WITHDRAWN: A Study Protocol for “Comparative Evaluation of Effectiveness of Demineralized Freeze-Dried Bone Allografts (DFDBA) with Titanium Platelet Rich Fibrin (T-PRF) and Autologous Dentin Graft (ADG) with T-PRF in Alveolar Socket Preservation: A Randomized Controlled Clinical Trial”

doi:10.21203/rs.3.rs-4433698/v1

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WITHDRAWN: A Study Protocol for “Comparative Evaluation of Effectiveness of Demineralized Freeze-Dried Bone Allografts (DFDBA) with Titanium Platelet Rich Fibrin (T-PRF) and Autologous Dentin Graft (ADG) with T-PRF in Alveolar Socket Preservation: A Randomized Controlled Clinical Trial”

https://doi.org/10.21203/rs.3.rs-4433698/v1

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Background: Socket preservation is a pivotal procedure in modern dentistry, dedicated to the preservation of the alveolar ridge architecture after tooth extraction. The techniques vary from basic socket fillers such as blood clot preservation to more advanced techniques using barrier membranes and bone grafts such as autografts, allografts, xenografts, and synthetic materials. The aim of this study is to evaluate and compare the effectiveness of alveolar socket preservation with T-PRF (Titanium-Prepared Platelet-Rich Fibrin) and ADG (Autologous Dentin Graft) with T-PRF in socket preservation. This assessment will be carried out through comprehensive clinical, radiographic, and histomorphometric analysis. The objective is to determine the most efficient method for maintaining socket integrity after tooth extraction.

Method and Design: A total of 16 patients who match the specified criteria will be randomly assigned to one of two groups:(1) Socket preservation using DFDBA in combination with T-PRF and (2) Socket preservation performed using ADG with T-PRF. Following four months all the clinical variables will be assessed, a CBCT radiograph will be used to examine volumetric bone status, and biopsies will be analyzed histomorphometrically obtained during implant placement. Linear phenotypic dimensional changes will be assessed as secondary outcomes.

Discussion: The results obtained from this study will demonstrate if T-PRF along with ADG will lead to better radiographic bone fill and improved socket measurements compared to that of DFDBA with T-PRF. The results and patient-reported outcomes will be used to help choose the most effective type of therapy for socket preservation.

Trial registration: The registration number for this trial is CTRI/2024/05/068192.

Demineralized freeze-dried bone allografts (DFDBA)

autologous dentin graft (ADG)

titanium platelet rich fibrin (T-PRF)

socket preservation

cone beam computed tomography (CBCT)

histomorphometric Analysis

Dental implants are the most widely used and reliable treatment method for individuals with fully or partially edentulous arches. The time frame of implant insertion following extraction are currently the main concerns of implant therapy, rather than osseointegration. Alveolar socket preservation (ASP) following tooth extraction is one of the most important dental advanced skills as numerous conditions, such as traumatic extraction techniques, periodontal diseases, tumors, infections, or cysts, can cause the loss of alveolar bone. (1) Alveolar ridge resorption is one of the physiological alterations that take place following tooth extraction. After tooth extraction, alveolar ridge modeling peaks over the first 4–6 weeks, as is well known, while progressive atrophy may persist over time at a slower rate. (2) Ridge atrophy results from a substantial degree of physiologic remodeling that occurs in the alveolar socket following tooth extraction. (3) To minimize stress to the alveolus and accomplish minimal socket enlargement, atraumatic extraction must be carried out. Treatment options for ridge atrophy include several forms of bone and/or soft tissue augmentation; nevertheless, these methods are known to have varying degrees of success and predictability. It is believed that socket grafting, which requires use of grafting materials with or without barrier membranes, reduces the amount of dimensional shrinkage that occurs in the alveolar socket following tooth extraction.

For the best results, an ideal bone graft should have osteoconduction, osteoinduction, and osteoproliferation properties.(4) A range of surgical methods and biomaterials have been created to enable socket preservation. For this objective, several bone grafting methods including synthetic and natural graft materials have been tried. The most often used, clinically approved, or modified bone allograft material for periodontal repair is "demineralized freeze-dried bone allografts" (DFDBA). Bone morphogenetic proteins (BMP) are linked to the osteoinductive capacity of DFDBA, this particular BMP combination includes BMPs 2, 4, and 7. DFDBA breaks down at a faster rate, which promotes the growth of new bone.(5) Its primary application is in the reconstruction of osseous deformities.

