Open access peer-reviewed chapter

Sinus Lifting and Leucocyte- and Platelet-Rich Fibrin

Written By

Berkem Atalay

Submitted: February 13th, 2018 Reviewed: August 27th, 2018 Published: November 5th, 2018

DOI: 10.5772/intechopen.81163

Chapter metrics overview

881 Chapter Downloads

View Full Metrics


The insufficient alveolar bone height due to the maxillary sinus in the posterior maxilla and postextraction bone resorption may limit implant placement. The sinus lifting procedure creates space between the maxillary alveolar bone and the Schneiderian membrane, which is filled with graft materials to maintain adequate space for new bone formation. Leucocyte- and platelet-rich fibrin (L-PRF)-mixed bone substitute or L-PRF has been used solely as a graft material for sinus lifting. The clinical and radiological findings of the application of PRF for sinus augmentation have been shown to have good results regarding new bone formation. The L-PRF can be an efficient biomaterial for graft particles in maxillary sinus lifting.


  • sinus lifting
  • leucocyte- and platelet-rich fibrin
  • bone graft
  • L-PRF block
  • Schneiderian membrane

1. Introduction

Alveolar bone resorption in the edentulous ridge can cause insufficient bone volume for placing dental implants and consequently cannot be rehabilitated by prosthetics. Sinus lifting is a surgical approach with the elevation of the Schneiderian membrane to place the bone grafts for treatment of atrophic posterior maxilla [1]. This surgical technique is a successful treatment for augmentation of the atrophic posterior maxilla and to gain bone volume for dental implant procedure [2].

Sinus lifting shows complexity due to anatomical variations and Schneiderian membrane. The lateral bone’s thickness changes the risk of membrane perforation. Evaluation of the thickness of the lateral wall before surgical treatment may affect the integrity of the Schneiderian membrane during the surgery [3].

Sinus lifting is a predictable technique, but various complications can occur during surgery or postoperative period [3]. These complications can be listed as edema, perforation of Schneiderian membrane, sinusitis development, bleeding, wound dehiscence, postoperative wound and bone graft material infection, implant failure if it is placed simultaneously, and disruption of normal sinus physiologic function. These complications can delay the healing process and may require additional surgeries [4, 5, 6]. Cone-beam computed tomography (CBCT) provides an accurate evaluation of the sinus and related anatomical structures. Danesh-Sani et al. recommend using CBCT before surgery to minimize the risk of Schneiderian membrane perforation [7].

Presurgical evaluation with CBCT has become an essential tool for diagnosis and surgical planning, including sinus lifting. Before performing a sinus lift, the clinician’s attention should not be only directed to the patency of the ostium through CBCT, because many anatomical features could influence the surgical approach of sinus lifting.

Postoperative swelling of the Schneiderian membrane mostly occurs with maxillary sinus lifting procedure. The mucosa of the Schneiderian membrane heals rapidly and recovers its homeostasis. If the ostiomeatal complex is unfavorable due to anatomic variations, its healing can be delayed, and risk of sinusitis is increased. The ostiomeatal complex plays an essential role in the development of maxillary sinusitis by dysfunction of the mucociliary system. If the patency of the ostiomeatal complex is interrupted, clearance of the maxillary sinus can be delayed and can increase the risk for development of sinusitis [8].

Surgeons must consider the risk of infectious sequelae after sinus lifting. The inflammatory reaction after any surgical procedure is unavoidable. Because of the interference of ciliary activity caused by the elevation of the Schneiderian membrane, altered mucous composition and bacterial infection can occur [9]. After sinus lifting, the maxillary sinus may be filled with hematoma or seroma. However, a mild inflammatory reaction can occur as a regular physiological activity of the nasal airway, and swelling of the mucosa can cause obstruction of the patency of the ostiomeatal complex. As a result, sinus lifting might compound the physiological drainage of the maxillary sinus into the middle meatus by inflammatory swelling on the mucosa of the ostium can predispose the patient to acute maxillary sinusitis [10]. Persisting effect on the ciliated mucosa can be expected because of raising the mucosa of the maxillary sinus [11]. The maxillary sinus mucosa can adapt adequately to the alteration following sinus lifting [12]. It is generally assumed that altered maxillary sinus, such as elevation of the Schneiderian membrane with curving outward or injured sinus mucosa, might change the physiological activity of the maxillary sinus.

