Vol.3, No.4, 200-205 (2011) Health
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Effects of chitosan on dental bone repair
Fatemeh Ezoddini-Ardakani1*, Alireza Navab Azam2, Soghra Yassaei3,
Farhad Fatehi4, Gholamreza Rouhi5
1Associate Professor of Oral and Maxillofacial Radiology, Faculty of Dentistry, Shahid Sadoughi University of Medical Sciences,
Yazd, Iran; *Corresponding Author: ezoddini@gmail.com;
2Lecturer of Oral and Maxillofacial Surgery, Faculty of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, Iran;
3Associate Professor of Orthodontics, Faculty of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, Iran;
4Yazd Diabetes Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran;
5Department of Mechanical Engineering, Faculty of Engineering & School of Human Kinetics, Faculty of Health Sciences,
University of Ottawa, Ontario, Canada.
Received 26 February 2011; revised 12 March 2011; accepted 1 April 2011.
Objectives: Bone defects following tumor re-
section and osteolysis due to dental and bone
lesions and periodentium tissue disorders are
serious challenges. One of these materials used
is chitosan, a derivative of crustaceans’ exo-
skeleton. The aim of this study was to assess
effects of chitosan on socket repair after dental
extraction. Methods: Twenty four dental sockets
of 15-24 year-old patients were visited by a
maxillofacial surgeon for extracting premolar
teeth for orthodontic purposes. The sockets in
one side were filled-in by chitosan. In the other
side, the sockets were left unfilled. After 10
weeks, periapical radiographs were obtained
from the repair sites, were digitalized and then
evaluated for densitometry using Adobe Pho-
toshop Software. Each socket was divided into
coronal, middle and apical. Dental density of
each socket in case and control groups was
recorded. The density of regenerated bone was
comp ared a gainst the maximum bone density of
each individual. Wilcoxon Singed-Rank test and
paired t-test were used for data analysis. Re-
sults: Bone density in middle and apical sec-
tions in case group was significantly more than
control group. In apical section in case group
regenerated bone reached up to 98.2% of nor-
mal bone density. In each patient, the bone
density in epical and middle sections was in-
crease 29.3% and 10.8% of normal bone density.
Conclusions: Chitosan significantly increased
bone density in epical and middle sections.
Chitosan can be used fo r bone rep air in cases of
bone loss. Various densitometry studies for
evaluating chitosan effects in different bone
defects are suggested.
Keywords: Chitosan; Bone Regeneration/Drug
Effects; Biocompatible Materials/Administration &
Bone defects may develop in various systemic and
dental disorders. Osteolysis in periodontal diseases ac-
counts for the most cases of need for bone repair. The
conventional methods of bone repair which commonly
are used, such as autografts and allografts have their
own shortcomings and drawbacks. Autografts are lim-
ited in terms of availability of materials and may result
in donor site morbidity [1]. Using allografts may be
more desirable in some cases, but the possible immune
reaction and infection transmission limit their applica-
tion. To overcome these limitations, various synthetic
bone substitutes made of metal, ceramics, polymers,
and various composite structures have been introduced
to accelerate and improve the process of bone regen-
eration; though their safety, effectiveness and efficacy
remain uncertain [2]. Recently, by increasing the rate of
invasive surgical procedures especially in the fields of
orthopedics and dentistry, the bone repair techniques
using new materials are getting more popular. The new
materials which are used should help us reduce the op-
eration time, scar size, post-operation pain, and also
improve patient recovery [3,4]. One of the best materi-
als which fulfill these requirements is chitosan [5-7].
Recently a special attention has been made toward
using the materials which are derived from nature.
Such materials would have some advantages over syn-
thetic ones. Most notably, they have been shown to
F. Ezoddini-Ardakan et al. / Health 3 (2011) 200-205
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
yield faster healing with less incompatibility in human
beings [8].
Chitosan is a chitin derived polymer which is pro-
duced by deacetylation of chitin. Chitin is mainly found
in exoskeleton of crustaceans and also in some fungi.
