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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.

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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.

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when are carried out sinus lift technique should be considered the arterial blood supply of the maxillary sinus. when preparing the bone window can be encountered intraosseous or extraosseous branches. A very good knowl-edge of the arterial blood supply of the antero-lateral wall of the maxillary sinus is absolutely necessary to perform this surgical procedure. In the cortical bone of the lateral wall of the sinus is present an intra-osseous anastomosis between the dental branch of the posterior su-perior alveolar artery also called alveolar antral artery and the infraorbital artery (12). Alveolar antral artery from antero-lateral wall of the sinus can cause hemorrhages in about a fifth of the osteotomy with lateral window (13) and the more residual alveolar ridge is resorbed, the better the chances that this artery to be injured.

Antral alveolar artery is partly situated in-traosseous in the area where it is practiced the antrostomy, from the second premolar to the second molar, being very close to Schneider membrane and partially embedded in the lat-eral wall of the sinus (12).

hemorrhages can reduce visibility and can cause the increasing of surgical time (14). Thus appear difficulties in visualization and elevation of sinusal membrane, complicating the inser-tion of the material for bone addition. hemor-rhage caused by injury of this artery can dislo-cate the material for bone addition by the effect of “washing” caused by blood pressure, can cause hematomas of the cheek, thus creating an ideal environment for bacterial multiplication and infection.

The presence of maxillary sinus septa can complicate the luxation of window and the lift-ing of sinus membrane (15). Boyne and James (9) have recommended the cutting of the septum with a chisel and removal of it with a hemo-static forceps to place the graft into the cavity without interruption. Sometimes, if it is carried out a sinus lift technique in the presence of maxillary sinus septa will be necessary to change the design of lateral window to avoid sinus membrane perforation and fracture of septa (16,17). It is essential to identify radiological the presence of these structures because the lateral window design in sinus lifting technique is based on the presence and size of maxillary sinus septa.

Double window antrostomy has been pro-posed in the presence septa (16, 18,19,20), with a window located anterior and one poste-

rior of septum. This technique allows better access to instruments and the risk of puncturing the membrane is much smaller, the vasculariza-tion is better preserved in the area and improves the integration and stability of implants and bone graft (21).

An important complication of antrostomy with lateral window is sinus membrane perfora-tion. If the perforation is small it can be covered with a resorbable collagen membrane, and if is large a suture is necessary to prevent the entry of graft particles in the maxillary sinus and the emergence of complications such as maxillary sinusitis. The perforations of membrane, ac-cording to the scientific literature, are strongly associated with the occurrence of postoperative complications and consist of acute or chronic sinus infection, bacterial invasion, swelling, bleeding, wound dehiscence, loss of graft mate-rial and an interruption of the normal sinus physiological function (22,23).

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 chanc-es of success than those in block. Cerabone (Botiss Biomaterials) is derived from the min-eral phase of bovine bone, which shows strong resemblance to the human bone with regard to chemical composition, porosity and surface struc-ture. The unique manufacturing process based on high-temperature heating removes all or-ganic 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 res-ervoir for proteins and growth factors. After the material has been sterilized, it can be used for bone additions, without causing the occur-rence of an immune response from the host. In general, this type of biomaterial is osteoinduc-tive, and while it goes through physiological remodeling and becomes incorporated into the surrounding bone.

The amount of material required for the ad-dition of bone depends on the type of proce-dure. Bilateral sinus lift for the rehabilitation of molars and premolars region will require a greater amount of material compared to a uni-lateral procedure.

Currently, the lateral approach of maxillary sinus augmentation has become a routine tech-

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nique which allows to obtain a long-term sur-vival rates of implants over 96% in the poste-rior maxilla (24,25).

The possibility of inserting all implants in a procedure with a single step is perhaps more demanding technically than two-step method, because it relies on residual bone volume, but it is more advantageous to the patient because it reduces the number of procedures and the time required to complete the implant support-ed prosthesis (26).

The purpose of this case report is to present the clinical results of bilateral sinus lifting pro-cedure 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.

CASe repOrTThe CP patient, aged 42 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 dimen-sion as a result of a posterior maxillary Ken-nedy class II division edentation.

It was absolutely necessary to evaluate pre-operatively 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 re-quire preliminary treatment or contraindica-tions to implant therapy.

were performed the following laboratory tests: complete blood count (red cells, white cells, globular value, leukocytes, platelets, hemo-globin), bleeding and coagulation time, clot retraction time, hematocrit, coagulogram.

