Professional Documents
Culture Documents
10 December 2015
"Sticky Bone"
Use in Implant Dentistry
Dong-Seok Sohn, DDS, PhD1 • Bingzhen Huang, MD, PhD2 • Jin Kim, DDS, MS3
W. Eric Park, DDS4 • Charles C. Park DDS5
Abstract
P
latelets are known to release several tion. PRF and CGF can be used as alternative
growth factors which stimulate tissue to traditional barrier membrane over bone graft,
regeneration. Several techniques for plate- therefore acceleration of tissue regeneration is
let concentrates have been introduced in surgi- acquired. Unlike PRF using constant centrifuga-
cal field for the prevention of hemorrhage and tion speed, CGF utilizes altered centrifugation
acceleration of tissue regeneration. Platelet rich speed to produce much larger, denser and richer
plasma (PRP) and plasma rich in growth factors fibrin matrix containing growth factors. A new con-
(PRGF) belong to the first generation of platelet cept of fabricating growth factors-enriched bone
concentrates. PRP and PRGF require chemical graft matrix (also known as “sticky bone”) using
additives such as anticoagulants and thrombin autologous fibrin glue has been demonstrated
or calcium chloride to induce fibrin polymeriza- since 2010. Sticky bone provides stabilization
tion before applying to the surgical site. Platelet of bone graft in the defect, and therefore, accel-
rich fibrin (PRF) and concentrated growth fac- erates tissue healing and minimizes bone loss
tors (CGF), as second generation of platelet con- during healing period. This report presents the
centrate, utilizes patient’s venous blood alone to method of preparing and utilizing CGF and sticky
trigger platelet activation and fibrin polymeriza- bone, and clinical cases that support its use.
KEY WORDS: Concentrated growth factors, platelet rich fibrin, ridge augmentation,
growth factors-enriched bone graft, sticky bone. guided bone regeneration
1. Professor, Department of Dentistry and Oral and Maxillofacial Surgery, Catholic University of Daegu, Republic of Korea
3. Lecturer, UCLA School of Dentistry; Private practice, Diamond Bar, California, USA
5. Lecturer, UCLA School of Dentistry; Private practice, Orange County, California, USA
Figure 1: Patient’s venous blood taken from patients’ healing of bone graft over the bony defect, numer-
vein in patient’s forearm is divided into two types of ous techniques utilizing platelet and fibrinogen
vacutainers without anticoagulant. Non-coated test concentrations have been introduced in the litera-
tubes (yellow cap) are used to obtain AFG, which will
ture. Platelet is known to contain high quantities
make sticky bone and glass coated test tubes (red cap),
is used to obtain CGF layer.
of growth factors, such as transforming growth
factors ß-1 (TGFß-1), platelet-derived growth
factor (PDGF), epithelial growth factor (EGF),
INTRODUCTION insulin growth factor-I (IFG-I) and vascular endo-
Implant supported dental restorations have thelial growth factors (VEGF), which stimulates
become a major option in the treatment of eden- cell proliferation and up regulates angiogenesis.2-4
tulous alveolar ridge for the past several decades. Platelet rich plasma (PRP) is the first form of
Extensive loss of alveolar bone presents a com- autologous platelet concentrate to replace com-
plex challenge for reconstruction. Numerous mercial fibrin glue.5,6 Small amount of PRP is pre-
augmentation techniques are currently in use to pared in dental office for use in clinical implant
create sufficient bone volume for reliable place- dentistry. Numerous PRP kits, such as the Plate-
ment of endosseous implants in severely resorbed let Concentrated Collection System (PCCS; 3i/
edentulous alveolar ridges.1 In order to accelerate Implant Innovations, Palm Beach Gardens, FL),
SmartPReP (Harvest Autologius Hemobiolog- is drawn via venipuncture, and the blood is col-
ics, Norwell, Massachusetts), Curasan PRP lected in collection tube that contains a chemi-
kit (Curasan, Pharma Gmbh AG, Lindigstrab, cal anticoagulant. Red cell layer is discarded
Germany) and Placon (Oscotec Co, Chunan, after first centrifugation, and the buffy coat layer
Korea), are available in the current dental market. and platelet-poor plasma is collected in a new
Preparation methods for all commercially avail- test tube for second centrifugation. Concentrated
able systems are somewhat similar. Relatively platelet with fibrinogen is obtained as a result of
small amount of patient’s venous blood (8-10cc) the second spin. PRP is mixed with particulate
Figure 9: Note horizontal bone deficiency after implant Figure 10: Mineral allograft (BioTis, Bone Bank, BioTis Co,
placement. Left site shows more larger deficiency than Seoul) saturated with exudate taken from compressed CGF
right edentulous area. was grafted on the bony defect.
