MRONJ: can PRF secure your high-risk extractions?

Medication-related osteonecrosis of the jaw (MRONJ) remains a major and dreaded complication, frequently occurring after tooth extraction in patients undergoing antiresorptive or antiangiogenic therapies. Faced with this clinical challenge, platelet-rich fibrin (PRF) is proposed as a biological adjuvant capable of stimulating local tissue repair. The stakes are high: moving from passive healing management to active intervention to prevent bone exposure.

This systematic review with meta-analysis aimed to evaluate the efficacy of PRF in preventing MRONJ and improving post-operative mucosal healing. By compiling data from studies comparing extraction with PRF addition to extraction alone, the authors of this synthesis sought to determine whether this platelet concentrate constitutes a protective barrier and a reliable regeneration lever.

The central hypothesis is based on the ability of PRF to release growth factors in a sustained manner, thus promoting rapid epithelial closure and improved vascularization of the surgical site. For the practitioner, the aim is to validate whether the systematic integration of PRF into the extraction protocol can significantly alter the prognosis for these complex patients in the dental practice.

Methodology of the meta-analysis

This systematic review with meta-analysis was conducted based on an exhaustive search of the PubMed, EMBASE, and CENTRAL databases, covering the period from their inception until June 1st, 2026. The authors included studies specifically comparing dental extraction assisted by platelet-rich fibrin (PRF) to extraction alone in patients undergoing antiresorptive or antiangiogenic therapies.

The analysis protocol was structured around seven qualitative and quantitative studies, segmented according to the following criteria:

• Sampling: For the analysis of MRONJ occurrence, six cohorts comprising 370 patients were treated. For the evaluation of postoperative healing, six studies totaling 512 patients were included.
• Experimental groups: Comparison between extraction with PRF addition (including a subgroup analysis for L-PRF and A-PRF) and conventional extraction without biomaterial.
• Statistical analysis: Relative risks (RR) and 95% confidence intervals (CI) were calculated using random-effects models. Heterogeneity was assessed using the I² index.
• Quality assessment: A sensitivity analysis was conducted on studies with a moderate risk of bias, and the certainty of evidence was graded according to the GRADE approach.

Significant reduction in the risk of osteonecrosis (MRONJ)

Data synthesis from six cohorts (n = 370 patients) demonstrates that the use of platelet-rich fibrin (PRF) during dental extraction drastically reduces the incidence of medication-related osteonecrosis of the jaw in patients undergoing antiresorptive or antiangiogenic treatments. The relative risk (RR) is 0.29 (95% CI: 0.15–0.57; p = 0.0003), with moderate heterogeneity (I² = 30%).

A sensitivity analysis, restricted to the two studies with a moderate risk of bias, confirms this trend with an even more pronounced protective effect (RR = 0.13; 95% CI: 0.02–0.69; p = 0.02; I² = 0%), although these data are limited in volume.

Improvement of postoperative healing

Analysis of six studies (n = 512 patients) indicates that the addition of PRF generally promotes better tissue healing after extraction (RR = 1.31; 95% CI: 1.11–1.54; p = 0.001). However, significant heterogeneity was observed (I² = 69%).

Comparison of PRF subtypes: L-PRF vs A-PRF

The authors performed a subgroup analysis to evaluate the impact of the centrifugation protocol on healing:

Although L-PRF appears statistically more effective than extraction alone, the direct difference between the L-PRF and A-PRF subgroups is not statistically significant (p = 0.51).

Quality of evidence and limitations

Despite encouraging clinical results, the authors highlight the following critical points:

• The certainty of evidence was rated as "Very Low" for both outcomes according to the GRADE approach.
• The included studies are mostly observational and present serious risks of bias.
• Sample sizes remain relatively modest to conclude definitively on the extent of the preventive effect.

Clinical analysis and limits of evidence

What should be retained from these results in daily practice? The contribution of PRF seems to transform a high-risk procedure into a more predictable intervention. With the risk of MRONJ divided by more than three (RR = 0.29), the clinical benefit is tangible, even if the certainty of the evidence remains qualified as 'very low' according to the GRADE system. This reservation is explained by the predominance of observational studies in this synthesis.

A technical point draws attention: the distinction between PRF subtypes. L-PRF stands out clearly for improving healing (RR = 1.36), while A-PRF shows less definitive results. Why this difference? Should the practitioner systematically favor L-PRF? Although the inter-group difference is not statistically significant (p = 0.51), the trend suggests that a specific leukocyte concentration could play a key role in modulating local angiogenesis, often compromised by antiresorptive therapies.

In summary, although current data are based on samples that are still modest for a meta-analysis, the use of PRF is emerging as a serious biological adjuvant. In the dental practice, the reduced biological and financial cost of this technique argues in its favor, pending more robust randomized controlled trials to confirm these encouraging initial signals.

Summary of results

This systematic review demonstrates that the addition of PRF during dental extractions reduces the risk of MRONJ by 71% (RR 0.29) and promotes better mucosal healing. The compiled data suggest a more pronounced clinical efficacy for the L-PRF protocol than for A-PRF in improving postoperative outcomes.

In concrete terms, for the practitioner:

• Systematize PRF for prevention: For patients taking antiresorptives or antiangiogenics, alveolar grafting with PRF provides additional biological safety to prevent osteonecrosis.
• Prioritize L-PRF: To optimize tissue repair, favor the L-PRF protocol, which shows a significant improvement in healing (RR 1.36) unlike A-PRF in this analysis.
• Maintain surgical rigor: Although the benefit is statistically clear, the certainty of evidence remains classified as "very low"; PRF is a powerful adjuvant but does not replace an atraumatic surgical technique.

Technical Lexicon of the Study

MRONJ (Medication-Related Osteonecrosis of the Jaw): Serious bone complication characterized by persistent maxillary or mandibular bone exposure in patients undergoing antiresorptive or antiangiogenic treatments.

PRF (Platelet-Rich Fibrin): Second-generation platelet concentrate, used here as a biological adjuvant to stimulate tissue repair and post-extraction healing.

L-PRF (Leukocyte- and Platelet-Rich Fibrin): Subtype of PRF rich in leukocytes; the subgroup analysis of this review shows a significant association with improved healing (RR = 1.36).

A-PRF (Advanced Platelet-Rich Fibrin): Variant of PRF obtained through modified centrifugation parameters; in this meta-analysis, its effect on healing did not reach the threshold of statistical significance (p = 0.07).

Relative Risk (RR): Statistical measure used to compare the risk of MRONJ occurrence or the healing rate between the PRF group and the control group (extraction alone).

GRADE Approach: A system for assessing the certainty of evidence (here judged as "Very Low" for the two primary outcomes) based on the methodological rigor of the included studies.

Antiresorptive and antiangiogenic therapies: Pharmacological agents (such as bisphosphonates or angiogenesis inhibitors) increasing the risk of bone necrosis after oral surgical trauma.

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