Enhancing Bone Regeneration with

the Use of Platelet Concentrates

by Randolph R. Resnik, DMD, MDS

chairside@glidewelldental.com

I
n implant dentistry today, many clinicians strive to implement procedures that enhance
and accelerate the predictable rates of healing. To increase the regeneration of hard
and soft tissues, the use of growth factors is commonly integrated into the surgical
protocol. There are more than 50 known growth factors that have been identified in the
healing process. Most of the factors enhance the formation and mineralization of bone,
induce undifferentiated mesenchymal
cells to differentiate into bone cells,
and trigger a cascade of intracellular
reactions.1 One popular source of
growth factors used in implant den-
tistry is blood concentrates — most
specifically, platelets. The platelet,
also called a thrombocyte, consists
of blood cells that play a crucial role
in hemostasis and wound healing.
Platelets have a life span of approxi-
mately 7–10 days and set the pace of
wound repair by releasing their growth
factors immediately after the initiation
of the clotting process.2 These plate-
let-derived growth factors have been
shown to enhance collagen produc-
tion, cell mitosis, blood vessel growth,
cell recruitment and cell differentiation
(Fig. 1).3
PLATELET CONCENTRATE
CLASSIFICATION
The two most utilized and studied
platelet concentrates in implant den-
tistry today are platelet-rich plasma
(PRP) and platelet-rich fibrin (PRF). The
first-generation blood concentrate,
platelet-rich plasma, was introduced
by Marx in 1998. His studies showed
bone maturity to be twice as effective
PDGF
Platelet-derived growth factor
Stimulates fibroblast mitogenesis
and collagen synthesis
TGF-ß
Transforming growth
factor beta
Enhances wound
healing via endothelial
angiogenesis
IGF
Insulin-like growth factor
Enhances rate and quality of
wound healing via bone matrix
formation and cell replication
Figure 1: Bone growth factors released by platelets.
with the use of PRP in grafted sites,
and the addition of PRP increased
bone density up to 30% in healed
sites.4
A second-generation blood substi-
tute, platelet-rich fibrin, was first
described by Choukroun in 2001. PRF
has been shown to be very effective
in the release of important growth
factors present in platelets, such as
platelet-derived growth factor (PDGF),
transforming growth factor beta
(TGF-ß), insulin-like growth factor (IGF),
fibroblast growth factor (FGF), and ep-
ithelial growth factor (EGF).5 Multiple
clinical studies with PRF have shown
greater soft-tissue healing, enhanced
healing of grafted bone, promotion of
angiogenesis and faster wound heal-
ing.6-8  This concentrate has become
popular in implant dentistry, as it has
a much simpler processing protocol
compared with PRP.
PLATELET-RICH CLOT
The PRF clot is a natural-based
biomaterial that is obtained from an
autogenous blood harvest without the
use of anticoagulants or biomedical
modifiers. This gel-type fibrin network
contains a high concentration of
EGF
Epithelial growth factor
Increases angiogenesis and
epithelial mitogenesis
FGF
Fibroblast growth factor
PLATELET Increases angiogenesis,
epithelialization, and
fibroblasts
VEGF
Vascular endothelial growth factor
Increases endothelial growth factor
and angiogenesis
platelets and white blood cells, which
release the growth factors at the
surgical site.9 The internal organiza-
tion makeup of platelet-rich fibrin is
unique, as it contains three adhesive
molecules — fibrin, fibronectin and
vitronectin — that result in a highly
elastic, matricial mesh architecture.
This complex three-dimensional
structure allows for a longer release
of growth factors, as compared with
PRP. As the platelets degranulate, a
sustained release of growth factors
may range from a time period of one
to four weeks.10
DIFFERENCES BETWEEN
PRF AND PRP
The PRF clot has become very popular
in clinical oral implantology in compari-
son to the PRP process because it:
• Is naturally polymerized and
requires no chemical use (PRP
requires a coagulant)
• Requires a conventional,
single-spin centrifuge (PRF) vs.
two centrifuge spins (PRP)
• Has a slower release of growth
factors in comparison to PRP
• Exhibits greater cell migration
and proliferation
• Contains a more advantageous
fibrin network that stores
cytokines and growth factors
• Has better healing properties
than PRP
• Requires fewer disposables,
reducing cost
PROTOCOL FOR
PREPARATION OF
PLATELET-RICH FIBRIN
a. Obtaining the Blood Sample
The standard protocol for PRF prepa-
ration begins with the venipuncture
technique, which involves obtaining
approximately 9 ml of blood collect-
ed in a sterile, glass-coated plastic
tube without anticoagulant (red tube)
(Table 1 and Figs. 2–7).
Table 1: Venipuncture
Technique

Step 1: Select site

for venipuncture (e.g.,
antecubital fossa, dorsum of
the hand or wrist). 2a

Figure 4: The site is cleaned with alcohol

Step 2: Place tourniquet gauze.
approximately 3–4 mm above
entry site.

