EGYPTIAN Vol.

70, 1213:1222, April, 2024

DENTAL JOURNAL Print ISSN 0070-9484 • Online ISSN 2090-2360
www.eda-egypt.org
Oral Medicine, X-Ray, Oral Biology and Oral Pathology
Submit Date : 26-12-2023 • Accept Date : 04-01-2024 • Available online: 05-04-2024 • DOI : 10.21608/EDJ.2024.258200.2850

CLINICAL AND RADIOGRAPHICAL ASSESSMENT OF THE ROLE

OF PLATELET RICH FIBRIN WITH DELAYED SHORT DENTAL
IMPLANTS PLACEMENT (COMPARATIVE CLINICAL STUDY)

Amr Yousef Elshahawy * , Laila Ibrahim Ragab ** ,

Mohamed Abd El-Rahman Ellayeh*** and Ayman Abdel Rahim Elkashty ****

ABSTRACT
Purpose: Assessment the efficacy of platelet rich fibrin (PRF) with delayed short dental
implants placement clinically and radiographically.
Methods: This study was a comparative clinical study, with 16 short dental implants were
used in the posterior edentulous region. Cases were distributed into two groups, the study group
who had lost posterior teeth to be restored with short dental implant, while the the control group
who were looking for missed molar restoration also. The study group patients have received short
dental implant with PRF membrane surrounding it. On the other hand, the control group patients
received short dental implants without PRF placement. Prosthetic procedures started after three
months, with the assessment of different clinical indices including; modified plaque index (mPI),
Osstell device to assess osseointegration, peri-implant probing depth index (PPDI) and the crestal
bone loss (CBL). Also the crestal bone surrounding short implants was assessed after placement
immediately (T0) using periapical digital x-ray with parallel technique and re-evaluated at the time
of the prosthetic phase (T3) again. Later on, all of these indices were re-evaluated for second time
after three months (T6).
Results: At recent clinical study it was found that the study group patients with PRF around the
placed short dental implant got better clinical and radiographical parameters than that of the control
group patients without PRF surrounding the short dental implants.
Conclusions: PRF can be used around the short dental implants to decrease the crestal bone
loss and enhance soft and hard tissue healing surrounding short dental implants.
KEYWORDS: PRF, Short dental implants, crestal bone loss.

* BDS, Mansoura University-Egypt 2013, Faculty of Dentistry - Mansoura University.

** Associate Professor of Oral Medicine, Periodontology, Diagnosis and Oral Radiology, Faculty of Dentistry- Mansoura University.
*** Associate Professor of Fixed Prosthodontics, Faculty of Dentistry-Mansoura University.
**** Lecturer of oral medicine, Periodontology, Diagnosis and oral Radiology, Faculty of Dentistry-Mansoura University.

Article is licensed under a Creative Commons Attribution 4.0 International License

(1214) E.D.J. Vol. 70, No. 2 Amr Yousef Elshahawy, et al.

