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Authors: Dr. Sapna Shastri, Dr. Sheetal Sanikop, Dr. Sachin Shivanaikar

ABSTRACT:

Wound healing is a process which involves the activity of leukocytes and platelets. For healing to work efficiently, the platelets play a vital role. Platelet consists of growth factor which guides the regenerating cells to the area of healing. Platelet-rich-fibrin (PRF) is one such material, which consists of growth factors and cytokines entrapped in a fibrin matrix. It creates an ideal environment for wound healing and regeneration of periodontal tissues by combination of fibrin sealant properties with growth factors that result in sustained release of growth factors over a period of time whichaccelerate the wound healing process.
Various platelet concentrates have been put forth on platelet-rich-plasma (PRP), butbecause of the short duration of cytokine release and its poor mechanical properties, the search was done on a new material with adequate properties and PRF was the one which played a lead role in the regenerative field owing to its advantages over PRP. This review focuses on the properties, various applications and recent advances of PRF in the clinical practice.
KEY WORDS: Platelet Rich Fibrin (PRF), Platelet Rich Plasma (PRP), Injectable Platelet Rich Fibrin (I-PRF), Advanced Platelet Rich Fibrin (A-PRF), Titanium Platelet Rich Fibrin (T-PRF)

INTRODUCTION

The ultimate goal of periodontal therapy is restoring the periodontal health and regeneration of the lost periodontal structures.There are various pathological etiologies which result in dysfunction of the oral tissues and create osseous defects.Many biomaterials have come into existence that can fill in osseous defects and accelerate wound healing. Materials like hydroxyapatite, freeze dried bone graft, tricalcium phosphate, bioactive glass etc. have been widely used in healing and regeneration of soft and hard tissues.
Some studies have been focused on the use of an autogenous material called Platelet Rich Fibrin which provides an osteoconductive scaffold along with growth factors to stimulate regenerative processHealing of any wound is initiated by clot formation and inflammation, followed by a proliferative stage which involves epithelialization, angiogenesis, granulation tissue formation and collagen deposition and at last the collagen maturation and contraction.
The use of blood derived products to heal wounds started in 1970 with the use of fibrin glues or fibrin sealants which were formed by polymerizing fibrinogen with thrombin and calcium. It was prepared by using donor plasma, but because of the low concentration of fibrinogen inplasma, the stability and quality of fibrin glue was low.1
Regenerative potential of platelets was introduced in 1974 and Ross et al. identifiedthat platelet derived growth factor play avital role in growth factor for fibroblasts, smooth muscle cells and glial cells.2
Nowadays, a variety of platelet concentrates has been developed and has shown promising results. Platelet concentrates have been developed with an thought to combine the fibrin sealant properties with the growth factors in platelets which provide an ideal environment for wound healing and regeneration of both hard and soft tissues.3
Platelet rich plasma (PRP), the first generation platelet concentrates was introduced by Marx et al. in 19984and it showed positive results in regenerative process but,the use of bovine thrombin for the activation of Platelet Rich Plasma (PRP) has been an issue of controversy which led to the development of the second generation platelet concentrate known as Platelet Rich Fibrin (PRF).
Platelet Rich Fibrin (PRF) is a Second-Generation Platelet Derivative, Developed in France by Choukrounetal.in 2001, PRF is a second-generation platelet derivative because, unlike other platelet concentrates like PRP, this PRF does not require anticoagulants nor bovine thrombin oranyothergelifyingagent.PRFconceptisastrictlyautologous fibrin matrix which consists of large quantity of platelet and leukocyte cytokines. 5 The PRF clot is yielded by a natural polymerization process during centrifugation and its natural fibrin architecture leads to slow release of growth factors and matrix glycoproteins during ≥7days.6 Such a slow release is inconceivable to advert in PRP techniques because of theirexcruciating platelet activation, contiguous release of growth factors, and production of a fibrin network that sustain the concentrate injection.7

The platelet concentrate products are classified based on their fibrin architecture and cell content: 8
  1. Pure platelet-rich plasma (P-PRP)
  2. Leukocyte and platelet-rich plasma (L-PRP)
  3. Pure platelet-rich fibrin (P-PRF)
  4. Leukocyte and platelet-rich fibrin (L-PRF)
 
