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Basic and Clinical Research

Maxillary Sinus Augmentation With Different Biomaterials: A Comparative Histologic and Histomorphometric Study in Man

Scarano, Antonio DDS, MD*; Degidi, Marco MD, DDS; Iezzi, Giovanna DDS, PhD; Pecora, Gabriele MD, DDS§; Piattelli, Maurizio MD, DDS; Orsini, Giovanna DDS, PhD; Caputi, Sergio MD, DDS#; Perrotti, Vittoria DDS, PhD; Mangano, Carlo MD, DDS#; Piattelli, Adriano MD, DDS**

Author Information
doi: 10.1097/01.id.0000220120.54308.f3
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Abstract

Rehabilitation of the edentulous posterior maxilla with dental implants may be a problem because of insufficient bone volume produced by buccolingual and/or apico-occlusal atrophy of the edentulous alveolar crestal bone and pneumatization of the maxillary sinus.1 In this anatomical situation, it can be very difficult to obtain primary stability because of the absence of a useful quantity of cortical bone and for the loose structure of type IV spongious bone. The maxillary sinus augmentation was first presented by Tatum et al2,3 in 1986, and long-term results of this technique showed that it could be an effective treatment option.4

Various grafting materials have been used for sinus augmentation: autologous bone; mineralized and demineralized freeze-dried allografts; coralline calcium carbonate; Bioglass® (US Biomaterials, Alachua, FL); polylactide-polyglycolide materials; synthetic polymers; calcium sulfate; anorganic bovine bone; and hydroxyapatite.5–19 There is a concern that some biomaterials may cause a foreign body reaction, and the ideal material for sinus augmentation is still under debate.1,20 Autologous grafts are considered the golden standard in terms of osteogenic potential, but they present some disadvantages, such as limited availability of material from the intraoral donor site and morbidity at bone graft donor site.21

Demineralized freeze-dried bone allograft (DFDBA) is readily available and has been used since the 1970s because of its osteoconductive properties.10–12 In 1996, it was recognized as fulfilling criteria for promotion of periodontal regeneration.13 Biocoral® (Inoteb, St. Gonnery, France) is mainly composed of calcium carbonate in the form of aragonite (97% to 98%), strontium, fluoride, magnesium, sodium, and potassium.14–16 It has a porosity of more than 45%, with pores of about 250 μm (range 150–400) in diameter, resembling spongious bone.17 Recently, it has been found that Biocoral® may be used as a bone replacement material for the treatment of osseous defects associated with adult periodontitis.18 The architecture of the aragonite crystals allows the ingrowth by granulation tissue into the coralline structure.17 In the open pores, there is a formation of a fibrovascular tissue that is progressively replaced by bone.

Bioglass® is composed of SiO2 (45%), CaO (24.5%), NaO2 (24.5%), and P2O5 (6%).19 It can elicit specific physiologic responses, including the provision of surface-reactive silica, calcium and phosphate groups, and alkaline pH levels, at interfaces with tissues, thus providing high bioactivity and conditions that are favorable for establishing a strong implant bond.20,21 Synthetic polymers of resorbable polylactic and polyglycolide acids, each alone or both combined in different proportions, are applied as bone substitutes.22,23 The polyglycolide acid is degraded more rapidly, whereas the polylactic acid remains for a longer period.24 A number of studies have shown beneficial effects of these copolymers in animals and human beings.23–26 A commercially available grafting material is a copolymer of polylactic and polyglycolide acids that combines both components at equal proportions.

PepGen P-15TM (Dentsply Friadent CeraMed, Lakewood, CO) is a highly conserved linear peptide, with a 15-amino acid sequence identical to the sequence contained in the residues 766–780 of the α-1 chain of type I collagen.27,28 It is a combination of the mineral component of bovine bone (Osteograf [Dentsply Friadent CeraMed]/N 300) with P-15. The anorganic bovine-derived bone mineral component provides the necessary calcium phosphate and natural anatomical matrix needed for osteoconduction.28 P-15 competes for cell surface sites for the attachment of collagen, and, when immobilized on surfaces, it promotes adhesion of cells. It has facilitated physiologic processes in a way similar to collagen, exchanged mechanical signals, and promoted cell differentiation.29 Like other bone augmentation materials, P-15, associated with anorganic bovine-derived matrix, has been helpful in the treatment of periodontal, alveolar ridge defects, or sinus lifting procedures.30–33

Calcium sulfate is a highly biocompatible material that has the characteristic of being one of the simplest as well as one of the synthetic bone graft materials with the longest clinical history, spanning more than 100 years.34–37 It has been successfully used to treat periodontal disease, endodontic lesions, alveolar bone loss, and maxillary sinus augmentation.38–47 Used as a membrane barrier, calcium sulfate may act as a binder, facilitating healing and preventing loss of grafting material; moreover, it is tissue compatible and does not interfere with the healing process.48 Calcium powder acts as a direct source of calcium supply,19 or the more rapid rate of resorption of calcium sulfate compared to other materials may allow an earlier ingress of osteoprogenitor cells.49 Calcium sulfate rapidly resorbs, leaving a calcium phosphate lattice, which promotes osteogenic activity, it mimics the mineral phase of bone and is resorbed at the rate of bone formation.50,51 Ricci et al50 showed that calcium sulfate induced new bone formation after 2 weeks in dogs, and after 1 month it was almost completely resorbed.

