V.A. Rybak, M.A. Pavlenko, V.G. Klуmentiev.
P.L. Shupik National Medical Academy of Postgraduate Education Institute of Stomatology
Summary. This study offers method of basal implants application with trans sinus method as the alternative solution of the problem which allows to obtain optimal treatment effect with minimum operating injury without using sinus-lift technique.
Keywords: sinus lift, allografts, autogenous plasma.
Statistic data show that osseous tissue is the most often transplantable material in the current medicine, falling behind only the blood products in the number of transplantations (D.J. Trantolo, D.L. Wise, K Lewandrowski, J.D. Gresser, 2000). Thus, Boyne (1973) developed and formulated a complex of fundamental scientific attitudes according to which the ideal osteoplastic material must:
– be available in the necessary quantity;
– have high potency of osseogenesis;
– promote revascularization of the defect zone;
– have high osseoinductive potential;
– provide regeneration of the tooth supportive tissues saving its mobility;
– have osseoconductive properties;
– promote formation new conjunctive tissue reattachment in the area of parodontal defects.
This work presents a trans-sinus basal implant placement as an alternative solution for the best treatment response and minimally invasive surgery.
At the moment frozen allografts, lyophilized, demineralized lyophilized and irradiated allografts obtained the widest extension in clinical practice (A. Garg, 2004). Untreated allografts possess pronounced antigenic specificities while the processing methods existing today allow reducing their antigenicity to a significant extent retaining at the same time the properties of grafts during quite a long period of time.
Formation of toxic peroxide compounds, hydroxide radical OH first of all, as a result of lipid peroxidation induces damage of the cellular structures, membranes in the first place. This process is performed in the presence of free H2O. Consequently, a complex process of water extraction from the graft till the minimal level lies at the root of all the contemporary methods aimed at long maintaining of the allogenic osseous tissue. The next sort of grafts are xenogenic osseous materials. Donors of the xenogenic (from Greek xeno - strange, unusual and genesis - origin) osseous materials are animal representatives of the species different from the recipient's one. Assessing the results we can make a conclusion that even transplanting osseous material from the donors which have very high structural similarity with a human, for example from primates, the outcome of the operation is still unpredictable and often ends with premature resorption and graft rejection.
Today the usage of allogenic osseous material is possible by virtue of the additional processing with plasma enriched with growth factors (PRGF-Endoret).
PRGF-Endoret is the first 100 % autogenic platelet-rich plasma. PRGF®-Endoret® contains a mixture of autogenic growth factors which are derivatives of both plasma and platelets. The platelets have a complicated storage system in a form of inclusion granules allowing them to transport a large number of biologically active molecules. According to the data of certain authors, the list of proteins and peptides includes about 500 kinds of molecules. Alpha granules are most widely spread as they amount to 40 to 80 ones per platelet, but they also have the highest retention degree. In addition they have a range of antibacterial proteins which are generally called thrombocytins and are lethal factors for a large variety of bacterial species.
Nevertheless it is important to remember that the plasma contains important growth factors and the combination of plasma and platelet factors is a key element in PRGF-Endoret biological activity.
The preparation of 100% autogenic platelet-rich plasma lies at the heart of PRGF-Endoret technology. The plasma application on the damaged areas accelerates regeneration rate in the majority of the tissues without any side effects. Biological activity of the composition obtained using PRGF-Endoret technology is based on two fundamental matters. On one hand, it is plasma content and in particular platelet growth factors which activity regulates the main processes are involved into the tissue regeneration.
On the other hand, it is fibrin matrix used as a temporal structure to organize the cells and control energy release of the growth factors available in PRGF-Endoret. Biological mediators PRGF-Endoret encourage and support such important processes as cell proliferation and migration, chemotaxis (or signal to the cells at a distance to get to the location of damage), inflammation and auto / paracrine synthesis of new biologically active molecules.
The studies have shown that the use of allogenic bone material + PRGF- Endoret as a result gives 30% of newly formed bone. If you use autogenic bone material + PRGF- Endoret, the result is 43% of newly formed bone.
It was found that the mucous membrane grows much faster than the bone, forming sometimes enormous defects in the maxillary sinus and consequently it is necessary to eliminate them through a serious surgery by maxillo-facial surgeon.
Clinical case No.1
Patient Y, born in 1960 (53 years old) was hospitalised in the center of maxillo-facial surgery of Kyiv Regional Clinical Hospital on September 26, 2013 with a preliminary diagnosis of left-handed odontogenic maxillary sinusitis. The patient complained of nasal discharge, nasal congestion. Pain in the left infraorbital area, difficulty in breathing, purulent discharge through the left nostril.
The patient complained of nasal discharge, nasal congestion, pain in the left infraorbital area, difficulty in breathing, purulent discharge through the left nostril. In 2010 bilateral sinus lifting was conducted.
