IMMEDIATE IMPLANT PLACEMENT BY USING

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1 IMMEDIATE IMPLANT PLACEMENT BY USING BONE-ALBUMIN ALLOGRAFT AND CONCEN- TRATED GROWTH FACTORS (CGFS): PRELIMINARY RESULTS OF A PILOT STUDY F. INCHINGOLO 1#, A. BALLINI 2,3,4,5#, P.G. GEORGAKOPOULOS 1,4, A.D. INCHINGOLO 1, S. TSANTIS 5, D. DE VITO 2, S. CANTORE 2,3,5#, I.P. GEORGAKOPOULOS 1,4 #, G. DIPALMA 2,3,5# 1 1 Deprtment of Interdisciplinry Medicine, School of Medicine, University of Bri Aldo Moro, Bri, Itly 2 Deprtment of Bsic Medicl Sciences, Neurosciences nd Sense Orgns, University of Bri Aldo Moro, Bri, Itly 3 City Unity College, Athens, Greece 4 World Acdemy of Growth Fctors & Stem Cells in Dentistry, Athens, Greece 5 BPP University, Fculty of Dentistry, Birminghm, United Kingdom # These Authors eqully contriuted SUMMARY The provision of structurl se nd soft tissue support in dentl implntology still remins complex tsk. In the present study new technique ws introduced, which employs Bone-Alumin llogrft nd Concentrted Growth Fctors (CGFs) integrted in 1-stge immedite implnt plcement. The llogrft is trnsformed from cuic to cylindricl shpe y mens of one cutting forceps, followed y centrl osteotomy for screwing the implnt within the llogrft. The implnt/grft comintion promotes grft union, increses dentl stility nd minimizes grft resorption. The successful outcome of the proposed technique is evluted y mens of clinicl nd rdiogrphic dt. In conclusion, the proposed method provides successful immedite dentl implnttion in terms of osseo-integrtion, stility nd esthetic results. Key words: one-lumin llogrft, concentrted growth fctors, immedite implnt plcement. Introduction Implnt primry stility is considered s the key fctor towrds successful dentl implnttion (1, 10). It cn e simulted to implnt nchoring inside the one. The implnt site must e surrounded y oth hrd nd soft tissues tht re comptile to ech other, to succeed in the rpid osseointegrtion of the inserted implnt. The mount nd nture of these dditionl fctors, especilly in res with lrge one deficiency, ply n importnt role towrds more stle nd esthetic results for the ptient (11, 18). The im of the present study ws to evlute new surgicl technique for immedite dentl implnttion employing Bone-Alumin llogrft (OrthoSer Products, Austri) nd Concentrted Growth Fctors (CGF), y mens of precise nd evluted protocol. Mterils nd methods A 32-yer-old mn referred persistent pin t tooth re #22. Following clinicl nd rdiogrphic (pnormic scns) evlution, tooth ORAL & Implntology - Anno XI - N. 1/

2 Figure 1 () Pre-opertive clinicl imge re #22, () clinicl imge of frctured tooth fter extrction. frcture (Figure 1) in this re ws determined s the cuse of the pin. After consulttion with the dentist conducting this study, the ptient chose the tooth extrction nd surgicl implnt solution y mens of immedite implnt plcement with simultneous one llogrft (Cncellous lock) nd CGF employment. He ws informed of the requirements for prticiption in this cse study nd written informed consent ws otined. Providine-iodine solution (Betdine) hs een employed extr-orlly for microil disinfection of the surgicl site. The frctured tooth extrction (Figure 1) nd dentl implnttion ws performed -trumticlly under locl nesthesi (2% lidocine solution, epinephrine 1: ). Preopertive nd postopertive ntiiotic ws dministrted orlly (Augmentin) every 8 hours from surgery dy until 7 dys lter. Additionl decontmintion within the post-extrction surgicl re ws employed using ND-Yg lser followed y etdine nd norml sline wsh (Figure 2). Additionl visul inspection t the surgicl re nd surrounding one ws followed to ensure successful trumtic removl. Any soft tissue remnnts in the extrction socket were crefully removed to ensure complete removl of ll contminted tissues. Depth mes- urement ws then employed for implnt size selection nd Bone-Alumin dpttion ccording to the corresponding extrction socket dimensions (Figure 2). CGF with Stem Cells Cd34+ Preprtion Initilly, lood ws pinched from the ptient with eight sterile tues of 9ml volume. Then immedite centrifugtion ws performed with Medifuge Benchtop centrifuge device (Silfrdent srl, St. Sofi, Itly) for pproximtely 14 minutes. Blood frctiontion derived from centrifugtion from top to ottom (Figure 3) comprises: 1. Upper component tht contins Serum (lood plsm without firinogen nd cogultion fctors). 2. Interim components tht consists of lrge nd dense polymerized firin uffy cot divided in two distinct intermedite su-components: () the upper Pltelet Poor Plsm (PPP), nd () the lower firin rich gel with ggregted pltelets nd concentrted growth fctors (CGF). 48 ORAL & Implntology - Anno XI - N. 1/2018