Anatomic variations of the maxillary sinus are commonly detected, with an estimated prevalence of 68% [13]. Some anatomic variations on the lateral nasal wall, such as the deviated nasal septum, concha bullosa or paradoxical middle turbinate, and bending of the uncinate process are significant because of their help to the blockage of ostiomeatal complexes. These variants can interfere with drainage and ventilation of the maxillary sinus, and can affect the risk of sinusitis [14]. Compromised maxillary sinus drainage is closely associated with a reduction of the maxillary ostium. Reduced size of the ostium diameter can cause sinusitis [15].

The risk of Schneiderian membrane perforation during sinus lifting, in the presence of antral septa, can be increased [1]. Antral septa divide the sinus into compartments and smaller accessory sinuses [16, 17]. The presence of septa may constitute a risk factor by causing the Schneiderian membrane to become perforated during surgery. The development of sinusitis is one of the possible complications associated with perforation of the Schneiderian membrane [9]. For the repair of such perforations, there are a variety of techniques, including a buccal fat flap, fibro-mucosal grafts, connective tissue, resorbable collagen membranes, amnion-chorion barriers, and the leucocyte- and platelet-rich fibrin (L-PRF) [18]. Obtaining L-PRF consists of a very simple and inexpensive protocol that produces a strong membrane after compression [19].

L-PRF acts as a bioactive bridge and releases growth factors. The release increases day by day and reaches its highest level on the 14th day and continues until the 28th day [20, 21, 22]. L-PRF has certain effects on wound healing [19]. The leukocytes and cytokines have a significant role in controlling infectious and inflammatory processes. While the fibrin matrix is resorbed, cytokines are released to accelerate neovascularization and protect from infection. So, when L-PRF is used in membrane form, it stabilizes the graft material, covers the perforation since it has an inherent attachment to the Schneiderian membrane [23], and protects the wound [18, 24] (

The limited quantity of autogenous bone graft in sinus lifting with high morbidity rates is important for the clinicians using bone substitutes rather than the autogenous grafts. So, the investigation of optimal biomaterial combinations to enhance bone regeneration properties is in progress [25, 26]. L-PRF with bone graft for sinus lifting is accelerating bone regeneration. Choukroun et al. reported that healing time between sinus lifting and implant placement could be reduced by using L-PRF [27].

The use of L-PRF with a high concentration of platelets, growth factors, and leucocytes may increase the development of new bone. The liquid L-PRF (i-PRF) has been proposed to agglutinate the bone substitute [28]. Mixing i-PRF with bone substitute creates the L-PRF block.


2. L-PRF block

Prior to sinus lifting surgery, 8–16 tubes of venous blood needed to be collected from the patients. Two tubes should be separated as a white cap, plastic coating, and placed in the centrifuge at 2700 rpm for 3 minutes. The remaining tubes as a red cap, glass coating should be placed in the centrifuge at 2700 rpm for 12 minutes.

The liquid fibrinogen in the white cap tubes has to be aspirated with a sterile syringe. When the centrifugation of the red cap tubes finishes, the L-PRF clots can be removed from the tubes and compressed using a sterile metal box to mold membranes (Figure 1).

Figure 1.

The ready-to-use L-PRF membranes in preparation kit.

For the preparation of the L-PRF block as described by Cortellini et al., L-PRF membranes are cut and mixed with a bone substitute at a ratio of two membranes with 0.5 g bone substitute. The liquid fibrinogen needed to be added to the homogenous mix and stirred for at least 10 seconds for the ideal form. By the chopped membranes, fibrinogen is polymerizing into platelets and leucocyte, forming the L-PRF block (Figure 2).

Figure 2.

The L-PRF block.


3. Conclusion

The L-PRF block is secreting bioactive molecules like; a platelet-derived growth factor, bone morphogenetic proteins, insulin-like growth factor, vascular endothelial growth factor, transforming growth factor-β1, and transforming growth factor-β2 [29].

