|ORIGINAL ARTICLE - COMPARATIVE STUDY
|Year : 2017 | Volume
| Issue : 2 | Page : 245-249
Autologous platelet-rich plasma after third molar surgery
Adil Gandevivala1, Amit Sangle2, Dinesh Shah1, Avneesh Tejnani3, Aatif Sayyed2, Gaurav Khutwad2, Arpit Arunbhai Patel4
1 Department of Oral and Maxillofacial Surgery, MGM Dental College and Hospital, Navi Mumbai, India
2 Department of Oral and Maxillofacial Surgery, M.A. Rangoonwala College of Dental Sciences and Research Center, Pune, India
3 MDS in Periodontology, Private Practitioner, Coral Dental Advance Care and Implant Center, Mumbai, India
4 BDS, Private Practitioner, Bapuji Dental Clinic, Surat, Gujarat, India
|Date of Web Publication||22-Nov-2017|
Department of Oral and Maxillofacial Surgery, MGM Dental College and Hospital, Navi Mumbai, Maharashtra
Aim and Objective: The aim of this study is to compare the efficacy of autologous platelet-rich plasma (PRP) in the third molar impactions, with respect to: pain, swelling, healing, and periodontal status distal to the second molar in patients who need surgical removal of bilateral impacted mandibular third molars. Materials and Methods: Twenty-five patients of both sexes aged between 16 and 60 years who required bilateral surgical removal of their impacted third molars and met the inclusion criteria were included in the study. After surgical extraction of the third molar, primary closure was performed in the control group, whereas PRP was placed in the socket followed by primary closure in the case group. The outcome variables were pain, swelling, wound healing, and periodontal probe depth that were follow-up period of 2 months. Quantitative data are presented as mean. Statistical significance was checked by t-test. Results: There was a difference in the pain (0.071) and facial swelling (0.184), reduction between test and control on day 3, but it was not found to be significant. Periodontal pocket depth (0.001) and wound healing (0.001) less in case group compared with the control group was found to be significant. Conclusion: The use of PRP lessens the severity of immediate postoperative sequelae and decreases preoperative pocket depth.
Keywords: Growth factor, Platelet-rich plasma, third molar
|How to cite this article:|
Gandevivala A, Sangle A, Shah D, Tejnani A, Sayyed A, Khutwad G, Patel AA. Autologous platelet-rich plasma after third molar surgery. Ann Maxillofac Surg 2017;7:245-9
|How to cite this URL:|
Gandevivala A, Sangle A, Shah D, Tejnani A, Sayyed A, Khutwad G, Patel AA. Autologous platelet-rich plasma after third molar surgery. Ann Maxillofac Surg [serial online] 2017 [cited 2018 Mar 17];7:245-9. Available from: http://www.amsjournal.com/text.asp?2017/7/2/245/218960
| Introduction|| |
Third molars are the teeth that are most commonly impacted. Third molars are present in 90% of the population with 33% having at least one impacted third molar, and these impactions are probably the result of both genetic and environmental factors. An impacted tooth can cause the patient mild to serious problems if it remains in the unerupted state. However, surgical removal of impacted third molars is one of the most frequently performed surgical procedure to treat pathosis caused by impacted teeth. The procedure requires sound understanding of surgical principles along with patient management skills. Although it is a minor surgical procedure, its relation to adjacent soft tissues, vital teeth, and neurovascular bundle makes it a complex procedure. Periodontal pocket formation on the distal of mandibular second molar and subsequent cementum exposure following the removal of partially erupted or impacted 3rd molars has been a problem in oral and maxillofacial surgical practice.,,, Management is usually directed at periodontal maintenance distal to the second molar and at prevention of osseous defects created by the surgical removal of third molar. Healing is a complex process which involves participation of many cell types and growth factors. The platelets, activated by coagulation cascade particularly thrombin and subendothelial collagen, release a number of growth factors from their alpha granules into the wound site.
Platelet-rich plasma (PRP) is an autologous concentrate of platelets suspended in plasma.,, It is a proven source of growth factors such as platelet-derived growth factors and transforming growth factor β 1 and 2, which is obtained by sequestering and concentrating platelets by gradient-density centrifugation., By combining with calcium chloride and thrombin, PRP releases these growth factors. PRP gel also contains a native concentration of fibrinogen. As a result, it permits stabilized coagulation of blood, thereby favoring regeneration of osseous defects particularly in the early stages.
