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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 7  |  Page : 1107-1114

Three-Dimensional evaluation of the effect of platelet-rich fibrin on edema in lower impacted third molar surgery performed with piezosurgery


1 Doctor, Private Practice, Adana, Turkey
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ankara Yıldırım Beyazıt University, Ankara, Turkey

Date of Submission27-Jul-2021
Date of Acceptance02-Jun-2022
Date of Web Publication20-Jul-2022

Correspondence Address:
Dr. M F Senturk
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ankara Yildirim Beyazit University, Ayvali 150.sk., Etlik/Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1700_21

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   Abstract 


Background: Platelet-rich fibrin (PRF) are widely used in impacted lower third molar (IL3M) 7 surgery and its effect on postoperative edema was generally analysed with linear methods. Aim: To analyze the effectiveness of platelet-rich fibrin (PRF) applied to the socket after tooth extraction in impacted lower third molar (IL3M) surgery performed with piezosurgery in the reduction of edema observed in the postoperative period, together with conventional (linear) and three-dimensional (volumetric) measurement methods. Materials and Method: The study was designed as a prospective randomized split-mouth study and was conducted on 30 patients with bilateral IL3M teeth. Extraction of the patients' IL3M teeth was performed in the same session with the help of piezosurgery. After the extraction, PRF was randomly applied to one socket, but it was not applied to the other socket, which formed the control group. On the first, second, and seventh days after the procedure, volume was measured using 3dMD, and the distance between the topographic guide points was measured using a flexible ruler. The results were analyzed statistically. Alveolar osteitis (AO) presence was also recorded. Results: A significant improvement in edema was observed in both groups, but no significant difference was found between the groups (P > 0.05). A moderate correlation was found between the two methods of measuring edema. AO was not seen in any patient. Conclusions: Although PRF reduces edema after IL3M tooth extraction and 3dMD is effective in its evaluation, it has no statistical advantage over classical methods.

Keywords: 3dMD, edema, IL3M, PRF, piezosurgery


How to cite this article:
Konuk B, Senturk M F. Three-Dimensional evaluation of the effect of platelet-rich fibrin on edema in lower impacted third molar surgery performed with piezosurgery. Niger J Clin Pract 2022;25:1107-14

How to cite this URL:
Konuk B, Senturk M F. Three-Dimensional evaluation of the effect of platelet-rich fibrin on edema in lower impacted third molar surgery performed with piezosurgery. Niger J Clin Pract [serial online] 2022 [cited 2022 Aug 8];25:1107-14. Available from: https://www.njcponline.com/text.asp?2022/25/7/1107/351456




   Introduction Top


Extraction of impacted lower third molar (IL3M) teeth is one of the most frequently performed procedures in oral and maxillofacial surgery, and patients often experience pain, edema, trismus, and alveolar osteitis (AO) in the postoperative period.[1],[2],[3] Edema, which is encountered by almost every patient after the surgical extraction of IL3M teeth, reaches its maximum level 48–72 h after the procedure.[4],[5]

Various methods have been used to evaluate facial edema after oral and maxillofacial surgery.[5],[6],[7],[8],[9],[10] Among these methods, the most preferred are linear measurement methods because they are easy to apply, objective, and harmless.[7] However, this method can only measure linearly and does not reflect volumetric changes in all dimensions. With the development of technology, computer-assisted volumetric edema measurement has been performed using the method of obtaining three-dimensional (3D) images.[6],[8] The fact that volumetric evaluation can be conducted using the registration method on a digital platform on the object created with a small margin of error provides a more detailed result than the linear method.[11]

Various medications, products containing biological factors, and surgical approaches (cryotherapy, piezosurgery, etc.) are used to minimize edema following IL3M surgery.[12],[13],[14],[15]

