Available online at www.sciencedirect.

com

British Journal of Oral and Maxillofacial Surgery 48 (2010) 121–126

Bone regeneration in sinus lifts: comparing

tissue-engineered bone and iliac bone
Pit Voss a,b,1 , Sebastian Sauerbier a,b,∗,1 , Margit Wiedmann-Al-Ahmad a,b,1 ,
Christoph Zizelmann a,b , Andres Stricker a,b , Rainer Schmelzeisen a,b , Ralf Gutwald a,b
a Department of Oral and Craniomaxillofacial Surgery (Chairman: Prof. Dr. Dr. R. Schmelzeisen, MD, DDS), University Hospital Freiburg,
Freiburg, Germany
b Universitätsklinik für Zahn-, Mund- und Kieferheilkunde, Abteilung Klinik und Poliklinik für Mund-, Kiefer- und Gesichtschirurgie,

Hugstetter Str. 55, D-79106 Freiburg, Germany

Accepted 26 April 2009

Available online 31 May 2009

Abstract

Lifting of the sinus floor is a standard procedure for bony augmentation that enables dental implantation. Although cultivated skin and mucosal
grafts are often used in plastic and maxillofacial surgery, tissue-engineered bone has not achieved the same success. We present the clinical
results of dental implants placed after the insertion of periosteum-derived, tissue-engineered bone grafts in sinus lifts. Periosteal cells were
isolated from biopsy specimens of periosteum, resuspended and cultured. The cell suspension was soaked in polymer fleeces. The cell–polymer
constructs were transplanted by sinus lift 8 weeks after harvesting. The patients (n = 35) had either one or both sides operated on. Seventeen
had a one-stage sinus lift with simultaneous implantation (54 implants). In 18 patients the implants were inserted 3 months after augmentation
(64 implants). Selected cases were biopsied. A control group (41 patients: one stage = 48 implants, two stage = 135 implants) had augmentation
with autologous bone only. They were followed up clinically and radiologically for at least 24 months. Both implants and augmentation were
significantly more successful in the control group. Failure of augmentation of the tissue-engineered bone was more common after large areas
had been augmented. Eleven implants were lost in the study group and only one in the control group. Lifting the sinus floor with autologous
bone is more reliable than with tissue-engineered transplants. Although lamellar bone can be found in periosteum-derived, tissue-engineered
transplants, the range of indications must be limited.
© 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Tissue engineering; Sinus floor elevation; Dental implants; Clinical trial; Bone substitutes; Biomaterial

Introduction For the reconstruction of bony defects of the jaws, autol-

Resorption of bone in edentulous regions often requires aug-
mentation before an implant can be inserted. In the posterior
maxilla, lifting the sinus floor is a standard procedure.
∗ Corresponding author at: Universitätsklinik für Zahn-, Mund- und
Kieferheilkunde, Abteilung Klinik und Poliklinik für Mund-, Kiefer- und
Gesichtschirurgie, Hugstetter Str. 55, D-79106 Freiburg, Germany.
Tel.: +49 761 270 4701; fax: +49 761 270 4933.
E-mail address: sebastian.sauerbier@uniklinik-freiburg.de
(S. Sauerbier).
1 These authors contributed equally.
ogous bone from the iliac crest is still the gold standard.
Its disadvantages are the limited availability of bone, and
the necessity for an additional operation under general
anaesthesia, a prolonged stay in hospital, and the risk of
postoperative pain, parasthaesia, hypersensivity, pelvic insta-
bility, and infection.1 To reduce morbidity at the donor site,
allogeneic, xenogenous, alloplastic, or composite materials
were introduced.2–6
The successful function of engineered tissues depends on
a three-dimensional arrangement of cells and the formation
of an adequate extracellular matrix. Optimised biomaterials

