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Revista Română de Anatomie funcţională şi clinică, macro- şi microscopică şi de Antropologie

Vol. XIV – Nr. 4 – 2015 CLINICAL ANATOMY

SINgLe IMpLANT INSerTION IN CANINe TOOTh regION Of MANdIbLe

Dorelia Lucia Călin1, Anca Rusu3, Mihaela Mitrea2

“Gr.T. Popa” University of Medicine şi Pharmacy, Iaşi1. Discipline of Anatomy

2. Discipline of Cariology and Restorative Odontotherapy3. Implantology at Private Dental Office “dr. Anca Rusu”, Bucureşti

Specialist in Dentoalveolar Surgery

SInGle IMPlAnT InSeRTIOn In CAnIne TOOTh ReGIOn Of MAnDIBle (Abstract): The region of mandibular canine tooth is the most common location in which where occur life-threatening haemorrhages and cause airway obstruction. The aim of this study was to evaluate the results of the insertion of a single implant in the mandibular canine region and the frequency of vascular and neuro-sensory complications associated with the procedure. Material and method: in 35 patients was carried out the insertion of a single implant in the canine mandibularregionn, immediate temporary reconstruction of edentulous area and thereafter the achievement of a metal-ceramic crowns on implant. Results: the achievement of an osteotomy depth and the use of implants having a maximum 14 mm length has prevented the perforation of blood vessels and ap-pearance of profuse bleeding, and also the emergence of neurosensory disorders. Conclusions: The insertion of the implant in the mandibular canine region proved to be a procedure with a high acceptance and satisfaction from the patients. If all the appropriate steps required for diagnosis and treatment planning are taken and an adequate surgical protocol is followed, mandibular canine region is undoubtedly a safe zone for implant placement. Key words: SInGle IMPlAnT, CA-nIne MAnDIBUlAR ReGIOn, vASCUlAR AnD neURO-SenSORy COMPlICATIOnS

INTrOdUCTIONThe use of dental implants to replace a sin-

gle tooth has evolved into a viable alternative that replaces the fixed prosthetic bridges.

Jemt (1) described the technique of using endosseous implants, if one tooth is missing

in a partially edentulous jaw. The advan-tages for single tooth replacement implant were related not only to aesthetic requirements, but also to the fact that adjacent teeth were not involved in prosthetic rehabilitation.

Mayer et al. (2) emphasized that the implant that replaces a single tooth is an independent unit, that during its function cannot rely on neighbor-ing teeth for lateral and tangential support.

long-term studies have reported excellent implant survival rates when it is applied to replace a single tooth (3,4).

Due to its accessibility and favorable loca-tion, mandibular anterior region is often pre-

ferred for inserting of implants. Mandibular anterior area was originally considered a secure area from surgical point of view. Over time, the serious complications resulting from dental im-plant procedures have been reported in the sci-entific literature.

ANATOMICAL CONSIderATIONS ON The ANTerIOr regION Of The MANdIbLeIdentification of anatomical structures of the

anterior mandible is extremely important for the success of the surgical procedure (5).

The main vital structures in this region are: mandibular incisive canal, mental foramen and anterior intraosseous loop the inferior alveolar canal. To avoid damaging these anatomical structures is absolutely necessary to know their precise location before surgery using CT and radiographic examination (6,7). The mandibu-

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Dorelia Lucia Călin et al.

gual space, the bleeding may increase, the result is a hematoma of the lingual floor (39). Dental implants that could cause major bleeding com-plications were most often located in the man-dibular canine region, followed by the incisors and first premolar.

Many authors have studied the location of major blood vessels in the jaw and their rela-tionship to the inferior alveolar nerve and the mandibular incisive nerve and cortical bone.

This bleeding is explained by the presence of sublingual and submental arteries in this area.

The most common cause of heavy bleeding in the anterior mandibular region is the lingual cortical bone perforation with sublingual artery damage, in case of introduction of long implants (15 mm or more). The use of short implants in the mandibular anterior region is recommend-ed, in order to avoid the risk of significant bleeding complications (20).

Sensory disorders can be caused by direct or indirect trauma (e.g., pressure induced by a hematoma into the incisive canal) or by chron-ic stimulation of neurovascular bundle of inci-sive canal or lingual lateral canals after implant placement in the interforaminal region. After direct trauma, which can occur if the implant is placed through the bone canal, the nerve endings may undergo retrograde degeneration in most of the cases (40). Indirect trauma can be caused by a hematoma affecting neurovas-cular package of the mandibular incisive canal (41). As this blood clot cannot be evacuated, the inflammation presses the nerve and leads to compression neuropathy.

Sensory disturbances could also be related to chronic stimulation. If the implant is placed near or on top of the nerve, the nerve can be stimulated regularly each time the patient bites or chews. It is possible that such a chronic stimulation can lead to the emergence of chron-ic neuropathy (42).

Sensory disorders such as hypoesthesia, par-esthesia and anesthesia may occur. In some cases, the sense of pain is predominantly dis-rupted, in others tactile senses and perception of temperature are affected (41). All these changes can be transient or persistent, depending on the extent of damage of the nervous tissue involved (43).

Another undesirable effect is damage to ad-jacent teeth by lack of parallelism between the implant and the neighboring teeth or by exces-

sive approaching. Placing of the implant should respect a minimum distance of 1.5 mm from adjacent teeth. In case of damage and depend-ing on its grade, the affected tooth treatment may include endodontic treatment, periapical surgery, apicectomie or extraction (44).

The purpose of this study was to evaluate the result of the insertion of a single implant in the mandibular canine and the frequency of vascular and neuro-sensory complications as-sociated with the procedure.

MATerIAL ANd MeThOdThe present study involved 35 patients (21

women and 14 men) aged between 28-46 years who presented at Private Dental Office “Dr. Anca Rusu” with esthetic and phonation disor-ders induced by the absence of canine tooth in mandible.

Criteria for inclusion of patients in this study were: non smoking, no bone loss in the af-fected teeth, absence parafunctions (bruxism), the absence of periodontal disease.

Patients were carefully evaluated from med-ical, clinical, radiological point of view in order to assess the current health status and to iden-tify any conditions that would require pre-treat-ment or contraindications to treatment. To all patients was exposed the treatment plan which involved the insertion of an implant, an im-mediate temporary reconstruction of the breach and subsequent realization of a metal-ceramic crowns on implant. furthermore, they were informed in detail about the surgical procedure and informed consent was obtained.

An example of the performed procedure in the group of patients is presented below. The patient KI, female, aged 33 years, without oth-er significant family history, presented at Pri-vate Dental Office „Dr Anca Rusu” accusing physiognomy and speech problems due to ab-sence of mandibular left canine.

At intraoral clinical examination was ob-served the absence of mandibular left canine (fig.1), being completed by radiological ex-amination (fig.2).

Panoramic radiograph was used to locate anatomical landmarks such as the mental fora-men, anterior loop of inferior alveolar canal and incisive canal and to determine the length of the implant (fig.3).

CT imaging was used to determine the ana-tomic status and tridimensional bone offer at the proposed implantation site and evaluate the

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Dorelia Lucia Călin et al.

fig. 4. Crestal incision with the detachment of vestibular flap to expose the bone

fig. 5. Realization of neoalveolus and the inser-tion of parallelism pin

fig. 7. Inserting the provisional abutment on implant

fig. 6. Inserting the implant

than 15 mm in order to avoid risks of bleeding complications through sublingual artery dam-age. The purpose of replacing a single tooth in the anterior mandible has been the restoration of functions and appropriate aesthetics without affecting hard structures and adjacent soft tissue.

The patient received detailed explanations on surgical procedures that will be performed, possible complications and the informed con-sent was obtained from her. Antibiotic prophy-laxis was performed 1 hour before the proce-dure, then local anesthesia.

After local anesthesia a crestal incision was made, supplemented by two vertical incisions with the detachment of vestibular flap in order to expose the bone (fig.4).

The osteotomy was performed to insert the implant up to a length determined by x-ray and after it was inserted the pin for guiding and parallelization, for assessing the depth, position and angle of neoalveolus (fig.5).

The Bredent implant has been inserted with a length of 14mm and a diameter of 3.5 mm, the torque was 40 (fig. 6).

Addition of bone was not carried out. There wasn’t observed the existence of any lingual perforations.