Odontal and periodontal clinical examina-tion was performed in the vicinity of maxillary sinus to detect any lesion that could cause od-ontogenic maxillary sinusitis. edentulous area is characterized by an atrophic alveolar ridge, low in height which makes impossible the placement of implants without bone addition procedures.

OPT radiographic examination and a preop-erative CT scan were performed for the evalu-ation of possible anatomical deformations (par-tial or total sinus septa) or the existence of sinus pathology (rhinosinusitis, sinusitis of odonto-genic origin, cysts, pseudocysts, polyposis, tu-mors).

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 simul-taneously with sinus floor augmentation (fig.2).

It was decided to perform a bilateral sinus lift intervention through lateral approach, in quadrants 1 and 2 for the reconstruction of the alveolar ridge by apposition and interposition and simultaneous insertion of dental implants. Patient received detailed explanations on surgi-cal procedures that will be performed and in-formed consent was obtained from him.

The ceramo-metal prosthesis was removed (fig.3) and the right second premolar extrac-tion was performed.

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.

The osteotomy was practiced with the achie-vement of a lateral window to open the sinus using globular atraumatic burs at the right first molar level (fig.5).

It is 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.

The Schneider membrane was carefully de-tached from the walls of the maxillary sinus and sinus floor using elevators without perforat-ing it. The sinus membrane is not bone form-ing, so raising them will not produce the amount of bone to fill the cavity. 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 sinus membrane was carefully lifted and the implant was placed in the crestal bone at the level of first premolar. Bredent classic SKy implant was the length of 12 mm and diameter of 4 mm.

It was then inserted the implant SKy classic Bredent in the first molar having a length of 10 mm and a diameter of 4.5 mm, that entered into the sinus cavity below the membrane. The bone addition material (xenograft with natural bone substitutes Cerabone, bovine bone) was

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fig. 5. The achievement of lateral bone window in antero-lateral wall of right sinus, detachment of

sinus membrane and prepairing for insertion of bone addition material

fig. 6. Application of resorbable membrane at right sinus and the implant inserted at level of

first premolar

fig. 7. Bone augmentation in the right sinus and insertion of implants

fig. 8. Coating with collagen membrane

fig. 9. Suture in first quadrant fig. 10. Initial clinical appearance in second quadrant

placed under sinus mucous membrane, around the exposed implant tip and in the antral space along existing bone (fig.7).

lateral window was covered with a resorb-able collagen membrane (Jason membrane Bot-iss) (fig.8) and after was performed soft tissue suture (fig.9).

for the second quadrant was used “double window” technique because of the presence of sinus septum, with the achievement of a bone window situated posterior and one anterior from septum. This technique allows a better access

to instruments and the risk of puncturing the membrane is much smaller. Osteotomy has been practiced with the realization of two lateral windows using atraumatic globular burs (fig.11). Carefully was detached the Schneider membrane from the walls and the floor of the maxillary sinus using elevators without perforating it.

Osteotomy was performed to insert implants to the length determined by radiography. In order to ensure the parallelism of the implants have been used the parallelization pins (fig. 12). If the implants are not parallel they could desta-

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Bilateral Sinus Lift with the Simultaneous Insertion of Implants: A Case Report

bilize each other after insertion of dentures due to masticatory forces.

The implants were screwed into the openings of the alveolar bone, taking care not to exert excessive forces on bone. for the canine has been used an implant 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, and for the first molar was used an implant with the a length of 10 mm, and diameter of 4.5 mm (SKy Classic Bredent). After placing the implants were screwed into them the healing caps.

Addition bone material was placed under the sinus mucous membrane through the two bone windows around the exposed part of implants at the level of premolar and molar and in the antral area over the existing bone.

The inserted bone particles through those two osseous windows in the sinus cavity were protected using resorbable collagen membranes (Jason membrane, Botiss) (fig.13,14) and after the gingiva was sutured.

Antiseptic solutions for oral irrigation with

Chlorhexidine 0.12% were indicated to reduce the plaque accumulation of in the area of im-plantation after surgery.

It were recommended anti-inflammatory pills, analgesics, nasal decongestant to improve per-meability osteo-meatal complex, cold water com-presses, 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.