L-PRF can have a positive effect on bone regeneration and osseointegration. Easy preparation of L-PRF, biological properties, and low cost could be considered as reliable support in sinus lifting surgery. The use of sufficient L-PRF clots and membranes, avoiding to close the patency of ostium, is crucial to gain a covetable bone volume [30] (Figure 3).

Figure 3.

The use of the L-PRF membrane to cover the lateral window.

The L-PRF block maintains the volumetric stability of the biomaterial during healing and by this way, it can prevent the shrinkage of the scaffold. The effects of L-PRF on tissue healing by the release of growth factors and increasing angiogenesis and osteogenesis can lead to the higher volume of newly formed bone with the L-PRF block [31]. The L-PRF block can be a successful new procedure for sinus lifting after further investigations with histological analysis and randomized controlled clinical trials.


  1. 1. Tatum H. Maxillary and sinus implant reconstructions. Dental Clinics of North America. 1986;30:207-229
  2. 2. Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. Journal of Clinical Periodontology. 2008;35:216-240
  3. 3. Zijderveld SA, Van den Bergh JP, Schulten EA, Bruggenkate CM. Anatomical and surgical findings and complications in 100 consecutive maxillary sinus floor elevation procedures. Journal of Oral and Maxillofacial Surgery. 2008;66:1426-1438
  4. 4. Moreno Vazquez JC, Gonzalez de Rivera AS, Gil HS, Mifsut RS. Complication rate in 200 consecutive sinus lift procedures: Guidelines for prevention and treatment. Journal of Oral and Maxillofacial Surgery. 2014;72:892-901
  5. 5. Schwartz-Arad D, Herzberg R, Dolev E. The prevalence of surgical complications of the sinus graft procedure and their impact on implant survival. Journal of Periodontology. 2004;75:511-516
  6. 6. Nkenke E, Schlegel A, Schultze-Morgau S, Neukam FW, Wiltfang J. The endoscopically controlled osteotome sinus floor elevation: A preliminary prospective study. The International Journal of Oral & Maxillofacial Implants. 2002;17:577-566
  7. 7. Danesh-Sani SA, Movahed A, ElChaar ES, Chong Chan K, Amintavakoli N. Radiographic evaluation of maxillary sinus lateral wall and posterior superior alveolar artery anatomy: A cone-beam computed tomographic study. Clinical Implant Dentistry and Related Research. 2017;19:151-160
  8. 8. Bertrand B, Eloy P. Relationship of chronic ethmoidal sinusitis, maxillary sinusitis, and ostial permeability controlled by sinusomanometry: A statistical study. Laryngoscope. 1992;102:1281-1284
  9. 9. Zimbler MS, Lebowitz RA, Glickman R, Brecht LE, Jacobs JB. Antral augmentation, osseointegration, and sinusitis: The otolaryngologist's perspective. American Journal of Rhinology. 1998;12:311-316
  10. 10. Timmenga NM, Raghoebar GM, van Weissenbruch R, Vissink A. Maxillary sinusitis after augmentation of the maxillary sinus floor: A report of 2 cases. Journal of Oral and Maxillofacial Surgery. 2001;59:200-204
  11. 11. Timmenga NM, Raghoebar GM, Liem RS, van Weissenbruch R, Manson WL, Vissink A. Effects of maxillary sinus floor elevation surgery on maxillary sinus physiology. European Journal of Oral Sciences. 2003;111:189-197
  12. 12. Stammberger H. Endoscopic endonasal surgery concepts in the treatment of recurring rhinosinusitis. Part II. Surgical technique. Otolaryngology and Head and Neck Surgery. 1986;94:147-156
  13. 13. Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope. 1991;101:56-64
  14. 14. Bayram M, Sirikci A, Bayazit YA. Important anatomic variations of the sinonasal anatomy in light of endoscopic surgery: A pictorial review. European Radiology. 2001;11:1991-1997
  15. 15. Laine FJ, Smoker WR. The ostiomeatal unit and endoscopic surgery: Anatomy, variations, and imaging findings in inflammatory diseases. AJR. American Journal of Roentgenology. 1992;159:849-857