Subsequently, the provisional abutment was inserted in the implant (fig.7), and then was

fig. 8. The provisional acrylic crown with a celluloid cape and flowable composite resin over

the provisional abutment

Romanian Journal of Oral Rehabilitation

Vol. 8, No. 2, April - June 2016

66

SINUS LIFT USING A-PRF AND CERABONE AND SIMULTANEOUS

INSERTION OF IMPLANTS - CASE REPORT Mitrea Mihaela

2, Rusu Anca

3, Călin Dorelia

1

1Discipline of Cariology and Restorative Odontotherapy,

2Discipline of Anatomy,

“Grigore T. Popa” University of Medicine şi Pharmacy, Iaşi, 3 specialist in dentoalveolar surgery, implantology at Private Dental Office “dr. Anca Rusu”, București

Corresponding author: dr. Mitrea Mihaela e-mail: mitrea.mihaela77@gmail.com tel.+4 0744.533.723

ABSTRACT Sinus floor elevation with autogenous bone grafts and/or bone substitutes is a generally accepted procedure

that allows the insertion of implants. Recent studies have shown good results of the use of the PRF in stimulating

bone regeneration, especially when it is used in combination with other grafting materials. The purpose of this case

report is to present the clinical results of sinus lift procedure through the lateral window antrostomy in the right sinus

using A-PRF and bone substituents (Cerabone) and simultaneous insertion of implants as well as the evaluation of

healing time. The results of this case report shows that A PRF can be used successfully in combination with bone

substitutes in lateral sinus lift technique with immediate insertion of implants. All implants that were inserted

immediately, simultaneously with sinus lift procedure were osteointegrated correctly and it was possible to proceed

to the stage of final prosthesis. Conclusions: The use of the combination of A-PRF and Cerabone in sinus lift

technique speeded healing time by approximately 50%, thus favoring implant osseointegration, went without

postoperative complications and showed good acceptance by the patient.

KEYWORDS: lateral sinus lift, aprf, bone substitutes

INTRODUCTION

Insertion of implants in the posterior

maxilla can be problematic due to small

amounts of subsinusal bone as a result of

resorption, progressive pneumatization of the

maxillary sinus and reduced bone density.

Maxilla consists mainly of cancellous bone,

being one of the least dense bone structures of

the oral cavity.

Maxillary sinus floor augmentation

became a routine treatment preprosthetic in

recent years. Sinus floor elevation with

autogenous bone grafts and/or bone substitutes

is a generally accepted procedure that allows

the insertion of implants (1).

This allows the insertion of dental

implants through simultaneously or in stages

procedures in the posterior maxillary area,

which in the past was considered inappropriate

for insertion of implants due to insufficient

bone volume. It is necessary to achieve a good

initial primary stability to perform

simultaneous implant insertion and sinus bone

grafting (2).

The technique of "sinus lift" consists

in increasing vertically the alveolar ridge of

maxillary posterior area by interposing

different types of bone grafts between

Schneider sinusal membrane and the floor of

the maxillary sinus (3). The procedure is one

of the most common preprosthetic surgical

procedures performed in dentistry today.

Sinus floor augmentation was

introduced by Tatum in 1976, modified by

Boyne and James in 1980 (3) and then

changed again by Tatum in 1986 (4), this

procedure is still used today. Sinus

augmentation procedure is indicated when the

penetration of the implant in antrum cannot be

avoided.

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Open sinus lift surgery is performed

under local anesthesia, an incision is practiced

on the alveolar ridge and two vertical

incisions. Crestal incision is made slightly to

palatal side in order to keep a wider band of

keratinized attached gingiva for a stronger

wound closure and to prevent its dehiscence. The flap is detached, a window is carried out

in the lateral wall of the sinus and with

appropriate tools the Schneider membrane is

rised from the walls of the maxillary sinus in

order to create the necessary space for bone

grafting. This new created space is filled with

material for bone addition and will provide the

platform for implant placement (5). It is very

important for the graft material to be stable.

The surgeon may opt to use a resorbable

membrane to cover the material for bone

addition. Finally, the created window will be

covered with an artificial membrane to protect

the addition material, and the gingiva will be

repositioned perfectly closing the operational

site. Wallace and Froum (6), have led a

systematic study about the the technique of

lateral fenestration, concluding that it is

advantageous to use graft particle

simultaneously with the insertion of implants

with rough surface and a barrier membrane

covering the bone window to enhance the

chances of success of the procedure. The use

of membrane showed a success rate of 93.6%

compared to 88.7% when not using it.

For sinus augmentation have been used

bone grafts in the form of particles or block,

coming from various sources. It has been

reported that bone grafts using particles have

greater chances of success than those in block.

Cerabone (Botiss Biomaterials) is derived

from the mineral phase of bovine bone, which

shows strong resemblance to the human bone

with regard to chemical composition, porosity

and surface structure. The unique

manufacturing process based on high-

temperature heating removes all organic and

potentially antigenic components, making the

material absolutely safe and free of

proteins. Its three-dimensional porous network

enables a fast penetration and adsorption of

blood and serum proteins and serves as a

reservoir for proteins and growth factors. After

the material has been sterilized, it can be used

for bone additions, without causing the

occurrence of an immune response from the

host. In general, this type of biomaterial is

osseoinductive, and while it goes through

physiological remodeling and becomes

incorporated into the surrounding bone.

The use of A-PRF in sinus lift

technique

Improving the regeneration of the

human body by using the the patient's own

blood is a unique concept in dentistry. Platelet

concentrates are used routinely for many years

in various surgical and medical specialties.

The platelets play a crucial role not only in

hemostasis but also in wound healing (7).

A-PRF (Platelet Rich Fibrin

Advanced) is the latest technology in dental

surgery and implantology shortening the

healing time by approximately 50% after any

intervention for oral surgery.

Advanced platelet-rich fibrin (A-

PRF) developed by dr. Choukroun in 2014

(8), is a third generation derived from a

concentration of platelets and white blood

cells (anti-infection). In order to create the A-

PRF material, shall be taken a small amount of

the patient's blood and centrifuged in the

dental office. To produce A-PRF the protocol

has been changed, the duration and spin speed

have changed (revolutions per minute). By

decreasing revolutions per minute and

increasing the spin time for A-PRF, all

monocytes are found equally distributed fibrin

clot, but equally we obtained a better

distribution of platelets, which was initially

focused equally on the inner end of the clot. It was necessary to prolong the coagulation time

in the tube, which was obtained through the

use of a special composite glass which allowed

the slowing of clot formation.

A-PRF membranes and plugs have

numerous applications in dentistry: the

protection and stabilization of bone

augmentation material in sinus elevation (9),

lateral ridge augmentation procedures, socket

preservation after dental extraction or avulsion

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(10,11), treatment of furcation defects (12),

infra-osseous defects from periodontitis (13),

for root coverage in the case of gingival

recession, filling of cystic cavities (14,15) etc.

A-PRF membranes and plugs and the

liquid obtained is used in combination with

bone graft in the bone additions (9) and in

implantology in order to cause the rapid

healing of bone and fixation of bone cells on

the titanium surface of dental implants.

Growth factors membranes and plugs

obtained through the A-PRF technique

are gradually released for 7 days and their

actions lead to a rapid healing from the first

days after surgery. By stimulating

angiogenesis (formation of new blood vessels)

and the intake of nutritional and healing

factors in the graft, A-PRF contributes

decisively in the consolidation phase of initial

results. Recovery periods are significantly

reduced in fractures, after surgery in the jaw

bone.

The purpose of this case report is to

present the clinical results of sinus lift

procedure through the lateral window

antrostomy in the right sinus using A-PRF and

bone substituents (Cerabone) and

simultaneous insertion of implants as well as

the evaluation of healing time.

CASE REPORT

The TD patient, aged 50 years

presented to the Dr. Anca Rusu Private Dental

Office in Bucharest having neuromuscular,

mastication, phonation disorders, changes in

position of the mandible and profile, reduced

vertical dimension as a result of a partial

maxillary edentation.

It was absolutely necessary to evaluate

preoperatively the medical and dental history

of the patient. The patient was carefully

evaluated from a medical, clinical, radiological

point of view in order to assess the current

health status and to identify any conditions

that would require preliminary treatment or

contraindications to implant therapy.

Were performed the following

laboratory tests: complete blood count (red

cells, white cells, globular value, leukocytes,

platelets, hemoglobin), bleeding and

coagulation time, clot retraction time,

hematocrit, coagulogram.

Odontal and periodontal clinical

examination was performed in the vicinity of

maxillary sinus to detect any lesion that could

cause odontogenic maxillary sinusitis.

Fig.1 Initial appearance of metal-ceramic prosthesis

OPT radiographic examination and a

preoperative CT scan were performed for the

evaluation of possible anatomical

deformations (partial or total sinus septa) or

the existence of sinus pathology

(rhinosinusitis, sinusitis of odontogenic origin,

cysts, pseudocysts, polyposis, tumors).

It was found that the volume of

residual bone at the level alveolar process is

sufficient in quality and quantity to ensure

primary initial stability of implants that will be

inserted simultaneously with sinus floor

augmentation.

