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© 2020 Annals of Maxillofacial Surgery | Published by Wolters Kluwer - Medknow 335
Original Article - Evaluative Study
IntRoductIon
Although removal of the mandibular third molar (M3M) is
a routinely attempted procedure, the anatomy of adjacent
structures and difcult accessibility impair its smooth surgical
management.[1] The removal of adjacent bone for safe delivery
of tooth dictates that bony healing of the extraction socket
should be studied and discussed thoroughly.
The osteoclastic activity post-extraction is markedly seen
on the buccal wall in comparison to lingual and more in the
mandible than the maxilla for about 3–6 months.[2] Clinicians
often wait for the cessation of physiological resorption before
opting for prosthetic rehabilitation, resulting in the decient
alveolar ridge.[3] To prevent dimensional changes of the
socket, many studies have employed autogenous bone grafts
or substitutes, guided bone regeneration with resorbable
or nonresorbable membranes, and various bone promoting
molecules such as enamel matrix derivative, recombinant
Efficacy of Sticky Bone as a Novel Autologous Graft for
Mandibular Third Molar Extraction Socket Healing - An
Evaluative Study
Taher Abbas Rupawala, Shital Mayank Patel, Naiya Hitesh Shah, Kunj Bhupeshchandra Sanghvi1, Sanjay Vinubhai Makwana, Kruna Kantilal Bhimani
Department of Oral and Maxillofacial Surgery, Ahmedabad Municipal Corporation Dental College and Hospital, Ahmedabad, Gujarat, India, 1N.Y.U College of Dentistry,
New York University, New York, USA
Introduction: Recently, initiation and enhancement of extraction socket healing has been amplied by platelet concentrates, whereas the positive
role of Sticky bone has been focused on maintaining alveolar bone dimensions. This study aimed to determine the effectiveness of Sticky Bone
for socket grafting of mandibular third molars (M3Ms) in terms of soft- and hard-tissue healing. Materials and Methods: This split-mouth
prospective trial constituted prophylactic removal of M3Ms with Sticky bone grafted in the study site as a primary predictor variable. Patients
underwent 3 months of mandatory follow-up where pain, swelling, interincisal mouth opening, and gingival healing were measured on the
3rd, 7th, and 14th day using the Numeric Rating Scale, anatomic landmarks, steel metric ruler, and criteria given by Landry et al. respectively.
Radiological healing was calculated based on the height of the socket, Kelly’s Index, and histogram values immediately after the procedure
at 1 week, 1 month, and 3 months, respectively. Statistical comparison was made using Paired t-test. P < 0.05 was considered signicant.
Results: Forty-seven patients (mean 26.83 ± 6.58 years) demonstrated signicantly lesser pain, swelling, and better gingival healing at the
study site on multiple periods of follow-up. Rapid bone formation with superior density, lesser alveolar resorption, earlier bone blending, and
trabecular formation were noticed on the study site with a signicant difference at all time intervals. Discussion: Sticky bone was chosen as
the graft owing to advantages such as simple preparation, convenient handling characteristics, safety, evident postoperative patient comfort,
better retention of the clot, enhanced soft-tissue healing, absence of infection, and decreased osseous deformation as compared to the control
site. This study validated the role of Sticky bone as an indispensable component of regenerative therapy in the orofacial osseous tissues as it
was an ideal biologic graft with brin rich structure. Conclusion: This study validated the role of Sticky bone as an indispensable component
of regenerative therapy in the orofacial osseous tissues as it was an ideal biologic graft with brin rich structure.
Keywords: Bone density, mandibular third molar, soft tissue healing, sticky bone
Address for correspondence: Dr. Taher Abbas Rupawala,
Department of Oral and Maxillofacial Surgery, Ahmedabad Municipal
Corporation Dental College and Hospital, Bhalakiya Mill Compound,
Opp. Anupam Cinema, Khokhara, Ahmedabad - 380 008, Gujarat, India.
