[Others]  Tissue Healing & Grafting - Bio-modifiers: PRP (Platelet rich Plasma), PDGF (Platelet Derived Growt

Let's discuss bio-modifiers.

by Bernard Jin at Tue, Jan 4, 2011 3:45 AM

11018 Views | 8 Replies


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Mark Kwon Replied at Thu, Jan 13, 2011 1:40 AM

Got this reply back from the participant: --------------------------------------------------- Hello Gentlemen, I just finished with Jarod and since you both have been so integrally involved i thought i would give you an update. Once flapped i decided to remove the implant bc most of the buccal threads were exposed. You would think that it would come out easily that being the case!! Wholly man!! was it still tight. Nevertheless got it out and then graft with a dynagraft mixed heavily with chopped up PRF. then covered the whole site in PRF and immobiliozed with a collagen membrane. (not sure if i needed to do that but felt better doing it. Got nice tension free primary closure with gortex suture. How long would i expect before i can go back and place another implant?? Thanks guys for all of your help!! PS - i took a picture once flapped that i can send to you if you are interested. ---------------------------- and Yes! We would love to have some photo of your beautiful case! thx for the post!

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Mark Kwon Replied at Thu, Jan 13, 2011 1:35 AM

Most likely you have waited too long before centrifuging. the vials need to be spun stat. can't wait. try it again. but this time don't wait at all. if in doubt, spin 2 first, then stop the machine to add on the other 2 vials. let me know how it works.

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Mark Kwon Replied at Thu, Jan 13, 2011 1:32 AM

Hi, Everyone! Just received email from one of the PRF participant. This is a common problem we may all encounter. ---------------------- Hello Guys! Happy New Year to you... I have my first big PRF case tomorrow,, (repairing my cousin Jarod's anterior implant with connective tissue graft and PRF) we practiced today with PRF but after spinning for 12 min at 2700rpm it was still liqiudy. so i spun for another 12min and it was still liquid... any suggestions? the vials went into th centrifuge within a few minutes. THX guys..... this case is tomorrow so i need to figure this out today

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Bernard Jin Replied at Tue, Jan 11, 2011 10:54 PM

If you see swelling, then you have a hematoma. Release the tourniquet and then withdraw the needle. Go to another site. Do not reattempt to find the lumen in cases of sub-dermal hematoma swelling, it's next to impossible. Withdraw the needle, place pressure and warn the patient of a bruise that will show.

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Bernard Jin Replied at Tue, Jan 11, 2011 10:51 PM

PRF Question: Drawing blood A couple of e-mails have come with the same concern. "When I perform the phlebotomy - after I connect the butterfly needle to the vials, the blood stops after a second of flow. Any suggestions?" Answer: I recommend having your assistant perform the butterfly-vial connection. Very often if you are trying to assist your CDA to connect the vial, your hand moves (albeit microscopically - even if you look away for a second). This can lead to the needle exiting the lumen of the blood vessel. My recommendation - when you see 'flash' on your butterfly, stabilize the tubing with the thumb of the other hand (i.e. hand which performed traction for the venipuncture) against the forearm surface. Try not to hold on to the needle itself while the blood is being drawn. Once you stabilize the tubing with the "non-needle holding" hand, you can let go of the needle while your CDA changes the vacuettes. If you did all that and the blood flow diminishes, then you may need to try to find the lumen of the vessel without withdrawing the needle completely. First, pull the needle back slowly and see if the flow resumes. If still no flow, then possibly advance the needle slowly (each time visualizing where the vessel is). Lastly, before you withdraw the needle completely, try having your CDA switch vacuettes. Sometimes, vacuettes may have a leak and the vacuum is lost. Let me know if these words helped you. Cheers!