After positioning the implants it was made a temporary prosthesis which has replaced missing teeth during implant osseointegration process (6 months).

reSuLTSThere 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, gingi-val inflammation, swelling and increasing the

fig. 11. Achievement of bone windows for sinus lift

fig. 12. Parallelization pins at the level of the left canine and first premolar

fig. 13. Application of collagen membrane at the first window of the sinus

fig. 14. Application of collagen membrane in the other window of the sinus

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fig. 15. Control panoramic radiography of patient after bilateral sinus lift intervention with lateral approach. final radiological appearance

fig. 16. Abutments appearance before prosthesis cementation

fig. 17. The final aspect of the patient. Zirconia dental prosthesis fixed on prosthetic abutments

and implants

height of the bone and implants stability. In all implants a bone-implant contact was clearly visible. There were no radiolucencies around implants.

All the implants which were inserted im-mediately, simultaneously with the bilateral sinus lift procedure were osseointegrated cor-rectly and it was possible to move to the pros-thetic stage.

A zirconia dental prosthesis fixed on pros-thetic abutments and implants (fig.16,17) was achieved.

DISCuSSIONRestoration of partial edentulism with dental

implant therapy requires careful planning. This applies especially in the posterior maxillary area when pneumatization of sinuses could lim-it the amount of alveolar bone for implant inser-tion (27). Careful preoperative planning will reduce the incidence of complications and ana-

tomical and pathological unforeseen situations.Surgical procedures in the posterior maxil-

lary region require detailed knowledge about the maxillary sinus anatomy and possible ana-tomic variations (presence of sinus septa).

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 (28).

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 inser-tion and sinus bone grafting (29).

numerous studies in the literature have reported long-term survival rates of implants

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Bilateral Sinus Lift with the Simultaneous Insertion of Implants: A Case Report

inserted in the augmented maxillary sinuses (30).

The most frequent surgical access continues to be lateral antrostomy, this involves the use of the thinnest areas of the anterolateral wall of the maxillary sinus. lateral antrostomy allows greater bone augmentation in the atrophic max-illa, but requires greater surgical access.

In the technique of double window antros-tomy proposed in the presence of sinus septa (34), the approach is through the anterior wall of the maxillary sinus, where bone is thinner, the use of instruments is simpler and therefore there is less chance of perforating the mem-brane (21).

Sinus lift is considered a safe procedure with a low prevalence of complications.

CONCLuSIONSBilateral sinus lift procedure with immediate

insertion of implants proved to be successful leading to osseointegration and stability of im-plants, went without postoperative complica-tions and showed good acceptance by the pa-tient.

Cerabone addition bone material (Botiss) demonstrated excellent osteoconductive proper-ties in grafted sinuses and allowed the survival of the implants. The barrier membrane

improved vital bone formation.

refereNCeS1. Pietrokovski J, Starinsky R, Arensburg B, Kaffe I. Morphologic characteristics of bony edentulous

jaws. J Prosthodont 2007;16:141-147.2. Misch Ce, Perel Ml, wang hl, et al. Implant success, survival, and failure: The International Con-

gress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent 2008;17:5-15.3. Sharan A, Madjar D. Maxillary Sinus Pneumatization following extractions: A Radiographic Study.

Int J Oral Maxillofac Implants, 2008; 23:48–56.4. Underwood AS. An Inquiry Into the Anatomy and Pathology of the Maxillary Sinus. J Anat Physiol.

1910, 44(Pt 4):354-69. 5. Dargaud J, lamotte C, Dainotti JP, Morin A. Venous drainage and innervation of the maxillary sinus.

Morphologie 2001;85(270):11–13.6. ekfeldt A, Christiansson U, ericksson T, et al. A retrospective analysis of factors associated with

multiple implant failures in maxillae. Clin Oral Implants Res, 2001; 12:462-467.7. Butz SJ, huys lwJ. long-term success of sinus augmentation using a synthetic alloplast: a 20 patients,

7 years clinical report. Implant Dent, 2005;14:36–42. 8. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral

Surg. 1980;38:613-16.9. Tatum h. Maxillary and sinus implant reconstruction. Dent Clin North Am, 1986, 30:207-229.10. Doud Galli SK, lebowitz RA, Giacchi RJ, Glickman R, Jacobs JB. Chronic sinusitis complicating

sinus lift surgery. Am J Rhinol. 2001;15:181–186.11. wallace SS, froum SJ. effect of maxillary sinus augmentation on the survival of endosseous dental

implants: A systematic review. Ann Periodontol, 2003 ; 8:328-343.12. Rosano G, Taschieri S, Gaudy Jf, Del fabbro M. Maxillary sinus vascularization: a cadaveric study.