Soft tissue healing is also substantially improved through the application of PRP, by increasing collagen content, promoting angiogenesis, and increasing early wound strength. The growth factors found in PRP regulate key cellular processes, such as chemotaxis, cell differentiation, and metabolism. It was Marx et al. popularized application of PRP in oral and maxillofacial surgery proving that PRP contains concentration of platelets up to 338% along with increased concentration of growth factors within them. When used along with bone grafts, PRP gives additional amount of growth factors shown by increased radiographic maturation rate by 1.6~ to 2.16 times.,,
| Materials and Methods|| |
Patients of both sexes aged between 16 and 60, who had presented with bilateral mandibular impactions of similar clinical presentation and difficulty index (Pell and Gregory) were subjected to the study. Exclusion criteria were medical history such as diabetes, on anticoagulant therapy, any blood dyscrasias, pregnancy, HIV and immunocompromised, allergy to LA, and any systemic disease which have its effect in healing. Routine records for the purpose of diagnosis and treatment planning along with panaromic/intraoral periapical radiograph were obtained from all the patients. Informed written consent was taken from all the patients before treatment.
A detailed case history of the patient was obtained. An informed consent was obtained from the patients regarding the surgery as well as the use of PRP.
The surgical sites were divided into two groups:
- Group I (control) – In which PRP was not placed in the extraction socket
- Group II (test) – In which PRP was placed in the extraction socket.
Preparation of platelet-rich plasma
Ten milliliters blood was drawn from the patient by venipuncture at antecubital fossa in either of the arms. This blood was transferred to autoclaved centrifugation tubes containing 1 ml of citrate phosphate dextrose adenine (CPDA). Blood sample was centrifuged at 1300 rpm for 10 min to be separated into red blood cells (RBCs), buffy coat layer, and plasma [Figure 1]. Five milliliters syringe was used to aspirate straw-colored plasma and 1– 2 mm of top part of RBC layer. It was then transferred to another tube and centrifuged at 2000 rpm for 10 min to separate serum and PRP. The PRP was aspirated by inserting the syringe as far as it can go. The contents of this syringe was emptied into a sterile container. In our technique, calcium gluconate alone was mixed with PRP to form an autologous platelet gel. This platelet gel was free of eliciting any antigen– antibody reaction as it was prepared from patients own blood.
Complete sterile and aseptic techniques were used before the surgery. Scrubbing of the surgical field was performed using savlon solution followed by intraoral irrigation with betadine and normal saline. Mandibular block was given to anesthetize the inferior alveolar, lingual, and long buccal nerve using 2% lignocaine hydrochloride with 1:200,000 adrenaline. Standard Ward's incision was used in all the cases. Full-thickness mucoperiosteal flap was raised to expose sufficient bone on the buccal and distal aspect of the impacted molar. The lingual flap was reflected to expose the distolingual aspect of the bone and the tooth.
The removal of bone was done with the help of stainless steel burs (number 8). A straight handpiece and micromotor were used. Buccal and distal bone was removed, and in some cases, a notch was made in bone near cementoenamel junction of impacted tooth for elevation. Constant irrigation with saline was used while removing bone to prevent thermal necrosis.
Tooth was luxated with the help of straight elevator and then extracted with the help of third molar forceps employing minimal forces. In some cases, sectioning of tooth was done. The surrounding bone was smoothened. The wound was gently irrigated using sterile saline solution. Wound was checked for any small detached fragments of bone or any tooth pieces.
In Group I, PRP gel was not placed in the extraction socket; closure of extraction socket was done.
In Group II, PRP gel was placed in the extraction socket, followed by closure of extraction socket [Figure 2].
|Figure 2: Gel form of platelet-rich plasma and its placement as grafting|
Click here to view
The irregular margins of the wound were trimmed. Wound was closed with 3-0 black braided silk sutures. Interrupted sutures were placed. Pressure pack was given. Regular postextraction instructions were given.
Two observers (guide and pg student) involved in this research observed the patient in a standardized review protocol on the 1st, 3rd, 7th, and 60th day after surgery for Pain, swelling, Wound healing, periodontal Probing depth.
Pain was evaluated using visual analog scale (VAS) on the 1st, 3rd, and 7th day. Swelling was evaluated by measuring the horizontal distance from the corner of the mouth to the lobe of the ear and the vertical distance from the outer canthus of the eye to the angle of the mandible. The measurements were transferred onto a scale and recorded on a sheet [Figure 3]. The measurements were made on the day of surgery, 3rd and 7th day postoperatively.
Healing was evaluated by visual control and cautious exploration of a periodontal probe. It was used to evaluate any possible dehiscence or gaping of the wound margins. In this study, every gaping along the entire incision line was defined as a dehiscence. Healing was evaluated on the 7th day postoperatively. Periodontal pocket depth was evaluated pre- and post-operative using a Williams periodontal probe on the distobuccal, distolingual, and distal surfaces. The mean value was calculated. Periodontal pocket depth was measured on the 60th day postoperatively.
| Results|| |
The results were evaluated based on clinical observations and measurements. All results were calculated using the mean value and standard deviation. Each of the parameters considered and checked for statistical significance using t-test.