Bio-Oss® (Geistlich Pharma AG, Wohlhusen, Switzerland) is a deproteinized sterilized bovine bone, with 75% to 80% porosity and a crystal size of approximately 10 μm in the form of cortical granules.52 It has been reported that Bio-Oss® promotes osteogenesis and shows very low resorbability.53–55 Bio-Oss® has been used often for maxillary sinus floor elevation.53–58

Bioceramics such as calcium phosphates, with hydroxyapatite being the prominent family member, have gained remarkable success.59–62 Fingranule® (Fin-Ceramica, Faenza RA, Italy) is a hydroxyapatite (Ca/P = 1.67 ± 0.03), made in potato-shaped granules, with a diameter ranging from 250 to 600 μm. This hydroxyapatite is characterized by a very low density and crystallinity; from the microstructural point of view, the grains present a nanometric dimension (range 0.05–0.1 μm). A specific characteristic of the material is a high degree of porosity, ranging from nano-dimension to 10 μm and from 10 to 60 μm.63

While using the different biomaterials, it is advisable to know their resorption profiles, and this profile should closely match the bone formation rate at the regeneration or implant sites.17 The resorption time and ultimate replacement of these graft materials with newly formed bone are not fully understood.64–66 The purpose of the present study was to make a histologic and histomorphometric comparison of the results obtained with the use of different graft materials in maxillary sinus augmentation procedures, in man.

Materials and Methods

A total of 94 consecutive patients participated in this study, ranging in age from 52 to 68 years (mean 61). There were 44 patients who received unilateral maxillary sinus augmentations, and 50 were treated with bilateral sinus lifts. The average bone thickness of the sinus floor was 4 mm. The Ethics Committee of the University of Chieti-Pescara approved the protocol, and informed written consent was obtained from all patients.

Inclusion criteria were a maxillary partial (unilateral or bilateral) edentulism involving the premolar/molar areas and the presence of 3–5-mm crestal bone between the sinus floor and alveolar ridge. Exclusion criteria were smoking, patients with systemic diseases, maxillary sinus pathology, and those with recent extractions (less than 1 year) in the involved area, and patients in whom primary stability could not be established. At the initial visit, all patients underwent a clinical and occlusal examination, periapical and panoramic radiographs, and computerized axial tomography was performed.

A total of 362 implants were inserted in the augmented sites. There were 9 biomaterials used in the sinus augmentation procedures: DFDBA (LifeNet, Virginia Beach, VA); Biocoral®; Bioglass®; Fisiograft® (Ghimas, Bologna, Italy); PepGen P-15TM; calcium sulfate (Surgiplaster sinus; ClassImplant, Rome, Italy); Bio-Oss®; Fingranule®; and hydroxyapatite. In all procedures, 100% of each biomaterial was used. There were 16 specimens evaluated for each biomaterial. A total of 144 specimens were retrieved and evaluated.

Surgical Protocol

Before surgery, the mouths were rinsed with a chlorhexidine digluconate solution 0.2% for 2 minutes. With the patient under local anesthesia, a crestal incision was performed slightly palatally, supplemented with 2 buccal releasing incisions, mesially and distally. Full thickness flaps were elevated to expose the alveolar crest and lateral wall of the maxillary sinus. Using a round bur under sterile saline solution irrigation, a trap door was made in the lateral sinus wall. The door was rotated inward and upward with a top hinge to a horizontal position. The sinus membrane was elevated with curettes of different shapes until it became completely detached from the lateral and inferior wall of the sinus. The grafting materials were mixed with venous blood and carefully packed in the sinus cavity, especially in the posterior and anterior parts.

The remaining sinus space around the implants was completely packed with the graft material. Flaps were sutured. Antibiotics and analgesics were given for 1 week. Sutures were removed 2 weeks after surgery. During the postoperative period, the patients were followed up at monthly intervals. The second-stage surgery was performed after a healing period of 6 months. At the second-stage surgery, bone cores were harvested from the lateral wall using a 4 × 10-mm diameter trephine under sterile saline-solution irrigation.

