simultaneous sinus-lift and implantation using

Simultaneous Sinus-Lift and ImplantationUsing Microthreaded Implants and

Leukocyte- and Platelet-Rich Fibrin as SoleGrafting Material: A Six-Year ExperienceAlain Simonpieri, DDS,* Joseph Choukroun, MD,† Marco Del Corso, DDS,‡ Gilberto Sammartino, MD, PhD,§

and David M. Dohan Ehrenfest, DDS, MS, PhD!

Sinus-lift for implant placement isa very predictable and reproduc-ible surgery.1,2 The choice of the

technique, either lateral using aCaldwell-Luc osteotomy or axial withthe Summers osteotomy,3 is mainly de-pendent on the residual bone height ofthe alveolar ridges, and both techniquesshow similar results.2,4 One key questionthat remains is to define the best fillingmaterial for the subsinus cavity after lift-ing the sinus membrane. The consensualapproach is to consider that most mate-rials are efficient for this surgery, con-sidering the high osteogenic potential ofthe Schneiderian membrane and itsperiosteum-like behavior.5,6 However,the choice of material or association ofmaterials will influence the waiting pe-riod before adequate healing andremodeling of the grafted material, im-plant placement, and functional loading.Many materials are potentially usable in

this clinical situation7: autogenous bonegraft (parietal, iliac, chin, retromolar,etc), xenograft (bovine, swine, etc), andallograft or synthetic (!-tricalcium phos-phate, hydroxyapatite, etc). Recently, thepossibility of sinus-lift without anygrafted material is hotly debated, fol-lowing the concepts of guided boneregeneration. Indeed, in a closed cav-ity such as a lifted sinus, the osteo-genic potential of the bone and thesinus membrane is highly protected

and efficient. This concept of limitedgrafting was first developed with theSummers osteotomy, using no graftingmaterial even in thin residual boneheight.4,8 And, recently, authors haveshown that a full sinus-lift can be per-formed using the lateral approach withwhole blood as sole filling material.9,10

The key point of this new guided boneregeneration strategy is to maintain theSchneiderian membrane in the highestpossible position, using simultaneous

*Private Practice, Monte Carlo, Monaco.†Private Practice, Pain Clinic Center, Nice, France.‡Private Practice, Turin, Italy.§Professor, Department of Odontostomatological andMaxillofacial Sciences, University Federico II of Naples, Italy.!Researcher, Department of Biomaterials, Institute for ClinicalSciences, The Sahlgrenska Academy at University ofGothenburg, Sweden; Professor, Department ofOdontostomatological and Maxillofacial Sciences, UniversityFederico II of Naples, Italy; Researcher, LoB5 Foundation forResearch, Paris, France.

Reprint requests and correspondence to: David M.Dohan Ehrenfest, DDS, MS, PhD, Department ofBiomaterials, Institute for Clinical Sciences, TheSahlgrenska Academy at University of Gothenburg,Medicinaregatan 8B, Gothenburg 41390, Sweden,E-mail: [email protected]

ISSN 1056-6163/11/02001-002Implant DentistryVolume 20 • Number 1Copyright © 2011 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e3181faa8af

Purpose: To assess the rele-vance of simultaneous sinus-lift andimplantation with leukocyte- andplatelet-rich fibrin (L-PRF, Chouk-roun’s technique) as sole subsinusfilling material.

Materials: Twenty-three lateralsinus elevations (SA4 sinus) were per-formed on 20 patients with simulta-neous implant placement. Sevenpatients were treated with 19 Astraimplants (AstraTech, Molndal, Swe-den) and 13 patients with 33 Intra-Lock implants (Intra-Lock Ossean,Boca Raton, FL). L-PRF membraneswere used to cover the Schneiderianmembrane, the implant tips served as“tent pegs” for the L-PRF-patched si-nus membranes, and the subsinus cav-ity was finally filled with L-PRF clots.Clinical and radiographic follow-upwas performed just after implantplacement, after 6 months, 1 year andeach following year.

Results: Six months after surgery,all implants were clinically stable dur-ing abutment tightening. The maxi-mum follow-up was 6 years, and allpatients were followed up for a mini-mum of 2 years. No implant was lostduring this 6-year experience, and thevertical bone gain was always sub-stantial, between 8.5 and 12 mm bonegain (10.4 ! 1.2). The final level ofthe new sinus floor was always in con-tinuation with the implant apical end,and the periimplant crestal boneheight was stable.

