Mansoura Universiy

Faculty of Dentistry
Department of oral medicine, periodontology,
oral diagnosis and oral radiology

Clinical and radiographical assessment of the role of platelet rich

fibrin with delayed short dental implants placement {Comparative
Clinical Study}.

A protocol of Thesis
Submitted to Faculty of Dentistry, Mansoura University partially fulfills
requirements of obtaining Master of Sceince Degree in Dentistry in Oral Medicine and
Periodontology.

Submitted by

Amr Yousef Kamal Aly Elshahawy

BDS, Faculty of Dentistry, 2013 Mansoura
University
Dentist at the Egyptian Ministry of Health

2022

1
 Supervisors

Dr. Laila Ibrahim Ragab Sedky.

Associate. Professor of Oral Medicine, Periodontology, Diagnosis and Oral

Radiology
Faculty of Dentistry
Mansoura University

Dr. Ayman Abdel Rahim Mohammed Elkashty

Lecturer of oral medicine, Periodontology, Diagnosis and oral Radiology

Faculty of Dentistry
Mansoura University

Dr. Mohamed Abd El-Rahman Ellayeh

Lecturer of Fixed Prosthodontics

Faculty of Dentistry
Mansoura University

2022

2
 Introduction

Dental implants are widely used nowadays. They have been proved to be a
boon to dentistry. A careful insertion of dental implants ensures high survival rate for
longer duration. Preferably longer dental implants are used depending on the amount of
bone available. However, shorter dental implants (SDIs) can be used in resorbed ridges
where there is limited bone height1.

However, in severe alveolar resorption, standard-length implant (≥10mm)

placement is not possible without additional surgical interventions including bone
grafting, sinus floor augmentation, distraction osteogenesis, mandibular nerve
transposition and zygomatic implant placement. These procedures are associated with
increased surgical morbidity, prolonged treatment times, and higher cost2.

The use of short implants is considered a major contribution to the field of

implant dentistry and is a novel therapeutic option for patients with severe alveolar
resorption. Although the predictability of short implants was initially controversial due
to decreased bone-to-implant contact, several studies have reported short implants to
have survival rates similar to those of standard-length implant2.

Generally, 5- to 8-mm-long implants have been defined as short implants. Short

implants have high success rate and good stability with the development of material
surface treatment technology and structural modifications of the titanium surface now.
The survival rate of single crowns in the posterior area showed no significant differences
between the short implant group and the long implant group3.

Platelet concentrates (PCs) have emerged as a potential regenerative

material, used alone or as scaffold for other graft materials. PCs are blood extracts,
obtained after processing a whole blood sample, mostly through centrifugation4.

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 A second PCs generation was introduced in 2001. The use of platelet-rich fibrin
(PRF) is simple and requires neither anticoagulant, bovine thrombin nor calcium
chloride. It is nothing more than centrifuged blood without any additives4 .

Enveloping the implant with platelet rich fibrin significantly speeds up the healing
process and tissue regeneration. The soft tissue healing occurs at an accelerated rate.
It also reduces and repairs the small osseous defects. The best advantage of PRF is its
cost effectiveness, prepared from patient’s own blood. The use of short implants offer,
in relation to the regenerative techniques, several advantages: low cost and treatment
length, simplicity, and less risk of complications5.

The null hypothesis is that PRF will enhance and give better results for
osseointegration of short implants. So, the present study is going to check the role of
the PRF on short implant osseointegration clinically and radiographically.

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 Aim of the study

The aim of the present study is to evaluate the effect of platelet -rich fibrin on
delayed placement of short dental implants both clinically and radiographically.

5
 Patients and methods

Study design: A comparative clinical study.

Study and population:
A total of sixteen Patients with missing posterior molar teeth in need of implant
placement will be selected from the outpatient clinic of Oral medicine and
Periodontology, Faculty of Dentistry, Mansoura University.

The patients will have all of the information available about the treatment that
they will receive and steps that will be done .This includes the possible effects or risks,
and other treatment options .The patients must understand this explanation in broad
terms. The patients must be legally competent to give written consent before performing
any required steps.