Specimen processing.

The specimens were immediately fixed in 10% buffered formalin and processed to obtain thin ground sections with the Precise 1 Automated System (Assing, Rome, Italy).67 The specimens were dehydrated in an ascending series of alcohol rinses and embedded in a glycolmethacrylate resin (Techonovit 7200 VLC; Kulzer, Wehrheim, Germany). After polymerization, the specimens were sectioned along their longitudinal axis with a high-precision diamond disc at about 150 μm and ground down to about 30 μm with a specially designed grinding machine. The slides were stained with acid fuchsin and toluidine blue. The slides were observed in normal transmitted light under a Leitz Laborlux microscope (Laborlux S, Leitz, Wetzlar, Germany). The histomorphometry was performed using a light microscope (Laborlux S, Leitz) connected to a high-resolution video camera (3CCD JVC KY-F55B), and interfaced to a monitor and personal computer (Intel Pentium III 1200 MMX). This optical system was associated with a digitizing pad (Matrix Vision GmbH) and a histometry software package with image capturing capabilities (Image-Pro Plus 4.5; Media Cybernetics Inc., Immagini & Computer Snc, Milano, Italy).

Statistical Analysis

The computerized statistical package Primer 4.02 (McGraw Hill Inc., New York, NY) was used to analyze all data.

Results

Clinical Observations

No postoperative complications were present. All implants were stable, and after the abutment connection, they received provisional fixed acrylic resin prostheses. The x-ray examination showed the presence of dense bone around and above the implants in the maxillary sinus. After 6–8 months, all patients underwent definitive prosthetic rehabilitation with ceramo-metal fixed prostheses. All patients were followed for a minimum of 3 years after prostheses placement. Mean follow-up was 4 years (range 2–7). There were 6 implants that failed, including 1 that inserted in a sinus augmented with Biocoral®, 1 with autologous bone, 1 with DFDBA, 2 with Bioglass®, and 1 with hydroxyapatite.

Histologic and Histomorphometric Results

Autologous bone.

In every specimen, it was possible to see that almost all particles of autologous bone were always completely surrounded by newly formed bone, and the material appeared to be highly osteoconductive (Fig. 1). In some fields, it was possible to see that a rim of osteoblasts lined this newly formed bone. No osteoclasts or macrophages were present. No resorption phenomena were present. In many areas, it was possible to observe the presence of compact, mature cortical bone, which could be easily differentiated from the newly formed bone. The grafted bone presented different structure and maturation features from the preexisting bone. It had a higher affinity for dyes; moreover, a basic fuchsin positive, highly stained line, similar to the cementing lines, divided the grafted from the newly formed bone. These lines had higher staining than the cementing lines observed in normal bone. Autologous bone grafts showed a pattern similar to that of host bone. Grafted autologous bone particles seemed to undergo a very slow resorption process. Histomorphometry showed that the percentage of newly formed bone was 40.1% ± 3.2%, marrow spaces 40% ± 2.1%, while residual grafted particles constituted the 18% ± 2.3% (Table 1).

F1-15
Fig. 1.:
Autologous bone (arrows) is completely surrounded by newly formed bone. No osteoclasts or macrophages are present.Fig. 2. Partial remineralization of particles of DFDBA and newly formed bone (arrows).Fig. 3. Biocoral® particles surrounded by mature bone and resorption are present.Fig. 4. Areas of resorption (arrows) are present at the surface of some graft particles of Bioglass®.Fig. 5. Fisiograft® appeared to be almost completely resorbed and substituted by newly formed bone (arrows).Fig. 6. Bone in direct contact with PepGen P-15TM particles. A few areas of resorption can be observed (arrows).Fig. 7. A few residual particles of calcium sulfate (arrows) are present and in the process of being substituted by newly formed bone.Fig. 8. Newly formed bone (arrows) in tight contact with a Bio-Oss® particle surface.Fig. 9. Hydroxyapatite particles that appear to be partially resorbed (arrows) and substituted by newly formed bone.
T1-15
Table 1:
Histomorphometry of Percentage of Newly Formed Bone, Marrow Spaces, and Residual Grafted Materials

DFDBA.

The particles of DFDBA that were located near preexisting bone were surrounded by newly formed bone, while particles at a distance did not show remineralization and new bone formation (Fig. 2). In the former particles, mineralization nuclei were present inside the graft material. These nuclei tended to fuse and substitute the demineralized matrix. Only in some areas were all DFDBA particles completely surrounded by newly formed bone. Histomorphometry showed that newly formed bone was 29% ± 2.3%, marrow spaces 37% ± 1.6%, while residual particles represented 34% ± 1.2%.

Biocoral®.