Platelet-rich fibrin (PRF) is the most recently developed product among platelet concentrates and is also called a second-generation platelet concentration. Choukroun et al.[16] first reported it as a fibrin matrix in which growth factors and cytokines are trapped and allow for continuous release for use in oral, dental, and maxillofacial surgery. The most significant feature that distinguishes this product from other platelet concentrates is that its fibrin structure is more robust and can remain unabsorbed for a long time. This is because no additional chemical material is used in the tube from which blood is drawn and the coagulation process is closer to the natural process.[17] Currently, the number of studies on the definitions of A-PRF (advanced), L-PRF (leukocyte-and), I-PRF (injectable), and T-PRF (titanium) is increasing, and the use of products rich in thrombocytes is becoming widespread.[18],[19],[20],[21]

This study aimed to evaluate the effect of applying PRF on edema observed in the postoperative period after the extraction of IL3M teeth using a 3D face scanner (3dMD, Atlanta, USA). The investigators hypothesize that PRF applied to the area after IL3M tooth extraction reduces edema.


   Materials and Methods Top


This work was designed as a prospective randomized split-mouth study. Thirty patients who applied to Süleyman Demirel University's Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, in 2019, who were classified as Class I-A or I-B based on the results of the examination of panoramic radiographs, who had bilateral symmetrical IL3M teeth in a vertical position and who were clinically indicated for orthodontic extraction were included. The study was approved by Süleyman Demirel University's Faculty of Medicine Ethics Committee (decision no. 182 dated 04.10.2017). Before the study, the patients were informed in detail about the content and stages of the study and signed voluntary consent forms in accordance with the Declaration of Helsinki.

Study inclusion criteria

  • Presence of impacted wisdom teeth in the bilateral, symmetrical, or vertical positions
  • Complete bone retention of impacted teeth
  • Patients over 18 years of age
  • Healthy teeth and surrounding tissues
  • Patients who can adapt to the study and comply with the requirements of the study


Study exclusion criteria

  • Patients with a systemic disease or infection that can affect their general health
  • Patients with a beard, mustache, acne, piercing, etc., which may negatively affect the volumetric measurement
  • Pregnant or suspected pregnant patients
  • Patients with alcohol and drug addiction.


PRF preparation

Immediately after local anesthesia, blood was collected from all patients in 2–9 mL vacuum tubes without an anticoagulant (Vacuette®). The continuous movement of the tubes was ensured to prevent coagulation during the blood collection process. Following this process, the tubes were quickly placed in a centrifuge device (Hettich® EBA 20 centrifuge) and centrifuged at 3,000 rpm for 10 min. The buffy coat, which is the richest part of the obtained PRF platelets, was separated from the red blood cell layer using a scalpel [Figure 1].
Figure 1: Centrifuged blood and PRF clot obtained

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Surgical procedure

The impacted teeth of the patients were extracted in the same session by the same surgeon under local anesthesia within the framework of the rules of asepsis. Inferior alveolar nerve, lingual nerve, and buccal nerve were anesthetized with 2.5% articaine (Ultracain® DS 40 mg/mL + 6 mcg/mL solution for injection) containing 1/100,000 epinephrine hydrochloride for both sides. Following the removal of the triangular mucoperiosteal flap, the bone around the impacted tooth was removed using the round burs [Figure 2] of a piezosurgical device (Guilin Woodpecker® Medical Instrument Co. Ltd., Ultrasurgery II Led, China), and the cleavage slot was prepared for the elevator to be used. Using the elevator, the tooth was extracted in one piece with support from the mesiobuccal orifice. To ensure standardization, the teeth on one side were extracted and primarily closed (control group). Conversely, the teeth on the other side were extracted after the socket was cleaned of debris and follicles, the PRF clots were placed in the extraction sockets (study group), and the wound area was closed with a 3/0, half-round vicryl suture (Alcalactine®). Fourteen tablets of amoxicillin + clavulanic acid (Augmentin® BID 1,000 mg) 2 × 1 for postoperative infection control, 20 tablets of flurbiprofen (Majezik® 100 mg) 2 × 1 for pain and edema control, and 0.12% chlorhexidine gluconate (Chloroben®) as an antibacterial agent mouth wash 3 × 1 were prescribed to all patients. Ice application was prescribed for the first 8 h of application.
Figure 2: Piezosurgery burs

