Applications for in office obtained PRF clot and/or PRP?

The growth factors with PRF and PRGF will help but a scaffold with particulate bone maintains the space. The same is true for BMP.

PRF and PRP have only soft tissue growth factors and no bone growth factors. The overwhelming evidence based on controlled clinical trials is that PRF and PRP do not stimulate bone formation and actually inhibit bone formation. Greg Steiner Steiner Biotechnology

I think PRF is a decent spacer/buffer material when doing sinus lifts with residual bone heights of atleast 5mm. But when you have a potato-chip-thin ridge, I don't feel PRF alone lasts long enough to maintain the space needed for bone formation. I can post a case I did using just PRF, and I did get 3mm of additional bone height but it was more dependent on the implants tenting up the membrane rather than PRF. Thus PRF is not very effective as a scaffold, but a great space filler. I believe most problems that occur with sinus lifts such as infections is due to traditional bone graft material escaping into the sinus space through a tear. Thus I'd like to see more effort initiated to eliminate the usage of bone particulates in the sinus space and find safer alternatives like PRF. I know there already is a school of thought that just tenting up the membrane and creating space is enough to increase bone height. I feel this is the correct trend. I only user PRP/PRF for two things in my office: 1: Wisdom tooth extraction site improved healing (seems to have real benefits) 2: Sinus lifts for cases with a residual bone height >5mm (Much safer than using bone particulates,since even if you have a tear, the implant will integrate and you eliminate the possibility of having graft material escaping into the space)

if we really know the biology and molecular biology of healing then we know exactly what ,why when to use material to booster bone healing. PRF is not only for soft tissue but it is essential for any healing process,why, because it is important for the most essential and important stage which is angiogenesis. without blood supply no healing. second it's fibrin mesh help to trap the growth factors whether inside the PRF(platelet growth factors) or locally induced from tissue area( depending on the site)

Greg not so. If one includes the Buffy coat.

This week I presented a lecture on osteointegration at an implant conference. In my lecture I presented a review of the literature on PRF. I reviewed only the controlled clinical trials. The conclusion of all of the studies is that PRF does not stimulate bone formation and a very well done study showed that because PRF only contains soft tissue growth factors that PRF inhibits bone formation. Dr. Choukroun followed me on the podium. He said he does not pay any attention to clinical studies and that whenever you use his products and the surgery fails it is because the dentist is a lousy surgeon. My presentation was primarily histology and when he was questioned why he did not present any histology he said histology did not mean anything either. If the clinical research showed that PRF works for bone regeneration Dr. Choukroun would be touting the results rather than presenting grainy panoramic films of his surgery. Greg Steiner Steiner Labnoratories

So we have some guys saying PRF will not contribute to growth and, in fact, retards and/or prevents it and we have others saying the exact opposite. It would seem that this kind of thing would be a bit more concrete at this point, no? Unless its use in dental bone grafting is really that novel an idea? I do know it is certainly a "hot topic" but that doesn't necessarily mean it is a new topic. Just look at the continued Mercury in amalgam discussion or 3rd molars contributing to anterior crowding. Richard, would you please expand on your menton of the "Buffy coat"?

Looking for articles concerning PRF I came across this interesting piece. I must say that I do not know the researchers or anything about their reputation nor that of whatever system they may be affiliated with but I believe it is worth noting... http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3557480/pdf/blt-11-102.pdf

Greg would you please give the reference that said that PRF inhibit bone formation.

Dr. Barghash Here is the study that found that growth factors in PRP and PRF inhibited bone growth. Tissue Eng Part A. 2014 Feb;20(3-4):874-82. doi: 10.1089/ten.TEA.2013.0058. Epub 2013 Nov 27. Effects of platelet-poor plasma, platelet-rich plasma, and platelet-rich fibrin on healing of extraction sockets with buccal dehiscence in dogs. Greg Steiner Steiner Biotechnology

thanks for posting the reference Greg. I read the whole article and it is about comparing PPP PRP and PRF. it state that PRF and PRP promote bone maturation in presence of abundant osteogenic cells. first this means that no bone resorption. seconed what is abundant in scientific term. how was the follow up in opened extraction socket as Russel stated. Forth in the contrary to this article there is ohtrer articleS stated the effect. of PRF .any how we still in the area understanding molecular biology but at the same time we need to red carefully what is published on judge on scientific bases not on believes .

