1.
Growth Factors
Periodontal andPeri–ImplantRegeneration
Presented by:
Dr.AhmedMohamedBadr

2.
Introduction
FDA approved growth factors
Platelet Concentrate( 1st , 2 nd, 3th and 4 th generation)
Applications of Growth Factors
Different cases application
Growth Factor Classification
Conclusions
ILOS:
• When ,Where To decide?
• How to use in proper
way?
• What you can do in
complex augmentation
cases?
• What are the precaution

3.
Growth factors
Transferring information
between cell populations
&their
micro-environment
Acting as signaling
molecules between cells
Introduction Polypeptide proteins that enable
and lead different cellular
processes

4.
When tissue undergo trauma,
Growth factors are released either from cells or extracellular matrix

5.
Introduction

6.
Introduction interactions

7.
How Wound Healing Occurs ?
Introduction

8.
Requirement of proper woundhealing
Introduction

9.
How can healing be accelerated ?
Introduction

10.
Autogenous
Allograft
Xenograft
Alloplastic
Autologous Cell
Harvesting
t
Cellular Bone
Matrix
Platelts
conc.
Recombinant
Growth
Factors

11.
Growth factors Forms
Recombinant
human
Growth
Factor

12.
Platelet concentrates
Group of products that are
prepared from autologous blood to
posses Supra- physiological healing
activitiy.

13.
Ease of preparation
1
2 High safety profile
High content of growth
factors
3
✓Platelet derived growth factor
✓Transforming growth factor
✓Bone morphogenic proteins
✓Fibroblast growth factor
✓Insulin like growth factor
Platelet
concentrate
(PC)

14.
Generations of PC
2nd
Generation
(PRF)
3rd
Generation (CGF)
1ST
Generation
(PRP)

15.
1st Generation (Platelet Rich Plasma)
• Whitman and Marx et al. in 1998
• two-steps centrifugation process
• anti-coagulant using EDTA, acid citrate dextrose (ACD)
or bovine thrombin
1st step : (Soft Spin) of centrifugation
(300g for 5 min at 12°C or 240g for 8 min at 16°C),
three layers are demarcated: red blood cells (RBCs)
on the bottom, middle layer that contains platelets
and leukocyte and platelet poor plasma (PPP) plasma
on top
Whitman DH, Berry RL, Green DM.Platelet gel: an autologous alternative to fbrin glue with applications in oral and maxillofacial surgery. Journal of oral and
maxillofacial surgery. 1997;55(11):1294–9.
Marx RE, Carlson ER, Eichstaedt RM,Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: growth factorenhancement for bone grafts. Oral
Surgery,Oral Medicine, Oral Pathology, OralRadiology, and Endodontology. 1998;85(6):638–46.

16.
2nd step : PPP and middle layerare
transferred to another tube then centrifugedfor
a second time (Hard Spin) to ensure proper
plasma separation
Modifications

17.
Comparing the efficacy of dual Platelet-Rich Plasma (PRP) and Hyaluronic Acid
(HA) therapy with PRP-alone therapy in the treatment of knee osteoarthritis: a
systematic review and meta-analysis
•Angeline Ai Ling Aw, ,Jun Jie Leeu, , Xinyu Tao & Hamid Rahmatullah Bin Abd Razak (2021)

18.
Clinical application
- PRP in skin lesions and wound healing
- Dermatological and autoimmune conditions
- genital fistulae
- premature ovarian failure implantation process, including
embryo quality, endometrial receptivity aesthetic
reconstruction
- Hair Loss

19.
PRP Drawbacks
⮚the several handling steps (1 hr) … not suitable for clinicalwork
⮚Adding anticoagulant .. Unnatural, retard healing, crossinfection
⮚Liquid … Not suitable to be combined with graft likeother
generations
⮚Higher centrifugation forces leads to fragmented platelets and
decrease enrichment
⮚the lack of standardized protocol …different centrifugation
devices and tubes

20.
Magalon J, Chateau AL, Bertrand B, Louis ML, Silvestre A, Giraudo L, et al. DEPA classification: a proposal for
standardising PRP use and a retrospective application of available devices. BMJ Open Sport Exerc Med. 2016
DEPA Classification (2016)
D dose of injected platelets
E efficiency of production
P purity of the PRP
Aactivation of the PRP

21.
Generations of PC
3rd
Generation
(CGF)

22.
Generations of PC
3rd
Generation
(CGF)

23.
2nd generation (PRF) by Choukroun et al 2001
1 No adding anticoagulant
2 More easy and simple processing technique
Technique
• 10 ml tube (approximately 400 g) which is
immediately centrifuged at 3,000 round per
minute (rpm) for 10 minutes.

