Alveolar ridge preservation: which platelet-rich fibrin protocol to choose?

The challenge of alveolar ridge preservation

Following an extraction, physiological resorption of the alveolar ridge remains a major concern for the implantologist, directly impacting the stability of the site and the quality of the future prosthetic support. Although platelet-rich fibrin (PRF) has established itself as an adjuvant solution to stabilise the clot and promote healing, the clinician faces a multitude of protocols without a clear consensus on the relative efficacy of each variant.

Study objectives and hypotheses

This systematic review and network meta-analysis (NMA) aims to clarify the real contribution of PRF in alveolar ridge preservation (ARP) procedures. The authors set two main objectives: to evaluate the impact of PRF on dimensional ridge preservation, soft tissue healing, and post-operative comfort, while ranking the different PRF protocols according to their clinical efficacy.

The study tests the hypothesis that the use of PRF-based preparations allows for a significant reduction in volumetric loss compared to spontaneous healing. The analysis focuses in particular on the comparison of dimensional changes measured by CBCT at 3 and 4 months, thus allowing to determine whether specific protocols, such as L-PRF or T-PRF, offer proven benefits for limiting crestal resorption.

Methodology

This study is a systematic review coupled with a network meta-analysis (NMA). The authors conducted an exhaustive electronic search in five databases to identify publications released up to 13 April 2026. The study protocol was duly registered on the PROSPERO platform under the reference CRD420251168408.

Inclusion criteria were limited to randomised controlled trials (RCTs) meeting the following conditions:

• At least one group treated with platelet-rich fibrin (PRF) monotherapy compared to a control group without PRF.
• Mandatory reporting of imaging assessments of bone formation at the extraction site.

A total of 42 trials were included in the systematic review, while 6 trials were selected for the network meta-analysis (NMA). The work focused on evaluating dimensional alveolar ridge preservation as the primary outcome, as well as soft tissue healing and post-operative pain level as secondary outcomes.

Data processing was based on a Bayesian random-effects model to evaluate dimensional changes of the alveolar ridge via cone-beam computed tomography (CBCT) over follow-up periods of 3 or 4 months. Treatment effects were expressed as mean differences with credible intervals, while the ranking of the efficacy of the different PRF protocols was established via the SUCRA (Surface Under the Cumulative Ranking Curve) curve. The quality of the included trials and the degree of certainty of the evidence were evaluated using the RoB 2 and CINeMA tools, respectively.

Results: The efficacy of PRF in alveolar ridge preservation

This synthesis of clinical data highlights the contribution of PRF to the healing of extraction sites. Compared to spontaneous healing (SH), PRF demonstrates consistent benefits regarding dimensional ridge preservation, the quality of soft tissue healing, and the reduction of post-operative morbidity. The use of "stick bone" (a mixture of biomaterials and PRF) also shows superior results compared to filling materials used alone.

The network meta-analysis (NMA) allowed for the ranking of protocols according to their probability of efficacy (SUCRA) for the preservation of the horizontal and vertical dimensions of the ridge:

Regarding the dimensional variations measured by CBCT, observations differ according to the follow-up period:

• At 3 months: No statistically significant difference was observed between the different interventions tested.
• At 4 months: T-PRF demonstrated a significantly lower vertical reduction compared to spontaneous healing (SH) on buccal and palatal sites, positioning itself as the protocol with the highest probability of success within this timeframe.

Although these data confirm the clinical interest of PRF for patient comfort and soft tissue management, the authors highlight marked heterogeneity between the 42 included trials, which limits the overall certainty of current evidence.

The contribution of PRF in alveolar preservation: what to remember?

The issue of alveolar ridge preservation (ARP) after extraction is central to optimizing conditions for future implant placement. This systematic review, integrating 42 clinical trials, confirms that the use of PRF provides a consistent benefit compared to spontaneous healing, not only in dimensional preservation, but above all in the quality of mucosal healing and the reduction of postoperative morbidity.

Efficacy nuanced by protocols

The network meta-analysis (NMA) reveals disparities according to protocols. While no statistically significant difference is noted between interventions at 3 months, L-PRF stands out with a higher probability of efficacy for horizontal and buccal preservation (SUCRA at 79-80%). At 4 months, T-PRF distinguishes itself by limiting vertical reduction more effectively compared to spontaneous healing. Furthermore, the "stick bone" concept seems to offer an interesting comparative advantage over the use of bone substitute materials alone.

Limitations and clinical caution

Let's be clear: despite these encouraging results, the certainty of the evidence is considered low due to high heterogeneity of protocols among the included studies. This methodological diversity makes it difficult to establish a strict universal protocol for the practitioner.

The efficacy of PRF in alveolar ridge preservation

This synthesis of 42 clinical trials confirms that the addition of PRF outperforms spontaneous healing for dimensional ridge preservation, soft tissue healing, and postoperative comfort. The network meta-analysis of data at 4 months places T-PRF in the lead for limiting vertical resorption, while L-PRF shows a 79-80% probability of efficacy for the preservation of horizontal width and buccal and palatal walls.

In practice, for the clinician:

• Optimize comfort: Systematically integrate PRF into your post-extraction sockets; its benefit on mucosal healing and the reduction of postoperative morbidity is clinically validated.
• Choose the right protocol: Favor L-PRF to stabilize your horizontal dimensions or T-PRF to limit vertical resorption, as both protocols offer the best probabilities of success according to current data.
• Nuance your expectations: Despite these favorable results, the heterogeneity of existing protocols requires cautious interpretation. PRF acts as a valuable adjuvant, but it does not guarantee total bone stability in the face of major anatomical defects.

Technical Glossary: Alveolar Ridge Preservation and PRF

Alveolar Ridge Preservation (ARP): Surgical procedure aimed at limiting the physiological resorption of bone and gingival volume after tooth extraction, in order to stabilize the site for future implant rehabilitation.

Leukocyte-platelet-rich fibrin (L-PRF): Second-generation platelet concentrate containing leukocytes, platelets, and growth factors, presenting in this analysis the highest probability of efficacy for horizontal and buccal preservation of the alveolar ridge.

T-PRF (Titanium-prepared platelet-rich fibrin): Preparation protocol using titanium tubes for centrifugation, associated in this review with a significant reduction in the loss of buccal and palatal vertical height at 4 months.

Stick bone: Configuration of graft biomaterials agglomerated with PRF, reported as offering superior bone preservation results compared to substitute materials used alone.

Network Meta-Analysis (NMA): Statistical methodology allowing for the simultaneous comparison of several interventions, even when they have not been directly compared in the same clinical trials, using a Bayesian random-effects model.

SUCRA (Surface Under the Cumulative Ranking Curve): Statistical indicator used to rank different PRF protocols according to their probability of being the most effective intervention within a comparative network.

Spontaneous Healing (SH): Control group used in the included studies, corresponding to the natural healing of the socket after extraction, without the addition of PRF or filling material.

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