**3. Bone quality**

It has become crucial in contemporary implantology to keep the alveolar ridge after extraction. There is currently agreement that alveolar ridge maintenance is necessary to prevent further bone loss [36, 37]. According to a recent study, the combination of PRF platelet concentrates with particle DFDBA (300–500 m) results in excellent outcomes for post-extractional bone preservation [36].

### *Particulate Allografts (DFDBA) Combined with Platelet Concentrate: An Effective… DOI: http://dx.doi.org/10.5772/intechopen.112929*

Alveolar ridge preservation and sinus lift procedures enable the favorable conservation or restoration of bone volume; however, for medium- and long-term implant results, it is also crucial to objectively evaluate the quality of the acquired reconstruction. To achieve this, authors frequently employ histomorphometry, a method for examining both qualitative and quantitative aspects of bone quality [37–40].

A. Wardani et al.'s recent work used DFDBA (300–500) and PRF platelet concentrate to assess bone quality in sinus lift and alveolar socket preservation. 40 2 mm-diameter bone samples from 21 patients were the subject of an interventional prospective investigation. In order to serve as control groups, 22 biopsies were taken from preserved sockets, 7 from grafted sinus locations, and 11 from native bone [37].

The samples were fixed, embedded in paraffin, sliced on a microtome, and then stained with Masson's trichrome and hematoxylin-eosin.

According to the ratios of woven (immature) and lamellar (mature) bone, a healing score ranging from 1 to 3 was given to each bone sample to make it easier to compare them. Score 1 showed a predominance of woven bone (difference between woven and lamellar bone proportion > 10%) and reflected an early stage of bone healing; score 2 showed the presence of lamellar and woven bone in similar proportions (difference between woven and lamellar bone proportion 10%) and reflected a moderate stage of bone healing; and score 3 showed a predominance of lamellar bone (difference between woven and lam) (**Table 1**).

#### **3.1 Native bone samples**

The majority of the native bone samples displayed a score of 3 (9/11), which denotes extensive bone repair. Only two samples (**Table 2**) got a score of 2, corresponding to a moderate level of healing. Only lamellar bone was visible in two samples, which indicates extraordinarily high bone density. Remember that the mandibular symphysis bone is where these samples originated. Lamellar bone made up an average of 52.73% of native bone, woven bone made up an average of 10.74% of native bone, and overall bone made up an average of 65.29% of native bone. Native bone received an average healing score of 2.82.

#### **3.2 Alveolar samples**

**Table 3** contains a list of the samples collected from grafted alveolar structures. A score of 1 was assigned to two out of the 22 samples, which were eliminated after 3 and 5 months of healing, respectively. Except for four samples that were obtained after 5 months had passed since the start of the healing process, 12 out of 22 samples


**Table 1.** *Bone healing score.*

*Recent Scientific and Therapeutic Advances in Allograft*


#### **Table 2.**

*Proportion of bone surfaces in native bone.*

(**Figures 8**–**11**) had a score of 2. **Table 3** shows that 8 out of 22 samples received a 3 rating. Alveolar structure samples were divided into two groups based on whether the healing duration was less than (A) or higher than (B) 5 months. In comparison to group A, the samples in group B had a higher average proportion of newly produced bone and a lower average proportion of DFDBA residual particles (**Table 4**).

#### **3.3 Sinus lift samples**

**Table 5** displays the samples taken from sinus lifts. The samples, all except one of which had a score of 3, were collected between six and 9 months after healing (**Figures 12** and **13**). A single sample was taken 8 months into the healing process and had a score of 2 (**Table 5**).

According to the study, as healing time increases, there is a greater proportion of lamellar neoformed bone than unformed tissue (**Figure 8**). The amount of newly produced bone in the grafted sockets significantly increased as healing progressed (average: 41.22% 5 months, 55.89% > 5 months). Additionally, it appears that DFDBA particle resorption and healing time in the grafted socket are associated (average: 15.43 5 months, 13.72% > 5 months). When utilizing DFDBA and PRF for sinus lift and alveolar socket preservation, high-quality, mature bone tissue is produced that meets histological standards [37].