These shells which were simply regarded as g arbage in
the past times are now seen as a valuable source of chi-
tin [9]. Many biomedical applications have been identi-
fied for chitosan including wound healing, bandage,
skin grafting, homeostasis, hemodialysis, drug delivery,
preventing d ental p laqu e, h yperten sion contro l, calciu m
absorption, bilirubin absorption, and cholesterol control
Several desirable properties have been described for
chitosan including high osteoinductivity, osteointegra-
tability, easy application and gradual biodegradability
that makes it a good candidate for bone regeneration.
Some researchers have studied the effects of chitosan
compounds on animal bone repair [14-16]. Regarding
the characteristics of chitosan as a biomaterial for bone
repair, in this study, investigation was made to see the
effects of chitosan on dental socket repair after tooth
In this study, we recruited 12 female orthodontic pa-
tients with the age of 16 to 24 years old. They were un-
dergoing extraction of 2-4 first premolar teeth as part of
their orthodontic treatment and were qualified as ASA
class I category. After extraction of the teeth, dental
socket on the right jaw was filled with chitosan powder
and duly sutured. The cavities on the opposite side got
sutured without filling by any excessive material. Chito-
san powder was procured from capsules made by Spring
Leaf Co., Sydney, Australia. Each capsule contains 250
mg of chitosan powder. The contents of 20 capsules were
removed to special plastic bags and sterilized by gamma
radiation of 13 -1 5 Ki l o gray ( KGy).
2.1. Surgical Procedures
After anesthetizing the patient by injecting 1½ car-
tridge of lidocaine 2% with 1:100 000 Epinephrine (Da-
rou Pakhsh Pharma. Chem. Co. Tehran, Iran), an intra-
sulcular incision was made to raise a distal papilla and
marginal gingival. This exposed the marginal bone to
allow visualization of the alveolar bon level. Extraction
of all the first premolars was done at one setting for each
patient using a straight elevator and forceps. After ex-
traction of all the premolar teeth, 2cc of fresh blood was
collected from the extracted tooth socket and mixed with
the chitosan powder for producing a thick pasty material
with which each socket on the right side was filled, and
the socket on the left side was left unfilled to be used as
control. None of the sockets were covered with a barrier
membrane or mucoperiosteal flap. The distobuccal, me-
siobuccal and palatal papilla with attached gingival at
the extraction sites were stabilized with two interrupted
suture to reduce the opening of the socket and also the
amount of exposed material. All the patients were pre-
scribed a course of prophylactic antibiotic therapy and
pain medication with post operative instructions for 7
days, at which point the suture was removed. The dress-
ing of all wounds was performed by the same nurse.
2.2. Radiological Study
The patients were recalled 10 weeks after surgery for
periapical dental radiography. Periapical radiographs of
the extraction sites were obtained using Planmeca
Proline X-ray unit (Planmeca Co., Helsinki, Finland) set
to 10 KVP, 8 mA and 0.16 sec. The radiographs were
taken by the same technician under the same conditions.
The films were processed by Velopex dental x-ray film
processors (Medivance Instruments Ltd., London, UK)
at 27˚C for 4 minutes (Figure 1).
2.3. Qualitative Histopathological Scoring
The radiographs were digitized by a scanner with 300
DPI resolution and the densitometry was done using
Adobe Photoshop software (Adobe Systems Incorpo-
rated, San Jose, CA) on a personal co mputer. Each socket
was vertically divided into 3 equal zones: coronal, mid-
dle, and apical. Regenerated bone density was assessed
2.4. Statistical Analyses
 
(a) (b)
 
(c) (d)
Figure 1. Periapical radiography of mandibular first premo-
lar in case (a) and control (b); and maxillary first premolar in
case (c) and control (d).
F. Ezoddini-Ardakan et al. / Health 3 (2011) 200-205
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
in each zone, in both intervention and control cavities.
The density of normal adjacent bone to each cavity was
also assessed to be compared with rege nerated bone.
