Platelet Rich Fibrin Course 1. Concept Principle : blood centrifugation without anticoagulants. PRF was launched in 2000 by J. Choukroun (Choukroun J. et al. 2001) PRF contains platelets, but also a high concentration of fibrin and leucocytes. PRF is often called L-PRF (Leucocytes - PRF) for its firm formulation by J. Choukroun in 2001. Nowadays, new modifications in centrifugation speed, G-force and time have led to the development of a more bioactive PRF now called A-PRF (Advanced - PRF) (= LSCC for Low Speed Centrifugation Concept, 2014). Fibrin is the main component of PRF. Discoveries from basic science researches show that :

- Fibrin is a provisional extra cellular matric entirely derived from autogenous sources - Fibrine contains a supra –physiological concentration of human growth factors - Fibrine releases slowly and continuously cytokines for up to and over 10 days.

2. Indications The use of PRF is indicated in all types of oral surgeries : - Socket preservation : PRF is used as a tissue matrix. Fill the socket as much as you

can (compress the plugs with a gauze or a compactor). The socket has to be left open, no primary closure is necessary. Sutures are done only to maintain PRF in the socket. There is no need to wait more than 3 months to place the implant. In most cases, no additional biomaterial is needed.

- Soft tissue management : PRF is used as a tissue matrix. The best technique is the tunnel technique with a full flap. Same rule applies : Use as much PRF as you can.

- Bone graft : Sticky bone with S-PRF. Otherwise, cut the membranes (1 or 2) into small pieces and mix them with the biomaterial. Hydrate this mix with the PRF exudate from the PRF box.

- Sinus lift : .Protection of the Schneiderian membrane : 2 membranes placed first .PRF mixed with the biomaterial .Treatment of Schneiderian membrane perforations .Closure of the osteotomy window .PRF can also be used alone, only with a simultaneous implant placement

- Guided Bone Regeneration : PRF can be used as a barrier membrane to cover the augmented bone and to improve the vascularization of both hard and soft tissues. It’s idealy placed especially when no re-entry is planned.

Dr Elisa CHOUKROUN, DDS elisa@a-prf.com

Dr Joseph CHOUKROUN, MD joseph@a-prf.com

3. Preparation/Protocols

PRF ou L - PRF (1st protocol of 2001) : 2700 tr/min & 12 min

A - PRF + (clots, membranes, plugs) : Red tubes :

1. Draw your tubes (fast filling) 2. Put them in the centrifuge, in a balanced way (use the colors to help you) 3. Launch the program A - PRF + : 1300 tr/min & 14 min 4. At the end of the spinning : Remove the tubes from the machine, remove the caps

& Put the tubes in the tube-holder.

Wait 5 minutes if the clots are not completely solid. Don’t leave the tubes in the centrifuge, and neither the clots in the tubes.

Remove the clot from the tube and peel of the red clot, to keep only the fibrin. - For a clot : Use like this - For a membrane : Place the clot in the PRF-BoX and put the tray over - For a plug : Place the clot in the dedicated white cylinder and press it with the piston

S - PRF : (Sticky bone & large membranes) : Green tubes : 1. Draw your green tubes (fast filling) + 1 red tube 2. Put them in the centrifuge, in a balanced way (use the colors to help you) 3. Launch the program A - PRF + : 1300 tr/min & 14 min 4. At the end of the spinning : Remove the tubes from the machine, remove the caps

& Put the tubes in the tube-holder. 5. With a 2mL seringue, take the liquid from the green tubes 6. Apply this liquid on your biomaterial (sticky bone) or alone in a container (large membrane) 7. To accelerate the clotting : Add 1 clot on your sticky bone or 1 membrane on your large

membrane (From the red rube)

To have more liquid, draw more green tubes. Add more liquid to yout sticky bone if you have a large graft

or if you want a denser sticky bone

If you want to graft first and then « congeal » it on site : - Cut 1 or 2 membranes in small pieces in the cup - Add your biomaterial - Add few drops of the PRF-BoX exsudate - Apply this mix on the site to graft - Congeal the mix with drops of S-PRF

Limits of this protocol : - If you do the blood drawing at the beginning of the surgery (A PRF for membranes), you’ll

need to do a second drawing at the time of the graft (S PRF for the liquid) - Or do the drawing for both A PRF (red) & S PRF (green) at the moment of the graft.