Conclusion: The use of L-PRF assole filling material during simulta-neous sinus-lift and implantationseems to be a reliable surgical optionpromoting natural bone regeneration.(Implant Dent 2011;20:2–12)Key Words: dental implant, fibrin,platelet-rich fibrin, platelet-richplasma

2 SIMULTANEOUS SINUS-LIFT AND IMPLANTATION WITH L-PRF • SIMONPIERI ET AL

implantation11: implants are stabilizedin the residual bone height, and theirtips keep membrane to the adequateheight such as “tent pegs.” The mainproblem of this approach is that fillingthe subsinus cavity with a stabilizedblood clot is not that easy in everydaypractice. Moreover, this technique im-plies that there should be a perfectmembrane lifting without membranetears.

Choukroun’s platelet-rich fibrin(PRF) is actually the more simple andinexpensive technique available in thefield of platelet concentrate technolo-gies.12 It was first described by Chouk-roun et al13 in 2001 in France and wasclassified as a leukocyte- and platelet-rich fibrin (L-PRF) concentrate.12 Inthis simple technique, blood is col-lected without anticoagulant and im-mediately centrifuged with low forces.Three layers appear in the tube then: ared blood cell base at the bottom, anacellular plasma as supernatant(platelet-poor plasma), and a PRF clotin the middle.14 This product is verydifferent from the common previouslydescribed platelet-rich plasma (PRP):Choukroun’s PRF is a consistent fibrinbiomaterial and not a platelet-enrichedfibrin glue such as the various platelet-rich plasmas.15 Moreover, the protocolbeing very inexpensive and easy,many PRF clots can be produced si-multaneously: a very significant vol-ume of biomaterial can be produced inless than 20 minutes. The clots canthen be transformed into fibrin mem-branes by compression between sterilegauzes or by using the PRF Box (Pro-cess, Nice, France), a surgical boxespecially designed to collect and stan-dardize PRF clots and membranes.16

Each PRF membrane concentratesmost platelets and more than the halfof the leukocytes from a 9-mL bloodharvest, merged or enmeshed into adense fibrin network.17–19 This fibrinbiomaterial releases high amounts ofgrowth factors (such as transforminggrowth factor !1, platelet-derived growthfactor AB, and vascular endothelialgrowth factor) and matrix glycoproteins(such as thrombospondin-1) during atleast 7 days in vitro.20 Some PRF appli-cations were already described in oraland maxillofacial surgery,21,22 ENT and

plastic surgery,23,24 and preimplant andimplant surgery.25–30 In a first publica-tion on this subject,26 it was assessedthat a sinus grafting material built withallograft and PRF in equal volume wassuitable for implantation after only 4months and potentially even more ma-ture than a sole allograft after 8 months.Another study28 showed that PRF mem-branes were easy to use during Sum-mers osteotomy and offered a goodcompromise as filling material, shockabsorber during sinus floor elevation,and healing support for the damagedSchneiderian membrane.

The objectives of this work wereto describe the use of PRF clots andmembranes as sole filling materialduring lateral sinus-lift with immedi-ate implantation, the evolution of thetechnical procedure during a 6-yearperiod, and the clinical success rate ofthis procedure in a significant caseseries.

DESCRIPTION OF THETECHNICAL PROCEDUREPRF Preparation

PRF clots and membranes wereprepared as described by Choukroun etal. During surgery, 72 mL whole bloodwas drawn in 8 glass-coated plastictubes,31 without anticoagulant, and wasimmediately centrifuged at about 400gduring 12 minutes, using a table centri-fuge specifically designed for this appli-cation (PC02; Process). Platelets wereimmediately activated, thus triggering acoagulation cascade. The result was afibrin clot located in the middle of eachtube. Each clot was removed from thetube and separated from the red bloodcell base with pliers, then stored in metalcups before subsinus filling. Some clotswere gently pressed in between 2 sterilecompresses to obtain an autologous fi-brin membrane. Five clots and 3 mem-branes were generally produced in thisway for the treatment of each sinus. In

Fig. 1. This patient was 1 of the first of this series. CT-scan was performed before surgery andshowed a SA4 sinus anatomy (A, B), with a thin residual bone height (often less than 2 mm).During surgery, 2 significant perforations were done in the Schneiderian membrane whiledetaching the window bone plate from the membrane (C). The sinus membrane was thencarefully lifted and covered with 2 PRF membranes to close the perforations. AstraTechimplants were inserted, and their tip blocked the PRF-patched sinus membrane in highposition (D). The subsinus cavity was then filled with PRF clots, and the bone window wasfinally closed with a PRF membrane only, the bone window fragment being too big and, thus,difficult to block correctly to close the subsinus regeneration cavity (E).

IMPLANT DENTISTRY / VOLUME 20, NUMBER 1 2011 3

the last cases, the PRF box was sys-tematically used for the collectionand preparation of standardized clotsand membranes.