0266-4356/$ – see front matter © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2009.04.032
122 P. Voss et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 121–126
have been developed with differences in the size of pores,
and their permeability and durability.7,8
Chondroprogenitor and osteoprogenitor cells, with the
potential to form both cartilage and bone, have been isolated
from periosteum. Experience in animals has encouraged the
approach of transplantation of those cells within a suitable
carrier structure for the reconstruction of critically sized bony
defects.9–11
The aim of this clinical study was to evaluate the suc-
cess of augmentation and implants after lifting of the sinus
floor using tissue-engineered bone transplants and autolo-
gous bone.
Materials and methods
The trial was approved by the local Ethics Committee of the
University of Freiburg.
Patients
Between June 2001 and June 2003, 35 patients (14 male,
21 female, mean age 53 years, range 35–69) were included
in this non-randomised clinical study to evaluate the aug-
mentation of the edentulous atrophic posterior maxilla with
tissue-engineered bone before insertion of an implant. Inclu-
sion criteria were classes 4 and 5 atrophy of the posterior
maxilla as described by Cawood and Howell, and no pre-
vious medical history.12 The patients were informed about
the risks and alternative procedures, and signed a consent
form. They were free to choose between the study or control
procedure.
In 18 of the 35 patients in the study group we did a
one-stage procedure that comprised simultaneous augmen-
tation of the maxillary sinus with tissue-engineered bone
and insertion of dental implants. In these patients the resid-
ual maxillary bone was at least 4–5 mm vertically and 6 mm
transversely, to assure sufficient primary stability of the total
of 54 dental implants. The other 17 patients had a two-stage
procedure with the implant being inserted 3 months after
bony augmentation. Sixty-four implants were placed in these
patients. Fifteen of the 35 patients had both sinuses operated
on (Table 1).
Table 1
Number of implants inserted.
Transplant Procedure Total no. of implants
One stage Two stage
Tissue-engineered 54 64 118
Autologous bone 48 135 183
Number of inserted implants used in the two different protocols. In the one
stage protocol the maxillary sinus augmentation is performed simultaneously
to the implant insertion. In the two-stage procedure the sinus elevation is
performed 3 months prior to the implant insertion. As control to the tissue
engineered transplants, autologous cancellous bone was used.
In the control group 41 patients (12 male, 29 female, mean
age 55 years, range 38–73) had augmentation with autologous
bone that had been harvested from the iliac crest. Implants
were placed simultaneously (n = 48) or in a second operation
(n = 135). A double-sided sinus lift was done in 22 patients,
and a one-sided augmentation in 19.
Tissue engineering of autologous bone
Periosteal cells were isolated from a biopsy of periosteum
1 cm × 1 cm of the mandibular angle in outpatients under
local infiltration anaesthesia. According to the principles of
Good Manufacturing Practice, the entire procedure, including
harvesting of the periosteum, cell cultivation, and transplan-
tation of the tissue-engineered graft, was done under sterile
conditions as described before.10
The osteogenic phenotype was proved by the manufac-
turer (BioTissue Technologies, Freiburg, Germany) before
the cells were transferred to the polymer fleeces (Ethisorb® ,
Ethicon, Norderstedt, Germany). Vitality of the cells was
confirmed by live-dead staining.
Eight weeks after the periosteal grafts had been harvested
they were transplanted in combination with a sinus lift.
Surgical technique
All the patients in the control group were operated on under
general anaesthesia with nasal intubation. Thirty-one of the
35 operations in the study group were done under local anaes-
thetic.
The procedure was as described by Boyne and James.2
Perforations of the Schneiderian membrane were covered
with an equine collagen membrane (Tissue foil, Baxter, Hei-
delberg, Germany).
