The present study aimed to compare the autogenous demineralized dentin graft (ADDG) versus xenograft (Bioss) for their effect on PES after 6 months and one year also on Buccal bone resorption, crestal bone volumetric changes assessed by 3D cone beam computed tomography (CBCT) & Implant stability using osstel .
To minimize confounders, different measures for the selection of participants have been taken in the study. Smokers were excluded due to the fact that smoking has unfavorable effects on bone healing, not only it adversely affects host cells function and causes alternations to the inflammatory response, but also it reduces the blood supply which leads to decrease in tissue perfusion and ischemia and in turn, negatively affects healing processes following tooth extraction (5). Clinically, smoking can increase the post-extraction alveolar crest loss by 0.5 mm (6). Pregnant females were excluded to avoid the teratogenic effect of high radiation exposure when performing CBCT scans (7).
Some metabolic diseases such as diabetes or hyperthyroidism as well as systemic medications such as chemotherapy or bisphosphonates are further known to affect bone remodeling (6). Accordingly, patients reporting having any of these conditions were excluded.
only patients over 18 years were included to be able to provide informed consent and to avoid the effect of bone growth and passive eruption of teeth on the quantitative measurements.
In addition to the above-mentioned general exclusion criteria, local site-specific criteria have been set as well. Exclusion of molars was done due to the fact that bone quality as well as the size and configuration of molar sockets are different than single-rooted teeth and consequently, healing time and processes are considered dissimilar (8), (9).
Damaged extraction sockets are generally believed not to be suitable for supporting graft material and require wall replacement by block graft (10) and therefore, such defects were not included. Teeth with root canal filling were not used as the filling material incorporated into the graft can act as a foreign body or affect local healing (2)
Finally, local infection at the site of extraction is known to delay healing, the high acidity is due to inflammation and bacterial byproducts can cause graft particle to dissolve via cell-mediated process or solution-mediated process (11) and hence no infected site was included.
For the surgical technique used in this study, the flapless approach was chosen since flap elevation is known to cause crestal bone resorption due to the transient deprivation of osteogenic cells and blood supply (12) In a systematic review it was concluded that leaving the periosteum undisturbed through a flapless approach shows less alveolar bone height and width resorption in comparison to flap elevation, making it the recommended approach to preserve the bone crest (9)
Choice of Periotomes was made as they serve the goal of atraumatic extraction by cutting periodontal ligament attachment along the root surface thus decreasing the tooth resistance to extraction forces. They also minimally dilate the extraction socket thus initiating tooth luxation and permitting an easier path of removal and at the same time, avoiding trauma to the alveolar process and the adjacent teeth.(13)
When compared to the conventional forceps, periotomes required more surgical time but resulted in less buccal bone fracture, less root fracture, less soft tissue laceration, and less postoperative pain (7).
After extraction, teeth were cleaned from caries it can act as a bacterial reservoir, restorations were removed to avoid foreign body reaction or inflammatory effect to the healing site and soft tissue attachment and their insertion in cementum were removed as they hinder the access of disinfectant or demineralizing agents to the tooth surface. The hand-driven bone mill is a tool used to grind autogenous bone for various applications. Its use for chairside preparation of tooth-bone graft (TBG) has been reported ((1) (14) & (13)). Unlike the bulky and expensive automated mills, it is a convenient and available tool that can be used in everyday clinical scenarios.
The Hydrochloric acid (HCl) was used for the preparation of the ADDG as it is one of the strongest demineralizing agents, it has germicidal effect and in the same time, it does not cause denaturation of collagen fibrils in the dentin matrix, hereby it is the most commonly employed acid in clinical use (16). The graft particles were immersed in 0.6N HCl for 30 minutes as recommended by (17)which reported that there was a significant difference concerning graft mineral content and crystalline structure between 10 minutes and 30 minutes of acid application, but there was not any difference when increasing the demineralized period beyond that. The same acid and time application was experimented in ARP clinically by (18) and showed to be an effective processing technique for ADDG.
Asepsis is essential for adequate healing ; bacterial virulence factors can cause fibrinolysis and disintegration of the formed blood clot, raise the local cytokines that can cause local matrix degradation and hence compromising the healing outcomes.(4). It is a common practice then to prescribe antibiotics post-operatively to avert any negative effects of bacteria during the blood clot phase till the beginning of granulation tissue formation which is less impervious and followed by epithelial closure (19) and therefore; antibiotics were prescribed during the early phase of healing for all participants.
