PRF/PLATELET RICH FACTOR IN BONE AUGMENTATION IN IMPLANT DENTISTRY

1. A new approach for better anterior
esthetic using
platelet-rich fibrin as sole graft material
combined with
ovate design dental bridge
MUAIYED MAHMOUD BUZAYAN, HAYDAR MAJEED MAHDEY1, CHONG JUN NING
THE JOURNAL OF INDIAN PROSTHODONTIC SOCIETY | VOLUME 20 | ISSUE 2 | APRIL-JUNE 2020 223
Journal club presentation
Presented by
Namitha AP
2nd MDS
DEPT.OF PROSTHODONTICS

2. Contents
 Introduction
 Main case report
1. Investigation
2. Clinical procedures
3. Discussion
4. Clinical significance
 Related articles
 Conclusion
 References

3. Once teeth are extracted, the residual alveolar ridge usually
heals with deficient contour, especially when the extraction
is due to periodontal-periapical lesions.
For upper anterior teeth extraction, the residual alveolar ridge resorption
would compromise the esthetics making the prosthodontics
management of such cases more challenging.
Introduction
ESTHETIC ZONE

4. How to overcome!
 augmentation of alveolar ridge
defect after infected and/or
resorbed tooth extraction
 use of full-thickness onlay and
subepithelial connective tissue
grafts.
 guided bone regeneration
(GBR) concept
 Platelet rich fibrin (PRF)
Immediate
Delayed
Optimal
residual
ridge width
Esthetic
improvement
objectives
better
foundation
for later
prosthesis
design

5. Guided bone regeneration
 Graft materials combined with barriers
 most common option
 predictable, and its success is well documented with either
nonresorbable or resorbable membranes.
 early membrane exposure is one of the most common clinical
complication - compromise healing.

6. Platelet Rich Fibrin/PRF
 Potential of the platelets as a
regenerative option was first
reported in the 1970s
 Platelet concentrates are a
concentrated growth factor
suspension that induce wound
healing by acting as bioactive
additives that are applied locally
during the surgery
Growth
factors
Induction of cell
differentiation
enhancing
the
collagen
productio
Increase blood vessel
growth

7. TYPE OF PLATELET CONCENTRATES
TYPES
PRP
PRF
PRF
 Dr. Choukroun was the first to use
PRF in oral and maxillofacial surgery,
and since that time, it has been
considered as a new generation of
platelet concentrate.
 easier preparation
 no chemical manipulation of blood

8. PRF
 complex fibrin matrix that contains autologous platelets,
leukocytes, and stem cells
 works as a biodegradable scaffold and has the ability to
guide the migration of the epithelial cells to its surface.
 potential for soft-tissue regeneration, without
inflammatory reactions
 used alone or in combination with bone grafts
 Chen et al. have used the PRF to augment the extraction
socket with buccal cortical plate dehiscence, and they found
that the use of PRF could offer numerous advantages such as
improving soft- and hard-tissue wound healing due to fibrin
bandage and growth factors’ release
Hemostasis
Bone growth
maturation

9.  This article describes a new approach using
the PRF to increase the soft-tissue volume for
preprosthetic preparation of a deficient
anterior ridge.
CHIEF
COMPLAINT
• 23-year-old male
• complaint of unpleasant smile.
H/O PRESENTING
COMPLAINT
• accident 8 years ago while he was playing a
basketball, which caused
• his upper front teeth to be intruded and discolored

10. INVESTIGATIONS
 diagnostic intraoral periapical radiograph showed that both the upper
right central and right lateral incisor teeth were treated with root canal
therapy.
 upper right central tooth suffered a major external root resorption

11. Smile has been analysed using digital smile
system software DSS
digital mock-up was designed to assess the space
availability and the need for ridge augmentation
decision was made to extract the upper right
central incisor, augment the defected socket
compensating the expected deficient soft tissue
with PRF
layered zirconia dental bridge incorporating into
design an ovate pontic.