Dental implants (Straumann SLA® , Waldenburg, Switzer-
land) were inserted simultaneously or in a staged procedure.
The minimum height of bone required for simultaneous inser-
tion was 4–5 mm.
In the control group the cancellous bone was harvested
with a trephine drill from the iliac crest. The cell-matrix
construct (BioSeed-Oral Bone® , BioTissue Technologies,
Freiburg, Germany) was used in the study group.
In the simultaneous procedure, the augmentation material
was first packed into the medial aspect of the cavity. Implants
were then inserted and primary stability evaluated. The aug-
mentation material was then packed and condensed into the
residual space. No membrane was used to cover the facial
defect in the sinus wall.
In the staged procedure the augmentation material was
packed into the sinus cavity that had been created (Fig. 1).
After it had been condensed, the mucoperiostal flap was
realigned and sutured. In this two-stage protocol, implants
were inserted after 15 weeks healing in both groups. In
selected cases, biopsy specimens were taken with a trephine
drill during insertion of the implant for histological evaluation
(pararosalinin azur II staining).
 P. Voss et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 121–126
Fig. 1. Insertion of a cell–polymer construct into the maxillary sinus by a
lateral approach.
After insertion of the implant, analgesics were given
and chlorhexidine gluconate mouthwash prescribed for oral
hygiene. Sutures were removed 10 days after the opera-
tion, and at that time the prostheses were relined. Patients
were asked to reduce the time that they wore dentures for
4 weeks after the operation. After 4 weeks there were no
more restrictions and patients were allowed to eat with the
relined dentures until prosthodontic treatment had been com-
pleted.
Patients were followed up clinically and radiographically
immediately after the operation, 6 weeks later, and then every
6 months.
Panoramic radiographs were obtained before sinus graft-
ing, before and after placement of the implants, and
after the final prosthodontic treatment. Panoramic radio-
graphs and paralleling technique periapical films were taken
at identical time intervals after delivery of the prosthe-
sis. Radiographs were evaluated by two specialist dental
radiologists.
The success of the implant was evaluated according to the
criteria of Albrektsson et al.13 Stable implants with no signs
of clinical or radiographic inflammation were considered to
be successful.
If the implant had failed, the interval between its insertion
and removal was noted. Success was recorded until the last
clinical and radiographic examination.
Results
Periosteal harvesting from the mandibular angle by an intrao-
ral approach under local anaesthesia was tolerated well by
the patients, and there were no complications. There were
Table 2
Comparison of one- and two-stage procedures in the study group.
Procedure
One stage (n = 18)
Secondary lift necessary 1 10
Number of patients treated with tissue engineered bone. Patients who required secondary surgery occurred more often when the two-stage protocol was applied.
123
Fig. 2. Histological evaluation showing mineralised trabecular bone (*)
with remnants of biomaterial (+). Pararasalinin and azur stain. (A) Original
magnification 6×. (B) Original magnification 50×.
no wound dehiscences after augmentation in either of the
groups.
Postoperative radiographs showed a tight implant-bone
interface in all cases after implantation.
Biopsy specimens taken during the two-stage protocol in
the study group showed mineralised trabecular bone with
remnants of biomaterial (Fig. 2A and B). Osteocytes were
apparent within the bony lacunae.
In this group, 7 patients in the two-stage protocol group
and 17 patients who had the one-stage procedure had satisfac-
tory clinical, radiological, and histological results 3 months
after augmentation. Both clinically and radiographically the
augmented sites showed good formation of new bone with
no signs of resorption compared with their original condi-
tion. In 10 patients (16 sinuses) in the two-stage group, the
biopsy specimens showed that the grafts had acquired con-
