A Radiological Evaluation of Bone Healing in Postextraction Sockets Following Bone Grafting Using Beta-Tricalcium Phosphate and Calcium Phosphosilicate: A Controlled Comparative Study.

BACKGROUND: Healing unbinds a well choreographed array of cellular, physiologic, biochemical, and molecular processes directed toward restoring the integrity and functional capacity of the damaged structures. The rate and degree of healing vary among individuals but is greatest during the first few months or years after tooth loss. Evidence suggests that alveolar bone ridge resorption may be prevented, initially by reconstructive surgical techniques using several materials which are employed at the time of extraction. This droves to the development of bone substitutes materials such as hydroxyapatite, beta tricalcium phosphate (β TCP), and bioactive glasses. These regenerative materials not only act as an osteoconductive scaffold but also interact with the surrounding tissues and impart an osseostimulatory effect.
METHODS: Twenty adult patients who required bilateral removal of homologous tooth, were informed and described regarding post extraction socket grafting using β TCP and CPS followed by covering with Collagen Membrane. Radiographic densitometry evaluation of postoperative visits of immediate; 1st month; 3rd month; and 6th month using orthopantomograph was done.
RESULTS: The Karl Pearson's Correlation coefficient was used to determine the degree of bone density with adjacent bone preoperatively and postoperatively. The statistical evaluation, CPS was more superior to β TCP, with a difference of 58.75 and P value showed more significance (<0.0001).
CONCLUSION: This article evaluates radiographically quality and quantity of bone formation in the socket, following extraction and bone grafting using Calcium Phosphosilicate (CPS) and β TCP, it is concluded that the two modalities of treatment were efficient in improving the clinical outcome parameters as well as showed comparable regenerative effects when used in the treatment of "socket grafting" while between them CPS more superior to β TCP biomaterials by Osteogenic properties. Copyright:

INTRODUCTION

Healing of extraction socket implies to the series of events and this process does not result in complete restitution of the alveolar bone due to physiological resorption and thus results in horizontal as well as vertical dimensional changes.[1] Prosthetic reconstruction and replacement of teeth and associated structures becomes more difficult and often unsatisfactory when anatomic deformities in the jaw bone ridges occur.[2] Thus to analyze, radiography is the major nonsurgical method for detecting bone formation in a healing osseous defect hence its use in clinical situations because of its speed, continuity of measurements, and noninvasive nature.[3] The objective of this study is to radiographically evaluate the quality and quantity of bone formed in extraction socket, following bone grafting using Calcium Phosphosilicate (CPS) (NovaBone Dental Putty) and Beta-Tricalcium Phosphate (β-TCP) (G-Bone Synthetic), the method of relative densitometry can be performed on standard or digitalized panoramic radiographs and can be used to monitor bone healing regularly, with low-costs and reduced irradiation hazards.

MATERIALS AND METHODS

Twenty adult patients who came to the Department of Oral and Maxillofacial Surgery, Sri Siddhartha Dental College and Hospital, Tumakur; who required bilateral removal of homologous tooth, were informed and described regarding postextraction socket grafting using β-TCP and CPS followed by covering with Collagen Membrane. Patients who fulfilled the inclusion and exclusion criteria were selected, after obtaining the institutional ethical clearance.

Surgical procedure

Creating the alveolar socket recipient site

The area selected for surgery was anesthetized. Soft tissue flap reflection was done to assure adequate visualization of the alveolar socket and allow easy management and placement of the test material. An envelope flap was performed to facilitate reflection of the full thickness flap, atraumatic tooth removals were performed. Sockets were thoroughly debrided.

Grafting procedure of extraction sites

The CPS and β-TCP were placed into the extraction sockets. A collagen membrane barrier cover was used randomly.

The tissue flaps were secured with appropriate sutures to achieve complete coverage of the surgical site. The approximate amount of product placed in the bone defect was recorded.

Radiographic densitometry evaluation of postoperative in visits of immediate; 1st month; 3rd month; and 6th month using orthopantomograph was done [Figures 1–4].