The face is symmetrical. Flesh-colored skin has no pathological changes. Breathing through the left nostril is difficult. Oral mucosa in 23-27 teeth is slightly hyperemic, as a result of scarring. Palpation: in the upper-left maxillary sinus slight soreness is noted. There was a slight serous discharge from the left nasal opening. Oral mucosa is of pale pink color. In the area of 23-27 teeth redness and swelling of the mucous membrane is noted. There is a complete atrophy of the alveolar process in the area of 24-26 teeth. On 23 and 27 teeth a mobile-metal construction is fixed. Mouth opening is free.
On a cone-beam computed tomography a defect of the alveolar bone of the upper jaw on the left at the level of 24-26 missing teeth with the transition to the anterior wall of the maxillary sinus and cheekbones-alveolar crest was determined. The sinus content is homogeneous. (Fig. 1,2,3).
Panoramic radiography of patient Y prior to the treatment.
Cone-beam computerized tomography of patient Y prior to the surgery.
Three-dimensional modelling based on the computerized tomography of patient Y prior to the surgery
Laboratory data of the patient on admission are within normal limits.
September 27, 2013 Surgery:
Removal of cortical plate and cancellousautograft from the crest of the right ilium.
Course of the operation:
After skin antisepsis under anesthesia, skin incision, subcutaneous tissue 4.0 cm length from the top front spine parallel to the anterior-upper area of the iliac crest was carried out. Sharp-dull passed to the inner surface of the crest (Figure 4). Divisions were made with a dental chisel, removal of the cortical cancellous block from the inner surface of the ilium and of cancellous bone material was performed (Figure 5).
The cortical cancellous plate was placed into 0.9% NaCl solution. After installing drainage ribbon silk sutures, antiseptic bandage, alcohol stove were put.
Photo of the course of the operation. Passing to the inner surface of the iliac crest
Photo of the course of the operation. Removal of the cortical cancellous block from the inner surface of the ilium
September 27, 2013 Surgery:
Augmentation of left maxillary with autograft from the iliac crest
After antiseptic treatment of the skin and oral cavity under anesthesia + infiltration anesthesia with Sol. Ultracaini 4% - 4 ml the bridge and the roots of the teeth 23,24 were removed. Incision of mucosa by Neumann-Zaslavsky was performed in the transitional fold in the upper jaw. A mucoperiosteal flap, curettage of the maxillary sinus was made (Figure 6). Fitting of cortical cancellousautograft, fixation with titanium screws was performed (Figure 7). After immobilization of mucoperiosteal flap - silk sutures, haemostasis during surgery (Figure 8).
Photo of the course of the operation. Exfoliation of the mucoperiosteal flap. Curettage of the maxillary sinus.
Photo of the course of the operation. Fitting of cortical cancellousautograft, fixation with titanium screws.
Photo of the course of the operation. Suturing of the surgical wound.
Drug therapy in the postoperative period:
Dopamine 600 2 times per day
Ketanov 1.0 i/m in pains
Dalacin C 300 1 drop 2 times per day
Lasix i/m 1 time per day.
The operation was carried out by V.A. Rybak, the head of the center of Maxillo-Facial Surgery and Dentistry of Kyiv Regional Clinical Hospital.
The patient was discharged in a satisfactory condition for the further dynamic outpatient care.
Postoperative panoramic radiography of patient Y
Clinical case No. 2
Preoperative panoramic radiography of patient X
In patient X a bicortical method of installing basal implants into the tuberalpterygoid seam on the left side through the maxillary sinus was used. Thanks to the polished surface of the implant, you can forget about such a negative post-operative complications, such as sinusitis, even in spite of the fact that a part of the structure is located directly in the maxillary sinus. The operation is performed under the protocol of immediate loading. Temporary crowns were fitted on the third day after the surgery (Figure 11). Six months later a constant-metal construction was placed.
The operation was performed by V.G. Klymentiev, a chief doctor of the European Dental Center.
Photo of the placed temporary bridges. The 3rd day after the surgery
Panoramic radiography of patient X in 6 months after the surgery
Photo of the placed permanent porcelain fused to metal bridges. 6 months after the surgery.
If you use an alternative method of installation of basal implants in a trans sinus way, we can talk about 97% survival rate, the index which is important, especially for professionals. Also, it should be noted that using this technique as an alternative to the sinus lifting, we can talk about a significant improvement in results for the patient:
- The rehabilitation period is reduced significantly;
- The indications for use of this technique expand;
- Absence of pain and comfort;
- Absence of risks associated with sinus lifting;
Analysis of clinical cases shows that rehabilitation of patients with indications for sinus lifting surgery is possible in the shortest possible time while using our techniques.