Pain was significantly reduced to 1.1 ± 0.6 on day 3 and on day 7 as compared to 2.1 ± 0.7 on day 1 in the control group as shown in [Table 1], P = 0.001. Pain had significantly reduced to 0.6 ± 0.6 on day 3 and to 0 on day 7 as compared to 1.8 ± 0.8 on day 1 in the test group as shown [Figure 4].
|Table 1: The within group comparison of pain and percent facial swelling in each study group|
Click here to view
Comparison of facial swelling within the group and between the groups was done. Facial swelling significantly reduced at day 7 compared to day 3 in both test and control group as shown in [Table 1]. In the control group, percentage facial swelling on day 3 was 4.3 ± 2.9 and day 7 was 0.1 ± 0.08. P value calculated when day 3 was compared to day 7 was found to be 0.001, which was found to be statistically significant. In test group, percentage facial swelling on day 3 was 2.9 ± 1.7 and day 7 was 0.04 ± 0.2, P value calculated when day 3 was compared with day 7 was found to be 0.001, which was found to be statistically significant. Percentage reduction in facial swelling at day 3 is significantly lesser in test group compared to the control group.
Wound healing was judged by the absence of dehiscence. Comparison between the test and control group was done. Significantly higher proportion of patients from control group had more dehiscence compared to test group. In all, 44% of patients had dehiscence in the control group. One patient or 4% of the patients had dehiscence. P value was found to be 0.001, which was statistically significant as shown in [Table 2].
Periodontal probing depth was measured 2 months postoperatively, and the mean periodontal probing depth is significantly higher in control group compared to the test group as shown in [Figure 5]. The mean value of periodontal probing depth was 3.9 ± 0.2 in control group compared to 2.6 ± 0.4 in the test group. P value was found to be 0.001, which was statistically significant as shown in [Table 3].
|Figure 5: Result of periodontal probe depth between the cases and control group|
Click here to view
| Discussion|| |
The optimal management of impacted mandibular third molars continues to challenge clinicians. There are various materials used at the time of tooth extraction to maintain or enhance ridge form for prosthetic rehabilitation and periodontal health. After the extraction of mandibular third molar, a reported complication is the development of periodontal osseous and soft tissue defects on the distal of second molar.
It was Whitman et al. who introduced the PRP to oral and maxillofacial surgery community, used it as fibrin glue for faster soft tissue healing. The author thought that through activation of the platelets within the gel and the resultant release of the growth factors, enhanced wound healing should be expected.
The PRP gel is a product of PRP with thrombin and calcium and was used initially as a soft tissue sealing agent., However, it was Marx et al. in 1998, who popularized PRP in oral and maxillofacial surgery after the publication of their landmark article, which showed that combining PRP with autogenous bone in mandibular continuity defects resulted in significantly faster radiographic maturation and histomorphometrically denser bone regenerate.
Landesberg et al. and Marx et al. stated that the use of ethylenediaminetetraacetic acid (EDTA) is potentially more harmful than citrate. Although EDTA gave greater yields of platelets, they appeared damaged by the presence of EDTA. Hence, we used CPDA anticoagulant solution in our study as it maintains or preserves platelet membrane integrity.
The positive effects of PRP as reported in literature are:,,,
- “Jump starts” the cascade of osteogenesis in bone graft
- Improves trabecular bone density
- Provides earlier availability of growth factors and bone morphogenetic proteins
- Promotes early consolidation of the graft
- Hastens the mineralization of the graft.
Pain was also assessed with VAS for pain and it was found that the severity of pain was equal both in study and control side, and the results were not significant at all the time recorded from day 1 to day 7.
We assessed the percentage of facial swelling in both the study and the control side according to the formula given by Amin and Laskin  The percentage of facial swelling was greater on the control side as compared to the study side at the third postoperative day and at the seventh postoperative day.
On evaluating wound dehiscence, we found that Group II (test) showed dehiscence in 1 (4%) case out of 25 and Group I showed dehiscence in 11 (44%) of cases on the seventh postoperative day. This signifies a better soft tissue healing of extraction sockets treated with autologous PRP. The difference is significant. Our finding is supported by Fennis et al in which comparison group showing Statically superior healing with PRP.
A comparison of the probing depth between both the groups at 2 months was done. The value of the periodontal pocket depth in the control group was significantly larger when compared to the test group. This result is supported by a study conducted by Sammartino et al. where notable reduction in probing depth was observed at 12 and 18 weeks in those extraction cases treated with PRP compared to controls where PRP was not used.
In the present study, PRP was placed in the third molar extraction sockets. We found that there was good soft tissue healing response in PRP-treated sites as compared to the other site.
