Dr. Irfanul Haque(Resident)

Dr. S.Girish RaoConsultant Faciomaxillary Surgeon

PLATELET RICH FIBRIN GEL

A NEW MANTRA FOR WOUND HEALING

Healing of hard and soft tissue is a complex procedure1. Scaffold (collagen and bone minerals)2. Signal molecules (growth factors)3. Cells (osteoclast,osteoblast,and fibroblast).

Introduction

Controlled Tissue Injury

Hemostatic Phase

Inflammatory Phase

Proliferative Phase

Remodelling Phase

HEALING PROCESS.

Require growth factors likea)Platelet derived growth factors

b)Transforming growth factors beta c)Vascular endothelial growth factorsd) Epithelial growth factors (EGF) e)Insulin-like growth factor-1(IGF-1)

With an overview of the healing cascades in mind

A natural human blood clot contains 95% red blood cells (RBCs), 5% platelets

on the other hand, PRF blood clot contains 4% RBCs, 95% platelets

Lindeboom J AH, Mathura KR, Aartman I HA, Kroon F HM, Milstein D M, Ince C. “Influenceof the application of platelet-enriched plasma in oral mucosal wound healing. Clin. Oral. Impl.Res.2007;18; pg 133-139

Increased numbers of degranulating platelets

increased concentration of GF or signal proteins

Undifferentiated stem cells migrate toward the GF

proliferation of cells required for healing

faster healing

Role of factors in wound healing:

The Journal of Lancaster General Hospital • Summer 2007 • Vol. 2 – No. 2

AIMS AND OBJECTIVE

• Evaluation of soft tissue healing and bone regeneration using platelet rich fibrin gel in post surgical bony cavity.

200 patients who underwent extraction of impacted lower wisdom teeth were included in the following study.

Out of them 100 were chosen as the test group and 100 as control group.

(THIS STUDY WAS FUNDED BY ICMR)

MATERIAL & METHOD

Criteria For Inclusion Of Patients

Patients willing to give informed consent Patients between18 to 40 years of age. Patients with blood concentration of thrombocytes

within the normal range (1.5 to 3.5 lakh cells/cubic cm)

Criteria For Exclusion Of Patients uncontrolled diabetes, immune disease, or other

contraindicating systemic conditions Radiation therapy Presence of any local infection Patient with poor oral hygiene A smoker A psychological problem An unwillingness to commit to a long-term post-therapy

maintenance program

PREPARATION OF PRF

The required quantity of blood is drawn .

5 ml is used for routine blood investigation.

5ml is transferred to tube containing 0.5mlanticoagulant(acidulated citrate dextrose-ACD) and centrifuged using a tabletop centrifuge for 20 min at

3400-4000 rpm.  

The resultant product consists of the following layers:•Top most layer consisting of a cellular Platelet Poor Plasma (PPP).•The second layer consists of Platelet rich fibrin (PRF).•RBC at the bottom.

•After which the top layer consisting of Platelet Poor Plasma (PPP) will be discarded as Platelet count is minimal.

•The second layer will be transferred to a neatly incubated test tube.• Calcium Gluconate is added to this solution (PRF).

• For 2ml of PRF, 0.5 ml of Calcium Gluconate is added and allowed to stand for 10 min for the standardization of the gel.

PRF thus prepared is in the form of a gel.

METHOD FOR GEL PREPERATION

10ml venous blood drawn

Blood placed in table top

centrifuge

Centrifuged at 3400rpm for

20 mins

Central layer of PRF obtained

Exposure of impacted tooth

Tooth removed PRF gel Sutures placed

USAGE

ANALYSIS

SOFT TISSUE HEALING:

Soft tissue healing was assessed clinically at one week interval post operatively and recorded in a questionnaire for the same.

The soft tissue parameters assessed qualitatively were: Postoperative swelling Erythema Wound dehiscence

On the scales of: absent(0),mild(1),moderate(2) and severe(3).

These readings were then tabulated statistically and the results compiled.

