PRP and PRF groups for swelling [Graph 2].[INLINE:3]

Preoperatively, mean ± SD of maximum interincisal distance in control, PRP, and PRF groups was 42.50 ± 5.97 mm, 42.70 ± 6.20 mm, and 42.70 ± 5.91 mm, respectively. One-way ANOVA showed no significant difference between the groups for maximum interincisal distance (F = 0.004, P > 0.05). Postoperatively on 1st day, mean ± SD of maximum interincisal distance in control, PRP, and PRF groups was 15.80 ± 3.91 mm, 26.80 ± 5.45 mm, and 27.50 ± 4.86 mm, respectively. On 3rd day, mean ± SD of maximum interincisal distance in control, PRP, and PRF groups was 25.70 ± 6.55 mm, 37.00 ± 5.16 mm, and 38.10 ± 5.30 mm, respectively. On 7th day, mean ± SD of maximum interincisal distance in control, PRP, and PRF groups was 30.70 ± 5.21 mm, 37.80 ± 5.62 mm, and 39.20 ± 4.21 mm, respectively. One-way ANOVA showed significant difference between the groups for maximum interincisal distance (F = 18.823, P < 0.001 on 1st day; F = 14.471, P < 0.001 on 3rd day; F = 8.149, P < 0.01 on 7th day). After this, LSD post hoc test was applied for pairwise comparison, which showed maximum interincisal distance in PRP and PRF groups were significantly higher than control group. Moreover, there was no significant difference between PRP and PRF groups [Graph 3].[INLINE:4]

Wound dehiscence and dry socket were present in 3 (30.00%) cases in control group and 1 (10.00%) case in PRP group. None of the individuals in PRF group were observed with wound dehiscence at postoperative day 1 and day 7. Chi-square test showed no significant difference between the groups for wound dehiscence (χ2 = 4.038, df = 2, P > 0.05). Infection was present in 1 (10.00%) case in control group. None of the individuals in PRF and PRP groups were observed with infection. Chi-square test showed no significant difference between the groups for infection (χ2 = 2.069, df = 2, P > 0.05) [Graph 4].[INLINE:5]

Mean ± SD of healing index scores in control, PRP, and PRF groups was 3.30 ± 0.95, 4.60 ± 0.52, and 4.70 ± 0.48, respectively. One-way ANOVA showed significant difference between the groups for healing index (F = 13.071, P < 0.001). After significant results of one-way ANOVA, LSD post hoc test was applied for pairwise comparison, which showed healing index scores in PRP and PRF groups were significantly higher than control group and there was no significant difference between PRP and PRF groups [Graph 5].[INLINE:6]

 Discussion



One of the emerging topic in dentistry is the use of PRP, PRF for the repair and regeneration of the hard and soft tissue after various surgery.[1],[2],[3],[4],[5],[6] PRP was introduced as the first generation of platelet concentrate. A classical blood sample has about 5% platelets while PRP had 95% platelets. The procedure required blood collection with anticoagulant. Later on, artificial polymerization of platelet was done using bovine thrombin. PRP required an expensive equipments and additives to reach the final product.[7],[8]

Choukroun et al. was the first who developed PRF in France. This technique requires neither anticoagulant nor bovine thrombin (nor any other gelling agent). It is nothing more than centrifuged blood without any addition. A blood sample is taken without anticoagulant in 5 mL tubes which are immediately centrifuged at 3000 rpm for 10 min.[9],[10]

PDGF, transforming growth factor-beta (TGFβ), vascular endothelial growth factor, and epidermal growth factor are the platelet-derived proteins. Plasma contains certain natural growth factors in the name of insulin like growth factor and hepatocyte growth factor.[11],[12]

The success of this technique depends on two factors: first, the speed of blood collection and second, transfer to the centrifuge. Upon contact with the tube glass, and it takes a minimum of a few minutes of centrifugation to concentrate fibrinogen in the middle and upper part of the tube. Quick handling is the only way to obtain a clinically usable PRF clot.

Dohan et al. proved a slower release of growth factors from PRF than PRP and observed better healing properties with PRF. They all concluded that PRF offers many advantages, it decreases the frequency of intra- and post-operative bleeding at the donor and the recipient sites, facilitates more rapid soft tissue healing, aids in the initial stability of the grafted tissue at the recipient sites, may promote rapid vascularization of the healing tissue by delivering growth factors and in combination with bone replacement materials, induces regeneration.[13],[14]

Our study included 200 female and 100 male patients who were the age group of 18–30 years, having impacted mandibular third molar. All the 300 patients were asymptomatic before the surgery.

All the patients were treated with extraction of impacted mandibular teeth with placement of PRP on 100 extracted sockets, PRF on 100 extracted sockets, and rest 100 extracted sockets left without any platelet concentrates on a random selection process.

Postoperatively pain was assessed using VAS score. On 1st, 3rd, and 7th day, VAS scores in control group were significantly higher than PRP and PRF groups. There was no significant difference between PRP and PRF groups.

Postoperative swelling was evaluated. On the 1st and 3rd day, swelling in control group was significantly higher than PRP and PRF groups. There was no significant difference between PRP and PRF groups for swelling. On 7th day, both sides, there is no significant difference between the groups for swelling.

On comparing the interincisal distance, on 1st, 3rd, and 7th day, maximum interincisal distance in PRP and PRF groups were significantly higher than control group. There was no significant difference between PRP and PRF groups for swelling.