Any way you read the article the authors conclude that PRP and PRF growth factors inhibits bone formation. I read all the published articles on PRF and bone regeneration. All of the articles were published by dentists. There were no articles on bone and PRF published by orthopedics. Most of the articles were well done and published by researchers in Turkey and India. The articles were designed as most all call clinical research articles to find positive results but they did not. So the orthopedic community and the dental academics in the US and Europe have no interest in this technology. This is just a word of caution to my dental colleagues. Greg Steiner Steiner Biotechnology

Greg,I read the article conclusion and it was that PPP is sufficient for bone preservation in socket with buccal dehiscence. he also stated that PRF and PRP play a significant rule in bone maturation.and he also stated that both would be stimulatory for bone formation. the intensive work on bone regeneration and growth factors include BMP was done by dentist, so I wounder that your advise is to follow what orthopedic do, any how I would like to know your scientific explanation how PRF and PRP inhibit bone formation

Dr. Barghash When bone is forming it is woven bone. After the bone stops growing it is remodeled into lamellar bone (mature bone). When a bone graft produces more bone it will grow for a longer period of time and therefore remodeling is delayed. The PRP and PRF group had more mature bone because they stopped growing earlier and produced less bone. The following study confirms that PRP and PRF inhibit osteoblasts and as a result less bone is produced. A three-dimensional cell-loading system using autologous plasma loaded into a porous β-tricalcium-phosphate block promotes bone formation at extraskeletal sites in rats. Greg Steiner Steiner Biotechnology

Interesting discussion, I use A-PRF almost everyday, for socket preservation, bone grafting and tissue augmentation. i-PRF is even more exciting, bone grafts are enhanced and seemed to heal quicker, less pain and better results. Maybe I'm getting better as a clinician? A-PRF+ is my go to material for grafting, mix Raptos cortico-cancellous with chopped up fragments of A-PRF+, cover with A-PRF+ membranes and Bob's your uncle. NO COW BONE! Never,ever resorbs... FOund myself picking it out of the surface when I opened up sites, like picking the fly shit put of pepper! Also no more comments from patients asking if they will be mooing tonight! Never mind cost saving and using the patients own materials! Dr. Choukroun has some papers with excellent histology and he is a real doctor not a tooth jockey like myself. SYFAC in Paris last July showed some grouind breaking research being done using A-PRF, like being done at Harvard, regenerating lungs in mice, never mind bone. Some still think the moons made of cheese soo....

My experience is that the any of the PPPPPP's are beneficial on soft tissue not for bone grafting. Dr. Mohamed Sharaway has done some studies and he alsobelieves that is the case. For bone grafting I favor NHP over the PPPP's Raul

Dear Friends, I would like to put few comments. 1. About the angle of the rotor. Changing the angle (going from 33 to 45°) increases only the G Force. The G force is calculated from the radius at the bottom of the tube. I wanted to reduce the G force, just for increasing the white cells amount. And also increasing the circulating stem cells (MSCs) . It's the concept of the new Advanced and injectable PRF..and will be published soon. 2. About the controversy of the bone formation. I agree with Dr Bargash: we need to see which surgical protocol was applied. In the article, they found less growth factors than in PRP: of course ! PRF releases slowly and constantly the factors.How many membranes do they use ? only one: it's not enough.. etc... I told to Dr Steiner in Miami that the most important when we do a surgery is the surgical protocol. Nowadays, we have several scientific and fundamerntal publications about the benefit of the PRF on the vascularization. Because the most important is first to get new vessels. However, if your clinical protocol is wrong, impossible to get sufficient bone: in time and in volume PRF is only the best physiological scaffold that we can use. Saying that some growth factors are only for soft tissue is a stupidity...

