|Year : 2019 | Volume
| Issue : 2 | Page : 30-36
Using concentrated growth factors as an alternative to bone graft material in sinus augmentation to rehabilitate atrophic posterior maxilla
Julio César Capella Cobos1, Adolfo Enriquez Granados2
1 Private Clinical Practice, Bogotá, Colombia
2 Private Clinical Practice, Santa Marta, Colombia
|Date of Web Publication||19-Aug-2019|
Dr. Julio César Capella Cobos
Aveda Carrera 15 #104-76 Of 308 Bogotá
Source of Support: None, Conflict of Interest: None
A larger number of senior patients want to eliminate the use of conventional overdenture such as Conventional Complete Denture or Removable Partial Denture and replace it by an Implant-supported fixed prosthesis or at least implant-supported overdenture with the purpose of restoring and improving the masticatory function, aesthetics besides helping them gain confidence to talk and smile. Most of those patients have lost their teeth and been posteriorly edentulous for extended periods of time, causing severe bone resorption and Pneumatized Maxillary Sinus that makes it impossible for conventional dental implant placement. This report reviews two successful cases of rehabilitation of the atrophic posterior maxilla with previous bilateral ridge augmentation in Pneumatized Maxillary Sinuses using solely Concentrated Growth Factors (CGF) without bone graft augmentation with simultaneous implant placement. Where CGF is obtained from the patient's which was collected in blood collection tubes and processed by a special centrifuge device.
Keywords: Atrophic posterior maxilla, concentrated growth factor, dental implants, maxillary sinus augmentation, pneumatized maxillary sinus
|How to cite this article:|
Cobos JC, Granados AE. Using concentrated growth factors as an alternative to bone graft material in sinus augmentation to rehabilitate atrophic posterior maxilla. Int J Growth Factors Stem Cells Dent 2019;2:30-6
|How to cite this URL:|
Cobos JC, Granados AE. Using concentrated growth factors as an alternative to bone graft material in sinus augmentation to rehabilitate atrophic posterior maxilla. Int J Growth Factors Stem Cells Dent [serial online] 2019 [cited 2019 Nov 20];2:30-6. Available from: http://www.cellsindentistry.org/text.asp?2019/2/2/30/264709
| Introduction|| |
Implant placement is a viable option in the treatment of partial or full edentulism. However, excessive bone resorption combined with poor bone quality and increased pneumatization of the maxillary sinus makes it impossible to place conventional dental implants.
To overcome these difficulties, sinus lift procedures, guided bone regeneration with both autogenous and allogenous materials, short implants, tilted implants (all on four concepts), zygomatic implants, and pterygoid implants were introduced. However, these procedures are not free of complications such as tears of the sinus membrane, postoperative sinusitis, bone graft displacement into the sinus cavities, rejection of bone grafts, screw loosening of tilted implants, and morbidity in patients when using general anesthesia for zygomatic implants.,
The maxillary sinus graft technique is widely used in rehabilitation of the edentulous posterior molar area of the maxilla. Crestal approach or lateral window approach for sinus augmentation is the most common surgical techniques to overcome vertical deficiencies of the atrophic posterior maxilla. In the past decades, bone grafts have been considered a prerequisite for successful sinus augmentation. Thus, variable bone grafts, such as autografts, allografts, xenografts, alloplasts, or combinations of different graft materials, have been widely used to augment the maxillary sinus, and they are considered highly predictable for new bone formation.,,,, However, there are reports that demonstrate the possibility of promoting bone formation in the sinus by lifting the Schneider membrane without using some type of bone graft material.,,,,,
Currently, a possible alternative to the bone graft for maxillary sinus augmentation is concentrated growth factors (CGFs) as developed by Sacco in 2006 and produced by centrifuging blood samples with a special centrifuge device (Medifuge, Silfradent srl, Italy). Nevertheless, the different centrifugation speed allows the isolation of a larger, denser, and richer in growth factors' fibrin matrix.,
The aim of this article is focused to the rehabilitation of the atrophic posterior maxilla with an implant-supported overdenture and implant-supported fixed prosthesis. However, previous to these prosthetic treatments, the pneumatized maxillary sinus floor is augmented using CGF as graft material and simultaneous implant placement.
