Leukocyte & Platelet-Rich Fibrin (L-PRF) in Ridge and Sinus Augmentation:

10-Year Clinical Experience

Extraction Sockets Lateral Window OsteotomyTranscrestal SFE

Michael Toffler DDS (info@michaeltoffler.com)

Peri-Implant DefectsRidge Augmentation

“PRF is easy to handle and modify, providing the defect with not only a matrix permitting cell

migration into the surgical site but also with crucial biological cues potentially accelerating the

wound healing process.” (Ghanaati et al 2014)

L-PRF: Simple Preparation

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24 gauge butterfly

needle

plastic tube coated internally with silica particles

2700 RPM (400g) 12 minutes

RBCs

Fibrin Clot (PRF)

Acellular Plasma (PPP)

Intra-Lock.com

L-PRF:Preparation (cont)

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•

•WBC

and PLT

Fibrinclot

RBC

Li et al 2013

PRF ‘s naturally polymerized fibrin network sustains a slow release of growth factors and matrix glycoproteins for 7 - 14 days (Ling 2009; Dohan-Ehrenfest et al 2009; He et al 2009; Wu et al 2012; Kawase et al 2015)

FRAGMENTSMEMBRANES PLUGS GF-ENRICHED BONE GRAFT MATRIX(PRF-BLOCK®)

Standard 12 Minute Protocol Modified 3 Min Protocol

PRF BLOCK

We graft sockets to offset the post-extraction catabolic process and minimize alveolar ridge degradation

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The positive effect of growth factors in L-PRF could be particularly relevant when combined with osteoconductivescaffolds with slow healing dynamics (Torres et al 2009; Anitua et al 2010), where bone metabolism is compromised (eg. osteoporosis) as well as in early implantation scenarios (Chen et al 2004).

My “Socket Cocktail”

CaSO4, PRF, D/M/FDB

PRF has shown promising results in the early phases of extraction socket healing

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•

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Flapless Extractions

• Socket grafted to a level 2 to 3 mm below free gingival margin

PRF provides an organized matrix at the start of healing, increasing the speed of vascular ingress and wound coverage (Dohan et al 2006)

Flapless Extractions

1 wk 4 wks

•1 or 2 PRF plugs placed in socket and secured with mattress and interrupted sutures

In Sites With Severe Bone Loss, Ridge Augmentation Is Usually Performed 6-8 Weeks After Tooth Removal

This Delayed Approach Provides Additional Soft-tissue Coverage Over The Augmented Site

1 WEEK

Maintenance of primary closure is essential to maximize bone gain

8 WEEKS after ext’s

L-PRF over Frenectomy and in Socket

8 wks

Ridge augmentation done simultaneously with ext #9 would require a larger flap with extensive

release, increasing postop pain and swelling as well as the risk of wound dehiscence.

Autogenous bone goes

here

PRE-OP

Toffler M. Guided Bone Regeneration (GBR) Using Cortical Bone Pins in Combination with Leukocyte- and Platelet-Rich Fibrin (L-PRF). Compend Cont Ed Dent 2014;35(3).

Salvin Dental

Cortical Bone Pins: Clinical Advantages

•No screws to retrieve

•Membrane support

•Graft retention

2 mm twist adjustable stop (hhco-store.com)

10-day post-op

Comparative healing at 6 months

• 6 months post-op • Pre-op

Stage-2 Final

Dr Michael Woloch

PRF BLOCK®

PREOP6 MOS

Consistent Use of L-PRF in Sinus Elevation Surgery for the Last 10 Years

• Slow sustained release of key growth factors (Ling 2009; Dohan-Ehrenfest et al 2009; He et al 2009; Wu et al 2012; Lauritano et al 2013; Kawase et al 2015)

• Expedited sinus graft healing (Choukroun et al 2006; Inchingolo et al 2010; Tatullo et al 2012; Cruzat et al 2015)

• Maintenance of primary wound closure (Khiste & Tare 2013; Baiju et al 2013; Toffler et al 2014)

• Membrane protection (Diss et al 2008; Toffler et al 2010) and repair (Choi et al 2006; Shin & Sohn 2005; Baykul & Findik 2014; Toffler & Rosen 2015)

All My Approaches to Sinus Floor Elevation Incorporate L-PRF

Transcrestal/Simultaneous LWOTranscrestal/Staged

10 mm long implants

“I use a transcrestal approach as often as I can, but prefer using a lateral (visual) approach not only in severely atrophic sites but also in………….

…….patients with ≤ 4 mm of subantral bone and significant sinus pathology.”

Optical and Instrumental Access to Optimize Healing Response

……and for extra added

safety, platelet-rich fibrin

(PRF) lines the sinus

membrane prior to grafting

Single Stage Placement 6 Months Later

10 mm

4.0 x 11 mm Implant PREOP

5 mm core prepped to a depth 3 mm

Subantral bone

height is now

doubled (7- 8 mm)

PRF in TSFE and Simultaneous Implant Placement

PRF will be added immediatedly after accessing sinus via direct infracture , drilling or piezosurgery

Direct Infracture Drilling/Controlled Erosion Piezosurgery

Sohn2010

2.8 mm tip to elevateWiden osteotomy

to 4.1 mm

PRF

PREOP

Bone Densification and Placement 5 x 11 mm Thommen Implant

PRF in Membrane Repair

Perforation Transcrestal Approach

PRF

Perforation Transcrestal Approach

4 mos

CBCT 3 years

At 4 months, full repair and 6.7 mm RSBH

6.73

6.73

3-4 mm of TSFE

4 years

64 y/ F, heavy smokerImplants placed 10 years ago, referred for tx peri-implant diseaseSevere sinusitis, failure of implants 13 (floor intact), 14 (OAC)

14

13

Double Pedicle

porcine collagen membrane covers plugs

PRF

PRF covers collagenCTG pedicle palate joins facial pedicles

CTG

1 week 8 weeks

Asymptomatic, Successful Closure OAC

I hope I have demonstrated the potential benefits of incorporating PRF into:

Extraction Sites• Serves as a matrix to accelerate the healing of wound edges much like a fibrin bandage

7 days

Ridge Augmentation

• Aids in hemostasis

• Provides a high quality of gingival maturation (Simonpieri et al 2009)

1 week

• The strength of PRF membranes enables a biomaterial to be maintained and protected

Ridge Augmentation

Composite Grafts

• PRF fragments serve as a biological connector between bone particles facilitating cellular migration, particularly for endothelial cells necessary for neo-angiogenesis (Simonpieri et al 2009; Kobayashi 2011)

Complex Reconstructive Surgery

• Platelet cytokines are gradually released as the fibrin matrix is resorbed, thus creating a perpetual process of healing

PRF is a welcomed addition for all my SFE procedures, but it is especially helpful in high risk membrane perf/sinus communication cases!

FAILED LWO SINGLE TOOTH SITESOAF EXT/OAC SINUS SEPTA

info@michaeltoffler.com

Thank You