INTRODUCTION derivatives contain growth factors crucial for tissue

healing and regeneration, making them valuable
In cases of severe alveolar resorption, placing
in dental treatments. This concept further fuels the
standard-length implants (≥10mm) is challenging
increasing interest in these biomaterials within the
without additional surgical steps such as distraction
realm of regenerative medicine. The diversity of
osteogenesis, bone grafting, mandibular nerve
platelet-rich types opens up numerous possibilities
transposition, sinus floor elevation and zygomatic
for their application(7). Enveloping implants with
implant placement. These interventions are linked
platelet-rich fibrin accelerates the healing process,
to extended treatment times, increased surgical
promotes tissue regeneration, and reduces and
morbidity and higher costs (1). Over time, different
repairs small osseous defects. PRF is cost-effective
strategies have been presented to overcome
and prepared from the patient’s blood, offering
dimensional shortages for implant placement(2).
advantages in terms of money saving, shorter
Short dental fixtures have been suggested as
treatment interval, easiness, and reduced risk of
an substitute for prosthetic solution of atrophic
drawbacks when used in combination with short
alveolar bone, offering surgical advantages such as
dental implants (4).
reduced morbidity, treatment time, and costs (2, 3).
Biomechanically, short dental implants are justified SUBJECTS AND METHODS
by the idea that the coronal part of the dental implant
Study population: A total of 16 short implant
fixture bears most of the load, with minimal stress
(length = 6-8 mm) were placed in periodontally
transferred to the apical portion (2). Biomechanical
healthy patients, with missing posterior molar
studies have indicated that highest magnitude of
teeth, in need of implant placement. Participants
bone stress is essentially without considering of
were chosen from the outpatient diagnostic clinic
implant height, emphasizing the importance of
in Oral Medicine and Periodontology department,
implant width over additional length (4).
Faculty of Dentistry, Mansoura University. All
Usage of short implants represents a significant participants had thorough clinical examination and
advancement in implantology and serves for a preoperative Cone Beam Computed Tomography
patients with severe alveolar bone resorption as a (CBCT).This research was conducted to help in the
new therapeutic option. Despite initial controversy assessment of the effectiveness of platelet rich fibrin
regarding the predictability of short dental implants with delayed short dental fixtures placement from
due to less bone-to-implant contact, different the clinical and radiographical points of view. All
researches have declared similar success rates for patients were given written informed consents. They
short dental implants compared to conventional were told about the risks, complications, benefits,
fixtures (1, 5). Short implants are generally defined and feedback times before procedures. Study
as five to eight mm long implants and exhibit protocol was checked by the ethical committee,
high success rates and stability, particularly with Faculty of Dentistry, Mansoura University with
advancements in material surface treatment approval number M07060722.
technology and titanium surface structural
Surgical, PRF and prosthetic protocol: Each
modifications. The survival rates of single crown in
subject underwent a comprehensive review of
the posterior region are comparable between short
their medical and dental history, accompanied by
and long implant groups (6).
the acquisition of preoperative photographs and
Platelet derivatives, such as platelet-rich fibrin radiographs. Clinical evaluation of the chosen
and platelet-rich plasma (PRP), have emerged surgical site for dental implant placement included
as potential regenerative materials. These blood an assessment of width and the identification of
CLINICAL AND RADIOGRAPHICAL ASSESSMENT OF THE ROLE OF PLATELET RICH FIBRIN (1215)

any significant undercuts. Cone Beam Computed polypropylene suture. A digital periapical radiograph
Tomography (CBCT) was utilized to precisely gauge was then captured to evaluate the implant’s position,
the volume of available bone and its proximity to its placement to vital structures, and the relationship
vital structures for each patient. A solution containing between the implant’s collar and the bone crest.
Articaine HCL 4% and 1:100,000 adrenaline was
Post-surgery, patients were prescribed a
employed for infiltration anesthesia. Before the
seven-day course of the antibiotic, having 125mg
procedure, it was recommended to conduct a 1-
of clavulanic acid and 875mg of amoxicillin.
to 2-minute rinse with chlorhexidine gluconate to
Additionally, Patients were also advised to use
minimize the bacterial load at the surgical site. The
mouthwash three times daily, 0.12% chlorhexidine
surgical approach involved a midcrestal incision
di-gluconate, for two weeks to serve as an antiseptic
made mesio-distally at the edentulous area along the
and aid in plaque management, especially in the
crest of the edentulous area. A full mucoperiosteal
initial post-surgery days when oral hygiene may
flap was raised buccally, and any narrow, sharp
be compromised. Patients were informed to apply
ridges present were surgically reduced or contoured
ice packs for the first 2 days to minimize expected
using a large round bur to create a reasonably flat
swelling. They were also educated on maintaining
ridge. The intended inclination was determined by
optimal oral hygiene, adopting a soft diet for at
the angulation of neighboring teeth and the pre-
least two days, and gradually transitioning back
operative radiographs, as the implant was properly
to a normal diet. A follow-up appointment was
positioned with the help of these guidelines.
scheduled for 7-10 days after implant placement
In the course of the surgical operation, into a plain for suture removal. Three months after implant
glass tube, 10 ml of blood was taken from the patient placement, local anesthesia was administered, a
(study group). The collected blood was promptly mid-crestal incision was made, followed by cover
centrifuged at 3000 rpm for 10-12 minutes at normal screw removal. A healing abutment of suitable
room climate, using a centrifugal machine without size and length was placed to achieve the desired
any delay (8). The upper layer was then extracted, emergence profile through the soft tissue.
and the middle section, identified as the PRF, was
The rigidity of the implants in both groups was
collected 2 mm below the lower separating line (9).
evaluated again through Resonance Frequency
It was transferred to a PRF box. Using the PRF Box,
Analysis (RFA) utilizing the Osstell device. The
a slow and uniform compression process of the
implant immobility values were noted in Implant
membrane within the clots was conducted, ensuring
Stability Quotient (ISQ) units on a calibration
that the formed membrane consistently remained
ranging from 1 to 100 (10). Intra-oral digital scan
uniformly wet and soaked in serum. Subsequently,
impressions for the dental implants were conducted
after the preparation of the osteotomy site, the
two weeks post 2nd stage surgery for both groups,
gelatinous PRF membrane was inserted into it. To
utilizing the intraoral scanner. The digital scan
insert the implant, a torque wrench and an implant
data was transmitted to the dental lab. The dental
fixture driver were utilized.
lab then selected the appropriate Ti-base abutment
A smart peg was screwed to the fixture to record with the best gingival height from the implant
stability, and the implant stability quotient (ISQ) company’s library for dental prosthesis fabrication.
value was documented in the chart. The surgical The lab proceeded to design the final crown with a
site underwent thorough irrigation with sterile screw channel. The screw-retained prosthesis was
saline to remove debris and cleanse the wound. examined and placed in position using a torque
Subsequently, the flap was carefully approximated wrench after the removal of the healing abutment
and sutured using 4/0 non-absorbable monofilament following manufacture’s instruction.
(1216) E.D.J. Vol. 70, No. 2 Amr Yousef Elshahawy, et al.