It was decided to perform a sinus lift

intervention through lateral approach in right

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maxillary sinus using A-PRF and bone

substituents (cerabone) and simultaneous

insertion of implants. the patient received

detailed explanations on surgical procedures

that will be performed and informed consent

was obtained from him.

Fig.2 Initial radiographic appearance

The ceramo-metal prosthesis was removed (fig.3).

Fig.3 Appearance of abutments after removal of the prosthesis

Fig.4 Specific A-PRF centrifuge

APRF was prepared according to the

protocol developed by Choukroun et al. There

were collected 8 ml of venous blood from

antecubital vein of the patient.

The patient's whole blood was

introduced into the tubes made of a special

composite based on glass, without

anticoagulant and has been centrifuged by

means of a machineA-PRF for 14 minutes at

1500 revolutions per minute (fig.4). Within

few minutes, the absence of anticoagulant

allowed the activation of most platelets

contained in the sample and was initiated the

coagulation. The fibrinogen at first has been

concentrated in the upper part of the tube, until

the effect of the circulating thrombin

transformed it into a fibrin network. The result

was a fibrin clot containing the platelets

located in the middle part of the tube, between

the red blood cell layer located at the bottom

and at the top the acellular plasma. One

centrifugation resulted in the formation of

three layers: the top layer is platelet poor

plasma, the intermediate layer is A-PRF and

the deep layer, contain red blood cells. The

clot was removed from the tube and attached

red blood cells were scraped and removed.

In order to obtain plugs, the clot has

been introduced into the special cylinders of

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A-PRF Box and slowly compressed with the

help the piston.

The clot was then cut to the

appropriate size (fig.5), being added a

metronidazole pill to prevent the development

of anaerobes (fig.5,6).

Fig.5 Realisation of A-PRF plugs

Fig.6 Metronidazole used to prevent the development of anaerobes

Fig.7 The sectioned clot

Fig.8 The mixture of metronidazole with APRF and Cerabone

Antibiotic prophylaxis was performed

1 hour before the beginning of the procedure

with a dose of 1000 mg Amoxiklav, and then

the local anesthesia.

After local anesthesia a crestal incision

was made, supplemented by two vertical

incisions and the detachment of a trapezoidal

vestibular flap in order to expose the lateral

wall of the sinus.

Osteotomy was performed to insert

implants for lateral incisor and first premolar

to the length determined by radiography

(fig.9). In order to ensure the parallelism of the

implants have been used the parallelization

pins. The implants were screwed into the

openings of the alveolar bone, taking care not

to exert excessive forces on bone. For the

lateral incisor has been used an implant with

the length of 12 mm and diameter of 3.5 mm,

for the first premolar was used an implant with

a length of 12 mm and a diameter of 4 mm.

The osteotomy was practiced with the

achievement of a lateral window to open the

sinus using globular atraumatic burs at the

right first molar level (fig.10). It was fractured

the well-defined bone fragment and pushed

very carefully inward and superior in order to

not perforate the sinus Schneider membrane,

that covers the sinus floor.

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Fig.9 Insertion of implants for lateral incisor and first premolar, achievement of sinus

bone window

Fig.10 Detachment of sinus membrane and prepairing for insertion of APRF and

bone addition material

The Schneider membrane was

carefully detached from the walls of the

maxillary sinus and sinus floor using elevators

without perforating it (fig.10). It is very

important to maintain intact the sinus

membrane what is coming in contact with the

bone graft material to prevent infection of the

sinus. The bone addition material (xenograft

with natural bone substitutes Cerabone, bovine

bone and APRF clot) was placed under sinus

mucous membrane, around the exposed

implant tip and in the antral space along

existing bone (fig.11).

Fig.11Sinus augmentation with a mixture of bone particles and APRF

Fig.12 Insertion of the third implant

Then inserted the 3rd implant in the first molar having a diameter of 4 mm and a length of 12

mm (fig.12).

Fig.13 The appearance of the grafted sinus

Fig.14 Coating with collagen membrane on the lateral window

At lateral incisor was done also the

lateral augmentation of the alveolar ridge with

Cerabone particles (fig.14).

Lateral window was covered with a

resorbable collagen membrane (Jason

membrane Botiss) (fig.14) and after was

performed soft tissue suture.

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Antiseptic solutions for oral irrigation

with Chlorhexidine 0.12% were indicated to

reduce the plaque accumulation of in the area

of implantation after surgery.

It were recommended anti-

inflammatory pills, analgesics, nasal

decongestant to improve permeability osteo-

meatal complex, cold water compresses,

antibiotics. The patient was instructed not to

blow his nose for 7 days after surgery, to

cough with open mouth to avoid increased

pressure in the operated sinuses and to sleep

upright.

RESULTS

The patient reported only the

appearance of swelling during the first 5 days

post surgery. There were no clinical signs of

postoperative sinusitis.

At an interval of 10-14 days the

sutures were removed.

Postoperative assessment was done at

one month, two months and three months after

the insertion of implants to notice any pain,

gingival inflammation, swelling and increasing

the height of the bone and implants stability.

In all implants a bone-implant contact was

clearly visible. There were no radiolucencies

around implants.

Fig.15 Control panoramic radiography of patient after sinus lift intervention

with lateral approach. Final radiological appearance

In clinical and radiologic examinations

performed at 2 months after surgery, it was

found that all implants that have been inserted

immediately, simultaneously with the

procedure of sinus lift were osseointegrated

properly and it was possible to proceed to the

stage for final prosthesis.

DISCUSSION

In the systematic literature reviews

conducted by Raffi et al. (16) and MR Oliveira

et al. (17), the authors observed that there is a

significant increase in the use of PRP to

promote integration of grafts or implants,

many papers have been published in this

regard.

Recent studies have shown good

results of the use of the PRF sau APRF in

stimulating bone regeneration, especially when

it is used in combination with other grafting

materials (18,19,24). Several researchers have

reported good results of using PRF in

maxillary sinus lift procedures (20,21). Tajima

et al. (22) reported success in this type of

approach, using PRF as the only graft material

with simultaneous installation of the implants.

Oliveira et al. (19), after the

histomorphometric assessment formation in

bone defects in rat skull, they concluded that

the PRF alone had a positive effect, but low on

bone formation and that better results are

obtained by associating PRF with bovine bone

particles (Bio-Oss).

Currently, lateral approach to

maxillary sinus augmentation has become a

routine technique for obtaining a long-term

survival rates of more than 96% of implants in

the posterior region of the jaw (6,23).

The use of advanced platelet rich fibrin

or A-PRF, which is an autologous healing

material, is a way to accelerate and enhance

the natural healing mechanisms in sinus lift

procedure. In this case report the use of the

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combination of A-PRF and Cerabone in sinus

lift technique speeded the healing time by

about 50%, thus favoring implant

osseointegration.

CONCLUSIONS

Sinus lift procedure with immediate

insertion of implants proved to be successful

resulting in osseointegration and stability of

implants, went without postoperative

complications and showed good acceptance by

the patient.

The results of this case report presents

the advantages of using APRF with bone

substitutes on how to obtain a more reliable

bone regeneration and a higher quality of bone

from biomechanical point of view in lateral

sinus lift with less patient morbidity compared

with traditional methods.

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regeneration? Literature review. Musculoskelet Regen. 2015; 2:e895. doi: 10.14800/mr.895.

18. Tatullo M, Marrelli M, Cassetta M, Pacifici A, Stefanelli LV, Scacco S, et al. Platelet rich fibrin (PRF) in reconstructive

surgery of atrophied maxillary bones: clinical and his-tological evaluations. Int J Med Sci. 2012; 9:872–880.

19. Oliveira MR, Silva AC, Ferreira S, Avelino CC, Garcia Júnior IR, Mariano RC. Influence of the association between

platelet-rich fibrin and bovine bone on bone regeneration. A histomorphometric study in the calvaria of rats. Int J Oral

Maxillofac Surg. 2015; 44:649-655.

20. Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan AJJ et al. Platelet-rich fibrin (PRF): A second-

geration platelet concentrate. Part V: Histologic evaluations of PRF effects on bone allograft maturation in sinus lift.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006; 101:299-303.

21. Zhang Y, Tangl S, Huber CD, Lin Y, Quiu L, Rausch-Fan X. Effects of Choukroun’s platelet-rich fibrin on bone

regeneration in combination with desproteinized bovine bone mineral in maxillary sinus augmentation. A histological

and histomorphometric study. J Cran Maxillofac Surg. 2012; 40:321-328.