Participants were advised to stop using the toothbrush and chewing at the surgical site .They were also advised to follow a soft and cold diet to avoid any undesired trauma to the surgical site, ice packs surgical site, Chlorhexidine mouthwash was used and it was used as it has been proved to be antiseptic, reduce biofilm buildup and gingival inflammation following dental surgeries (20)
Esthetic-outcome assessment has been an emerging area of focus in implant dentistry. To sustain an esthetic appearance, it is essential to consider the characteristics of the surrounding soft and hard tissues. (21) therefore The pink esthetic score (PES) was used to evaluate the esthetic outcomes with the clinical photographs before the treatment and after the follow-up period. The PES includes seven variables (the mesial papilla, the distal papilla, the midfacial level, the midfacial contour, the alveolar process deficiency, the soft tissue color, and the soft tissue texture), and was assessed by using a 0-1-2 score, with 0 = lowest score, and 14 = highest score. (22)
The PES is a tool for reproducibly evaluating the esthetic appearance of the soft tissue around single-tooth implant crowns. (22)
Pink esthetic in our study is statistically non-significant between immediate implants with dentin chips & immediate implant with xenograft in 6 months & 12 months.
To our knowledge there has not been any published comparison between dentin chips and other grafts with immediate implants.
A significant decrease of PES was observed in each group at 6 and 12 months with no clinical relevant which is inconsistent with (23)who said that esthetic outcome of soft tissue around the single-tooth implant had improved significantly at follow-up compared with baseline according to PES assessment. As that may be explained by immediate restoration of immediate implants in his study. His results suggested that the potential for significant changes in soft-tissue levels after restorative therapy needs to be considered for single-implant therapy in the anterior maxilla.
Crestal bone loss showed statistically significant more bone loss from 0–6 months than from 6–12 months in the two groups more over statistically significant bone loss was observed in control group than interventional group which is inconsistent with (24)Showed that implants placed in post-extraction sockets augmented with DFDBA exhibited minimal marginal bone loss similar to implants placed in native bone.
Our results is in contrast to (25) reported that No matter using autogenous tooth bone or xenogenous bone, the horizontal bone loss at the first or the latter 6 months was almost the same in the level 0 mm, 3mm and 6mm of the implant facial part and No matter what the follow-up period is, and bone graft material used, the horizontal bone loss at the level of 6mm was much less than the level of 0mm and 3mm in the facial of the implant. All implants achieved the success criteria without (24) claimed that grafting of extraction sockets is beneficial in terms of limiting the dimensional changes of the alveolar ridge following tooth/teeth extraction.
Implant stability in our study increased at 6 months than upon insertion which may be consistent with systematic review of (26) who claimed that primary implant stability can be influenced by the macro design of dental implants, and roughness enhancing surface treatments can increase ISQ values in later osseointegration phases, improving secondary implant stability. Primary implant stability is lesser with lower bone density and may be enhanced by the utilization of thinner drills (under preparation) or osteotomes when the bone density is inadequate.
Bajaj G et al.2017 (27)claimed that primary and secondary stability of immediately loaded group comparison has shown that there was a significant statistical difference and early loaded group comparison has shown that there was the significant statistical difference. But when differences of primary and secondary stability of immediate loaded and early loaded group comparison have shown that after after osseointegration there is no difference in stability.
But we have an implant failed after 1 month due to trauma patient have faced in intervention
& another one failed after 6 months before loading may of unknown
Brisman et al, 2001(28) reported that even asymptomatic endodontically treated teeth with a normal periapical radiographic appearance could be the cause of an implant failure. They also suggested that microorganisms may persist, even though the endodontic treatment is considered radiographically successful, because of inadequate obturation or an incomplete seal.
In our present study pain (VAS) score successfully decrease day to day.
A study was conducted in past in implant surgery and found that the female gender was significantly associated with pain (29), and another study claine that women had a significantly higher anxiety level than men, and that this again led to more pain (30). Accordingly, in our study, women experienced more pain than men on the second postoperative day. However, other studies found no difference between genders in pain perception (31). In many experimental studies on pain, though, women reported more severe pain and a longer duration of pain than men .(32)
In our study we had a success rate of almost 94% which nearly the same as (33) results was a higher failure rate was found for the implants in the posterior region of the maxilla, and when periodontitis was cited as a reason for tooth extraction. The overall success rates were 93.4% and 95.7% in the immediate and delayed implant placement groups, respectively, after a 2-year follow-up. No obvious relationship of success rate was observed with the implant placement method, cause of tooth extraction, and implants' position.
With all of the advantages of the ATG, it also exhibits limitations. The process of chairside preparation includes cleaning, grinding and disinfection which requires time and effort. As an autogenous graft, it is only available in limited quantity. It requires the extraction of a tooth for graft preparation and hence cannot be used in individuals that do not have any teeth indicated for extraction or in completely edentulous subjects. A possible solution to this problem can be done by using tooth derived graft materials obtained from allogenic sources but the practice of using allogenic tooth-bone graft has been only investigated in a handful of clinical studies with concerns about effective preparation and donors screening for commercial release. (34)
(35) they concluded that AWTG or ADDG employed in ARP is equally effective at reducing dimensional losses after 6 months, with no adverse effects. Histologically, both grafts were biocompatible and osteoconductive, with ADDG seeming to exert higher osteoinductive properties. Chairside preparation and application of ATG are feasible, cost-effective and can provide an alternative source to commercially available grafting materials. Further investigations are needed to optimize the two graft preparation techniques and explore and compare their effects in different clinical scenarios in the oral cavity.