Case report 1: Comparison of CGF free primary suture was placed. Bone graft site
Membrane and Collagen Membrane was surgically re-entered after a 6-month heal-
A 39 year old female patient presented with ing period, and favorable ridge augmentation
missing teeth #7, #8, #9, #10. She wanted was seen at the both augmented site. To com-
implant supported fixed restoration. Prophylac- pare both augmented sites using collagen mem-
tic oral antibiotics, Cefditoren pivoxil (Meiact®; brane and CGF membrane, bone biopsy using
Boryung Parm.,Seoul, Korea) 300mg t.i.d. were 2mm wide trephine bur was taken at the buccal
used routinely, beginning one day prior to the wall of both sites (Fig 12). The specimens was
procedure and continuing for five days. Implant fixed with 4% paraformaldehyde for 24 hours,
site was exposed under local anesthesia with no and washed with 0.1M phosphoric buffered
intravenous sedation. Implants (Biocer implant, solution and decalcified with 10% formic acid
OMT GmbH, Lübeck, Germany) were placed for five days. The specimen was embedded in
at the site of tooth numbers #7, #9 and #11, paraffin (Paraplast®, Oxford, USA), and sliced
and horizontal bone deficiency was seen. Min- coronally into serial sections about 5㎛ thick. The
eral allograft (BioTis, Bobe Bank, BioTis Co, specimens were stained with Hematoxylin-Eosin
Seoul) was mixed with exudate taken from com- (H-E) stains, and examined under light micros-
pressed CGF and grafted on horizontal bony copy to verify newly-formed bone. Both speci-
defect and a collagen membrane (Pericardium, mens reveals favorable new bone formation
Zimmer Dental, CA) was covered on the right along mineral allograft without sign of inflamma-
side and two CGF membrane was covered tion (Fig 13, 14). Esthetic final results have been
on the left augmented site (Figs 9-11). Tension maintained after 2 years follow up (Figs 15-17).
Figure 11: A collagen was covered on the right augmented Figure 12: Reentry was done after a 6-month healing
site and two CGF membrane was covered on the left period. Favorable ridge augmentation was seen at the both
augmented site. augmented site. To compare both augmented sites using
collagen membrane and CGF membrane histologically,
bone biopsy core using 2mm wide trephine bur was taken
at the buccal wall of both sites.
Figure 13: Biopsy in left augmented site shows newly Figure 14: Biopsy in right augmented site shows favorable
formed bone along mineral allograft. Hematoxylin-Eosin new bone formation along mineral allograft without sign
(H-E) stains (X100). of inflammation.. Hematoxylin-Eosin (H-E) stains ( X100).
Figure 15: Esthetic final result in 2 years follow up. Figure 16: A postoperative periapical radiograph.
Figure 18: A plain radiograph reveals sever vertical bony Figure 19: Prepared sticky bone using bovine and mineral
deficiency on the right posterior mandible. allograft.
Case 2: Three Dimensional Ridge sticky bone using bovine bone (Biocera, Oscotec
Augmentation using Sticky bone with/ Co, Chunan, Korea) and mineral allograft (Puros
without Titanium Mesh allograft, Zimmer Dental, CA) was grafted over
A 45-year-old male patient with a complaint the exposed implant surface and boney defect for
of masticatory difficulty was referred from pri- 3-dimentional ridge augmentation, and resorbable
vate dental clinic for the ridge augmentation and collagen membrane (Pericardium, Zimmer Dental,
implant placement. Radiographic and clinical CA) alone was covered over the bone graft (Figs
examination revealed severe vertical and horizon- 19-22). The left edentulous ridge revealed sever
tal ridge resorption on the right mandibular eden- horizontal deficiency. Three implants were placed
tulous ridge and severe horizontal ridge deficiency at the sites corresponding to tooth numbers #18,
on the left the mandibular edentulous ridge (Fig #19, and 20 with good stability, and severe expo-
18). Sticky bone was prepared as described sure of implants was shown. Particulate bone
above before surgery (Fig 19). The surgery was graft was placed on the defect and titanium
performed under the local anesthesia through mesh (Neo implant Co, Seoul, Kora) was covered
maxillary block anesthesia by using 2% lidocaine to stabilize particulate bone graft. Three CGF
that includes 1:100,000 epinephrine. Full thick- membrane was covered over the bone graft and
ness mucoperiosteal flap was elevated to expose mesh (Figs 23-25). Implants were exposed after
the both implant sites. Right edentulous poste- 4months healing. Favorable 3-dimentional ridge
rior area showed severe vertical defect and nar- augmentation was observed on the right area
row (2-3mm wide) alveolar ridge. Three implants even titanium mesh was not used because sticky
(Dentis implant Co, Daegu, Korea) were placed bone didn’t migrate during healing period. Favor-
at the sites of tooth numbers #29, #30, and 31 able horizontal ridge augmentation was observed
with good stability. Exposure of implant surface on the left site. The patient came back to her
was shown at the site of #30 and #31. Prepared dentist for prosthetic restoration (Figs 27-29).
Figure 20: Note severe exposure of implant surface after Figure 21: Sticky bone was grafted on the exposed
implant placement and vertical bone defect. implant surface and bony defect for 3-dimentional ridge
augmentation.
Figure 22: A resorbable collagen membrane alone was Figure 23: Note sever exposure of implant surface on the
covered over the bone graft without additional bone edentulous left posterior mandible.
stabilization procedure.