673

Revista Română de Anatomie funcţională şi clinică, macro- şi microscopică şi de Antropologie

Vol. XIV – Nr. 4 – 2015 CLINICAL ANATOMY

BILATerAL SINuS LIfT wITh The SIMuLTANeOuS INSerTION Of IMpLANTS: A CASe repOrT

Mihaela Mitrea1, Anca rusu3, Dorelia Lucia Călin2

“Grigore T. Popa” University of Medicine şi Pharmacy, Iaşi1. Discipline of Anatomy

2. Discipline of Cariology and Restorative Odontotherapy3. Private Dental Office “dr. Anca Rusu”, Bucureşti

Primary dentist

BIlATeRAl SInUS lIfT wITh The SIMUlTAneOUS InSeRTIOn Of IMPlAnTS: A CASe RePORT (Abstract): Sinus floor augmentation is a technique that is used to improve long-term retention of the implants.The purpose of this case report is to present the clinical results of bilateral sinus lifting procedure with simultaneous insertion of implants through the antrostomy with a single lateral window in the right sinus and double window antrostomy in the left sinus. Bone addition material was Cerabone (Botiss Biomaterials) and 5 implant Sky Classic from Bredent. Results: All the implants (five in number) which were inserted immediately, simultaneously with the bilateral sinus lift procedure were osseointegrated correctly and it was possible to move to the prosthetic stage. There were no clinical signs of postoperative sinusitis.Conclusions: Bilateral sinus lift procedure with immediate insertion of implants proved to be successful leading to os-seointegration and stability of implants, went without postoperative complications and showed good acceptance by the patient. Key words: BIlATeRAl SInUS lIfT, IMPlAnT, DOUBle wIn-DOw AnTROSTOMy

INTrODuCTIONedentulous maxillary posterior region pre-

sents difficulties concerning the insertion of implants as compared to other areas of the oral cavity. After the loss of teeth, anatomical and functional changes occur in the maxilla, the mandible position modifies as well as the aes-thetic profile, malocclusion, difficulties in mas-tication and speech arise etc.

Maxillary alveolar process is resorbed grad-ually in vertical and horizontal senses (1). This reduction interests especially the vertical dimen-sion of bone, between the top of the alveolar ridge and the floor of the maxillary sinus, called by Misch (2) subsinusal vertical dimension.

loss of teeth in the posterior maxilla can induce expansion of the maxillary sinus as a result of pneumatization, through a positive air pressure created during breathing.

It is not uncommon for maxillary sinus floor to be present close to the alveolar ridge. The tendency towards sinus pneumatization is sig-

nificantly higher after molar extraction com-pared to that generated by the extraction of premolars (3). Moreover, the residual alveolar ridge is reduced due to centripetal resorption of the alveolar bone at the level of maxilla, especially in the buccal area.

ANATOMICAL CONSIDerATIONS regArDINg The pOSTerIOr regION Of The MAxILLAThe use of oral implants in the posterior region

of the maxilla has become a routine practice in dentistry. The frequency of oral implant place-ment has raised the number of neurosensory disorders and hemorrhages, it is there fore im-portant for surgeons to detect the neurovascular structures from the level of maxilla.

The maxillary sinus and nasal cavity occupy a large space in the middle of the face, and expansion of the sinus cavity towards alveolar processes occurs due to loss of teeth. The max-illary sinus is constantly expanding with age.

674

Mihaela Mitrea et al.

Its expansion is noticed especially after extrac-tion of molars and premolars. edentation has as result a very thin bony wall that separates the oral cavity from the maxillary sinus.

The maxillary sinus is a large solitary cav-ity, but sometimes it can be divided into small-er cavities which are separated by septa. These would have their origins in the development of the maxillary sinus and tooth eruption, being known as primary septa. Sometimes they are acquired structures, resulting from pneumatiza-tion of the maxillary sinus after tooth loss, a situation in which are called secondary septa (4).

Maxilla has a dense vascular network. The maxillary sinus is vascularized by maxillary artery branches via infraorbital artery, the great palatine artery and facial artery. The venous system is collected either by a single trunk, which is a continuation of the spheno-palatine vein, or by three venous plexus: the anterior and posterior pterygoid plexus, and the alveolar plexus. The anterior and posterior pterygoid plexus converge through the lateral pterygoid muscle and connects with the alveolar plexus which drains partly into the maxillary vein and partly into the facial vein. The innervation of the maxillary sinus is ensured by the maxillary nerve (V2): the second branch of the trigemi-nal nerve and its collateral branches (5).

Insertion of implants in the posterior max-illa can be problematic due to small amounts of subsinusal bone as a result of resorption, pro-gressive pneumatization of the maxillary sinus and reduced bone density. Maxilla consists mainly of cancellous bone, being one of the least dense bone structures of the oral cavity.

Available bone volume and bone quality de-termine the type of the implant and the used surgical technique, having a vital role in the success of treatment (6). Sinus floor augmenta-tion is a technique for reconstruction of bone anatomy and is used to develop a sufficient bone volume in order to improve long-term retention of the implant (7).

The technique of “sinus lift” consists in increasing vertically the alveolar ridge of max-illary posterior area by interposing different types of bone grafts between Schneider sinusal membrane and the floor of the maxillary sinus (8). The procedure is one of the most common preprosthetic surgical procedures performed in dentistry today.

Sinus floor augmentation was introduced by Tatum in 1976, modified by Boyne and James

in 1980 (8) and then changed again by Tatum in 1986 (9), this procedure is still used today. Sinus augmentation procedure is indicated when the penetration of the implant in antrum can not be avoided.

external lateral sinus lift technique (la­teral antrostomy) can be conducted in a single surgical step (implants are placed simultaneosly with the elevation of Schneider membrane) or two surgical steps (implants are inserted in a few months after sinus augmentation). The choice of using one or another of described techniques is based on bone offer in vertical direction. Thus, if the height of the alveolar ridge is less than 4-5 mm is recommended to choose the two-stage technique in order to obtain a good stability for the implant and where the ridge height is greater than 5 mm the one-stage technique can be carried out. lateral sinus lift technique allows to obtain a bone height of 8 to 15 mm.

Open sinus lift surgery is performed under local anesthesia, an incision is practiced on the alveolar ridge and two vertical incisions. Crestal incision is made slightly to palatal in order to keep a wider band of keratinized attached gin-giva for a stronger wound closure and to prevent its dehiscence. The flap is detached, a window is carried out in the lateral wall of the sinus and with appropriate tools (antral curette, elevators) the Schneider membrane is rised from the walls of the maxillary sinus in order to create the necessary space for bone grafting. This new created space is filled with material for bone addition and will provide the platform for im-plant placement. It is very important for the graft material to be stable. The surgeon may opt to use a resorbable membrane to cover the material for bone addition. finally, the created window will be covered with an artificial mem-brane to protect the addition material, and the gingiva will be repositioned perfectly closing the operational site.

wallace and froum (11), have led a system-atic study about the the technique of lateral fenestration, concluding that it is advantageous to use graft particle simultaneously with the insertion of implants with rough surface and a barrier membrane covering the bone window to enhance the chances of success of the proce-dure. The use of membrane showed a success rate of 93.6% compared to 88.7% when not using it.

JIACD Continuing Education

Platelet-rich fibrin (PRF), developed in France by Choukroun et al (2001), is a second gen-eration platelet concentrate widely used to

accelerate soft and hard tissue healing. Its advan-tages over the better known platelet-rich plasma (PRP) include ease of preparation/application, min-

imal expense, and lack of biochemical modification (no bovine thrombin or anticoagulant is required). PRF is a strictly autologous fibrin matrix containing a large quantity of platelet and leukocyte cytokines. This article serves as an introduction to the PRF “concept” and its potential clinical applications.

Michael Toffler, DDS1 • Nicholas Toscano, DDS, MS2 • Dan Holtzclaw, DDS, MS3

Marco Del Corso, DDS, DIU4 • David Dohan Ehrenfest, DDS, MS, PhD5

1. Private Practice limited to Periodontics, New York, NY, USA

2. Private Practice limited to Periodontics, Washington DC, USA

3. Private Practice limited to Periodontics, Austin, TX, USA

4. Private Practice, Department of Periodontics, Turin University, Turin, Italy

5. Researcher, Department of Biomaterials, Institute for Clinical Sciences, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden

Abstract

KEY WORDS: Platelet rich fibrin, platelet rich plasma, autologous growth factors

The Journal of Implant & Advanced Clinical Dentistry • 21

JIACD Continuing EducationIntroducing Choukroun’s Platelet Rich

Fibrin (PRF) to the Reconstructive Surgery Milieu

This article provides 2 hours of continuing education credit. Please click here for details and additional information.

The Journal of Implant & Advanced Clinical Dentistry • 29

JIACD Continuing Education

Figure 17: PRF has been placed into cylinders in the PRF Box®.

Figure 16: “Extraction Mix” – PRF fragments + FDBA + calcium sulfate (Ace Surgical, Brockton, MA).