  • Pure Platelet-Rich Plasma (P-PRP) and Leukocyte- and Platelet-Rich Plasma (L-PRP) are liquid platelet suspensions, respectively without and with leukocytes. After activation with thrombin, calcium chloride, batroxobin or others agents, these preparations become respectively P-PRP and L-PRP fibrin gels, with incomplete fibrinogen polymerization and a light fibrin architecture.
  • Pure Platelet-Rich Fibrin (P-PRF) and Leukocyte- and Platelet-Rich Fibrin (L-PRF) are solid fibrin biomaterials, respectively without and with leukocytes. In these techniques, the platelet activation is part of the production process: it can be natural (L-PRF) or artificial (P-PRF) and it leads to strong fibrin architecture. Preparation of PRF follows the protocol developed by Choukroun et al. in Nice, France.9(Figure 1)It includes collection of whole venous blood (around 5 ml) in each of the two sterile tubes without anticoagulant and the tubes are then placed in a centrifugal machine at 3,000 revolutions per minute (rpm) for 10 min, which settles into the three layers: Upper straw-colored acellular plasma, red-colored lower fraction containing red blood cells (RBCs), and the middle fraction containing the fibrin clot. The upper straw-colored layer is discarded and middle fraction is collected, which is PRF.

The advantages of PRF over PRP are as follows
  1. Simple and cost effective method.
  2. Eliminates the use of bovine thrombin and thereby reduces the chances of cross infection.5
  3. Slow natural polymerization of PRF with equilateral junctions in PRF allows the establishment of a fine and flexible fibrin network that support cytokines enmeshment and cellular migration, but whereas 3-D organization of PRP consists bilateral junctions constituted with strong thrombin concentrations which allows the thickening of fibrin polymers leading to a rigid network, which is not feasible to cytokine enmeshment and cellular migration.10
  4. PRF has supportive role on immune system. Platelets contain some growth factors which increases cell mitosis, collagen production, recruit other cells to the site of injury and induce cell differentiation.11
  5. PRF helps in hemostasis.Platelets contribute to the hemostatic process in two different ways. First, through their adhesive and cohesive functions which lead to the formation of a hemostatic plug. Second, by activating coagulation mechanisms through the exposure of an adequate phospholipidic surface which act as a catalytic site for the development of coagulation and the coalition of the hemostatic plug.12




PRF applications are as follows:

ORAL APPLICATIONS
  1. PRF and PRF membrane both have been used in combination with bone grafts to in lateral sinus floor elevation procedures which propel healing process.13
  2. Stabilization of graft materials in ridge augmentation procedures14
  3. Socket preservation in case of tooth extraction or avulsion15
  4. Root coverage procedure with single and multiple teeth recession16
  5. Regenerative procedures in treatment of intrabony osseous defect17
  6. In case of furcation defect treatment18
  7. In combined periodontic- endodontic lesion19

EXTRAORAL
 
  1. Augmentation of Achilles tendon repair20
  2. In long-term diminution of deep nasolabial folds21
  3. Application in facial plastic surgery22


Recent advances came into existence as follows:

(a)I-PRF23
Mourao et al. have postulated a study which represent an alternative to platelet concentrates by using the platelet-rich fibrin in liquid form (injectable) and its use with particulated bone graft materials in the polymerized form.
To obtain i-PRF, blood collection was doneby using 9 ml tubes without any additive. After collecting three tubes, they were placed in the horizontal centrifuge with a tube filled with water in order to maintain the balance during centrifuging for two minutes at 3300 rpm.

