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| CASE REPORT |
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| Year : 2022 | Volume
: 12
| Issue : 1 | Page : 11-14 |
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Clinical applications of injectable platelet-rich fibrin: A case series
Rucha Shah, MG Triveni, Raison Thomas, A B Tarun Kumar, Dhoom Singh Mehta
Department of Periodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India
| Date of Submission | 14-Dec-2020 |
| Date of Acceptance | 09-Jun-2021 |
| Date of Web Publication | 30-Apr-2022 |
Correspondence Address:
Dr. Rucha Shah
Room No. 5, Department of Periodontics, Bapuji Dental College and Hospital, Davangere - 577 004, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jid.jid_87_20
 Abstract | | |
The latest innovation in the field of platelet concentrates is the completely autologous, additive-free, injectable platelet-rich fibrin (i-PRF). It is the first PRF in a liquid form. This makes it possible for it to have much more versatile applications in regenerative dentistry as compared to its predecessors. Even though there is some published literature on the in vitro properties of i-PRF, there are no clinical reports demonstrating its clinical applications. This case series throws light on the preparation protocol, possible applications, and clinical handling experience with i-PRF.
Keywords: Blood platelets, fibrin, growth factors, injectable platelet-rich fibrin, leukocytes, platelet concentrates, platelet-rich fibrin
How to cite this article:
Shah R, Triveni M G, Thomas R, Kumar A B, Mehta DS. Clinical applications of injectable platelet-rich fibrin: A case series. J Interdiscip Dentistry 2022;12:11-4 |
How to cite this URL:
Shah R, Triveni M G, Thomas R, Kumar A B, Mehta DS. Clinical applications of injectable platelet-rich fibrin: A case series. J Interdiscip Dentistry [serial online] 2022 [cited 2023 Mar 23];12:11-4. Available from: https://www.jidonline.com/text.asp?2022/12/1/11/344467 |
| Clinical Relevance to Interdisciplinary Dentistry | |  |
This article highlights the multipurposeness of this new, versatile and completely autologous, growth factor rich platelet concentrate injectable PRF and its clinical applications to enhance local wound healing.
| Introduction | | |
The introduction of additive-free platelet-rich fibrin by Choukroun et al. can be considered as a milestone in the development of newer platelet concentrates.[1] The newest member of the platelet-rich fibrin (PRF) family is a liquid form, the injectable PRF (i-PRF).[2] The concept was introduced by Miron et al. in 2017. The other platelet concentrate that can be obtained in a liquid form is PRP which requires collection of blood in the presence of an anticoagulant and further activation using bovine thrombin and calcium chloride.[3]
Recently, properties of i-PRF to PRP were compared and it was found that i-PRF demonstrated significantly higher total release of platelet-derived growth factor (PDGF)-AA, PDGF-AB, epidermal growth factor, and insulin-like growth factor-1. Furthermore, it induced higher fibroblast migration and higher expression of transforming growth factor (TGF)-β (7 days), PDGF (3 days), and collagen 1 (3 and 7 days) mRNA.[2],[4] When the osteoblast behavior was compared, i-PRF demonstrated 3-fold higher migration and significantly higher proliferation than PRP. Greater alkaline phosphatase activity and alizarin red staining indicative of osseous tissue formation were observed in i-PRF.[5]
These results indicate that i-PRF has the requisite properties to be used as a biosurgical additive like its predecessors. However, there is a lack of literature describing the clinical applications of i-PRF. Hence, the aim of this case series is to describe the application of i-PRF in three different clinical scenarios.
Injectable platelet-rich fibrin preparation protocol
The conventional concept of i-PRF proposes centrifugation of freshly collected blood at 700 rpm for 3 min in uncoated plastic tubes. After this, the liquid concentrate that is obtained in the upper part of the tube after centrifugation is collected.[2] Thanasrisuebwong et al. compared the top yellow half without buffy coat to a red part including to buffy coat of i-PRF.[6] They reported that viscoelastic properties such as clot formation time, α-angle, and maximum clot firmness were superior in yellow half. However, red i-PRF was found to be more cellular and demonstrated increased release of VEGF, TGF-β1, and PDGF. When the response of these two was assessed on periodontal ligament stem cells, it was found that red i-PRF caused greater cell migration and proliferation and prevented premature mineralization leading the authors to conclude that the use of red i-PRF may be more desirable than yellow fraction.
