maxillary sinus lift using concentrated growth factors

MAXILLARY SINUS LIFT
USING CONCENTRATED GROWTH FACTORS
Torrisi P.1, Palmeri E.*2, Liardo C.2, Sorbello G.2, Santangelo S.3 Ferlito S.4
Università degli Studi di Catania, Master di II livello “Riabilitazioni Orali Complesse”
1
Docente e Tutor ,2 Masterizzandi, 3 Igienista dentale libero professionista, 4Coordinatore
CASES PRESENTATION
We report 8 cases of sinus lift using concentrated growth factors (CGFs) and autologous fibrin-rich blocks rounded-up with Bio-Oss. 6 patients, 4 women and 2 men, with a mean age of 53,5,
were selected for this study.A total of 8 sinus grafts were performed using the lateral window approach.
PREPARATION OF FIBRIN RICH BLOCKS WITH CGFs
CGF is a fibrin matrix with a complex tridimensional architecture which makes it a real platelet, leukocyte and growth factor rich biomaterial. It is prepared according to Sacco's protocol who
developed the technique in 2006. 20 to 6o mL of blood is taken from the patient's forearm, divided into 2/8 glass-coated tests tubes without anticoagulants, and centrifugated at 2400/2700 using a
specific centrifuge with a rotor turning at alternated and controlled speed for 12 minutes.(Medifuge®; Silfradent). At the end of the process 6/8 pieces of fibrin-rich-blocks are obteined caracterized by
4 phases: the uppermost platelet poor plasma (PPP) layer (serum); the middle fibrin buffy coat layer; the third liquid layer, conteining white stem cells and concentrated growth factors (CGF);
the lowest platelet rich coagulation (RBC) layer. Serum can be separated right after centrifugation and used to amalgamate graft materials or irrigate cavity before sinus lifting. Red clot is separated
from fibrin gel before the use; it can be used alone or in combination with particulate fibrin coat and autologous or hetereologous bone grafts. Fibrin buffy coat is a dense polymerized fibrin network; it
contains platelets, leukocytes, growth factors and provides a matrix for fibroblasts and endothelial cells involved in angiogenesis and tissue remodeling. In particular, platelets are important since they
release high concentrations of biologically active proteins (PDGF-BB, il TGFI3-1 e l'IGF-1) and support recruitment, growth and cell morphogenesis. Fibrin gel blocks can be used as fillers or membrane
or fragmented and mixed with other grafts material.
We use fibrin buffy coats and blood clots cut into small pieces and mixed with particulate bone graft (Bio-Oss®; Geistlich).The whole is mechanically homogenized into the Round Up device (Silfradent,
Italia) for about 6 second.The mix results in a dense and adhesive autologous graft, easily to wedge into the cavity, capable of release growth factors (tgf-β1, PDGF, VEGF) slowly,
stimulate cell proliferation, matrix remodeling and angiogenesis, during healing process. The remaining fibrin blocks are pressed down with special pliers to obtein membrane, used to cover
CGFs/Bio-Oss graft, previously inserted into the sinus cavity.
AA
D
C
B
Case 1
E
F
SURGICAL AND PROSTHETIC PROCEDURES
G
G
Case 2
Panoramic radiograms and CT-scan (Cone-Beam) were taken before surgery, to evaluate preoperative sinus conditions and residual bone heights (H-I-M-N). The full thickness of mucoperiosteal flap
was elevated to expose the lateral wall of the maxillary sinus. Piezoelectric device (Surgybone, Silfradent®) was used to create the replaceable rectangular bony window at the lateral wall of the maxillary
sinus.(L-O) Detachment of the sinus membrane was started from the sinus floor and continued to reach the anterior and medial walls of the sinus cavity.
I
H
M
L
N
O
The bony window is rotated inward and CGFs, rounded up with Bio-Oss, is grafted into the new compartment between the elevated membrane and the sinus floor (P-S). The whole is covered with
fibrin membrane (Q-T). After an average of 5 months healing period, panoramic x-ray shows newly formed bone beyond the original sinus floor (R-U).
P
Q
R
T
S
U
Reentry surgery was performed in 7 cases after a 5 months healing period, and, in 4 cases, bone biopsy was performed on the alveolar ridge before implant placement.In 1 case, implants were
placed simultaneously to the sinus lift surgery. Panoramic x-ray was taken after implants placement (Z-K). Histologic examination (X-Y) shows dense and mature new bone (NB) observable in
hematoxylin and eosin stain and in Masson's Trichrome stain (NB). Abundant osteoblasts are shown along newley formed bone(ARROWS). Graft particles (BO)
NB
NB
NB
BO
NB
NB
BO
BO
NB
BO
BO
NB
V
Z
X
J
NB
K
Y
Y
RESULTS
New bone formation, beyond the original sinus floor, is revealed, afther 5 months, from the histologic and radiographic results in all cases. After sinus grafting, no significant postoperative
complications developed in any augmented sinus. A total of 26 implants (Astra Tech) were placed ranging from 9 to 13 lenght 3,5 and 5 to diameter. Panoramic x-ray shows newly formed bone along
implant bodies and around implant apices in all cases.
CONCLUSION
CGFs is a stimulating multifactorial system, different from all other regenerative techniques, because all phases and constituent can be used depending on the specific needs.Compared with PRP or
PRGF, fibrin rich bloks with CGFs are simple to make and do not require any synthetics or chemical additives, such as bovine thrombin or anticoagulants. This technique provides: fibrin rich blocks,
activated clots, with high growth factors concentration, serum, with protein and antibody. In our case series, CGF rounded-up with Bios-Oss, have been used successfully in maxillary sinus augmentation in order to facilitate new bone formation and reduce healing time. We tried to take advantage of Bio-Oss osteoconductive property matched with CGF's regenerative potential.
ACKNOWLEDGEMENTS
Prof. Luigi Fabrizio Rodella Professore Associato di Anatomia Umana presso la Facoltà di Medicina e Chirurgia dell’Università degli Studi di Brescia, coordinatore del Settorato Anatomico e responsabile dei Laboratori di Neuroanatomia e di Rigenerazione dei Tessuti e degli Organi della Sezione di Anatomia Umana.
REFERENCES
1-Bone regeneration in the maxillary sinus using an autologous Fibrin-rich-block with Concentrated Growth Factors alone.Dong-Seok Sohn Implant Dentistry 2011Vol20 Num5
2- The use of Concentrated Growth Factors as alternative to bone substitutes for sinus augmentation.Dong- Seok Sohn Dental Inc. March/April 2009
3- Growth Factors, CD34 Positive cells, and fibrin network analysis in Concentrated Growth Factors Fraction.Luigi Fabrizio Rodella Microscopy research and technique 2010
4 -New bone formation in the maxillary sinus without bone grafts.Dong-Seok Sohn Implant Dentistry 2008 Vol17 Num 3
5 -CGF, una proposta terapeutica per la medicina rigenerativaCorigliano Massimo