Fig. (1): (a) Showing PRF membrane placement and (b) implant insertion surrounded by PRF membrane at the osteotomy.

Fig. (2) Showing (a) Screw retained prosthesis with Ti-base abutment (b) 3 months post-operative CBCT showing relation of
implant to vital structure and bone implant relation. (c) periapical radiograph showing (M) distance between implant
platform and first bone contact mesially (D) distance between implant platform and first bone contact distally (V) distance
between implant apex and inferior alveolar canal.

Clinical and radiographical evaluation and score between zero and four, with zero demonstrate
periodontal assessment: Pain has been measured a tooth with sound gingiva and four the most serious
using visual analogue scale (VAS) on the first inflammation with continuous bleeding. Modified
post-operative day, third day, one week and two gingival index was recorded at T3 (at the prosthetic
weeks (11). ISQ values for implants with successful phase) and T6 (3 months after the prosthetic phase)
osseointegration are reported between 57 and 82. It is according to Mombelli et al (13). Also plaque was
commonly acknowledged that ISQ scales exceeding assessed according to modified plaque index
70 indicate very high stability, scales ranging and was recorded described by Mombelli et al(13)
between 60-69 indicate medium stability, while Measuring the Probing depth of the sulcus around
scales below 60 indicate low stability (12). Modified the short implant is a critical clinical measure in
Gingival index (mGI): The mGI applies a rating evaluating implant health and stability. A color
CLINICAL AND RADIOGRAPHICAL ASSESSMENT OF THE ROLE OF PLATELET RICH FIBRIN (1217)

