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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 93-98

The efficacy of synthetic allograft and bioresorbable xenograft in immediate implant procedures: A comparative clinical study


Department of Oral and Maxillofacial Surgery, Oxford Dental College, Bengaluru, Karnataka, India

Date of Submission09-Jun-2020
Date of Acceptance12-Oct-2020
Date of Web Publication18-Dec-2020

Correspondence Address:
Dr. Jerin Jose
Department of Oral and Maxillofacial Surgery, Oxford Dental College, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdi.jdi_12_20

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   Abstract 

Aim: Immediate placement of an implant into the fresh extraction socket often leaves a space between the implant periphery and the surrounding bone, and the space between the implant and the bone is required to be filled with a biocompatible material such as a graft. This study aimed to compare the efficacy of synthetic bioactive glass allograft and dried freeze bovine bone grafts in the immediate implant site.
Materials and Methods: The study comprised a total of thirty individuals in the age group between 16 and 60 years with at least one tooth indicated for extraction. The thirty participants were further divided into two groups. Group A comprised 15 participants who underwent extraction and buccal plate preservation (BPP), followed by immediate implant placement using synthetic allograft material (PerioGlas). Group B comprised 15 participants who underwent extraction and BPP, followed by immediate implant placement using xenograft as the graft material (Bio-Oss). The participants were evaluated both clinically and radiographically for 3 months, 6 months, and 1 year. The level of significance was set at P < 0.05.
Results: PerioGlas and Bio-Oss in immediate implant site showed excellent osseointegration around the immediate implant site. However, the difference between the groups was not statistically significant.
Conclusion: Both synthetic allograft and bioresorbable xenograft are promising and equally potential in bone formation around the immediate implant site.

Keywords: Allograft, immediate implants, osseointegration, xenograft


How to cite this article:
Daniel D, Shetty V, Jose J, Kumar A H, Santosh B S, Saikrrupa S P. The efficacy of synthetic allograft and bioresorbable xenograft in immediate implant procedures: A comparative clinical study. J Dent Implant 2020;10:93-8

How to cite this URL:
Daniel D, Shetty V, Jose J, Kumar A H, Santosh B S, Saikrrupa S P. The efficacy of synthetic allograft and bioresorbable xenograft in immediate implant procedures: A comparative clinical study. J Dent Implant [serial online] 2020 [cited 2021 Apr 13];10:93-8. Available from: https://www.jdionline.org/text.asp?2020/10/2/93/303915


   Introduction Top


The long state of edentulism can compromise not only the function but also it might affect the self-confidence and quality of life of an individual. The emergence of osseointegration and advances in biomaterials and techniques has contributed to increased application of dental implants in the restoration of partial and completely edentulous patients. Immediate implant placement has become a favored treatment protocol by many clinicians worldwide. The immediate implant procedure outweighs the delayed implant placement first because it preserves alveolar bone height and width. Second, it avoids a second surgery with an added advantage of less operator time. Third, it causes less trauma to the tissues and discomfort to the patient. Overall, it improves the function and esthetics of the individual.[1],[2] To achieve an optimum treatment outcome with dental implants, adequate bone should be available to support and stabilize them. Although advanced diagnostic facilities are available, it is a challenge to placing an implant with the same extracted tooth dimensions. For enhanced osseointegration, and to prevent buccal plate resorption in an extracted socket, the space between the implant and the socket needs to be filled with a biocompatible material such as a graft.[2],[3] Buccal plate preservation (BPP) counteracts the changes in the esthetic zone of the soft tissue and maintains the contour while permitting natural socket healing. Besides, in the BPP technique, grafts are placed outside rather than inside the socket.[4],[5] The autogenous bone graft is considered the gold standard because it has got an excellent osteogenic, osteoinductive, and osteoconductive properties without the risk of graft rejection or adverse reactions. However, because of its donor-site morbidity and unpredictable resorption, a range of biomaterials, primarily bone xenografts and allografts, are used in the immediate implant site.[5] Synthetic allografts and xenografts are osteoconductive materials with low resorbability and provide primary stability with limited socket resorption. Bio-Oss is a biocompatible material that is more stable with a slow resorption rate and, in turn, helps in new bone formation.[6],[7] PerioGlas is an alloplastic material with osteoconductive properties. It acts as a scaffold for bone formation. It has no possible risk of cross-infection or disease transmission; moreover, it is easily available.[6],[7] However, this study attempted to compare the efficacy of synthetic allograft and bioresorbable xenograft in the immediate implant site for enhanced osseointegration.