Step 3: Identify the vein

location and trajectory. If
visualizing the vein is difficult,
the following may be used
to ease the location of
veins: light tapping on the
site, warm and moist towel, 2b

nitrous oxide, or a vein locator. Figures 2a, 2b: Common venipuncture 5a

sites include the dorsum of the hand (2a)
Step 4: Clean injection area and antecubital fossa (2b).
with alcohol gauze.

Step 5: Venipuncture with a

vacutainer, butterfly needle
or catheter. Enter tissue
and vein to collect the blood
sample: 5b

Figures 5a, 5b: Skin is pulled tight and

• Pull skin in opposite needle is directed at a 30-degree angle
direction of needle. (5a). Vein is entered; needle angle is
reduced and slightly advanced (vacutainer
• Ensure needle bevel is technique) (5b).
facing upward.

• Tissue is entered at a
30-degree angle.

• Perforate vein. Then,

decrease angle and
advance needle slightly.

• Remove tourniquet.

• Obtain approximately
9 ml blood collection in
a sterile, glass-coated
plastic tube without
anticoagulant (red tube). Figure 3: A vein finder allows for ease of
locating and determining the trajectory of Figure 6: Blood sample is obtained in a
veins. sterile tube without anticoagulant.

Figure 7: Alternative venipuncture tech-
nique: A butterfly needle is used to obtain
the blood sample.
b. Blood Sample Centrifuge
When using a plain collection tube
(without anticoagulant), the centrifuge
process activates the coagulation pro-
cess as soon as the blood comes into
contact with the tube walls. Therefore,
it is imperative that there is no extend-
ed delay between obtaining the blood
sample and the start of the centrifuge
process. If an extended delay occurs,
the fibrin clot will be less distinct.
Ideally, the centrifuge should spin at
approximately 2,700–3,000 rpm for
about 10–12 minutes.
c. Blood Concentrate
Two different intrinsic processes re-
sult from the high-speed centrifuging
of a blood sample: blood coagulation
and separation of the blood elements.
The centrifugal force separates cells
of different densities, which results in
three layers of blood product: The top
layer consists of an acellular superna-
tant platelet-poor plasma (PPP), the
platelet fibrin clot forms the middle
layer, and the bottom layer is com-
posed of concentrated red blood cells.
The top layer (PPP), which contains a
small percentage of platelets, may be
discarded or used to hydrate the par-
ticulate bone. The middle layer (PRF
clot) may be used as a membrane or
integrated with the particulate bone.
The bottom layer (red blood cells) is
discarded. (See Table 2 and Figs. 8–13.)
Table 2: Single-Spin Platelet-Rich Fibrin Protocol
Step 1: Immediately place blood
collection tube in centrifuge for
10–12 minutes at approximately
2,700–3,000 rpm. Make sure
the centrifuge is balanced with
an even number of tubes and an
equal volume of liquid.
Step 2: Carefully remove the
blood sample tube from the
centrifuge. Three distinct layers
will be present:
• Top layer:
Platelet-poor plasma (PPP)
• Middle layer:
Platelet-rich fibrin (PRF)
• Bottom layer:
Red blood cells (RBCs)
Step 3: Remove the rubber top
from the blood sample tube.
Using a sterile 5 ml syringe with
a blunted needle, draw off the
yellow liquid top layer (PPP). This
may be discarded or added to the
particulate graft material.
Step 4: Using sterile college
Figure 8: For the PRF preparation tech-
nique, a sample is placed in the centrifuge,
which is capable of reaching a speed of
3,000 rpm.
pliers (pick-ups), remove the
fibrin clot (PRF) from the center
of the tube. If coagulated RBCs
are attached to the clot, they may
be removed with scissors and
discarded.
Step 5: PRF processing:
• Membrane
Place the fibrin clot into a PRF
box or biocompress instru-
ment to compress the clot.
This will result in an approxi-
mately 1 mm thin membrane.
The PRF membrane is then
placed over the graft site
membrane, serving as a
double membrane between
the primary membrane (e.g.,
collagen) and the soft-tissue
flap.
• Graft incorporation
The PRF clot may be cut into
small pieces and added to
the graft. In addition, the PPP
may be added to the graft if
more hydration is required, as
the PPP does contain a low
concentration of platelets.
Figure 9: After 10–12 minutes of centri-
fuge spinning, three distinct layers are
present: acellular platelet-poor plasma
(PPP) on top, the PRF clot in the middle,
and red blood cells (RBCs) on the bottom.
 Enhances rate and quality of Increases endothelial growth factor
wound healing via bone matrix and angiogenesis
formation and cell replication