13. Clinical procedure
Teeth preparations - upper left central and right lateral incisor teeth adjacent to
the tooth to be extracted.
Irreversible hydrocolloid impression of the maxillary arch including both the
teeth prepared and the tooth to be extracted
upper right central was scored off from the poured cast making 3 mm
depression simulating the postextraction socket.
to simulate the gingival volume expected to be gained postplacement of PRF
membrane, plaster of Paris has been added to the labial gingival margins.
Provisional dental bridge

15. A volume of 20 cc of the patient’s own blood was drawn to prepare the PRF
before the extraction of the indicated tooth.
The upper right central was extracted atraumatically taking great care to preserve
both buccal and lingual plates.
The extracted socket was debrided from the remnant granulation tissue and
refreshing bleeding was achieved using Busar periosteal elevator instrument.
This was very crucial to preserve the bone as well as to maintain the interdental
papillae

16.  Neither bone dehiscence nor
fenestrations were noticed.
The extracted socket was
then packed with the PRF;
the PRF membrane was
extruded out of the socket to
fill up the labial gap formed
post extraction of the upper
right central.
 A tension-free horizontal
mattress suture was placed
to fix the membrane in place

17. The patient was followed up at 10
days for review and suture to be
removed, 1 month, 3 months, and
6 months subsequently.
The final impression for the
preparation was taken 3 months
later following the PRF placement,
and the final prosthesis was
cemented in place
By the end of the treatment, the
patient was satisfied with
the results and his psychology and
self-confidence have
been improved

18. Discussion
 After extraction of the tooth 11, the residual alveolar ridge - Class II defect
(Siebert’s classification).
 new approach to augment the soft-tissue defect vertically using the PRF as a
sole graft material.
 Zhao et al. studied the effect of using PRF as a sole grafting material, and they
found it to preserve the alveolar ridge.
 PRF was used as a sole graft material for both socket packing and to increase
the alveolar ridge height; hence, the first benefit is given by improving the
esthetic appearance instead of waiting the gingiva to fill the gap, and this
provides greater comfort to the patient in the postoperative period as well as
reducing the healing time

19.  Reduces the pain by avoiding food stagnation
inside the socket, avoiding postoperative swelling
and achieving fast hemostasis.
 By drawing the patient own blood and preparing a
PRF, it was very significant cost cutting instead of
using bone graft materials and membranes.
 use of restorative design with ovate pontic is a
well-established method to guide the soft-tissue
healing to more favorable contour

20.  The result was promising, as the ridge gained height, and the gap cervical
to the ovate was completely obturated within the first 2 weeks.
 challenging part was to regain the interdental papilla; at the 10-day
review visit, it has been noticed that black triangle still there, especially
distal to the upper right lateral.
 ovate pontic neck then was adjusted and reformed at the neck region
adding flowable composite resin to compress the soft tissue and to
enhance the interdental papilla esthetic.
 immediate and the black triangle disappeared.

21. success and
predictability of
this protocol
relies on
Disadvantages/limitations
handling, blood collection time
Lack of rigidity
patient may refuse the puncture
required for blood collection
its transference for the centrifuge
size of the defect and amount of
bone loss
fast degradation of the PRF

22. Clinical significance
 According to the encouraging result obtained in this
clinical case in regard to tissue healing and esthetic,
the authors suggest that PRF can be used as a sole
graft material for small anterior deficient areas. This
may reduce the need of bone augmentation and
graft in such selected cases. Further studies are
needed to validate the clinical result.

23. Posıtıve effect of platelet rich fibrin on
osseointegration
ELIF ÖNCÜ , BURAK BAYRAM , ALPDOĞAN KANTARCI , SERAP GÜLSEVER ,
EMINE-ELIF ALAADDINOĞLU
The aim of this study was to evaluate the L-PRF-induced osseointegration
and bone-implant contact (BIC) in an experimental animal model

24.  Twelve 4-month-old New Zealand white
rabbits were used.
 Following general anesthesia, 3-5 mL of blood
was obtained from the central artery in rabbit
ear and L-PRF was prepared.
 Two implant cavities (5 mm long and 3 mm in
diameter) were created in each tibia with a
total of four cavities in each animal.
 Two of these cavities were selected and
covered with PRF (test group). The remaining
L-PRF was used to soak the implants placed
into the L-PRF covered sockets. Other cavities
were left as controls.
 In total, 48 implants were placed. Animals
were sacrificed after two, three, or four weeks.
Histological samples were obtained and peri
implant tissues were histo morphometrically
evaluated for bone-to-implant contact and
new bone formation.