Initial Technique, Started in 2003

In this case series, 23 sinus eleva-tions were performed on 20 patientsbetween January 2003 and January2008 with Choukroun’s PRF as solefilling biomaterial. All the treatedsinuses showed severe maxillary re-sorption (Figs. 1 and 2) and were allclassified as SA4 ("5 mm residualbone height under the sinus).32

Two implant systems were usedduring this period. From 2003 to Janu-ary 2006, all cases were treated withAstra implants (AstraTech, Molndal,Sweden). From January 2006 up to now,all cases were treated with Intra-Lockimplants (Intra-Lock, Boca Raton, FL).

The initial technique was a classicallateral sinus-lift using the Caldwell-Luc

approach. Surgery was performed withlocal anesthesia. Access to the buccalmaxillary wall was achieved via a mu-cosal crestal incision and anterior andposterior releasing vestibular incisions.A large bone window was outlined us-ing a diamond bur on a surgical hand-piece, with constant saline irrigation.After careful elevation of the Schneide-rian membrane, the bone window wasstill attached to the membrane andserved as a new sinus floor. In one of thefirst cases, the bone plate was carefullyseparated from the lifted sinus mem-brane (Fig. 1) to close the subsinuscavity after filling; however, the bonefragment was finally unusable, becauseit was too large and difficult to stabilizecorrectly (it would have lead to a bonesequestrum).

Two PRF membranes were placedon the Schneiderian membrane to pro-tect it before implant drilling and to healall visible or invisible holes and tears of

the sinus membrane. Implant sites werethen prepared with a careful drilling. Toavoid sinus membrane perforation andto compress the residual bone height, thefinal stage of osteotomy was performedwith a manual osteotome. Implants werethen inserted in compression within theresidual alveolar bone. Implant stabilitywas always obtained because of the ta-pered profiles and the microthreadedcollars of the implants. The end of theimplants always touched the PRF mem-branes covering the released sinus mem-brane and served as tent pegs (Fig. 1, D).

Five PRF clots on average werethen inserted and compressed insidethe subsinus cavity to fill all the vol-ume stabilized with the implants. Fi-nally, 1 PRF membrane was used tocover the osteotomy window and pro-tect the filled subsinus from potentialmucogingival invagination (Fig. 1, E).

For postoperative management,medications were prescribed, includingchlorhexidine rinses twice a day untilsutures removal, 1 g amoxicillin (2times daily for 6 days; pristinamycin2 # 100 mg, 2 times daily was pre-scribed in penicillin-sensitive patients),ibuprofen (400 mg) 4 times daily unlessmedically contraindicated, and painmedication as needed for pain. Patientswere not allowed to use any removableprosthesis. The sutures were removed 8to 10 days postoperatively.

Evolution of the Technique

The first main evolution appearedsince 2005 and was related to the po-sition and size of the Caldwell-Lucbony window. In the first cases, thewindow was outlined quite close fromthe crestal horizontal part ($4 mmabove the crestal line), and the sinuswas widely opened, using a quite largebone incision (Fig. 1, C and D). Thistechnique allowed a better viewpointand control of the PRF membranesand implant placement but presentedsome disadvantages. Indeed, taperedimplants were inserted in compressionwith a quite high torque and blockedin the residual bone height (thin inSA4 sinus), and crestal fractures mayoccur. This event could have severeconsequences, because this techniquerequired the implants to be stable andto maintain the sinus membrane in

Fig. 2. Twenty days after surgery, a first panoramic x-ray showed the Astra implants blocked in thethin residual bone height (1 mm), with $12 mm of the implant standing in the sinus without bone:PRF filling is not observable with the x-rays (A). Six months after surgery, a control CT-scan wasperformed and showed that implants were surrounded in a new bone tissue. Only the last 2 mm ofthe implants were not clearly covered with bone, but a shadow image appeared up to the implanttip (white dotted line), which indicated the presence of a tissue not yet calcified. Moreover, thelateral bone window was no more visible, and the cortical outline seemed already reconstructed(B). On the panoramic x-ray, most of the implant cavity was filled with new bone, but the new sinusfloor was still blurred (C). Four years after sinus filling, panoramic x-ray showed that the subsinuscavity filled with PRF was completely filled with bone up to the implant tip, leading to a final bonegain around 12 mm. The new periimplant bone was very natural, and the final sinus floor clearlyappeared in the continuation of the implant tip. The final bone regenerated volume looked likeexactly adapted to the size of the implants (D).


high position. Moreover, a large bonewindow reduced the regeneration po-tential of the subsinus cavity walls andcould, thus, impair bone healing.Thus, it was quickly decided to reducethe size of the bony window and toplace the window in the upper part ofthe sinus wall, $6 to 8 mm above thecrestal line (Fig. 3). These simple evo-lutions of the technique seemed highlybeneficial to secure this procedure andto increase the bone regeneration po-tential of the filled subsinus cavity.