At low magnification, it was possible to observe that almost all Biocoral® particles were surrounded by mature bone. Only around some particles was it possible to observe the presence of osteoid material (Fig. 3). Only in a few areas were the material particles near marrow spaces. In all specimens, no inflammatory cell infiltrate was present. No foreign body reactions were present. No osteoblasts were present. The histochemical analysis for mineralized tissue (von Kossa) did show that the bone around the Biocoral® particles was mature and highly mineralized. Graft particles appeared to be fused by newly formed bone. No gaps were present at the interface between bone and biomaterial. Areas of resorption were present at the surface of some graft particles. In some areas, small capillaries were present in the marrow spaces located between the particles. Histomorphometry showed that newly formed bone was 39% ± 3.1%, marrow spaces 40% ± 1.5%, while the residual Biocoral® particles constituted 22% ± 2.8%.

Bioglass®.

The particles were surrounded by newly formed bone (Fig. 4). No gaps or fibrous tissues were present at the bone-biomaterial interface. Graft particles were connected by newly formed bone. Histomorphometry showed that newly formed bone was 31% ± 1.9%, marrow spaces 49% ± 1.8%, while remnants represented 18% ± 2.4%.

Fisiograft®.

It was possible to observe mature cortical bone, while in the more central and apical parts of the specimens, the bone appeared to be more trabecular (Fig. 5). In some areas, it was possible to observe not yet mineralized bone. No inflammatory cells were observed. The biomaterial appeared to be almost completely resorbed and substituted by newly formed bone. Newly formed bone constituted was 33% ± 2.1%, marrow spaces 59% ± 2.3%, while residual Fisiograft® was 3% ± 2.1%.

PepGen P-15TM.

The internal portion of most of the particles was colonized by a tissue with the staining characteristics of newly-formed bone. Many resorption lacunae were present on the surface of the particles; multinucleated cells were present in these lacunae. In some areas, it was possible to observe, at the periphery of the biomaterial, the presence of detached portions of the graft particles. The bone near the particles was mainly lamellar without osteonic structures (Fig. 6). Newly formed bone was found in most areas to be about 100–200 μm away from the particles' surface. Tissue constituted the space between the bone and graft, where it was possible to find small capillaries, fibroblasts, and macrophages. No areas of necrosis were present. No inflammatory cell infiltrate or foreign body reaction was present. Newly formed bone represented 37% ± 2.3%, marrow spaces 23% ± 1.6%, and residual particles represented 37% ± 3.2%.

Calcium sulfate.

Newly formed bone with wide osteocyte lacunae was present. In some areas, small residues of calcium sulfate were present and surrounded by newly formed bone (Fig. 7). Newly formed vessels were present. No inflammatory cell infiltrate was present. Newly formed bone was 38% ± 3.2%, marrow spaces 45% ± 1.3%, and residual calcium sulfate was 13% ± 2.1%.

Bio-Oss®.

Most of the particles were surrounded by newly formed mature, compact bone with well-organized osteons (Fig. 8). In some fields, osteoblasts were observed in the process of apposing bone directly on the particle surface. No gaps were present at the bone-particles interface, and the bone was always in close contact with the particles. No inflammatory cell infiltrate was present around the particles or at the interface with bone. Osteocyte lacunae of the graft particles were filled by osteocytes.

Some of the particles appeared to be cemented by this newly formed bone. At higher magnification, the bone presented wide osteocytic lacunae. In almost all particles, the haversian canals appeared to be colonized by capillaries and cells. The inner surface of some haversian channels was lined by osteoblasts deposing an acid fuchsin positive not yet mineralized material. The most peripheral osteocytic lacunae present in the Bio-Oss® appeared to be always filled by osteocytes, while the most central ones appeared to be filled by small cells with morphologic and staining features different from the osteocytes. Only in a few cases were the osteocytic lacunae empty. The Bio-Oss® particles presented marked staining differences from the host bone and had a lower affinity for the stains. Only in a few areas was it possible to see multinucleated giant cells. Histomorphometry showed that newly formed bone was 39% ± 1.6%, marrow spaces 34% ± 1.6%, while the residual graft material represented 31% ± 1.4%.

Hydroxyapatite.

Newly formed bone with the presence of large osteocytic lacunae, lamellar bone, and haversian systems were present. Newly formed bone surrounded the hydroxyapatite particles that appeared to be partially resorbed and substituted by new bone (Fig. 9). No inflammatory cell infiltrate was present around the particles or at the bone-biomaterial interface. No gaps were present at the bone-particle interface, and the bone was always in close contact with the particles. Sometimes, osteoblasts were observed near the hydroxyapatite particles. Histomorphometry showed that the percentage of newly formed bone was 32% ± 2.5%, marrow spaces 40% ± 1.6%, and residual hydroxyapatite was 34% ± 1.6%.