CLINICAL USES OF Periodontal defects: The use of PRF

PLATELET-RICH FIBRIN in conjunction with periodontal and
PPP Discarded or added to graft
peri-implant disease procedures are
Compression Platelet-rich fibrin has been used in well documented. Chang et al. report-
device

PRF
Membrane
RBC
Discarded
Figure 10: PRF processing: The centrif-
ugal force separates cells of different
densities, which results in three layers of
blood product available for processing.
Figure 11: The fibrin clot is removed.
Figure 12: Use of a biocompress for a
membrane.
many oral implant procedures, ranging ed that PRF is an effective modality in
from guided bone regeneration to pro- the treatment of infrabony periodontal
cedures requiring a hemostatic agent defects.15
(Figs. 14–18).
Hemostasis: PRF is an excellent
Guided bone regeneration: With hemostatic agent when used in
bone augmentation procedures, PRF procedures that may result in excess
may be used as either a membrane or postoperative bleeding. PRF has
added to the particulate bone grafting been shown to exhibit very good
material. Studies have shown that
antihemorrhagic properties, along
PRF is advantageous in healing during with increased tissue healing, wound
regenerative procedures either as a closure, and decreased postoperative
membrane or when added to partic- pain. PRF membranes can be placed
ulate bone.11 Because the PRF mem- over the surgical site or the surgical
brane resorbs rather quickly (approxi- site can be lavaged with the material
mately seven days), it is not the most to decrease bleeding.16
ideal membrane to be used to prevent
soft-tissue invasion. Therefore, the
PRF membrane is commonly placed
over the primary membrane (e.g.,
collagen) to aid in hard- and soft-tissue
healing.
Sinus augmentation: During sinus
augmentation procedures, PRF is
often used with the graft material,
as a second membrane over the
lateral wall, or as a membrane during
crestal approaches. Choukroun et al.
showed that when PRF was added to
freeze-dried bone allograft, there was
Figure 14: PRF used as a membrane after
a reduction in healing time prior to im-
implant placement.
plant placement.12 Diss et al. showed
that PRF used with the osteotome cr-
estal approach for sinus augmentation
procedures resulted in faster healing
and sufficient torque values when
implants were placed in areas with
reduced bone height.13

Socket grafting: Many studies have

evaluated the use of PRF after ex-
traction as a socket membrane, sole
socket filling material, or the addition
to particulate socket grafting proce-
dures. Most studies show positive
healing effects when PRF is used in Figure 15: PRF used as a membrane over
combination with socket graft proce- a lateral wall sinus augmentation.
dures.14

Figure 13: Fibrin clots placed in PRF box.