 Inclusion criteria:
1. Patients with missing posterior molar tooth /teeth.
2. Patient’s age range between 18 and 60 years old includes both genders.
3. Sufficient bone width mesiodistally and buccolingually at least 8 mm in both directions.

 Exclusion criteria:
1. Insufficient bone width (less than 8 mm) mesiodistal or buccolingually.
2. Patients having any uncontrolled systemic disease which could affect bone healing.
3. Patients treated with radiotherapy to the head and neck area within the past 12
months.
4. Heavy Smokers (more than 20 cigarette per day) according to WHO.
5. Inability or unwillingness to return for follow-up visits.

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 Pre-operative assessment:
Personal, medical, and dental history will be taken from each patient. Every
patient will be examined clinically and radiographically.

 Clinical examination:
Every patient will be examined at site of future implant placement for the
following:
1. Examination of the edentulous area where the implant will be placed.
2. Inspection of gingival tissue and amount of attached gingiva.
3. General periodontal status.
4. Any clinical signs of pathological conditions.

 Radiographic evaluation:
Cone Beam Computed Tomography (CBCT) will be taken at baseline to evaluate
the following:
1. Screening of patient before inclusion in the study.
2. Exact bone height and width of alveolar ridge.
3. Dimensions of the implant to be placed.
4. Presence of any lesions or bony defect.
5. Proximity of the bone crest to surrounding vital structure.
6. The divergence of the root adjacent to the operative area for proper implant
angulation.

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  Study groups:
All patients will be divided equally into 2 groups:

Group (1): (control group)

Eight patients will receive short dental implants only.
Group (2): (Study group)
Eight patients will receive short dental implants with PRF application at the
osteotomy sites.

 Treatment plan:
.
Implant placement:
For both groups, after local anesthesia administration, full thickness flap will be
raised at future implant site then after proper osteotomy preparation; the implant will be
seated completely within the confine of the prepared site in vertical plane and screwed
manually to its final position. Primary implant stability will be evaluated by resonance
frequency analysis (RFA) technique using the osstell device.

A smart peg will be screwed to the fixture to record the stability and implant
stability quotient (ISQ) value will be recorded into chart. Also, analyzing the insertion
torque values (ITVs) at the implant placement.
Platelet‑rich fibrin preparation protocol:

During surgery, 10 ml of blood is collected from the patient (study group) in a

plain vacutainer tube and immediately centrifuged at 3000 rpm for 10 min, at room
temperature in a centrifugal machine5,6. After which it settles into the following layers:
red lower fraction containing red blood cells, upper straw colored a c e l l u l ar plasma
and the middle fraction containing the fibrin clot.
The upper straw colored layer is then removed and middle fraction is
collected, 2 mm below lower dividing line, which is the PRF7.The processed PRF
is ready for placement in the prepared site.
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Post-operative care:
Cold fomentation for the first 24 hours, warm mouthwash will start from the next
day, and oral hygiene recommendations. Antibiotic in the form of Amoxicillin +
Clavulanic acid 1000 mg tablets twice daily for 7 days, Ibuprofen 400 mg tablets 3
times daily for 5 days, Chlorhexidine (0.12%) as a warm mouth wash will be
prescribed 3 times daily for one week, and Trypsin + Chymotrypsin as antiedemetous
will be prescribed 3 times daily for one week.

Post-operative follow-up:
Patients will be evaluated clinically for wound healing, soft tissue dehiscence,
excursion, or wound infection.

A) Clinical evaluation:
1- Pain:
It will be evaluated using visual analogue scale VAS on the first post-operative
day, third day, one week and two weeks8.

2- Implant stability:
The implants will be assessed in terms of stability immediately after insertion (T0)
and three months (T1) post operatively by using osstell device.

3- Gingival index(GI):
Modified gingival index will be recorded according to Mombelli et al9 , as
follows: score 0; normal gingiva, score 1; mild inflammation (slight change in color &
slight edema), but no bleeding on probing, score 2; moderate inflammation (redness &
edema), and bleeding on probing, and score 3; sever inflammation (marked redness,
edema & ulceration) with tendency to spontaneous bleeding.