coded plastic probe is recommended for use when RESULTS

assessing dental fixtures. Implant probing entails Sixteen short implants were used in this study.
inserting the probe implant-abutment interface area Patients’ age range was from 20 to 60 years. They
and the oral mucosal tissues surrounding it (14). were included into two classes. Group 1 (study
Post-operative digital periapical radiograph group) (which included eight short dental implants
with parallel technique was taken immediately then surrounded by PRF membrane at the site of molar
at follow up at 3 months later and at 6 months of area with bone height ≤ 10 mm. Group 2 (control
implant placement to assess the crestal bone amount group) which included eight short dental implants
changes mesio-distally. The vertical marginal bone without PRF membrane surrounding it at the site of
molar area with bone height ≤ 10 mm.
level was calculated from the implant-abutment
interface to the initial bone-implant contact. CBCT Table (1): Shows the resonance frequency
was taken for the site of implant placement after 6 analysis (RFA), bucco-lingual (BL) and mesio-
months from implant insertion to evaluate accurate distal (MD), of the study groups at (T0) (directly
placement of dental implant related to surrounding after implant placement), and at (T3) (3 months
vital structures and neighboring teeth and amount of of implant insertion). There were statistically no
crestal bone loss mesio-distally and bucco-lingually. significant difference between the study groups at
(T0) BL (P = 0.0688) and MD (P=0.1675) but there
Statistical analysis were statistically significant differences between
the study groups at (T3) BL (P = 0.0002*) and MD
Data was fed to the computer and analyzed using
(P=0.0005*). There was also statistically significant
GraphPad Prism 8 (GraphPad Software). Patients’
difference between T0 and T1 in control group BL
age, and crestal bone measurements were normally
(P= 0.0002*) and MD (P= 0.0002*) and in study
distributed, while the other assessed parameters
group BL (P= 0.0002*) and MD (P= 0.0002*).
were not normally distributed as evident by using
test of normality (Shapiro-Wilk tests). Data were Table (2): Shows the crestal bone margin at (T0)
provided as mean, and standard deviation (SD) (immediately after implant insertion) and amount
of crestal bone loss at (T3) (immediately after
values except for gender that was presented as
prosthetic phase) and at (T6) (3 month of prosthesis
frequencies and percentages. Student unpaired T
insertion) in the study groups at the mesial (M)
test was used to analyze between the two groups
and distal (D) sides. There was statistically no
and Repeated measures. One way ANOVA followed
significant differences between the study groups at
by post hoc Tukey’s multiple comparison test were
(T0) at (M) (P>0.9999) or (D) (P=0.8891). There
used to compare between the time points within
was statistically significant difference between the
the same group in normally distributed data. The study groups at (T3) at (M) (P=0.0011*) and (D)
Mann Whitney test was used to compare between (P=0.0035*). Also there was statistically significant
the two groups and the Kruskal-Wallis test followed difference between study groups at (T6) at (M)
by post hoc Dunn’s multiple comparisons test were (P<0.0001*) and (D) (P<0.0001*). In control group
used to compare between the time points within the there was statistically significant difference in
same group in not normally distributed data. Binary comparison between (T0-T3) at (M) (P=0.0266*)
categorical data (gender) was analyzed by Fisher but no statistically significant difference at (D)
exact test. Significance of the collected results was (P=0.067). In study group there was statistically
judged at the (0.05) level. significant difference in comparison between (T0-
(1218) E.D.J. Vol. 70, No. 2 Amr Yousef Elshahawy, et al.

T3) at (M) (P=0.0003*) and (D) (P<0.0001*). difference in comparison between (T0-T6) at (D)
Additionally, in control group there was statistically (P ≥ 0.05). In study group there were statistically
significant difference in comparison between (T0- significant differences in comparison between (T0-
T6) at (M) (P< 0.05a) but no statistically significant T6) at (M) and (D) (P< 0.05a).

TABLE (1): Shows the resonance frequency analysis (RFA) bucco-lingual (BL) and mesio-distal (MD) of
the study groups:

RFA Mean±SD Comparison between

Groups
T0 T3 T0-T3

BL 57.88±1.13 63.75±1.6 P=0.0002*

Control N=8
MD 58.13±1.36 66.75±1.4 P=0.0002*

BL 59.50±2.20 69.50±1.0 P=0.0002*

Study N=8
MD 60.13±2.85 70.25±1.4 P=0.0002*

P value BL P=0.0688 P=0.0002*

MD P=0.1675 P=0.0005*

Data provided as mean±SD, Used test: Mann Whitney test.*p value is significant at level ≤0.05

TABLE (2): Shows the amount of crestal bone loss in the study groups mesial and distal:

Crestal bone loss Mean±SD Comparison

Groups
T0 T3 T6 between T0-T3

M 0.98±0.21 0.83±0.14 0.71±0.08a P=0.0266*

Control N=8
D 0.93±0.17 0.84±0.13 0.75±0.12 P= 0.067

M 0.98±0.31 0.49±0.19a 0.36±0.14a P=0.0003*

Study N=8
D 0.94±0.18 0.58±0.17a 0.38±0.15a P<0.0001*

P value M P>0.9999 P=0.0011* P<0.0001*

D P=0.8891 P=0.0035* P<0.0001*

Data presented as mean±SD, Used test: Unpaired t test to compare between groups within the same time point and repeated
measures ANOVA test followed by post hoc Tukey’s multiple comparison test to compare between time points within the
same group.*p value is significant at level ≤0.05. a: Significance Vs. T0 at p < 0.05
CLINICAL AND RADIOGRAPHICAL ASSESSMENT OF THE ROLE OF PLATELET RICH FIBRIN (1219)

DISCUSSION is a pro-inflammatory cytokine, and modulation of

its levels by PRF may contribute to a more controlled
In spite of the insipidity of short implants was
firstly a subject of debate due to reduced bone- inflammatory response, promoting optimal healing
implant contact, many studies have demonstrated conditions.
that short dental fixtures exhibit similar prognostic Additionally, this study also showed that there
rates to standard-length implants (15). were higher ISQ values detected in the PRF group
In this research it was constructed that there than in the control group during the insertion of
was enhancement in the periodontal indices around the dental implants (T0) and after 3 months at the
the short dental implants inserted with PRF more second stage surgery (T3). This means that PRF can
than that in the control group patients without PRF. increase primary stability of the implant in the initial
Therefore, as per PRF’s application; The study by phase of osseointegration. Two randomized trials
Pradeep et al. has demonstrated a similar reduction examining the effect of PRF before implantation
in probing depth, gain in clinical attachment level, (Öncü and Alaaddinoglu, 2015; Tabrizi et al.,
and bone fill in areas treated with PRF or PRF 2017) showed comparable results. The use of PRF
with open flap debridement. Yet, because of PRF increased implant stability during the initial healing
is not very tricky technique, it can be offered as phase, as evidenced by higher ISQ values. It seems
an improved treatment choice (16). The positive that the ease of use of this material guarantees faster
outcomes accompanied by usage of Platelet-Rich osseointegration (18, 19). This can be attributed to
Fibrin (PRF) in dental operations can be considered the influence of growth factors on the promotion
to its rich content of soluble growth factors and of bone healing around implants. The well-
cytokines. These include transforming growth established osteo-inductive impact of TGF-β and
factor beta-1 (TGF-β1), insulin-like growth factor bone morphogenetic proteins (BMPs) in the context
1 and 2 (IGF-1 and IGF-2), platelet-derived growth of dental implant-related bone healing is widely
factor (PDGF), vascular endothelial growth factor acknowledged (20, 21). Platelet-rich fibrin (PRF)
(VEGF), and interleukins such as IL-1, IL-4, and serves as an autologous cicatricial matrix, akin to
IL-6. fibrin glue. PRF comprises a polymerized matrix
of fibrin arranged in a tetra-molecular structure,
These growth factors and cytokines play crucial
encompassing platelets, cytokines, leukocytes and
roles in tissue regeneration, wound healing, and
circulating stem cells (22).
the modulation of the inflammatory response. For
example, TGF-β1 is known for its involvement in As indicated by He et al.’s research, PRF
tissue repair and collagen synthesis, while PDGF demonstrates the ability to gradually release
stimulates cell proliferation and angiogenesis. autologous growth factors, exhibiting a more
VEGF promotes angiogenesis, supporting tissue robust and enduring impact on the proliferation
vitality, but after 10 days showed a slight increase and differentiation of osteoblasts compared to
in levels of tissue MMP-1 inhibitor, promoting PRP in vitro. The utilization of PRF has proven
healing of periodontal wounds in the early stages(17). to be among the most dependable approaches for
Moreover, PRF has been shown to reduce levels augmenting bone healing (23). PRF elevates the
of matrix metalloproteinase-8 (MMP-8) and concentration of platelet-derived growth factor
interleukin beta (IL-1β). MMP-8 is an enzyme (PDGF) and manifests a potent chemotactic effect
associated with tissue degradation, and its reduction on osteoblasts and other connective tissue cells.
suggests a potential anti-inflammatory effect. IL-1β Furthermore, it possesses the capacity to mobilize
(1220) E.D.J. Vol. 70, No. 2 Amr Yousef Elshahawy, et al.