Growth factor such as platelet-derived growth factor (PDGF) is present intracellularly and essential for the healing of wounds. Utilizing platelet concentrates has several benefits. They are crucial to regeneration. Their application has been effectively linked to bone and connective tissue repair. Platelet concentrates promote bioactivity and demonstrate non-stimulative properties. "Titanium Platelet Rich Fibrin (T-PRF)" is one of the 3rd generation platelet concentrates.(6) This platelet concentrate, is recognized to remove the potentially harmful effect of silica, which is found in the glass vacuum containers used to prepare "Platelet Rich Fibrin" (PRF). Platelet and leukocyte cell enriched fibrin, or T-PRF, is made with titanium and resembles fibrin made with the traditional PRF process. Titanium is the most corrosion-resistant metal with the highest amount of toughness. Furthermore, the titanium has an amazing osseointegration quality. (6) Titanium platelet-rich fibrin (T-PRF) presents a longer resorption time and a denser fibrin structure compared to PRF, making it a promising option for sustained release of growth factors. (7)

Histologically stated, hydroxyapatite makes up the majority of the inorganic structure that makes up human enamel and dentin, which is composed of 45% organic material. Type I collagen and BMP comprise most of the organic components. ADG (Autologous Dentin Graft) are a viable substitute for alveolar socket preservation due to their composition of organic and inorganic components, as well as their ability to promote bone formation and support bone growth. (4) The osteoconductive characteristics of human dentin are attributed to four types of calcium phosphate: amorphous calcium phosphate, tricalcium phosphate, octacalcium phosphate, and hydroxyapatite. As hydroxyapatite in dentin is primarily found as calcium phosphate with a low crystal concentration, osteoclast activity can readily break it down. 90% of its 20% organic content is composed of type I collagen network; the remaining 10% is made up of non-collagenous proteins (such as phosphoprotein, sialoprotein, osteocalcin, and osteonectin, which help calcify bone) and 10% is made up of growth factors (like insulin-like growth factor and bone morphogenetic proteins, or BMPs, which give teeth their osteoinductive properties).(8) Owing to all these properties it can be considered as potential graft material and have been used in the past for regenerative procedures.

Accurate assessments need the establishment of a consistent point for the CBCT linear measurements. CBCT is currently the most widely used 3D radiographic imaging technique in dentistry, offering several benefits over traditional CT scans and 2D imaging instruments. A more precise method involves using subtraction analysis of CBCT data. (9) The fundamental advantage of using CBCT in implant dentistry is its ability to provide detailed volumetric imaging data of the craniofacial region for preoperative and diagnostic planning.

In several studies it has been found that CBCT radiographs may sometimes show certain discrepancies hence to eliminate those in final results, the outcomes will be confirmed by histomorphometric analysis. The bone sample for histomorphometric analysis will be obtained using trephine bur while placement of implant. (10)

Hence in this investigation, the effectiveness of DFBDA with T-PRF and ADG with T-PRF for socket preservation will be assessed radiographically and histomorphometrically. Our study strategy intends to assess the healing success by placing implants after appropriate socket dimensions has been preserved. (11)

Study Design

This research is a clinical trial with randomized controlled prospective parallel arms, to achieve a side-by-side comparison between ADG with T-PRF and a commercially available DFDBA bone graft and T-PRF.

Study Population

Based on the necessity for a single tooth replacement via implant fixture, about sixteen healthy individuals without a history of any systemic disease will be enrolled in this research, from “Department of Periodontics”, “Sharad Pawar Dental College, Sawangi (Meghe), Wardha.” The study protocol is approved by the “Institutional Ethics Committee” of “Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha.” The subjects will be informed about the study's goal, methodology, and design prior to the study start. Written Aconsent will be taken. The following requirements must be met by patients in order to participate in the study.

Eligibility Criteria and Recruitment

Following the clinical and radiographic assessment, 16 patients must precisely meet the criteria that are listed below.

Inclusion Criteria

Patients indicated for implant following tooth extraction because of reasons such as residual roots, over-retained primary teeth, non-restorable carious lesions, internal and external resorption, fractured roots, and failed endodontic therapy.