24.
Miron RJ, Bosshardt DD. OsteoMacs: Keyplayers around bone biomaterials. Biomaterials. 2016;82:1–19

25.
Preparation of PRF

26.
Fibrin Clot

27.
1st Case of PRF
- Lyell syndrome (Toxic epidermal necrolysis) with repeated
failed antibiotic treatment
-Over the years, science has shown that
infection was often a secondary problem to
poor blood supply
-The idea was that by introducing supra-
physiological doses of growth factors from
blood, one could potentially re-introduce blood
flow into these tissues
Concept

28.
Fibrin Clot

29.
PRF Advantages
1. Easy to prepare and use
2. No biochemical modification
3. Cost effective process
4.An immune organizing node … High cytokines content … Accelerates the
healing process …. Helps in hemostasis
7. Elasticity and flexibility due to three dimensional structure of PRF membrane
8. Reservoir of natural GF release over 10-14 days ... GF trapped inside matrix
9. Contain (extremely) low conc. of stem cells
Marx RE. Platelet-rich plasma: evidence to support its use. Journal of oral and maxillofacial surgery : ofcial journal of the American Association of Oral and
Maxillofacial Surgeons. 2004;62(4):489–96.
Kobayashi E, Fluckiger L,Fujioka-Kobayashi M, Sawada K, Sculean A, Schaller B, et al. Comparative release of growth factors from PRP, PRF, and advanced-PRF.
Clinical oral investigations. 2016.

30.
PRF Advantages
1.Easy to prepare and use
2.No biochemical modification
3.Cost effective process
4. Reservoir of natural GF release over 10-14 days ... GF
trapped inside matrix
Marx RE. Platelet-rich plasma: evidence to support its use. Journal of oral and maxillofacial surgery : ofcial journal of the American Association of Oral and Maxillofacial Surgeons. 2004;62(4):489–
96. Kobayashi E, Fluckiger L,Fujioka-Kobayashi M, Sawada K, Sculean A, Schaller B, et al. Comparative release of growth factors from PRP, PRF, and advanced-PRF.
Clinical oral investigations. 2016.

31.
PRF Advantages
5. High cytokines content … Acceleratesthe healing
process …. Helps in hemostasis
6. Elasticity, flexibility and strength due to three-dimensional
structure of
7. Contain (extremely) low conc. of stem cells
Marx RE. Platelet-rich plasma: evidence to support its use. Journal of oral and maxillofacial surgery : ofcial journal of the American Association of Oral and Maxillofacial Surgeons. 2004;62(4):489–
96.Kobayashi E, Fluckiger L,Fujioka-Kobayashi M, Sawada K, Sculean A, Schaller B, et al. Comparative release of growth factors from PRP, PRF, and advanced-PRF.
Clinical oral investigations. 2016.

32.
1. PRF is totally specific to the donor??
2. Should be used immediately
3. Has dense structure (A-PRF) *******
4.Less amount of leukocytes, uneventful
distribution **** of leucocytes (L-PRF)
5. Cannot be injected (i-PRF) *****
PRF Disadvantages
Kubesch A, Barbeck M, Orlowska A, Booms P, Al-Maawi S, Sader RA, Kirkpatrick CJ, Choukroun J, Ghanaati S. Pre-clinical in vivo evaluation of
Platelet-rich fbrin (PRF) scaffolds: G-force reduction in advanced platelet-rich fbrin (A-PRF) scaffolds increases scaffold integration and
vascularization: First pre-clinical in vivo evaluation, (n.d.)JMSM, submitted.

33.
LYMPHOCYTE
Stem Cells
Neutrophile
B lymphocyteCells
Monocyte
Platelets
LYMPHOCYTE
Monocyte
Kubesch A, Barbeck M, Orlowska A, Booms P, Al-Maawi S, Sader RA, Kirkpatrick CJ, Choukroun J, Ghanaati S. Pre-clinical in vivo evaluation of
Platelet-rich fbrin (PRF) scaffolds: G-force reduction in advanced platelet-rich fbrin (A-PRF) scaffolds increases scaffold integration and
vascularization: First pre-clinical in vivo evaluation, (n.d.)JMSM, submitted.

34.
PRF LIMITATIONS
1- Adequate sample according to needs.
2. Time gap between sample taking and
centrifuge is a critical point
3. Should be prepared and used immediately.