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Evaluation procedure

All patients were evaluated based on whether PRF was applied in terms of omitting the presence of AO, smoking status, and a linear and volumetric edema evaluation. Patients who experienced severe pain for at least three postoperative days, with healthy healing tissue were called AO. The presence of AO in the groups was recorded as either present or absent in the first postoperative week, and the patients were recorded as either smokers or non-smokers.

As a kind of modification of the linear measurement method defined by Gabka and Matsumara,[7] tragus and lateral canthus (a) were observed in all patients on the preoperative day (t0) and first (t1), second (t2), and seventh (t3) postoperative days. Commissural labiorum oris (b), soft tissue pogonion (c), and angulus mandible (d) distances were measured using a flexible ruler [Figure 3]. The measurements were made by a single physician when the patient was in an upright position in the unit without making any gestures, whereas the mouth was closed and kept in a resting position (14). The measured values were recorded in millimeters (mm). The average edema value of the days of measurement was calculated according to the following formula:
Figure 3: Guide points for linear measurement

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Facial scans of all patients before surgery (t0) and on the first (t1), second (t2), and seventh (t3) days after the operation were made using eight different cameras that shoot simultaneously as the volumetric volume measurement with the stereophotogrammetry method and position detecting sensors that send data to these cameras.

Care was taken to ensure that male patients had their beards and mustaches trimmed every day because they would adversely affect the volumetric measurements. In female patients, care was taken to ensure that they had no make-up, earrings, piercings, and nose studs. Any jewelry was removed during the scan. All patients were seated upright on a stool that was fixed at a distance of 1.5 m from the scanning device, and they were instructed to look ahead in a resting position without making any gestures during the acquisition. A 3D image was created by evaluating the data obtained with the photos taken and the coordinates from the location sensors using a software algorithm. The 3D images obtained were evaluated using 3dMD software (3dMD Vultus® software version 2.2.0.18, 3dMD, Atlanta, GA 30339, USA) [Figure 4].
Figure 4: Volumetric measurement with 3dMD

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Statistical analysis

The data were analyzed using the Statistical Package for Social Science version 21. The distribution of normality of the data was checked using the Kolmogorov–Smirnov test. The Mann–Whitney U test was used for between-group comparison, and the Wilcoxon sign test was used for within-group comparison. The significance level was set at 0.05. In the comparison of the measurement methods, the mean level of edema was calculated by adding the differences between the linear measurements made on the first (t1), second (t2), and seventh (t3) days and the preoperative (t0) measurements and by dividing them by four using the guide points. A correlation analysis was conducted between these values and the differences between the preoperative (t0) measurements and the volumetric measurements made on the first (t1), second (t2), and seventh (t3) days using 3dMD face scanning and the scatter plot diagram.


   Results Top


Among the patients, 22 were female and eight were males, with ages ranging from 18 to 28 (mean 20.36 ± 2.85 years). Thirteen of the 30 patients were smokers, and 17 were non-smokers. No AO was found in any of the patients during the first week of follow-up.

In the evaluation of volumetric edema measurements made using both linear measurement and 3dMD, edema reached the highest value on the second day in the evaluation of the groups with and without PRF, and swelling on the seventh day was statistically significantly lower than the edema on the first day (P < 0.05). In the evaluation between the groups, although the level of edema was found to be less in the PRF group than in the non-applied group on all days, the results were not statistically significant (P > 0.05) [Table 1] and [Table 2].
Table 1: Bivariate analysis of predictor variable vs linear edema values

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Table 2: Bivariate analysis of predictor variable vs volumetric (3dMD) edema values

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A moderate correlation was found between volumetric measurements and linear measurements on all days (0 < r < 1) [Table 3].
Table 3: Correlation (0<r <1) between measurements (Linear-volumetric)

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   Discussion Top


The purpose of this study was to evaluate the efficiency of PRF applied to the socket after tooth extraction in IL3M surgery performed with piezosurgery in the reduction of edema observed in the postoperative period, together with conventional (linear) and three-dimensional (volumetric) measurement methods. PRF reduced the edema values in both groups but these results were not found to be significant (P > 0.05). In this situation, our null hypothesis was rejected.