E-mail: taherrupawala1153@gmail.com
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How to cite this article: Rupawala TA, Patel SM, Shah NH, Sanghvi KB,
Makwana SV, Bhimani KK. Efcacy of sticky bone as a novel autologous
graft for mandibular third molar extraction socket healing - An evaluative
study. Ann Maxillofac Surg 2020;10:335-43.
Abstract
Received: 09-02-2020
Accepted: 14-09-2020
Revised: 10-08-2020
Published: 23-12-2020
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Rupawala, et al.: Sticky bone in extraction socket healing
Annals of Maxillofacial Surgery ¦ Volume 10 ¦ Issue 2 ¦ July-December 2020
336
growth, and differentiation factors, and autologous platelet
derivatives to augment the regenerative process of the socket.[4]
Autografts are considered as GOLD STANDARD owing to
its osteogenicity, osteoinductivity, and osteoconductivity.
However, due to operational pitfalls and limited quantity, they
have been replaced with allografts such as Demineralized
Freeze-Dried Bone Allografts or Xenografts such as Bovine
bone.[5] Over the past few decades, application of platelet
concentrates in socket healing has been explored to harness
favorable properties of platelets such as cellular differentiation
and angiogenesis.[4]
The specic use of platelets in grafting procedures is credited to
Whitman et al. and Marx et al. through their use of platelet-rich
plasma (PRP) in mandibular continuity defects.[6,7] However,
long preparation time, addition of bovine thrombin, and
variable quality of preparation of PRP forced researchers
to create platelet-rich brin (PRF) and concentrated growth
factor (CGF) as second-generation platelet concentrates which
exhibited greater promotion of wound healing, eliminated the
role of thrombin, had easier preparation and denser matrix of
boosted growth factors.[8,9]
Despite the numerous advantages of the above mentioned
autologous grafts, space maintenance of defect and subsequent
stability of grafts was always questionable. Unlike PRP, PRF
and CGF layer failed to stabilize particulate or powder bone. To
contain the particulate bone graft within the cavity during the
postoperative healing period in attempt to repair bony defects or
for three dimensional ridge augmentation, the use of bone tack,
collagen membrane, or titanium mesh was almost inevitable.
However, these procedures are surgically time-consuming,
technique sensitive, and cause an additional nancial burden.
Therefore, Sticky Bone was introduced in 2010 by Sohn
et al. as a solidied bone graft entrapped in brin network. It
is a growth factor enriched bone graft matrix prepared using
autologous brin glue (AFG) and an alloplast.[10] Stabilization
of bone graft in the defect to accelerate tissue healing and
elimination of loss of graft is a characteristic feature of Sticky
bone. It also prevents the ingrowth of soft tissue in the graft.[11]
The study objective was to demonstrate successfully the use
of Sticky Bone as a graft material in osseous healing of socket
after the M3M extractions.
MateRIals and Methods
This prospective clinical study was conducted at the
Department of Oral and Maxillofacial Surgery at our
institute after due authorization from the Institutional Ethics
Committee (AMC Institutional Ethics Committee Reg No:
ECG/236/Indt/GJ/2015/RR-18). The split-mouth study,
conducted from December 2017 till December 2019 with
a minimum follow-up period of 3 months, constituted of a
sample of 47 patients.
Inclusion criteria
•All healthy patients aged 18–45 years with bilaterally
symmetrical M3M indicated for extraction (Class 1/2 ;
Position A/B-according to Winter’s and Pell and Gregory
classication) [Table 1 and Figure 1]
•ASA Class 1 patients
•Patients without any oral destructive habits such as
smoking, chewing tobacco, bruxism, etcetera
•Patients who were presurgically asymptomatic.
Exclusion criteria
•Patients with a history of allergy to any drugs or
biomaterial to be used in the procedure or with a history
of intake of drugs which may alter the physiologic healing
potential
•Patients with a history of radiotherapy/chemotherapy
•Patients who were pregnant, lactating, or on oral
contraceptives
•Patients having acute/chronic infections or any kind of
pathology (evaluated and conrmed radiographically)
•Cases with complications such as – fracture of tooth
crown or root, fracture of the adjacent alveolus, fracture
of mandible, dislocation of the adjacent tooth, or excessive
intraoperative hemorrhage.