Figure 18: Pistons are used to gently compress PRF. Figure 19: Compression results in the formation of a PRF plug.

membrane prior to grafting as “membrane insur-ance” possibly sealing an undetected perforation which can lead to serious postoperative sequelae.

DISCUSSIONPRF is a matrix of autologous fibrin, in which are embedded a large quantity of platelet and leu-kocyte cytokines during centrifugation.24,25 The

intrinsic incorporation of cytokines within the fibrin mesh allows for their progressive release over time (7-11 days), as the network of fibrin disinte-grates.30 The easily applied PRF membrane acts much like a fibrin bandage,5 serving as a matrix to accelerate the healing of wound edges.11 It also provides a significant postoperative protection of the surgical site and seems to accelerate the

30 • Vol. 1, No. 6 • September 2009

JIACD Continuing Education

integration and remodeling of the grafted biomate-rial.25-27 According to Simonpieri et al,31 the use of this platelet and immune concentrate during bone grafting offers the following 4 advantages: First, the fibrin clot plays an important mechanical role, with the PRF membrane maintaining and protecting the grafted biomaterials and PRF fragments serving as biological connectors between bone particles. Second, the integration of this fibrin network into the regenerative site facilitates cellular migration, particularly for endothelial cells necessary for the neo-angiogenesis,24 vascularization and survival of the graft. Third, the platelet cytokines (PDGF, TGF-β, IGF-1) are gradually released as the fibrin matrix is resorbed, thus creating a perpetual process of healing.20,30 Lastly, the presence of leukocytes and cytokines in the fibrin network can play a signifi-cant role in the self-regulation of inflammatory and infectious phenomena within the grafted material.21

CONCLUSIONEarly publications and clinical experience seem to indicate that PRF improves early wound closure, maturation of bone grafts, and the final esthetic result of the peri-implant and periodontal soft tissues. Additional reports are forthcoming, highlighting the many clini-cal applications and healing benefits of this second generation platelet concentrate. ●

Professional Dental Education and Pro-fessional Education Services Group are joint sponsors with The Academy of Dental Learning in providing this continuing dental education activity.

The Academy of Dental Learning is an ADA CERP Recognized Pro-vider. The Academy of Dental Learn-ing designates this activity for two hours of continuing education credits.

ADA CERP is a service of the Ameri-can Dental Association to assist den-tal professionals in identifying quality providers of continuing dental educa-tion. ADA CERP does not approve or endorse individual courses or instruc-tors, nor does it imply acceptance of credit hours by boards of dentistry

Correspondence:Michael Toffler, D.D.S.Diplomate American Board of Periodontology116 Central Park South, Suite 3New York New York 10019mtoffler@earthlink.net

Figure 20: PRF plug has been placed in grafted socket immediately after removal of fractured #9.

Elbaradie et al. Platelet Rich Fibrin Effect Following Lateral Sinus Lifting

72

Alexandria Dental Journal. (2015) Vol.40 Pages:72-78

INTRODUCTION Replacement of lost natural teeth by osseointegrated

implants has been represented as one of the most significant

advances in prosthetic dentistry. Endosseous dental implants

are widely inserted to restore oral function, including

mastication and speech, as well as for aesthetic

improvement in partly or completely edentulous patients (1, 2).

However, insufficient height and/or width of the alveolar

ridge when placing implants for oral rehabilitation in the

atrophied maxilla is a challenge. Ridge resorption and sinus

pneumatization in the posterior maxilla, compounded with

poor quality of bone, can compromise implant rehabilitation

of the patient (3).

The maxillary sinus elevation procedure has become an

important preprosthetic surgical procedure for the creation

of bone volume in the edentulous posterior maxilla for the

placement of dental implants (4).

The most widely used techniques for maxillary sinus floor

elevation is the classical lateral antrostomy introduced by

Tatum in 1976. Lateral window may be performed using a

1- or 2-step approach. Implants are installed simultaneously

with the bone graft (1-stage lateral antrostomy) or after a

delay to allow for bone healing (2-stage lateral antrostomy) (5).

The most common intraoperative complication with these

surgical approaches is the perforation of the Schneiderian

Membrane. Wallace et al (6) stated that the membrane

perforation rate has been reduced from the average reported

rate of 30% with rotary instrumentation to 7% using the

piezoelectric technique. The piezosurgery device provides a

clear surgical site, as it maintains a blood-free surgical field

during bone cutting. This allows improved visualization of

the surgical area. A very small amount of pressure is applied

which allows a very precise cut. The typical cavitation effect

induces a hydropneumatic pressure in the physiological

saline solution that contributes to atraumatic sinus

membrane elevation (5).

Although sinus elevation using autogenous bone graft is

considered to be the gold standard, many researchers have

attempted to modify this procedure, because of the

morbidity associated with bone harvesting. Various non-

autogenous substitutes, such as xenogenic, allogenic and

some artificial materials have been developed to reduce the

risks associated with autogenous bone grafts. However, the

use of xenogenic or allogenic materials also induces the risk

of disease transmission and have been found to be

insufficient for bone regeneration, and artificial bone grafts

have been found to be insufficient for osteogenic

regeneration (7-9).

The use of blood preparations such as plasma

concentrates or fibrin glue might be an interesting option to

improve this approach. Platelet rich fibrin has many

characteristics that make it suitable for application as a

filling material for sinus floor augmentation. It is an

autologous fibrin matrix that is rich in platelets, leukocytes

and growth factors. It has moderate strength, is easy to

handle and promotes healing of the sinus membrane and

bone (7).

Therefore, the present study was designed to evaluate the

effect of PRF on bone regeneration in sinus lifting using

piezosurgery and simultaneous implant placement.

EVALUATION OF PLATELET RICH FIBRIN IN

SINUS LIFTING WITH SIMULTANEOUS

IMPLANT PLACEMENT Elbaradie R

1 BDS; Ossman S

2 PhD; Eldibany R

2 PhD

Abstract: Introduction: Rehabilitation of the edentulous posterior maxilla with dental implants is challenging. The deficient alveolar ridge interferes with

implant insertion of adequate length placed in the correct position and with the accurate inclination. The maxillary sinus elevation procedure has

become an important preprosthetic surgical procedure for bone creation in the posterior maxilla prior to implant placement. The use of PRF during

sinus-lift procedures has been advocated for many years.

Objectives: This study was designed to evaluate the use of platelet rich fibrin (PRF) following sinus lifting with piezosurgery and simultaneous

implant placement.

Materials and methods: 7 patients were selected to perform sinus lifting with simultaneous implant placement using PRF as a sole agent and

piezosurgery device.

Results: Cone beam computerized tomography 6 months postoperatively showed statistically significant increase in bone height and density. The

mean of the newly formed bone height was (6.55 ± 1.14 mm). The mean postoperative bone height measured from the floor of the maxillary sinus

and alveolar crest was (11.35 ± 0.56 mm). The mean of the newly formed bone density was 507 HU. The mean of the postoperative bone density

around the implants after 6 months was (547.71 ± 188.42 HU). The mean marginal bone loss was (0.82 ± 0.25 mm).

Conclusion: PRF could be successfully used as a sole agent for bone regeneration in lateral sinus lifting with simultaneous implant placement.

Key words: lateral sinus lifting, platelet rich fibrin, Piezosurgery, implants, bone density.

----------------------------------------------------

1- Dentist, Alexandria Dental Research Center, Ministry of Health, Egypt.

2- Professor of Oral and Maxillofacial Surgery, Faculty of Dentistry, Alexandria University, Egypt.

Elbaradie et al. Platelet Rich Fibrin Effect Following Lateral Sinus Lifting

74

Alexandria Dental Journal. (2015) Vol.40 Pages:72-78

Korea.) were used in this study. A platform switching is

present between the implant and the abutment, which

minimizes the microgap and maximizes the biologic width

in order to minimize bone loss. It has a tapered body with

powerful threads at the apex to facilitate implant insertion.

They were inserted using a ratchet wrench until the implant

body was flushed with bone surface.

PRF preparation:

Platelet rich fibrin (PRF) was prepared according to the

protocol developed by Choukroun et al (10) (3000 RPM for

10 min) using a table centrifuge.

During surgery 20 ml of whole blood was obtained from

the brachial vein, the blood was transferred and divided into

two 10 ml sterile glass tubes without anti-coagulant.

Immediate centrifugation was performed using a table

centrifuge. The coagulation cascade starts during

centrifugation and the blood is divided into 3 parts in the

tube: serum at the upper part, red blood cells (RBCs) at the

bottom and PRF in between which is separated and used as

the augmentation material.

PRF was prepared and placed over the implants tented

under the maxillary sinus membrane, as shown in (figure 3).

Then the flap was repositioned and sutured using 3-0 black

silk suture material.

Fig. 3: A picture showing PRF in the maxillary sinus with

simultaneous implant placement.