   Materials and Methods Top


A comparative clinical study was conducted on individuals who reported to the Outpatient Department, Oxford Dental College, Bommanahalli, Bengaluru. A total of 30 individuals, including both men and women, aged between 16 and 60 years, were enrolled in the study. The thirty participants were further divided into two groups. Group A comprised 15 participants who underwent extraction and BPP, followed by immediate implant placement using synthetic allograft material (PerioGlas). Group B comprised 15 participants who underwent extraction and BPP, followed by immediate implant placement using xenograft as the graft material (Bio-Oss). The inclusion criteria were as follows: individuals with at least one tooth indicated for extraction with sufficient bone quality and quantity around the implant site and individuals with good systemic health and oral hygiene. The exclusion criteria were as follows: patients with any local infection around the implant site, pregnant or lactating mothers, patients with any systemic disease, individuals with a history of smoking habits, those who had or were undergoing irradiation therapy, patients on anticoagulant therapy, and patients with an existing condition or disease that would interfere with good mucosal and bone healing. Ethical clearance was obtained from the Institutional Ethical Committee on November 10, 2016, Ref No: 192/2016-17. Informed consent was also obtained from each individual for their participation in the study. Before placing implants, a detailed case history, intraoral, extraoral, and radiographic examination was done. This was followed by implant placement using standardized clinical and laboratory protocols.

Surgical procedures

Surgery was performed under local anesthesia (2% lignocaine with 1:200,000 concentration of adrenaline). Surgical procedures were carried under proper aseptic conditions. The teeth indicated for extractions were removed atraumatically. The sockets were then further evaluated on a computed tomography scan for any dimensional changes, and the final decision regarding the dimensions of the implant was taken. A crevicular incision was around the implant site. Full-thickness subperiosteal labial and palatal flaps were reflected to expose the crest to provide visualization of the buccal and lingual bone plates. A surgical pouch was created on the buccal/labial side using a periosteal elevator.

A pilot drill, usually 2 mm in diameter, was drilled at the implant site to establish the depth and axis of the implant recipient site. The implant was placed with its axis parallel to the occlusal forces. Furthermore, parallel pins were used to check the parallelism of the drill holes to the adjacent teeth. The drill was used in a reduction gear handpiece along with a physio-dispenser, enabling internal and external irrigation to prevent excessive heat generation. Sequential drilling at 800–1000 rpm was carried out until the desired dimensions depended on the required size of the implant. Furthermore, the implant (genesis) of size (4.0 mm × 11 mm and 3.5 mm × 11 mm) was placed, respectively, into the prepared site using a torque wrench. The discrepancies between the implant and walls of the socket were evaluated in all the thirty participants, and a bone graft was placed in the created surgical pouch of 15 sockets with synthetic allograft material (PerioGlas) and 15 sockets with xenograft (Bio-Oss) [Figure 1] and [Figure 2]. The membrane was placed over the graft, and 3-0 vicryl sutures were used to close the surgical wound. Oral hygiene instructions were given to patients and were followed up periodically both clinically and radiographically for 1 year.
Figure 1: (a) Immediate implant site, (b) PerioGlas as the graft material, (c) implant placement along with PerioGlas as the graft material, (d) 6-month postoperative radiograph, (e) clinical picture after 1-year follow-up

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Figure 2: (a) Immediate implant site, (b) Bio-Oss as the graft material, (c) implant placement along with Bio-Oss as the graft material, (d) 6-month postoperative radiograph, (e) clinical picture after 1-year follow-up

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Soft-tissue evaluation criteria

Evaluation of the soft tissue was done at four sites (mesial, buccal, distal, and lingual) using a modified plaque index, gingival index, and by measuring the probing depth. Probing depth was measured using a calibrated probe at both the full-mouth (FM) site and the Immediate implantation site (IMP).

Radiographic evaluation criteria

Intraoral periapical (IOPA) radiographs were taken using the long-cone paralleling technique. The radiograph was assessed at 3 months, 6 months, and 1 year. The radiographs were then analyzed using CorelDRAW software Software from Corel Corporation, Montreal,Quebec,Canada. The IOPA radiographs were transferred to the computer, enlarged to the actual implant size, and the amount of bone resorption was measured from the crestal bone level to the implant crest module at the mesial and distal sites.

Success criteria

The success of the implant was assessed based on the following criteria: first, the absence of any sign of peri-implant inflammation or infection both clinically and radiographically at the implant site, and second, the absence of clinical mobility.

