Platelet Rich Fibrin and its Applications in Dentistry-A Review Article

Abstract

Platelet rich fibrin (PRF) is an autogenous biomaterial consisting of growth factors and cytokines entrapped in a fibrin matrix. It combines the fibrant sealant properties along with growth factors thereby providing an ideal environment for wound healing and regeneration of tissues. In recent times it has been used various disciplines in dentistry in a wide range of treatment modalities.

Full text

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National Journal of Medical and Dental Research, April – June 2014: Volume-2, Issue-3, Page 51-58
Platelet Rich Fibrin and its Applications in Dentistry- A
Review Article
Megha AgrawalA, Vineet AgrawalB
A Private Dental Practioner, Vadodara, Gujrat, India
B Senior Lecturer, Department of Conservative Dentistry and Endodontics,
Manubhai Patel Dental College, Vadodara, Gujrat, India
Abstract:
Platelet rich brin (PRF) is an autogenous biomaterial consisng of growth factors
and cytokines entrapped in a brin matrix. It combines the brant sealant properes
along with growth factors thereby providing an ideal environment for wound healing
and regeneraon of ssues. In recent mes it has been used various disciplines in
denstry in a wide range of treatment modalies.
Key Words: Platelet rich brin (PRF), Wound healing, Denstry, Maxillofacial surgery
Natl J Med Dent Res 2014; 2(3) : 51-58
Manuscript Reference
Number: Njmdr_231_14
Date of submission: 28 April 2014
Date of Editorial approval: 03 May 2014
Date of Peer review approval: 16 May 2014
Date of Publication: 30 June 2014
Conict of Interest: Nil; Source of support: Nil
Name and addresses of corresponding author:
Dr Megha Agrawal
Nisha Dental Clinic, 68, Gayatri Chambers
B/H Railway Station, Alka Puri Road
Vadodara, Gujarat – 390007
India
Phone – 07567146877
Email: drmeghaa4u@gmail.com
Review Article
Introduction:
In the last few decades a variety of
biomaterials have been introduced in
dentistry that can ll in osseous defects and
accelerate wound healing. Materials like
hydroxyapatite, freeze dried bone graft,
tricalcium phosphate, bioactive glass etc.
have been widely used and tested for their
contribution in healing and regeneration of
soft and hard tissues. It was rst described
by Dr. Joseph Choukroun in France to
promote wound healing in implants.
Currently, the studies have been focussed
on the use of an autogenous material
called Platelet Rich Fibrin that provides
an osteoconductive scaffold along with
growth factors to stimulate patient’s own
cells towards a regenerative response [1].
Platelet rich brin (PRF) is a brin matrix
in which platelet cytokines, growth factors
and cells are trapped and may be released
after a certain time and that can serve as a
resorbable membrane [2]. It can be obtained
from blood with the help of a simple
process. PRF is basically a concentrate of
growth factors that promote wound healing
and regeneration which is used in various
disciplines of dentistry to repair various
lesions and regenerate dental and oral
tissues.
Healing of any wound is initiated by clot
formation and inammation, followed by
a proliferative stage which comprises of
epithelialization, angiogenesis, granulation
tissue formation and collagen deposition
and nally collagen maturation and
contraction. Growth factors are mitogenic
(proliferative), chemotactic (stimulate
directed migration of cells) and angiogenic
(stimulate new blood vessel formation).
Therefore, they appear to be critical to the
wound-healing process [1].

