Platelet Rich Fibrin (PRF) for extraction site preservation

Michael Toffler, DDS 1-19-2010

Platelet rich fibrin (PRF) is a second generation platelet concentrate widely used to accelerate soft and hard tissue healing. Its advantages over the better known platelet-rich plasma (PRP) include ease of preparation/application, minimal expense, and lack of biochemical modification (no bovine thrombin or anticoagulant is required). PRF is a strictly autologous fibrin matrix containing a large quantity of platelet and leukocyte cytokines.

This case presentation demonstrates how PRF may be used in site preservation procedures. Additional uses for PRF and detailed explanations of the science behind PRF may be obtained at the official Choukroun PRF Lecture Series

Pre-Op Presentation

Patient presented with a nonrestorable tooth #8.

Pre-Op Preparation of PRF

Blood is drawn from the patient and spun down in the Process(c) PRF centrifuge.

The PRF is then converted to PRF membranes.

Site Preservation of Site 8

Tooth 8 is atraumatically extracted and grafted.

The grafted site 8 is covered with PRF membranes.

Healing of Site 8

After an 8 week healing period, site 8 is ready to receive a dental implant.

Delivery of Dental Implant to Site 8

Implant fixture is delivered to site 8 and covered with another PRF membrane to facilitate and enhance soft tissue closure.

Comments

Sat, 01/01/2011 - 06:49 — newport383

PRGF or PRF which should I try?

Thu, 09/29/2011 - 03:18 — damsdesai

PRF membrane

Hi Everyone

Is anyone using this technique in the UK??

if so where do you get the blood collection vials from???

Thanks

Dams

Mon, 01/03/2011 - 05:58 — SamBusich

PRGF or PRF which should I try? Answer on dentalxp.com

Go to www.dentalxp.com and join. Watch lectures on PRGF by Dr. Eduardo Anitua,the inventor of PRGF and then watch the lecture from Dr. Joseph Choukroun, the inventor of PRF and then make up your own mind? It would seem better than to rely simply upon the recommendations of a few bloggers on this or any other site. Get educated and make your own decision is always BEST!
Good luck
Sam

Wed, 12/29/2010 - 23:11 — Dr Satish Bhardwaj

P R F: What is the best way to make it?

What is the best way to make P R F in your clinic?

Tue, 12/14/2010 - 23:12 — thirtzpn

PRGF: Far Superior

PRGF: Been using in for years and I find it far superior to PRP or PRF.
There are seven text books written on PRGF and cant say the same for the others/

Mon, 12/06/2010 - 07:06 — welperio3

PRF or PRGF: Does it help bone healing or just soft tis?

I know PRP does little to the bone.
Does PRF or PRGF help bone healing or just soft tissue?
Anyone take any courses on PRGF or PRF?

Alex

Tue, 12/07/2010 - 03:53 — Richard Hughes DDS

prf suture technique and membrane protection

I many times use perio pack to protect the membranes. Remember we can only do so much. The patients have to help. So, try to make it patient proof.

Mon, 11/29/2010 - 18:50 — GuamDoc

Suturing the Membrane

I've been doing a lot of reading on PRF membrane usage and like what I hear. I tried a ridge preservation last week with PRF but today the top PRF membrane was gone. I believe it was due to the suturing technique I used (multiple interrupted)Even though, the lower membrane still seems intact and appears to be already integrating.

Question: What is the best technique for suturing PRF membranes over a intact Molar socket? Since every time you lay a flap there is some bone loss; would you need reflect a flap bucal/lingually to tuck it in?

Tue, 11/30/2010 - 07:57 — Dr Chace Heatly

GuamDoc Suture PRF is easy to do

First off I wouldnt hold it in with Co PAck. It compresses the area to much. The advantage of PRF it can be sutured easily. Its almost like rubber.

In a socket I will not tuck it under but simply lay it in the socket over the graft and do a figure 8 and a horizontal mat suture to secure it in place.

Chace.

Tue, 11/30/2010 - 14:37 — GuamDoc

Suture Type

Do you have a preference of what type of suture to use.

