Int Poster J Dent Oral Med 2007, Vol 9 No 03, Poster 369
Sinus Augmentation with Periosteum derived Tissue Engineered Bone
Dr. med. Sebastian Sauerbier, Dr. med. Pit Voss, Dr. med. Nils Weyer, r. med. Dr. med. dent. Jens Kuschnierz,
Dr. med. dent. Christoph Zizelmann, PD Dr. med. Dr. med. dent. Ralf Schön, Prof. Dr. med. Dr. med. dent. Ralf Gutwald,
Prof. Dr. med. Dr. med. dent. Rainer Schmelzeisen,
Department of Maxillofacial Surgery, Universitiy Hospital Freiburg
19th to 21th of Oktober 2006
AO-Biotechnology-Symposium, From basic research to clinical applications using biotechnology and bioengineering
DGZMK-Poster-Award 2008 für das beste Poster 2007
Tumors in the oral cavity cause loss of bone and soft tissue (Sauerbier et
al., 2006). More often than the reconstruction of soft tissue the
improvement of the hard tissue bearing of dentures and dental implants is
required. For the reconstruction of bone defects the gold standard is still
the autologous bone harvested from the iliac crest, the mandible or the
maxilla. Tissue-engineering procedures for hard tissue augmentations of the
maxilla offer significant advantages compared with conventional grafts, as
there is minimal or no donor site morbidity, limited availability of bone
and the necessity of an additional surgical procedure. Periosteum has been
demonstrated to have cell populations, which include chondroprogenitor and
osteoprogenitor cells, that can be isolated in tissue culture and form both
cartilage and bone. The aim of this prospective study was to evaluate the
feasibility of the clinical application of periosteum derived tissue
Material and Methods
Periosteal cells were isolated from a biopsy of periosteum of the
mandibular angle carried out as an outpatient protocol under local
anaesthesia (Fig. 1). The transplants were prepared as described by Perka et
al. (2000). After four passages the periosteal cells were trypsinized and
subsequently resuspended in DMEM/Ham's F12 (1:1) medium and mixed with human
fibrinogen (3:1, TissueColl, Baxter, Vienna, Austria). The cell suspension
was soaked into polymer fleeces (Ethicon, Norderstedt, Germany) and by
adding bovine thrombin polymerized (TissueColl, Baxter, Vienna, Austria)
diluted in PBS (1:10). Subsequently, cell polymer transplants were
cultivated for 1 week in DMEM/Ham's F12 (1:1) medium, supplemented with 5%
autologous patient serum, ascorbic acid (50 mg/l), dexamethasone
(10 -7M) and β-glycerolphosphate (10 mM). Eight weeks
after harvesting the periosteal grafts, the transplantation was performed in
combination with a sinus lift as described by Boyne and James (1980). The
tissue-engineered autologous bone was placed and condensed into the depth of
the sinus cavity (Fig. 2). The control group underwent the same procedure
except that autologous cancellous bone from the iliac crest.was used instead
of tissue engineered bone substitute. Turkey's Studentized Range Test and
the Mann-Whitney-Test were used for statistical evaluation.
|Fig. 1: Harvesting the specimen of periosteum (below V).
|Fig. 2: Insertion of a cell-polymer construct into the maxillary sinus.
|Fig. 3: The x 50 magnification reveals mineralized trabecular bone (*) with remnants of biomaterial (+).
Periosteal harvesting from the mandibular angle via an intraoral approach
under local anaesthesia was tolerated well by the patients, and throughout
the complete procedure no complications occurred. The wounds resulting from
replantation of the engineered tissue healed without complications. The
implants were inserted into the grafted areas. When the implant was inserted
primary stability was tested and proven clinically. Radiographs demonstrated
a tight implant-bone interface (Fig. 3A-C). A total number of 118 (TE) and
183 (control group, see Stricker et al. 2003) ITI implants (Straumann AG,
Waldenburg, Switzerland) were inserted into the grafted areas (Table 1).