A complete mouth plaque score of less than 25% indicating good oral hygiene.

Presence of a natural tooth in opposition

Presence of adjacent teeth

The thick gingival biotype

Presence of 4mm bone apical to root apex

The bone quality of D-1, D-2, or D-3 type

Exclusion criteria:

Individuals with systemic conditions such as diabetes mellitus, osteoporosis, blood-related diseases, and titanium allergy that could compromise their overall health and impede the process of bone healing and repair.

Space between the maxilla and mandible.

Parafunctional habits like clenching or bruxism are present.

A history of substance misuse, excessive smoking, or drinking.

D-4 bone quality.

Past experiences with chemotherapy and radiation.

TMJ disorders

Untreated oral health conditions.

Pregnant and lactating mothers

Primary outcomes

Four months following the socket preservation procedure, the formation of new bone and changes in the alveolar socket dimensions in both groups will be assessed with radiological and histomorphometric analysis.

Secondary outcomes

After four months of surgical procedure, linear phenotypic dimensional changes, at baseline and four months after healing at two locations in the thickness of soft tissues and the midfacial and midpalatal bones will be evaluated.

Sample Size Calculation

Sample Size Formula Using Mean And Standard Deviation

n ≥ $\:\frac{{\left({Z}_{\raisebox{1ex}{$1-\:\alpha\:$}\!\left/\:\!\raisebox{-1ex}{$2$}\right.}+{Z}_{1-\beta\:}\right)}^{2}\left({\sigma\:}_{1}^{2}+\raisebox{1ex}{${\sigma\:}_{2}^{2}$}\!\left/\:\!\raisebox{-1ex}{$\gamma\:$}\right.\right)}{{({\mu\:}_{1}-\:{\mu\:}_{2})}^{2}}$

Where;

Alpha α = 0.01

Beta β = 0.01

Standard Deviation of newly formed bone with spontaneous healing(group 1)

SD in group 1 ($\:\sigma\:1)$= 0.23

Mean in group 1 ($\:{\mu\:}_{1})$=0.72

Standard deviation of newly formed bone with autogenous dentin graft(group 2)

SD in group 1 ($\:\sigma\:2)$ = 0.24

Mean in group 2 ($\:{\mu\:}_{2})$ = 1.33

Ratio (group 2/ group 1) = 1

Total samples required = 8 per Group.

The calculation gives the result as, sample required = 8 per group

Study Reference: As per the reference article - Hussain AA, Al-Quisi AF, Abdulkareem AA. Efficacy of Autogenous Dentin Biomaterial on Alveolar Ridge Preservation: A Randomized Controlled Clinical Trial. Biomed Res Int. 2023 Dec 27;2023:7932432. doi: 10.1155/2023/7932432. PMID: 38179035; PMCID: PMC10764647.

Randomization And Masking

The study group, consisting of socket preservation with ADG and T-PRF, or the control group, consisting of DFDBA and T-PRF, will be randomly assigned to the two groups. Patients will be clinically examined for periodontal diseases. Every patient will be required to complete a comprehensive medical history form, give informed consent, and receive a thorough description of the study.

CLINICAL PROCEDURE

Presurgical Phase

Following a comprehensive clinical examination and radiographical diagnosis, initial therapy will consist of guidance on maintaining good oral hygiene and a full mouth ultrasonic scaling procedure. Patients will receive plaque control instructions until their plaque score is less than 25%. Before any surgical procedure, a diagnostic cast will be made for every patient in order to ascertain the maxilla-mandibular relationship. Clinical photographs will be captured throughout the procedure. Cone beam computed tomography (CBCT) will be obtained for every subject.

PREPARATION OF T-PRF

Just prior to the surgery, by venipuncturing the (antecubital) vein, 10 milliliters of venous blood will be obtained under aseptic conditions and transferred to a new, sterile titanium tube. Titanium platelet-rich fibrin (T-PRF) is an autogenous blood concentrate of the third generation, characterized by a thick and durable fibrin meshwork that is triggered by a titanium tube.(12) Centrifugation is carried out for a total of 15 minutes at 3500 rpm. After transferring the resulting T-PRF clot onto a PRF box and separating it with sterile tweezers and scissors, the serum will be squeezed out of the clot to create a stable fibrin membrane.(13) A portion of the membrane was chopped up for use as graft material, and the remaining portion will be trimmed to fill the defect with membrane.

