MATOTE, JIA MAE E.
DMD5A
Application of Advanced Platelet-Rich Fibrin in Oral and Maxillo-Facial Surgery: A Systematic
Review
Marek Chmielewski 1, Andrea Pilloni 2, Paulina Adamska 3,*
PMCID: PMC11678554 PMID: 39728177
Abstract
Background: Advanced platelet-rich fibrin (A-PRF) is produced by centrifuging the patient’s blood in
vacuum tubes for 14 min at 1500 rpm. The most important component of A-PRF is the platelets, which
release growth factors from their ⍺-granules during the clotting process. This process is believed to be the
main source of growth factors. The aim of this paper was to systematically review the literature and to
summarize the role of A-PRF in oral and maxillo-facial surgery. Materials and Methods: A systematic
review was carried out, following the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines (PROSPERO: CRD42024584161). Results: Thirty-eight articles
published before 11 November 2024 were included in the systematic review. The largest study group
consisted of 102 patients, and the smallest study group consisted of 10 patients. A-PRF was most often
analyzed compared to leukocyte-PRF (L-PRF) or blood cloth. A-PRF was correlated with lower
postoperative pain. Also, A-PRF was highlighted to have a positive effect on grafting material integration.
A-PRF protected areas after free gingival graft very well, promoted more efficient epithelialization of donor
sites and enhanced wound healing. Conclusions: Due to its biological properties, A-PRF could be
considered a reliable addition to the surgical protocols, both alone and as an additive to bio-materials,
with the advantages of healing improvement, pain relief, soft tissue management and bone preservation,
as well as graft integration. However, to determine the long-term clinical implications and
recommendations for clinical practice, more well-designed randomized clinical trials are needed in each
application, especially those with larger patient cohorts, as well as additional blinding of personnel and
long follow-up periods.
Keywords: advanced platelet-rich fibrin, A-PRF, autografts, dentistry, growth factors, wound healing
Introduction
Since the first clinical introduction of platelet-rich fibrin (PRF) in dentistry by Choukroun in 2001 [1,2,3,4],
PRF has grown to be one of the most influential natural resources in regenerative dentistry. In 2014,
advanced platelet-rich fibrin (A-PRF) was introduced and described by Ghanaati et al. [5] and Choukroun
[6] as one of the most promising iterations. So far, three generations of blood-derived platelet-rich
preparations rich in growth factors have been identified:
[Link]-rich plasma (PRP), plasma-rich in growth factors (PRGF);
II. platelet-rich fibrin;
[Link] platelet-rich fibrin, advanced platelet-rich fibrin plus (A-PRF+), injectable platelet-rich
fibrin (I-PRF), concentrated growth factor (CGF), titanium platelet-rich fibrin (T-PRF) and
autologous fibrin glue (AFG) [7,8].
A-PRF (Figure 1) is derived from the patient’s venous blood drawn prior to surgery (most commonly from
the brachial vein) without the use of anticoagulants. The autogenous origin ensures no undesirable
antigen reactions after graft placement and during integration. The gelatinous consistency and state are
similar to PRF due to a similar process of obtaining it [9,10]. It consists of a fibrinous matrix with mixed
platelets, leukocytes, macrophages, neutrophils, proteins, cytokines and growth factors present in the
blood, which are densely trapped. The matrix ensures mechanical strength and serves as a binding agent
for cytokines and growth factors. A looser structure provides a more even distribution of cytokines than
PRF, and more interfibrous space allows for more cells present in the cloth [5,9,10].
Figure 1.
A-PRF clot in glass-coated plastic tubes.
Cytokines and growth factors play an important role in biochemical properties. A-PRF affects both soft
and hard tissues, mainly due to the effects on tissue fibroblast regeneration [10,11] and osteoblasts [11].
