Bone Grafting using Platelet Rich Fibrin (PRF Therapy)

Optimal Choice of Bone Graft Materials

All bone grafting materials that Dr. Yuriy May employs in the practice have been hand selected through thousands hours of clinical research and are by design considered the most natural, effective and of course, premium materials available on the dental market. All the below grafting material choices have infection reducing properties, along with helping blood clotting in a bone graft, thus allowing the bone graft material to hold together and develop the necessary density. Very few traditional dentists or oral maxillofacial dental surgeons use the materials Dr. May utilizes as his choice of materials require more time, effort and cost on the part of the dentist, relative to the most widely used animal or synthetic bone graft material made of either animal material (bovine or porcine) or synthetic compounds, including various forms of PTCP (beta-tricalcium phosphate).

Dr. May’s grafting material is extremely effective, beneficial and safe because it is made from patients’ very own blood thus making it 100% natural, derived from patients’ own bodily tissue. The blood is spun down into a serum with white blood cells and healing properties, and used as a the perfect grafting matrix instigating dense, healthy and incredibly robust bone growth, which is the goal of a bone graft. The materials described below have been very well studied and documented for many years. Dr. May’s patients experiencing the largest bone grafts in the case of sinus lifts and large cavitation grafts typically only need a mild pain reducer such as ibuprofen or acetaminophen afterwards if they have had a dental bone graft with any of the below materials. Dr. Yuriy may has an extremely high success rate in rebuilding and transplanting bone for dental implants and for full mouth reconstruction cases, including post-dental cavitation procedures.

Platelet Rich Plasma (PRP)

PRP, or platelet-rich plasma therapy can accelerate bone and tissue growth and wound healing and help assure long-term success of dental implant placements. PRP is the premium grafting material for sinus lift bone grafts, onlay block bone grafts, bone and ridge expansion, extractions, nerve repositioning and most surgical dental procedures. In addition to PRP’s amazing properties for accelerated healing of dental implant procedures and excellent bone growth regeneration, this amazing bone grafting medium is quickly gaining acceptance in orthopedics and sports medicine as well. Various orthopedic physicians have been using PRP with success for painful and hard to treat injuries like tennis elbow, tendonitis and ligament damage. It is worth mentioning that PRP was used in 2009 pre-game Super Bowl treatment for two Pittsburgh Steelers players (Heinz Ward and Troy Polamalo), and both were instrumental in the team winning its 6th Super Bowl. James Rutkowski, DMD, PhD, and a prominent dental researcher and editor of the Journal of Oral Implantology reported at the recent annual scientific meeting of the American Academy of Implant Dentistry (AAID) that platelet-rich plasma therapy can accelerate bone and tissue growth and wound healing and help assure long-term success of dental implant placements.

“What could be better than using the body’s own regenerative powers to grow bone and soft tissue safely and quickly? For dental implant procedures, PRP treatments can jump start bone growth and implant adherence in just two weeks, which cuts down the time between implant placement and affixing the dental crown,” said Dr. Rutkowski.

Platelet-rich plasma is obtained from a small sample of the patient’s own blood. It is centrifuged to separate platelet growth factors from red blood cells. The concentration of platelets triggers intense, rapid growth of new bone and soft tissue.

“There is very little risk because we are accelerating the natural process in which the body heals itself,” says Dr. Rutkowski. “PRP speeds up the healing process at the cellular level, and there is virtually no risk for allergic reaction or rejection because we use the patient’s own blood.”

For dental surgery applications PRP is mixed as a gel that can be applied directly in tooth sockets and other sites within the oral cavity. It highly effective in cases when bone grafts are required to foster proper bone integration for dental implants, which is where Dr. May exclusively uses PRP. Growth factors in PRP preparations help the grafts bond faster with the patient’s own bone. Studies by Dr. Rutkowski have reported findings of increased radiographic bone density during the initial two weeks following PRP treatment when compared to dental implant sites that did not receive PRP treatment.

“Accelerated healing is a goal we’re constantly seeking in implant dentistry and we now have treatment that activates the natural healing process. It is a most promising development for implant dentistry,” explained Dr. Rutkowski.