mesenchymal cells during both bone formation and in terms of enhancement in life quality during the
remodeling processes. PDGF has the capacity to first seven days post-surgery (33).Consequently,
impact alterations in bone directly and indirectly by patient-reported verbal results, such as pain, should
elevating the transcription of collagen and enhancing be interpreted cautiously.
the expression of interleukin 6 in osteoblastss (24).
Finally, in this study, the marginal bone
Moreover, in this investigation, a noticeable surrounding the short dental implants at the PRF
reduction in postoperative pain was observed in application site showed significant improvement
the PRF group during the initial healing phases, compared to the control group, as assessed by CBCT
as assessed through the visual analog scale up to and digital periapical radiograph 3 months after the
the 14th day, in comparison to the control group. prosthetic phase (T6). These results parallel those
Plausible explanations for this phenomenon include obtained in a randomized controlled trial by Boora
a great impact on the immunity, attributed to the et al. (2015), demonstrating statistically significant
stimulation of defense mechanisms as suggested crestal bone loss within three months in the PRF
by Gassling et al. 2009(25). fibrin network facilitated group (34). In the same study, the control group also
the safeguarding of growth factors from proteolysis exhibited statistically crestal bone level significant
the fibrin network, leading to release of substantial changes within three months, but the amount
amounts of platelet-derived growth factor AB of crestal bone level changes in the study group
(PDGF-AB), transforming growth factor Beta-1 had a statistically significant fewer value than
(TGF beta-1), vascular endothelial growth factor the control group (34). Typically, bone loss before
(VEGF), and thrombospondin-1, which stimulate loading is connected with factors such as poor
various biological tasks such as chemotaxis, surgical protocols(35), infection(36), or inadequate
angiogenesis, proliferation, differentiation, and oral hygiene (37). Additional bone loss was recorded
modulation, as highlighted by Choukroun et al. after a 3-month follow-up in both groups, possibly
2001, Singh et al. 2012, and Kumar et al. 2015a (25- due to ongoing restorative procedures including
27)
. many healing abutment separations. It has been
These findings align with results from two demonstrated that the disarranging of the peri-
researches employing patient-reported outcomes implant tightness during abutment unscrewing may
measured through the VAS. Temmerman et al. come up with bone loss (38). This phenomenon can
(2016) concluded that substantially reduced pain be attributed to the protective nature of the original
sensations by PRF after three to five days, and fibrin framework, which shields growth factors
Marenzi et al. (2015) observed quite reduced pain from lysis of protein, allowing them to remain
in the PRF group up to three weeks (28, 29). However, active for an extended event (up to 28 days) (23). This
important considering that both researches did not gives effective neovascularization and better wound
specify if the patients were sufficiently blinded. closure with reduced post-operative morbidity (39).
While numerous studies have evaluated the effect While PRF has been successfully tested in surgical
of PRF on pain in mandibular third molar extraction procedures related to osseous tissue augmentation
(30)
, only a few employed a blinded protocol (31, 32). (sinus elevation, socket preservation) (40) and in the
Conversely, a report by Meschi et al., which included area of periodontal regeneration (41), publications on
the use of platelet-rich fibrin contain leukocytes PRF usage in conjunction with short dental implants
(L-PRF) and an occlusive cover in endodontic are scarce, providing limited grounds for conclusive
surgery, resulted in no statistically quite differences statements at this point.
CLINICAL AND RADIOGRAPHICAL ASSESSMENT OF THE ROLE OF PLATELET RICH FIBRIN (1221)

CONCLUSION 10. Vidyasagar L, Salms G, Apse P, Teibe U. Dental implant

stability at stage I and II surgery as measured using res-
PRF in conjunction with short dental implants onance frequency analysis. Stomatologija. 2004; 6(3):
in the molar area is a successful treatment and 67-72.
associated with improved soft and hard tissue and 11. Williamson A, Hoggart B. Pain: a review of three com-
improve implant primary stability during the early monly used pain rating scales. Journal of clinical nursing.
phase of osseointegration. 2005;14(7):798-804.

12. Meredith N, Alleyne D, Cawley P. Quantitative determina-

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