Surgical procedure
Before the study, its purpose was explained to the patients
and routine blood investigations were advised. They were
informed about possible complications and follow-up
visits. Detailed clinical history was recorded in a proforma
sheet, and preoperative clinical plus radiographic records
were taken (Intraoral Periapical Radiographs [IOPA]
with GRID (Bluedent India, Chennai, India) and
Orthopantomogram [OPG]). Patients were prescribed
Table 1: Data regarding the type of impactions included
in the sample
Angulation Position Class n
Vertical A 1 6
A 2 4
B 1 4
B 2 7
Distoangular A 1 6
A 2 7
B 1 8
B 2 5
Total 47
Figure 1: Preoperative orthopantomogram
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Rupawala, et al.: Sticky bone in extraction socket healing
Annals of Maxillofacial Surgery ¦ Volume 10 ¦ Issue 2 ¦ July-December 2020 337
standard prophylactic medications (capsule amoxicillin 500
mg TDS, tablet diclofenac sodium 50 mg + tablet paracetamol
500 mg BD and tablet ranitidine 150 mg BD) 1 day before
the procedure and were advised to be continued for 4 days
postoperatively.
Under strict asepsis, surgical removal of bilateral M3Ms
was performed using local anesthesia. The standard surgical
technique was followed for each patient and was performed by
a single operator. The operated sites were randomly divided, by
toss of a coin, into control and study groups. Primary closure
was done at the control site using 3-0 black braided silk suture,
and study site was grafted with Sticky Bone (prepared as per
the protocol laid by Sohn et al., and primary closure was
achieved.[10] Immediate postoperative radiographs were taken,
and patients were recalled on the 3rd day, 7th day, 14th day, 1
month, and 3 months for follow-up.
Preparation of sticky bone
Around 20 cc of venous blood was taken from the cubital
vein and centrifuged at 2400–2700 rotations per minute (rpm)
using a specic centrifuge machine (REMI R4C) (REMI
Laboratory Instruments, Mumbai, India) running at alternated
and controlled speed for 2 min. The upper layer of AFG thus
prepared was aspirated and mixed with an alloplastic particulate
bone graft (mixture of hydroxyapatite + tricalcium phosphate)
to polymerize for 10–15 min to form Sticky Bone [Figure 2].
Clinical evaluation
The pain was assessed at Day 3, Day 7 and Day 14 using the
Numerical Rating Scale to subjectively record the pain score
from 0 to 10.[12]
Assessment of swelling was made through the distance
measured between three anatomical points: lateral canthus
of eye to gonial angle, tragus to the commissure of the
mouth, and tragus to Pogonion[13] [Figure 3]. Evaluation of
soft-tissue healing was done at Day 3, Day 7, and at Day 14
using the index given by Landry et al. based on tissue color,
bleeding on palpation, epithelialization of incision margins,
and suppuration.[14]
Interincisal mouth opening was recorded by measuring the
distance between the incisal edges of maxillary and mandibular
central incisors on Day 3, Day 7, and Day 14.[15]
Radiographic evaluation
IOPA with Grid, at the control and the study sites, were taken
at immediate postoperative, 7th day, 1 month, and 3 months to
observe the bone re-ll in the socket. The scores for healing
were recorded as per the modication of Kelly’s Index given
by Ogundipe et al.[15]
The IOPA radiographs were also evaluated to measure the
height of the alveolar socket. A straight line was drawn
parallel to the occlusal plane from the cementoenamel
junction on the distal surface of the second mandibular
molar. Then another straight line was drawn from the base
of the socket perpendicular to the previously drawn line to
measure the height of the socket. OPG, taken at a similar time
period, was analyzed using Mean grayscale measurement
of the extraction sockets employing C.S. Imaging Software
7.0.3 (Carestream Health, Inc, 2010, Rochester New York,
United States) [Figure 4].