| Case Reports|| |
Case report 1: Bilateral sinus augmentation by means of a lateral approach using concentrated growth factor clots alone
A male patient aged 68 years totally edentulous wanted to change his conventional upper full prosthesis for a dental implant-supported fixed prosthesis or an implant-supported overdenture because the patient feels insecure when talking, smiling, and chewing due to the mobility of his conventional prosthesis. Medical history indicated a non-smoking and healthy patient. Radiographic examination demonstrated pneumatized maxillary sinuses bilaterally with 1.5–2 mm bone height making at the crest, rending it impossible to place conventional dental implants [Figure 1] and [Figure 2].
|Figure 1: Pretreatment cone-beam computed tomography. Pretreatment panoramic view showing low bone height in both maxillary sinuses|
Click here to view
|Figure 2: (a) The cross-sectional view of the site of the right first molar showing approximately 2 mm of bone height. (b) The cross-sectional view of the site of the left first molar with approximately 1.9 mm of bone height|
Click here to view
An implant-supported overdenture without palatal coverage with four ball attachments in the maxilla was recommended to the patient and it was accepted.
Concentrated growth factor blocks preparation
Previous to the surgical procedure, eight tubes of 10 ml without anticoagulant venous blood were taken from the patient's antecubital fossa. These tubes were then immediately centrifuged from 2400 to 2700 rpm using a special centrifuge with a rotor turning at alternated and controlled speeds for 12 min (Medifuge; Silfradent srl, Sofia, Italy). At the end of the process, there were three blood fractions: (1) the upper platelet-poor plasmalayer; (2) the middle fibrin-rich gel with aggregated platelets and CGF; and (3) the lower red blood cell layer [Figure 3].
|Figure 3: Red cap tube showing the three blood fractions after the special centrifugation|
Click here to view
In this case, the second layer is used as alternative to bone grafting for sinus augmentation [Figure 4].
|Figure 4: Concentrated growth factor clot to be used instead of bone graft material for sinus augmentation|
Click here to view
Onset of the treatment
The patient was instructed for antibiotic prophylaxis taking amoxicillin (Amoxal®; GlaxoSmithKline Lab, Bogotá, Colombia) 500 mg each 8 h beginning 1 day before the procedure and continuing for 6 days postsurgically. The surgery was performed under local anesthesia with no intravenous sedation using 2% lidocaine with 1:80,000 epinephrine (Newcaína 2%; New Stetic, S.A. Guarne, Colombia). A #15 scalpel blade was used to make a crestal incision with two vertical releasing and a full-thickness flap elevated to expose the lateral osseous wall of the maxillary sinus. A replaceable bony window was created in each maxillary sinus using a piezoelectric saw (S-Saw; S Dental Co., Daegu, Korea), connected to a piezoelectric device (Surgybone; Silfradent, Sofia, Italy) and abundant irrigation with distilled water and both bony windows were removed carefully.
The anterior vertical osteotomy was made 2–3 mm distal to the anterior vertical wall of the maxillary sinus, and the distal osteotomy was made approximately 20 mm away from the anterior vertical osteotomy.
Superior and inferior osteotomies were performed. The height of the vertical osteotomy was approximately 10 mm. Thus, the bony window obtained in rectangular shape was carefully separated to expose the sinus membrane. The sinus membrane was carefully disinserted and lifted from the sinus floor with a sinus membrane elevator [Figure 5].
Once the Schneider membrane is lifted from the sinus floor, a new compartment is noted between the sinus floor and membrane. An osteotomy created in each maxillary sinus to accommodate the implants to be placed with a diameter narrower than the planned implant at each site was performed to achieve initial stability of the implants at the sites with low bone height.
A dental implant of 4.20 mm × 11.5 mm (Seven MIS Implants Technologies Ltd., Israel) was placed in each maxillary sinus at the osteotomies that correspond to the bilateral 1st molar sites. After the dental implant placement, three CGF clots were inserted into the new compartment between the sinus floor and the Schneider membrane lifted in both maxillary sinuses as an alternative to bone grafting [Figure 6].
|Figure 6: Right maxillary sinus filled with three concentrated growth factor clots and immediate implant placement|
Click here to view
The lateral windows were repositioned in their respective presurgical positions at the maxillary sinus to prevent soft tissue sinus cavity ingrowths and to promote new bone formation.