Dear Colleagues, I have been following this discussion for a while and must say it takes on the same form and tone the companies and 'researchers' have been conversing in over the last few years. In Europe clinical application really started with PRGF after PRP did not prove to be easily integrated into daily practice. Ever since we have had the same discussion: It does nothing, only soft-tissue, it harms the graft... I am with Cliff and I have 15 years of surgical experience backing me up. PRGF, PRF and now my own clinical protocol with post-extraction CBCTs showing a higher bone density in the former alveoli than in the surrounding bone, strong soft tissues around the implants and happy, pain free patients. About the biology from a humble clinicians point of view: We are inside an extraction socket, surrounded by bone and we reduce the inflammatory process and boost angiogenesis. What else can happen but bone growth? I would not say we should discard the studies completely but it can't be a coincidence that these studies are promoted either by the different plasma product companies trying to discredit each other or by the biomaterial multinationals trying desperately to get rid of the annoying competition.

Most of you may not believe it but I have supported the use of PRF mixed with our beta tricalcium phosphate granules. When asked by our customers if this was appropriate my opinion was that because PRF is biocompatible the two should work well together. Because of these questions I have read all of the research relating to PRF and bone so I would know the facts. There are four sinus augmentation studies that looked at mixing PRF with xenografts and allografts and found that PRF did not improve bone regeneration. However, PRF was doomed to fail before the start because they used non-biocompatible particulate grafts that produce bone through an inflammatory process resulting in sclerotic bone. Because PRF is biocompatible it produces bone without inflammation and the result is normal bone. Whenever you mix non-biocompatible bone graft material with biocompatible bone grafts the inflammatory process blocks normal bone formation so the PRF in these studies never had a chance to improve bone formation. There are four studies that looked at PRF in sockets and three of the four studies found no benefit using PRF over no graft. This was surprising to me because I would think that covering bone with a biocompatible material would be better than leaving bone exposed to the oral environment. For those interested in researching PRF I suggest you study PRF in combination with a second generation beta TCP such as Cerasorb or our 3rd generation OsseoConduct. If you mix it with a non-biocompatible bone graft you will just be producing more studies where PRF fails to improve regeneration. My customers say PRF works very well with our beta TCP and I continue to support the use of PRF with our products. Greg Steiner Steiner Biotechnology

Greg, What do you mean by using a graft that is not biocompatible?

Raul Bone grafts are considered non biocompatible if they produce significant inflammation in the host. Most bone grafts are non biocompatible because they contain foreign proteins. The foreign proteins from either another human or animal, stimulate the hosts immune system to eradicate the antigenic material. However, because the bone graft contains foreign proteins osteoclasts cannot resorb the bone graft and the only option for the host is to surround the bone graft in minerals to isolate it from the host. Once the bone graft is encased in minerals the inflammation reduces but the bone that is produced is sclerotic. Sclerotic bone cannot be remodeled and therefore once it is formed it cannot adapt to changes which is why you see implants placed in sclerotic bone have a higher failure rate than implants placed in normal bone. The density of the sclerotic bone is related to the antigenicity of the foreign proteins & that is why animal bone grafts produce a higher level of sclerosis than allografts. Clinicians who favor allografts and xenografts don't accept these statements but they have never seen human histology of how these materials heal in humans and they do not have long term studies on implants placed in these materials. The inflammatory response to non biocompatible bone grafts overwhelms any other material that is attempting to produce normal bone. Greg Steiner Steiner Biotechnology

Greg, I fully understand what is a biocompatible material, but I never heard of using a non-compatible material for grafting. As far as I know In order to do grafting the material needs to be biocompatible. Thanks for your posting. Raul