The most impacted teeth are IL3M teeth. In studies on PRF activity in IL3M teeth, the incidence of impact was higher in women than in men.[5],[6],[22],[23],[24] In our study, the number of women (22) was found to be higher than that of men (eight).

Piezosurgery is a highly advanced, less invasive, and conservative tool compared with conventional drills for the treatment of bone and soft tissues and the reduction of edema after the extraction of IL3M teeth.[22],[25],[26] In IL3M surgery, studies have indicated that its use with PRF gives better results than when used alone.[13],[22],[26] In our study, piezosurgery was used to minimize the risk of complications and reduce the symptoms that can be seen postoperatively.

Although many methods have been defined to measure facial edema in similar previous studies, the most commonly used method for measuring the distance between guide points (linear measurement) was developed. It was first defined by Gabka and Matsumara,[7] and many modifications were made.

Uyanık et al.[13] investigated the effects of piezosurgery and PRF on pain, edema, trismus, and the number of analgesics taken after IL3M surgery on 20 patients. In their study, in which they used the linear measurement method as the edema measurement method and evaluated the distance between the guide points (tragus–pogonion, angulus–canthus, and angulus–commissure), they found the level of edema to be 3, 2.3, 1.4, and 0 mm on the first, second, third, and seventh days in the piezosurgery and PRF groups, respectively. In conclusion, they found that the combined use of piezosurgery and PRF reduced pain and the number of analgesics taken, the results were statistically significant, and there was no statistically significant difference in the edema. Examining the effects of PRF on pain and edema after IL3M surgery, Gülşen and Şentürk[5] separately evaluated three different distances, namely, tragus–commissure, gonion–commissure, and canthus–gonion, using the linear measurement method. The tragus–commissure distance was 10.8 cm in the preoperative measurement, 11.3 cm on the second day, and 10.9 cm on the seventh day in the PRF group. The gonion–commissure distance was 8.7 cm in the preoperative measurement, 9.5 cm on the second day, and 8.8 cm on the seventh day. The canthus–gonion distance was 9.8 cm in the preoperative measurement, 10.1 cm on the second day, and 9.7 cm on the seventh day. The statistical analysis of the measurements showed no significant difference between the groups (P > 0.05). However, the edema in the PRF group in the evaluation of the visual analog scale (VAS), edema was statistically significantly lower (P < 0.05). Ozgul et al.[24] examined the reducing effects of PRF on pain and edema after IL3M surgery in 56 patients and evaluated the distance between the tragus and commissure and between canthus and angulus, respectively, as the level of horizontal and vertical edema on the first, third, and seventh days after surgery using linear measurement. They found that the level of horizontal edema was 3.28, 1.83, and 0.57 mm on the side applied with PRF and that the level of vertical edema was 5.19, 3.42, and 0.82 mm on the first, third, and seventh days, respectively. Horizontal edema was found to be statistically significantly lower on the first and third days in the PRF group. Kumar et al.[27] applied PRF to the wound sites of 16 of 31 patients after IL3M surgery. The postoperative follow-up was after one day, one month, and three months. Pain, edema, and trismus were evaluated using the VAS on the first day after surgery. PRF application was found to have a statistically significant reducing effect on edema (P < 0.05). In our study, the distances between the tragus and the canthus, commissure, pogonion, and angulus were evaluated in the assessment of the distance between the guide points by conducting linear measurements. The edema values were 1.7, 2.9, and 0.28 mm on the first, second, and seventh days, respectively, in the PRF group. No statistically significant difference was found between the groups (P > 0.05). Different studies have been conducted on the subject. Therefore, we consider that the different values occur because of the reference of the distances between different points and the measurements being made on different days.