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4- Plaque index (PI):

Plaque will be assessed according to modified plaque index describe by

Mombelli et al9 as follows: score 0; no plaque detected, score 1; plaque recognized
only by running a probe across a smooth marginal surface of the implant, score 2;
plaque can be seen by naked eyes, score 3; abundance of soft mater.

5- Pocket depth (PD):

Using a calibrated plastic periodontal probe, the distance between marginal

border of the gingiva and the tip of the probe will be measured in mm and considered
as pocket depth (PD).

Radiographic evaluation:

1- Digital periapical radiographic view:

Post-operative digital periapical radiograph with parallel technique will be taken

immediately (T0) then at follow up at 3 months (T1) and at 6 months (T2) of implant
placement for evaluation of amount of crestal bone changes mesiodistally.

2- Cone Beam Computed Tomography (CBCT):

CBCT will be taken for the site of implant placement after 6 months to evaluate:

1- Accurate placement of dental implant related to surrounding vital structures and

neighboring teeth.
2- Amount of crestal bone loss mesiodistally and buccolingually.

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  Statistics:
The data will be collected and subjected to statistical analysis using Statistical
Package for the Social Science (SPSS) program.

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References
1. Singh, Anuj & Kochhar, Anuraj & Das, Abhaya & Razi, Mohammed. (2020).
Assessment of the Survival Rate of Short Dental Implants in Medically Compromised Patients. The
journal of contemporary dental practice. 21. 880-3.

2. Hasanoglu Erbasar GN, Hocaoğlu TP, Erbasar RC. Risk factors associated with
short dental implant success: a long-term retrospective evaluation of patients followed up for up to 9
years. Braz Oral Res. 2019;33:e030. doi: 10.1590/1807-3107bor-2019.vol33.0030. Epub 2019 Apr 11.
PMID: 30994707.

3. Chen S, Ou Q, Wang Y, Lin X. Short implants (5-8 mm) vs long implants (≥10 mm) with
augmentation in atrophic posterior jaws: A meta-analysis of randomised controlled trials. J Oral
Rehabil. 2019 Dec;46(12):1192-1203. doi: 10.1111/joor.12860. PMID: 31295755.

4. Pietruszka P, Chruścicka I, Duś-Ilnicka I, Paradowska-Stolarz A. PRP and PRF-

Subgroups and Divisions When Used in Dentistry. J Pers Med. 2021 Sep 23;11(10):944. doi:
10.3390/jpm11100944. PMID: 34683085; PMCID: PMC8540475.

5. Kaur, Dapinder & Sharma, Abhay & Dudeja, Palak & Gupta, Renu &
Luthra, RP & Sharma, Neha & Sheth, Hardik Hitesh. (2019). A novel way to place
short implants using platelet- rich fibrin (PRF): An original research.

6. Mitra DK, Potdar PN, Prithyani SS, Rodrigues SV, Shetty GP, Talati MA.Comparative
study using autologous platelet-rich fibrin and titanium prepared platelet-rich fibrin in the treatment of
infrabony defects: An in vitro and in vivostudy. J Indian Soc Periodontol 2019;23:554-61.

7. Saluja H, Dehane V, Mahindra U. Platelet-Rich fibrin: A second generation platelet concentrate

and a new friend of oral and maxillofacial surgeons. Ann Maxillofac Surg 2011;1:53-7

8. Williamson A, Hoggart B. Pain: A review of three commonly used pain rating scales. J Clin
Nurs. 2005;14:798–804.

9. Mombelli A, Marxer M, Gaberthüel T, Grunder U, Lang NP. The microbiota of osseointegrated

implants in patients with a history of periodontal disease. J Clin Periodontol. 1995 Feb;22(2):124-30. doi:
10.1111/j.1600-051x.1995.tb00123.x. PMID: 7775668.

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‫‪2022‬‬

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