nective tissue-like consistency. The condition of 7 of these
patients was complicated by infection (Table 2).
In the study group, 62 of the implants were supplied with
single crowns (58 interlocked), 39 with bridges, and 6 with
bar constructions, after roughly 8 months. Eleven implants
were lost.
No patient of the control group required a secondary oper-
ation. Only one case of slight sinusitis developed in this
Total no. of patients in the study group
Two stage (n = 17)
11
124 P. Voss et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 121–126
Table 3
Complications.
Complication Tissue-engineered Autologous bone
bone (n = 18) (n = 17)
Sinusitis 5 1
Abscess 3 0
Loss of implant 8 1
Failure of augmentation 11 0
Table showing the complication in sinus-elevation procedures in absolute
numbers of patients.
Table 4
Augmentation materials used in the study group after failure of tissue-
engineered transplants (no of sinuses).
Cerasorb only
Autologous bone
Cerasorb and autologous bone
BioOss and autologous bone
Total no. of sinuses
In the study group, in 16 sinuses (11 patients), a second augmentation was
necessary after failure of the tissue-engineered transplants. The table shows
a list of augmentation material used in the second procedure.
group. One implant was explanted during fixation of the abut-
ment. Implants were loaded after about 5 months. Forty-one
implants carried single crowns, 106 bridges, 20 bar recon-
structions, and 15 had not been used prosthodontically up to
the date of follow up.
More augmentation procedures with BioSeed-OralBone®
showed infections than the autologous bone group (Table 3).
All these cases required an additional augmentation proce-
dure with autologous bone and bone substitutes (Table 4).
The loss of augmentation material is higher in the study group
(Fig. 3A and B).
Discussion
Surrogate bony material and growth factors have been
tested in animal models.14–16 Autologous chondroblasts and
osteoblasts, and cellular elements of hard tissue, were cul-
tured and successfully tested in animals together with several
biomatrices.17 Lee et al. noted that all matrix constructs using
calcium metaphosphate showed lamellar bone formation in
subcutaneous sites.18
Perka et al. treated critical size defects in rabbit ulnas.10
The cell–polymer construct that was used in our trial had
the best osteogenic properties in that study. Fibrin and
periosteal cells, polymers without cells, fibrin without cells,
and untreated defects, served as controls. Polymer–fibrin con-
structs without cells were therefore not tested.
Our results showed the advantage of autologous bone
over periosteum-derived cell constructs for augmentation in
the posterior maxilla, even though our study has the limi-
tation that the groups were not randomised. Nevertheless,
trabecular bone containing viable osteocytes could be con-
firmed histologically 3 months after the augmentation with
6
5
4
1
16
Fig. 3. Augmentation of the sinus floor after 3 months. (A) Computed tomo-
gram of a patient from the control group who was treated with autologous
cancellous bone from the iliac crest. (B) Computed tomogram of a patient
treated with periosteum-derived tissue-engineered bone.
tissue-engineered bone. Because of graft resorption and other
complications, the two-stage procedure had a higher rate of
additional interventions than the one-stage procedure in this
group.19 It is possible that the transplanted cells profited from
the cyclic strain conducted by the inserted implants. The
supply of the augmented cells with sufficient oxygen and
nutrients in large augmentations might be another critical
point. There was a significant loss of transplants, particularly
in patients with extended areas of augmentation who were
treated by the two-step protocol.1 The low pH that is pro-
duced while the polymer is being resorbed could also be a
factor that prevents the survival of osteoblasts.
Other possible suitable carrier materials are cur-
rently being evaluated; these include equine and bovine
bone for tissue-engineered osteoblast-like cells.20 Unlike
polylactic-co-glycolic acid and poly-l-lactide acid polymers,
xenogenic bone substitutes have high osteoconductive prop-
