{"id":30754,"date":"2026-05-04T12:35:22","date_gmt":"2026-05-04T17:35:22","guid":{"rendered":"https:\/\/www.aae.org\/specialty\/?p=30754"},"modified":"2026-05-02T12:45:09","modified_gmt":"2026-05-02T17:45:09","slug":"comparison-of-piezotome-bone-window-lid-with-prf-and-bone-crushing-techniques","status":"publish","type":"post","link":"https:\/\/www.aae.org\/specialty\/comparison-of-piezotome-bone-window-lid-with-prf-and-bone-crushing-techniques\/","title":{"rendered":"Comparison of Piezotome Bone Window\/Lid With PRF and Bone Crushing Techniques"},"content":{"rendered":"

By Drs. Samuel Kratchman and Andrew Grinsell<\/em><\/p>\n

The technique of drawing blood from a patient and centrifuging platelet-rich fibrin (PRF)(1) has been used in dentistry for some time, mostly in the periodontal and oral surgery specialties, where it is commonly used for sinus lifts or ridge preservation\/augmentation for eventual implant placement (2-4). In medicine, a very popular method designed to speed healing is to draw the patient\u2019s blood, centrifuge it in a test tube with additives that prevent clotting, and produce platelet-rich plasma (PRP), which can then be injected directly into the wounded muscle, ligament, or tendon to reduce inflammation and speed up healing. At the University of Pennsylvania, we have been studying the incorporation of PRF into endodontic microsurgery, along with using the piezotome to remove a bone window (lid), and then crush that bone to be mixed with the serum of the PRF membrane, creating autogenous \u201csticky\u201d bone, which is then placed back into the osteotomy site along with the PRF graft and covered by the PRF membrane.<\/p>\n

All dentists agree that the very best types of grafts are autogenous, meaning derived from the patient (5, 6). These are better than allografts, that is, from the same species, for example, cadaver grafts, which lose their osteogenic properties due to processing. Next are xenografts, which are animal-derived, such as bovine or porcine, and have a greater chance of rejection by the recipient. Finally, alloplasts are synthetic bone and have no osteogenic properties.<\/p>\n

The process of harvesting PRF is simple; the patient has two vials of blood drawn (four vials if the lesion is very large) into test tubes that have no additives, such as anticoagulants, and spun in a centrifuge at 2700 rpm for 12 minutes. The vials need to be counterbalanced and of equal volume when spun. The only time constraint is that the blood should be gently inverted a few times and placed in the centrifuge within 90 seconds. After the PRF is spun out in 12 minutes, you can take your time removing the PRF, cutting off the blood clot and then pressing the PRF into plugs (graft) and flattening into a membrane. These can be left in the Expression Kit (BioHorizons, Birmingham, AL, USA) throughout the surgery or placed into small metal basins and kept hydrated with serum derived from pressing the membrane. After the bioceramic root-end filling (EndoSequence Fast-set putty; Brasseler USA; Savannah, Georgia) is placed, the PRF plugs are placed into the osteotomy site and covered by the PRF membrane.<\/p>\n

For every endodontic surgery, an osteotomy must be made or enlarged to gain access to the roots. For years, this has been accomplished by burs in a high-speed handpiece, where the bone is obliterated by the burs. With the advent of the piezoelectric unit, we can now create a bony window (lid), preserve the window in a solution such as Hanks Balanced Salt Solution (HBSS), and then, after the root-end filling is complete, replace the window and secure it into place. This is an excellent opportunity to preserve the bone, but it can be time-consuming, technique-sensitive, and difficult to secure back into place, especially if the osteotomy is altered after bone window (lid) removal. Many preoperative measurements from the CBCT need to be made, the bone needs to be removed in one piece, and if it is not securely repositioned, it can become dislodged and cause a foreign body reaction in the vestibule near the surgical site. These limiting factors have led to the concept of crushing the bone window, mixing the bone particles with the serum derived from the PRF to create \u201csticky bone,\u201d and placing it back into the osteotomy before closure. This eliminates the need for many preoperative measurements, as all that matters is that the bone window is initiated 3 mm from the apices of the roots being resected. The piece of bone can come out in pieces, eliminating the often difficult part of the procedure, as the fragments of bone are crushed before being replaced at the site. Perhaps the most important reason for the bone crushing procedure is that when we traditionally cut out a window\/lid, we are actually severing the blood supply to that bone, and when we reposition, we place a graft inside the osteotomy and collagen around the periphery of the window to secure it and cover it with a membrane before suturing. All chances of revascularization of this bony lid are delayed; therefore, this piece of bone maintains the space until healing can occur. The benefit of crushing the bone, mixing it with serum containing growth factors and stem cells, and placing it back into the osteotomy site sandwiched between pieces of PRF plugs and covered by a PRF membrane is that it is an autogenous graft with little to no chance of rejection and contains many progenitor cells that speed up healing.<\/p>\n