25. CONCLUSION
 The results of this
study demonstrated
that L-PRF
application may
increases amount
and rate of new
bone formation
during the early
healing period and
provides a faster
osseointegration
around implants

26. RESULTS
 Histomorphometric analyses of the defects revealed
that the L-PRF was detectable up to the second week.
Application of L-PRF increased the rate and amount
of new bone formation in the experimental group
compared to the control group. Bone-to-implant
contact was enhanced when the surface was pre-
wetted with LPRF

27. A pre-prosthetic soft tissue
augmentation using
a simplified technique
TANYA JADHAV, JOTHI VARGHESE, JYOTI HASSIJA1, G. S. BHAT, K. M. BHAT
This case report describes a simple novel technique of soft tissue ridge
augmentation for ovate pontic placement using the excised tissue as a
connective tissue graft and PRF membrane. The correction of the ridge defect
was planned pre-prosthetically, so as to achieve maximum aesthetics and
maintainable the periodontal health.

28. Pre-operative occlusal view showing missing maxillary first premolar with a deficient buccal ridge.
Two parallel incisions across edentulous area and placement of excised connective tissue graft on bone.
Placement of excised de-epithelialized tissue as connective tissue graft on bone.
Adaptation of Platelet rich fibrin membranes.
Post-operative 3
month follow-up
Post-operative occlus
view at 10 days which
shows healed ridge
augmentation with th
prosthesis
Graft sutured
in position.

29. CONCLUSION
removing any scope for graft
rejection
Minimal chances of disease
transmission
expeditious healing which permits
faster prosthetic rehabilitation
single surgical site of operation
And use of patients’ own blood for
PRF membrane
Alveolar ridge modification is a pre-requisite for both the implant and/or
fixed prosthesis.
• advantageous to both the patient and clinician
• optimal aesthetics
• lesser time consumption
Improves both gingival and bone architecture for
aesthetic and functional purposes

30. Qualitative and Quantitative Analysis
of Bone Formation in the Peri-Implant
Defects Grafted with Polycaprolactone
(Pcl) Alloplast Enriched with Platelet
Rich Fibrin (PRF): A Clinical and
Radiological Study
HONEY VERMA, RAYAPATI DILIP KUMAR, PRASHANTH N T, SHOBHA E S

31. Aim and objectives
 To radiologically and clinically evaluate the quantity and
quality of bone formed in peri implant defect in patients with
insufficient alveolar bone grafted with Platelet Rich Fibrin and
Polycaprolactone.
 Identify the role of Platelet rich fibrin and PCL in bone healing.
 Evaluation of this was done at the end of three months by
clinical and radiological methods

32.  study was conducted on ten patients with peri implant deficient regions in
the maxillary and mandibular edentulous regions. The selected patients
underwent Implant surgery with PCL enriched with Platelet rich fibrin
placed in the peri implant deficient regions.

33. Alloplast used in the study was
POLYCAPROLACTONE mesh (syncronie)
measuring 2 x 2 cm. The graft was trimmed
according to the platform size of the
implant placed, using sterile ophthalmic
scissors and suitable drill bit of appropriate
size to fit as collar around the implant

36.  Patients were assessed both clinically and radio logically pre
operatively and 3 months post operatively. Computed tomograms
were used for radiographic assessment by comparing the area
measurements obtained using the VOLUME TOOL , SYNGO
SOLARIS 7 software, from pre-operative and three months post-
operative scans

37. 3 MONTHS FOLLOW UP

38. BONE DENSITY IN PERI IMPLANT AREA

41. Results
 Clinically pain, swelling, wound dehiscence, and implant exposure was
assessed. Pain and swelling was present in some cases on third post-
operative day. Loss of graft in one patient was observed which was
removed completely maintaining the primary stability of the implant.
Results suggested substantial increase in the volume wise measurements
when pre-operative and three-month postoperative results were
compared