The 3D volumetric measurement method was developed as an advantage of new technology. In our study, volumetric evaluation with stereophotogrammetry was performed to obtain results with a minimum error margin. There is only one study in the literature that has evaluated edema using volumetric measurement after IL3M extraction with PRF. Asutay et al.[6] evaluated the effect of PRF on disorders after IL3M surgery in 30 patients and examined edema using volumetric measurement. The measurement was 19.85 on the second day and 7.25 on the seventh day in the PRF group, and there was no statistically significant difference between the groups (P > 0.05). It was not specified in which unit the values were measured. In our study, the level of edema was 6.63, 8.21, and 1.86 cc on the first, second, and seventh days, respectively, in the PRF group, and the results were not statistically significant (P > 0.05).

Our study, which differs from that of Asutay et al.[6] in the use of piezosurgery, also aimed to obtain more detailed information about the precision of the results by comparing two edema measurement methods (linear and volumetric). In limited correlation studies on edema measurement methods, Koçer et al.[8] reported a strong correlation between the methods in their patients who underwent surgically assisted rapid maxillary expansion and argued that the volumetric measurement method should be the first choice in the evaluation of edema. For linear measurement, they used the tragus–commissure, commissural–angulus mandibula, lateral cantus–angulus mandible, and lateral cantus–commissure as reference distances. In our study, a moderate correlation was found between the measurement methods. The difference in operation types and measurement reference points may have affected the results. They concluded that to obtain more precise results, the volumetric evaluation should also be included in the edema evaluation process. To our knowledge, this is the first correlation study to give results between different edema measurement methods in IL3M surgery.

Eshghpour et al.[28] evaluated the effects of postoperative PRF on AO in 78 patients with bilateral IL3M teeth and on AO on the second and seventh days. AO was found to be statistically significantly less in the PRF group than in the group without PRF (P < 0.05). Ünsal and Hasanoğlu-Erbaşar[2] examined the effect of PRF on the incidence of AO after semi-impacted third molar extraction and found that the incidence of AO was 8% in patients who received PRF and 18% in patients who did not. They also found that PRF application decreased the incidence of AO statistically significantly (P < 0.05). Although there were 13 smokers and 17 non-smokers in our study, AO was not found on the seventh postoperative day in either group. We consider this result to be due to the primary closure of the wound area, the application of piezosurgery, and the PRF applied to some of the extraction sockets.

There are various opinions about the significant changes in edema after PRF application. Canellas et al.[29] reported that PRF statistically significantly reduced postoperative edema in a meta-analysis of studies examining the effects of PRF application after IL3M surgery (P < 0.05). Xiang et al.[23] found that the results of a meta-analysis of studies examining the effects of PRF on IL3M surgery were significantly less on the first day in the study group (P < 0.05) and that the results obtained on the third and seventh days were not statistically significant (P > 0.05). In their study on 59 patients, Bilginaylar and Uyanık[22] reported that PRF reduced pain and the number of analgesics taken on the second and third days after IL3M surgery, but there was no significant difference in terms of postoperative edema (P > 0.05). In our study, as a result of using guide points and 3D volumetric measurements, PRF application after IL3M surgery was found to reduce edema on the first, second, and seventh days, but the results were not statistically significant (P > 0.05).

The pain perception and experienced pain levels of the patients were not evaluated in this study, which is a limitation.


   Conclusion Top


PRF application is effective in reducing edema after IL3M surgery. 3dMD is a reliable application for more accurate results in the evaluation of edema measurements. However, there was no significant difference between the findings when compared with the known classical methods. We consider that a safe surgery performed with piezosurgery may be preferred, as it reduces postoperative discomfort and the risk of complications that may be encountered afterward.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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