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Bernard Jin Replied at Tue, Jan 11, 2011 10:34 PM

Sounds like a great case - here's my answer: I would perform the extraction & perform ridge preservation. Here, PRF would come in handy. Following that, after the graft has healed, I would perform the implant placement. Rationale: typically the labial bone is paper-thin. If you are able to probe down the labial place to the apex, more than likely, you would have an osseous dehiscence (vertical defect); not to mention the periapical infection. Although placing an implant in conjunction with bone may be a viable option, it assumes risk that you spoke about - especially if the flap design, blood supply, etc. is not ideal. To answer the graft question: If you have a very narrow dehiscence in the labial bone where the 3-dimensional integrity of the bone architecture is preserved, then you could certainly use PRF alone as your graft material. On the other hand, if the labial bone is absent and the defect is wide (or deep) - and the alveolar ridge is reduced to a thin plate (instead of using only PRF as your graft material), then I would recommend mixing the PRF with particulate allo/auto-graft. I would then place a PRF membrane overtop the dehiscence and socket to protect the graft and socket access. My recommended flap design is the envelope flap (try to avoid vertical incisions if at all possible for blood flow & esthetic reasons). Lastly, I would then fabricate a PRF plug to sit on top of the socket site (overtop the PRF membrane), held in with a figure-8 suture. Use of a collaplug or CT graft is also fine, instead of the PRF plug. If you want another level of security, you could also utilize bovine collagen membrane (type 4) overtop your PRF membrane [the one on top of the dehiscence]. We know the bovine membrane will need to last 20+ weeks or so. Having said all that, you could perform immediate implant placement AND grafting at the same time. You just need to be mindful of your surgical flap design and over-engineer your treatment. For example, exo, debride site completely, place implant (ensure proper torque), place PRF+particulate graft, protect with PRF membrane(s), place CT graft overtop, suture with primary closure . But, yes - it could be done too, but with greater risk of complication if steps taken are not ideal. Keep us posted! Now, if the dehiscence is very wide and deep, where the labial wall is absent, I would definitely consider using particulate + PRF, and possibly a Ti mesh with tacs. Or a Ti-reinforced PTFE membrane with tacs. Hope that helps! Bernard

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Bernard Jin Replied at Tue, Jan 11, 2011 10:25 PM

Case Question: Hi there, I have a case coming up where I would like to try using PRF. My patient has a 2.2 with a root fracture on the buccal. Probing on the buccal reaches the apex. I would like to extract the tooth and immediately socket graft it, then have the patient wear a flipper for a few months while the graft heals, before placing the implant. First of all, is this the protocol you would follow, or would you prefer exo and immediate implant placement with immediate temporization? The reason I want to socket graft it first is to clean up the lesion near the apex, and also allow the buccal bone where the defect is to heal first. I don't want to place the implant and have some threads on the buccal exposed, and then place some grafting material on the buccal and hope bone forms around the exposed threads. I've done this once before, and the results were not that great. Secondly, if you do recommend the socket graft first, would you use just the PRF, or would you mix it with some allograft material? Also, would you need to use a collagen membrane on the buccal at all, around the osseous defect? Or perhaps a PRF membrane? Finally, do you just close the socket graft with a collaplug and a suture, or perhaps a plug of PRF and a suture? Thanks!

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Bernard Jin Replied at Tue, Jan 4, 2011 9:31 PM

Quite a number of study club members have posed questions about the Platelet Rich Fibrin (PRF) system. Namely, the 2 main questions are: 1. What is PRF? 2. How is PRF different than other systems that harvest/utilize autologous biomodifiers. Platelet Rich Fibrin (PRF), also known as Leukocyte-Platelet Rich Fibin (L-PRF), is an autologous fibrin matrix. Dr. Joseph Choukroun, a physician & surgeon in France, first pioneered this PRF fabrication technique for the purpose of wound healing in his field of medicine. The fibrin matrix works by releasing growth factors for the purpose of tissue healing/grafting into the surgical site/wound. The PRF matrix is fabricated by centrifuging whole blood drawn chairside from the patient's arm. The PRF matrix is a reservoir of platelets, fibrin and leukocytes (white blood cells). The matrix can be fabricated and easily modified into various forms that facilitate handling during the surgery. For example, the PRF matrix could be converted into a membrane for purposes of hard/soft tissue grafting; it may converted into a plug for cases such as post-extraction ridge preservation. The main differences between PRF and other systems is that the PRF system is - not heavily dependent on operator technique for successful PRF fabrication (e.g. no need for pipette technique, multiple spins, etc.) - utilizes leukocytes (for the purpose of GF up-regulation over several days) - completely and truly autologous (where no extrinsic citrate dextrose, EDTA, calcium chloride or thrombin is introduced) These are but a few of my thoughts on PRF. I hope that helps.