Statistical power analysis

The Statistical Package for the Social Sciences for Windows version 22.0 released 2013. IBM Corp., Armonk, NY, USA, performed the statistical analyses. The sample size was calculated using power analysis at 80% power of the study. The total sample size of the study was 30 individuals. Each group consisted of 15 individuals. The Mann–Whitney U-test was used to compare the mean values of various study parameters between the two groups at different time intervals. Friedman's test, followed by the Wilcoxon signed-rank test as post hoc analysis, was used to compare the mean values of various study parameters between different time intervals in both Group A and Group B. The level of significance was set at P < 0.05.


   Results Top


The present study aimed to evaluate the efficacy of synthetic allograft and bioresorbable xenograft in the immediate implant site. For this purpose, we placed 15 implants of size 4.0 mm × 11 mm with allograft material (PerioGlas) and 15 implants of size 3.5 mm × 11 mm with bioresorbable xenograft (Bio-Oss), respectively, in the immediate implant site. All the patients included in the study were between the ages of 16 and 60 years. Of the 30 patients, 18 patients were female and 12 were male. The treatment outcome was evaluated both clinically and radiographically for a period of 1 year.

[Table 1] shows the comparison between mean plaque index values between Groups A and B in different periods at different sites. The treatment procedure was effective by placing both allograft and xenograft in the immediate implant site. At the end of 1 year, the plaque index values for Groups A and B were 0.68 and 0.7, respectively. However, comparing the plaque index values at 3 months, 6 months, and 1 year between Groups A and B showed no statistically significant difference [Table 1].
Table 1: Demonstrate the comparison between mean plaque index values between groups A & B for a period of 3M, 6M, and 1 year at different sites

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[Table 2] shows the comparison between mean gingival index values between Groups A and B for different sites (FM and IMP) 3 months, 6 months, and 1 year. In Group A, the FM gingival index was as follows: 0.86 ± 021 at 3 months, 0.82 ± 0.41 at 6 months, and 0.86 ± 0.31 at 1 year. Similarly, in Group B, the FM was 79 ± 0.24 at 3 months, 0.84 ± 0.31 at 6 months, and 0.82 ± 0.12 at 1 year. However, in the IMP site, the gingival index of Group A was as follows: 0.93 ± 0.25 at 3 months, 0.83 ± 0.26 at 6 months, and 0.94 ± 0.21 at 1 year, and in Group B, the IMP gingival index was 0.84 ± 0.2 at 3 months, 0.78 ± 0.27 at 6 months, and 0.80 ± 0.26 at the end of 1 year. Clinically excellent healing was observed after placement of the implant with both allograft and xenograft. Moreover, there were no signs of inflammation. However, a comparison of the mean gingival index in both Groups A and B showed no statistically significant difference. This could be due to the good oral hygiene routine maintained by the participants [Table 2].
Table 2: Demonstrate the comparison between mean gingival index values between groups A & B for different sites (FM & IMP) from baseline to 6 months

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[Table 3] demonstrates the values of probing depth in mesial, distal, buccal, and lingual sites at 3 months, 6 months, and 1 year. The results showed that the probing depth was further decreased over a period of 1 year, suggesting that the implant has good stability. However, there was no statistically significant between the two groups [Table 3].
Table 3: Demonstrate the mean values of probing depth which was evaluated at 6M, and 1 year

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[Table 4] demonstrates a considerable amount of bone resorption around the implant on the mesial and distal sites for both the groups at 3 months, 6 months, and 1 year. However, there was no statistically significant difference between the groups. These results suggest a good implant to bone osseointegration [Table 4].
Table 4: Demonstrate the considerable amount of bone resorption around the implant both on mesial and distal sites for both the groups at 3M, 6M, 1 year

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   Discussion Top


In the past two decades, implants have become one of the most exciting and rapidly developing treatment options in dental practice because of the high predictability of treatment outcomes compared to conventional prosthodontics. The emergence of the concept of osseointegration has contributed to an increase in the application of dental implants in the restoration of partially and completely edentulous patients. Immediate implant placement after extraction has become a favored treatment protocol as the natural socket has abundant periodontal cells and matrix, which promotes rapid healing and further decreases the risk of bone necrosis. Moreover, it eliminates the waiting period for socket ossification, fewer surgical sessions required, shortened edentulous period, reduced overall cost, preservation of alveolar bone height and width, and decreased operatory time with less trauma to the tissues and less discomfort to the patient.[8]

Becker et al. reported 93.3% of the survival of implants when placed at the time of extraction.[9],[10] However, it is well recognized that the extraction of a tooth can cause a reduction in bone volume, especially in the labial/buccal and marginal areas.[11] Socket preservation techniques may minimize remodeling and resorption; however, they cannot eliminate them completely. Besides, BPP is an alternative to traditional socket preservation.