The second main change was re-lated to the use of the bone plate (from

the access window) during the sur-gery. In the last cases of this series, itwas decided to carefully separate thebone plate (from the access window)from the lifted sinus membrane and touse it for subsinus cavity closure afterfilling with the PRF clots. To blockthis bone plate in the right position,this rectangular fragment could beplaced transversely on the bone win-dow, and the final PRF membrane wasplaced over it. This modified tech-nique seemed relevant to increase theregeneration potential of the filledsubsinus cavity.

RESULTS OF A6-YEAR EXPERIENCE

This clinical experience is based ona case series of 23 sinus elevations per-formed on 20 patients between January2003 and January 2008 with Chouk-roun’s PRF as sole filling biomaterial.Patients were 12 women (60%) and 8men (40%) with a mean age of 59.8 !11.1 years, from 37 to 80 years.

Both the implant systems used inthis study show similar profile, with atypical tapered and microthreaded col-lar. It was the more adequate implantshape and design for this specific ap-plication where implants have to beplaced in a very limited residual boneheight. In this case series, a total of 52implants were placed. Seven patientswere treated with 19 Astra implants(AstraTech; Figs. 1 and 2), and 13patients with 33 Intra-Lock implants(Ossean; Intra-Lock, Boca Raton, FL;Fig. 3). Astra implants were 13 mmlong and 4.5 mm in diameter; Intra-Lock implants were 11.5 or 13 mmlong and 4.3 mm in diameter.

Implants were inserted in 23 firstmolar, 19 second molar, and 10 pre-molar sites, under clean but not sterileconditions as defined by Scharf andTarnow.33 In 3 patients, clear sinusmembrane perforations were noticedduring the sinus-lift and patched easilywith PRF membranes (Fig. 1). Aftersurgery, healing was uneventful for allpatients. Six months after surgery, allimplants were clinically stable duringabutment tightening.

The maximum follow-up was 6years, and all patients were followed upfor a minimum of 2 years. Clinicalfollow-up was associated with retroal-veolar and panoramic x-rays just afterimplant placement, after 6 months, after1 year, and finally after each followingyear (Figs. 2 and 3). In some cases,low-dose volumetric computed radiog-raphy or CT scan examinations wereperformed 6 months after sinus-lift sur-gery, and even sometimes after 1 year ormore, to evaluate accurately the sinusbone gain around each implant.

The main results in this case serieswere that no implant was lost during this6-year experience and that the verticalbone gain (assessed by x-ray follow-up)

Fig. 3. This patient showed SA4 sinus morphology (A). The sinus lateral bone window wassmaller than in previous cases and placed in the upper part of the sinus wall ($6 – 8 mmabove the crestal line). After careful elevation of the Schneiderian membrane, the windowbone plate was still attached to the sinus membrane (B). Intra-Lock implants were in-serted, and their tip maintained the Schneiderian membrane in high position (C). The newsubsinus cavity was then filled with PRF clots (D), and the bone window was covered witha PRF membrane a sole protection (E). After 3 months, the panoramic x-ray showed ablurred opacity around the implant (F). After 3 years, the x-ray proved an almost completebone regeneration around the implants, with a clear cortical sinus floor in the continuationof the implant end (G).


was always substantial and stable.34 Allimplants were inserted in a residualbone height between 1 and 3 mm (1.8 !0.5). Thus, the final bone gain was al-ways very significant with these quitelong implants, between 8.5 and 12 mmbone gain (10.4 ! 1.2). The final levelof the new sinus floor was sometimesdifficult to assess precisely with onlyx-rays as investigation tools, but itseemed that the position of the finalsinus floor was always in the continua-tion of the implant end (Figs. 2 and 3).

The periimplant crestal bone heightwas always very stable. This resultcould be associated with the typical mi-crothreaded profiles and the similarplatform-switching prosthetic system35

of both implant systems. It proved thatthis kind of screw implants placed inresidual bone height can maintain astrong periimplant bone tissue as long asthey are blocked in stable position.

No statistical comparison betweenthe different implant systems was per-formed to define which implant sys-tem was the more efficient for bonegain around implants. Indeed, in thistechnique, implants were used as tentpegs to delineate the bone regenera-tion chamber, and the implant shape orsurface did not seem to influence theposition of the new sinus floor.