Tue, 11/30/2010 - 14:41 — Dr Chace Heatly

Suture Type: Gortex or Chromic Gut

I dont think it matters but I like Gortex or Chromic Gut myself.

Tue, 11/30/2010 - 16:11 — GuamDoc

Would you expect the graft to

Would you expect the graft to be integrated before the chromic gut resorbed? If you were to use Co-Pack how long would you leave it in? Thanks for your help, it's much appreciated.

Wed, 12/01/2010 - 06:19 — Dr Chace Heatly

The Graft is stabilized by the time the Gut resorbs

The Graft is stabilized within the clot by the time the Gut resorbs. So there sohould be no issues.

I dont use Copak so cannot answer.

Mon, 07/12/2010 - 23:58 — marias

PRF VS PRP VS PRGF: Research

hi everybody, I too would like to see the research. But I would also like to see the clinical results and hear from peoples experience. Research is crucial but you cant discount what people are seeing in the clinical practice with improved results with using these items.

Mon, 07/05/2010 - 08:59 — alogos

Repeat question for either of

Repeat question for either of you. What is the rpm of the centrifuge please?? Jason M

Wed, 04/21/2010 - 02:55 — alisultan11

I have a problem plz help

regarding the collecting tubes, I could not find plane tubes in the market, I found 9ml collecting tubes without anticoagulant but coated with z serum activator are they suitable for PRF preparation???

Tue, 11/30/2010 - 19:57 — Richard Hughes DDS

collection tubes for prf

I use the BD 9ml. red top w/o anticoagulant. This is the old style BD Vacutainer tube. I use a medical type centrifuge which spins at about 2700rpms.

Wed, 04/21/2010 - 06:10 — Richard Hughes DDS

COLLECTING TUBES

Use 9 ml. red top BD Vacutainer tubes without any coating. They cost about $18.oo USD per 100.

Tue, 04/20/2010 - 04:52 — Barbegio

My experience with PRP PRGF PRF:

My experience with PRP PRGF PRF:
I started in 2000 using PRP and after 4 years I transformed my practice in PRGF as indicated by Anitua.
Two years ago I met in Nizza Dr. Choukroun and he teach me the PRF system.
When I was back in my office I started to use both, PRF and PRGF, but in my opinion PRF is more predictable because there are less variables.
In the PRGF preparation you have to pipe in the vaquette and like Anitua say you have to do “un pipetado muy meticuloso”.
The problem is that I use a force to pipe and my Assistant another one, the same thing in your office, so you have different results and sometime you don’t have the result because the calcium clorure you have to add in the vaquette is not in the same quantity and so on a lot of variables.
With PRF the product you receive after 12 minutes is always the same and is always ready.
One of the best advantages you see just in the first application of PRF is that after the positioning of the PRF membrane on the surgical site you have always “NO BLEEDING”
So you can suture with more visibility.
That’s it.
Dr. Giovanni Barbè, Codigoro (FE) Italy

Fri, 11/19/2010 - 21:50 — Dr. Santos

PRF protocol

Hi, I have a question: it is possible to obtain this protocol in a PCCS biomet 3i PRP system adapted for PRGF?, and second, it´s possible to use 7ml tubes?, I appreciate your response!

Sat, 11/20/2010 - 06:53 — G Baxter

PRF Protocol

I attended the course last year. I recommend taking the course. I do not believe you can adapt the protocol utilizing the 3i machine. Also the test tubes need to be glass lined.

The machine is cheap go to intra-lock.com
to purchase.

Sat, 11/27/2010 - 21:40 — Dr. Santos

PRF Protocol

Thank you very much, G. Baxter, I will consider taking the course soon.

Sun, 04/25/2010 - 10:04 — Dr. X

PRF PRGF PRP: Good response Giovanni Barbe

Thanks for the info Dr. Barbe. Very helpful. I would like to hear from PRF and PRP users for comparison.

Sun, 04/18/2010 - 12:33 — Oliver Queen DDS

PRF Courses:When is the next one offered?

Went to the intralock website but there was no update. When is the next PRF course as I would like to attend?