Surgical intervention in the BPP technique includes bone graft placement outside rather than inside the socket.[11] However, these bone substitutes implanted into extraction sockets prevent labial or buccal bone resorption and counteract the changes in the esthetic zone and maintain the soft-tissue contour while permitting natural socket healing.

Low availability and donor-site morbidity of autogenous bone grafts have patented the use of alternative products, such as allogeneic and alloplastic materials. Bio-Oss is a highly porous structure with a large contact surface area, which in turn promotes more capillaries in the growth, migration, and proliferation of osteoblasts.[12] On the other hand, PerioGlas helps in osteoconduction, and their ability to bond to soft and osseous tissues makes it unique when compared to other alloplastic materials available.[13] The current study evaluated the efficacy of synthetic bioactive glass (allograft) and demineralized bovine bone matrix graft (Bio-Oss) in the immediate implant site. The outcome of treatment was evaluated both clinically and radiographically for 1 year.

The present study evaluated both the FM plaque index and plaque index of the IMP site. Comparing the mean plaque index values in both the groups at 3 months, 6 months, and 1 year, respectively, showed that although there was a decrease in plaque index values in the follow-up period. This indicates that this treatment procedure was effective using synthetic allograft and xenograft, respectively, in the immediate implant site. However, there was no statistically significant difference between either the groups. This could possibly be due to the better oral hygiene routine that was maintained by the patients in both the groups. Similarly, a study done by Vishwambaran et al.[14] compared the mean plaque index in the FM as well as the immediate implant site. The results showed a decrease in the mean value of the plaque index from baseline to 12 months, and this reduction was not statistically significant (P > 0.05).

The gingival index is another parameter for evaluating both the peri-implant mucosa and oral hygiene of the participants. In the current study, the results suggested the following: first excellent healing postoperatively with both allograft and xenograft, and second, mild gingivitis and good peri-implant tissue with no signs of inflammation. However, a comparison of the mean gingival index between Groups A and B showed no statistically significant difference. This could be due to the good oral hygiene routine maintained by the participants. Vishwambaran et al. reported that the mean gingival index for Group A was 0.901 and that for Group B 0.845 at the end of the 12-month period. Besides, gingival indices showed intermittent fluctuations without any statistical significance (P > 0.05).[14]

Peri-implant probing is an important parameter for the evaluation of periodontal health in the maintenance phase of periodontal therapy. The current study evaluated the probing depth at buccal, lingual, mesial, and distal sites for both Groups A and B. The present study showed a stable probing depth of <2 mm. This suggests that the implant site showed no signs of peri-implantitis and all the patients had good periodontal health. A study conducted by Vishwambaran et al. reported that the probing depths have increased because the implants were placed 1 or 2 mm below the level of the alveolar crest.[14]

The present study evaluated radiographically for bone resorption at the mesial and distal sites of the implant. The amount of bone resorption was measured from the crestal bone level to the implant crest module at the mesial and distal sites using CorelDRAW software. The results showed a significant decrease in bone height, indicating bone remodeling around the immediate implant site. However, further studies with larger sample sizes are recommended to obtain a significant statistical difference between the two groups.

Even though immediate implant placement is a very reliable and predictable procedure, to attain excellent osseointegration and primary stability, the jumping distance/voids between the implant and the buccal cortical plates need to be filled with a graft material. Buccal preservation techniques have had an added advantage as they do not interfere with the natural physiological healing of the socket and allow immediate implant placement by maintaining the soft-tissue contour. In addition, it is cost-effective since augmenting the labial plate externally requires less graft material than intrasocket grafting.[15] In the current study, the success of all the thirty implants at the end of 1 year was 100% with no sign of clinical mobility or infection both clinically and demographically. Thus, concerning the efficacy of synthetic allograft and bioresorbable xenograft, both showed excellent osseointegration around the immediate implant site. Moreover, there was no donor site morbidity, and overall, it was cost-effective, maintained excellent esthetics, and shortened edentulous period.


   Conclusion Top


Despite the limitations of this clinical trial, our study proved that both the synthetic allograft (PerioGlas) and xenograft (Bio-Oss) have equal potential in bone forming around the implant in various augmentation procedures. However, further research studies with more emphasis on the current topic are recommended.