Bone density measurement was done using the radiographic
landmarks delineated over the area of the extraction socket,
as described by Kaul et al.[16]
Statistical analysis
The mean value and standard deviation (SD) of each parameter
were calculated and checked for statistical significance
using the Paired Samples t-test. All the data were compiled
and analysis was completed using IBM SPSS Statistics for
Windows (version 11, IBM Corp, Armonk, NY, USA).
d
c
b
a
Figure 2: (a) Autologous fibrin glue after centrifugation. (b) Polymerised
sticky bone. (c) Sticky bone grafted in socket. (d) Primary closure done
Figure 3: Three imaginary lines joining AC, AD and BE for calculation of
postoperative facial swelling
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Rupawala, et al.: Sticky bone in extraction socket healing
Annals of Maxillofacial Surgery ¦ Volume 10 ¦ Issue 2 ¦ July-December 2020
338
Results
The study sample constituted of 16 male and 31 female
patients with a Male:Female ratio of 1:1.93 showing a clear
female predominance [Figure 5]. The participants of the
study ranged from 18 to 39 years with a mean (SD) age of
26.83 ± 6.58 years.
The mean difference between experimental and control group
with respect to the class, position, and angulation of the tooth
was − 0.83, −0.83 and 9.00, showing no statistical signicance.
The difculty index of the sample was constant on both sides,
with a mean (SD) of 6.08 ± 1.165.
Assessment of pain and swelling
The mean (SD) score for pain on the 3rd day for the study site
was 7.25 ± 0.62 and for the control site was 7.75 ± 0.62. Both
the study and control sites showed a gradual reduction in
pain, which was negligible at 2 weeks interval with a common
mean (SD) value of 0.08 ± 0.289 for both the sites.
The results of Table 2 show a gradual reduction in facial
swelling over a period of 2 weeks with a signicant reduction
on study site at Day 3 and Day 7 with a mean difference of
0.792 (P = 0.005) and 0.642 (P = 0.000), respectively.
Assessment of gingival healing
Both study and control sites showed similar healing scores
of the mean (SD) 2.08 ± 0.289 on Day 3, which improved
comparatively on study site on Day 7 and Day 14 with a
mean difference of 12.833 (P = 0.039) and 0.000 (P = 0.026),
respectively [Table 2].
Assessment of postoperative mouth opening
Patients had a statistically significant increase in their
interincisal mouth opening at each follow-up intervals with
the lowest mean (SD) values of 15.58 ± 3.059 mm seen at
Day 3 and the mean (SD) values of 37.42 ± 1.88 mm seen
at Day 14, which were nearly similar to the preoperative
measurements [Table 3].
Assessment of height of the socket
The decrease in the height of the socket measured at 1 week
showed a mean (SD) value of 10.08 ± 0.996 mm, which then
reduced to 9.42 ± 0.900 mm and 8.58 ± 7.17 mm at 1 month
and 3 months, respectively, at the study site. The reduction
in the height of the socket was markedly more at the control
site (P = 0.000) at all-time intervals as its height of socket
reduced to mean (SD) 7.17 ± 1.193 mm, whereas at the study
site mean (SD) reduced to 8.58 ± 0.996 mm at the end of 3
months [Table 4 and Figure 6].
Assessment of radiographic healing (Kelly’s Index)
The mean (SD) radiographic healing scores at 1 week, 1
month and 3 months for the study site were 1.08 ± 1.290,
2.92 ± 0.669, and 4.75 ± 0.622, respectively, which showed a
statistical signicance (P = 0.000) over the mean (SD) scores
of − 1.17 ± 1.586, 0.75 ± 0.965 and 2.42 ± 0.515 of the control
group at the same time of follow-up [Table 4].
