Postextraction osteotome sinus floor elevation technique using plasma-rich growth factors

Sinus floor elevation and simultaneous implant placement in fresh extraction sockets: a systematic review of clinical data

Combining different procedures to reduce the number of surgical sessions and patient discomfort in implant placement and sinus floor elevation has been recommended, and evidence supports good outcomes. The aim of this study was to review the results of clinical studies on sinus floor elevation through extraction sockets and simultaneous immediate posterior implant placement. An electronic search was carried out in PubMed, Scopus, and Web of Science to find English articles published in or before August 2020. A manual search was also performed. Titles, abstracts, and the full-text of the retrieved articles were studied. Thirteen studies met our eligibility criteria: 6 retrospective case series, 3 case reports, 2 prospective cohort caseseries, 1 prospective case series, and 1 randomized controlled trial. Overall, 306 implants were placed; 2 studies reported implant survival rates of 91.7% and 98.57%. The others either did not report the survival rate or reported 100% survival. Sinus floor elevation through a fresh extraction socket and simultaneous immediate implant placement appears to be a predictable modality with a high success rate. However, proper case selection and the expertise of the clinician play fundamental roles in the success of such complex procedures.

Evidence-Based Clinical Efficacy of Leukocyte and Platelet-Rich Fibrin in Maxillary Sinus Floor Lift, Graft and Surgical Augmentation Procedures

Bone augmentation techniques have increasingly been indicated for re-creating adequate bone height and volume suitable for dental implant sites. This is particularly applicable in the severely atrophic posterior maxilla where sinus perforation (ruptured Schneiderian membrane) is a very common complication and sinus floor elevation or lift is frequently considered a standard procedure. The augmentation of the maxillary sinus can be performed with or without grafting biomaterials. Herein, numerous biomaterials and bone substitutes have been proposed, primarily to sustain the lifted space. In addition, cytokines and growth factors have been used to stimulate angiogenesis, enhance bone formation as well as improve healing and recovery period, either as the sole filling material or in combination with bone substitute materials. Within such, is the family of autologous blood extracts, so-called platelet concentrates, which are simply the "product" resulting from the simple centrifugation of collected whole blood samples of the patient, immediately pre-surgery. Platelet-Rich Fibrin (PRF), a sub-family of platelet concentrates, is a three-dimensional (3-D) autogenous biomaterial obtained, without including anti-coagulants, bovine thrombin, additives, or any gelifying agents during the centrifugation process. Today, it is safe to say that, in implant dentistry and oral and maxillofacial surgery, PRFs (particularly, the pure platelet-rich fibrin or P-PRF and leukocyte and platelet-rich fibrin or L-PRF sub-classes) are receiving the most attention, essentially due to their simplicity, rapidness, user-friendliness/malleability, and cost-effectiveness. Whether used as the sole "bioactive" filling/additive material or combined with bone substitutes, the revolutionary second-generation PRFs have been very often associated with promising clinical results. Hence, this review aims to provide a 10-years update on the clinical effectiveness of L-PRF when applied/used as the "sole" biomaterial in maxillary sinus augmentation procedures. An electronic search using specific keywords for L-PRF and maxillary sinus augmentation was conducted in three main databases (PubMed-MEDLINE database, Google Scholar and Cochrane library) for the period between January 2009-February 2020. The quest yielded a total of 468 articles. Based on the pre-established strict inclusion/exclusion criteria, only seven articles were deemed eligible and included in the analysis. Surprisingly, of the 5 studies which used de-proteinized bovine bone mineral (DBBM) in combination with L-PRF, 60% acclaimed no significant effects and only 40% declared positive effects. Of the two articles which had used allogenous bone graft, 50% declared no significant effects and 50% acclaimed positive effects. Only one study had used L-PRF as the sole grafting material and reported a positive effect. Likewise, positive effects were reported in one other study using L-PRF in combination with a collagen membrane. Due to the heterogeneity of the included studies, this review is limited by the inability to perform a proper systematic meta-analysis. Overall, most of the published studies reported impressive results of L-PRF application as a grafting material (sole or adjuvant) in maxillary sinus augmentation and dental implant restorative procedures. Yet, distinct technical processing for L-PRF preparation was noted. Hence, studies should be approached with caution. Here in, in sinus lift and treatment of Schneider membrane, the formation of mature bone remains inconclusive. More studies are eagerly awaited in order to prove the beneficial or detrimental effects of PRFs, in general and L-PRFs, in specific; especially in their tissue regenerative potential pertaining to the promotion of angiogenesis, enhancing of cell proliferation, stimulation of cell migration and autocrine/paracrine secretion of growth factors, as well as to reach a consensus or a conclusive and distinct determination of the effect of leukocytes (and their inclusion) on inflammation or edema and pain; a call for standardization in PRFs and L-PRFs composition reporting and regimenting the preparation protocols.