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The use of blood derived products to heal wounds started
back in 1970 with the use of brin glues or brin sealants
which were formed by polymerizing brinogen with
thrombin and calcium. It was originally prepared using
donor plasma; however, because of the low concentration
of brinogen inplasma, the stability and quality of brin
glue was low [3, 4].
Regenerative potential of platelets was introduced in 1974
when Ross et al. identied platelet derived growth factor
as a serum growth factor for broblasts, smooth muscle
cells and glial cells (Kohler and Lipton 1974; Ross et al.
1974; Westermark and Wasteson 1976). Now it has been
well documented that platelets provide a rich pool of varied
growth factors such as PDGF-AB (platelet derived growth
factor A B), TGF-Beta1 (transforming growth factor beta-
1), VEGF (vascular endothelial growth factors) broblast
growth factor, insulin like growth factor, epidermal growth
factor, connective tissue growth factor etc.
In transfusion medicine, platelet concentrates were
originally used for the treatment and prevention of
haemorrhage due to severe thrombopenia which is often
caused by medullar aplasia, acute leukemia or signicant
blood loss during long lasting surgery.[3] Platelet
concentrates have also been used in plastic surgery, nerve
injuries, tendinitis, osteoarthritis etc.
In recent times, a variety of platelet concentrates has
been developed and has shown promising results. Platelet
concentrates have been developed with an idea to combine
the brin sealant properties with the growth factors in
platelets thereby providing an ideal base for wound healing
and regeneration of tissues [5]. Platelet rich plasma (PRP),
the rst generation platelet concentrates showed positive
results, however, the complexity of PRP preparation
protocol and the risk of cross-infectiondue to the use of
bovine thrombin led to development a newer generation of
completely autologous platelet concentrates- platelet rich
brin also called as Choukroun’s platelet rich brin named
after its inventor.
PRF was developed in France by Joseph Choukroun et al.
in 2001. They used PRF to improve bone healing in cases
of implants. It is a brin matrix in which platelet cytokines,
growth factors and cells are trapped and may be released
after a certain time and that can serve as a resorbable
membrane. Growth factors are released after activation
from the platelets trapped within brin matrix, and have
been shown to stimulate the mitogenic response in the
periosteum for bone repair during normal wound healing
[2].
A variety of materials are available for bone regeneration,
which are highly osteoconductive or osteoinductive like,
freeze dried bone graft, bioactive glass, emdogain, PTR
polymer, MTA, tricalcium phosphate, and octacalcium
phosphate. PRF is an autogenous osteoinductive material
that enhances osteogenesis in the extraction tooth socket
in comparison to the physiological healing process. It
is an optimized blood clot. It also provides a signicant
postoperative protection of the surgical site and seems to
accelerate the integration and remodeling of the grafted
biomaterial [6].
Preparation of PRF:
The classical technique for PRF preparation was invented
by Dr. Joseph Choukroun in 2000. It is the current PRF
technique authorized by the French Health Ministry in
which PRF is prepared without using an anticoagulant
during blood harvesting or bovine thrombin during gelling
[7].
For preparation of PRF, blood sample is collected from the
patient without anticoagulant using a buttery needle and
10 ml blood collection tubes. After collection of blood, it
is immediately centrifuged on a table-top centrifuge at a
rate of 3000 rpm for 10 minutes. After centrifugation, 3
layers are obtained in the test tube (Figure 1). The topmost
layer consisting of acellular PPP (platelet poor plasma),
PRF clot in the middle and RBCs at the bottom of the test
tube. The middle layer of PRF clot is then removed with
sterile tweezers and separated from the underlying RBC
layer using scissors and then transferred on a sterile dish
and stored in a refrigerator. It is supposed that the junction
of PRF to the RBC layer is rich in growth factors and
therefore this region is preserved [8].
Figure 1 – Layers of PRF