Mucoperiosteal flaps were sutured with 4/0 monofilament polypropylene nonabsorbable sutures (Prolene, Ethicon Country location).
Two dental implants of 3.75 mm × 11.5 mm (Seven MIS Implants Technologies Ltd., Israel) were placed bilaterally in the canine sites.
The patient was advised not to blow his nose for 2 weeks after the surgery and to cough or sneeze with open mouth to prevent potential displacement of the CGF clots placed into the sinuses. Antibiotic therapy was continued postoperatively for 7 days, and the sutures were removed 14 days postoperatively.
After sinus augmentation, panoramic radiographs were requested immediately following surgery as a control, at 3 months [Figure 7] and 6 months.
The healing period was 32 weeks (8 months) to allow new bone consolidation and osseointegration of the dental implants at the sites. At 9 months postsurgically, the four implants were uncovered and O-ring abutments (MIS Implants Technologies Ltd., Israel) were installed with 35 Ncm of torque to each abutment as measured with a torque wrench.
A definitive impression with light-bodied consistency impression material (SILAGUM-DMG, Hamburg Germany) and a stock tray was taken for the new implant-supported overdenture without palatal coverage, and it was delivered with 4 nylon installed in the prosthesis [Figure 8].
|Figure 8: Final treatment: Four dental implants, four ball attachments, and implant-supported overdenture without palatal coverage. (a) Occlusal view with 4 ball attachments in 3, 6, 11, 14 zones. (b) Inner view of the overdenture with 4 nylon caps|
Click here to view
The patient received instructions on how to insert and remove the prosthesis, oral hygiene instructions, and cleaning of the prosthesis.
A cone-beam computed tomography (CBCT) was taken to assess the new bone formation around the dental implants placed in the CGF sinus augmentation [Figure 9].
|Figure 9: (a) Panoramic view showing the dental implants activated with new bone formation in 3 and 14 sites with 2 years loading and functioning. (b) Right maxillary sinus before treatment and 2 years after the Initial surgery. The cone-beam computed tomography shows new bone formation around the implant. (c) Left maxillary sinus before the Initial surgery and 2 years after the surgery. The cone-beam computed tomography shows new bone formation into the sinus and around the implant|
Click here to view
The treatment was initiated in February 2015, and the final rehabilitation was delivered in March 2016.
Case report 2: Bilateral sinus augmentation through of crestal approach using concentrated growth factor clots alone
A 72-year-old female patient partially edentulous Kennedy Class I desired to eliminate her conventional upper partial removable prosthesis and replace it with a fixed prosthesis supported by dental implants [Figure 10]. Medical history noted controlled hypertension and she was a nonsmoker. The radiographic examination noted bilateral pneumatized maxillary sinuses with 2–3 mm crestal bone height, making it impossible for placement of conventional dental implants.
|Figure 10: Kennedy Class I (bilateral edentulous area). (a) Bilateral maxillary posterior edentulous ridge. (b) Panoramic view from maxillary sinus right and left with 3.7 mm minimum bone height|
Click here to view
An implant-supported fixed prosthesis in the maxilla was suggested to the patient, and it was accepted by her.
Onset of the treatment
One week before surgery, a CBCT was ordered for evaluating pretreatment sinus conditions and residual bone height and comparing it with a new CBCT to assess the new bone formation around the dental implants in each maxillary sinus [Figure 11].
|Figure 11: Pretreatment cone-beam computed tomography. (a) Pretreatment panoramic view shows the low bone height at the residual ridge of each maxillary sinuses. (b) The cross-sectional corresponding to the upper right second molar with approximately 3.7 mm of bone height. (c) The cross-sectional corresponding to the upper right first molar with approximately 5.1 mm of bone height. (d) The cross-sectional corresponding to the upper left second premolar with approximately 4.1 mm of bone height. (e) The cross-sectional corresponding to the upper left first molar with approximately 4.6 mm of bone height|
Click here to view
The patient was instructed for antibiotic prophylaxis taking amoxicillin (Amoxal®; GlaxoSmithKline Lab, Bogotá, Colombia) 500 mg each 8 h beginning 1 day before the procedure and continuing for 6 days postsurgically. The surgery was performed under local anesthesia with no intravenous sedation using Prilocaína Clorhidrato (Pricanest 4%, Ropsohn Therapeutics SAS, Bogotá, Colombia). A #15. scalpel blade was used to make a crestal incision with two vertical releasing and full-thickness flap was elevated to expose the alveolar ridge of the dental implants placement site in both maxillary sinuses. Venous blood was drawn and centrifuged to develop the CGF clots.