DISCUSSIONPRF Membrane, an Inexpensive andPowerful Tool to Secure Sinus-Lift

Filling or not filling duringsinus-lift? During sinus-lift, the bio-materials are used as space maintain-ers and bone scaffold to promotebone regeneration in the subsinusarea. The general consensus is thatmany biomaterials are usable in thesinus, because of the high osteogenicactivity of the Schneiderian mem-brane.7 Consequently, both crestalapproach with osteotome (Summerstechnique)4 and lateral sinus-lift caneasily be performed without any ma-terial, particularly for small graftingvolume.10,11,36 Unfortunately, whenno filling is used, some authors haveshown that the true bone gain is infact always limited and that implantapical ends might be enmeshed inthe sinus connective tissue and, thus,not osseointegrated.37,38

Choukroun’s PRF is a simple andinexpensive technique that can be usedcurrently in daily practice. This tech-nique is the simplest and cheapest wayto produce autologous fibrin mem-brane or platelet concentrate.12 Thesystematic use of this biomaterial dur-ing sinus-lift, with or without bonesubstitute, seems a very interesting op-tion, particularly for the protection ofthe Schneiderian membrane. More-over, the use of PRF as sole fillingmaterial seems able to stabilize a quitehigh amount of bone around the im-plants: indeed, in this case series, thelong term follow-up showed that peri-implant bone finally stabilized up tothe implant end. This result was quitedifferent from some actual availabledata about the sinus-lift procedurewithout any material,38 and it showedthat the use of PRF, as an optimizednatural blood clot, seemed to avoid theenmeshment of the implant end in athick sinus connective tissue.

This result could be the conse-quence of the applications of PRF mem-branes on the Schneiderian membrane.Indeed, a PRF cover on the sinus mem-brane can potentially improve the heal-ing of the membrane, induce a stimulationof the periosteum, and perhaps sta-bilize a new bone volume at the endof the implant.39,40 This effect maybe both related to the platelet41 andfibrin42,43 content of the PRF mem-brane. From a practical standpoint,the use of PRF membranes on theSchneiderian membrane is a simplemechanical and biological protectionthat can be used in daily practice,whatever the filling material.

Therefore, we can clearly answerthe question: Filling or not filling dur-ing sinus-lift? Filling is not absolutelynecessary because the natural bloodclot inside the subsinus chamber isenough for bone healing; but filling atleast with PRF, ie, optimized bloodclots, seems the adequate alternativeto improve natural healing and to se-cure the surgical procedure.

Implant Design and Evolution of theTechnical Procedure

In this case series, all implantsachieved primary stability even in athin residual bone height. Implant sta-

bilization was achieved by the micro-threads of the implant collar and itsadequate tapered profile. This implantdesign seems the best for such subsi-nus implantation, to block correctlythe implant, but other designs could bediscussed, such as microthreaded non-tapered implants or tapered nonmicro-threaded implants. However, it seemsvery important to be as cautious aspossible with this technique and to usethe more adequate profile from themechanical point of view.

The influence of the implantshapes and surfaces on the bone regen-eration in the cavity could also be dis-cussed, because both implants used inthis series showed improved surfa-ces.44 New surfaces (such as AstraOsseospeed or Intra-Lock Ossean) in-fluence bone cell response,45–47 and itcould, thus, be a relevant parameter toimprove local bone regeneration.

Another key point was revealed inthis case series, concerning the effectof the PRF membrane placed on thesinus bone window. It is often consid-ered that the lateral window of thesinus should be protected with a mem-brane (such as collagen membranes) toavoid invagination of the mucogingi-val tissues in the subsinus cavity. Thegeneral explanation about this phe-nomenon is that the subsinus cavitymust be protected with a barrier suchas a guided bone regeneration area. Inthe first cases of this series, PRF mem-branes were used as sole protectionmembrane covering each sinus win-dow. The x-ray analyses of these cases6 months after surgery showed no in-vagination/fibrosis, and a neat corticallimit was clearly observed after 3years, even if the cortical surface ap-peared to be a little bit depressed at thelevel of the wide bone window (thiswas another argument to reduce thesize of the window).

This result indicated that PRFmembranes alone were able to protectthe sinus graft area. This point is veryinteresting, because PRF is an inex-pensive autologous biomaterial with asignificant slow release of growthfactors and could easily replace xeno-geneic and expensive collagen mem-branes in this application.48


CONCLUSION

The use of PRF as sole graftingmaterial during simultaneous sinus-liftand implantation is a secure and reli-able option. This autologous and inex-pensive material can be considered asan optimized blood clot, and thisL-PRF matrix seems a relevant bioma-terial for natural bone regeneration.However, in this technique, the expe-rience of the surgeon and the choice ofthe implant profile are also significantparameters, because implant stabilityin the residual alveolar ridge is the keycondition to the firm support of theimplants as tent pegs on the Schneide-rian membrane. Finally, by extension,the systematic use of PRF duringsinus-lift, with or without bone graft-ing material, may be beneficial, par-ticularly for the protection of theSchneiderian membrane, and shouldbe analyzed in further studies.

ACKNOWLEDGMENTS

This work was partially supportedby a grant from the LoB5 Foundationfor Research, Paris, France.