Post operative swelling Cases Control

(a)absent (0) 46 38

(m)mild (1) 34 38

(mo)moderate (2) 17 20

(s)severe (3) 3 4

0

10

20

30

40

50

60

70

80

90

100

absent mild moderate severe

case

control

POST OPERATIVE SWELLING

Erythema Cases Control

(a)absent (0) 7 3

(m)mild (1) 72 36

(mo)moderate (2) 20 44

(s)severe (3) 1 17

0

10

20

30

40

50

60

70

80

90

100

ABSENT MILD MODERATE SEVERE

case

control

ERYTHEMA

Wound dehiscence Cases Control

(a)absent (0) 89 67

(m)mild (1) 10 22

(mo)moderate (2) 0 7

(s)severe (3) 1 4

0102030405060708090

100

ABSENT MILD MODERATE SEVERE

case

control

WOUND DEHISCENCE

Group

n Mean

Std dev

Mean difference t P-Value

Control 100 6.90 1.422.600 14.227 <0.0001*

Test 100 4.30 1.92

Comparison of healing parameters between control group and test group:

The difference in mean soft tissue healing recorded between control group and test group is found to be statistically significant (P<0.001). Higher mean soft tissue healing in recorded in control group compared to test group and this difference is found to be statistically significant

Radiographs were assessed for amount of radiologic bone filling.

• RVG (Radio Visuo Graphs) is taken to study the bone maturation.

• Further follow up of the Patients is done in the next consultation with RVGs regularly for 1st month, 3RD month, 6TH month.

IMMEDIATECASE with PRF CONTRO L without PRF

AT 1 MONTH FOLLOW UP:

3RD MONTH FOLLOW UP:

6TH MONTH FOLLOW UP:

CASE CONTROL

The size of the residual defect is calculated by the technique described by Matteo Chiapasco et al.

The radiographs were converted to a digital format by a scanner

using the Corel Draw software. They were then converted to gray scale tonalities of 256 using Corel Photo paint Software.

The residual cavity area marked was converted into a histogram which gave the number of pixels in the residual cavity.

The decreasing number of pixels in the surgical defect over time gave us the absolute bone filling in the area of the lesion. The percentage of bone filling was then calculated.

Matteo Chiapasco, Alessandro Rossi, Jason Jones Motta and Michele Crescentini , Spontaneous Bone Regeneration After Enucleation of Large Mandibular Cysts: A Radiographic Computed Analysis of 27 Consecutive Cases J Oral Maxillofac Surg 58:942-948, 2000

N Mean Std. Deviation

Mean Std. Deviation P value

Immediate 100 1232.59 260.70 1241.35 203.43 0.79(Not significant)

1 month 100 1127.00 237.43 1199.60 191.22 0.02(Significant)

3 months 100 1023.03 203.40 1158.95 189.57 0.001(Significant)

6 months 100 935.51 204.55 1120.94 191.33 <0.0001(Significant)

GROUP 1: Cases (With PRF Gel) Group 2: control ( without PRF Gel)  Descriptive pixel values

Time periods

Percent increase(Bone density)

T value P value

Test(Mean + SD)

Control(Mean + SD)

After 1 Month

7.1 + 6.4 5.2 + 3.4

2.6 0.01

After 3 months

14.4 + 8.7 9.7 + 4.6

4.7 <0.001

After 6 months23.7 + 11.1 12.8 + 4.8

8.9 <0.001

On the basis of pixels value bone density at different time points relative

to baseline

BONE REGENERATION:ANOVA (Analysis of Variance) method was applied and

Scheffe test was used within the groups.

The tests applied were found to be statistically significant.

DISCUSSION

In our study we achieved a 19 fold increase in the platelet concentration in PRF constitution.

Clinical observation showed that oral mucosa healed faster in patients after using PRF gel as compared with control sites where gel was not added.

Also, the sites of the experimental group experienced less discomfort 1 week post operatively compared to the control group.

Bone maturation is faster in PRF group.