erties, whereas osteoblast-like cells are osteoinductive by
themselves.10
Landers et al. reported rapid prototyping technol-
ogy for three-dimensional desktop fabrication of hydrogel
scaffolds.21 The matrices have a designed external shape
and a well-defined internal pore structure and are prepared
with a surface coating that facilitates the adhesion of cells.
These scaffolds could potentially have a versatile application
beyond cell culture.
Nowadays, cell/biomatrix-constructs consist of trans-
plants from one single type of cell. At the time of
transplantation they show a low grade of differentiation. Typ-
ical characteristics of specific tissue (such as extracellular
matrix) are missing. In future, tissue engineering will be
improved in different respects, including the inclusion of vas-
cular components, and the variation of biomatrix and culture
 P. Voss et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 121–126
conditions. Further research must deal with the mechani-
cal stability of engineered bone, its possible resorption, and
its application in less vascularised environments.20,22 Bone-
inducing cytokines, as, for example, bone morphogenetic
protein, will be tested.14,23
Jaquiery et al. found that the osteogenic capacity of
periosteum-derived osteoblasts decreases when it is donated
by older patients, because of increased contamination of
periosteum-derived cell cultures by fibroblasts.24 A thick
layer of subcutaneous tissue as found in young patients prob-
ably serves as source of mesenchymal stem cells. In vitro,
these cells seem to possess more reliable osteogenic potency.
The use of a mix of mononuclear cells concentrated from
bone marrow is being evaluated by our group.25
The clinical application of cultured autologous tissue and
tissue engineering techniques are often limited by the costs.
The costs of general anaesthesia and admission to hospital
depend on the health care system, but are lower than the
cultivation costs in most cases. The costs of the applications
of cultivation are expected to decrease when they are used
for more indications, in other disciplines, and on a larger
scale.
Conclusion
This study reveals the necessity to limit the indications
for tissue-engineered bone. Because of higher infection
and resorption rates in larger augmentations, its application
should be restricted to sinuslift procedures with simultane-
ous implant insertion at sites providing sufficient bone and to
patients who cannot be operated in general anaesthesia. To
improve results, modifications are needed in cell cultivation
and carrier materials.
Acknowledgements
We thank Ute Hübner1 , Heike Jahnke2 , Annette Lindner2 and
Dr. Heiner Nagursky2 for technical assistance.
1. Cell Laboratory, Department for Oral- and Maxillofacial
Surgery, Head: Prof. Dr. Dr. R. Schmelzeisen, University
Hospital Freiburg, Germany
2. Hard Tissue Research Laboratory, Department for Oral-
and Maxillofacial Surgery, Head: Prof. Dr. Dr. R.
Schmelzeisen, University Hospital Freiburg, Germany
References
1. Schimming R, Schmelzeisen R. Tissue-engineered bone for maxillary
sinus augmentation. J Oral Maxillofac Surg 2004;62:724–9.
2. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autoge-
nous marrow and bone. J Oral Surg 1980;38:613–6.
3. Schmelzeisen R, Schimming R, Sittinger M. Making bone:
implant insertion into tissue-engineered bone for maxillary sinus
125
floor augmentation—a preliminary report. J Craniomaxillofac Surg
2003;31:34–9.
4. Stricker A, Voss PJ, Gutwald R, Schramm A, Schmelzeisen R. Maxillary
sinus floor augmention with autogenous bone grafts to enable placement
of SLA-surfaced implants: preliminary results after 15–40 months. Clin
Oral Implants Res 2003;14:207–12.
5. Valentini P, Abensur D, Densari D, Graziani JN, Hammerle C. His-
tological evaluation of Bio-Oss in a 2-stage sinus floor elevation and
implantation procedure. A human case report. Clin Oral Implants Res
1998;9:59–64.
6. Yildirim M, Spiekermann H, Biesterfeld S, Edelhoff D. Maxillary sinus
augmentation using xenogenic bone substitute material Bio-Oss in com-
bination with venous blood. A histologic and histomorphometric study