Currently, only 10% of practicing implant dentists use PRP treatment due the higher level of effort and expertise required by the dental implant specialist, however, PRP is widely considered as setting the bar for best in class bone grafting material in the holistic and implant dentistry field. Dr. Yuriy May is one of the few dental implant specialists in Connecticut using platelet-rich plasma therapy for dental implant placement and bone grafting.

Platelet Rich Fibrin (PRF)

Platelet Derived Growth Factor (PDGF)

Recombinant Human Bone Morphogenic Protein (rhBMP-2)

This is an additive known as recombinant human Bone Morphogenetic Protein-2 (rhBMP 2) made by Mectron.BMP is something that helps bone grow. BMP increases the price of dental implant bone grafts by $1500 to $7500, only for the BMP additive itself, not including the actual bone graft or dental implant and abutment, or the restorative crown! But, interestingly, BMP is not something Dr. May considers is necessary in all cases due to the fact that Natural Dentistry we are able to extract the natural Bone Morphogenetic Protein that each individual makes through the PRP (platelet-rich plasma therapy). The most cutting edge and effective of BMP is the natural, patient’s own modern PRP additive. Unlike PRP, the BMP available on the dental market is derived from other human beings, instead of the 100% bio-identical PRP made from each patient’s very own plasma and blood.

Why is Platelet Rich Therapy the Optimal in Bone Grafting & Tissue Regeneration?

Platelet rich therapy is the ultimate bioavailable therapy for stimulation and regeneration of cells in the body. While various growth factors are routinely used in reconstructive and regenerative therapies, the platelet rich therapy is the simplest and one of the most effective methods to extract growth factors from the blood’s platelets.

The Process of Platelet Rich Therapy and Blood work

Spinning to create PRP, PRF, i-PRF and A-PRF
In the office, Dr. May takes a blood draw from a patient and inserts the blood into a centrifuge to start the PRF procedures. The entire process takes approximately 20-30 minutes. Both PRP (platelet rich plasma), and PRF (platelet rich fibrin) can be extracted from the blood cells using the centrifuge. After the initial blood draw from the patient, a platelet concentrate technique is applied through use of the centrifuge to separate the blood’s components, with the goal of increasing and concentrating the platelet count. The most essential component is the clotting because the platelets release their growth factors only after clotting, and it is after the growth factors are created that their use can be determined.

PRF
In PRF, the white cells are in the bottom of the clot. If blood is spun a high G force, valuable cells can be destroyed and to preserve the cells, Dr. May spins the blood cells using a reduced RPM (revolutions per minute) and lower G force, to maximize the cell count and usage of the blood cells.

Difference in A-PRF and i-PRF
The main difference between Advanced PRF (A-PRF) and injectable PRF (i-PRF) is that A-PRF is a gel like substance used for bone and tissue grafting in the gingiva, while i-PRF is a liquid form used to regenerate tissue through injection.

Advanced PRF (A-PRF) forms a clot, creating a thicker, gel-like substance. With the A-PRF, the RCF (relative centrifugal force) is low: 200 G force — in order to get more white cells. An eight minute spin is needed to create A-PRF. Increasing the white cells, increases both vascularization and release of growth factors. By increasing vascularization, the vessel density and the percentage of vascularization can also be increased.

Injectable-PRF (i-PRF) is the injectable version of PRF, which is liquid. i-PRF is made slightly differently, with an even lower G force, of 60 only (vs 200 for A-PRF) — followed by the same protocol, with no additive and no anticoagulant. The goal of i-PRF is to create a formation of a high concentration of white cells, plus fibrinogen, plasma protein have it clots spontaneously after the injection. Nothing additional needs to be added into the injection site to get the clot and to get the platelet to release growth factors. Injectable-PRF can be created by spinning for only three minutes. Spinning for four minutes will reduce the quality while increasing the liquid content and is generally suboptimal. The best concentration of the stem cells is spinning only for three minutes. More blood can be used to create more liquid.

When comparing the white cells between PRP and i-PRF, i-PRF has over 20 times more white cells. However, the level of the platelets is the same in all three techniques (PRP, A-PRF, i-PRF); as the the difference in G force during centrifuging does not reduce the platelet enrichment.

How does the biology of Platelet Rich Therapy Work?

For PRP, the platelets are enriched 2x to 4x and few white cells remain.

