dr michael toffler: 10-year experience using l-prf in ridge and sinus augmentation
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Leukocyte & Platelet-Rich Fibrin (L-PRF) in Ridge and Sinus Augmentation:
10-Year Clinical Experience
Extraction Sockets Lateral Window OsteotomyTranscrestal SFE
Michael Toffler DDS ([email protected])
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
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
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).
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.
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
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
PRF will be added immediatedly after accessing sinus via direct infracture , drilling or piezosurgery
Direct Infracture Drilling/Controlled Erosion Piezosurgery
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
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