Disclosure

Dr. Joseph Choukroun is the inven-tor of the PRF technique and scientificdirector of Process, Nice, France, a med-ical company that distributes in Francethe adapted PRF centrifuge and prepa-ration kits (certified for use outside ofhospitals and blood banks) under thedirect control and agreement of theFrench Health Ministry. However,the Choukroun’s PRF is a free and openaccess protocol; so, there is no financialconflict of interest. The other authorshave no competing financial interests todisclose in this work.

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Abstract Translations

GERMAN / DEUTSCHAUTOR(EN): Alain Simonpieri, DDS, Joseph Choukroun,MD, Marco Del Corso, DDS, Gilberto Sammartino, MD,PhD, David M. Dohan Ehrenfest, DDS, MS, PhDGleichzeitige Sinusanhebung und Implantierung mittels Im-plantaten mit Mikrogewinde und L-PRF als alleinigem Trans-plantierungsmaterial: eine Erfahrungsbericht uber 6 Jahre.

ZUSAMMENFASSUNG: Zielsetzung: Es war beabsichtigt,die Bedeutung einer gleichzeitigen Sinusanhebung und Implan-tierung mit L-PRF (Leukozyt- und Thrombozytreichem Fibrin,Choukroun-Methode) als alleinigem Subsinusfullmaterial zu

beurteilen. Materialien und Methoden: 23 laterale Sinusanhe-bungsbehandlungen (SA4 Sinus) wurden bei 20 Patienten beigleichzeitiger Implantatsetzung durchgefuhrt. Sieben Patientenwurden mit 19 Astra-Implantaten behandelt (AstraTech, Moln-dal, Schweden). Weitere 13 Patienten bekamen 33 Intra-Lock-Implantate eingepflanzt (Intra-Lock Ossean). Zur Abdeckungder Schneiderschen Membrane wurden L-PRF-Membrane ver-wendet. Dabei fungierten die Implantatspitzen als “Zeltpflocke”fur die mit L-PRF-versetzten Sinusmembrane. Schlussendlichwurde die Hohle des Subsinus mit L-PRF-Klumpchen gefullt.Eine klinische sowie radiologische Nachuntersuchung wurdedirekt nach Implantateinpflanzung, nach 6 Monaten, nach 1 Jahrsowie in jedem darauf folgenden Jahr durchgefuhrt. Ergebnisse:


6 Monate nach dem chirurgischen Eingriff waren alle Implantatewahrend der Befestigung der Stutzapparatur klinisch stabil. Diemaximale Nachverfolgungszeit betrug 6 Jahre. Alle Patientenunterzogen sich fur mindestens 2 Jahre Nachuntersuchungen. Eswar im Verlauf dieser 6 Jahre andauernden Erfahrungsberichtekein Implantatverlust zu verzeichnen. Immer war der vertikaleKnochengewinn betrachtlich und lag zwischen 8.5 und 12 mman Knochengewebszugewinn (10.4 ! 1.2). Der abschließendeLevel des neuen Sinusbodens bildete immer die Fortfuhrung mitdem Wurzelende des Implantats. Die Kammknochengeweb-shohe im das Implantat umlagernden Gewebe war stabil.Schlussfolgerung: Die Verwendung von L-PRF als alleinigemFullmaterial wahrend gleichzeitiger Sinusanhebung und Implan-tierung scheint eine zuverlassige chirurgische Option dar-zustellen, die die naturliche Knochenregeneration fordert.

SCHLUSSELWORTER: Zahnimplantat, Fibrin, Throm-bozytreiches Fibrin (PRF), Thrombozyteiches Plasma (PRP)

SPANISH / ESPAÑOLAUTOR(ES): Alain Simonpieri, DDS, Joseph Choukroun,MD, Marco Del Corso, DDS, Gilberto Sammartino, MD,PhD, David M. Dohan Ehrenfest, DDS, MS, PhDImplante y elevacion simultanea del seno usando implantescon micro roscas y L-PRF como unico material de injerto:Experiencia de 6 anos.