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PRF results from a natural and progressive polymerization
which occurs during centrifugation [9]. Because of the
absence of an anticoagulant, blood begins to coagulate
as soon as it comes in contact with the glass surface.
Therefore, for successful preparation of PRF, speedy blood
collection and immediate centrifugation, before the clotting
cascade is initiated, and is absolutely essential [10]. The
slow handling of blood to centrifugation process will result
in diffuse polymerization of brin leading to the formation
of a small blood clot with irregular consistency [2].
Also, PRF membrane can be obtained by squeezing out
the liquids present in the brin clot. Liquid removal from
the PRF fraction can be done through mechanical pressure
between gauze layers resulting in a fairly solid, gel-like
material that can be used in various clinical applications
as a lling material or as a suturing membrane [11]. PRF
membrane can also be prepared by compressing PRF clot
in special tools like “PRF Box” resulting in standardized
membranes of constant thickness and size along with
PRF exudate. PRF exudate contains good amount of
growth factors (TGF-b1, PDGF-AB, VEGF etc.), matrix
glycoproteins (bronectin, vitronectin etc.) and proteins
specialized in increasing cell attachment to biomaterials
and titanium and therefore can be used for biomaterial
impregnation, rinsing surgical sites, hydration of graft
materials and for storage of autologous grafts[2,12].
Advantages of PRF over PRP:
1. Simple and cost effective method of preparation of
PRF
2. Eliminates the use of bovine thrombin and thereby
reduces the chances of crossinfection.It has been
discovered that the use of bovine thrombin may be
associated with the development of antibodies to the
factors V, XI and thrombin, resulting in the risk of life-
threatening coagulopathies [2].
3. Slow natural polymerization of PRF on contact with
glass particles of the test tube results in physiologic
thrombin concentration, while in PRP, there is sudden
brin polymerization depending on the amount of
surgical additives (thrombin and calcium chloride) [5].
4. Fine and exible 3-D structure of PRF more
favourable to cytokine enmeshment and cellular
migration.3-D network-connected tri-molecular or
equilateral junctions in PRF allows the establishment
of a ne and exible brin network able to support
cytokines enmeshment and cellular migration while
3-D organization of PRP consists of a brin network-
condensed tetra molecular or bilateral junctions
constituted with strong thrombin concentrations which
allows the thickening of brin polymers leading
to a rigid network, not very favourable to cytokine
enmeshment and cellular migration [5].
5. PRF has supportive effect on immune system [13]
6. PRF helps in hemostasis [13]
7. A in-vitro study showed that PRF is superior to PRP,
considering the expression of alkaline phosphatase
and induction of mineralization, caused markedly by
release of TGF-β1and PDGF-AB [14]
Role of PRF in Wound Healing:
Wound healing consists of three phases:
Role of PRF in wound healing:
• Prolonged release of growth factors
at the wound site
• Proliferation of fibroblasts and
osteoblasts
• Promotes angiogenesis
• Induces collagen synthesis
• Guides in wound coverage
• Mechanical adhesion by fibrin
• Trapping of circulating stem cells
• Regulation of immunity
1. Inammatory phase (1-4 days) (substrate-preparation
phase)
2. The proliferation phase (2-22 days) (collagen-building
phase)
fEpithelialation
fAngiogenesis
fGranulation tissue formation
fCollagen deposition
3. Maturation (remodeling phase) (6-12 months)
fCollagen maturation and contraction
PRF consists of a brin matrix polymerized in a tetra
molecular structure with the incorporation of platelets,

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leukocyte and cytokines, and the presence of circulating
stem cells [9]. PRF stimulates osteoblasts, gingival
broblasts, and periodontal ligament cells proliferation
as a mitogen. Its molecular structure with low thrombin
concentration is an optimal matrix for migration of
endothelial cells and broblasts [15] It permits a rapid
angiogenesis and an easier remodelling of brin.The
Leukocytes and key immune cytokines like IL 1β, IL 6,
IL 4 and TNF α trapped in PRF give it the anti-infectious
effect and lets PRF act as an immune regulation mode [8].
It features all the necessary parameters permitting optimal
healing.
PRF matrix can release various growth factors and
cytokines locally at the wound site for a prolonged period
of time which play important role in various stages of
wound healing promoting periapical tissue generation.
Growth factors are released from the alpha-granules in the
platelets when they are activated, secreted, or aggregated
by collagen or epinephrine [15]. TGF-beta and PDGF
are the typical two growth factors which promote healing
of soft tissue and bone through stimulation of collagen
production to improve wound strength and initiation of
callus formation [16].
Platelet-derived growth factor (PDGF) is a potent activator
for cells of mesenchymal origin. It is among the rst cells
to reach at the wound site. Strayhorn et al suggested that
PDGF might act mostly on osteoblastic cell proliferation,
exerting most of its effects during the early phases of wound
healing [1]. It also stimulates chemotaxis, proliferation,
and new gene expression in monocytes-macrophages and
broblasts in vitro, cell types considered essential for tissue
repair.
Vascular endotheilial growth factor (VEGF) is a major
angiogenic growth factor. It acts on endothelial cells,
being produced by numerous cell types, including vascular
smooth muscle cells (VSMC), broblasts etc. initiating
blood vessel formation.
Transforming growth factor Beta-1 (TGF beta-1), an
inammatory regulator, is the most powerful brosis agent
amongst all cytokines and can induce a massive synthesis of
collagen and bronectin either by broblasts or osteoblasts
[2].
The physiologic brin matrix of PRF, obtained as the result
of slow polymerization, has the ability to hold various
growth factors and cytokines and release them at the wound
site for a prolonged time period. Moreover, the brin matrix
itself shows mechanical adhesive properties and biologic
functions like brin glues: it maintains the ap in a high
and stable position, enhances neoangiogenesis, reduces
necrosis and shrinkage of the ap, and guarantees maximal
root coverage. It plays an important role in angiogenesis
and wound coverage [17].
Angiogenesis requires an extracellular matrix to allow
migration, proliferation and phenotype differentiation of
endothelial cells. The angiogenesis property of the brin
matrix is explained by the 3-dimensional structure of the
brin gel and the simultaneous action of the cytokines
trapped in brin meshes [18]. Furthermore, main
angiogenesis soluble factors such broblast growth factor-
basic (FGFb), vascular endothelial growth factor (VEGF),
angiopectin and platelet derived growth factor (PDGF) are
included in brin gel which can bind to brin with high
afnity.
Fibrin matrix guides the wound coverage affecting
the metabolism of broblasts and epithelial cells. The
epithelial cells around the wound margins lose their basal
and apical polarity and produce basal andlateral extensions
towards the wound site. These cells then migrate onto the
transitory matrix made by brinogen, bronectin, tenascin
and vitronectin [18]. Fibrin, bronectin, PDGF and TGF-B
are essential to modulate integrin expression, broblast
proliferation and their migration inside the wound. After
migration and degradation of brin, broblasts start the
collagen synthesis.
PRF also aids in trapping circulating stem cells brought
to the wound site due to initial neovascularization during
hemostasis and healing [18]. Set in the brin matrix, these
cells converge on a secretory phenotype, allowing the
vascular and tissue restoration. This aspect of PRF serving
as a net to the stem cells can be benecial in cases of wide
defects.
Current Applications of PRF In Dentistry:
In recent times a lot of research has been done on PRF and
numerous cases have been reported regarding the use of
PRF clot and PRF membranes. Majority of the research
has been concentrated on the use of PRF in oral surgery
for bone augmentation, sinus lifts, avulsion sockets etc
and in periodontics to correct intra-bony defects, gingival