Acknowledgment

We would like to thank the authors who viewed and agreed for submission and specially acknowledge Dr. Neelakamal Hallur, Dr. Ashwini, Dr. Shereen, and Dr. Kapil.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Becker W, Clokie C, Sennerby L, Urist MR, Becker BE. Histologic findings after implantation and evaluation of different grafting materials and titanium micro screws into extraction sockets: Case reports. J Periodontol 1998;69:414-21.  Back to cited text no. 1
    
2.
Froum SJ, Weinberg MA, Tarnow D. Comparison of bioactive glass synthetic bone graft particles and open debridement in the treatment of human periodontal defects. A clinical study. J Periodontol 1998;69:698-709.  Back to cited text no. 2
    
3.
Hall EE, Meffert RM, Hermann JS, Mellonig JT, Cochran DL. Comparison of bioactive glass to demineralized freeze-dried bone allograft in the treatment of intrabony defects around implants in the canine mandible. J Periodontol 1999;70:526-35.  Back to cited text no. 3
    
4.
Brugnami F, Caiazzo A. Efficacy evaluation of a new buccal bone plate preservation technique: A pilot study. Int J Periodontics Restorative Dent 2011;31:67-73.  Back to cited text no. 4
    
5.
Brugnami F, Caiazzo A. Immediate placement and provisionalization with buccal plate preservation: A case report of a new technique. J Oral Implantol 2013;39:380-5.  Back to cited text no. 5
    
6.
Cordioli G, Mazzocco, Schepers, Brugnolo Z. Maxillary sinus floor augmentation using bio active glass granules and autogenous bone with simultaneous implant placement. Clinical and histological findings. Clin Oral Implants Res 2001;12:270-8.  Back to cited text no. 6
    
7.
Artzi Z, Nemcovsky CE, Dayan D. Bovine-HA spongiosa blocks and Immediate implant placement in sinus augmentation procedures histopathological and histomorphometric observations on different histological stainings in 10 consecutive patients. Clin Oral Implants Res 2002;13:420-7.  Back to cited text no. 7
    
8.
Nevins M, Camelo M, De Paoli S, Friedland B, Schenk RK, Parma-Benfenati S, et al. A study of the fate of the buccal wall of extraction sockets of teeth with prominent roots. Int J Periodontics Restorative Dent 2006;26:19-29.  Back to cited text no. 8
    
9.
Becker W, Dahlin C, Becker BE, Lekholm U, van Steenberghe D, Higuchi K, et al. The use of e-PTFE barrier membranes for bone promotion around titanium implants placed into extraction sockets: A prospective multicenter study. Int J Oral Maxillofac Implants 1994;9:31-40.  Back to cited text no. 9
    
10.
Becker W, Dahlin C, Lekholm U, Bergstrom C, van Steenberghe D, Higuchi K, et al. Five-year evaluation of implants placed at extraction and with dehiscences and fenestration defects augmented with ePTFE membranes: Results from a prospective multicenter study. Clin Implant Dent Relat Res 1999;1:27-32.  Back to cited text no. 10
    
11.
Misawa M, Lindhe J, Araujo MG. The alveolar process following tooth extraction: A study of maxillary incisor and premolar sites in man. Clin Oral Implant Res 2016;27:884-9.  Back to cited text no. 11
    
12.
Shirmohammadi A, Roshanagar L, Chitsazi MT, Pourabbas R, Faramarzie M, Rashmanpour N. Comparative study on the efficacy of anorganic bovine bone (bio-oss) and nanocrystalline hydroxyapatite (ostim) in maxillary sinus floor augmentation. Int Sch Res Notice 2014;1:1-7  Back to cited text no. 12
    
13.
Chacko NL, Abraham S, Rao HN, Sridhar N, Moon N, Barde DH. A Clinical and radiographic evaluation of periodontal regenerative potential of PerioGlas®: A synthetic, resorbable material in treating periodontal infrabony defects. J Int Oral Health 2014;6:20-6.  Back to cited text no. 13
    
14.
Vishwambaran M, Aorar V, Tripati RC, Dhiman RK. Clinical evaluation of immediate implants using different types of bone augmentation materials. Med J Armed Forces India 2014;70:154-62.  Back to cited text no. 14
    
15.
Caiazzo A, Brugnami F, Galletti F, Mehra P. Buccal plate preservation with immediate implant placement and provisionalization: 5-year follow-up outcomes. J Maxillofac Oral Surg 2018;17:356-61.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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