Data were analyzed by SPSS ver. 11 (SPSS Inc., Chi-
cago, USA) using Paired t-test and Wilcoxon signed rank
test. P-values less than 0.05 were considered as signifi-
2.5. Ethical Consideration
After explaining the research protocol, an informed
consent was obtained from each subject. The proposal of
this study got approved by the Ethics Co mmittee of Sha-
hid Sadoughi University of Medical Sciences.
A total o f 2 4 dental so ckets in 12 ortho dontics p atien ts
were studied. The sockets were either in upper or lower
jaws. The sockets on the right side (n = 12) were filled
with chitosan paste, whereas the sockets on the left (n =
12) got sutured after tooth extraction without any filling.
After ten weeks of tooth extraction, the density of re-
generated bone in each socket was assessed for each
three zones (coronal, middle, and apical). Extraction site
of all the cases healed with no complication. The mean
density of the regenerated bone in each zone was as-
sessed by measuring the gray level on the scanned ra-
diographs. The mean density of regenerated bone in each
zone of repaired tooth socket for the case and control
groups is presented in Table 1.
The mean density of regenerated bone was signifi-
cantly higher in middle and apical zones of case group
compared to control group, whereas this difference was
not considerable between the coronal zones of the two
As the normal bone density differs from one person to
another, the density of regenerated bone in each patient
is compared with the maximum bone density of the same
patient. The mean bone density of the mandibles of the
participants was 92.2 ± 10.4 with a range of 78 to 110.
For each person, the ratio of regenerated bone density to
the maximum mandibular bone density in both groups of
sockets was calculated. These figures and their statistical
analysis results and the differences between the two
groups are summarized in Table 2.
In this study, an investigated was made on the bone
healing effects of chitosan on 12 patients who referred
for premolar teeth extraction for orthodontic purposes.
The tooth extraction was planned for maxilla, mandible
or both of them.
A substance used for improving bone regeneration
Table 1. The mean gray level of each zone of the sockets in
case and control subjects .
Group Coronal
mean ± SD
(min ~ Max)
mean ± SD
(min ~ Max)
mean ± SD
(min ~ Max)
(n = 12) 35.3 ± 12.0
(21.7 ~ 60) 57.7 ± 12.3
(42 ~ 78.2) 90.9 ± 12.5
(68 ~ 110)
(n = 12) 34.2 ± 1.6
(22.8 ~ 57.1) 47.3 ± 13.4
(31.7 ~ 76.3) 64 ± 16.5
(34.3 ~ 95.5)
P value* 0.583 0.05 0.002
*Wilcoxon Signed Rank Test.
Table 2. Ratio of regenerated bone density to the maximum
mandibular bone density at the three zones in chitosan-filled
and control groups.
Group Coronal
% ± SD Middle
% ± SD Apical
% ± SD
Chitosan (n = 12) 37.8 ± 9.8 61.9 ± 7.9 98.2 ± 3.9
Control (n = 12) 37.3 ± 11.6 51.1 ± 13.1 68.9 ± 14.6
P value * 0.896 0.040 0.000
* Paired t-test.
should be biocompatible, biodegradable, and effective. It
should also be cheap and easy to apply [1]. The gold
standard for restoring missing bone is autogenous bone
graft, which is hard to perform and has some limitation-
sand drawbacks [17-19]. Moreover, this method is asso-
ciated with the risk of graft rejection and/or immu-
nological reactions [9,10]. Chitosan has been reported as
a biodegradable and biocompatible substance [20], and
according to numerous studies it is effective in restoring
bone defects [21-26]. Chitosan can be used as a bio-
compatible coating for orthopedic and craniofacial im-
plants [14]. Minimal inflammatory reactions have been
observed in tissues which have been in contact with the
chitosan co ated pins; while the healing sequence of bone
remains typical. So, chitosan coatings have shown to be
able to develop suitable osseointegration of dental and
orthopedic implants [27]. Chitosan microparticles can
also improve drug delivery to localized areas which
leads to increased and accelerated bone growth [28].