Once the alveolar ridge is exposed, the procedure continues performing two perforations on the alveolar crest exactly in the sites where will be the dental implants using a 1.6-mm round carbide insert with external irrigation (SO16; BukBu Dental Co., Daegu, Korea), connected to the ultrasonic piezoelectric device (Surgybone; Silfradent srl, Sofia, Italy), allowing deepening and perforation of the maxillary sinus floor without tearing of the sinus membrane.
After perforating the sinus floor with the round carbide insert, a 2.8-mm wide cylindrical carbide insert (HPISE insert, SO28i; BukBu Dental Co.) was used to enlarge the osteotomy site and elevate the sinus membrane using hydraulic pressure by internal irrigation at the same time according to the Sohn's protocol.
The hydraulic pressure produced by the internal irrigation of saline solution through the HPISE insert penetrates the sinus floor and elevates the sinus membrane, creating a secluded compartment between the sinus floor and Schneider membrane [Figure 12].
|Figure 12: The HPISE technique for sinus augmentation. (a) HPISE insert, SO28i was invented by Dr. Sohn. (b) The HPISE insert that produces the jet of water ready to begin the elevation of the Schneider membrane. (c) This photograph shows the sinus augmentation procedure and the flow of water coming out through the other osteotomy, which means that the sinus membrane is not perforated|
Click here to view
The membrane perforation was evaluated by means of Valsalva maneuver that consisted in perform a moderately forceful attempted exhalation with closed nose as if blowing up a balloon, what permitted the direct visualization of the sinus membrane confirming that it was not perforated.
The return of water from the sinus cavity during the application of hydraulic pressure also confirmed the absence of perforation of the sinus membrane.
A twist drill of 3.2 mm diameter of dental implant system was used to finalize the osteotomy procedure. Six CGF clots were inserted into the new compartment of each maxillary sinus (3 CGF clots per osteotomy) as an alternative to bone grafting and to accelerate the new bone formation in the sinus [Figure 13].
|Figure 13: During the sinus augmentation procedure. (a) The photograph showing the moment of the insertion of concentrated growth factor clots through each osteotomy. (b) Dental implants in position. (c) Panoramic view showing the dental implants in position at 8 months after the Initial surgery|
Click here to view
Two dental implants of 4.20 mm × 11.5 mm (Seven, MIS Implant Technologies, Ltd, Israel) were placed in each maxillary sinus into the osteotomies that had been created. The dental implants achieved primary stability due to undersizing the osteotomies and lateral bone condensing when the wider implants were placed into the sites.
The flaps were sutured with 4/0 monofilament polypropylene nonabsorbable sutures (Prolene, Ethicon). The patient was instructed not to blow her nose for 2 weeks after the surgery and to cough or sneeze with open mouth. The sutures were removed 10 days postoperatively. Panoramic radiography was ordered immediately after surgery and before dental implant uncovery. Implants were uncovered after 32 weeks of healing. Two individual screw-retained porcelain fused-to-metal crowns were placed in the upper right implants, and a three-unit screw-retained fixed prosthesis metal-ceramic with mesial cantilever was placed in the upper left implants.