In the present investigation, samples taken from native bone were examined, and it was shown that 10.72% of the samples (8 out of 11) included immature woven bone, which is probably the result of normal bone remodeling [41, 42]. Furthermore, lamellar bone was only present in two native bone samples, making up more than 80% of the sample area and indicating advanced bone maturity. With an average healing score of 2.32 and a majority of lamellar bone, all 22 samples tested from grafted alveoli showed freshly created bone. The average percentage of newly produced bone across all prepared cell samples was 46.56%, demonstrating the effectiveness of


### *Particulate Allografts (DFDBA) Combined with Platelet Concentrate: An Effective… DOI: http://dx.doi.org/10.5772/intechopen.112929*

#### **Table 3.**

*Proportions of newly formed bone surface, residual particles, and healing score of samples from alveolar grafted sockets.*

using PRF and DFDBA alveolar fillers to encourage bone neoformation. The average percentage of newly produced bone in samples collected within the first 5 months of recovery was 41.22%, but the average percentage in samples taken more than 5 months later was 55.89%.

An average proportion of newly produced bone of 47.41% was seen 4 months after healing in a previous histomorphometric study that used DFDBA without PRF [42], which is marginally greater than the proportion attained in the current study. It was noticed that the DFDBA (donor variability) origin difference in our study may have had an impact on the outcomes.

Our study found an average of 15.43% at healing periods less than or equal to 5 months and an average of 13.72% at healing periods more than 5 months, indicating gradual resorption of the allograft particles over time. This proportion of residual DFDBA particles was found to exist within the grafted alveoli. According to a recent study [43], there were 37.42% residual DFDBA particles at 2 months and

#### **Figure 8.**

*Sample from a grafted alveolar socket showing a healing score of 2 (H&E). Lamellar bone (LB), woven bone (WB), residual particle (RP).*

*Particulate Allografts (DFDBA) Combined with Platelet Concentrate: An Effective… DOI: http://dx.doi.org/10.5772/intechopen.112929*

#### **Figure 10.**

*Sample from a grafted alveolar socket showing a healing score of 2 (H&E). Residual particle (RP).*


#### **Table 4.**

*Average proportions as a function of the healing time for alveolar grafted sockets.*


#### **Table 5.**

*Proportions of newly formed bone, residual particles, and healing score of sinus lifts.*

26.80% at 4 months. This suggests that particles in our study were absorbed more quickly.

The study found a propensity to see equal amounts of both at healing durations of less than 5 months with regard to the proportions of lamellar and woven bone, indicative of bone maturity. In contrast, there was a tendency toward a predominance of lamellar bone after 5 months of healing, which suggests that the graft evolved over time toward better bone maturity. These results suggest that the post-extraction alveolar arrangement using particle DFDBA (300–500 m) and A-PRF produces good results in terms of bone quality and maturity. It is difficult to compare these findings with other histomorphometric studies because many of them just look at the overall proportion of freshly created bone rather than distinguishing between lamellar and woven bone.

After 6 to 9 months, samples from the locations that received a sinus lift revealed an average proportion of newly produced bone of 48.57% in all seven samples, with a higher proportion of lamellar bone (scoring 3) than woven bone in six of the seven samples. This demonstrates that sinus grafts that were treated with particulate DFDBA (300–500 m) and PRF successfully healed the bone.

In a different study [43], sinus lift patients were divided into two groups: one with DFDBA alone and the other with DFDBA with PRF. At 6 months, the group with PRF had a larger percentage of newly created bone (18.35%) than the group without PRF (12.95%), indicating that PRF has a beneficial effect on new bone production.

As comparing these findings to those of our study, it appears that DFDBA and PRF for sinus lift produce superior results in terms of new bone creation as compared *Particulate Allografts (DFDBA) Combined with Platelet Concentrate: An Effective… DOI: http://dx.doi.org/10.5772/intechopen.112929*

#### **Figure 12.**

*Sample from a sinus lift displaying a healing score of 3 (H&E). Woven bone (WB), lamellar bone (LB), residual particle (RP).*

#### **Figure 13.**

*Sample from a sinus lift displaying a healing score of 3 (TM). Woven bone (WB), lamellar bone (LB), residual particle (RP).*

to DBBM and PRF. By exposing lingering BMPs, the osteoinductive capability of DFDBA—a product of its demineralization during preparation—might be able to explain this discrepancy. However, because of the small sample size in our study, additional research with bigger sample sizes is preferred to improve the findings. We found 13.07% of residual particles in the sinus lift samples, with an average healing time of 7.35 months.

After an average healing duration of 10.81 months, histomorphometric analysis of samples taken without sinus lifts using FDBA and DFDBA revealed an average proportion of residual particles of 9.56% and 10.11%, respectively [44]. These findings are consistent with our research and point to a long-term beneficial absorption of allograft particles after sinus lift surgeries.