Figure 24: Sticky bone was not prepared, so particulate Figure 25: Three CGF membrane was covered over the
bone graft was placed on the defect and customized bone graft and mesh to accelerate tissue regeneration.
titanium mesh (Neo implant Co, Seoul, Kora) was utilized to
stabilize particulate bone graft.
Case 3: Minimally Invasive Horizontal Ridge mentation and simultaneous implant placement.
Augmentation using Sticky Bone and Tunnel Osteoinductive replaceable bone window was
Technique prepared with a thin bladed saw insert (S-Saw,
A 49 year old female patient visited at our Bukboo Dental Co., Daegu, Korea), connected
department with complaint of masticatory dif- to piezoelectric devices (Surgybone®, Sil-
ficulty and esthetic problem. She has suffered fradent srl, Sofia, Italy) to access sinus cavity.
from chronic periodontitis in whole dentition The bony window was detached from sinus
and showed the missing of upper two central membrane and sinus membrane elevation was
incisors (Figs 30, 31). The hopeless upper performed carefully. Four pieces of CGF was
right and left lateral incisor and left canine inserted in the new compartment under the
were extracted under local anesthesia. Three elevated sinus mucosa and three implants were
implants (MIS Implant, Israel) were placed placed immediately at the sites correspond-
immediately. Labial fenestration defect was veri- ing to tooth numbers #13, #14 and #15. The
fied in the all implant sites through the vertical detached bony window was repositioned and
releasing incision which was made in buccal particulate bovine bone was grafted in the
mucosa adjacent to implant site. Sticky bone extract defect and collagen membrane was
prepared with bovine bone (Biocera, Oscotec covered over the bone graft to prevent soft tis-
Co, Chunan, Korea) and mineral allograft (Puros sue invasion and stabilize particulate bone graft
allograft, Zimmer Dental, CA) was grafted over (Figs 36-41). Immediate temporary restora-
the exposed implant surface through the verti- tion on anterior implant was delivered on
cal incision. Collagen membrane or titanium the next day. Final ceramic restoration was
mesh was not used to stabilize bone graft (Figs cemented in all implant sites after 6 months
32-35). After closing of incision area in eden- healing. The cross sectional image of cone
tulous anterior maxilla, hopeless upper right beam computed tomogram shows stable
second premolar and first and second molar bone augmentation over the exposed implant
were extracted in order to perform sinus aug- surface after 1 year loading (Figs 42-46).
Figure 30: Preoperative intraoral view reveals the missing Figure 31: Preoperative intraoral image reveals chronic
of upper two central incisors and chronic periodontitis in periodontitis with severe bone resorption in entire
whole dentition. dentition.
Figure 32: A pain radiograph reveals severe alveolar bone Figure 33: Implants were placed immediately after
resorption in entire dentition. extraction of upper right and left lateral incisor and left
canine. Dehiscence defect was detected on implant site
corresponding to right lateral incisor.
Figure 34: Labial fenestration defect was verified in Figure 35: Prepared sticky bone was grafted over the
implants corresponding to tooth number #10 and #11. exposed implant surface by tunnel technique. Any barrier
membrane was not utilized.
Figure 36: After extraction of hopeless upper right second Figure 37: Sinus membrane was elevated carefully after
premolar and first and second molar, laterally approached detachment of the bony window.
sinus augmentation was performed. Osteoinductive
replaceable bone window was prepared with a thin bladed
saw insert to access sinus cavity.
Figure 38: Four pieces of CGF was inserted in the sinus Figure 39: Particulate bovine bone was grafted in the
and implants were placed simultaneously at the site of extraction defect and collagen membrane was covered
tooth numbers of #13, #14 and #15. The detached bony over the bone graft.
window was repositioned.
Figure 42: Postoperative radiograph. Figure 43: Final ceramic restoration was cemented after 6
months healing.
Figure 44: The cross sectional image of CBCT reveals stable bone augmentation over the exposed implant surface after 1 year
loading.
ADVERTISE
nected each other by fibrin network. Sticky bone
has numerous advantages: 1) it is moldable, so
ADVERTISE WITH well adapted over various shape of bony defect;
2) Micro and macro movement of grafted bone
is prevented. So the volume of augmentation
is maintained during healing period, therefore
the need of block bone and titanium mesh is
Correspondence:
Professor Dong-Seok Sohn
Department of Oral & Maxillofacial Surgery,
Catholic University Hospital of Daegu,
3056-6 Daemyung-4 Dong,
Namgu, Daegu,
Republic of Korea
e-mail: dssohn@cu.ac.kr
WWW.JIACD.COM
Disclosure 13. Dohan Ehrenfest DM, Rasmusson L, Albrektsson 22. Gassling V, Purcz N, Braesen JH, Will M, Gierloff
The authors report no conflicts of interest with T.Classification of platelet concentrates: M, Behrens E, Acil Y, Wiltfang J. Comparison
anything mentioned in this article. from pure platelet-rich plasma (P-PRP) to of two different absorbable membranes for the
leucocyte- and platelet-rich fibrin (L-PRF).Trends coverage of lateral osteotomy sites in maxillary
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