SURGICAL PROCEDURE FOR TEST GROUP

Patients are instructed to gargle for one minute with 0.12% chlorhexidine gluconate. Local anesthesia will be administered. In order to minimize surgical trauma during the flapless tooth extraction process, periotomes and forceps will be used. Using a number 15 blade, a crevicular incision will be created, removing periodontal ligament (PDL) fibers on the distal and mesial sides. The teeth will be carefully luxated using elevators. Precautions will be taken to prevent trauma to adjacent tissues. After tooth extraction, bone curettes will be used to completely debride the socket's granulation tissue. Initially, a high-speed handpiece will be used to remove any debris, artificial material, rot, and gutta-percha from the extracted roots, leaving just the clean tooth root. The roots that contain dentin will be crushed using a dentin grinder. First, the generated root dentin particle material passes through three steps:

Pour the dentin cleansing solution into the dish containing the particles and let it sit at room temperature for five minutes. The solution is then allowed to dehydrate using sterile gauze.

The particle is then totally covered with phosphate-buffered saline (PBS), which is then put into the plate. The particle is mixed with fresh, sterile gauze to dehydrate it, using a sterile device. With the PBS solution, repeat this step once more. To neutralize the pH levels, this step is the crucial.

At last, the ADG, whose particle size ranges from 300 to 1200 microns, is prepared for prompt grafting. The extraction sockets will be filled with mixture of T-PRF and ADG.

After enclosing the resistant bone with a collagen plug, non-resorbable suturing material is used to sew the plug to the surrounding soft tissues.

SURGICAL PROCEDURE FOR CONTROL GROUP

DFDBA, a completely resorbable alloplastic bone substitute, will be inserted into the extraction socket together with T-PRF following an atraumatic extraction. It is important to exercise caution when filling the socket after applying the graft since this could cause the exposed coronal particles to get sequestered or cause the graft mass to disperse as a whole. T-PRF is applied to compact the graft particles even more and accelerate in-situ healing.

POSTSURGICAL CARE

Participants will be given explicit instructions not to eat or drink anything hot on the surgical site, nor should they rinse their mouths vigorously. All the patients will receive antibiotics (Cap Amoxicillin, 500 mg t.i.d., Tab Metronidazole 400mg t.i.d) and analgesics (Tab Ibugesic t.i.d.) after surgery for a period of atleast 5 days. Two weeks following the surgical procedure, participants are recommended to gently brush the area surrounding the surgical site; nevertheless, regular tooth brushing should be continued for the remaining areas of the dentition starting on the day following the procedure. In addition, two weeks of twice-daily mouthwash containing 0.2% chlorhexidine have been prescribed. Seven days following the procedure, the sutures will be removed.

FOLLOW UP

A complete examination will be conducted at the four-month follow-up appointment.(14) Every clinical variable is going to be evaluated. Both a clinical and radiographic evaluation will be performed. Histomorphometric analysis will be performed on bone obtained by trephine bur during implant placement.

STATISTICAL ANALYSIS:

The values of the mean ± standard deviations, or mean and standard deviations, will be found for each clinical periodontal parameter, such as "PI, PBI, PPD, WKG, CAL, PH, PIS, and marginal bone level." Next, from baseline to two months, the mean data will be statistically analyzed. To equate baseline to two-month findings for every patient, the Student's paired test will be employed. If the probability value (p) exceeds 0.05, the observed difference will be considered non-significant; if it falls below 0.05, it will be considered significant.

Socket preservation is a fundamental technique in dentistry, preserving alveolar bone structure post-extraction to facilitate optimal healing and support future dental restoration procedures. According to the clinical study by Hussain et al. (4) demonstrated promising outcomes regarding the utilization of ADG in alveolar ridge preservation. Their study revealed superior dimensional stability in the study group compared to the control group, as evidenced by standardized CBCT scans. The study group's successful graft remodelling was further validated using histomorphometric analysis, demonstrating the potential of using ADG for effectively retaining the dimensional integrity of ridges. These findings highlight the need to utilize innovative biomaterials, such as ADG, to enhance clinical results and facilitate optimal wound healing.