ABSTRACTO: Proposito: Para evaluar la relevancia delimplante y elevacion simultanea del seno con L-PRF (fibrinarica en plaquetas y leucocitos, tecnica de Choukroun) comounico material de relleno en el subseno. Materiales y meto-dos: Se realizaron 23 elevaciones laterales del seno (senosSA4) en 20 pacientes con colocacion simultanea del im-plante. Siete pacientes fueron tratados con 19 implantes Astra(AstraTech, Molndal, Suecia), y 13 pacientes con 33 implan-tes Intra-Lock (Intra-Lock Ossean, Boca Raton, FL). Seusaron membranas de L-PRF para cubrir la membranaSchneideriana, las puntas de los implantes sirvieron como“estacas de carpa” de las membranas del seno emparchadascon L-PRF y la cavidad del subseno finalmente se lleno concoagulos de L-PRF. El seguimiento clínico y radiografico serealizo inmediatamente luego de la colocacion de los implan-tes, despues de 6 meses, 1 ano y cada ano posterior. Resulta-dos: Seis meses despues de la operacion, todos los implanteseran clínicamente estables durante el apretado de los linderos.El seguimiento maximo fue 6 anos y todos los pacientesfueron seguidos durante un mínimo de 2 anos. No se perdioningun implante durante esta experiencia de 6 anos y laganancia vertical del hueso fue siempre importante, entre8.5 y 12 mm de ganancia de hueso (10.4 ! 1.2). El nivelfinal del piso del nuevo seno estuvo siempre en continu-acion con el extremo apical del implante y la altura delhueso crestal periimplante fue estable. Conclusion: El usode L-PRF como unico material de relleno durante unimplante y elevacion simultanea del seno parece ser una

opcion quirurgica confiable para promover la regeneracionnatural del hueso.

PALABRAS CLAVES: Implante dental, fibrina, fibrina ricaen plaquetas (PRF por sus siglas en ingles), plasma rico enplaquetas (PRP por sus siglas en ingles)

PORTUGUESE / PORTUGUÊSAUTOR(ES): Alain Simonpieri, Cirurgiao-Dentista, JosephChoukroun, Medico, Marco Del Corso, Cirurgiao-Dentista,Gilberto Sammartino, Medico, PhD, David M. Dohan Ehren-fest, Cirurgiao-Dentista, Mestre em Ciencia, PhDElevacao e implantacao simultaneas da cavidade usandoimplantes microrrosqueados e L-PRF como unico materialde enxertamento: experiencia de 6 anos.

RESUMO: Objetivo: Avaliar a relevancia da elevacao eimplantacao simultaneas da cavidade com L-PRF (FibrinaRica em Leucocitos e Plaquetas, tecnica de Choukroun) comounico material de enchimento da subcavidade. Material eMetodos: 23 elevacoes da cavidade lateral (cavidade SA4)foram realizadas em 20 pacientes com colocacao simultaneade implante. Sete pacientes foram tratados com 19 implantesAstra (AstraTech, Molndal, Suecia) e 13 pacientes com 33implantes Intra-Lock (Intra-Lock Ossean, Boca Raton, FL).Membranas L-PRF foram usadas para cobrir a membranaSchneideriana, as pontas do implante serviram como “paus debarraca” para as membranas da cavidade remendadas comL-PRF, e a subcavidade foi finalmente preenchida com co-agulos de L-PRF. O acompanhamento clínico e radiograficofoi realizado logo apos a colocacao do implante, apos 6meses, 1 ano e cada ano seguinte. Resultados: Seis mesesapos a cirurgia, todos os implantes estavam clinicamenteestaveis durante o aperto do suporte. O acompanhamentomaximo foi de 6 anos e todos os pacientes foram acompan-hados durante o mínimo de 2 anos. Nenhum implante foiperdido durante esta experiencia de 6 anos e o ganho de ossovertical foi sempre substancial, entre 8.5 e 12 mm de ganhode osso (10.4 ! 1.2). O nível final da nova superfície dacavidade esteve sempre em continuacao com a ponta apicaldo implante e a altura da crista ossea do peri-implante ficouestavel. Conclusao: O uso de L-PRF como unico material deenchimento durante a elevacao e implantacao simultaneas dacavidade parece ser uma opcao cirurgica confiavel, promov-endo a regeneracao natural do osso.

PALAVRAS-CHAVE: implante dentariom, fibrina, fibrinarica em plaquetas (PRF), plasma rico em plaquetas (PRP)

RUSSIAN /!"#$%&: Alain Simonpieri, !"#$"% &'%(%)'*+,#"-,$"./$"0")'', Joseph Choukroun, !"#$"% .+!'1'23,Marco Del Corso, !"#$"% &'%(%)'*+,#"- ,$"./$"0")'',Gilberto Sammartino, !"#$"% .+!'1'23, !"#$"%


4'0","4'', David M. Dohan Ehrenfest, !"#$"%&'%(%)'*+,#"- ,$"./$"0")'', ./)',$% +,$+,$5+223&2/(#, !"#$"% 4'0","4''$'()*+,-,((), .+)*,',(/, 0/(10-2/34/(56 / /--.26(467// 0 .)-)89: /-.26(464)* 0-/;+)+,<9=)> / L-PRF * ;6?,04*, ,'/(04*,(()5)4+6(0.26(467/)(()5) -64,+/626: @,04/2,4(/>).A4.