Discussion

Sinus augmentation procedures can be successfully used for implant supported restorations in the posterior atrophic maxilla when the residual bone is ≤5 mm. This study is consistent with other studies in that all the tested materials showed bone formation and no presence of inflammatory cell infiltrate.68–76 Close contact among most of the materials and the newly formed osseous tissue was present.

Autologous bone appears to be the best type of graft used in orthopedics, and is the most predictable and successful material available.9,77,78 The main problem concerning the use of autologous bone is its availability; for this reason, many other types of materials have been used as substitutes of autologous bone.8 Demineralized freeze-dried bone has been widely used, and it has been biocompatible, osteoconductive, and slowly resorbable.79 The particles of DFDBA located near preexisting bone are surrounded by newly formed bone, while particles at a distance show scarce remineralization and new bone formation. It has been suggested that the combined use of DFDBA with other biomaterials can give a more advantageous result.75

Biocoral® has been shown to be degradable. The degradation appears to be related to the amount of porosity of the coral, and it may take 2 forms: dissolution at the surface or resorption by macrophages and multinucleated giant cells.80,81 From a physical point of view, Biocoral® seems similar to β-TCP, porous hydroxyapatite, and resorbable hydroxyapatite, but the chemical composition of Biocoral® is different from these other bone replacement materials.80,82 Biocoral® is natural in a calcium carbonate form, which may be useful for bone formation, while other materials may need a transformation of the surface layer from hydroxyapatite to carbonate to start the bone formation process.81 Moreover, Biocoral® is easy to handle, resorbable, and has the potential to improve bone regeneration, without evoking an inflammatory infiltrate or fibrous encapsulation.83,84

Bioglass® has the potential to promote bone regeneration, does not evoke an inflammatory infiltrate or fibrous encapsulation, and slowly resorbs.85,86 When exposed to tissue fluids, bioactive glasses are covered by a double layer composed of silica gel and a calcium-phosphorous rich layer.86 The latter has bioactive properties and may promote osteogenesis, allowing rapid formation of bone.

The grafting material Fisiograft® is a synthetic resorbable sponge composed of a 50–50 lactide-glycolide polymer, and it has the fastest degradation rate of the D-L lactide-glycolide materials, with the polymer degrading in about 50–60 days. This material has a low density, and complete absorption occurs between 4 and 8 months. It has been successfully used as a space filler, inducing newly formed bone similar to the surrounding osseous tissue and showing the fastest degradation rate.87,88

Many of the materials are engineered to be porous, and bone can form inside the graft particles as well as between the particles.89 PepGen P-15TM is a combination of a natural anorganic bovine-derived hydroxyapatite matrix and synthetic cell-binding peptide. The particles have enhanced bone formation in periodontal and osseous defects.90–92 In this study, they show signs of resorption and appear almost completely surrounded by lamellar bone.

Calcium sulfate is easy to handle, resorbable, and can be considered a bioactive material that promotes the migration of osteoprogenitor cells and does form new bone through the intermediate calcium phosphate-rich layer.50,93 Cement and granule formulation can be used, and both have revealed good results because the granular form is resorbed slower than the cement one.51 In some cases, it can be very advantageous to use a material that shows very little degradation, such as Bio-Oss®.94 It is constituted by a calcium-deficient carbonate apatite with a crystal size of about 10 nm, and this material is identical to human bone from a chemical and physical point of view.56

Bio-Oss® has a compressive strength of 35 Mpa, and its porous nature (75% of the total volume) serves to increase highly the surface area of the material.55 This increased surface area provides a substratum for an increased angiogenesis and represents a scaffold for bone formation. When Bio-Oss® is used, bone grows upward from the preexisting bone at the sinus floor into the grafted area, maintaining the space, helping to prevent the unwanted early resorption, and not showing inflammatory reaction. The success of Bio-Oss® for maxillary sinus augmentation has been confirmed in a long-term study.95 Recently, a study has shown that the new porous hydroxyapatite Fingranule® has a possible osteogenetic role attracting circulating biocomponents (bone sialoprotein and osteopontin) at sites of tissue repair, thus promoting bone regeneration.63

Histologic evaluation of the newly formed tissues in sinus augmentation procedures will be very helpful in understanding issues like the nature and amount of newly formed bone and the grafting material that remains. A considerable variation in the quality and quantity of newly formed bone in sinus augmentation procedures has been reported in the literature in relation to the type of grafting material and time of the biopsy. Previous studies have shown that, sometimes, a very poor quality of bone was obtained, even after several months of healing. This study shows that all tested materials can be used as graft in maxillary sinus augmentation procedures, and appeared to be well tolerated in all cases and highly biocompatible. At the observed time, the histomorphometric results showed that differences among the materials related to the amount of marrow spaces and residual graft material more than new bone formation. However, apart from autogenous bone, a slightly higher percentage of newly bone formation was observed with Biocoral®, calcium sulfate, and Bio-Oss®. Newly formed bone after Fisiograft® placement was highly trabecular, showing many marrow spaces and the fastest degradation rate.