Sun, 04/04/2010 - 07:41 — tamada

How to attain PRF?

Is it right? just buy a lab centrifuge(aroud $500),collecting two to eight 10-ml tubes of blood and spinning them in the centrifuge right away at 2700RPM for 12 minutes? Necessary to buy the whole kit from the Process company? It costs $2300.

Wed, 03/31/2010 - 12:18 — big4cep

PRGF PRF

Thank you for your reply. PRGF was better for me then PRP, and at that time PRF was not mentioned in the US. However, from what I observed clinically in my patients and in other clinicians who used PRGF much longer then I did, their clinical results demonstrated thousands of implants under load over multiple years without failure. Including grafted sinuses with implants supporting restorations. I do not find it time consuming, once one trains his team properly. In addition, The clinician that developed this technique was and is using it in his own clinic on his own patients and getting excellent results. How many researchers can claim that? I found that significant.

Tue, 03/30/2010 - 10:14 — choukroun

Answer to big4cep

We are not talking about a product feeling but only on scientific arguments.
The main action of growth factors is cell stimulation and new vessels growth. We know for several years that the growth factors release from PRGF is poor. Please read this article. http://www.ncbi.nlm.nih.gov/pubmed/15747683
With so low concentrations of growth factors you cannot obtain the best result. You say that you have good results with PRGF. Sure, it’s better than nothing. However you have to test the PRF in the same conditions and you’ll see the difference. Because with GF slow release you’ll get better results through a long term cell stimulation.
There are already many international publications about the strong release of growth factors of PRF and its in vitro and in vivo effects.
And the PRF exudate is also rich in growth factor, fibronectin and vitronectin, and is thus usable in combination with bone grafting materials or on implant surface.
Last but not least, the production of PRGF is much more complicated and time-consuming that the production of PRF.
I sincerely believe that you should first read the literature on the topic and try the various techniques before claiming that PRGF is the best for your patients...

Tue, 03/23/2010 - 19:48 — Dr Chace Heatly

PRF, CGF, PRGF..... What is the clinical experience

Just looking to see what are people opinions between the three? What type of clinical results are you seeing?

Sun, 03/28/2010 - 17:58 — big4cep

PRGF PRP don't know about PRF

I have been using PRGF for the past 4.5 years. Prior to that I was using PRP. I practice in NYC USA. The main reason I started using PRGF is because I took it upon myself to go and visit BTI in spain and spend time with Dr. Anitua and his team, the developers of this technology. Once one is able talk to the scientists in the facility, see how the company operates, and see how patients benefit from this science once will be using PRGF. I see the benefits in my own patients and my own surgical outcomes. THe argument of cost is irrelevant because you can charge for that service, and it will replace most of your needs for membranes ( so you are making money this way as well). So then it boild down to science. Not one believes or does not believe, but what is known and discovered through meticulous applications of scientific methodology. If one read hematology reseach and specifically the coagulation cascade, one will see that white blood cells join in wound repair hours to days after the initial clot is established, the platelets released their various factors and direct the wound to heal in the proper manner to generate the appropriate tissue. This happens at any wound. Thus the major factor in the initiation of healing of any wound in the presence of platelets and the release of growth factors. The BTI protocol is the only one that allows the clinician a way to control platelet activation, clot formation and growth factore release. These are three activities that are separated by the PRGF protocol only. One does not have that ability with PRP or PRF because these methods include WBC as well as generate a clot already at the latter method. That is wby PRP does not exhibit hard tissue benefits, and PRF can only be used as a membrane and hard tissue benefits are inconclusive. However PRGF allows one the following: 1-Formation of clot rich in growth factors that can be used as an autogenous graft or used together with particulate graft material, 2-FOrmation of fibrin membrane to be used as membrane in covering grafts or PRGF clots 3- wetting of wound sites or implants. Wetting of wound sites or implants with a concentrate of platelets will allow a higher percentage of growth factors to be released in the wound site, or on the implant surface thus leading to a higher percentage of bone formation or bone to implant surface contact. PRGF protocol is unique in that respect and as far as I am concerned, its the best option for the patient. I encourage you to seek more information from BTI, and if you can go visit their headquartets and see how they operate. You will not be disappointed.