The most important part of A-PRF are platelets that release growth factors from their ⍺-granularities
during clotting. This process is believed to be the main source of growth factors, such as platelet-derived
growth factor (PDGF), vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF),
transforming growth factors (TGF-⍺ and β), bone morphogenetic proteins (BMPs, such as BMP-2) and
matrix metalloproteinases (MMPs, such as MMP-9). A-PRF has been shown to release more of these
growth factors and MMPs than PRF due to its modified centrifugal processing. Research works indicate
that A-PRF is currently the most favorable PRF-like material available, providing cytokines for up to 10
days [6,9,12,13,14]. Also, the addition of Ca2+ can alter the amount of growth factors secreted into
surrounding tissues [15].
In order to obtain A-PRF, the patient’s blood has to be placed in a centrifuge and processed at 1500 rpm
for 14 min, as opposed to the classical PRF at 3000 rpm for 12 min. There is also no anticoagulant, which
gives A-PRF better biological properties compared to classical PRF. The lower centrifugation parameters
of A-PRF compared to PRF or L-PRF do not allow the platelets to be pushed down the tube. The
advantage of lower centrifuge speed in A-PRF preparation is the improvement of properties. Neutrophils
can migrate to the fibrin matrix [6]. It is proven that in A-PRF in the peripherals of the cloth, there are
platelets present. The difference in the processing can be responsible for more optimized, longer lasting
and more even distribution and release of growth factors from A-PRF to the surrounding tissues, affecting
tissue regeneration and maturation in comparison to PRF and L-PRF. The distribution of lymphocytes,
macrophages and stem cells is greater in the proximal part of the cloth, whereas neutrophils are located
mainly in the distal part [2,5,6]. It is postulated to reduce the formation time of A-PRF to 8 min, which
further improves its biological properties. Further modifications of centrifugation led to the creation of
I-PRF (700 rpm, 3 min), which has even more concentrated factors than advanced and leukocyte PRF. In
comparison to PRF, it must be used within 20 min of preparation vs. 4 h for A-PRF. It is very important to
maintain the speed of rotations per minute, time, relative centrifugal force, diameter and angulation of the
rotor in the centrifuge, size and type of test tubes. Any change may lead to the incorrect production of
blood-derived platelet-rich preparations rich in growth factors and loss of the related properties. Horizontal
vs. fixed angle centrifugation is also important because horizontal centrifugation leads to four times higher
cell concentration, which is evenly distributed across the top of the tube and is not damaged as much.
The more hydrophilic the tube surface, the better the clot quality [2,5,6,16,17].
A-PRF is primarily used in surgical procedures. However, it can also be used in general oral surgery
(filling the post-extraction socket, in treatment of alveolar osteitis, used to control bleeding–hemostatic
effect), endodontics (in regenerative endodontic treatment (RET) of traumatized immature non-vital teeth),
implantology (bone regeneration, socket preservation, alveolar ridge preservation, maxillary sinus
augmentation), periodontics (in treatment recessions) and to enhance general wound healing (reduced
pain, swelling or trismus) [2,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40]. This
makes A-PRF just as versatile as PRF. The aim of this paper was to collect and review the information
about A-PRF, its role and its advantages in oral and maxillo-facial surgery.