Conclusions

Many important questions regarding the predictability of sinus augmentation procedures remain unanswered. However, with our study, we may confirm that different materials can be safely used, and, depending on the needs and preference of the clinician, the choice should be directed to one or the other. In each case, selection of the appropriate biomaterial has to be performed knowing its properties and ultimate fates, considering advantages and disadvantages, and keeping in mind that we may expect predictable results and clinical success.

Acknowledgments

This work was partially supported by the National Research Council (C.N.R.), Rome, Italy, the Ministry of Education, University and Research (M.I.U.R.), Rome, Italy, and AROD (Research Association for Dentistry and Dermatology), Chieti, Italy.

Disclosure

Dr. Adriano Piatelli and Dr. Marco Degidi lecture or present materials on behalf of Dentsply Friadent Ceramed, whose product, PepGen P-15TM, is mentioned in this article. Dr. Gabriele Pecora lectures or presents materials on behalf of ClassImplant, whose product, Surgiplaster P-30, is mentioned in this article. Dr. Carlo Mangano lectures or presents materials on behalf of Angipore, whose products are mentioned in this article. All other authors claim to have no financial interest in any company or any of the products mentioned in this article.

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Abstract Translations

GERMAN

AUTOR(EN): Antonio Scarano, D.D.S., M.D.,* Marco Degidi, M.D., D.D.S.,**, Giovanna Iezzi, D.D.S., Ph.D.***, Gabriele Pecora, M.D., D.D.S.#, Maurizio Piattelli, M.D., D.D.S.##, Giovanna Orsini, D.D.S., Ph.D.###, Sergio Caputi, M.D., D.D.S.+, Vittoria Perrotti, D.D.S., Ph D.++, Carlo Mangano, M.D., D.D.S.+++, Adriano Piattelli, MD, DDS ˆ * Mitglied des Forschungsteams, zahnmedizinische Fakultät, Universität von Chieti-Pescara, Italien. **Gastprofessor, zahnmedizinische Fakultät, Universität von Chieti, privat praktizierender Arzt, Bologna, Italien. ***Studentin, Mitarbeiterin des Forschungsteams, zahnmedizinische Fakultät, Universität von Chieti-Pescara, Italien. #Privat praktizierender Arzt, Rom, Italien. ##A.O. Professor, zahnmedizinische Fakultät, Universität von Chieti-Pescara, Italien. ###Studentin, zahnmedizinische Fakultät, Universität von Chieti-Pescara, Italien. + Professor, zahnmedizinische Fakultät, Universität von Chieti-Pescara, Italien. ++Studentin, zahnmedizinische Fakultät, Universität von Chieti-Pescara, Italien. +++Privat praktizierender Arzt, Gravedona (Como), Italien. ˆ Professor, zahnmedizinische Fakultät, Universität von Chieti-Pescara, Italien. Schriftverkehr: Prof. Adriano Piattelli, M.D., D.D.S., Via F. Sciucchi 63, 66100 Chieti, (Italien). Fax: 011-39-0871-3554076, eMail:[email protected]

Aufbau des Oberkiefersinus durch Zuhilfenahme verschiedener Biomaterialien: eine vergleichende histologische und histomorphometrische Studie am Menschen