The fixed prosthetics have been in function after 2 years loading [Figure 14] and [Figure 15].
|Figure 14: The cone-beam computed tomography revealed the new bone formation at both maxillary sinuses. (a) The cone-beam computed tomography showing each dental implant into the maxillary sinus with new bone formation. (b) The cross-sectional corresponding to the implant zone 2 with 7.8 mm of bone gain from sinus floor to dental implant apex. (c) The cross-sectional corresponding to the implant zone 3 with 6.4 mm of bone gain from sinus floor to dental implant apex. (d) The cross-sectional corresponding to the implant zone 13 with 7.4 mm of bone gain. (e) The cross-sectional corresponding to the implant zone 14 with 6.9 mm of bone gain. The measurements of bone gain were obtained by subtracting the length of the implant with the approximate measurement of the residual bone height in the tomography|
Click here to view
|Figure 15: Final treatment. (a) Two individual porcelain fused-to-metal crowns were screwed in the 2 and 3 implants. (b) Occlusal view of the restorations. (c) Three-unit fixed prosthesis metal-ceramic with mesial cantilever was screwed in the 13 and 14 implants|
Click here to view
The treatment for this case was started in March 2015, and the final rehabilitation was finished and delivered in March 2016.
| Discussion|| |
The use of bone graft materials has been considered a mandatory requirement for maxillary sinus augmentation, allowing the successful placement of dental implants into maxillary sinuses with minimal height bone. However, previous investigations have reported loss of graft material within the sinus, leading to sinusitis in cases of sinus membrane perforation with postoperative acute maxillary sinusitis potentially causing implant failure.
There are new reports regarding maxillary sinus augmentation without bone graft placement as a predictable method for new bone formation, decreasing the risk of sinusitis.,,,,, This method is predictable for new bone formation and consists of creating a compartment between the sinus floor and sinus membrane through a lateral or crestal approach, inserting CGF blocks with immediate implants placement, even in failed cases, the new bone formation could be observed.,
The reported cases showed new bone formation in the new compartment of the maxillary sinus after filling it with CGF blocks followed by immediate implant placement, demonstrating the potential benefits of the technique, especially in challenging ridges with a bone height of <3 mm. Thus, sinus floor augmentation without grafted bone materials is a natural and predictable technique, with minimal risk of sinusitis, even tearing the sinus membrane during the procedure.
| Conclusion|| |
The insertion of CGF blocks alone as graft material and simultaneous implants placement allow successful bone formation around the dental implants in the new compartment between sinus floor and Schneider membrane, according to the images of CBCT. The bone quality of the neoformation could not be evaluated histologically due to the difficult to perform other lateral approach and take a drawn of the new bone around the osseointegrated dental implants. A limitation to this technique is the perforation of the Schneider membrane during the crestal approach; if this perforation happens, immediately we have to perform a lateral approach. The respective implant-supported rehabilitation of each case has kept the bone levels during their function, as evidenced in the radiographic follow-up. We can conclude that CGF is an excellent biomaterial for bone regeneration; in sinus augmentation, CGF does not produce rejection or sinusitis; CGF helps with new bone formation around dental implants placed into the maxillary sinus that was previously augmented. This new bone is resistant to allow dental implants to be rehabilitated with implant-supported overdentures and fixed prosthesis. Further clinical study is needed.
Consent for publication
Written informed consents were obtained from both patients for the publication of this report and any accompanying images.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Deshpande S, Deshmukh J, Deshpande S, Khatri R, Deshpande S. Vertical and horizontal ridge augmentation in anterior maxilla using autograft, xenograft and titanium mesh with simultaneous placement of endosseous implants. J Indian Soc Periodontol 2014;18:661-5.
] [Full text]
Timmenga NM, Raghoebar GM, Boering G, van Weissenbruch R. Maxillary sinus function after sinus lifts for the insertion of dental implants. J Oral Maxillofac Surg 1997;55:936-9.
Tzerbos F, Bountaniotis F, Theologie-Lygidakis N, Fakitsas D, Fakitsas I. Complications of zygomatic implants: Our clinical experience with 4 cases. Acta Stomatol Croat 2016;50:251-7.
Aghaloo TL, Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? Int J Oral Maxillofac Implants 2007;22:49-70.
Kent JN, Block MS. Simultaneous maxillary sinus floor bone grafting and placement of hydroxylapatite-coated implants. J Oral Maxillofac Surg 1989;47:238-42.
Adell R, Lekholm U, Gröndahl K, Brånemark PI, Lindström J, Jacobsson M, et al.