DISCUSSION

Autologous platelet-rich fibrin matrix as cell therapy in the healing of chronic lower-extremity ulcers .Wound Repair and Regeneration volume 16, issue 6,  pages 749–756, November–December 2008

A study done to assess the ability of novel autologous platelet-rich fibrin matrix membrane (PRFM) to facilitate healing in patients with chronic lower-extremity ulcers.  From the results of this small-scale pilot study, they found PRFM shows significant healing potential for closing of chronic leg ulcers.

A study was conducted ,where they placed PRF gel during closure following total knee arthoplasty, they found that rate of wound healing was faster.

William J. Berghoff, William S. Pietrzak, Richard D. Rhodes, platelet rich fibrin application during closure following total knee arthoplasty. Clin Orthop 2006 ;29 :7

A retrospective study found that use of autologous platelet-rich fibrin on a range of hard-to-heal wounds (chronic leg ulcers) achieved full healing or a significant reduction in wound diameter with no adverse effects.

P. Steenvoorde, L.P. Van doorn, C. Naves, oskam, use of autologous platelet-rich fibrin on

hard-to-heal wounds, Journal Of Wound Care , Vol 1 7 , No 2 , F ebruary 2 0 0 8

Study conducted to evaluate the effectiveness of platelet-rich fibrin (PRF )on the regeneration of autogenous cancellous bone and marrow grafted in the alveolar cleft. Autogenous cancellous bone grafting with PRF, which significantly reduces postoperative bone resorption, is a reliable technique for alveolar bone grafting of cleft patients.

Eriko Marukawa*, Hidekazu Oshina, Gaichi Iino, Keiichi Morita, Ken Omura Reduction of bone resorption by the application of platelet-rich fibrin(PRF )in bone grafting of the alveolar cleft . Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 278e283

CONCLUSION

In summation the PRF GEL :

Accelerates soft tissue healing and bone maturation.

Eliminates the need of secondary surgery to remove carriers as it is fully biocompatible and biodegradable

Is autologous .

Is convenient for patients as visit to the blood bank is avoided

CONCLUSION

In the modern surgical practice, PRF is boon for faster healing as it is autologous, easy to procure and is cost effective too…

TAKE HOME MESSAGE…

REFERENCES

References:

1). S.Girish Rao et al , Bone Regeneration in Extraction Sockets with Autologous Platelet Rich Fibrin Gel JMOSI(2013)Vol 12,Issue 1,Page11-16

2) Marx R, Carlson ER, Eichstaedt RM, et al. Platelet Rich Plasma growth factorsenhancement for bonegrafts.(1998) Oral Surg Oral Med Oral Pathol Oral Radiol Endod 85:638-46.

3) O‟Connell S, Carroll R, Beavis A, et al. Flow cytometric characterization of Cascadeplatelet-rich fibrin matrix (PRFM); The impact of exogenous thrombin on plateletconcentrates (PC). Musculoskeletal Transplant Foundation. Edison, N. J. 2006.

4) Lucarelli E, Beretta R, Dozza B, Tazzari TL, O‟Connell S ,Ricci F, Pierini M, SquarzoniS, Pagliaro PP, Oprita EI, and Donati D (2010) A recently developed bifacial platelet-richfibrin matrix.European cells and materials 20;13-23

5) Carroll RJ, Amoczky SP, Graham S, O‟Connell SM. Characterization of autologousgrowth factors in Cascade platelet rich fibrin matrix (PRFM). Edison, NJ: MusculoskelatalTransplant Foundation 2005.

6) Simon BI, Zatcoff AL, Kong JJW and O‟Connell SM. (2009) Clinical and HistologicalComparison of Extraction Socket Healing Following the Use of Autologous Platelet-RichFibrin Matrix (PRFM) to Ridge Preservation Procedures Employing Demineralized FreezeDried Bone Allograft Material and Membrane The Open Dentistry Journal 3; 92-99

7) Kuo TF , Lin MF, Lin YH, Lin YC, Su RJ, Lin HW, Wing P (2011) Implantation ofplatelet-rich fibrin and cartilage granules facilitates cartilage repair in the injured rabbit knee:preliminary report .CLINICS;66(10):1835-1838.

Thank You!