Figure 16: PRF may be added to hydrate
the graft material.
17a
17b
Figures 17a, 17b: PRF may be used in
conjunction with crestal-approach sinus
augmentation procedures.
Figure 18: A membrane may be hydrated
in PPP or PRF.
CONCLUSION biologic features. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2006 Mar;101(3):e45-50.
In the field of oral implantology, clini- 10. Kobayashi E, Flückiger L, Fujioka-Kobayashi M, Sawada
cians are always looking for ways to K, Sculean A, Schaller B, Miron RJ. Comparative release
of growth factors from PRP, PRF, and advanced-PRF. Clin
provide faster and more predictable
Oral Investig. 2016 Dec;20(9):2353-60.
hard- and soft-tissue healing. The most
11. Montanari M, Callea M, Yavuz I, Maglione M. A new bio-
commonly used blood concentrate, logical approach to guided bone and tissue regeneration.
platelet-rich fibrin, has been shown BMJ Case Rep. 2013 Apr 9;2013:bcr2012008240.
to be advantageous in a full array of 12. Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler
implant procedures. Whether using C, Dohan SL, Dohan AJ, Mouhyi J, Dohan DM. Platelet-
rich fibrin (PRF): a second-generation platelet concen-
PRF as a membrane or integrating
trate. Part V: histologic evaluations of PRF effects on
it into the particulate bone graft, a bone allograft maturation in sinus lift. Oral Surg Oral Med
favorable physiologic support system Oral Pathol Oral Radiol Endod. 2006 Mar;101(3):299-303.
is achieved, which allows for an en- 13. Diss A, Dohan DM, Mouhyi J, Mahler P. Osteotome si-
hanced and more predictable healing nus floor elevation using Choukroun’s platelet-rich fibrin
as grafting material: a 1-year prospective pilot study with
process. This article has summarized microthreaded implants. Oral Surg Oral Med Oral Pathol
a simple, clinically proven protocol Oral Radiol Endod. 2008 May;105(5):572-9.
for the use of blood concentrates for 14. Temmerman A, Vandessel J, Castro A, Jacobs R, Teu-
bone regeneration procedures that ghels W, Pinto N, Quirynen M. The use of leucocyte and
platelet-rich fibrin in socket management and ridge pres-
may be easily integrated into the
ervation: a split-mouth, randomized, controlled clinical
general dentist’s practice. CM trial. J Clin Periodontol. 2016 Nov;43(11):990-9.
15. Chang YC, Zhao JH. Effects of platelet-rich fibrin on hu-
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Mar;101(3):e56-60. EARN CE CREDIT
7. 
Kang YH, Jeon SH, Park JY, Chung JH, Choung YH, Earn free CE credit for this
Choung HW, Kim ES, Choung PH. Platelet-rich fibrin is
a bioscaffold and reservoir of growth factors for tissue article. Scan the code or go to
regeneration. Tissue Eng Part A. 2011 Feb;17(3-4):349-59. glidewelldental.com/1501-ce
8. Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, to enter your answers.
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generation platelet concentrate. Part I: technological con-
cepts and evolution. Oral Surg Oral Med Oral Pathol Oral
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QUESTIONS ON
9. Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ,
Mouhyi J, Gogly B. Platelet-rich fibrin (PRF): a second- NEXT PAGE
generation platelet concentrate. Part II: platelet-related
Enhancing Bone Regeneration with by Randolph R. Resnik,
the Use of Platelet Concentrates DMD, MDS

1. Which of the following bone growth factors are 6. When performing a venipuncture, the needle
released by platelet concentrates? should penetrate the tissue at a 40-degree angle to
a. Platelet-derived growth factor obtain the blood sample.
b. Transforming growth factor beta a. True
c. Insulin-like growth factor b. False
d. Epithelial growth factor
e. All of the above 7. In the single-spin centrifuge technique for PRF,
the blood sample is spun at approximately
2. Platelet-rich plasma (PRP) is a first-generation 1,200–1,500 rpm.
blood concentrate that requires two centrifuge a. True
spins and was introduced by Dr. Robert Marx in
b. False
1998.
a. True 8. After centrifuge completion with the PRF
b. False technique, there will be three layers within the
collection tube. The top layer consists of which
3. Platelet-rich fibrin (PRF) is a second-generation end product?
blood concentrate that requires only one a. Acellular platelet-poor plasma (PPP)
centrifuge spin and was developed by Dr. Joseph
b. Platelet-rich fibrin (PRF) clot
Choukroun in 2001.
c. Sticky bone
a. True d. Red blood cells
b. False e. Buffy coat
4. As a platelet degranulates, growth factors are 9. After centrifuge completion with the PRF tech-
released over what time period? nique, which end product forms the middle layer
a. 24 hours of the collection tube?
b. 48 hours a. Acellular platelet-poor plasma (PPP)
c. 1–4 weeks b. Platelet-rich fibrin (PRF) clot
d. 6 months c. Sticky bone
e. 1 year d. Red blood cells
e. Thrombin
5. Which of the following techniques may be utilized
to help in identifying the location of a vein? 10. After centrifuge completion with the PRF tech-
a. Light tapping on the site nique, which end product forms the bottom layer
b. Warm, moist towel of the collection tube?
c. Nitrous oxide a. Acellular platelet-poor plasma (PPP)
d. Vein locator b. Platelet-rich fibrin (PRF) clot
e. All of the above c. Sticky bone
d. Red blood cells
e. Thrombin

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