Reconstruction of severely resorbed edentulous maxillae using osseointegrated fixtures in immediate autogenous bone grafts. Int J Oral Maxillofac Implants 1990;5:233-46.
Wagner JR. A 3 1/2-year clinical evaluation of resorbable hydroxylapatite osteoGen (HA resorb) used for sinus lift augmentations in conjunction with the insertion of endosseous implants. J Oral Implantol 1991;17:152-64.
Hürzeler MB, Kirsch A, Ackermann KL, Quiñones CR. Reconstruction of the severely resorbed maxilla with dental implants in the augmented maxillary sinus: A 5-year clinical investigation. Int J Oral Maxillofac Implants 1996;11:466-75.
Cordioli G, Mazzocco C, Schepers E, Brugnolo E, Majzoub Z. Maxillary sinus floor augmentation using bioactive glass granules and autogenous bone with simultaneous implant placement. Clinical and histological findings. Clin Oral Implants Res 2001;12:270-8.
Raghoebar GM, Vissink A, Reintsema H, Batenburg RH. Bone grafting of the floor of the maxillary sinus for the placement of endosseous implants. Br J Oral Maxillofac Surg 1997;35:119-25.
Lundgren S, Andersson S, Gualini F, Sennerby L. Bone reformation with sinus membrane elevation: A new surgical technique for maxillary sinus floor augmentation. Clin Implant Dent Relat Res 2004;6:165-73.
Hatano N, Sennerby L, Lundgren S. Maxillary sinus augmentation using sinus membrane elevation and peripheral venous blood for implant-supported rehabilitation of the atrophic posterior maxilla: Case series. Clin Implant Dent Relat Res 2007;9:150-5.
Thor A, Sennerby L, Hirsch JM, Rasmusson L. Bone formation at the maxillary sinus floor following simultaneous elevation of the mucosal lining and implant installation without graft material: An evaluation of 20 patients treated with 44 Astra Tech implants. J Oral Maxillofac Surg 2007;65:64-72.
Sohn DS, Heo JU, Kwak DH, Kim DE, Kim JM, Moon JW, et al.
Bone regeneration in the maxillary sinus using an autologous fibrin-rich block with concentrated growth factors alone. Implant Dent 2011;20:389-95.
Chen Y, Cai Z, Zheng D, Lin P, Cai Y, Hong S, et al.
Inlay osteotome sinus floor elevation with concentrated growth factor application and simultaneous short implant placement in severely atrophic maxilla. Sci Rep 2016;6:27348.
Javi K, Kurtzman GM, Nadi M, Javi H. Utilization of concentrated growth factor as a sole sinus augmentation material. Int J Growth Factors Stem Cells Dent 2018;3:95-100.
Rodella LF, Favero G, Boninsegna R, Buffoli B, Labanca M, Scarì G, et al.
Growth factors, CD34 positive cells, and fibrin network analysis in concentrated growth factors fraction. Microsc Res Tech 2011;74:772-7.
Bernardi S, Mummolo S, Tecco S, Continenza MA, Marzo G. Histological characterization of Sacco's concentrated growth factors membrane. Int J Morphol 2017;35:114-19.
Damghani S, Masri R, Driscoll CF, Romberg E. The effect of number and distribution of unsplinted maxillary implants on the load transfer in implant-retained maxillary overdentures: Anin vitro
study. J Prosthet Dent 2012;107:358-65.
Small BW. Cemented or screw-retained implant restorations: How do you decide? Gen Dent 2011;59:14-8.
Kim JM, Sohn DS, Heo JU, Park JS, Jung HS, Moon JW. Minimally invasive sinus augmentation using ultrasonic piezoelectric vibration and hydraulic pressure: A multicenter retrospective study. Implant Dent 2012;21:536-42.
Kasabah S, Krug J, Simůnek A, Lecaro MC. Can we predict maxillary sinus mucosa perforation? Acta Medica (Hradec Kralove) 2003;46:19-23.
Sohn DS. The use of concentrated growth factors as alternative to bone substitutes for sinus augmentation. JIACD 2015;7:11-29.
Sohn DS, Lee JS, Ahn MR, Shin HI. New bone formation in the maxillary sinus without bone grafts. Implant Dent 2008;17:321-31.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]