In our study, only 30 patients (control – 20 and PRP – 10) had wound dehiscence and dry socket, and 10 patients from control group had postoperative infection.

Mostly PRF inhibits bacterial growth. Thereby, platelet concentrates especially PRF enhance soft tissue regeneration both in rate and growth.[15],[16],[17],[18],[19],[20]

PRF in the form of a platelet gel can be used in conjugation with bone grafts. It has several advantages, like it promotes wound healing, bone growth and maturation, and hemostasis. It also imparts better handling properties to graft materials. It can be used as a membrane too.

 Conclusion



Autologous PRP and PRF can be used as an adjunct to promote wound healing in mandibular-impacted third molar extraction socket.

The present study done on 30 patients clearly indicates a definite improvement in the soft tissue healing and faster regeneration after the surgical removal of mandibular-impacted third molar. It showed excellent soft tissue healing and lesser postoperative complication on PRP and PRF group compared to control group.

Preparation of autologous PRP and PRF in dental office is not a time-consuming procedure; it is easy to use and beneficial to patient and as well as clinician. It is cost-effective also. It contains growth factors especially PDGF and TGF-β. PRP and PRF in dental clinic reduce bleeding and rapid healing, which holds promise for further procedures. Most importantly, this autologous product eliminates the chances of immunogenic reactions and disease transmission.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Yelamali T, Saikrishna D. Role of platelet rich fibrin and platelet rich plasma in wound healing of extracted third molar sockets: A comparative study. J Maxillofac Oral Surg 2015;14:410-6.
2Ross R, Glomset J, Kariya B, Harker L. A platelet-dependent serum factor that stimulates the proliferation of arterial smooth muscle cells in vitro. Proc Natl Acad Sci U S A 1974;71:1207-10.
3Dutta SR, Singh P, Passi D, Patter P. Mandibular Third molar extraction wound healing with and without platelet rich plasma: A comparative prospective study. J Maxillofac Oral Surg 2015;14:808-15.
4Gupta V, Bains VK, Singh GP, Mathur A, Bains R. Regenerative potential of platelet rich fibrin in dentistry: literature review. AJOHAS 2011;1:22-8.
5Khiste SV, Tari RN. “Platelet-Rich Fibrin as a Biofuel for Tissue Regeneration,” ISRN Biomaterials, 2013;2013:1-6.
6Choukran J, Diss A, Simonpieri A. Platelet rich fibrin (PRF): A second generation platelet concentrate. Oral Surg Oral Med Oral Pathol Oral Endol 2006;101:299-303.
7Kedarnath NS, Abhilash PR. Role of platelet rich plasma in healing after impacted mandiber 3rd molar surgery. J Orofac Res 2011;1:6-10.
8Singh A, Kohli M, Gupta N. Platelet rich fibrin: A novel approach for osseous regeneration. J Maxillofac Oral Surg 2012;11:430-4.
9Pal US, Mohammad S, Singh RK, Das S, Singh N, Singh M, et al. Platelet-rich growth factor in oral and maxillofacial surgery. Natl J Maxillofac Surg 2012;3:118-23.
10Zhao QM, Ding YJ. Platelet rich fibrin in plastic surgery. Evid Based Med 2013;1:1-6.
11Lauritano D, Avantaggiato A, Candotto V, Zollino I, Carinci F. Is platelet-rich fibrin really useful in oral and maxillofacial surgery? Lights and shadows of this new technique. Ann Oral Maxillofac Surg 2013;1:25.
12Carso Del M, Choukroun J, Dohan D. Use of PRF in bony regeneration surgery. Dent Trib Asia Pac Ed 2012;8:10-3.
13Gandevivala A, Sangle A, Shah D, Tejnani A, Sayyed A, Khutwad G, et al. Autologous platelet-rich plasma after Third molar surgery. Ann Maxillofac Surg 2017;7:245-9.
14Lafzi A, Faramarzi M, Shirmohammadi A, Behrozian A, Kashefimehr A, Khashabi E. Subepithelial connective tissue graft with and without the use of plasma rich in growth factors for treating root exposure. J Periodontal Implant Sci 2012;42:196-203.
15Kaul RP, Godhi SS, Singh A. Autologous platelet rich plasma after third molar surgery: A comparative study. J Maxillofac Oral Surg 2012;11:200-5.
16Girish Rao S, Bhat P, Nagesh KS, Rao GH, Mirle B, Kharbhari L, et al. Bone regeneration in extraction sockets with autologous platelet rich fibrin gel. J Maxillofac Oral Surg 2013;12:11-6.
17Sommeling CE, Heyneman A, Hoeksema H, Verbelen J, Stillaert FB, Monstrey S. The use of platelet-rich plasma in plastic surgery: A systematic review. J Plast Reconstr Aesthet Surg 2013;66:301-11.
18Ogundipe OK, Ugboko VI, Owotade FJ. Can autologous platelet-rich plasma gel enhance healing after surgical extraction of mandibular third molars? J Oral Maxillofac Surg 2011;69:2305-10.
19Sndeep KA, Satyanarayana J, Rajani T. Tennis elbow treatment with platelet rich plasma: A prospective study. Int J Sci Study 2015;3:85-7.
20Nishimoto S, Fujita K, Sotsuka Y, Kinoshita M, Fujiwara T, Kawai K, et al. Growth factor measurement and histological analysis in platelet rich fibrin: A pilot study. J Maxillofac Oral Surg 2015;14:907-13.