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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