Platelet-Rich Fibrin as a True Bone Graft Substitute: A Systematic Review and Meta-Analysis of Its Osteogenic Potential in Dental and Maxillofacial Surgery

Platelet-rich fibrin (PRF) has gained popularity as an autologous biomaterial used to enhance bone healing. This systematic review and meta-analysis aimed to assess whether the use of PRF alone achieves comparable osteogenic outcomes to conventional bone grafts. It involved a comprehensive search of the databases PubMed, Scopus, and Google Scholar for articles published from 2019-2024, seeking to identify clinical studies comparing PRF alone to grafts or controls in bone regeneration procedures. Primary outcomes in the studies included histologic bone formation (%), radiographic bone gain (mm), and implant success. Risk of bias was evaluated using the Cochrane risk-of-bias tool for randomized trials (RoB 2) for RCTs and ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) for non-RCTs. Meta-analysis employed the random-effects model (95% confidence intervals (CIs), and evidence certainty was graded via the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation). Of 142 screened studies, 18 met the inclusion criteria (nine RCTs, five CCTs, and four observational studies), encompassing extraction sockets, sinus augmentations, and periodontal defects. In large defects, PRF alone demonstrated inferior bone volume versus grafts (MD: -12.4%, 95% CI: -15.2 to -9.6; p<0.001; I² = 32%) but reduced ridge resorption versus natural healing in sockets (MD: 1.2 mm, 95% CI: 0.8-1.6; p<0.01). Heterogeneity in PRF protocols (centrifugation speeds of 700-3000 rpm) and outcome measures was high. Overall, the certainty of evidence was low for PRF's equivalence to grafts. While PRF exhibits osteopromotive properties, current evidence does not support its use as a standalone graft substitute in major defects. PRF may serve as an adjunct or alternative in small, contained defects (e.g., socket preservation), but standardized protocols and long-term RCTs are needed to further validate its efficacy.