Use of CGF in Oral and Implant Surgery: From Laboratory Evidence to Clinical Evaluation
Andrea Palermo 1, Laura Giannotti 2, Benedetta Di Chiara Stanca 2, Franco Ferrante 3, Antonio Gnoni 4,
Paola Nitti 5, Nadia Calabriso 6, Christian Demitri 5, Fabrizio Damiano 2, Tiziano Batani 7, Massimo
Lungherini 7, Maria Annunziata Carluccio 6, Biagio Rapone 8, Erda Qorri 9, Antonio Scarano 10, Luisa
Siculella 2,*, Eleonora Stanca 2,*, Alessio Rochira 2
Abstract
Edentulism is the condition of having lost natural teeth, and has serious social, psychological, and
emotional consequences. The need for implant services in edentulous patients has dramatically
increased during the last decades. In this study, the effects of concentrated growth factor (CGF), an
autologous blood-derived biomaterial, in improving the process of osseointegration of dental implants
have been evaluated. Here, permeation of dental implants with CGF has been obtained by using a Round
up device. These CGF-coated dental implants retained a complex internal structure capable of releasing
growth factors (VEGF, TGF-β1, and BMP-2) and matrix metalloproteinases (MMP-2 and MMP-9) over
time. The CGF-permeated implants induced the osteogenic differentiation of human bone marrow stem
cells (hBMSC) as confirmed by matrix mineralization and the expression of osteogenic differentiation
markers. Moreover, CGF provided dental implants with a biocompatible and biologically active surface
that significantly improved adhesion of endothelial cells on CGF-coated implants compared to control
implants (without CGF). Finally, data obtained from surgical interventions with CGF-permeated dental
implants presented better results in terms of optimal osseointegration and reduced post-surgical
complications. These data, taken together, highlight new and interesting perspectives in the use of CGF in
the dental implantology field to improve osseointegration and promote the healing process.
Keywords: CGF, growth factor, stem cells, blood-derived biomaterials, osteogenic differentiation, dental
implants, dental implantology, osseointegration
1. Introduction
Partial or total edentulism could be replaced with removable dentures, and such a solution is often
rejected by the patient due to poor functionality and stability. The implant-retained and implant-supported
prosthesis have become a common device that improves the treatment of edentulous patients [1,2,3,4].
Osseointegration is a critical and fundamental process for the favorable outcome of the dental implant.
The most important aspects for successful osseointegration are the biological characteristics of the host
site (the patient) and the macro- and micro-structure of the prosthetic implant [5,6]. Dental implant
surfaces have now achieved outstanding performances and several physical, mechanical, or chemical
procedures have been used to increase roughness, resulting in improved wettability [7]. Common implant
surfaces are classified into two great categories: smooth and treated. It has been clearly demonstrated
that micro-rough surface implants determine a greater and faster new bone tissue addition when
compared to smooth surface implants.
Osteoblast differentiation and its implication in the osseointegration process are affected by implant
surface nano- and micro-topographical characteristics. Several phenomena, such as clot formation, fibrin
texture retention, and cell population differentiation, are influenced by the surface topography. The
biomechanical processes occurring at the interface between the tissues and the implant surface, as well
as the implant–prosthetic material are governed by the implant design (external micro- and
macro-structure), the patient response, the surgical technique, by the conditions, and by the loading
times. Air exposure of the implant surface leads to an oxidized layer formation which represents a suitable
substrate for its interaction with body fluids, the first and fundamental mediator of all biological processes.
Implant insertion and the consequent surgical trauma cause bone blood vessel interruption, with
subsequent bleeding: this determines contact between biological fluids of the host and the inserted
implant surface. The absorption of ions and macromolecules of blood origin on the implant surface is
immediate and important both for the platelet adhesion itself and for the consequent osteogenesis.
Implant surfaces have achieved remarkable performance, thus guaranteeing highly successful
osseointegration [8].
However, the success of dental implants and optimal control in the post-operative period in elderly
subjects and in patients with chronic degenerative diseases is still under debate; therefore, new strategies
are needed to accelerate wound healing and prevent or mitigate post-operative complications even in
unfavorable conditions. Further improvements to modern implants can be obtained biologically by adding
autologous growth factors, obtained by processing the patient’s venous blood.
Based on their characteristics and methods of preparation, platelet derivatives can be classified into three
different generations. The first generation is platelet-rich plasma (PRP), which contains several growth
factors involved in tissue repair, but the use of anticoagulants and bovine thrombin is required to induce
fibrin polymerization [9,10]. Currently, the PRP has been divided into two subclasses: pure platelet-rich
plasma (P-PRP) and leukocyte- and platelet-rich plasma (L-PRP) [9].