in humans. Clin Oral Implants Res 2000;11:217–29.
7. Burg KJ, Porter S, Kellam JF. Biomaterial developments for bone tissue
engineering. Biomaterials 2000;21:2347–59.
8. Thomson RC, Mikos AG, Beahm E, Lemon JC, Satterfield WC,
Aufdemorte TB, et al. Guided tissue fabrication from perios-
teum using preformed biodegradable polymer scaffolds. Biomaterials
1999;20:2007–18.
9. Fialkov JA, Holy CE, Shoichet MS, Davies JE. In vivo bone engineering
in a rabbit femur. J Craniofac Surg 2003;14:324–32.
10. Perka C, Schultz O, Spitzer RS, Lindenhayn K, Burmester GR, Sit-
tinger M. Segmental bone repair by tissue-engineered periosteal cell
transplants with bioresorbable fleece and fibrin scaffolds in rabbits.
Biomaterials 2000;21:1145–53.
11. Breitbart AS, Grande DA, Kessler R, Ryaby JT, Fitzsimmons RJ, Grant
RT. Tissue engineered bone repair of calvarial defects using cultured
periosteal cells. Plast Reconstr Surg 1998;101:567–76.
12. Cawood JI, Howell RA. A classification of the edentulous jaws. Int J
Oral Maxillofac Surg 1988;17:232–6.
13. Albrektsson T, Zarb GA, Worthington P, Eriksson AR. The long-term
efficacy of currently used dental implants: a review and proposed criteria
for success. Int J Oral Maxillofac Implant 1986;1:11–25.
14. Terheyden H, Warnke P, Dunsche A, Jepsen S, Brenner W, Palmie S,
et al. Mandibular reconstruction with prefabricated vascularized bone
grafts using recombinant human osteogenic protein-1: an experimental
study in miniature pigs. Part II. Transplantation. Int J Oral Maxillofac
Surg 2001;30:469–78.
15. Terheyden H, Knak C, Jepsen S, Palmie S, Rueger DR. Mandibular
reconstruction with a prefabricated vascularized bone graft using recom-
binant human osteogenic protein-1: an experimental study in miniature
pigs. Part I. Prefabrication. Int J Oral Maxillofac Surg 2001;30:373–9.
16. Terheyden H, Jepsen S, Moller B, Tucker MM, Rueger DC. Sinus floor
augmentation with simultaneous placement of dental implants using a
combination of deproteinized bone xenografts and recombinant human
osteogenic protein-1. A histometric study in miniature pigs. Clin Oral
Implants Res 1999;10:510–21.
17. Ishaug SL, Crane GM, Miller MJ, Yasko AW, Yaszemski MJ, Mikos
AG. Bone formation by three-dimensional stromal osteoblast culture in
biodegradable polymer scaffolds. J Biomed Mater Res 1997;36:17–28.
18. Ishaug SL, Crane GM, Miller MJ, Yasko AW, Yaszemski MJ, Mikos
AG. Tissue-engineered growth of bone by marrow cell transplantation
using porous calcium metaphosphate matrices. J Biomed Mater Res
2001;54:216–23.
19. Lee YM, Seol YJ, Lim YT, Kim S, Han SB, Rhyu IC, et al. Bone
formation after sinus augmentation with engineered bone. Clin Oral
Implants Res 2007;18:69–73.
20. Wiedmann-Al-Ahmad M, Gutwald R, Gellrich NC, Hubner U,
Schmelzeisen R. Search for ideal biomaterials to cultivate human
osteoblast-like cells for reconstructive surgery. J Mater Sci Mater Med
2005;16:57–66.
21. Landers R, Hubner U, Schmelzeisen R, Mulhaupt R. Rapid prototyping
of scaffolds derived from thermoreversible hydrogels and tailored for
applications in tissue engineering. Biomaterials 2002;23:4437–47.
22. Sittinger M, Bujia J, Rotter N, Reitzel D, Minuth WW, Burmester
GR. Tissue engineering and autologous transplant formation: practical
126 P. Voss et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 121–126

approaches with resorbable biomaterials and new cell culture tech-
niques. Biomaterials 1996;17:237–42.
23. Ebisawa K, Hata K, Okada K, Kimata K, Ueda M, Torii S, et al. Ultra-
sound enhances transforming growth factor beta-mediated chondrocyte
differentiation of human mesenchymal stem cells. Tissue Eng 2004;10:
921–9.
24. Jaquiéry C, Schaeren S, Farhadi J, Mainil-Varlet P, Kunz C,
Zeilhofer HF, et al. In vitro osteogenic differentiation and in
vivo bone-forming capacity of human isogenic jaw periosteal
cells and bone marrow stromal cells. Ann Surg 2005;242:
859–68.
25. Sauerbier S, Palmowski M, Vogeler M, Nagursky H, Al-Ahmad A, Fisch
D, et al. Onset and maintenance of angiogenesis in biomaterials: in vivo
assessment by dynamic contrast-enhanced MRI. Tissue Eng Part C:
Methods 2009 [e-pub ahead of print].