Bhombe et al. (5) investigated the use of platelet-rich fibrin matrix (PRFM) and demineralized freeze-dried bone allograft (DFDBA) as adjuvants during immediate implant placement procedures following tooth extraction. Their findings indicate that using PRFM and DFDBA in jumping gap distance as an adjuvants resulted in significant coronal bone remodelling and a significant decrease in bone resorption. In another clinical study by Elfana et al. (15), histomorphometrical findings demonstrated that the autogenous whole tooth (AWTG) and autogenous demineralized dentin graft (ADDG) groups exhibited higher proportions of newly formed bone (48.40%). The histology study confirmed that both types of transplants were compatible with the host tissues and showed no symptoms of inflammation.

Dwivedi et al. (16) demonstrated that chair-side autogenous tooth grafts offer several advantages, including greater primary implant stability, faster recovery times, ease of preparation, a reduced rate of bone resorption, and qualities that promote bone growth and socket augmentation.

Autogenous dentin graft, which has both osteoconductive and osteoinductive qualities, appears to be a promising alternative for ARP treatments, according to a systematic study by Luis et al. 2023 (17). Positive outcomes in terms of volume preservation and histomorphometric data were noted; they were reinforced by the properties of material such as low complication rate and cost-effectiveness in comparison to alternative bone substitutes.

Thus, the purpose of the study is to assess and compare the effectiveness of DFDBA with T-PRF and ADG with T-PRF in socket preservation using clinical, radiological, and histomorphometric analysis. This study plan will be reliable to prove advantages pertaining to improvements in maintenance of vertical and horizontal socket dimensions and phenotypic dimensions.

Oversight and monitoring

Composition of the coordinating Centre and trial steering committee.

The committee consist of the following:

The head of the department of periodontics
P.G. guide
Research scientist
Principal investigator
Surgeon
Statistician
Data manager

Composition of the data monitoring committee, its role and reporting structure: Composition of data monitoring committee (DMC) is as follows: research in charge of the institute and research in charge of the department.

Adverse event reporting and harms

Data will be collected, assessed, and spontaneously reported during adverse events and other unintended effects of trial interventions or trial conduct.

Frequency and plans for auditing trial conduct

The project management group meet will review the trial conducted every month. The trial steering group and the independent data monitoring and ethics committee meet will review and conduct the trial period till the trial is complete.

Dissemination plans: Publication

Trial status: [Ref.No. DMIHER(DU)/IEC/2024/ 226]protocol version number 1; recruitment began on 1 July 2024 and approximately will be completed by January 2026.

Acknowledgements: N/A

Corresponding author: Correspondence to Shivani Thakre

Availability of data and materials: Access to investigator

Ethics approval and consent to participate: Ethical approval for the study is obtained from the Institutional ethics committee Ref.No. [DMIHER(DU)/IEC/2024/ 226]

Written informed consent to participate will be obtained from the parents of all participants.

Consent for publication: The participants are provided a model consent form and other relevant documents.

Competing interests: The authors claim to have no conflicting interests.
Funding: Institutional funding
Authors' contributions: The author(s) read and approved the final manuscript.
Authors' information: Department of Periodontics, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Higher Education and Research, Wardha, India

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WITHDRAWN: A Study Protocol for “Comparative Evaluation of Effectiveness of Demineralized Freeze-Dried Bone Allografts (DFDBA) with Titanium Platelet Rich Fibrin (T-PRF) and Autologous Dentin Graft (ADG) with T-PRF in Alveolar Socket Preservation: A Randomized Controlled Clinical Trial”

Status:

Version 1

Editorial Note

Abstract

Figures

INTRODUCTION

MATERIALS AND METHOD

Study Design

Study Population

Eligibility Criteria and Recruitment

Primary outcomes

Secondary outcomes

Sample Size Calculation

Randomization And Masking

CLINICAL PROCEDURE

Presurgical Phase

PREPARATION OF T-PRF

SURGICAL PROCEDURE FOR TEST GROUP

SURGICAL PROCEDURE FOR CONTROL GROUP

POSTSURGICAL CARE

FOLLOW UP

STATISTICAL ANALYSIS:

DISCUSSION

Oversight and monitoring

Declarations

References

Supplementary Files

Status:

Version 1