3 Figure 2 () Surgicl re post-extrction decontmintion with ND-Yg lser, () depth mesurement mde towrds implnt size selection nd Bone-Alumin dpttion. 3. The lower component which is the red lood cell portion (RBC). The mjority of growth fctors nd stem cells CD34+ re minly ggregted etween CGF nd the upper 3-4 mm of red lood cells (RBC) portion (Figure 3). It hs een shown tht CD34 positive cells exist on oth lyers recording higher numer in the CGF lyer due to the CGF network composition in which the cells re trpped (15-25) CGF nd CD34+ re isolted from the red corpuscles employing scissors (Figure 3c) to derive the CGF-CD34+ mtrix (Figure 3d). Bone-Alumin (Cncellous Block) Preprtion nd modifiction The Bone-Alumin llogrft employed in this study is depicted in Figure 4. Its dimensions were 10x10x20 mm. A series of implnt drills with incresing dimeters ws susequently utilized to modify the grft s centrl osteotomies ccording to the finl implnt dimeter to e plced in the center of the llogrft. The drill dimeters from lower to higher were: 2.1 mm, 3 mm, 3.5 mm nd 4 mm. The Bone- Alumin grft dimensions were crefully trnsformed from cuic to cylindricl y mens of one cutting forceps, for n optimum insertion in the osteotomy site (Figure 4c). The osteotomies previously crried out corresponded to n possile plcement of Durvit EV 4 mm L. 14 implnt with ggressive tretments (B&B Dentl Itly) (Figure 4d). The trnsformed Cncellous 2 Allogrft C2A nd the implnt were individully emedded nd immersed into the Liquid Phse of the Concentrted Growth Fctors (LPCGF) to form n utologous ioctive memrne on their surfces nd to enhnce the osseointegrtion procedure. LPCGF ws derived y squeezing the CGF-CD34+ mtrix with the CGF-forceps (Silfrdent, Itly) (Figure 4d) (10). ORAL & Implntology - Anno XI - N. 1/

4 c d Figure 3 () Four lood components fter centrifugtion Serum PPP CGF RBC, () Sterile tues fter centrifugtion, (c) Seprtion of the dense pltelet-rich cogultion smple using scissors, (d) the CGF-CD34+ mtrix. 50 ORAL & Implntology - Anno XI - N. 1/2018

5 c d Figure 4 () Allogrft Bone-Alumin, () centrl osteotomies corresponding to the dimeter for implnt to e plced (c) cuic to cylindricl trnsformtion, (d) C2A emedded with implnt into LPCGF immersion. Implnt surgery The CGF mtrix, creted in the previous process of lood centrifugtion, ws plced within the osteotomy site y mens of firin injector (Silfrdent-Itly), which proved to e gret tool for the swift insertion of the firin gel lock (Figure 5, ). The CGF mtrix relese liquid growth fctors within the site prior to implnt/c2a plcement. Additionl CGF- CD34+ gel is pplied to fill ny oserved gps found etween C2A nd the implnt (Figure 5c). The cylindriclly trnsformed C2A together with ORAL & Implntology - Anno XI - N. 1/