42. Conclusion
 PRF is efficacious clinically and radiographically in the treatment of a peri-
implant defect. PRF is an autologous preparation and found to be clinically
effective and economical than any other available regenerative materials
and is more fruitful when used along with PCL. However, long term,
multicenter randomized, controlled clinical trial will be required to know its
clinical and radiographic effect over bone regeneration

43. Immediate Dental Implants Enriched
with L-PRF in the
Esthetic Zone
MANOTI SEHGAL , LOVLEEN PURI, SAPNA YADAV, PUJA MALHOTRA, SUMIT SINGH
PHUKELA,
BHUPENDER YADAV , AND BHARTI RAINA

44. 24-year-old female patient in a good
health condition
without any chronic diseases
chief complaint of abnormal-looking
upper front
teeth since 10 years
On examination, the retained
deciduous maxillary right lateral incisor and canine
and
deciduous left canine were observed along with the
congenitally
missing permanent maxillary left lateral incisor

45. treatment plan was formulated which included immediate implant placement following extraction wrt the
deciduous teeth (52, 53, and 63) and fixed prosthesis following intentional endodontic therapy wrt 23.
• prophylactic antibiotic therapy
• asepsis protocol.
• procedure was performed atraumatically with the careful
use of luxators (SDI®) and periotomes (Medessa®) to
avoid damage of the continuity of the alveolar ridge and
with anterior forceps

46. minimal tissue damage
to preserve the gingiva as well as
the socket.
extraction sites were examined
for the presence of any
bony defect
root measurements of the
extracted
teeth were taken to decide the
tentative implant sizes
Ten mm of venous blood was
withdrawn from the antecubital
vein
immediately centrifuged at
3000 rpm for 13 min to obtain
an L-PRF clot
clot was condensed on a surgical
plate and converted into a high-
tensile-strength L-PRF membrane

47. osteotomy
sites were prepared on the
palatal and apical aspects
palatal orientation of the osteotomy sites
was checked using paralleling pins
implants were inserted into the
bone (with an
insertion torque of 35–40 Ncm)
using hand tools to achieve
primary stabilization. The implant
surfaces were coated with PRF
gel
The implants were placed in the
sockets,
and cover screws were placed
along with the L-PRF membrane
PRF membranes
were wrapped around the healing
cap to favor soft
tissue attachment and prevent
infection and help to maintain
the soft tissue profile

48. Poncho membranes can be placed around the implant
collars to facilitate more rapid soft tissue healing without
having to utilize a collagen barrier membrane.
provisional composite crowns were placed in the patient
for immediate replacement of the missing front teeth due
to functional and esthetic requirements.
intentional root canal therapy was done wrt 23. Following
completion of the endodontic therapy, temporization was
done wrt tooth no. 23 as well

49. After a 3-month healing period, recalled for the definitive
prosthesis. single-phase impression Monophase Polyether
Impression Material) of implant transfers was made with
an open tray technique, and a jig trial was done prior to
prosthesis fabrication

50. The effect of PRF (platelet-rich fibrin)
inserted with a split-flap technique on soft
tissue thickening and initial marginal bone
loss around implants: results of a
randomized, controlled clinical trial
JULIA HEHN, THOMAS SCHWENK, MARKUS STRIEGEL AND MARKUS SCHLEE
INTERNATIONAL JOURNAL OF IMPLANT DENTISTRY (2016) 2:13

51. BACKGROUND
 Adequate thickness or initial
augmentation of soft tissue has
a positive effect on the stability
of peri-implant bone.
AIM
 to evaluate the influence of augmenting
soft tissue with platelet-rich fibrin (PRF) on
crestal bone and soft tissue around
implants

52. 31 fully threaded titanium
implants were inserted in 31
patients (16 men and 15 women)
in the lower mandible using a
split-flap technique.
In the control group (21 patients), implantation was realized
without soft tissue augmentation.