| Case Reports | | |
Case-1
A 35-year-old male patient reported with a chief complaint of fractured tooth in upper front region and a history of fall 3 days back. On examination, fracture in relation to #11 was noted with the fracture margin involving the entire crown extending subgingivally [Figure 1]a. Considering the same, it was decided to extract #21 with simultaneous socket preservation. | Figure 1: (a) Fractured tooth #21 indicated for extraction. (b) Following tooth extraction, sticky bone was filled in the socket, topped with a platelet-rich fibrin plug, and sutured with a cross-mattress suture. (c) Uneventful healing at the end of 4 months. (d) Radiograph at the end of 4 months
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On the day of the surgery, atraumatic extraction was performed in relation to #21 using periotome and the socket was debrided and irrigated. Nine milliliter of the patient's blood was collected in plain plastic vacutainers and subjected to centrifugation at 700 rpm for 3 min to prepare i-PRF.[2] One milliliter of the centrifuged blood (i-PRF) just above the RBC layer was then aspirated (i-PRF) and mixed with xenograft. Within a few seconds, the mixture was converted to a gel, following which socket was filled with this sticky bone and roofed with a PRF plug (9 ml blood without anticoagulant in glass-coated plastic vacutainers at 2700 rpm for 12 min).[7]
A cross-mattress suture was placed to seal the socket [Figure 1]b. At the 14th day, the healing was uneventful and at the end of 4 months, a loss of 0.6 mm in the mesiodistal width of the socket and 0.5 mm loss of height were observed [Figure 1]c and [Figure 1]d.
Case-2
A 39-year-old female patient reported with a chief complaint of food lodgment in the lower left back tooth region for the past 3 months. On examination, a pocket of 10 mm was observed on the mesial aspect of tooth #46, and radiographic evidence of a vertical defect was observed mesially [Figure 2]b. | Figure 2: (a) A two-wall vertical defect noted mesial to #46. (b) Preoperative radiographic appearance suggesting vertical defect. (c) Defect site filled with sticky bone. (d) Radiographic bone filled at the end of 6 months
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Following phase-I periodontal therapy, a full-thickness flap was reflected. After thorough debridement, a crater was observed in relation to the mesial aspect of #46 [Figure 2]a. The site was then grafted with sticky bone (i-PRF in combination with bone graft) and covered with L-PRF membrane [Figure 2]c. The flap was sutured back in place. Suture removal was performed at the 10th day and healing was uneventful. Six months postoperatively, the probing depth was reduced to 3 mm, and intraoral periapical radiograph showed radioopacity in related area, indicative of bone fill [Figure 2]d.
Case-3
A 23-year-old male patient reported with a chief complaint of pus discharge in upper anterior teeth for 6 months. On examination, a pocket measuring 12 mm was found on the buccal aspect of #12 with no mobility. Intraoral periapical radiograph showed a periapical radiolucency of 3 mm diameter around the apex of #22. A diagnosis of primary endodontic lesion with secondary periodontal involvement was made. Conventional root canal therapy was completed, and on 3-month follow-up, the pocket was still persisting and no resolution of periapical radiolucency was observed. Hence, a full-thickness flap was reflected and the defect was exposed [Figure 3]a. After complete debridement, sticky bone was prepared [Figure 3]b and compacted into the defect till the most coronal aspect of the adjacent bone [Figure 3]c. The flap was sutured back in place [Figure 3]d and no postoperative complication was observed. Four-month follow-up radiograph demonstrated resolution of apical defect and the probing depth was reduced to 3 mm. | Figure 3: (a) Periapical defect at #22. (b) Formation of sticky bone. (c) Compaction of sticky bone into the defect site. (d) Suturing with interrupted sutures
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| Discussion | | |
Injectable PRF being liquid brings with it all the benefits of PRF including being 100% natural, easy and quick to prepare, and no chances of any complications (such as life-threatening coagulopathies seen with PRP) along with the versatility of PRP (being injected or mixed with bone graft to form matrix).[3] Even though a few studies assessing the in vitro properties of i-PRF have been published, there are no studies detailing the clinical applications of i-PRF with follow-up.[2],[4],[5] In this article, we have used i-PRF in combination with particulate bone graft to demonstrate its possible clinical applications. The other PRF protocols including l-PRF and A-PRF are obtained in a gel form. As such, they can neither be injected nor mixed readily with any biomaterials. The rationale of using i-PRF with sticky bone is that when particulate graft is mixed with i-PRF, the PRF clot incorporates the bone particles in its matrix. This improves the consistency, thus handling, working characteristics of the graft that overcomes technical difficulties in compaction and leaching of the graft. The second rationale is the bioactivation that i-PRF causes by releasing a plethora of growth factors including platelet-derived growth factor, transforming growth factor-β, collagen, and fibronectin turning the otherwise osteoconductive graft into a osteopromotive one.[2],[4]