One-year implant survival following lateral window sinus augmentation using plasma rich in growth factors (PRGF): a retrospective study

Background

The aim of this study was to assess one-year implant survival after lateral window sinus augmentation using PRGF combined with various bone grafting materials.

Material and Methods

This was a retrospective chart review and radiographic analysis of patients that had undergone lateral window sinus augmentation with PRGF and had dental implants placed at least 6 months post augmentation. All implants included were followed up for at least one year after placement. Demographic, sinus and implant related characteristics (residual ridge height, sinus membrane perforation, type of graft material, implant length and width and ISQ at placement) were analyzed.

Results

A total of 31 patients with 39 sinus augmentations and 48 implants were included. The mean follow up was 22.8 ± 9.9 months. Implant survival was 95.8%, with 2 implants overall failing. Among all the variables assessed, the only one found to be associated with an increased risk for implant failure was the use of xenograft as bone grafting material in the sinus.

Conclusions

Within the limitations of this study, dental implants placed in maxillary sinuses grafted with PRGF in combination with bone grafting materials, exhibit high implant survival rates after at least one year follow up.

Key words:PRGF, sinus graft, growth factors, implant survival, platelet concentrates.

Effects of Platelet-Rich Fibrin on Hard Tissue Healing: A Histomorphometric Crossover Trial in Sheep

Bone defects lead to aesthetic and functional losses, causing dental rehabilitation to be more difficult. The objective of this work is to histologically assess the hard tissue healing of bone defects filled with platelet-rich fibrin (PRF) alone or as an adjuvant for mixing with and covering anorganic bovine bone (ABB), compared to ABB covered with a resorbable collagen membrane (CM). This study was designed as a crossover animal study. Four 5-mm tibia defects, 5 mm apart from each other, were surgically created on the tibias of 6 sheep. The defects were randomly filled with ABB + CM; PRF alone; ABB+PRF; or were left empty. The animals were euthanized on days 10, 20, and 40 post-operatively. No group showed any signs of bone necrosis. Inflammation was observed in 2 control and 3 test defects with no statistically significant difference between groups at each time point. The ABB + CM and ABB + PRF groups experienced the highest bone regeneration ratios. No differences between the empty-defect and PRF groups were observed in regard to bone regeneration. No statistical difference was observed between the ABB+PRF and ABB + CM groups in regard to bone regeneration and the amount of residual graft material at each time point. The use of PRF should be preferred due to its autogenous origin, low cost, and ease of use.

Therapeutic outcomes of non-grafted and platelet concentrations-grafted transcrestal maxillary sinus elevation (TSFE): a systematic review and meta-analysis

To evaluate and compare the stability, quantity and quality of bone augmentation at maxillary sinus elevation sites by non-grafted transcrestal sinus floor elevation (TSFE) and platelet concentration grafted transcrestal sinus floor elevation (PC-TSFE). A complete literature search was performed up to April 2019. Clinical controlled trials, retrospective cohort studies, and prospective cohort studies were selected based on inclusion criteria. The clinical outcomes were implant survival rate (ISR), marginal/crestal bone loss (MBL/CBL) and endo-sinus bone gain (ESBG). Meta‐analysis was conducted on these 1-year based values. Furthermore, another meta-analysis on 1-year ISR value was conducted among studies with different residual bone heights (RBH) within the non-grafted TSFE group. A total of 18 studies were included: 13 in TSFE group and 5 in PC-TSFE group. No significant differences were displayed between the 1-year ISR of TSFE (97%, 95%CI = 0.96–0.99) and PC-TSFE group (99%, 95%CI = 0.97–1.00). Among the various studies with different RBH within TSFE group, no significant differences in 1-year ISR were displayed. The 1-year MBL/CBL value of PC-TSFE group (0.73 mm, 95%CI = 0.43–1.13 mm) did not show significant difference as compared to TSFE group (0.60 mm, 95%CI = 0.10–1.10 mm). Furthermore, no significant enhancement was observed on 1-year ESBG value on PC-TSFE group (3.51 mm, 95%CI = 2.31–4.71 mm) in comparison with the TSFE group (2.87 mm, 95%CI = 2.18m–3.55 mm). Grafting platelet concentrations around dental implants at TSFE sites did not significantly enhance the adjacent bone regeneration. Moreover, TSFE was shown to be a reliable therapeutic option for implant sites that need simultaneous maxillary sinus augmentation, even under limited RBH.