The second generation consists of platelet-rich fibrin (PRF) and can be classified into three subgroups:
pure platelet-rich fibrin (P-PRF), leukocyte- and platelet-rich fibrin (L-PRF), and injectable PRF (I-PRF)
[9]. For its preparation, blood samples are collected without the use of anticoagulants or biological agents
[10].
The third and latest generation of platelet concentrate products is concentrated growth factors (CGF),
developed by Sacco in 2006 [11]. CGF is produced by the centrifugation of venous blood without the
addition of any exogenous product and is therefore free from cross-contamination. Repeated switch of the
centrifugation speed leads to the production of CGF with high amounts of cytokines, platelets, nucleated
cells, and very dense fibrin scaffolds [12,13,14,15]. CGF, as a platelet concentrate, is rich in multiple
growth factors released by activated platelets capable of mediating inflammation, angiogenesis, and
wound repair [16,17,18]. The autologous growth factors can be released by CGF gradually over a period
of time, playing a crucial role in hard and soft tissue repair [17,18]. Moreover, the fibrin scaffold of CGF, or
products obtained from its processing, entangle stem cells able to differentiate into several cell types
[17,18,19,20,21]. Cell-based therapy for the regeneration of bone tissue has been extensively
investigated [22,23]. Recently, we demonstrated that CGF induced osteogenic differentiation of human
bone marrow stem cells (hBMSC) and promoted endothelial angiogenesis due to the release of soluble
and cellular components suggesting CGF as a biomaterial for therapeutic vasculogenesis in the field of
tissue regeneration. [10,18].
However, the potential role of the CGF in improving the process of osseointegration of dental
implants is unclear. In the present study, we used an innovative method which allowed us to permeate the
titanium dental implants with CGF before their implantation in the patients. The aim of this work was to
investigate the effects of CGF-permeated dental implants on the osseointegration process both in in vitro
and in vivo models.
In recent years, CGF was widely recognized as an autologous blood derivative able to promote
tissue repair affecting vascularization, cell migration, and differentiation [10,17,18,28,29,30]. Tissue repair
is a complex mechanism that takes place through inflammatory processes, cell proliferation,
differentiation, and matrix remodeling. Several mediators can be involved including cytokines, growth
factors, and matrix-degrading enzymes [31]. Despite the large literature on CGF use and applications in
the regenerative medicine field [30,32], up to the present, few data are provided on the effects of CGF in
improving the bioactivity of the dental implant surface as well as osseointegration processes and tissue
regeneration.
The osseointegration is defined as a direct structural and functional connection between the living
bone and the surface of the load-carrying implant. This process is critical for implant stability and is
considered a prerequisite for implant loading and long-term clinical success of osseous dental implants
[33]. The key steps in osseointegration are the tissue response to the implantation, and the peri-implant
osteogenesis and bone remodeling. Implant design and composition, patient systemic factors, surgical
technique, and loading characteristics can all affect the success of osseointegration [34].
Dental implant surfaces have now achieved outstanding performances. Common implant
surfaces are classified into two great categories: smooth and treated. The implant micro-surface and
nano-surface modifications have been proven to affect cellular responses such as cell adhesion,
proliferation, differentiation, and migration, thus influencing bone healing. Due to surface modifications, it
was possible to overcome the adverse effects of length reduction and the unfavorable crown–implant ratio
of short implants, shortening the time needed to achieve secondary stability and deliver prosthetic
restoration [35]. The decontamination of the implant surface is also of fundamental importance. This
procedure is useful for prosthetic loading and to minimize peri-implantitis, which is the main cause of
implant failure [36].
In the present study, we used an innovative method capable of permeating titanium dental implants with
CGF in order to make the surface of the device biologically active, before their implantation in patients.
The aim of this work was to investigate the effects of CGF-permeated titanium dental implants on the
osseointegration process by analyzing the molecular mechanisms involved.