ZUSAMMENFASSUNG:Zielsetzung: Die Wiederherstellung des zahnlosen hinteren Oberkiefers mittels Zahnimplantaten kann sich aufgrund unzureichend vorhandenem Knochenvolumen schwierig gestalten. Dieser Mangel kann durch Pneumatisation des Oberkiefersinus sowie durch Resorption des des Kammknochens hervorgerufen werden. Unterschiedliche Biomaterialien wurden zur Sinusanreicherung eingesetzt. Zielsetzung der Studie war die Ermittlung eines Vergleichs der verschiedenen Materialien bei Anwendung zum Sinusaufbau beim Menschen. Methoden: Insgesamt nahmen 94 Patienten an dieser Studie teil. Zu den Teilnahmekriterien gehörten teilweise (einseitig oder beidseitig) Zahnlosigkeit im Oberkiefer inklusive der Prämolar-/Molarbereiche sowie ein Vorkommen an Kammknochen zwischen Sinusboden und alveolarem Kamm von 3 bis 5 mm. Alles in allem wurden 362 Implantate eingepflanzt und 9 verschiedene Biomaterialien wurden zur Aufbaubehandlung des Sinus eingesetzt. Bei jedem Patienten wurde nach 6 Monaten eine Biopsie durchgeführt. 144 Proben wurden insgesamt entnommen. Ergebnisse: Bei keinem der 94 Patienten traten Komplikationen auf. Alle Implantate verhielten sich stabil, eine Röntgenuntersuchung wies dichtes Knochengewebe rund um die Implantate herum auf. Der durchschnittliche Nachuntersuchungszeitraum betrug 4 Jahre. Sieben Implantate versagten. Histologische Untersuchungen zeigten, dass fast alle Partikel der verschiedenen Biomaterialien (autologes Knochengewebe, DFDBA, Biocoral, Bioglass, Fisiograft, Pep-Gen P-15, Kalziumsulfat, Bio-Oss und Hydroxylapatit) von Knochengewebe umlagert waren. Einige Biomaterialien erwiesen sich als besser resorbierbar als andere. Mit eingeschlossen waren dabei die histomorphometrisch erschlossenen Eigenschaften des neu gebildeten Knochengewebes um die verschienen transplantierten Partikel. Schlussfolgerung: Alle untersuchten Biomaterialien waren biokompatibel und schienen die Bildung neuen Knochengewebes in der Anhebungsprozedur des Oberkiefersinus zu fördern. Es gab keinerlei Anzeichen für Entzündungen. Die Ergebnisse sind aufgrund der gro[gerds]en Anzahl erfolgreich behandelter Patienten sowie der in den Proben nachgewiesenen guten Qualität des neu gebildeten Knochengewebes sehr ermutigend.

SPANISH

AUTOR(ES): Antonio Scarano, D.D.S., M.D.,* Marco Degidi, M.D., D.D.S.,**, Giovanna Iezzi, D.D.S., Ph.D.***, Gabriele Pecora, M.D., D.D.S.#, Maurizio Piattelli, M.D., D.D.S.##, Giovanna Orsini, D.D.S., Ph.D.###, Sergio Caputi, M.D., D.D.S.+, Vittoria Perrotti, D.D.S., Ph D.++, Carlo Mangano, M.D., D.D.S.+++, Adriano Piattelli, MD, DDS ˆ *Investigador, Facultad de Odontología, Universidad de Chieti-Pescara, Italia. ** Profesor Visitante, Facultad de Odontología, Universidad de Chieti, Práctica Privada, Bologna, Italia; ***Estudiante, Ayudante de Investigación, Facultad de Odontología, Universidad de Chieti-Pescara; #Práctica Privada, Roma, Italia; ## Profesor Asociado, Facultad de Odontología, Universidad de Chieti-Pescara; ###Estudiante, Facultad de Odontología, Universidad de Chieti-Pescara; +Profesor, Facultad de Odontología, Universidad de Chieti-Pescara; ++Estudiante, Facultad de Odontología, Universidad de Chieti-Pescara; +++Práctica Privada, Gravedona (Como), Italia; ˆ Profesor, Facultad de Odontología, Universidad de Chieti-Pescara. Correspondencia a: Prof. Adriano Piattelli, M.D., D.D.S., Via F. Sciucchi 63, 66100 Chieti, (Italy). Fax:011-39-0871-3554076, Correo electrónico:[email protected]

Aumento del seno maxilar con diferentes biomateriales: Un estudio comparativo histológico e histomorfométrico en hombres

ABSTRACTO: Objetivo: La rehabilitación de la maxila posterior edentulosa con implantes dentales puede resultar difícil por el volumen insuficiente de hueso debido a la neumatización del seno maxilar y reabsorción del hueso crestal. Se han usado diferentes biomateriales para el aumento del seno. El objetivo del estudio fue comparar diferentes materiales en el aumento del seno maxilar en hombres. Métodos. Un total de 94 pacientes participaron en el estudio. El criterio de inclusión fue el edentulismo maxilar parcial (unilateral o bilateral) incluyendo las áreas molares y premolares, presencia de un hueso crestal de 3 a 5 mm entre el piso del seno y el borde alveolar. Se insertaron un total de 362 implantes. Se usaron un total de 9 biomateriales en los procedimientos de aumento de seno. Cada paciente completó una biopsia después de 6 meses. Se recuperaron un total de 144 especimenes. Resultados. Ninguno de los 94 pacientes sufrió complicaciones. Todos los implantes eran estables y las radiografías demostraron un denso hueso alrededor de los implantes. El seguimiento medio fue de 4 años. Siete implantes fallaron. Los resultados histológicos demostraron que casi todas las partículas de los diferentes biomateriales (hueso autólogo, DFDBA, Biocoral, Bioglass, Fisiograft, Pep-Gen P-15, sulfato de calcio, Bio-Oss, e hidroxiapatita) estaban rodeados por hueso. Algunos materiales eran más reabsorvibles que otros. Se incluyen las características clarificadas de la histomorfometría del hueso recientemente formado alrededor de las diferentes partículas injertadas. Conclusiones. Todos los materiales examinados resultaron ser biocompatibles y parecen mejorar la formación de nuevo hueso en la elevación del seno maxilar. No se notó ninguna indicación de inflamación. Los datos son prometedores debido al alto número de pacientes tratados exitosamente y la buena calidad del hueso que se encontró en las muestras obtenidas.