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National Journal of Medical and Dental Research, April – June 2014: Volume-2, Issue-3, Page 51-58
recession, guided bone regeneration, periapical lesions
etc. It has also been used for regeneration in open apex,
regenerative pulpotomies, periapical surgeries etc.
In Oral and Maxillofacial Surgery:
Studies show that PRF can be used as lling material in
extraction sockets. As a lling material in extraction sockets,
PRF will act as a stable blood clot for neovascularization
and accelerated tissue regeneration. This can be used to
improve wound healing in immunocompromised and
diabetic patients. Also, as PRF stimulates coagulation (with
thrombospondin) and wound closure, it can be used as an
adjuvant in patients on anticoagulant therapy [12]
PRF has been extensively used in sinus lift procedures.
Some studies show the use of PRF as the sole lling
material during sinus lift and implantation. Some studies
show the use of PRF in combination with other bone graft
materials in various direct and indirect sinus lift techniques
like bone-added sinus oor elevation, osteotome-mediated
sinus oor elevation, minimally invasive antral membrane
ballon elevation etc [2]. Some studies also show the use
of PRF in combination with beta Tricalcium phosphate
(beta TCP) without bone graft in sinus lift procedures and
chronic periodontal lesions.
The lling of avulsion sockets with PRF leads to
very favourable results when bony walls are intact. A
combination of PRF with bone substitutes and other
adjuncts may be necessary in residual defects where one
or several walls are missing or damaged in order to provide
an adequate reconstruction of bone volume. PRF increases
the cohesion between the graft materials as brin act as
physiological glue between the wound tissues [12]. Natural
blood coagulation leads to formation of a brin matrix that
biologically links wounded tissue together along with cell
proliferation, cell migration, neomatrix apposition and
remodelling. Therefore, the combination of PRF with other
graft materials should improve the integration of graft
material, since PRF is an optimized blood clot.
In cases of wide sockets and lesions where primary closure
is difcult, PRF membrane can be used as a covering and
protective membrane that promotes re-epithelialization of
the site and accelerates the merging of the wound margins.
The elasticity and strength of PRF brin membrane
makes it easy to suture. As a membrane for guided bone
regeneration (GBR), the PRF dense matrix architecture
covers, protects and stabilizes bone graft material and
operative site in general.
In Periodontics:
In periodontics, PRF has been used to treat gingival
recession, intra-bony defects and periapical lesions. Some
case reports show the use of a combination of PRF gel,
hydroxyapatite graft and guided tissue regeneration (GTR)
membrane to treat IBD [10]. Some studies show the use of
PRF gel and PRF membrane in combination with a bone
graft for treating a tooth with a combined periodontic-
endodontic lesion [19]. Some studies show use of two layers
of PRF membrane with to cover the defect. The membranes
are very thin and inhomogeneous and leucocytes and
platelet aggregates are believed to be concentrated in end
of the membrane. Therefore, two layers of membrane in
opposite sense can be used to prevent the resorption of
the thin membrane and to allow the entire surgical area to
be exposed to same components (leucocytes and platelet
aggregates) [19]. Platelet rich brin as a potential novel
root coverage approach has been reported by Anil kumar et
al. for covering localised gingival recession in mandibular
anterior teeth using combined laterally positioned ap
technique and PRF membrane.
PRF can promote the healing of osseous defects by the
following mechanisms. According to Chang et al. PRF
promotes the expression of phosphorylated extracellular
signal-regulated protein kinase (p-ERK) and stimulates
the production of osteoprotegerin (OPG) which in turn
causes proliferation of osteoblasts [7, 13]. Another
study by Huang et al. reported that PRF stimulates the
osteogenic differentiation of the human dental pulp cells
by up regulating osteoprotegerin and alkaline phosphatise
expression. PRF also releases growth factors such as
platelet-derived growth factor and transforming growth
factor which promote periodontal lregeneration [7].
In Endodontics:
Studies have shown that PRF can be used as a scaffolding
material in an infected necrotic immature tooth for pulpal
regeneration and tooth revitalization [20]. Also, some case
reports show that the combination of PRF membrane as a
matrix and MTA in apexication procedures prove to be an
effective alternative for creating articial root-end barriers
and to induce faster periapical healing in cases with
large periapical lesions. Use of a membrane can prevent