Assessment of mean bone density
The bone histogram analysis at the sites of extraction showed
mean (SD) preoperative density values of 170.17 ± 31.866 and
160.92 ± 28.523 at the site of study and control. The increased
density at study site in the immediate postoperative period was
202.08 ± 38.068, which was signicantly higher (P = 0.000)
than the decrease in mean (SD) bone density at the control
site. The mean bone density difference of −9.250, −45.083
and −52.667 between study and control sites observed at
Figure 5: Distribution of gender in the sample
Figure 6: (A) Immediate (Grid) imaging of the study site. (A’) (Grid)
imaging of the study site after 3 months. (B) Immediate (Grid) imaging
of the control site (B’) (Grid) imaging of the study site after 3 months
Figure 4: Densitometric Analysis done with Carestream Imaging Software
7.0.3
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Rupawala, et al.: Sticky bone in extraction socket healing
Annals of Maxillofacial Surgery ¦ Volume 10 ¦ Issue 2 ¦ July-December 2020 339
the end of 1 week, 1 month, and 3 months was statistically
signicant (P = 0.000) although a decrease in bone density
was observed at both the sites in comparison to preoperative
values [Table 5 and Figure 7].
dIscussIon
The concept of early and superior new bone formation has
rapidly gained momentum as newer treatment modalities
pertaining to oral and maxillofacial reconstruction are
contingent upon faster bony regeneration and lesser alveolar
resorption.[17] Restoration of bony defect subsequent to
surgical trauma represents a challenge in comprehensively
treating patients who demand early, socially pleasing, and
esthetic restorative options.[18] Healing of the socket is an
intricate process wherein the clot lls the alveolus immediately
after extraction, followed by the recruitment of constructive
inammatory cells and growth factors.[19] The accumulation of
granulation tissue within the socket is followed by epithelium
migration and the activity of osteoblasts and osteoclasts
demonstrates alterations in the dimensions of alveolus, which
leads to the deposition of bone within the entire socket with
its radiopacity comparable to the adjacent bone at the end of
15 weeks.[19-21]
The rationale of socket grafting intends to hasten this
physiologic healing by providing a solid scaffold to strengthen
the coagulum during early phases of healing using a plethora of
biomaterials. The recent surge in the use of platelet concentrates
for superior epithelial and osseous regeneration has provided
substantial evidence which display reduced inammation,
untoward complications, and stimulated ossication.[4,22-25]
Table 2: Comparison of pain, swelling and gingival healing scores between the two groups at postoperative day 3rd, 7th and 14th
Pain Swelling Gingival healing
3rd day 7th day 14th day Preoperative 3rd day 7th day 14th day 3rd day 7th day 14th day
SCSCSCS C SCSCSCSCSCSC
Mean 7.25 7.75 4.25 4.83 0.08 0.08 36.46 36.69 38.68 39.48 37.28 37.92 36.65 36.94 2.08 2.08 3.08 2.75 4.58 4.08
Standard deviation 0.622 0.622 0.622 0.835 0.289 0.289 1.113 0.977 1.416 1.786 1.284 1.356 1.157 1.016 0.289 0.289 0.515 0.754 0.515 0.515
Mean difference 0.500 0.583 0.000 −0.233 0.792 0.642 −0.292 −23.333 12.833 0.000
P*0.053 0.002 1.000 0.097 0.005 0.000 0.075 1.000 0.039 0.026
Signicance NS S NS NS S S NS NS S S
*Paired t-test. S=Study group; C=Control group; NS=Not signicant; S=Signicant
Table 3: Data representing the increase in interincisal
mouth opening at each follow-up interval
Interincisal mouth opening
Preoperative 3rd day 7th day 14th day
Mean 38.92 15.58 24.58 37.42
Standard deviation 2.392 3.059 3.232 1.881
Mean difference −23.33 −14.33 −1.50
P*0.000 0.000 0.026
Signicance S S S
*Paired t-test. S=Signicant
Figure 7: Variation in bone density levels with time
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340
However, conditions such as technique sensitivity, prolonged
preparation time of PRP, the addition of chemical additives in
PRGF, and limited graft stability achieved with PRF and CGF
demanded the advent of a newer autologous graft material
which could be amenable for use in all conditions.[8,10] Sticky
bone, the latest among the autologous concentrates, was
introduced by Sohn et al. in 2015 as a biologically solidied
bony matrix trapped within a brin meshwork, prepared by
alternated and controlled centrifugation of venous blood at
a variable speed of 2400–2700 rpm. The blood collection
excluded prior addition of anticoagulant and centrifugation
time of only 2–12 min was required to obtain AFG.[8,10] After
centrifugation, AFG was aspirated and mixed with particulate
bone powder, and after a polymerization period of 10–15 min,
yellow-colored Sticky bone was formed. This method of
preparation was simple, cost-effective, and could be readily
incorporated in surgical practice.