PORTUGUESE

AUTOR(ES): Antonio Scarano, Cirurgião-Dentista, Médico* Marco Degidi, Médico, Cirurgião-Dentista**, Giovanna Iezzi, Cirurgião-Dentista, Ph.D.***, Gabriele Pecora, Cirurgião-Dentista, Cirurgião-Dentista#, Maurizio Piattelli, Médico, Cirurgião-Dentista##, Giovanna Orsini, Cirugião-Dentista, Ph.D.###, Sergio Caputi, Médico, Cirurgião-Dentista+, Vittoria Perrotti, Cirurgião-Dentista, Ph D.++, Carlo Mangano, Médico, Cirurgião-Dentista+++, Adriano Piattelli, Médico, Cirurgião-Dentista ˆ. * Pesquisador, Faculdade de Odontologia, Universidade de Chieti-Pescara, Itália. **Professor Visitante, Faculdade de Odontologia, Universidade de Chieti, Clínica Particular Bologna, Itália; ***Estudante, Bolsista-Pesquisador, Faculdade de Odontologia, Universidade de Chieti-Pescara; #Clínica Particular, Roma, Itália; ## Professor Associado, Faculdade de Odontologia, Universidade de Chieti-Pescara; ### Estudante, Faculdade de Odontologia, Universidade de Chieti-Pescara; +Professor, Faculdade de Odontologia, Universidade de Chieti-Pescara; ++Estudante, Faculdade de Odontologia, Universidade de Chieti-Pescara; +++Clínica Particular, Gravedona (Como), Itália; ˆ Professor, Faculdade de Odontologia, Unviersidade de Chieti-Pescara. Correspondência para: Prof. Adriano Piattelli, M.D., D.D.S., Via F. Sciucchi 63 66100 Chieti, (Italy). Fax:011-39-0871-3554076, e-Mail:[email protected]

Aumento da cavidade maxilar com biomateriais diferentes: Estudo comparativo, histológico e histomorfométrico, no homem

RESUMO: Objetivo: A reabilitação da maxila posterior desdentada com implantes dentários pode ser difícil por causa de insuficiente volume de osso devido à pneumatização da cavidade maxilar e reabsorção do osso da crista. Biomateriais diferentes foram usados para o aumento da cavidade. O objetivo do estudo foi comparar materiais diferentes no aumento da cavidade maxilar no homem. Métodos: Um total de 94 pacientes participaram deste estudo. Os critérios de inclusão foram desdentamento maxilar parcial (unilateral ou bilateral) envolvendo as áreas pré-molares/molares, presença de 3-5 mm de osso da crista entre a superfície da cavidade e o rebordo alveolar. Um total de 362 implantes foram inseridos. Um total de 9 biomateriais foram usados nos procedimentos de aumento da cavidade. Cada paciente passou por uma biópsia após 6 meses. Resultados. Nenhum dos 94 pacientes mostrou complicações. Todos os implantes estavam estáveis e exames de raio-x mostraram osso denso em torno dos implantes. O acompanhamento médio foi de 4 anos. Sete pacientes falharam. Os resultados histológicos mostraram que quase todas as partículas dos diferentes biomateriais (osso autólogo, DFDBA, Biocoral, Bioglass, Fisiograft, Pep-Gen P-15, Sulfato de cálcio, Bio-Oss, e Hidroxiapatita) foram circundadas por osso. Alguns biomateriais eram mais reabsorvíveis do que outros. Estão incluídas as características histomorfométricas do osso recém-formado em torno das diferentes partículas enxertadas. Conclusão: Todos os biomaterias examinados resultaram em serem biocompatíveis e parecem melhorar a formação de osso novo na elevação da cavidade maxilar. Nenhum sinal de inflamação estava presente. Os dados são muito encorajadores por causa do alto número de pacientes tratados com sucesso e a boa qualidade encontrada nos espécimes recuperados.

JAPANESE

FU2-15
Figure:
No caption avaliable.
Keywords:

maxillary sinus augmentation; biomaterials; histology

© 2006 Lippincott Williams & Wilkins, Inc.