Tue, 03/30/2010 - 14:19 — zivmazor

Differences between growth factors concentrates

I totally agree with Dr Choukroun's comments. One has to understand biology and read the research and not rely on intuition.Studies has shown without doubt that all blood concentrates will promote soft tissue healing due to the growth factors found in the platelets yet for hard tissue repair and healing it is a different story.You need VEGF for blood vessels growth and guess what-it is not found not in PRP and not in PRGF because they do not contain leukocytes yet it is found in PRF...
I will cover these issues in my upcoming courses both in NYC and Atlanta in the next two weeks.

Sat, 01/08/2011 - 22:05 — drramesh3153

PRF: Question for Dr. Mazor on Sinus use.

Dr Mazor, I had read your article on use of PRF as the sole grafting material in sinus augmentation with simultaneous implant placement in J Periodontology Dec.2009. I have recently joined master's course in implantology at the Muenster University in Germany. I am working on the same subject for my dissertation.I have not been able to find comparative values of growth factors concentrations in PRP and PRF. Would you have any articles on this subject? I would appreciate if you could forward them to me. Thanks and regards,

Sun, 01/09/2011 - 09:59 — LaurenJones

Dr Mazor PRF question and osteotome PRF article.

http://journals.lww.com/implantdent/Abstract/2010/10000/Osteotome_Mediat...

Osteotome-Mediated Sinus Floor Elevation Using Only Platelet-Rich Fibrin: An Early Report on 110 Patients

The above article by Dr. Toffler is a very good article on the use of PRF alone in sinus procedures.

Purpose: This article describes a technique and reports on the early healing for localized sinus augmentation using a crestal approach in combination with an autologous leukocyte- and platelet-rich fibrin (PRF) concentrate.

Materials: From November 2008 to January 2010, 138 implants were placed in 110 patients using osteotome-mediated sinus floor elevation (OMSFE) with PRF.

Results: The mean residual subantral bone height of the alveolar ridge was 6.6 mm (range, 4–8 mm). The mean increase in the height of implant sites by OMSFE/PRF was 3.4 mm (range, 2.5–5 mm). A variety of 8- to 11.5-mm long (mean length, 10.1 mm) and 3.5- to 6-mm wide (mean width, 4.4 mm) screw-type implants were used. Of the 138 implants that had been placed, 97 have been restored and in function for an average loading time of 5.2 months (range, 1–11 months). The mean healing time for the loaded implants was 4 months until abutment insertion (range, 3–5 months). Three implants failed before loading for an early survival rate of both loaded and unloaded implants of 97.8%.

Conclusions: Early review of the OMSFE/PRF technique presented for localized sinus floor elevation and implant placement demonstrates a high degree of safety and success at sites with 5- to 8-mm residual subantral bone height.

Lauren

Sun, 03/21/2010 - 08:05 — yazadgandhi

thank you Dr.Toffler

Tue, 03/16/2010 - 04:46 — OrthoKing

PRF, CGF, PRGF Whats the start up costs and price per case

PRF, CGF and PRGF all look interesting and have benefits. For me it may come done to costs.

What is the intial start up costs for each and residual price per case?

Thu, 03/18/2010 - 19:26 — Richard Hughes DDS

Start up cost for prp

Iy you know what to look for and where to look, you can get into it for as little as $300 TO $450 USD.

Fri, 03/12/2010 - 04:22 — yazadgandhi

PRF RPM

DR CHOUKROUN/TOFFLER,

Repeat question for either of you. What is the rpm of the centrifuge please????

Fri, 03/12/2010 - 09:55 — michael toffler

PRF spin

To attain PRF, 2 to 8 9-ml tubes of blood are spun immediately at 2700 RPM for 12 minutes. PRF membranes and plugs remain hydrated in the PRF Box for up to 2 or 3 hours prior to use. See article September issue and review bibliography

Fri, 03/12/2010 - 06:46 — dssohn

rpm for prf

3000 rpm is required

Thu, 03/11/2010 - 13:40 — Ti Doc

Dr. Watkins, Very nice case in the rotator box

Dr. Watkins,

That is a very nice case you have in the rotator box on the bottom of the homepage.