Although the use of sticky bone has been successfully
demonstrated in multiple case reports, the authors have
largely concentrated on the dimensional stability of the
alveolus with respect to implant placement in the anterior
regions.[10,26-28] Interestingly, the mandibular posterior region
is also vulnerable for vertical bone resorption with subsequent
soft tissue recession as the cleft between the mandibular
second molar, and a mesioangular/horizontally inclined
M3M attracts colonization of potential pathogens leading
to postextraction periodontal defects, although conicting
evidence have emerged which support vertical impactions
as having the highest potential (18.8%) to cause distal bone
loss.[29,30] The grafting of sticky bone in mesioangular or
horizontally impacted molars was absent in this study due
to the unavailability of bilaterally symmetrical cases, which
may have served as a better indicator for its use as a graft
material. Furthermore, it is binding to acknowledge that the soft
tissue defect may appear over a long period of 6–36 months
and is also dependent upon other factors such as iatrogenic
trauma during extraction, increased age, status of eruption
and preexisting periodontal defects, all of which have been
taken into consideration during the design of this study.[30-32]
In addition, as M3M removal is one of the most frequently
attempted surgical procedure across the world, it was chosen as
a template for grafting, the results of which can be meticulously
replicated in areas which demand enhanced bone regeneration,
comparable to other similar trials conducted earlier.[13,15,17,33]
This study hypothesized sticky bone as a biologic model
socket graft material due to ease of its preparation, better
handling properties, mechanical retention in socket evident
through a number of clinical and radiographic parameters.
The confounding factors such as gender, oral hygiene, age
and smoking inuencing pain, edema, trismus, and subsequent
healing were eliminated as it was a split-mouth trial. The
gender variation in the study sample was in line with the
inclusion criteria of previous studies, which exhibited a
clear female preponderance, and hence it justies our sample
selection. In addition, all surgical procedures were carried
Table 4: Comparison of height of the socket - preoperatively, at immediate postoperatively, at 1 week, 1 and 3 months and radiographic healing scores between
the two groups at immediate postoperative period, 1 week, 1 and 3 months respectively
Height of the socket Kelley’s index
Preoperative Immediate 1 week 1 month 3 months Immediate 1 week 1 month 3 months
S C S C S C S C S C S C S C S C S C
Mean 10.50 10.25 10.50 10.25 10.08 9.00 9.42 8.17 8.58 7.17 −0.75 −3.25 1.08 −1.17 2.92 0.75 4.75 2.42
Standard deviation 1.168 1.215 1.168 1.215 0.996 1.348 0.900 1.267 0.996 1.193 1.357 1.422 1.240 1.586 0.669 0.965 0.622 0.515
Mean difference −0.333 −0.500 −0.250 −0.250 −1.083 −1.250 −1.417 −2.500 −2.250
P*0.339 0.339 0.000 0.000 0.000 0.000 0.000 0.000 0.000
Signicance NS NS S S S S S S S
*Paired t-test. S=Study group; C=Control group; NS=Not signicant; S=Signicant
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Rupawala, et al.: Sticky bone in extraction socket healing
Annals of Maxillofacial Surgery ¦ Volume 10 ¦ Issue 2 ¦ July-December 2020 341
out by a single surgeon to remove any possibility of operator
variability.[17,34]
The NRS score, originally given by Downe in 1978, offered
great accuracy and was used to record the pain score, which was
highest initially, decreasing subsequently with lesser scores for
the study group at all times, showing statistical signicance
only at one week. Similarly, percentage increase in facial
swelling, which was measured using xed anatomic landmarks
in accordance with the ndings of multiple studies, reected
signicantly better results for the study site up to one week with
comparable results present at the end of 14 days.[13,18,35] These
ndings reinforce the efcacy of sticky bone in mitigating the
adverse postoperative ndings of pain and swelling as both
sites undergo similar inammatory process and eliminate any
concern due to the presence of alloplastic bone graft in the
polymerized mixture.[13,15,18,19,35,36] Moreover, as socket healing
commences, hemostasis and coagulation result in the formation
of a clot,[37] similar for both sites, but with better retention in
the study group due the brin network of the AFG imparting
an obvious mechanical advantage. Thus, the positive results for
the study site promulgate its use to lessen patient’s discomfort
and derive better patient co-operation and compliance.