Journal of Craniofacial Surgery, 2009;20:940–943.13. ella B, Sedarat C, Da Costa noble R, normand e, lauverjat y, Siberchicot f, Caix P, Zwetyenga n.

Vascular connections of the lateral wall of the sinus: surgical effect in sinus augmentation. Int J Oral Maxillofacial Implants, 2008;23: 1047–1052.

14. Zijderveld SA, van den Bergh JP, Schulten eA, ten Bruggenkate CM. Anatomical and surgical findings and complications in 100 consecutive maxillary sinus floor elevation procedures. J Oral Maxillofac Surg 2008;66:1426–1438.

15. Krennmair G, C. Ulm C, lugmayr h. Maxillary sinus septa: incidence, morphology and clinical implications. Journal of Cranio-Maxillo-Facial Surgery, 1997; 25(5): 261–265.

16. Betts Jn, Miloro M. Modification of the sinus lift procedure for septa in the maxillary antrum. Jour-nal of Oral and Maxillofacial Surgery, 1994;52(3):332–333.

17. Van den Bergh JP, Ten Bruggenkate CM, Disch fJ, Tuinzing DB. Anatomical Aspects of Sinus floor elevations. Clin Oral Implants Res, 2000 ;11(3):256-65.

18. González-Santana h, Peñarrocha-Diago M, Guarinos-Garbó J, Sorní-Bröker M. A study of the septa in the maxillary sinuses and the subantral alveolar processes in 30 patients. J Oral Implantol. 2007; 33:340-3.

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

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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

Romanian Journal of Oral Rehabilitation

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

Romanian Journal of Oral Rehabilitation

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

17

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

Romanian Journal of Oral Rehabilitation

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

18

was recalled every 1,3,6 months for routine

intraoral examination. Radiographic

examination revealed bone regeneration with

bone trabeculae appearance.

DISCUSSIONS

Periapical cyst is most frequently found

and was classified as inflammatory. Pulp

necrosis leading to periapical inflammation

appears to be the most common etiology of

periapical cyst (14). However, it usually goes

unnoticed and rarely exceeds the palpable

size, being found after an radiological

examination.

In the specialized literature, most cases of

periapical cysts have been described in the

anterior area of the upper jaw (15,16). Some

of the possible reasons for such cysts develop

in maxilla and are reported in the literature

could be: the spongy structure of maxillary

bone and the reluctance to extract the anterior

teeth which present periapical processes and

their prolonged maintenance in the arch leads

to the formation of cysts.

Periapical surgery includes removal of

damaged tissue and sometimes the

application of different grafting materials to

enhance new bone formation at the remained

defect site.The surgical approach of maxillary

periapical cystic lesion is marsupialization or

total enucleation through intraoral approach

(17). The treatment is dependent on the size

and location of the lesion, the bone integrity

of the cyst walls and its proximity to vital

structures.

Post-surgically, the formation of blood

clots initiates the healing and regeneration of

hard and soft tissues. Wound healing is an

organized process involving leukocyte and

platelet activity. For this process to work

effectively, the platelets play a vital role.

Growth factors present in blood platelets are

important to guide the regenerative cells to

the healing area.

Platelet concentrates are used routinely for

many years in various surgical and medical

specialties. The principle is to recover the

cytokines or growth factors contained in

platelets after centrifugation of the whole

blood of the patient.

Omar et al. (18) demonstrated that

monocytes are the first to send positive

signals to stimulate bone progenetic cells.

This effect is crucial because it will

immediately triggers a cascade of reactions

that will lead to osteogenesis.

The use of platelet-rich fibrin, or A-PRF

that is a healing autologous material is a way

to accelerate and enhance the natural wound

healing mechanisms of the body.

CONCLUSIONS

A-PRF speeds up the healing process, as

shown in our case report in which A-PRF is

effective in the healing of the bone defect

resulting from cyst enucleation in a faster

rate, both clinically and radiologically, so the

healing time of cystic cavity was reduced to 3

months instead of 6 to 12 months.

Accelerating the healing process

makes the treated area to be less sensitive to

external factors (mechanical, bacterial and

chemical), at the same time influencing the

aesthetic result and post-operation patient

comfort.

The results of this case report shows

that APRF can be successfully used as

monotherapy for obtaining periapical

regeneration, not being an expensive

procedure it can be used in patients who

cannot afford expensive regenerative

therapies.

Romanian Journal of Oral Rehabilitation

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

19

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