In our first case, we used it for socket preservation to develop the site for future implant placement. In a recent systematic review, it was demonstrated that socket preservation caused a significant reduction in dimensional changes of alveolar ridges as compared to normal healing.[8] In the present case, a 4-month follow-up demonstrated minor changes in the horizontal and vertical dimensions of the socket demonstrating the fact that application of sticky bone was able to prevent a major percentage of bone loss that would have happened if the socket was left as is. Although it was not able to completely eliminate bone loss, the remaining bone was sufficient to plan for implant placement. In the second case, a two-wall intrabony defect was treated with sticky bone. We found that using sticky bone made the procedure less time consuming, easier and suturing were quite easy as has been described in previously published reports.[2],[9] The results obtained were satisfactory. In the third case, we demonstrated the use of sticky bone in a combined endo-perio lesion. Similar to previous cases, the grafting was quite easy and clinical results at the end of 3 months were acceptable. Although other forms of PRF have been used to manage endo-perio lesions, the authors did not come across any articles which have used sticky bone for the management of endo-perio lesions.[10]
| Conclusion | | |
From these cases, we found i-PRF to be an excellent material in terms of enhancing the handling characteristics of bone grafts. It seems to be a promising biosurgical additive not only to improve graft handling but also to reduce chair side time and enhance local wound healing by its inherent properties of growth factors. However, there are no clinical reports detailing the use of this material, and hence, studies should be done to demonstrate its clinical applicability and its biological effects.
Declaration of patient consent
The authors declare that they have obtained consent from patients. Patients have given their consent for their images and other clinical information to be reported in the journal. Patients understand that their names will not be published and due efforts will be made to conceal their identity but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Choukroun J, Adda F, Schoeffler C, Vervelle A. Une opportunity en paro-implantologie: Le PRF. Implantodontie 2001;42:55-62.  |
| 2. | Miron RJ, Fujioka-Kobayashi M, Hernandez M, Kandalam U, Zhang Y, Ghanaati S, et al. Injectable platelet rich fibrin (i-PRF): Opportunities in regenerative dentistry? Clin Oral Investig 2017;21:2619-27. |
| 3. | Jain NK, Gulati M. Platelet-rich plasma: A healing virtuoso. Blood Res 2016;51:3-5. |
| 4. | Wang X, Zhang Y, Choukroun J, Ghanaati S, Miron RJ. Behavior of gingival fibroblasts on titanium implant surfaces in combination with either injectable-PRF or PRP. Int J Mol Sci 2017;18:E331. |
| 5. | He L, Lin Y, Hu X, Zhang Y, Wu H. A comparative study of platelet-rich fibrin (PRF) and platelet-rich plasma (PRP) on the effect of proliferation and differentiation of rat osteoblasts in vitro. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:707-13. |
| 6. | Thanasrisuebwong P, Surarit R, Bencharit S, Ruangsawasdi N. Influence of fractionation methods on physical and biological properties of injectable platelet-rich fibrin: An exploratory study. Int J Mol Sci 2019;20:1657. |
| 7. | MacBeth N, Trullenque-Eriksson A, Donos N, Mardas N. Hard and soft tissue changes following alveolar ridge preservation: A systematic review. Clin Oral Implants Res 2017;28:982-1004. |
| 8. | Moraschini V, Barboza Edos S. Use of platelet-rich fibrin membrane in the treatment of gingival recession: A systematic review and meta-analysis. J Periodontol 2016;87:281-90. |
| 9. | Shah M, Deshpande N, Bharwani A, Nadig P, Doshi V, Dave D. Effectiveness of autologous platelet-rich fibrin in the treatment of intra-bony defects: A systematic review and meta-analysis. J Indian Soc Periodontol 2014;18:698-704. [ PUBMED] [Full text] |
| 10. | Nagaveni NB, Kumari KN, Poornima P, Reddy V. Management of an endo-perio lesion in an immature tooth using autologous platelet-rich fibrin: A case report. J Indian Soc Pedod Prev Dent 2015;33:69-73. |
[Figure 1], [Figure 2], [Figure 3]
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