Platelet-Rich Plasma in Maxillary Sinus Augmentation: Systematic Review

Background: Sinus augmentation can be performed with or without grafting biomaterials, and to date, there is no quality evidence regarding the augmentation of the sinus floor using only platelet concentrates, which can improve the healing period and enhance bone regeneration by stimulating angiogenesis and bone formation. The main objective of this paper was to assess the effect of the sole use of platelet concentrates in sinus augmentation in terms of newly formed bone, augmented bone height, and clinical outcomes and to assess the additional beneficial effects of platelet-rich fibrin (PRF) in combination with other grafting biomaterials. Methods: A systematic review was conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Pooled analyses were performed with the Review Manager software. Results: For sinus elevation only using platelet concentrates, 11 studies met the inclusion criteria and were included for qualitative synthesis. Only one study was a clinical trial, which reported improved outcomes for the allograft group compared to the titanium-PRF (T-PRF) group. A total of 12 studies where PRF was used in addition to grafting biomaterials met eligibility criteria and were included in the review. Results from meta-analyses provided no additional beneficial effects of PRF in sinus augmentation in terms of bone height and percentage of soft tissue area. There was a statistically significant lower percentage of residual bone substitute material in the PRF (+) group compared to the PRF (−) group. The percentage of newly formed bone was slightly higher in the PRF (+) group, but this was not statistically significant. Conclusion: There is no robust evidence to make firm conclusions regarding the beneficial effects of the sole use of platelet concentrates in sinus augmentation. However, studies have shown favorable outcomes regarding implant survival, bone gain, and bone height. The use of PRF with other grafting biomaterials appears to provide no additional beneficial effects in sinus lift procedures, but they may improve the healing period and bone formation. Well-conducted randomized clinical trials (RCTs) are necessary to confirm the available results to provide recommendations for the clinical practice.

The effect of autologous leukocyte platelet rich fibrin on the rate of orthodontic tooth movement: A prospective randomized clinical trial

Objective:

The aim of this study was to evaluate the effect of LPRF, placed in extraction sockets, on orthodontic tooth movement (OTM).

Materials and Methods:

Thirty extraction sockets from eight patients (five males, three females, with a mean age of 17.37 years; range 12–25 years) requiring extraction of first premolars based on their orthodontic treatment plan participated in this split-mouth clinical trial. In one randomly selected quadrant of each jaw, the extraction socket was preserved as the experimental group by immediate placement of LPRF in the extraction socket. The other quadrant served as the control group for secondary healing. Immediately, the teeth adjacent to the defects were pulled together by a NiTi closed-coil spring with constant force. A piece of 0.016 × 0.022-inch stainless steel wire was used as the main arch wire. The amount of OTM was measured on the study casts at eight time points with 2-week intervals for 3 months. Analysis of random effect model was performed for the purpose of comparison between the experimental and control groups.

Results:

According to the random effect model, a statistically significant difference was found between the experimental and control group in rate of OTM (P = 0.006).

Conclusion:

According to the results, application of LPRF, as an interdisciplinary approach combining orthodontics and surgery, may accelerate OTM, particularly in extraction cases.

Plasma rich in growth factors (PRGF) in intraoral bone grafting procedures: A systematic review

PURPOSE

This systematic review aimed at assessing the effects of PRGF in new bone formation, soft tissue healing and post-operative pain and swelling in sites that underwent ridge preservation, ridge augmentation and maxillary sinus augmentation procedures.

MATERIALS AND METHODS

A comprehensive literature search employing seven databases was conducted by two independent reviewers. Only randomized and non-randomized controlled clinical trials using PRGF alone or in combination with bone grafting materials were selected.

RESULTS

Overall, 919 studies were identified, of which a total of 8 articles were included in the qualitative analysis. Two of the selected studies reported on ridge preservation, one on ridge augmentation and five on maxillary sinus augmentation. Positive results were recorded for soft tissue healing and post-operative pain and swelling following these procedures. However, outcomes of PRGF on new bone formation post extraction and on maxillary sinus augmentation when combined with other biomaterials were conflicting. Meta-analysis could not be conducted for any variables due to the heterogeneity of selected studies.

CONCLUSION

Limited evidence exists on the effects of PRGF in different intraoral bone grafting procedures, with some benefit reported on soft tissue healing and post-operative symptomatology. As this platelet concentrate is commonly used in clinical practice, further research is needed to fully assess its clinical indications and effectiveness.

Transcrestal sinus floor augmentation with immediate implant placement applied in three types of fresh extraction sockets: A clinical prospective study with 1-year follow-up

BACKGROUND

Immediate implant insertion and transcrestal sinus augmentation both can provide a lot of advantages for patients and clinicians.

OBJECTIVE

This prospective study aims to verify the use of a modified technique for immediate implant insertion simultaneously with sinus augmentation in different types of sockets.

