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Application of fibrin rich blocks with concentrated growth factors in pre-implant augmentation procedures/ Upotreba fibrinskih blokova bogatih koncentrovanim faktorima rasta u preimplantoloskim augmentacionim procedurama.

Introduction

In our everyday clinical practice, we face a relatively large number of patients presenting with a substantial deficit of the residual alveolar ridge due to the loss of single or several teeth who require implant-prosthetic treatment. In such situations, the augmentation of lost bony structures is indicated in order to provide optimal conditions for dental implant placement and subsequent prosthetic rehabilitation [1]. Nowadays, a whole range of modern surgical procedures and a variety of dental materials for reconstruction of bony defects of the upper and lower jaws and for the augmentation of lost structures of the residual alveolar ridge are available. The application of fibrin rich blocks with concentrated growth factors (CGF) is one of the latest approaches to guided bone regeneration (GBR). Fibrin rich blocks are applicable either alone or mixed/ combined with any of synthetic bone grafts [1, 2].

According to numerous studies, growth factors are mainly located in blood plasma and thrombocytes. Growth factors are biological mediators regulating the major processes of tissue restoration, including cell proliferation and differentiation, extracellular matrix synthesis, chemotaxis and angiogenesis. In addition to the role they play in haemostasis and inflammatory processes, thrombocytes are of major importance in the reparation of mineralized and soft tissues [3].

The most important and most extensively investigated growth factors are platelet-derived growth factor (PDGF), transforming growth factor (TGF), epidermal growth factor (EGF) and insulin-like growth factor 1 (IGF-1) [4]. The first generation of these preparations, platelet rich plasma (PRP), has been well known for more than 15 years. PRP was first introduced into clinical practice by Marx in 1998 [5], whereas platelets rich in growth factor (PRGF) are the second-generation platelet concentrates. Platelet-rich fibrin (PRF) was first introduced by Choukroun in 2000 as the platelet concentrates of the third generation along with CGF introduced by Sacco in 2006. CGFs are characterized by higher density, larger amount of growth factors, higher viscosity and better adhesion capacity as compared to PRF. All preparations are produced from the patient's fresh venous blood [6].

The application of autologous fibrin rich blocks has no adverse effects; it is considered a safe and simple procedure for the surgeon. At the same time, it is highly effective and economically feasible for the patient.

Case report

A 28-year-old female patient came to the Department of Oral Surgery and Implantology of the Dental Clinic of Vojvodina because of the loss of tooth 22 and pain in the region of tooth 23. The clinical examination revealed fresh extraction wound after the last extraction of tooth 22 and intraoral fistula in the root tip area of the tooth 23. The patient was referred to cone beam computed tomography (CBCT) scan. The CBCT scan revealed a radicular cyst on tooth 23 associated with massive destruction of the surrounding bony tissue (Figure 1).

After completing the diagnostic procedure and consulting the specialist in dental prosthetics, the therapy options were considered. The definitive therapeutic strategy was established, encompassing three stages. Stage 1 included the extraction of tooth 23, cyst curettage and the reconstruction of bony defects in regions of teeth 22 and 23 by applying CGF blocks. The second stage, after bone healing, included the placement of two endoosseous titanium implants at the position of teeth 22 and 23. The third stage, subsequent to the successfully completed osseointegration, included the placement of two implant-supported metal-ceramic crowns. After obtaining the patient's written consent, the suggested therapy plan was carried out. After full-thickness mucoperiosteal flap had been lifted, the extraction of tooth 23 along with complete curettage of the cystic process and surrounding pathologically altered tissue was performed under local anaesthesia. The resulting bony defects were entirely filled out with CGF blocks previously prepared from the patient's venous blood and the flap was sutured back in place with synthetic non-absorbable monofilament suture (figures 2 and 3).

Five months after surgery, the control CBCT scan revealed the complete regeneration and reparation of the bone tissue and satisfactory dimensions of the residual alveolar ridge, that being the prerequisite for the placement of endoosseous implants of 3.3 mm in diameter and 12 mm in length. (figures 4 and 5). After implantation, the entire surgical region was covered with pressed CGF barrier membrane and the flap was put back in place and sutured with synthetic non-absorbable monofilament suture in order to minimize the accumulation of soft deposits and to alleviate potential tissue reactions [7, 8].

Four months after implantation procedure, the patient underwent prosthetic restoration procedure at the Department of Dental Prosthetics. The procedure included the placement of two implant-supported metal-ceramic crowns (Figure 6).

