L-PRF in the treatment of intrabony defects
Introduction
Intrabony defects are a common feature of Stage III and IV periodontitis. They are associated with an increased risk of progression (Papapanou & Wennström 1991) and often require surgical intervention. It is well established that regenerative surgical procedures using Guided Tissue Regeneration (GTR), Enamel Matrix Derivative (EMD), or bone grafts provide significant adjunctive clinical benefits compared to open flap debridement (OFD) alone. These strategies are recommended as the treatment of choice for residual pockets with deep (≥3 mm) intrabony defects that persist after Steps 1 and 2 of periodontal therapy (as defined by the EFP S-3 clinical guidelines, Sanz et al. 2020, Nibali et al. 2020, Herrera et al. 2022). The same treatment approach applies to teeth with class II or III furcation defects (Jepsen et al. 2020). A large number of RCTs indicate that the application of L-PRF during OFD also has a significant adjunctive benefit.
Protocol: step by step
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prepare the bony defect(s) and oral cavity for a regenerative procedure,
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complete a thorough root planing and remove all granulation tissue,
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rinse the bony defect with L-PRF exudate (antibacterial capacity),
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create some perforations in bony defect if the blood supply is insufficient,
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apply chopped pieces of an L-PRF membrane in the defect,
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seal the defect with an L-PRF membrane (extending over the bony borders),
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suture for primary healing.
Video: Treatment of intrabony defect on premolar
step-by-step flow chart
The initial steps of periodontal therapy must always be completed before a regenerative treatment. After preparing a minimally invasive flap, thorough root planing and removal of all granulation tissue are crucial. Rinse the socket with L-PRF exudate to disinfect it. Fill the intrabony defect with pieces of chopped L-PRF membrane (preferably the face portion) and cover it with L-PRF membranes. Ensure the membranes extend over the buccal and lingual bony borders. Primary closure should be obtained.
For this indication, several strategies have been proposed, but this protocol seems to be the most effective.
Cases
(d = day, w = week, m = month, y = year)
1: Open flap debridement + application of L-PRF only.
d 0: 6 mm deep intrabony defect (mesial site) after root planing.
d 0: application of an L-PRF membrane as sealing.
d 0: application of pieces of chopped L-PRF membrane.
d 0: primary wound closure.
d 0: the defect is well filled, and the L-PRF graft is condensed.
m 3: optimal healing with PPD ≤ 3 mm.
2: Open flap debridement + application of L-PRF only.
Intraoral radiographs: the top row shows images before, and the bottom row 3 m after OFD combined with the application of L-PRF (chopped pieces in the bony defect and covered with L-PRF membranes). The red line represents marginal bone level before the L-PRF application.
Data:
1. RCTs comparing OFD vs. OFD + the use of L-PRF only
Numerous studies have investigated the application of L-PRF as the sole substitute in guided tissue regeneration. Various protocols have been explored, often with an open flap debridement (OFD) as a control therapy. The predominant strategies include: (a) covering the intrabony defect solely with L-PRF membranes as a barrier membrane; (b) filling the defect exclusively with L-PRF (membrane/clot); and (c) the most advantageous approach, which involves filling the defect with L-PRF (chopped pieces) and covering it with L-PRF membranes. To further elucidate the beneficial effects of L-PRF, a subanalysis of the most common strategies (b and c) has been conducted (table below).
1a RCTs comparing OFD vs. OFD + filling the defect with L-PRF (option b)
Abbreviations: RCT = randomized controlled trial, Subjects: n = number, ♀ = female, ♂ = male; Treatment: OFD = open flap debridement, M-Mist = modified minimally invasive surgical technique, C = control group, T = test group, PRF = leukocyte- and platelet-rich fibrin (acronym as mentioned in the paper: A = advanced, CGF = concentrated growth factor); cl = clot; m = membrane; Outcome: PPD = probing pocket depth, CAL = clinical attachment level, RAL = relative attachment level, IBD = intrabony defect, DDR = defect depth reduction.
Conclusion
Twelve randomized controlled trials (RCTs) evaluated the beneficial effects of L-PRF application in intrabony defects during open flap debridement. Nine of these studies reported additional reductions in probing depth, gains in clinical attachment level, and/or increased bone fill when applying L-PRF. Some recent studies (Mubarak et al. 2023, Alshujaa et al. 2024), however, did not confirm these statistically significant benefits, and no clear explanations have been provided for these conflicting observations. L-PRF does not seem to offer a benefit when combined with an M-Mist (updated from Miron et al. 2025a).