All patients were advised to; apply cold packs extra orally

intermittently and avoid hot food on the first day, apply hot

packs on the second day, avoid eating hard food at the

surgical site, chlorhexidine mouth wash was started on the

2nd post-operative day 3 times daily for 10 weeks. Broad

spectrum antibiotic Amoxicillin 875 mg + Clavulanic acid

125 mg tablets (Augmentin 1 gm Smithline Beecham

Pharmaceutical Co., Bentford, England) in combination with

metronidazole 500 mg capsule (Amrizole 500 mg tablets,

Amriya Pharmaceutical Industries, Egypt) twice daily for 5

days to avoid post-operative infection. Non-steroidal anti-

inflammatory analgesic in the form of diclofenac potassium

50 mg tablets (Cataflam 50 mg tablets, Novartis Pharma

AG,Basle, Switzerland) 3 times daily for 7-10 days to avoid

the possibility of inflammation, oedema and pain. Ephidrine

nasal drops (Otrivin spray/nasal Drops 10 ml, Novartis

Pharma AG, Basle, Switzerland) 3-5 times daily for 5 days.

Sutures were removed after 10 days.

Postoperative evaluation

All patients were examined the day after surgery then

weekly for the first month postoperatively, then on intervals

of 1, 4 and 6 months postoperatively. The clinical

parameters of importance for determination of implant

success included: Absence of pain, tenderness, discomfort,

wound dehiscence, implant mobility or any other

complications related to the sinus lifting or implant

placement. Pain and discomfort were examined using visual

analogue scale (VAS). Patients were asked to assess the

level of their average pain by placing a mark on a horizontal

line that was 10 cm long (11). Tenderness by palpation and

swelling was measured by inspection.

Immediate CBCT were obtained to evaluate the surgical

procedure and implant placement, as shown in (figure 4).

.

Fig. 4: Immediate post-operative CBCT (sagittal cut) to evaluate

the surgical procedure and implant placement.

Periapical x-rays were obtained immediately

postoperative and on intervals of 1 and 4 month. CBCT was

obtained 6 month postoperatively for all patients to measure

bone density, marginal ridge resorption and the height of the

newly formed bone, as shown in (figure 5).

CBCT measurements were performed using On Diamond

3DApp-DBM software system (Cypernet, Korea) where the

bone height could be measured and through which the bone

density is calculated directly in HU.

RESULTS In this study, seven sinus floor augmentations were

performed on seven patients. The selected patients were 2

males and 5 females, and their age ranged from 28-60 years

with a mean age (39.86 ± 13.02 years). The mean height of

the alveolar ridge from the marginal crest to floor of the

maxillary sinus was 5.84 mm ± 0.79 mm (Range: 4.49 - 6.8

mm), as shown in (table 1).

Romanian Journal of Oral Rehabilitation

Vol. 7, No. 2, April - June 2015

12

THE MANAGEMENT OF PERIAPICAL MAXILLARY CYST

BY USING THE A-PRF (PLATELET RICH ADVANCED FIBRIN):

A CASE REPORT

Mihaela Mitrea1*

, Anca Rusu2, Dorelia Lucia Călin

3

1“Grigore T. Popa" University of Medicine and Pharmacy - Iași, Romania, Faculty of Dentistry,

Department of Anatomy 2Specialist in dentoalveolar surgery, implantology at Private Dental Office “Dr. Anca Rusu”,

București 3“Grigore T. Popa" University of Medicine and Pharmacy - Iași, Romania, Faculty of Dentistry,

Department of Cariology and Restorative Odontotherapy

*Corresponding author: Mihaela Mitrea, DMD

“Grigore T. Popa" University of Medicine and Pharmacy

- Iași, Romania;

e-mail: mitrea.mihaela77@yahoo.com

ABSTRACT

Periapical or radicula cysts are the most common inflammatory cysts of the jaw. The surgical intervention aims

to remove periapical pathology to obtain bone regeneration and healing of periapical tissues. Improving the

regeneration of the human body by using the the patient's own blood is a unique concept in dentistry. The

purpose of this case report is to illustrate the effectiveness of advanced platelet-rich fibrin (A-PRF) inserted into

the bone defect resulting from a periapical cyst enucleation. The physiological time of healing of the cystic

cavity is from 6 months to 1 year, but when the cystic cavity is filled with A-PRF, this phenomenon of

physiological healing is accelerated, the healing period decreasing to three months. The results of this case

report shows that APRF can be used successfully as monotherapy for obtaining periapical regeneration.

Keywords: periapical cyst, enucleation, A-PRF

INTRODUCTION

Radicular or periapical cysts are the most

common inflammatory cysts of maxilla and

develop from the epithelial remnants of

Malassez of the periodontal ligament that are

remnants of Hertwig's epithelial sheath,

which are stimulated to proliferate by an

inflammatory process that originates from an

infection or pulp necrosis of a non-vital tooth

with the development of a periapical

granuloma (1). By the liquefaction of the

apical granuloma the radicular cyst appears.

Over the years, the cyst may regress, should

remain stationary or should increase in size.

In the maxilla, the anterior region appears

to be more prone to the development of the

periapical cysts while in the mandible they

occur more frequently in the premolar region

(2). The radicular cyst pathogenesis

comprises three distinct phases: the initiation

phase, the phase of cyst formation and

expansion phase (3). Initially, the patient may

experience specific pain of pulpitis and apical

periodontitis, followed by a period without

symptoms corresponding to the moment of

the cyst formation. Therefore, when radicular

cysts are detected, they are usually painless,

but can sometimes have mild pain or

Romanian Journal of Oral Rehabilitation

Vol. 7, No. 2, April - June 2015

13

sensibility on percussion of causal tooth.

Periapical cysts become symptomatic when

are infected or reach large dimensions and

cause nerve compression.

Since it is an inflammatory cyst, its wall

usually contains a dense mixed inflammatory

infiltrate that is rich in plasma cells and

lymphocytes. Cyst wall, in addition to its

inflammatory component, is fibrous and often

contain numerous capillaries, especially in the

areas adjacent to the epithelial lining (4).

Several treatment options are available for

a radicular cyst such as endodontic treatment,

the extraction of causal tooth,

marsupialization, complete enucleation (5).

The surgical intervention aims to remove

periapical pathology to obtain bone

regeneration and healing of periapical tissues.

The treatment of periapical cysts by using

the A-PRF

Hard and soft tissue healing is mediated by

a variety of intra- and extracellular events that

are regulated by signaling proteins. A number

of studies from the literature have shown that

the bone regeneration procedures may be

improved by the addition of specific growth

factors.

Improving the regeneration of the human

body by using the the patient's own blood is a

unique concept in dentistry. Platelet

concentrates are used routinely for many

years in various surgical and medical

specialties. The platelets play a crucial role

not only in hemostasis but also in wound

healing (6).

Many techniques for obtaining autologous

platelet concentrates were developed and

applied in oral and maxillofacial surgery. The

first generation includes platelet-rich plasma,

the second generation involving platelet rich

fibrin, while a third generation product is

advanced platelet-rich fibrin.

Platelet-rich plasma was first introduced

by Marx et al. in 1998 (7), which showed that

its use accelerates the rate and extent of new

bone formation. Platelet-rich plasma (PRP)

has been proposed as a method for

introducing concentrate of growth factors

PDGF, TGF-ß, and IGF-1 at the surgical site,

enriching the the natural blood clot, in order

to accelerate the healing of wounds and to

stimulate bone regeneration (8).

Platelet-rich fibrin (PRF) is a tissue

engineering product that has gained a lot of

popularity due to its promising results in the

induction of bone healing. It was developed

in France by dr.Choukroun et al in 2001 (9)

and is a second-generation of platelet

concentrate widely used to accelerate soft and

hard tissue healing. Its advantages compared

to the platelet-rich plasma (PRP) include:

ease of preparation / application, minimum

cost as well as lack of biochemical changes

(bovine thrombin, gelling agent or

anticoagulant are not required), favorable

healing due to slow polymerization, promotes

hemostasis, has a favorable effect on the

immune system (10).

PRF is strictly autologous the fibrin matrix

containing a large amount of platelets and

leukocyte cytokines. Although platelets and

leukocyte cytokines play an important role in

the biology of the biomaterial, the fibrin

matrix which supports them certainly

constitutes the decisive factor responsible for

real therapeutic potential of PRF (11).