Discussion

Application of CGF blocks is one of the most recent approaches to practical application of tissue engineering methods in oral surgery and implantology [4]. This is of particular importance in implantology, having in mind the growing need for augmentation procedures in cases of unfavourable anatomic conditions (horizontal and vertical augmentation, sinus-lift, etc.) [2].

The comparison of protocols for CGF block preparation revealed different utilization rates of collected blood, being 10% in PRP and PRGF and 30-40% in PRF and CGF. Numerous authors have reported positive results of the application of CGF in the augmentation of bone architecture of the residual alveolar ridge and establishment of adequate anatomical conditions for a successful implant-prosthetic rehabilitation of toothless patients. Blocks with CGF enhance the processes of bony structure reparation and regeneration thus shortening the healing time from the initial surgical procedure, i.e. alveolar ridge augmentation to the moment of placing the endoosseous implant into the augmented region. As aforementioned, CGF blocks are applicable alone or combined with any of synthetic bone grafts. However, novel trends in GBR give preference to natural graft material, i.e. auto-transplants. In a broader sense, CGF blocks could be considered natural graft material [1, 2, 6].

Conclusion

In our everyday clinical practice, we face a relatively large number of patients indicated for implant-prosthetic treatment. The loss of a single tooth or several teeth results in substantial deficit of the residual alveolar ridge in such patients. Such situations require the augmentation of lost bony structures in order to provide optimal conditions for dental implant placement and subsequent prosthetic rehabilitation. Oral surgeons have the whole range of modern surgical procedures and a variety of dental materials for reconstruction of bony defects of the upper and lower jaws at their disposal. The method presented in this paper, i.e. the application of concentrated growth factors is one of the latest approaches, which carries no risk of either transmissible or allergic diseases, and is at the same time highly effective and economically feasible.

Abbreviations

CGF    -concentrated growth factors
PRP    -platelet rich plasma
PRGF   -platelets rich in growth factor
PRF    -platelet-rich fibrin
CBCT   -cone beam computed tomography
GBR    -guided bone regeneration


DOI: 10.2298/MPNS1406177T

Rad je primljen 18. III 2014.

Recenziran 20. III 2014.

Prihvacen za stampu 25. III 2014.

BIBLID.0025-8105:(2014):LXVII:5-6:177-180.

References

[1.] Mirkovic S, Durdevic Mirkovic T, Puskar T. Application of concetrated growth factors in reconstruction of bone defects after removal of large jaw cyst: report of two cases. Vojnosanit Pregl 2014 in press.

[2.] Mirkovic S, Durdevic Mirkovic T, Petrovic L, Bozic D. The use of concentrate growth factors in gyded bone regeneration after lateral sinus lift procedure: case report. HealthMED 2013; 7(2):700-4.

[3.] Plachokova AS, Nikolidakis D, Mulder J, Jansen JA, Creugers NH. Effect of platelet-rich plasma on bone regeneration in dentistry: a systematic review. Clin Oral Implant Res 2008; 19(6):539-45.

[4.] Lazic Z, Bubalo M, Petkovic-Curcin A, Duka M, Mihajlovic B. Terapijska primena plazme bogate trombocitima u oralnoj hirurgiji. Vojnosanit Pregl 2009; 66(10):821-5.

[5.] Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 85(6):638-46.

[6.] Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C. Platelet-rich fibrin (PRF): a second generation platelet concentrate. Part IV: clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 101(3):56-60.

[7.] Mirkovic S, Dzambas LJ, Selakovic S. Uticaj razlicitih materijala za sivenje na intenzitet tkivne reakcije usne supljine. Zb Matice Srpske Prir Nauke 2008; 115:91-9.

[8.] Mirkovic S, Durdevic Mirkovic T, Bajkin B, Sarcev I. Izbor hirurskog savnog materijala prilikom suturiranja u usnoj duplji: klinicka studija. Med Pregl 2010; 63(7-8):497-501.

Ana TADIC (1), Tatjana PUSKAR (2) and Branislava PETRONIJEVIC (2) Univesity of Novi Sad, Faculty of Medicine, Novi Sad Dental Clinic of Vojvodina

Department of Oral Surgery (1) Department of Dental Prosthetics (2)

Corresponding Author: Dr Ana Tadic, Klinika za stomatologiju Vojvodine, 21000 Novi Sad, Hajduk Veljkova 12, E-mail: tadic.ana76@gmail.com
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Title Annotation:Case report/Prikaz slucaja
Author:Tadic, Ana; Puskar, Tatjana; Petronijevic, Branislava
Publication:Medicinski Pregled
Article Type:Case study
Date:May 1, 2014
Words:1447
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