%BCDEB. !"#$. 61+2#/ 72/*'.",$'"!2"5%+.+22")" 8%"5+!+2'9 ,'2(,-0'4$'2)/ ' '.-80/2$/1'' , 8".":;< L-PRF (4'=%'2/ , 53,"#'.,"!+%>/2'+. 0+-#"1'$"5 ' $%".="1'$"5, .+$"!'#/?(#%(2/) 5 #/*+,$5+ +!'2,$5+22")" 2/8"02'$+09 !2/)/-."%"5"- 8/7(&'. %&'"()&#* ) +"',-*. @/ 208/1'+2$/& =30" 8%"5+!+2" 23 0/$+%/0;23& ,'2(,-0'4$'2)/ (SA4 ,'2(,) , "!2"5%+.+22"- (,$/2"5#"-'.80/2$/$/. A09 0+*+2'9 ,+.' 8/1'+2$"5',8"0;7"5/0',; '.80/2$/$3 Astra (AstraTech, Mölndal,?5+1'9), !09 0+*+2'9 13 8/1'+2$"5 – '.80/2$/$3 33Intra-Lock (Intra-Lock Ossean, Boca Raton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– 12 .. (10,4!1,2). 6#"2*/$+0;23- (%"5+2;2"5")" !2/ 8/7(&' 5" 5,+& ,0(*/9& 95090,98%"!"0>+2'+. 5+%&(E#' ,$+%>29 '.80/2$/$/, / 53-,"$/ /0;5+"09%2")" )%+=29 5"#%() '.80/2$/$/ =30/,$/='0;2"-. 1*2,-. J,8"0;7"5/2'+ L-PRF 5 #/*+,$5++!'2,$5+22")" 7/8"02'$+09 8%' "!2"5%+.+22".8%"5+!+2'' ,'2(,-0'4$'2)/ ' '.80/2$/1'' 9509+$,9

2/!+>23. &'%(%)'*+,#'. .+$"!". ,$'.(091''%+)+2+%/1'' 2/$(%/0;2"- #",$2"- $#/2'.

!"#$%&'% (")&*: 7(=2"- '.80/2$/$; 4'=%'2;4'=%'2 , 53,"#'. ,"!+%>/2'+. $%".="1'$"5 (PRF);80/7./ , 53,"#'. ,"!+%>/2'+. $%".="1'$"5 (PRP)

TURKISH / TURKCEYAZARLAR: Alain Simonpieri, DDS, Joseph Choukroun,MD, Marco Del Corso, DDS, Gilberto Sammartino, MD,PhD, David M. Dohan Ehrenfest, DDS, MS, PhDMikro-yivli implantlar ve tek greft materyali olarak L-PRFkullanılarak es-zamanlı sinus kaldırma ve implantasyon: 6yıllık deneyim.

OZET: Amac: Tek sub-sinus dolgu materyali olarak L-PRF(Lokosit ve plateletten zengin fibrin, Choukroun teknigi)kullanarak es-zamanlı sinus kaldırma ve implantasyon is-lemini degerlendirmek. Gerec ve Yontem: 20 hastada 23 adetlateral sinus kaldırma (SA4 sinus) islemi, implant yerlestirmeile es zamanlı olarak yapıldı. Yedi hasta, 19 adet Astraimplantı (AstraTech, Molndal, Isvec) ile ve 13 hasta da 33adet Intra-Lock implantı (Intra-Lock Ossean, Boca Raton,FL) ile tedavi edildi. Schneiderian membranı kaplamak icinL-PRF membranları kullanıldı ve implant ucları, L-PRF ileyama yapılan sinus membranları icin “cadır civisi” islevinigordu. Subsinus boslugu son olarak L-PRF pıhtıları ile dol-duruldu. Hemen implant yerlestirme sonrasında, 6 ay sonra, 1yıl sonra ve sonraki her yılda bir kez klinik ve radyografikizlem yapıldı. Bulgular: Cerrahiden altı ay sonra abutmansıkıstırma esnasında tum implantların klinik olarak stabiloldugu goruldu. En uzun izlem donemi 6 yıldı ve hastalarıntumu en az 2 yıl boyunca takip edildi. 6 yıl boyunca implantkaybı olmadı ve dikey kemik kazancı daima kayda degerolup, 8.5 ile 12 mm arasında degisti (10.4 ! 1.2). Yeni sinustabanının son duzeyi daima implantın apikal ucuna kadardevam etti ve peri-implant sırt kemik yuksekligi stabil idi.Sonuc: Es zamanlı sinus kaldırma ve implantasyon islemisırasında L-PRF’nin tek dolgu materyali olarak kullanılmasıdogal kemik rejenerasyonunu tesvik eden guvenilir bir cer-rahi secenektir.

ANAHTAR KELIMELER: Dental implant, fibrin, platelet-ten zengin fibrin (PRF), plateletten zengin plazma (PRP)


JAPANESE /


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KOREAN /


simultaneous sinus-lift and implantation using

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