53. In the test group (10 patients), mucosa was treated
with a PRF membrane.

54. Tissue thickness was measured at point of implant insertion (baseline)
and at time of re entry after 3 months
Standardized digital
radiographs-
evaluation at time of
implant placement,
reentry after 3 months
and at a 6-month
follow-up.

57. Results
CRESTAL TISSUE THICKNESS
TEST GROUP
At baseline-
2.20mm+0.48 SD
At reentry-
0.9 mm+1.02 SD
CONTROL GROUP
2.64 mm± 0.48 SD
2.62 mm± 0.61 SD
MEAN BONE LOSS
TEST GROUP
0.77 mm± 0.42 SD/0.57
mm± 0.44 SD MESIAL
SIDE
0.82 mm± 0.42 SD/0.62
mm± 0.36 SD DISTAL
SIDE
CONTROL GROUP
0.72 mm± 0.61 SD/0.51
mm± 0.48 mm MESIAL
SIDE
0.82 mm± 0.77 SD/
0.57 mm± 0.58 SD
DISTAL SIDE
(defect
depth/
defect
width)

58. Conclusions
 After 6 months, all 31 implants were osteointegrated.
 Soft tissue augmentation with PRF led to a significant tissue loss.
crestal mucosa in the control group showed higher stability
 For ethical reasons, the test group was terminated after 10 cases, and
the remaining cases were finished within the control group.
 Within the limits of this study and the early determination of the test
group, this study concludes that soft tissue augmentation with PRF
performed with a split-flap technique cannot be recommended for
thickening thin mucosa. Further studies focusing on different
techniques and longer follow-ups are needed to evaluate whether PRF
is suitable for soft tissue thickening.

59. Platelet-rich fibrin (PRF) in implant
dentistry in combination with new
bone regenerative technique in elderly
patients
ANTONIO CORTESE ET AL
INTERNATIONAL JOURNAL OF SURGERY CASE REPORTS

60. This study wants to
demonstrate how PRF in
association with a new split
crest augmentation
technique can be a great
aid in implant rehabilitation,
especially in the elderly
patients, when bone
regeneration is required
AIM

61.  Ten patients were treated in this study, five following the flapless split crest new procedure and other
five patients following traditional procedure without split crest as control.
 Five patients with an average age between 50 and 60 years were selected to be operated with a split
crest flapless modified technique in order to optimize the regenerative conditions with a bone
augmentation and implant insertion in one single stage procedure. For all the patients autologous
PRF has been used to fill the split crest gap or simply as regenerative material

62. Orthopantomography,
intraoral radiography
and CT DentaScan/CT
Cone beam were
performed for every
patient before the
treatment and at follow-
uptime exeption made
for CT.

63. RESULTS

64. RESULTS
 All cases were successful, there were no problems at surgery time, at post-
operative and at osteointegration periods. All implants achieved
osteointegration. These results were obtained by accu-rately managing
immediate and late post operative period in all of the operated cases.
Mean difference for height bone loss between the two groups of patients
was 2.4 mm at T1 and 2.2 mm at T3.

65. DISCUSSION
 The rationale of this split crest flapless modified technique is to obtain a
proper buccal cortex expansion preserving its vascular supply avoiding
periosteal elevation for better cortical bone nourishing. Moreover,
advantages are reported related to the use of PRF. The effectiveness of PRF
is shown in promoting the healing of surgical wounds, it has, in fact,
platelet growth factors that can improve the vascularisation of the surgical
site, promoting neoangiogenesis. Furthermore, by simply changing the
settings of the centrifuge, it is possible to obtain a normal gelling if it has
to be used as regenerative and stimulating material, or more consistent
substance to be used as a filler in the split crest gap.

66. CONCLUSION
 The main advantages in using the platelet-rich fibrin are healing and bone
regenerativeproperties in combination with its complete resorption after
surgery, thus avoiding a second surgerytime, important factor in the
elderly patients. Currently, it is a minimally invasive technique with lowrisks
and satisfactory clinical results such preventing complications or implant
failure particularly inelderly patients for age related conditions

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