35.
Too High Centrifugation speed pushing
leukocytes down to the bottom of
centrifuge tubes and away from PRF
matrix
Redistibute leuckocytes across the
entire matrix we need to decrease
cell bull down.
(the Low Speed Centrifugation Concept)
(LSCC)

36.
The low-speed centrifugation concept (LSCC)
reducing the relevant centrifugation force (RCF) advances PRF matrices
with an enhanced number of inflammatory cells and platelets
Increase of of macrophages
and leukocytes contained
within PRF
a. Secretion of a wide range
of growth factors.
b. Tissue wound healing.
c. New blood vessel
formation.

37.
1- L-PRF
- 2700 rpm for 12 min
- Quick collection (less than 20 sec)
- abundant amount of leukocytes and PC
-(97% PC and 50 % leukocytes)
PRF Modifications
Anti infectious action secrete iL1B,iL6, iL4, TNF alpha
Regulator controlling ability for biomaterials to adapt to new
host.

38.
2- A-PRF
- 1300 rpm for 14 min
- High amount of
macrophages
- Slowly release GF
- More porous
- Eventual distribution of
leukocytes
Ghanaati S, Booms P, Orlowska A, Kubesch A, Lorenz J, Rutkowski J, Landes C, Sader R, Kirkpatrick C, Choukroun J. Advanced Platelet-Rich Fibrin: A
New Concept for Cell-Based Tissue Engineering by Means of Inflammatory Cells, J. Oral Implantol. 2014;40:679–89

39.
=
=
=
=
=
=
Kubesch A, Barbeck M, Orlowska A, Booms P, Al-Maawi S, Sader RA, Kirkpatrick CJ, Choukroun J, Ghanaati S. Pre-clinical in vivo evaluation of
Platelet-rich fbrin (PRF) scaffolds: G-force reduction in advanced platelet-rich fbrin (A-PRF) scaffolds increases scaffold integration and
vascularization: First pre-clinical in vivo evaluation, (n.d.)JMSM, submitted.

40.
3- A-PRF +
- Which is not only lower centrifugation speed (1300 rpm) but also time
(8min) has been shown to increase growth factor release of TGF-beta1,
PDGF-AA, PDGF-AB, PDGFBB, VEGF, IGF, and EGF
Fujioka-Kobayashi M, Miron RJ, Hernandez M, Kandalam U, Zhang Y, Choukroun J. Optimized Platelet Rich Fibrin With the Low Speed Concept: Growth Factor
Release, Biocompatibility and Cellular Response. J Periodontol. 2017;88(1):112–121. Epub 2016 Sep 2.

41.
4- i-PRF
- 700 rpm for 3 min (60 gm)
- must be utilized within 15 min.
- Plain vacuum tube
- High amount of macrophages
- injectable

42.
Kobayashi E, Fluckiger L,Fujioka-Kobayashi M, Sawada K, Sculean A, Schaller B, et al. Comparative release of growth factors from PRP, PRF, and advanced-PRF.
Clinical oral investigations.2016.

43.
• Miron RJ, Fujioka-Kobayashi M, Hernandez M, Kandalam U, Zhang Y, Ghanaati S, Choukroun J. Injectable platelet rich fbrin (i-PRF):
opportunities in regenerative dentistry? Clin Oral Investig. 2017 Feb 2. doi: 10.1007/ s00784-017-2063-9.

44.
• sinus lift procedures Zhang et al., 2012
• socket augmentation Hauser et al., 2013
• Furcation treatment Sambhav et al., 2014
• Intrabony defects Mathur et la., 2015
• Gingival recession Aroca et al., 2009
• alveolar bone defect for implant installation
• filling of cystic cavity
PRF Uses

45.
Generations of PC

46.
Fibrin rich blocks that are much larger, denser and richer
in growth factors. This exhibits better regenerative capacity
and higher versatility when using the fibrin richblock
3rd generation (CGF) by Sacco et al 2006

47.
Advantage over PRF
✔higher tensile strength,
✔more growth factors,
✔higher viscosity
✔higher adhesive strength than PRF.
✔Furthermore, part of CGFs can be mixed with bone graft to form
sticky bone ,The Sticky bone provides stabilization of bone
graft in the defect and therefore, accelerates tissue healing and
minimizes bone loss during healing period