Advanced platelet-rich fibrin (A-PRF)

developed by dr. Choukroun in 2014 (12), is a

third generation derived from a concentration

of platelets and white blood cells (anti-

infection). In order to create the A-PRF

material, shall be taken a small amount of the

patient's blood and centrifuged in the dental

office. To produce A-PRF the protocol has

been changed, the duration and spin speed

have changed (revolutions per minute). By

decreasing revolutions per minute and

increasing the spin time for A-PRF, all

monocytes are found equally distributed in

Romanian Journal of Oral Rehabilitation

Vol. 7, No. 2, April - June 2015

14

the fibrin clot, but equally was obtained a

better distribution of platelets, which was

initially focused equally on the inner end of

the clot. It was necessary to prolong the

coagulation time in the tube, which was

obtained through the use of a special

composite glass which allowed the slowing of

clot formation.

The protective membrane and plugs that

are produced release the key proteins that

stimulate growth of bones and soft tissue,

promote healing of soft tissue and bone. A-

PRF membranes and plugs are made from

own cells, and are not made from animal

products. A-PRF has a higher concentration

and a more homogeneous distribution of

monocytes, which are believed to play an

essential role in bone formation (12).

Advanced-PRF initiates the sustained

release of multiple growth factors, including

platelet-derived growth factor (PDGF), a

protein that plays an important role in the

replication of stem cells and osteoblasts

which are organized to create a new bone.

Studies conducted in The Clarion laboratory

Research Group, Pennsylvania University

(USA) and Repair-Lab, Institute of

Pathology, Johannes Gutenberg University of

Mainz (Germany) demonstrated that are

released bone morphogenetic protein-2 BMP

(Bone Morphogenetic Protein) and BMP-7. It

also are launched the VEGF by monocytes

that stimulate the formation of new blood

vessels, increasing the blood flow to the

surgical site.

Transforming growth factor (TGF-B),

another protein, stimulates the growth of

tissue by recruiting stem cells at the surgical

site and stimulates them to reproduce and

create the basis for new bone tissue. Also, the

thrombospondin 1, an adhesive glycoprotein

helps cell interactions (12). The first scientific

and clinical results showed that

vascularization is greater and early soft tissue

growth is faster, more cytokines are released,

BMP VEGF, PDGF, TGF beta and

thrombospondin than the classic PRF.

A-PRF membranes and plugs have

numerous applications in dentistry: the

protection and stabilization of bone

augmentation material in sinus elevation,

lateral ridge augmentation procedures, socket

preservation after dental extraction or

avulsion, treatment of furcation defects (13) ,

for root coverage in the case of gingival

recession, filling of cystic cavities etc.

The purpose of this case report is to

illustrate the effectiveness of advanced

platelet-rich fibrin (A-PRF) inserted into the

bone defect resulting from a periapical cyst

enucleation. After the complete enucleation

of a cyst, the cavity usually is filled quickly

with blood. This clot is the physiological

version of A-PRF. The physiological time of

healing of the cystic cavity is from 6 months

to 1 year, but when the cystic cavity is filled

with A-PRF, this phenomenon of

physiological healing is accelerated, the

healing period decreasing to three months.

CASE REPORT

The GB female patient, in the age of 50,

came to the Private Dental Office "Dr. Anca

Rusu", Bucharest accusing pain, swelling in

the anterior maxilla.

The patient reported that the pain started

about 3 years ago, at the level of anterior

maxilla. Disease progression was slow, in

bursts, with numerous acute exacerbations

accompanied by pain of increased intensity at

the level remaining teeth and a painful

vestibular swelling associated with general

malaise.

Following extra and intraoral clinical

examination, neuromuscular, aesthetic,

masticatory, phonation disorders were

detected, changing in the position of the

mandible, the vertical dimension and profile

as a result of front and lateral, mandibular and

maxillary edentations. Following a

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Vol. 7, No. 2, April - June 2015

16

area was made to verify that the cyst was

totally removed without residual tissue

remains.

The cyst was placed in 10% formalin

neutral solution and sent for histopathological

examination to confirm the definitive

diagnosis of periapical cyst.

The remaining bony walls were very thin

and the bone defect was deep and extended,

thus presenting a significant risk of

incomplete healing bone and fibrous

invagination. APRF was prepared according

to the protocol developed by Choukroun et al.

There were collected 8 ml of venous blood

from antecubital vein of the patient.

Figure 4. The extraction of remaining left

lateral incisor root

Figure 5. The cyst was enucleated totally

Figure 6. The appearance and size of the cyst

The patient's whole blood was introduced

into the tubes made of a special composite

based on glass, without anticoagulant and has

been centrifuged by means of a A-PRF

machine for 14 minutes at 1500 revolutions

per minute (fig.7). Within few minutes, the

absence of anticoagulant allowed the

activation of most platelets contained in the

sample and was initiated the coagulation. The

fibrinogen at first has been concentrated in

the upper part of the tube, until the effect of

the circulating thrombin transformed it into a

fibrin network. The result was a fibrin clot

containing the platelets located in the middle

part of the tube, between the red blood cell

layer located at the bottom and at the top the

acellular plasma. One centrifugation resulted

in the formation of three layers: the top layer

is platelet poor plasma, the intermediate layer

is A-PRF and the deep layer, contain red

blood cells. The clot was removed from the

tube and attached red blood cells were

scraped and removed (fig.8).

Figure 7. Specific A-PRF centrifuge

Figure 8. The fibrin clot containing platelets

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In order to obtain plugs, the clot has been

introduced into the special cylinders of A-

PRF Box and slowly compressed with the

help of the piston (fig.10). The clot was then

cut to the appropriate size (fig.11) and

inserted into the bone defect resulting from

the enucleation of the cyst with the purpose of

filling it (fig.12).

Figure 9. Realisation of A-PRF plugs

Figure 10. The clot introduced in special

cylinders of A-PRF Box

Figure 11. Appearance of A-PRF plugs

Figure 12. A-PRF application into the bone

defect after the cyst enucleation

Then it was reapplied and repositioned on

the bone bed mucoperiosteal flap in trapeze

and the suture was performed with resorbable

threads (fig.13).

Figure 13. The suture

The growth factors of A-PRF plugs are

gradually released for 7 days and their action

leads to rapid healing from the first days after

surgery. By stimulating the angiogenesis and

thus the intake of nutritional factors and

healing in the grafted area, A-PRF contribute

decisively also in the consolidation phase of

the initial results.

The patient has received post-operative

instructions. Antibiotics, analgesics, oral rinse

with mouthwash has been prescribed for 5

days after surgery.

At 24 hours after surgery was noted a

moderate edema of area concerned, which

gradually decreased during the first 7 days.

No signs of infection were noted. The patient

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19

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IInntteerrnnaattiioonnaall JJoouurrnnaall ooff MMeeddiiccaall SScciieenncceess 2012; 9(10):872-880. doi: 10.7150/ijms.5119

Research Paper

Platelet Rich Fibrin (P.R.F.) in Reconstructive Surgery of Atrophied Maxillary Bones: Clinical and Histological Evaluations Marco Tatullo1,2,3 *, Massimo Marrelli 2,3 *, Michele Cassetta4, Andrea Pacifici4, Luigi Vito Stefanelli4, Salvatore Scacco1, Gianna Dipalma2, Luciano Pacifici4 *, Francesco Inchingolo2,5 *

1. Dept. of Basic Medical Science, University of Bari, Italy; 2. Unit of Maxillofacial Surgery, Calabrodental clinic, Crotone, Italy; 3. Tecnologica, Research Institute in Regenerative Medicine, Crotone, Italy; 4. Department of Oral and Maxillofacial sciences, University of Rome "Sapienza", Italy; 5. Department of Dental Sciences and Surgery, University of Bari, Italy.

* These Authors contributed equally to this work.

Corresponding author: Dr. Marco Tatullo DDS, PhDs. Tecnologica Research Institute, Crotone, Italy. St. E. Fermi, Crotone, Italy. Dept. of Basic Medical Sciences – University of Bari – Bari, Italy. P.ce G. Cesare, 70100 Bari, Italy.

© Ivyspring International Publisher. This is an open-access article distributed under the terms of the Creative Commons License (http://creativecommons.org/ licenses/by-nc-nd/3.0/). Reproduction is permitted for personal, noncommercial use, provided that the article is in whole, unmodified, and properly cited.