(b) Advanced-PRF (A-PRF) 24
Itis a fourth generation PRF, which is obtained at 1500 rpm for 14 minutes centrifugation time. A-PRF has a greater concentration and more homogenous distribution of monocytes which play a key role in bone formation and also in case of clot formation.
Nagasri M et al conducted a studywhich compare and evaluate the efficacy of Nanocrystalline hydroxyapatite bone graft with advanced platelet rich fibrin and Platelet rich fibrin in the treatment of bilateral intrabony periodontal defects. Twenty intrabony defects in 9 systemically healthy patients aged between35‑55 years were randomly assigned into Group A and Group B. The Plaque index (PI), Gingival index (GI), Probing pocket depth (PPD), Clinical attachment level (CAL), and Radiographic bone fill were recorded.
In Group A NcHA bone graft with A- PRF was placed and in the Group B NcHA and PRF was placed, Post-operative recall was done at 7th day, 1st month, 3rd month, and 6th month. Statistically significance with p values of < 0.0001was observed for all clinical parameters at group A, Group B pre operatively and post operatively with more significance observed in Group A (NcHA and A-PRF).The study concluded that Group A which was treated with NcHA and A-PRF showed better results when compared with NcHA and PRF in Group B.

(c) Titanium-PRF (T-PRF) 25
The T-PRF method is based on the hypothesis that titanium plays an effective role in activating platelets when compared to silica activators. Titanium contains the highest strength-to-weight ratios and is corrosion resistance among metals. Due to its noncorrosive properties, titanium has got excellent biocompatibility. The material passivates itself in vivo by forming an adhesive oxide layer. Titanium also plays a role in osseointegration, connecting both structurally and functionally with the underlying bone. PRF has got some limitations such as- 26
 
  1. As PRF is an autologous product, the availability of this biomaterial in larger amounts is a concern. Hence, its usage in surgical procedures should be well superintended.
  2. PRF possesses the circulating immune cells and antigenic molecules that prevent its use as an allogenic material. Also, there is an increased risk of transmitting infectious agents. Future directions for PRF are that more studies should be carried out to correlate the clinical outcome of PRF with its biologic mechanisms.


CONCLUSION

PRF stepped in a new revolutionary of platelet gel therapeutic concept. Theaddition of bovine-derived thrombin promotes conversion of fibrinogen to fibrin in PRP which is eliminated in PRF. The elimination of these steps considerably reduces biochemical handling of blood as well as risks associated with the use of bovine-derived thrombin.

REFERENCES
 
  1. Kanakamedala A, Ari G, Sudhakar U, Vijayalakshmi R, Ramakrishnan T, Emmadi P. Treatment of a furcation defect with a combination of platelet-rich fibrin (PRF) and bone graft – a case report. ENDO 2009; 3(2):127–35.
  2. Heldin CH, Westermark B, Wasteson A.Platelet- derived growth factor: purification and partial characterization.Proc Natl Acad Sci USA.1979; 76(8):3722-6.
  3. Prakash S, Thakur A. Platelet concentrates: present, past and future. J Maxillofac Oral Surg 2011; 10(1): 45–9.
  4. Marx RR, Carlson ER, Eichstaedt RM, Schimmele SR.Platelet-rich plasma: growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 85:638-46.
  5. Gupta V, Bains VK, Singh GP, Mathur A, Bains R. Regenerative Potential of Platelet Rich Fibrin In Dentistry: Literature Review. Asian J Oral Health Allied Sci 2011; 1(1):22-8.
  6. Dohan Ehrenfest DM, de Peppo GM, Doglioli P, Sammartino G.Slow release of growth factors and thrombospondin-1 in Choukroun’s platelet-rich fibrin (PRF): a gold standard to achieve for all surgical platelet concentrates technologies. Growth Factors.2009; 27(1): 63–9.
  7. J. Choukroun, A. Diss, A. Simonpieri et al., “Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part IV: clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 101(3):E56–E60.
  8. Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: From pure platelet-rich plasma (P-PRP) to leucocyte and platelet rich fibrin (L-PRF). Trends Biotechnol. 2009; 27:158-67.
  9. Appel TR, P¨otzsch B, M¨uller J, von Lindern JJ, Berg´e SJ, Reich RH.Comparison of three different preparations of platelet concentrates for growth factor enrichment.Clin Oral Implants Res.2002; 13(5): 522–8.
  10. Prakash S, Thakur A. Platelet concentrates: present, past and future. J Maxillofac Oral Surg 2011; 10(1): 45–49.

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