|Table 1: Number of inserted dental Implants
All patients could be provided with fixed prosthetic rehabilitation like either
crowns and bridges or dentures. . The biopsies taken during the two-way
protocol revealed mineralized trabecular bone with remnants of biomaterial
(Fig. 3). Osteocytes were apparent within the bone lacunae. In seven
patients of the two-stage protocol group and in 17 patients if the one-stage
procedure, an excellent clinical, radiological, and histological result
could be proved 3 months after augmentation. In comparison to the initial
situation, the clinical inspection showed a good formation of new bone
without signs of resorption. This was confirmed by radiological imaging
(Fig. 4)(Zizelmann et al., 2007). In 10 patients (16 Sinus) of the two-stage
protocol group the biopsies showed that the grafts had turned into a
clinically appearing connective tissue-like consistency. In seven of these
patients the situation was complicated by infection (Table 2).
|2nd lift necessary
|Table 2: Comparison of two different techniques of application of tissue engineered bone
of augmentation procedures with BioSeed® -Oral Bone to infections as for
example sinusitis and abscess is highly significant (p=0,000). All these
cases required an additional augmentation procedure with autologous bone and
bone substitutes. Only one patient of the control group which had been
operated on just with autologous bone required secondary surgery (Fig. 5).
Also no infection was seen in this group. The loss of augmented material is
significantly higher in the group in which the tissue engineered material
was applied (p=0,000) (Fig. 6AB).
|Fig. 4a: Orthopantomogram of a 56-year-old patient with an atrophy of the left maxilla
||Fig. 4b: Postoperative radiograph after simultaneous augmentation and implantation
|Fig. 4c: 3 months later, the augmented material demonstrates beginning mineralization
|Fig. 5: Box-plot showing the complication in sinus-elevation procedures in absolute numbers of patients. The blue bars indicate the oral bone. The pink bars symbolize autologous bone.
|Fig. 6a: Sinus floor augmentation after three months. CT-scan of a patient from the control group which was treated with autologous cancellous bone from the iliac crest
||Fig. 6b: CT-image of a patient treated with periosteum derived tissue engineered bone
Our experiences from this pilot study with tissue engineered bone
transplants reveal the necessity to limit the indications for tissue
engineered bone. Its application is restricted to the sinus augmentation
with simultaneous implant insertion at sites providing a sufficient bone
bearing. These techniques are a new approach in hard tissue-impairment
therapy and were applied in the region of the jaw and the face for the first
time. To improve long term results modifications in the field of cell
cultivation and carrier materials and a better understanding of the
physiological part of the healing process are necessary.
- Boyne, P.J., James, R.A. (1980) Grafting of the maxillary sinus floor with autogenous marrow and bone. Journal of Oral Surgery. 38: 613-616.
- Perka, C., Schultz, O., Spitzer, R.S., Lindenhayn, K., Burmester, G.R., Sittinger, M. (2000) Segmental bone repair by tissue-engineered periosteal cell transplants with bioresorbable fleece and fibrin scaffolds in rabbits. Biomaterials 21: 1145-1153.
- Sauerbier, S., Gutwald, R., Wiedmann-Al-Ahmad, M., Lauer, G., Schmelzeisen, R. (2006) Clinical Application of tissue engineered Transplants - Part I: Mucosa. Clin Oral Implants Res. 17: In press.
- Stricker, A., Voss, P.J., Gutwald, R., Schramm, A., Schmelzeisen, R. (2003) Maxillary sinus floor augmentation with autogenous bone grafts to enable placement of SLA-surfaced implants: preliminary results after 15-40 months. Clin Oral Implants Res. 14(2): 2007-12
- Zizelmann, C., Schoen, R., Metzger, M.C., Schmelzeisen, R., Schramm, A., Gellrich, N.C. (2007) Bone formation after sinus augmentation with engineered bone. Clin Oral Implants Res. accepted for publication
This Poster was submitted by Dr. med. Sebastian Sauerbier.
Dr. med. Sebastian Sauerbier
Department of Maxillofacial Surgery
Universitiy Hospital Freiburg
Hugstetter Str. 55