6 c d Figure 5 (), () CGF mtrix insertion within osteotomy site with firin injector, (c) implnt/grft gps coverge with CGF-CD34+ gel (d) Implnt/C2A plcement into extrction socket. the implnt were then fitted in the extrction socket. Minor contour djustments were necessry to ensure dpttion nd stility (Figure 5d). A CGF iologicl memrne is then prepred with the specil Silfrdent pincers (Figure 6) nd sutured in order to sel the opertion site y mens of 3/0 surgicl sutures (Figure 6). This procedure provides continued soft tissue support nd minimizes postopertive edem. 52 ORAL & Implntology - Anno XI - N. 1/2018

7 c Figure 6 () CGF Biologicl memrne preprtion with the specil Silfrdent pincers, () CGF mtrix insertion within osteotomy site CGF iologicl memrne, (c) surgicl suture within the opertion site to sel it. Results The implnt is osseo-integrted. At the follow up pnormic rdiogrph fter six (6) months the improvement in the overll lveolr one height nd surrounding soft tissue in the opertion site is pprent (Figure 7). No signs of infection were oserved round the implnt s one interfce. The postopertive (6 months) pnormic rdiogrph (down) depicts the incresed crestl one height gined y the utiliztion of C2A nd CGF round the implnt. In the sme rdiogrph the new generted one surrounding the cervicl prt of the implnt is lso shown. The high lumin concentrtion, tht comprises the Cncellous Block comined with the regenertive properties of CGF, provides the ility of stem cells to grow nd therefore the growth of the new tis- ORAL & Implntology - Anno XI - N. 1/

8 Figure 7 () Preopertive pnormic rdiogrph (up) showing frctured tooth t re #22, () postopertive (6 months) pnormic rdiogrph (down). sue, s well. In ddition, the specil properties of Bone-Alumin llogrft induce the restructuring procedure filling the whole cvity nd slowly forming new one tissue round the grft/implnt. Discussion Ptients hving ilterl gps on the implnt coronl plne or ptients with res hving smll crestl one height cn e ddressed successfully y n immedite implnt plcement descried within this study (12, 15, 18-20). The proposed method sed on C2A nd CGF provides dditionl stility of the implnt t the crestl region y screwing the implnts to the trnsformed C2A nd immersing oth in LPCGF prior to the precise fitting within the extrction socket (10-19). The simultneous utiliztion CGF-CD34+ gel nd CGF iologicl memrne enhnces the soft tissue regenertion procedure providing good esthetic result. The Bone-Alumin llogrft cn e formed into ny desired dimension, regrd- 54 ORAL & Implntology - Anno XI - N. 1/2018