Raul If you want normal bone the bone grafts must be biocompatible. The non biocompatible bone grafts such as allografts and low temp xenografts produce mineralized scar tissue called sclerotic bone. The histology of freeze dried bone allografts and some xenografts during healing in the 6 to 8 week period are filled with an inflammatory infiltrate of cytotoxic T cells. Cytotoxic T cells are responsible for organ rejection. Most all of us have sclerotic bone in our bodies. Hardening of the arteries is actually sclerotic bone and is called atherosclerosis. If you have a joint with osteoarthritis you will have a joint with sclerotic bone formation. Atherosclerosis and osteoarthritis are induced via inflammation just like the sclerotic bone produced by allografts and xenografts. None of the clinicians using these materials know how they heal and what type of bone they are producing but when we come to the realization that the type of bone we put our implants in will determine how long they last this subject will gain increasing interest. We have a free CD on this material if you have further interest in this subject. Greg Steiner Steiner Biotechnology

Cliff I am interested to read the studies on bTCP and inflammatory infiltrate. Could you please provide the references. Thank you Greg Steiner Steiner Biotechnology

Raul Let's share histology. You can contact me at my office. I also would be happy to have our histologic discussion on this web site if the webmaster would agree so our colleagues can be part of the discussion. If you want an impartial opinion you can also ask any general pathologist to look at your histology. Greg Steiner Steiner Biotechnology

I think the key for the discussion is understanding biology, broad terms like inflammation is not acceptable to use without understanding the molecular biology of the term. we can not claim we do understand every thing but many things started to be different. for example we use to generalized macro phage cells because they all look the same but at the molecular level they are different as we have M1 macrophage which are catabolic and M2 macrophage the anabolic one. but still inflammation is the first step in healing. and of course I can not talk about the whole molecular biology of the process, but it is the preparatory for the most important step in healing (what ever the tissue kind) , it is angiogensis the key of survival for all tissue and especially when the tissue we are talking about(bone) is defined as highly vascularized tissue. now we can tell if PRF is useful or not for bone even we just look from one angle of angiogensis. by the way all the last cases of sinus lift I have done in the last few years I only use PRF with no other graft materials

Cliff Thanks for the reference. The article was well done and multinucleated giant cells were found on the surfaces of the graft particles but there was no inflammatory infiltrate. Any foreign object will be lined with cells that identify the material as foreign. They are necessary for the removal of the foreign material. The important thing is that the histology showed no inflammatory infiltrate which would have indicated an immune response. Greg Steiner Steiner Biotechnology

Just plug into Goggle, there is a ton of them, especially the Journal of Oral Implantology. This is why I stopped using beta-tricalcium phosphate, CaSO4 instead. Cheers

Dr. Leachman made the statement that A-PRF unequivocally grows bone. Guess he has not read the current papers just published by the Dohan group from France. Dr. Dohan is the undisputed expert on PRF and has published more papers on this subject than any other researcher. In the papers comparing the quality of fibrin using different protocols and 4 different centrifuges, the A-PRF system performs the most poorly. In measuring production of TGFb1, PDGF-ab, or VEGF, the standard L-PRF system produces 100% more growth factors at all stages of testing than A-PRF. When measuring the release of BMP, contrary to what Dr. Choukroun has claimed, there is close to ZERO production of bone morphogenic protein from A-PRF. Worst of all, A-PRF membranes are completely resorbed at 3 days (70 hours), and therefore can no longer release ANY growth factors. If bone growth begins at 7-14 days, would Dr. Leachman like to explain how the "jury" has come back to suggest that A-PRF produces bone? Read the papers on the POSEIDO website and leave the emotion behind. Sorry for the doctors who bought into the A-PRF hype before there were any peer-reviewed papers to prove clinical efficacy (or lack thereof). Dohan Ehrenfest DM, et al. The impact of the centrifuge characteristics and centrifugation protocols on the cells, growth factors, and fibrin architecture of a Leucocyte- and Platelet-Rich Fibrin (L-PRF) clot and membrane. Parts I, II, and III. POSEIDO 2014 (poseido.net) RJM