1b RCTs comparing OFD vs. OFD + defect fill and coverage with L-PRF (option c)
Abbreviations: Subjects: n = number, ♀ = female, ♂ = male; Treatment: OFD = open flap debridement, C = control group, T = test group, PRF = leukocyte- and platelet-rich fibrin (acronym as mentioned in the paper: A = advanced, CGF = concentrated growth factor); cl = clot; m = membrane; Outcome: PPD = probing pocket depth, CAL = clinical attachment level, RAL = relative attachment level, IBD = intrabony defect, DDR = defect depth reduction, RBF = radiographic bone fill, BDF = bone defect fill.
Conclusion
Fourteen randomized controlled trials (RCTs) have examined the benefits of an L-PRF application in intrabony defects (both as a filling material and as a barrier membrane) during open flap debridement. All these studies reported statistically significant improvements in favor of L-PRF (e.g., additional reductions in probing depth, gains in clinical attachment levels, and/or increased bone fill, and one study even improved HbA1c levels; updated from Miron et al. 2025a).
2: RCTs comparing OFD + bone substitute vs. OFD + bone substitute + L-PRF
The literature remains inconclusive regarding the added value of combining L-PRF with a bone substitute during guided tissue regeneration, partly due to the variability in protocols and the selection of bone substitutes. For the control group, two options are frequently considered: OFD combined with the application of a bone substitute in the intrabony defect, either without or with a barrier membrane. In the test group, several options have been evaluated, including: (a) the mixture of the bone substitute and chopped L-PRF membranes; (b) using this mixture in combination with L-PRF as a barrier membrane (or a slow resorbing membrane); or (c) the application of an L-PRF bone-block.
To elucidate the adjunctive effect of L-PRF, a subanalysis for each of the aforementioned combinations is essential. However, this is currently unfeasible due to the lack of sufficient RCTs for each study protocol.
Miron and colleagues (2025a) concluded in their recent systematic review that adding L-PRF to a bone grafting material may offer additional clinical advantages, thus warranting further investigations. Future studies should explore various L-PRF protocols, assess longer-term outcomes, and incorporate histology.
Important Notice
Clinical experience:
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Minimally invasive surgical techniques (e.g., MIST or M-MIST) enhance the outcomes of GTR procedures.
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Vertical releasing incisions should be avoided.
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Due to the higher biological activity in the "face" portion of L-PRF membranes, this section should be used to fill the intrabony defects.
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Ensure an optimal blood supply to the graft.
Additional Benefits:
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Utilizing L-PRF as the sole grafting material ensures that the treatment is entirely autogenous, without any foreign materials.
Is the use of L-PRF in furcation defects beneficial?
Miron and co-workers (2025b) evaluated the benefits of incorporating L-PRF into furcation defect treatments during OFD. Their analyses included twenty-one RCTs focusing on class II furcations with various treatment strategies. The addition of L-PRF to OFD significantly improved clinical outcomes, such as:
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probing pocket depth (PPD): 1.7 mm more reduction (95% CI: 1.1-2.3),
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vertical clinical attachment level (VCAL): 1.4 mm more gain (95% CI: 1.0-1.8),
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and horizontal clinical attachment level (HCAL): 1.2 mm more gain (95% CI: 0.7-1.7).
When L-PRF was added to a bone graft during OFD, improvements were also observed:
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0.7 mm more PPD reduction (95% CI: 0.3-1.2),
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0.8 mm more VCAL gain (95% CI: 0.3-1.4),
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and 1.3 mm more HCAL gain (95% CI: 0.7-1.9), respectively.
Direct comparisons between OFD with L-PRF alone and OFD with other substitutes (bone graft, collagen membrane, or rhBMP2) revealed similar outcomes across all parameters, including PPD reduction, VCAL/HCAL gain, and radiographic bone fill (RBF).
The additional incorporation of a bone graft to OFD+L-PRF only slightly enhanced the outcomes.
Furthermore, adding small biomolecules such as metformin, bisphosphonates, or statins to L-PRF during OFD significantly further improved PPD, VCAL, and HCAL compared to OFD with L-PRF alone. For more details, see Miron et al. 2025b.
Interesting references
Several videos and/or cases on this webpage are discussed more in detail in the following book: Quirynen M & Pinto N 2022. Leukocyte- and Platelet-Rich Fibrin in Oral Regenerative Procedures. Quintessence Publishing;
ISBN: 978-1-78698-105-9