Maximum reduction in the mouth opening in the immediate
postoperative period was followed by notable improvement
with no comparison of the degree of trismus between the two
extraction sites as it was a split-mouth study, unlike previous
studies.[15,18] Preoperative mouth opening achieved in 41.66%
of patients by Day 14 and at the end of 1 month, for the rest
of the sample, followed normal operative healing pattern after
third molar impactions and was not adversely hindered by the
addition of the graft.
Even though sticky bone did not affect the immediate gingival
healing index scores, calculated using criteria given by Landry
et al. to judge the degree of gingival inammation and repair,
it resulted in better healing for the study site ultimately by the
end of 2 weeks, comparable to other similar studies done using
PRF as a graft material.[1,13,17,19] Biologically, the inammatory
phase witnesses the action of neutrophils and macrophages
in the form of phagocytosis and the release of growth factors
that are concentrated, larger and denser in the brin matrix
of Sticky Bone due to lesser time of centrifugation used to
prepare AFG.[10] This might expedite the cellular processes of
chemotaxis and angiogenesis, leading to rapid tissue repair,
as evident by the tissue color and margin on the study site
within 14 days of extraction.[37] Progressively, as the socket
gets impregnated with intense fibroblast migration and
extracellular collagen during the proliferative stage, it allows
enhanced adhesion and anchorage.[37] This process, evident by
the absence of exposed granulation tissue, was precipitated
on the study site as AFG may lead to sustained release of
plasma-derived growth factors, insulin-like growth factors,
and transforming growth factor-beta.
Owing to the nature of the surgical procedure, patients of
both the groups experienced minor discomfort in the form of
postoperative edema, reduced mouth opening, and a case of
buccal sulcus ecchymosis, which were efciently managed
conservatively using warm saline gargles and mouth opening
exercise along with medications. None of the patients in either
group experienced episodes of any major complications such
as alveolar osteitis or postoperative infections owing to strict
adherence to standard aseptic protocols and comprehensive
prophylactic medications.
The use of grids for determination of the height of the socket
proved to be an efcient method of saving undue cost and time,
and it showed a signicant decrease in the rate of resorption of
the socket heights of M3M on the study site as radiographic
healing progressed periodically till 3 months. The positional
stability of sticky bone prevented brous in-growth, which
reduced alveolar resorption and helped in preserving the
postoperative socket height. Hence, the present study afrms
the positive role of sticky bone in maintaining the dimensions
of the M3M socket and adds to the existing reports promoting
the favorable properties of the graft in the anterior region.[10,30,38]
The quality of osseous regeneration was studied by evaluating
IOPA for the presence or absence of lamina dura, increase
or decrease in density, and coarseness or fineness of the
trabeculations as stated by Kelly in 1980.[39] The results of the
present study simulated the ndings of earlier studies done
using PRF, as it showed marked absence of the lamina dura,
denser relled bone, and coarser trabecular patterns on the
study site at follow up intervals of 1 month and 3 months.[15,18]
Furthermore, panoramic radiographs were used to judge the
density of the relled bone using densitometric analysis, as they
were conveniently available, caused reduced radiation exposure
and allowed simultaneous observation of both extraction sites. It
revealed signicantly higher bone density at the study site due
Table 5: Comparison of bone density levels - preoperatively, at immediate postoperatively at 1 week, 1 and 3 month
Immediate 1 week 1 month 3 months
SCSCSCSC
Mean 202.08 157.00 188.25 135.58 166.92 108.58 143.67 77.67
Standard deviation 38.068 28.626 39.162 21.940 37.999 24.138 33.765 22.552
Mean difference −2.333 −9.250 −45.083 −52.667
P*0.000 0.000 0.000 0.000
Signicance SSSS
*Paired t-test. S=Study group; C=Control group; NS=Not signicant; S=Signicant
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Rupawala, et al.: Sticky bone in extraction socket healing
Annals of Maxillofacial Surgery ¦ Volume 10 ¦ Issue 2 ¦ July-December 2020
342
to the presence of graft in the immediate postoperative period.