Great management of a misplaced implant. I am sure that your surgeon is thanking you profusely!

Good job.

Fri, 03/12/2010 - 21:31 — Ben Watkins

Prosthetic Correction of a Malplaced Implant Placement

Thanks for your comments. This was a very challenging correction of a malpositioned implant and fortunately it turned out well. Funny, I never heard back from the surgeon that placed this implant but I made the patient well aware of the difficulties of restoring this near impossible situation. I wish that all surgeons had the knowledge not to place implants like this. If only they grafted the site first or used a properly designed and fabricated surgical guide that gave them the type of feedback necessary to make the correct clinical decision. If they had used one then I would not have had to go through restorative gymnastics to restore this single maxillary premolar. I am just glad that the patient didn't need to have this implant trephined out and restarted.

Sat, 03/13/2010 - 09:37 — Richard Hughes DDS

Reply to Dr. Watkins

Nice case. A job well done.

Thu, 03/11/2010 - 10:54 — leopold

implant placement

why You place implant so buccul(may be picture is not clear, but it seems to me implant has to be placed more palatal)???
please explain.THANK YOU

Wed, 03/10/2010 - 06:56 — yazadgandhi

Dr. Choukroun some questions on PRF technique.

What is the RPM of the centrifuge ?
Is there a time delay between withdrawal of blood and the centrifuging process ?
Is there any relation between the Blood profile of the patient and the amount of Fibrin clot obtained ? (As in Hb/MCV/PCV etc.)

Wed, 03/10/2010 - 06:45 — yazadgandhi

PRF preparation

Hi Dr Toffler,
How long between withdrawing the blood and starting the centrifuge??
Is it immediate?
What is the RPM of the centrifuge?
Thanks

Thu, 03/11/2010 - 21:53 — Mental Foramen

Ooh, I had some nice PRF results today

Had a PRF site preservation case come back today for the implant. Niiiiiiiice result. Good bone and nice keratinized gingiva.

I would love to post some pics. When are you guys gonna let us post pics? That would be a GREAT feature. Can you make it happen?

Thanks

Thu, 03/11/2010 - 05:43 — Dr Chace Heatly

yazadgandhi article on PRF

yazadgandhi Dr. Toffler has an nice artilce in the Sept issue of this jounral that explains the PRF protocol nicely. I encourage you to check it out.

Fri, 03/05/2010 - 06:27 — Dr. X

PRF question for Dr. Toffler

Do you find the PRF asks as a nice cushion to your graft material to prevent sinus membrane tears doing an osteotome lift?

Fri, 03/05/2010 - 10:56 — michael toffler

PRF and osteotome

Hey Dr X
PRF is my only graft material in osteotome mediated sinus floor elevation (OMSFE). There is no need to use particulate graft material in OMSFE. Study results with or without graft material are equivocal, PRF introduces element of safety and may also expedite apical healing (my article is now in review at Implant Dentistry).
Best
MT

Sun, 02/28/2010 - 11:30 — Dr. Wentkel

Dr. Toffler another question on PRF

Dr. Toffler while you say improved healing and reduced concentration with PRF.

What are you seeing with the nature of your bone grafts?

I think all the platelet concentrates improve soft tissue aspects, but would like to know if you are seeing improved hard tissue healing?

Sun, 02/28/2010 - 13:41 — michael toffler

PRF

In my experience, improved soft tissue healing and primary coverage of grafted sites always translates into better hard tissue healing and PRF has certainly been helpful in this arena.
Prior to using PRF mixed with the graft and to cover the graft, I would more frequently see a softer quality to the superficial aspect of the graft at a ridge augmentation site and also the crestal aspect of the graft at the extraction site. I believe the addition of PRF is expediting hard tissue healing, attaining the same or improved quality of the graft in a shorter time period.