Results reported in this study showed that dental implants were efficiently permeated with CGF. The
CGF-permeated implants presented a dense network of fibrin with trapped corpuscular elements. These
observations agree with our previous studies reporting the presence of resident cells with different
morphology into the CGF scaffold [17,18]. We reported that CGF entangled, in the fibrin matrix, a large
number of cells with stem cell features that regulated the production and sustained the release of
CGF-soluble mediators, including growth factors and MMPs.
In order to verify whether the CGF layer covering the implants retained the ability to release over time
soluble mediators involved in wound repair and tissue regeneration, as reported earlier for the CGF
scaffold [17], in this work we incubated the CGF-permeated implants in the culture medium and analyzed
the presence of growth factors and MMPs.
We found that CGF-permeated implants released into the surrounding environment over time both growth
factors, including VEGF, TGF-β1, and BMP-2, and matrix-degrading enzymes, such as MMP-2 and
MMP-9.
Among the factors released by the CGF, VEGF is a crucial molecule in tissue repair and regeneration
being implicated in post-natal neo-vascularization in terms of angiogenesis, the formation of new
capillaries from pre-existing vessels by mature endothelial cells, and vasculogenesis, the de novo vessel
growth by bone-marrow-derived endothelial progenitor cells [37,38]. Due to the very short half-life of
VEGF [39], a system of prolonged release of this growth factor is necessary to provide effective
therapeutic action. This challenge can be overcome by the use of CGF, which could guarantee a
prolonged release of VEGF over time.
In addition to VEGF, the implant permeated with CGF also released the growth factor TGF-β1, which is
critical at wound healing sites and particularly in the oral cavity, where different types of cells, such as
fibroblasts and osteoblasts, must be stimulated to proliferate and promote the process of tissue
regeneration/remodeling [40].
BMP-2, another important member of the TGF-β superfamily, plays a prominent role in bone and cartilage
development. It is a growth factor that can promote the differentiation and maturation of osteoblasts [41].
Our findings, reporting a sustained release of BMP-2 over time from CGF-permeated implants, suggest
that the coverage of devices with CGF could improve the repair processes at the injury site. In addition to
growth factors, we also found that CGF released matrix-degrading enzymes involved in many biological
processes, including inflammation and cell migration during wound healing and tissue repair in
coordination with different growth factors and cytokines [42].
Moreover, our results demonstrated that CGF-permeated implants possessed a biocompatible and
biologically active surface which improved the adhesion of endothelial cells on CGF-coated implants with
respect to the untreated traditional implants.
The fibrin matrix, covering dental implants, appears as an excellent substrate for the adhesion, migration,
and invasion of endothelial cells, and subsequent formation of new capillary-like structures [19,43].
Endothelial cells can be recruited from tissues adjacent to the wound, bind to fibrin through various cell
adhesion receptors, and lead to the formation of new vascular structures [18,44]. In addition to fibrin,
growth factors and MMPs, concentrated in the CGF and gradually released, help to promote the
adhesion, proliferation, migration of endothelial cells, and new capillaries formation, favoring the
integration of CGF-permeated implants.
The results here reported showed that the CGF provided the implants with a biologically active and
biocompatible surface for endothelial cells, improving their adhesion, which is a fundamental step for
inducing angiogenesis and wound healing with promoting effects on the stability of the implants and
confirming CGF as a valuable biomaterial to be applied also in the field of dental implants.
Recently, we demonstrated the ability of CGF to release primary cells, capable of differentiating into
osteoblasts by producing a mineralized matrix [17], and to promote the osteogenic differentiation of stem
cells [10]. Here we found that CGF permeated on the implants was able to induce hBMSC differentiation
in osteoblasts, as supported by the evaluation of hBMSC matrix mineralization. The hBMSC osteogenic
differentiation induced by the CGF-permeated implants was supported by the increased expression of the
transcription factor RUNX2, key regulator of osteogenesis, and of two extracellular matrix proteins
COL1a1 and OCN. It is interesting that a similar trend of osteogenic marker gene expression has been
previously observed using the whole CGF [10]. Several studies supported the role of the BMP-2-triggered
signaling pathway in mediating the CGF induction of mesenchymal cells’ osteogenic differentiation,
through the stimulation of RUNX2 and OCN expression [29,45,46]. It has also been reported that CGF
stimulated the proliferation and osteogenic differentiation of gingiva-derived mesenchymal stem cells by
regulating the expression of BMP2 and RUNX2 [46], and upregulating the expression and secretion of
osteogenic differentiation markers, including COL1 and OCN, in rabbit periosteum-derived cells [29].