For PRF, there is no anticoagulant added during the spin, the clotting is physiological and the spin creates a clot, which contains platelets, white cells and fibrin. In the PRF, there are all platelets, 50% of white cells and all the fibrin of the blood. The role of the fibrin is very specific, it’s a recipient of growth factors and this recipient will allow very specific release of growth factors, very slowly and continuously over a time period of more than one week. PRF can be prepared as aPRF (gel form) for gum grafting and bone grafting or iPRF (liquid form) for tissue shaping and stimulating collagen around the mouth and smile lines.

Natural Dentistry uses growth factors to not just for tissue stimulation for tissues undergoing regeneration, but to regenerate hard tissue – to regenerate and grow bone. While bone stimulation itself only needs the platelets, with or without leukocytes, the ultimate goal of regeneration requires fibrin. Regeneration requires a scaffold, which is created upon Dr. May adding in the fibrin matrix, in addition to platelets and leukocytes. The most critical element for the biological interaction of PRF to work optimally is the amount of growth factor released into the grafted site and not the concentration of growth factor in the actual substance, which needs to be released in a stable manner over the course of weeks for bone and/or soft tissue to regenerate.

To regenerate tissue we need a scaffold that the body can not provide without Dr. May’s manipulation of a patients blood, as fat is insufficient on its own to create a matrix. While fat can be used as a base, the most efficient scaffold in the body is fibrin.

How is PRF used outside of dentistry in medicine, dermatology, and cosmetic facial aesthetics?

By using PRF as a matrix, it can be used to promote healing in an infected wound. Examples include post-surgery infection and necrosis, for example in a diabetic foot, after amputation. The concept is to inject the fibrin with growth factor, and the fibrin will release over a few days. “By leaving the wound untouched for four to five days, a very fast vascularisation can be achieved without any anti-infectious threat. If vascularisation can be achieved on the surface, the healing is very easy, because the vessels are doing the job by slowly infusing the growth factors.”(1)

The healing in soft tissues always begins with formation of a provisional matrix. While all PRF components are active, the tissue needs platelets and the white cells most in the beginning. The objective is to create homeostasis and inflammation, to draw blood and vascularization to the area of treatment. After five – seven days granulation tissue begins to form and the matrix deposition becomes visible because the endothelial cells and the fibroblasts start to work, and after ten days collagen forms within the treated tissue. The provisional matrix is the most important, because when fibrin is introduced to into the site new vascularisation is immediately created.

Cell biology and the creation of collagen

Both plasma protein and white cells are necessary to create collagen synthesis, as white cells stimulate the inflammation response needed to draw fresh blood flow to the treatment area to create vascularization. At an injury site, the endothelial cells immediately separate themselves and then the white cells squeeze through the gaps and then by chemotaxis they move through the injury site, and begin to release the pro-inflammatory interleukins. This is the sort of inflammation that causes activation of monocytes into macrophages. The macrophages then dominate the inflammatory phase, and then they start to release growth factors and BNPS. Stem cells are necessary alongside white cells in order to achieve a smart blood concentrate and regenerate new tissue. White cells influence the quality of the PRP, so enriching the PRP with white cells creates greater tissue augmentation and a significantly higher proliferation of mesenchymal stem cells.(1)

Traditional Bone Grafting Materials

There are currently procedures to save or preserve bone, and there are a number of conventional bone graft materials available to be used with these procedures in dentistry today, all of which are suboptimal in holistic dentistry as they use foreign material to create a matrix to rebuild a dental patients’ oral and facial bone structure.

They include:

Autograft: Recipient’s Own Bone
Autograft is obtaining of bone from the patient’s own body and typically is the gold standard grafting procedure available now.
Concerns: Autograft has its limitations, which include potential problems such as second surgical site and patient discomfort in terms of harvesting of a graft from another part of the patients body. It’s also a painful, complex and costly procedure for the patient.

Allograft: Bone from another Human Being
Allograft is obtaining of bone graft materials from human cadavers.
Concerns: The disadvantage of allograft is that the bone graft materials may be rejected by the recipient’s immune system. Also there is chance of disease cross transmission.