The mean bone density subsequently decreased with lesser
grayscale values over the time interval of 3 months for both the
groups with a signicantly lesser reduction seen over the study
socket. Growth factors present within AFG might stimulate
the deposition of precursors of bone-forming cells and hinder
the osteoclast activity. Consequently, deposition of sticky bone
acts as a nidus for the accelerated conversion of osteoid into
mineralized tissue having superior bone density and elimination
of lamina dura within 4–8 weeks as compared to inferior bone
density seen on the control site for the same time interval.
These observations made by clinical and image histogram
analysis were encouraging as parallel inferences have been made
with respect to older generations of platelet concentrates,[17-19,38,40]
but further histomorphometric studies are warranted to establish
the precise roles of chemical mediators in sticky bone for
providing radiographically detectable favorable bone healing.
Although the use of autologous concentrates such as PRP, PRF,
and CGF has been widely documented in interventions such as
alveolar ridge augmentation, improving implant stability and
marginal bone loss and alveolar grafting in cases of cleft lip
and palate, recent evidence have presented confounding results
doubting the potential of PRF and PRGF in osseous healing
of the extraction sockets.[41,42] Conversely, over and above
the clinical benets of sticky bone usage, it is a fairly ideal
autologous graft which can be rapidly prepared to ll up the
entire socket cavity according to the shape of the socket due to
its excellent mouldability without disintegration into adjacent
soft tissues, as its inherent mass is made up of particulate
bone which had brin interconnections. This obviated the
incorporation of titanium mesh and bone blocks, and a CGF
membrane can also be prepared using the same methodology
to cover the grafted site instead of an alloplastic option. All
these properties have been previously afrmed to distinguish
sticky bone as the rst choice for any surgeon who wishes to
opt for an autologous graft with minimum morbidity, relatively
decreased burden on the cost and time of the surgery.[8,30,43,44]
Even though the observations derived from this study were
consistent in the support of the use of Sticky bone in bony
defects, recent advances such as laser scanning for swelling
and quantitative computed tomography, bone scintigraphy,
and dual-energy X-ray absorptiometry (DEXA) for measuring
bone density would be a more conclusive option for assessing
the osseous healing potential of Sticky bone.[17,42] Owing to
the practical difculties in pursuing these options in multiple
follow-ups for a developing country like India, we believe
that we were able to carry out the present study in the most
comprehensive, convenient, and fairly accurate manner.
conclusIon
The ndings of the present study conrmed the hypothesis that
utilization of AFG enriched bone graft matrix (Sticky Bone)
leads to promising results for gingival healing and reossication
of alveolar defects. The preparation of sticky bone was
convenient, and it was suitable for grafting as it has superior
handling characteristics. The strong brin interconnection
allowed it to be retained within the socket while maintaining
the socket dimensions.[10] Further exhaustive trials with sticky
bone engaging newer investigative techniques such as cone
beam computed tomography, stereo lithography, DEXA scan
or scintigraphy are warranted in all kinds of osseous defects
which demand superior and rapid ossication to conclusively
establish it as an indispensable part of any surgical intervention
which necessitates xed prosthetic replacements, especially in
younger individuals.[40,45]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
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