MATERIALS AND METHODS

Thirty-seven patients were recruited for the clinical study and were divided into 3 groups according to the relationship of their maxillary molar roots and sinus floor: group 1 with none of the teeth roots contacts sinus floor; group 2 as at least 1 teeth root contacting sinus floor, but no root is observed penetrating into sinus cavity; group 3 with at least 1 teeth root penetrating into sinus cavity. Implants were inserted after transcrestal sinus floor augmentation and immediately after tooth extraction. The change of mucosa thickness, diagnosis of rhinosinusitis, marginal bone loss (MBL), pocket depth (PD), and sulcus bleeding index were examined through radiographic measurement or clinical monitoring.

RESULT

During the study period, no implants failed. The relationship of the root of maxillary molars and sinus floor may have an effect on the bone height of the interradicular crest. Sinus mucosa was observed thicker after surgery. After healing period, sinus mucosa returned as thin as presurgery. At the time of 1-year follow-up, MBL was measured on X-ray (group 1: mesial: 0.63 ± 0.20 mm, distal: 0.70 ± 0.14 mm; group 2: mesial: 0.67 ± 0.21, distal: 0.65 ± 0.22 mm; group 3: mesial: 0.70 ± 0.15 mm, distal: 0.73 ± 0.19 mm). No statistical difference was found in MBL and PD as well as bleeding index among 3 groups.

CONCLUSION

In consideration of the advantages of sinus floor augmentation and immediate implant placement, our clinical result confirms that it is promising to combine the 2 techniques for replacing maxillary molars especially when using residual roots as implant orientation and taking full advantage of the interradicular crest bone.

Update of Surgical Techniques for Maxillary Sinus Augmentation: A Systematic Literature Review

OBJECTIVE

A wide range of surgical techniques are available for maxillary sinus augmentation. This review aimed to determine which techniques have achieved the highest success rates and so offer the greatest predictability.

MATERIALS AND METHODS

A systematic literature review was performed using the PubMed, MEDLINE, and Scopus databases, identifying clinical trials that assessed different surgical techniques for maxillary sinus augmentation, and registered the success rates of subsequent implant placement.

RESULTS

A total of 40 articles described clinical studies involving different maxillary sinus augmentation procedures with follow-up periods of at least 6 months after dental implant placement. Implant success rates varied between 94% and 100% during the follow-up periods.

CONCLUSION

A wide variety of clinical techniques are available for maxillary sinus augmentation; the choice of the technique will depend chiefly on the characteristics of the edentulous site, which will permit or prevent the placement of the implant at the moment of sinus augmentation surgery.

Role of Platelet rich fibrin in wound healing: A critical review

AIM

The aim is to review and discuss the strategies available for use of platelet rich fibrin as healing aid in dentistry.

BACKGROUND

Platelet rich fibrin (PRF) is a fibrin matrix in which platelet cytokines, growth factors, and cells are trapped and may be released after a certain time and that can serve as a resorbable membrane. Choukroun and his associates were amongst the pioneers for using PRF protocol in oral and maxillofacial surgery to improve bone healing in implant dentistry. Autologous PRF is considered to be a healing biomaterial, and presently, studies have shown its application in various disciplines of dentistry.

MATERIALS AND METHODS

By using specific keywords, electronic search of scientific papers was carried out on the entire PubMed database with custom range of 5 years. The electronic search yielded 302 papers; based on inclusion and exclusion criteria which were specifically predetermined, 72 papers were identified as suitable to the inclusion criteria and the remaining 230 papers were excluded. After adding three more selected papers through hand search, full text of all the articles retrieved and review was done. By pooling the extracted data from selected papers, the reviewed data was synthesized.

CONCLUSION

Recently by showing good promising results with use of the PRF, it has proved to have a good prospect for its use as healing aid in various aspects of the dentistry.

Osteotome-Mediated Sinus Lift without Grafting Material: A Review of Literature and a Technique Proposal

Implant rehabilitation of the edentulous posterior maxilla may be a challenging procedure in the presence of insufficient bone volume for implant placement. Maxillary sinus augmentation with or without using grafting materials aims to provide adequate bone volume. The aim of the present study was to systematically review the existing literature on transalveolar maxillary sinus augmentation without grafting materials and to propose and describe an osteotome-mediated approach in postextraction sites in combination with platelet derivative. The systematic review showed that high implant survival rate (more than 96% after 5 years) can be achieved even without grafting the site, with a low rate of complications. Available alveolar bone height before surgery was not correlated to survival rate. In the described case report, three implants were placed in posterior maxilla after extraction of two teeth. An osteotome-mediated sinus lifting technique was performed with the use of platelet derivative (PRGF); a synthetic bone substitute was used to fill the gaps between implant and socket walls. No complications occurred, and implants were successfully in site after 1 year from prosthetic loading. The presented technique might represent a viable alternative for the treatment of edentulous posterior maxilla with atrophy of the alveolar bone though it needs to be validated by studies with a large sample size.