Xenograft: Bone from animal, usually porcine or bovine origins
Xenograft is the obtaining of bone graft materials from tissue of animal origin, which includes bovine (cow’s bone) or porcine (pig’s bone)
Concerns: Similar to allograft, such bone graft materials may be rejected by the recipient’s immune system or pose concerns of potential disease transmission.

Alloplast: Synthetic grafting materials
Alloplast are synthetic grafting materials used for grafting.
Concerns: They have limitations in terms of biocompatibility, resorption timing, local tissue reaction, and bone regeneration.

Clinical Research & Studies

In recent research, my objective was to try to extract stem cells from the blood. We did a flow cytometry to analyze the mesenchymal stem cells into the iPRF. Using information from the International Society for Cell Therapy, we knew we needed to find cells that are CD 34- and 45-, and CD44+, CD73+, CD90+ and CD105+ positive, since those are the characteristics of the mesenchymal stem cells. The scientists performed an elimination of all the cells, and found that in the iPRF they have a 1% to 3% of mesenchymal stem cell concentration – far outpacing current PRP stem cell concentrations. When researchers analyzed the iPRF they found the magical cells they’ve been looking for: a concentrated quantity of if stem cells that equaled 1%-3% of total Platelet Rich Fibrin cells.
At Natural Dentistry, it is possible to produce thousands of stem cells in just three minutes, by collecting patients’ blood into several small 100 ml tubes and spinning in a centrifuge with a low force. When comparing the concentration of the mesenchymal stem cells in the new iPRF to the older and more known PRP, the difference of concentrated stem cells and growth factors using a low spin speed in the centrifuge is evident. Dr. May only needs to draw a patient’s blood, spin it in the centrifuge for three minutes at 900 rpm in the iPRF tube, without any additive, without any anticoagulant. It’s that simple.

Other Applications of i-PRF

Several dermatologists and osteopaths have treated a significant amount of patients with arthritis in the knee and hip, with the discovery that iPRF has the capability to regenerate cartilage and reduce pain. Several of Dr. May’s physician partners, including Dr. Paul Tortland of Valley Sports Physicians in Avon Connecticut, have achieved tremendous healing and pain relief by injecting iPRF into arthritic joints. Multiple studies and patient testomonials haveb documented the results of iPRF Therapy including regeneration of the cartilage with the stem cells from the iPRF, reduced inflammation, and reduced pain. Applying iPRF to the scalp with microneedling can improve the hair when the patient has alopecia or undergoes hair restorative procedures. iPRF is also be used in the lips to regenerate collagen and improve fullness, plumpness and overall form — to augment lips, new tissue must be created and for that, a fibrinogen is required to stimulate collagen development. Our Natural Dentistry APRN has achieved remarkable results for patients looking to naturally enhance their lip shape and appearance using injectable platelet rich fibrin or i-PRF, bringing the most cutting edge and biological regenerative procedures to the Northeast and Connecticut. Natural Dentistry is also offering iPRF hair rejuvination therapy, iPRF microneedling skin therapy and cystic acne iPRF treatments by our highly trained APRN with over 3000 clinical training hours.

Conclusion

The best results are the ones created from the body’s own biological materials and frankly, are the most simple and safe to create and use. When we follow nature and our body’s natural biology it makes sense to be safe and avoid any manufactured additives. Using this method of using RCF and controlling the RPM, Dr. Yuriy May not only can harvest more cells, but is able to generate a relatively large concentration of mesenchymal stem cells very quickly, simply, naturally and at a low cost. In addition, as Natural Dentistry continues to be involved in scientific research for cosmetic and regenerative uses of iPRF therapies we will be working with our APRN located in our Farmington, Connecticut headquarters to offer:

  • Hair Regeneration Therapy using iPRF
  • Skin Regeneration Therapy using iPRF
  • Cystic Acne Treatment Therapy using iPRF
  • Lip Augmentation Therapy using iPRF
  • Face Augmentation Therapy using iPFR & Hydrolauronic Acid injections*

References:

  1. “Stimulation and regeneration” by Dr. Joseph Choukroun, 3/31/2016
  2. HA injections paired with iPRF increase collagen formation and reduce the amount of Hydrolauronic Acid needed to be used due to iPRF’s property of generating far more collagen and acting as the perfect cellular framework to generate HA stability