48.
Hideo Masuki1†, Toshimitsu Okudera1†, Taisuke Watanebe1
, Growth factor and pro-inflammatory cytokine contents in
platelet-rich plasma (PRP), plasma rich in growth factors
(PRGF), advanced platelet-rich fibrin (A-PRF), and
concentrated growth factors (CGF) 2016
Both A-PRF and CGF extracts
contained compatible or higher
levels of platelets and platelet-
derived growth factors

49.
• LUIGI FABRIZIO RODELLA,1 LUIGI SACCO,3 TIZIANO BATANI,4 AND RITA REZZANI growth factors, CD34 positive
cells, and fibrin network analysis in concentrated growth factors fraction 2011
Fibrin network (A) in which are trapped multiple platelet cell elements

50.
Uses
• sinus augmentation Sohn et al. 2015
• reconstruction of bone defects after removal of large jawcysts
Mirković et al 2015
• ridge augmentation Gheno et al.,
• socket preservation Ayoub et al., 2017
• treatment of gingival recession Doğan et al., 2016
• treatment of intra-bony defects ☺

51.
Preparation of
CGF

52.
Growth factors Forms
Recombinant
human
Growth
Factor

53.
3rd generation (CGF) Sacco in 2006
• is produced by the centrifugation of venous blood as
same as PRF. However, the technique is different on
centrifugation speed.
• fibrin rich blocks that are much larger, denser and richer
in growth factors.
• This exhibits better regenerative capacity and higher
versatility when using the fibrin rich block

54.
•Preparation of
CGF :

55.
∙ Concentrated growth factors (CGF)
Whichispreparedby usingaprogramwiththe following
characteristics:
30sacceleration
2 minat2700 rpm,
4 minat2400 rpm,
4 minat2700 rpm,
3minat3000rpmand
36s deceleration andstop

56.
Advantage over PRF
✔ease ofpreparation,
✔ ease of application,
✔minimal expense, and
✔ lack of biochemical modification (no bovine thrombin or
_____anticoagulant is required).
✔ It can also serve as a resorbable interpositional membrane which is
not present in PRP preparations

57.
Advantage over PRF
✔higher tensile strength,
✔more growth factors,
✔higher viscosity and
✔higher adhesive strength than PRF.
✔Furthermore, part of CGFs can be mixed with bone
graft to form sticky bone ,The sticky bone provides
stabilization of bone graft in the defect and therefore,
accelerates tissue healing and minimizes bone loss
during healing period

58.
Uses
• sinus augmentation Sohn et al. 2015
• reconstruction of bone defects after removal of large jaw cysts
Mirković et al 2015
• ridge augmentation Gheno et al.,
• socket preservation Ayoub et al., 2017
• treatment of gingival recession Doğan et al., 2016
• treatment of intra-bony defects ☺

59.
Growth factors Forms
Recombinant
human
Growth
Factor

60.
Types of growth factors
• Fibroblast Growth Factor (FGF):
- chemo-attractants for endothelial cells as well as for a variety of mesenchymal cells
including: fibroblasts, osteoblasts, chondrocytes, skeletal myoblasts and smooth muscle cells.
• Insulin-like Growth Factors (IGFs):
- increase DNA synthesis in osteoblastsand stimulated the formation of bone matrix

61.
• Platelet- derived Growth Factors (PDGF):
- chemoattractant for fibroblasts and inflammatory cells and in addition it
stimulates production of matrix components.
• Transforming Growth Factor (TGF):
-have been shown to affect bone metabolism through modulation of both osteoclastic
and osteoblastic cell differentiation and activity.
•Bone morphogenic proteins (BMPs):
-multi-functionalgrowth factors.
-periodontal regeneration.
•Epithelial Growth Factor (EGF):
-promote re-epithelialization andwound healing.

62.
•The active component of INFUSE Bone Graft
- rhBMP-2- is a recombinantly-
produced form of a signaling protein naturally occurring in the
human body.
•Mesenchymal stem cells proliferate, or increase rapidly in
number, at the site due to
Presence of rhBMP-2, supported by increased angiogenesis
at the site.