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the extrusion of material [6]. Use of PRF in regenerative
pulpotomy procedures have also been documented where
coronal pulp is removed and the pulp wound is covered by
PRF followed by sealing it with MTA and GIC [6]. PRF
has also been used to ll in the bony defects after periapical
surgeries like root end resection etc.
PRF might serve as a potentially ideal scaffold in
revascularization of immature permanent teeth with
necrotic pulps as it is rich in growth factors, enhances
cellular proliferation and differentiation, and acts as a
matrix for tissue ingrowth. The potential theory behind the
success of the use of PRF for regeneration of open apex
could be attributed to a study conducted by Huang et al,
who concluded that the PRF causes proliferation of human
Dental Pulp Cells and increases the protein expression of
these Dental Pulp Cells differentiate into odontoblasts like
cells. OPG and ALP expression are generally regarded as
markers of odontoblastic differentiation [20].
In Tissue Engineering:
The use of PRF as a tissue engineering scaffold was
investigated by many researchers for the past few years. In
a study by Gassling et al. reported that PRF appears to be
superior to collagen as a scaffold for human periosteal cell
proliferation and PRF membranes can be used for in vitro
cultivation of periosteal cells for bone tissue engineering.
Thus PRF is a potential tool in tissue engineering but clinical
aspects of PRF in this eld requires further investigation.
Conclusion:
The use of PRF as an adjunct in wound healing and
periodontal regeneration has shown promising results. It
has been successfully used for correction of osseous defects
in periodontics, oral and maxillofacial surgery and implant
dentistry. In addition to these, PRF has shown good results
in regeneration of pulp-dentin complex for endodontic
procedures. However, most studies with PRF have shown
short term results only. More controlled clinical trials with
long term results are needed to acquire deeper knowledge
about the efcacy and credibility of this biomaterial on a
long term basis and to optimize its use in daily procedures.
In addition to clinical trials, histopathological studies are
also required to learn about the nature of the newly formed
tissue in the defect and to understand the biology, efcacy
and its mode of action of PRF more effectively.
APPLICATIONS OF PRF
ORAL AND MAXILLOFACIAL SURGERY
• Filling material in avulsion
sockets, bony defects etc.
• Bone augmentation in sinus
lifts for posterior maxilla
augmentation for implants,
bony defects etc.
• Ridge preservation
• Guided bone regenetration,
ENDODONTICS
• In treatment of open apex
 For regeneration
of pulp-dentin
complex
 In combination
with MTA to
create root end
barriers in
apexification
procedures to
prevent extrusion
of material
• In regenerative pulpotomy
• To fill in bony defect after
periapical surgeries like root
PERIODONTICS
• For treatment of
intrabony defects
• For treatment of
gingival recession
• Guided tissue
regeneration
• Periapical lesions
TISSUE ENGINEERING
• For in vitro
cultivation of
human periosteal
cellsfor bone
tissue engineering

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