Figure 1

Beta-Tricalcium Phosphate preoperative

Figure 4

Calcium Phosphosilicate postoperative - 6 months

Beta-Tricalcium Phosphate postoperative – 6 months

Calcium Phosphosilicate preoperative

Radiographic analysis

In this study, we measured “clinical outcome” on a basis of observer-reported outcome. The observed densitometry changes of two biomaterials on grayscale by Adobe Photoshop Software and compared each biomaterial-filled socket to adjacent bone density every 6th-month postoperatively. The entire radiographs were taken on the same exposure rate, then converted to “.jpg” format, followed by calculation of measurements by single observer, who was blind to the experimental group, and histogram was used to obtain the mean density of the selected area in pixels.

Statistical analysis

Descriptive statistics such as mean and standard deviation was calculated. Paired t-test was used to test the significance between CPS (NovaBone Putty) and β-TCP (G-Bone Synthetic). The Karl Pearson's Correlation coefficient was used to determine the degree of bone density with adjacent bone preoperatively and postoperatively.

RESULTS

All the patients showed good compliance and the healing was uneventful in both groups, without any signs of infection, which indicates the biocompatibility of graft materials. The handling characteristic of CPS was better compared to β-TCP as CPS was placed in the sockets using a cartridge delivery system.

The statistical evaluation, CPS was more superior to β-TCP, with difference of 58.75 and P value showed more significant (<0.0001) [Tables 1 and 2].

Table 1

Beta-tricalcium phosphate

Characteristic	Preoperative	Postoperative
Mean	112.2485	129.031
SD	16.14	13.05
Variance	260.7976555	170.4471253
Observations	20	20
Pearson correlation	0.040635488
T statistics	3.55
P	0.002

SD: Standard deviation

Table 2

Calcium phosphosilicate

Characteristic	Preoperative	Postoperative
Mean	110.8735	124.6875
SD	13.41	14.59
Variance	179.9451292	212.9980618
Observations	20	20
Pearson correlation	0.628154427
T statistics	5.095561972
P	<0.0001

SD: Standard deviation

DISCUSSION

Extraction sites heal in a pattern of constantly changing tissue, two fundamental concepts, modeling, and remodeling process.[4] The present study was designed to compare radiographically, postextraction socket graft using CPS, which is Class A 45S5 bioactive material, and β-TCP, which is Class B S53P4 bioactive material.[5]

Nguyen et al. used CPS putty bone substitute for the sinus augmentation along with implant placement which was evaluated preoperatively and postoperatively using panoramic radiograph and cone-beam computed tomography. The findings revealed 100% implant osseointegration along with significant change of 6–8 mm vertical bone height, 6 months postoperatively.[6]

Tarun Kumar, Sudhindra Kulkarni, Raison Thomas, and Dhoom Mehta, used CPS putty grafting for gaining the ridge width for implant placement in 15 patients. Clinical analysis revealed a difference of 4 mm increase in width along with maximal insertion torque difference of 12.1 ncm in 12–14 months postoperatively.[7]

On histomorphometric analysis and clinical analysis of NovaBone Putty versus Dynablast following single tooth extraction and socket grafting revealed 33.01% new bone formation for novabone whereas 30.22% for dynablast, marrow space for novabone 58.49% and dynablast is 53.05%, and remaining residual graft observed for novabone grafting is 8.5% and dynablast is 16.73%. Thus, concluded CPS seems to favor soft tissue healing as well as hard tissue favorable graft.[8]

Furthermore, many studies on histomorphometric analysis of β-TCP showed large amounts of new bone formation consisting of woven bone, marrow and lamellar bone after 9-month of healing and additional membrane placement on graft did not demonstrate any statistical difference in any parameters of bone remodeling, and also showed less residual graft material remaining along with 100% implant osseointegration and loading.[8910]

In the current study, the densitometric changes of two biomaterials were observed on grayscale by Adobe Photoshop Software, the mean value obtained on grayscale for β-TCP was 112.24 preoperatively, which was calculated from the adjacent bone of the particular tooth region, whereas postoperatively mean value was 129.03, which was calculated particularly on the grafted region, with standard deviation of 16.14 and 13.05, respectively. The preoperatively mean value of CPS was 110.87 and postoperatively mean value was 124.68, with standard deviation of 13.41 and 14.59, respectively.

CONCLUSION

Thus, the two modalities of treatment were efficient in improving the clinical outcome parameters as well as brought about comparable regenerative effects when used in the treatment of “socket grafting” or “ridge augmentation” procedure.

However, long-term clinical traits along with large samples, histomorphometric analysis along with radiographic densitometric analysis are needed to evaluate the regenerative potential of these biomaterials.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.