Several studies have investigated various effects of
chitosan on bone healing and raised some hypotheses on
its mechanisms [29-31]. For instance, according to a
study by Chevrier and co-workers, chitosan increases the
vascularization of blood vessels and stimulates budding
tissue (tissue comprising of budding capillaries and fi-
broblasts) [32].
Park and co-workers [33] reported that spongy chito-
san activates osteoblasts and could increase osteogenesis.
F. Ezoddini-Ardakan et al. / Health 3 (2011) 200-205
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Klokkevold [34] also reported that chitosan increases the
activity of osteoblasts and helps bone formation. Lee and
co-workers [35] reported that spongy chitosan supports
the proliferatio n of osteoblasti c cells. Considerin g the rate
of bone formation and the speed of bone regeneration in
the dental cavities (see Tables 1 and 2), results of this
study are in agreement of the above mentioned studies.
Kim and co-workers [36] studied chitosan and its de-
rivatives and their applications in tissue engineering,
such as the formation of skin, bone, cartilage, liver,
nerves, and blood vessels. In the present study, chitosan
powder is u sed to see its effect on bone r egener ation . It
was interestingly found that after a period of 10 weeks,
the bone density in the apical zone of the sockets treated
with chitosan was 98.2% of maximum mandibular bone
density, which was 29.3% more than that of untreated
In a study by Zhang and co-workers [37], chitosan
was used as a biocompatible and biodegradable polymer
along with mannitol and calcium phosphate cement
(CPC) for bone healing. They reported that this new
formulation could be used for shaping hydroxyapatite in
surgeries and implants. This new formulation can be
used in improving the macroporosity of apatitie frame-
works, in order to help reduce the stress shielding in an
implant-bone complex, also implant longetivity. In our
study, higher speed of bone formation in the apical and
middle zones of the dental sockets filled with chitosan
can be justified by an increase in scaffold and position-
ing of the bone forming cells in this framework. Xu and
co-workers [38] used CPC for repair of teeth and cra-
niofacial tissue. In their study, CPC was used for repair
of periodontal bony tissue and loose teeth following
fractures. They used tetra-calcium phosphate and chito-
san in order to make non-rigid and strong calcium phos-
phate cement, which they believe is more useful in repair
of periodontal tissue and bone surrounding an implant.
Chitosan has been used also for producing fast-setting
CPC and makes it resistant to washout [38]. Chitosan
can solve the problem of handling the particulate form of
calcium hydroxyapatite as it can stabilize the p articles in
surgical sites [39]. Bumgardner and co-workers [14] re-
ported that chitosan is a biopolymer that accelerates
bone formation, facilitates wound healing and has an-
timicrobial properties. It also helps bone formation and
makes orthopedic procedures and craniofacial implants
easier. In the present study, the chitosan powder was
mixed with blood of each person and filled in the dental
socket, and it was found that bone tissue regeneration
will be faster in chitosan-filled socket than untreated
dental socket.
Ma and co-workers [40] studied the heat sensitive ef-
fects of chitosan hydrogel on periodontal bone healing.
They concluded that chitosan thermosensitive hydrogel
loading rhBMP-2 can facilitate regeneration of the peri-
odontal tissue and simplify the surgical operation. De-
fects were made in the anterior section of the jaws of
three healthy dog s and ch itosan hydrogel was injected in
the wounds and the flaps were sutured. But, a number of
defects were left untreated and not filled with the hy-
drogel. After a period of 5 weeks, the periodontal tissue
was regenerated in all main regions of the study group,
while only a small section of the tissue was regenerated
in the control group. In their study, in the cavities filled
with chitosan, not only the bone regeneration was faster,
but also the density was similar to the density of the
bone of the subject under study. Zhang and co-workers
[41] used chitosan scaffold and adenovirus vector for
regeneration of alveolar bone in dental implant defects.
They reported that chitosan-collagen scaffold can be
used as a good mediator in bone regeneration.
Chitosan has been shown to be one of th e most prom-
ising biomaterials for orthopedic and dental applications.
Due to its interesting characteristics, chitosan is consid-
ered as a suitable alternative for bone graft. Chitosan
improves bone regeneratio n i n dent al bo ne loss.
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