9 less of the dimensions of the extrction socket, to optimize its iomechnicl properties. The implnt/c2a comintion promotes grft union nd minimizes grft resorption. In conclusion, the proposed method provides successful immedite dentl implnttion in terms of osseointegrtion, stility nd esthetic results. References 1. Aghloo TL, Moy PK. Which hrd tissue ugmenttion techniques re the most successful in furnishing ony support for implnt plcement? Int J Orl Mxillofc Implnts. 2007;22(suppl): John V, De Poi R, Blnchrd S. Socket preservtion s precursor of future implnt plcement: review of the literture nd cse reports. Compend Contin Educ Dent. 2007;28: ; quiz 54, Cmpelo LD, Cmr JR. Flpless implnt surgery: 10-yer clinicl retrospective nlysis. The Interntionl Journl of Orl & Mxillofcil Implnts. 2002;17(2): Georgkopoulos IP, et l. A cse-study of Seven Implnts Plced in the Mxillry Sinus With Intentionl Schneiderin s Memrne Perfortion. Journl of Implnt nd Advnced Clinicl Dentistry. 2014;6(1): Mrrelli M, Puji A, Plmieri F, Gtto R, Flisi G, Grgri M, Cruso S, Apicell D, Rstelli C, Nrdi GM, Pduno F, Ttullo M. Innovtive pproch for the in vitro reserch on iomedicl scffolds designed nd customized with CAD-CAM technology. Int J Immunopthol Phrmcol Dec;29(4): Epu 2016 Apr Mrrelli M, Flisi G, Apicell A, Apicell D, Amnte M, Cielo A, Bonnome L, Plmieri F, Sntcroce L, Ginnini S, Di Frizio E, Rstelli C, Grgri M, Cud G, Pduno F, Ttullo M. Behviour of dentl pulp stem cells on different types of innovtive mesoporous nd nnoporous silicon scffolds with different functionliztions of the surfces. J Biol Regul Homeost Agents Oct-Dec;29(4): Ttullo M, Mrrelli M, Flisi G, Rstelli C, Plmieri F, Grgri M, Zvn B, Pduno F, Bengino V. Mechnicl influence of tissue culture pltes nd extrcellulr mtrix on mesenchyml stem cell ehvior: A topicl review. Int J Immunopthol Phrmcol Mr;29(1): Cntore S, Bllini A, Mori G, Diello V, Mrrelli M, Mirgldi R, De Vito D, Ttullo M. Anti-plque nd ntimicroil efficiency of different orl rinses in 3-dy plque ccumultion model. J Biol Regul Homeost Agents Oct-Dec;30(4): Bllini A, Mstrngelo F, Gstldi G, Tettmnti L, Bukvic N, Cntore S, Cocco T, Sini R, Desite A, Gherlone E, Sccco S. Osteogenic differentition nd gene expression of dentl pulp stem cells under lowlevel lser irrdition: good promise for tissue engineering. J Biol Regul Homeost Agents Oct- Dec;29(4): Bllini A, Cntore S, Frronto D, Cirulli N, Inchingolo F, Pp F, Mlcngi G, Inchingolo AD, Diplm G, Srdro N, Lippolis R, Sntcroce L, Cosci MF, Pettini F, De Vito D, Sccco S. Periodontl disese nd one pthogenesis: the crosstlk etween cytokines nd porphyromons gingivlis. J Biol Regul Homeost Agents Apr-Jun;29(2): Grssi FR, Ppplettere C, Di Comite M, Corslini M, Mori G, Bllini A, Crincoli V, Pettini F, Rpone B, Boccccio A. Effect of different irrigting solutions nd endodontic selers on ond strength of the dentin-post interfce with nd without defects. Int J Med Sci. 2012;9(8): doi: /ijms Epu 2012 Sep Scttrell A, Bllini A, Grssi FR, Cronr A, Ciccolell F, Dituri A, Nrdi GM, Cntore S, Pettini F. Tretment of orontrl fistul with utologous one grft nd ppliction of non-resorle memrne. Int J Med Sci Aug 11;7(5): Bllini A, Tetè S, Scttrell A, Cntore S, Mstrngelo F, Pp F, Nrdi GM, Perillo L, Crincoli V, Gherlone E, Grssi FR. The role of nti-cyclic citrullinted peptide ntiody in periodontl disese. Int J Immunopthol Phrmcol Apr-Jun;23(2): Ttullo M, Flisi G, Amnte M, et l. Dentl Pulp Stem Cells nd Humn Peripicl Cyst Mesenchyml Stem Cells In Bone Tissue Regenertion: Comprison Of Bsl And Osteogenic Differentited Gene Expression Of A Newly Discovered Mesenchyml Stem Cell Linege. J Biol Regul Homeost Agents. 2015;29(3): PMID: Ttullo M, Gentile S, Pduno F, et l. Crosstlk etween orl nd generl helth sttus in e-smokers. Medicine (Bltimore) Dec;95(49):e5589. DOI: /MD Ttullo M, Simone GM, Trullo F, et l. Antioxidnt nd Antitumor Activity of Bioctive Polyphenolic Frction Isolted from the Brewing Process. Sci Rep. 2016;6: DOI: /srep Mrrelli M, Gentile S, Plmieri F, et l. Correltion etween Surgeon s experience, surgery complexity nd the ltertion of stress relted physiologicl prmeters. PLoS One. 2014;9(11):e doi: /journl.pone Ttullo M, Mrrelli M, Sccco S, et l. Reltionship etween oxidtive stress nd urning mouth syndrome in femle ptients: scientific hypothesis. Eur Rev Med Phrmcol Sci Sep;16(9): PMID: Ttullo M, Mrrelli M, Amnte M, et l. Bioimped- ORAL & Implntology - Anno XI - N. 1/

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