With these new advances in endodontic microsurgery, we are taking an already successful procedure and increasing the potential for healing and reforming healthy, vital bone. More studies need to be conducted, and many more cases utilizing these techniques need to be performed and followed up carefully with 3D imaging, but the future is promising (7, 8).<\/p>\n

\"\"

Courtesy: Dr JouJou Nguyenphuc<\/p><\/div>\n

Figure 1. 55 year old female for surgery #30. A) Pre-op PA image shows PARL associated with mesial root. B) Coronal view of Pre-op CBCT showing associated low density area. C) Bone window being removed during surgery. D) Bone Crusher kit from H&amp;H. E) L-PRF extracted from patient\u2019s blood. F) Crushed bone mixed with L-PRF Serum (not from the case shown). G) BC putty placed. H) L-PRF graft with crushed bone. I) Crushed bone placed into osteotomy. J) L-PRF Membrane placed over osteotomy. K) Post-op PA image. The outline of the bone window is noticeable. L) Coronal view of Post-op CBCT. M) 12 month follow up PA showing complete healing. N) Coronal view of 12 month follow up CBCT showing complete cortical plate regeneration. Some bone particles are noted in the apical area.<\/p>\n

\"\"

Courtesy: Dr Jawad Jaghab<\/p><\/div>\n

Figure 2. 25 year old female for surgery #19: A) Pre-op PA image showing PARL associated with the mesial root. B) Coronal view of Pre-op CBCT. C) Bone window cut. D) Bone window placed in dish. E) End of Bone Crusher plug, highlighting the ridge that disperses force to crush bone into fine particles. F) Bone after crushed. G) Post-op PA. H) Coronal view of Post-op CBCT. I) 12 month follow up PA showing complete healing of the mesial root. J) Coronal view of 12 month follow up CBCT showing complete regeneration of cortical plate, PDL, and Lamina dura around the mesial root.<\/p>\n

Reference:<\/h1>\n
    \n
  1. Jia K, You J, Zhu Y, Li M, Chen S, Ren S, et al. Platelet-rich fibrin as an autologous biomaterial for bone regeneration: mechanisms, applications, optimization. Front Bioeng Biotechnol 2024;12:1286035.<\/li>\n
  2. 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. J Clin Periodontol 2017;44(2):225\u2013234.<\/li>\n
  3. Castro AB, Meschi N, Temmerman A, Pinto N, Lambrechts P, Teughels W, et al. Regenerative potential of leucocyte- and platelet-rich fibrin. Part A: intra-bony defects, furcation defects and periodontal plastic surgery. A systematic review and meta-analysis. J Clin Periodontol 2017;44(1):67\u201382.<\/li>\n
  4. Meschi N, Castro AB, Vandamme K, Quirynen M, Lambrechts P. The impact of autologous platelet concentrates on endodontic healing: a systematic review. Platelets 2016;27(7):613\u2013633.<\/li>\n
  5. Acocella A, Bertolai R, Colafranceschi M, Sacco R. Clinical, histological and histomorphometric evaluation of the healing of mandibular ramus bone block grafts for alveolar ridge augmentation before implant placement. J Craniomaxillofac Surg 2010;38(3):222\u2013230.<\/li>\n
  6. Aoki N, Kanayama T, Maeda M, Horii K, Miyamoto H, Wada K, et al. Sinus Augmentation by Platelet-Rich Fibrin Alone: A Report of Two Cases with Histological Examinations. Case Rep Dent 2016;2016:2654645.<\/li>\n
  7. Sabeti M, Gabbay J, Ai A. Endodontic surgery and platelet concentrates: A comprehensive review. Periodontol 2000 2025;97(1):308\u2013319.<\/li>\n
  8. Rebimbas Guerreiro S, Marto CM, Paula A, Pereira JRA, Carrilho E, Marques-Ferreira M, et al. Platelet-Rich Plasma and Platelet-Rich Fibrin in Endodontics: A Scoping Review. Int J Mol Sci 2025;26(12).<\/li>\n<\/ol>\n

    The authors can be reached at sikratch@comcast.net<\/a>.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

    By Drs. 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