In our study, results showed clinical significant in reduced facial swelling, good wound healing, reduction periodontal probe, and clinical insignificant for pain between both study groups. The limitation of this study was that 2-month postoperative follow-up is of short duration to comment on the efficacy of PRP in complete soft tissue healing process but adequate enough to evaluate the effects of PRP in initiating and enhancing both hard and soft tissue healing. Long-term follow-up is required along with histological study of the bone for assessment of the efficacy of PRP.
| Conclusion|| |
In our study, results showed clinically significant reduced facial swelling, good wound healing, reduction periodontal probe, and clinical insignificant for pain between both study groups. The limitation of this study was that 2-month postoperative follow-up is of short duration to comment on the efficacy of PRP in complete soft tissue healing process but adequate enough to evaluate the effects of PRP in initiating and enhancing both hard and soft tissue healing. Long-term follow-up is required along with histological study of the bone for assessment of the efficacy of PRP
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Scherstén E, Lysell L, Rohlin M. Prevalence of impacted third molars in dental students. Swed Dent J 1989;13:7-13.
Osborne WH, Snyder AJ, Tempel TR. Attachment levels and crevicular depths at the distal of mandibular second molars following removal of adjacent third molars. J Periodontol 1982;53:93-5.
Kugelberg CF, Ahlström U, Ericson S, Hugoson A. Periodontal healing after impacted lower third molar surgery. A retrospective study. Int J Oral Surg 1985;14:29-40.
Peng KY, Tseng YC, Shen EC, Chiu SC, Fu E, Huang YW. Mandibular second molar periodontal status after third molar extraction. J Periodontol 2001;72:1647-51.
Richardson DT, Dodson TB. Risk of periodontal defects after third molar surgery: An exercise in evidence-based clinical decision-making. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:133-7.
Throndson RR, Sexton SB. Grafting mandibular third molar extraction sites: A comparison of bioactive glass to a nongrafted site. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:413-9.
Tsay RC, Vo J, Burke A, Eisig SB, Lu HH, Landesberg R. Differential growth factor retention by platelet-rich plasma composites. J Oral Maxillofac Surg 2005;63:521-8.
Tischler M. Platelet rich plasma. The use of autologous growth factors to enhance bone and soft tissue grafts. N
Y State Dent J 2002;68:22-4.
Landesberg R, Roy M, Glickman RS. Quantification of growth factor levels using a simplified method of platelet-rich plasma gel preparation. J Oral Maxillofac Surg 2000;58:297-300.
Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: Growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:638-46.
Marx R, Garg A. Dental and Craniofacial Applications of Platelet Rich Plasma. London: Quintessence Publishing Co, lnc.; 2005.
Kanno T, Takahashi T, Tsujisawa T, Ariyoshi W, Nishihara T. Platelet-rich plasma enhances human osteoblast-like cell proliferation and differentiation. J Oral Maxillofac Surg 2005;63:362-9.
Marx RE. Platelet-rich plasma: Evidence to support its use. J Oral Maxillofac Surg 2004;62:489-96.
Whitman DH, Berry RL, Green DM. Platelet gel: An autologous alternative to fibrin glue with applications in oral and maxillofacial surgery. J Oral Maxillofac Surg 1997;55:1294-9.
Gerard D, Carlson ER, Gotcher JE, Jacobs M. Effects of platelet-rich plasma on the healing of autologous bone grafted mandibular defects in dogs. J Oral Maxillofac Surg 2006;64:443-51.
Simon D, Manuel S, Geetha V, Naik BR. Potential for osseous regeneration of platelet-rich plasma – A comparative study in mandibular third molar sockets. Indian J Dent Res 2004;15:133-6.
Lynch S, Genco R, Marx RE. Platelet rich plasma: A source of multiple autologous growth factors for bone grafts. Tissue Engineering- Applications in Maxillofacial Surgery and Periodontics. Ch. 4. London : Quintessence Publications Co., Inc.; 1999. p. 71-82.
Damante JH, Da S Guerra EN, Ferreira Jr O. Spontaneous resolution of simple bone cysts. Dentomaxillofac Radiol 2002;31:182-6.
Amin MM, Laskin DM. Prophylactic use of indomethacin for prevention of postsurgical complications after removal of impacted third molars. Oral Surg Oral Med Oral Pathol 1983;55:448-51.
Fennis JP, Stoelinga PJ, Jansen JA. Mandibular reconstruction: A histological and histomorphometric study on the use of autogenous scaffolds, particulate cortico-cancellous bone grafts and platelet rich plasma in goats. Int J Oral Maxillofac Surg 2004;33:48-55.
Sammartino G, Tia M, Marenzi G, di Lauro AE, D'Agostino E, Claudio PP. Use of autologous platelet-rich plasma (PRP) in periodontal defect treatment after extraction of impacted mandibular third molars. J Oral Maxillofac Surg 2005;63:766-70.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]