  16. 16. van den Bergh JP, ten Bruggenkate CM, Disch FJ, Tuinzing DB. Anatomical aspects of sinus floor elevations. Clinical Oral Implants Research. 2000;11:256-265
  17. 17. Tidwell JK, Blijdorp PA, Stoelinga PJ, Brouns JB, Hinderks F. Composite grafting of the maxillary sinus for placement of endosteal implants. A preliminary report of 48 patients. International Journal of Oral and Maxillofacial Surgery. 1992;21:204-209
  18. 18. Aricioglu C, Dolanmaz D, Esen A, et al. Histological evaluation of the effectiveness of platelet-rich fibrin on the healing of sinus membrane perforations: A preclinical animal study. Journal of Cranio-Maxillo-Facial Surgery. 2017;45:1150-1157
  19. 19. Dohan Ehrenfest DM, Del Corso M, Diss A, et al. Three-dimensional architecture and cell composition of a Choukroun’s platelet-rich fibrin clot and membrane. Journal of Periodontology. 2010;81:546-555
  20. 20. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part I: Technological concepts and evolution. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. 2006;101:37-44
  21. 21. Choukroun J, Diss A, Simonpieri A, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part V: Histologic evaluations of PRF effects on bone allograft maturation in sinus lift. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. 2006;101:299-303
  22. 22. Sohn DS, Heo JU, Kwak DH, Kim DE, Kim JM, Moon JW, et al. Bone regeneration in the maxillary sinus using an autologous fibrin-rich block with concentrated growth factors alone. Implant Dentistry. 2011;20:389-395
  23. 23. Simonpieri A, Choukroun J, Del, Corso M, Sammartino G, Dohan DM. Simultaneous sinus-lift and implantation using micro-threaded implants and leukocyte- and platelet-rich fibrin as sole grafting material: A six-year experience. Implant Dentistry. 2011;20:2-12
  24. 24. Öncü E, Kaymaz E. Assessment of the effectiveness of platelet-rich fibrin in the treatment of Schneiderian membrane perforation. Clinical Implant Dentistry and Related Research. 2017;19:1009-1014
  25. 25. Corbella S, Taschieri S, Weinstein R, Del Fabbro M. Histomorphometric outcomes after lateral sinus floor elevation procedure: A systematic review of the literature and meta-analysis. Clinical Oral Implants Research. 2016;27:1106-1122
  26. 26. Shanbhag S, Shanbhag V, Stavropoulos A. Volume changes of maxillary sinus augmentations over time: A systematic review. The International Journal of Oral & Maxillofacial Implants. 2014;29:881-892
  27. 27. Choukroun J, Diss A, Simonpieri A, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part IV: Clinical effects on tissue healing. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. 2006;101:56-60
  28. 28. de Almeida Barros MCF, Helder V, Rodrigues ME, Freitas MNBM, Diuana-Calasans MM. Obtenção da fibrina rica em plaquetas injetável (i-PRF) e sua polimerização com enxerto ósseo: Nota técnica. Revista do Colégio Brasileiro de Cirurgiões. 2015;42:421-423
  29. 29. Cortellini S, Castro AB, Temmerman A, et al. Leucocyte- and platelet-rich fibrin block for bone augmentation procedure: A proof of concept study. Journal of Clinical Periodontology. 2018;45:624-634
  30. 30. Castro AB, Meschi N, Temmerman A, Pinto N, Lambrechts P, Teughels W, et al. Regenerative potential of leucocyte- and platelet-rich fibrin. Part B: Sinus floor elevation, alveolar ridge preservation and implant therapy. A systematic review. Journal of Clinical Periodontology. 2017;44:225-234
  31. 31. Pichotano EC. The İnfluence of Leukocyte and Platelet-Rich Fibrin on Bone Formation after Maxillary Sinus Floor Elevation with a Deproteinized Bovine Bone: A Randomized Clinical Trial [thesis]. UNESP Institutional Repository; 2018

Written By

Berkem Atalay

Submitted: February 13th, 2018 Reviewed: August 27th, 2018 Published: November 5th, 2018