63.
INFUSE Bone Graft:
received approval for use in
sinus augmentation and
for localized ridge
augmentation for defects
associated with extraction
sockets.
1965:
Dr. Marshall R. Urist
discovers
That
demineralized bone
matrix
stimulates the formation of
new bone tissue
in lower-order animal muscle.
This led to :
The isolation of bone
morphogenetic proteins
(BMPs), the only proteins
known to induce new bone
formation(osteoinduction).
2002:
INFUSE Bone
Graft :
received
approval for use
in anterior
lumbar spine
fusion with
Medtronic
titanium
threaded
interbody
devices.
2004:
INFUSE Bone
Graft:
received approval
for use in open
tibial fractures with
intramedullary (IM)
nail fixation.
2007:

64.
•Reasons to consider INFUSE Bone Graft:
•Eliminates the need for a second bone harvest surgery.
•Regenerates 100% vital, vascular de novo bone with no residual graft
material remaining to destabilize bone formation.
• complex augmentation cases.
•Supported by over 20 years of research and clinical results,
including 60 preclinical studies and 5 clinical trials.

65.
•Important Information about INFUSE® Bone Graft:
•The potential for prolonged swelling may occur in some (but not
all) patients. This is most likely due to:The influx of the patient’s own
cells and fluids into the treatment site.
•INFUSE Bone Graft has not been studied in patient who are
skeletally immature (<18 years of age) or no radiographic
evidence of epiphyseal closure.)

66.
•INFUSE Bone Graft should not be used in patients with an active
infection at the operative site.
•INFUSE Bone Graft should not be used in the vicinity of a resected or
extant tumor, in patients with any active malignancy or patients
undergoing treatment for malignancy.
•This product has not been tested in pregnant women to determine if it
could harm a developing fetus. This product has also not been studied
in nursing mothers.

67.
Women of childbearing age should not become pregnant
for one year following treatment with the product. Women
of childbearing age should be warned of potential risks to
a fetus and should discuss other possible treatments with
their doctor.

68.
i-FACTOR BIOLOGIC BONE GRAFT
P-15/ABM has been in
human clinical use for
more than 17 years in an
estimated 500,000
patients worldwide

69.
i-FACTOR technology is based on the biological activity of a 15 amino acid peptide naturally
found in Type I human collagen. The only bone graft that combines a unique anorganic bone
ABM particles are a natural form of hydroxyapatite [Ca10(PO4 ) 6 OH2] mineral (ABM) particles
are a natural form of hydroxyapatite [Ca10(PO4 ) 6 OH2]
SYNTHETIC REPLICATE OF P-15

70.
1
ATTRACT
P-15 facilitates and
expedites ingrowth of bone
by promoting the
immigration of reparative
cells from the surrounding
tissues.
ATTACH
2
The high affinity between cells and
P-15 supports the physiological
mechanism in which cells bind to
collagen via the domain simulated
by P-15 and continue to organize
the matrix by tractional forces. Cells
attach to and migrate on Type I
collagen by haptotactic
mechanisms.
ACTIVATE
P-15 enhances bone formation by
facilitating cellular attachment with
subsequent increase in cell binding,
proliferation, and differentiation of
cells increasing TGFb-1, BMP-2, and
BMP-7 levels that positively
influence all processes of new bone
formation.
3

71.
GEM 21S®
rhPDGF-BB
with
ß-TCP.

72.
EMDOGAIN
ENHANCES HEALING
POSSIBLE STIMULATION OF
BONE AND CEMENTUM

73.
Emdogain is a biological product consisting of a
unique group of proteins that are found in
developing teeth( enamel matrix derivative) an
extract of porcine fetal tooth
Amelogenin: The Dominant Protein in
Emdogain

74.
• Act in a process mimics normal root
development by stimulating release
of autocrine growth factors from periodontal
ligament undifferentiated mesenchymal cells.
• EMD also, stimulates osteoprotegerin, serving to
trigger osteoblasts and indirectly inhibit both
osteoclastogenesis and osteoclastic function,
both of which are important in attaining alveolar
bone growth in the area of desired regeneration.

75.
Zuchhelli et al

76.
1 million viable cells/cc, 100%
Mesenchymal Stem Cells and/or
Osteoprogenitor Cells*
Higher amounts of BMPs-2
and BMPS-7

77.
CBMs on the Market
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
2005 2020
Osteocel
TrinityMatrix™
TrinityEvolution™
Osteocel Plus
Cellentra
TrinityELITE™
Ovation OS
Osteocel Pro
PrimaGen
OsteoVive
V92
ViaGraft
ViviGen
Bio4
map3
BioFuse
ViaCell
Orios
AlloFuse SelectCM
ViviGenFormable
ViBone
Scylla
FiberCel
All third party trademarks used herein are the
trademarks of their respective owners.

78.
https://www.extremitymedical.com/bone-graft/biofuse/

79.
Conclusions

80.
L/O/G/O
Thank You!
Ahmed_bader@dent.tanta.edu.eg
01004699564