Received: 2012.08.28; Accepted: 2012.10.17; Published: 2012.11.07

Abstract

Introduction. Maxillary bone losses often require additional regenerative procedures: as a supplement to the procedures of tissue regeneration, a platelet concentrate called PRF (Platelet Rich Fibrin) was tested for the first time in France by Dr. Choukroun. Aim of the present study is to investigate, clinically and histologically, the potential use of PRF, associated with deproteinized bovine bone (Bio-Oss), as grafting materials in pre-implantology sinus grafting of severe maxillary atrophy, in comparison with a control group, in which only deproteinized bovine bone (Bio-Oss) was used as reconstructive material. Materials and Methods. 60 patients were recruited using the cluster-sampling method; in-clusion criteria were maxillary atrophy with residual ridge < 5mm. The major atrophies in selected patients involved sinus-lift, with a second-look reopening for the implant insertion phase. The used grafting materials were: a) Bio-Oss and b) amorphous and membranous PRF together with Bio-Oss. We performed all operations by means of piezosurgery in order to reduce trauma and to optimize the design of the operculum on the cortical bone. The reo-pening of the surgical area was scheduled at 3 different times. Results. 72 sinus lifts were performed with subsequent implants insertions. We want to underline how the histological results proved that the samples collected after 106 days (Early protocol) with the adding of PRF were constituted by lamellar bone tissue with an interposed stroma that appeared relaxed and richly vascularized. Conclusions. The use of PRF and piezosurgery reduced the healing time, compared to the 150 days described in literature, favoring optimal bone regeneration. At 106 days, it is already possible to achieve good primary stability of endosseous implants, though lacking of functional loading.

Key words: Reconstructive Surgery; Platelet Rich Fibrin; Grafting Materials; Bone replacement.

Ivyspring

International Publisher

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Introduction Maxillary atrophy is an increasingly common

clinical condition and its management requires pa-tient-specific procedures, allowing for a reduced in-tra-operative timing and maximum postoperative compliance.

The causes that lead to focal or generalized at-rophy lie in multiple factors, but edentulism plays a primary role 1.

After loss of compromised teeth, resorption is maximum in the first year and more marked in the anterior areas than in the posterior ones 2.

In the following years, there is a minimum but constant decrease in the residual bone quantity.

Bone density influences the operative protocol and the choice of the type of implant used in order to replace the lost teeth. Maxillary bone losses often re-quire additional surgical procedures 3-6.

A grafting material takes the role of substitute of the insufficient bone tissue if it meets biocompatibility criteria, if it has an optimal response to biomechanical stress and a great capacity to replace the functions of synthesis/reshaping of the bone structure, essential for a correct turnover and for a good functionality of the tissue 7.

Of course gold standard is a biomaterial with the greatest biocompatibility: the autologous bone col-lected from the intraoral area, thanks to the same embryogenetic derivation and for the presence of the Bone Morphogenetic Protein (BMP) favoring osteoin-duction, is the perfect material for sinus lift. Besides, it is the only material having osteogenic properties in addition to osteoinductive and osteoconductive properties 8-13.

From the second half of the 1990s, the attention of the “Oral and Maxillofacial Surgery Community” was attracted by a series of scientific papers: they claimed that a platelet-derived growth factor could be valid not only for hemostasis, but also in the emerging field of bone grafting 14-22.

In the last years, a platelet concentrate called PRF (Platelet Rich Fibrin) was tested for the first time in France by Choukroun et al.

PRF belongs to a new generation of platelet concentrates: PRF is obtained without adding antico-agulants like heparin, EDTA, bovine thrombin etc. During the production of PRF, other cellular elements like leukocytes are activated, in addition to platelets. After the artificial hemostatic and inflammatory phenomenon induced by centrifugation, they release cytokines16-18. Then we will find three pro-inflammatory cytokines (IL-1β, IL-6 e TNFα), an

anti-inflammatory cytokine (IL-4) and a key promoter of angiogenesis (VEGF) 14,15,23,24.

PRF is then able to regulate inflammation and to stimulate the immune process of chemotaxis14,15,23. PRF is an autologous grafting material that eliminates any risk of disease transmission; besides, its jelly-like consistency favors stability of the clot and of the grafting material. This natural material seems to ac-celerate the physiological wound healing; besides, in association with bone grafts, it seems to accelerate new bone formation 14,15,19,20.

PRF has many advantages: • Simple and cheap protocol • Contains a great quantity of fibrins, platelets and

leukocytes 18 • Accelerates angiogenesis 14,15, multiplication of

fibroblasts and osteoblasts, and cicatrization. Aim of the work: the aim of the present study is

to investigate, clinically and histologically, about the potential of PRF, used as grafting material in pre-implant reconstructive surgery of severe maxil-lary atrophy; in particular, we want to assess what changes histologically and clinically after sinus lift procedures at 106-120-180 days, to determine if the use of PRF is able to accelerate the process of bone regeneration, which is essential to promote implant stability. This study also includes a control group, in which only deproteinized bovine bone (Bio-Oss) was used as reconstructive material, used without PRF.

Materials and Methods Patients were recruited using the cluster-sampling

technique, in order to obtain a heterogeneous sample, representing the macro-area of South Italy.

This study focused on 60 patients (48 females and 12 males aged between 43 and 62 years), ade-quately informed of the surgical and rehabilitative procedures they had to undergo. In order to minimize the operator's bias, surgical procedures were per-formed by only two operators, maintaining the same equipe in all surgical procedures performed.

Exclusion criteria were: • Diabetes • Hemocoagulative disorders • Incompetence/Immunological deficiency • Previous radiant therapies of the head-neck area • Anomalies of normal bone physiology • Therapies with Bisphosphonates • Smokers or ex-smokers.

Inclusion criteria were: • Maxillary atrophy, with residual ridge < 5mm,

found with a preoperative radiological and tomographic evaluation

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Table 2. Histomorphometric Evaluations. We evaluate the results of “Test-Side” and “Control-Side” in the three pro-tocols.

“EARLY” PROTOCOL Test Side Control Side Medullary Spaces (%) 70,2 68,44 Osteoid borders (%) 7,01 5,12 Trabecular bone (%) 22,79 26,44 “INTERMEDIATE” PROTOCOL Test Side Control Side Medullary Spaces (%) 70,01 68,18 Osteoid borders (%) 3,84 3,12 Trabecular bone(%) 26,15 28,7 PROTOCOLLO “LATE” Test Side Control Side Medullary Spaces (%) 61,41 58,15 Osteoid borders (%) 3,53 2,88 Trabecular bone(%) 37,06 38,97

Discussion The purpose of treating toothless areas with en-

dosseous implants has often clashed with the as-sumption that the loss of teeth is reflected in a pro-gressive bone resorption 25.

The modern and sophisticated techniques of GBR involve the use of grafting materials in order to restore anatomy and physiology of the areas with bone decrement 26.

The autologous bone is the selected grafting material (gold standard) as it is the only material to have osteogenic properties apart from osteoinductive and osteoconductive properties 9-11. However, the grafts performed with deproteinized bovine bone (Bio-Oss) are largely used in sinus lift 27-28; in fact, deproteinized bovine bone is able to cause a physio-logical process of perimplant bone reshaping, with neoapposition and significant bone gain thanks to its chemical and physical characteristics, which are very similar to those of the human bone. Beyond the ad-vantage of good osteoconductive properties, the mineral of bovine origin does not involve risks of in-tolerance or infection; the biocompatibility of the ma-terial depends on its preparation, aiming at eliminat-ing the protein and lipidic components from the original material and making it inorganic before being sterilized by heat and irradiation 12,13.

Platelet Rich Fibrin (P.R.F.) was first described by Dr. Choukroun and introduced with the European Directive n. 2004/23/CE of March 31, 2004.

Choukroun et al. reported encouraging results by using fibrin rich in growth factors for bone regen-eration in sinus-lift 19. Histological studies showed an equal bone growth and trabecular organization be-tween the areas treated with PRF and those of the control sample (F.D.B.A.); the rate of vital bone/inert

bone of the neoformed trabecular bone revealed that, in these studies, about 1/3 of neoformed bone graft is inert while over 2/3 of new bone is vital. The Authors concluded that, with the aid of PRF, the healing time is significantly reduced and the implant can be placed already 4 months (120 days) after surgery. A histo-logical control 4 months later revealed that bone quality between the areas treated with PRF and FDBA and the control areas were the same 8.

Conclusions The clinical cases reported in the present study

achieved a clinical success rate of 100% in sinus lift, by using the PRF obtained following Choukroun’s pro-tocol 16. Besides, the use of PRF and piezosurgery re-duced the healing time, compared to the 120-150 days described in literature 6-8, favoring optimal bone re-generation. At 106 days, it is already possible to achieve good primary stability of endosseous im-plants, though lacking of functional loading.

Platelet-rich fibrin is a grafting material that eliminates any risk of xenopathy transmission; be-sides, its gelatinous consistency favors clot stability and the membranous shape allows creating a natural “barrier effect” on the bone breaches that were opened in the surgical areas.

In the light of the good regenerative and implant technique suggested in the present study, as well as other similar studies 29, in order to achieve therapeutic success, it will be fundamental to combine a strong initial motivation of patients and increase their level of collaboration during the various reconstruction stages.

Acknowledgments The study was carried out in collaboration with

the Dental Clinic "Calabrodental" and the Institute of

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Research "Tecnologica". This research work has been the degree thesis of Dr. Marco Tatullo.

Competing Interests The authors have declared that no competing

interest exists.

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