Thus, the present findings suggested that the continuous and prolonged release of multiple bioactive
factors over time by the CGF-coated implants can stimulate the complex and long process of tissue
regeneration.
These findings were achieved in preclinical models, known as reliable tools for studying osteogenesis and
the endothelial biocompatibility of CGF-permeated devices. However, our in vitro experimental results do
not necessarily translate directly into the in vivo situation. Therefore, the following investigations have
been performed to evaluate the in vivo efficacy of CGF-permeated implants in promoting osseointegration
and tissue regeneration, and reducing post-surgical complications.
Data obtained from surgical interventions with CGF-coated dental implants presented better results in
terms of osseointegration as well as of post-surgical complications. In particular, subjects enrolled in the
present study reported that CGF-permeated implants produced a lower level of pain than traditional
implants 1 day after surgery. The effect of CGF in lowering the level of pain is in agreement with another
previous study by Taschieri et al. [47] showing the positive influence of CGF on quality of life by
minimizing post-operative discomfort after dental implant rehabilitation. Furthermore, CGF was found to
be effective in reducing pain levels after extraction of the mandibular third molar [27].
We also reported data regarding bleeding on probing and dental implant success 6 months after dental
implant surgery. We found that CGF improved the success of the dental implant and the post-surgical
complications, observing a trend in the reduction of bleeding on probing of CGF-permeated implants
compared to traditional implants. Our results agree with a recent study by Shetye et al. [48] reporting that
CGF accelerated osseointegration and had a positive effect on stabilization values.
Nevertheless, the results regarding the beneficial effects of CGF in dental implants are still conflicting.
Özveri Koyuncu et al. [49] found that the use of CGF during dental implant surgery had a neutral effect on
implant stability compared to traditional implants. However, in the studies conducted so far, the CGF was
inserted into the dental socket prior to the insertion of the dental implant.
Otherwise, we obtained an implant permeated with CGF before its implantation in the dental cavity. This
was an innovative, easy, and fast method based on the permeation of titanium dental implants with CGF,
obtaining a biologically active surface ready to be used in dental rehabilitation. Here we characterized the
biological properties of these implants in terms of the release of key factors in wound healing and tissue
regeneration including growth factors and matrix metalloproteinases. Furthermore, we reported the
osseointegration properties of CGF-permeated implants and verified the effects in vivo.
We had excellent results in all patients treated with both immediate loading and conventional (late)
loading. Immediate loading provides benefits such as short treatment time, the elimination of the second
surgery required for later loading protocols, the protection of the gingival papilla, an immediate esthetic
effect, and high patient satisfaction [50]. However, no significant differences in the survival rate were
reported between the immediately and conventionally loaded implants.
The importance of correct implant rehabilitation is also fundamental for improving one’s real and
perceived quality of life. Numerous studies show that this phenomenon is particularly evident in
vulnerable groups such as the elderly [51]. Most of the older adults perceived that the most affected
dimensions were psychological discomfort and functional limitation. Age, educational level, marital status,
type of insurance, and level of income had a statistically significant relationship with oral-health-related
quality of life.
Overall, our findings highlighted CGF as a healing biomaterial that can be utilized in dental implantology
surgical procedures to fasten healing and reduce post-operative discomfort, with positive effects in the
success of the dental implant and suggested new interesting perspectives in the use of CGF in tissue
repair and regeneration.