It's obvious that you have not read any of the three papers. I would suggest that before anyone denigrates scientific research projects, they at least read the contents and then debate them on their merits, not on the basis of some accusation of "bias". Are you aware of who the additional authors are, or their academic positions? Several authors, including Hom Lay Wang of University of Michigan Department of Periodontics, have NEVER been paid lecturers for Intra-Lock International. Do you think that they would put their academic honesty on the line by falsifying scientific results for the sake of publishing? These papers are as well written as anything I have seen in the PRF world and represent the collated research from respected institutions from around the world. You make the statement that A-PRF membranes last as long as L-PRF membranes in your patients. How did you determine this? Did you open up these sites and do the histology on the membranes to prove your statement? Further, did you do the histology on the quality of fibrin and the vitality of cells in the A-PRF sample? Are you aware that damaged cells will not release growth factors? Look at the histology in these papers and then respond. That is exactly what this outstanding group of researchers did and simply published their findings. I know that the defenders of A-PRF may feel slighted or even offended by the results of the research, but sometimes the truth hurts. The research suggests that those who use the A-PRF system are not getting the clinical efficacy they have been promised. At the same time, the authors have shown that the L-PRF protocol still remains the standard by which all other iterations should be judged. RJM

Sorry, Cliff, if you believe that bona fide scientific research is laughable if you find it contrary to your personal opinions. First, I get NO income from the sale of PRF systems, and never have in the past. Second, I did have an affiliation with Dr. Choukroun many years ago, but when he was dishonest about having both European CE and FDA clearances for Process for PRF, I decided to end that association. It was Dr. Dohan, and the original PRF researchers, that put Dr. Choukroun on the map, NOT the other way around. So why wouldn't I decide to work with the researchers who actually created this protocol? If you find the results of this research so objectionable, why don't you author an open letter to these doctors accusing them of intellectual dishonesty? I actually find your response to be highly objectionable and offensive. Let the clinicians reading this post log onto the POSEIDO website,and peruse ALL of the papers being published, not just on PRF. I believe they will find them to be highly enlightening, well written, erudite, and great contributions to the body of knowledge in our profession. And, while the L-PRF protocol preceded A-PRF, it is obvious that the "older" protocol clearly outperforms the poorly conceived and inadequately researched new one. RJM

You should follow the rules of holes, when you in one, stop digging....

Dr Scheiter; You are correct when you make the statement that the use of growth factors gives superior results over cold surgical steel alone. But you made the statement previously that "I’ve tried PRGF, L- and A-prf and CGF over the years. They all work clinically. But with varying levels of success in different patient groups." Isn't that the point; that all formulations do not have the same efficacy? When an individual claims to have developed a superior, or in this case an "Advanced" formula for a biologic, do we not have the right to challenge that assertion? And those challenges, unlike the rollout of this product that was devoid of literature and research, should be based on science, not emotion. Here we have, arguably, the finest researchers in PRF in the world publishing a bona fide challenge to the marketing hype for A-PRF and what do we get in return? Derision, claims of academic dishonesty, and excoriation because of a claimed alliance with a corporate entity. I challenge the users of A-PRF to demonstrate that the papers from POSEIDO are inaccurate, that the authors were tainted by fiduciary gain, or that they have a vendetta against an indivdual who is bringing a new product to market. Clinical observation is wholly subjective and, in a court of law, would have no credence. Only cold, hard science in the light of day will be the true arbiter of clinical efficacy. Go to the POSEIDO website, read the papers, and make your decision based on histology and biochemistry. Then we can debate PRF on it's merits, not on emotion. RJM

Typical slight of hand. What does this have to do with A-PRF Joseph? Please respond directly to the research as published by POSEIDO. RJM