i - PRF : Green tubes : Liquid for 15-20 min. Women : i PRF settings : 700 tr/min (60 g) & 3 min Men : i PRF M settings : 700 tr/min (200 g) & 4 mn

i - PRF + (Aesthetics & Orthopedics) : Purple tubes : Liquid for 20 min. Women : i PRF + settings : 700 tr/min (60 g) & 5 min Men : i PRF + M settings : 700 tr/min (200 g) & 6 mn

5. Biological conditions

LDL Cholesterol The cholesterol metabolism mainly occurs into osteoblasts. LDL cholesterol is an oxidant and induces cell apoptosis. A high level of LDL cholesterol deteriorates the bone health.LDL cholesterol testing is highly recommanded : it has to be < 1,4 g/L. Lab prescription : LDL Cholesterol + Cholesterol total

Vitamin D Vitamin D is a major hormon, necessary to the bone homeostasis and to an efficent immune response. Many failures and peri-implantitis should be linked to this metabolic desease. Lab testing is also recommanded : it has to be > 50ng/mL for a surgery. Lab prescription : 25 OH - vit D2 + D3 Supplementation : - Starts the day of the pre-op consultation : 2000 UI/day

- Adapt to the patient serum level after lab test results : If level > 30ng/mL : 2000 UI/day

If level is between 20 & 30ng/mL : 4000 UI/day If level is between 10 & 20ng/mL : 6000 UI/day If level < 10ng/mL : 10 000 UI/day

Metronidazole (pure powder) The use of metronidazole helps to reduce the contamination of the bone graft during surgery. Metronidazole is the most efficient molecule against anaerobe bacteria. The powder (pure) is mixed to the biomaterial before addind the i-PRF, A-PRF or PRF exudate. Only few milligrams are necessary, around 50mg (1 cap).

6. Pressure & tension Pressure on a tissue leads to a lack of angiogenesis. This essential rule was published by Mammoto in 2009. All healing failures are linked to a deficit of vascularization.

Tension Tension free flap closure is highly recommended. However the tension is also coming from the vestibule (speaking, smilling, coughing, chewing…). With high tension, the periosteum becomes ischemic and the bone resorbtion becomes obligatory.

Solutions : - Decrease the tension of the flap at the maximum. - Suture with apical mattress : deep U suture in the vestibule. - Always check the tension at the end of the surgery: pull lips and cheeks - If tension persist (flap mobilité despite apical mattress) : Incision in the vestibule.

Pressure

Apical mattress

1cm

Vestibule

The pressure is applied by the flap and will induce ischemia of the periosteum.Solutions :- Screw tenting - Apical mattress - Titanium mesh - Cortical bone plate

Pressure free implant placement When placed with a high torque, implants can cause a high pressure on the bone, , especially on the cortex, leading to an ischemia of this bone and its resorbtion. The best is to over-drill the cortical bone on 2mm depth or to perform subcrestal implant placement, to free this bone from any pressure. The grafted bone, less elastic, is even more fragile. Any implant placement will increase the stress applied on the bone. Strongly reduced insertion torque is highly recommended. Immediate loading should be avoided. Sutures When a flap is raised, the re attachment of the periosteum needs ew weeks to be sufficient. The sutures have to stay least 3-4 weeks. The use of a monofilament is highly recommended The easiest solution is to use a resorbable monofilament.

7. Pain management

Analgesia Pain is coming from the inflammation. In order to reduce inflammation, cortison is the most efficient molecule. Its biologic hal life is around 3 days. One dose is enough to reduce the inflammation : Prednisolone : 1mg/kg de Prednisolone or Dexamethasone : 0,20 mg/kg Only one dose is sufficient is most of the cases. If necessary, a second dose can be given after 3 days. Pain killers as Ibuprofen or Paracetamol should be associated. Anesthesia To improve a weak anesthesia (local acidity), it’s possible to increase the pH of the gum with Sodium Bicarbonate 1,4% : 5-10mL injected in the area of the anesthesia, after the injection of anesthetics.

Allergia Allergic symptoms are coming from the release of histamine from the macrophages after allergens exposure. It’s easy to prevent any allergic reaction by blocking the histamine release before the surgery : Use of antihistaminic drugs as Hydroxyzine : Atarax® 1 tablet of 25 mg/day/3 days before the surgery, at bedtime. Sedation Use of antihistaminics (ex:Hydroxyzine) : Atarax® About 1mg/kg for an adult, to start 2h before the surgery. In case of an high anxiety, give the same quantity the night before. Do not drive. Saliva Atropine Sulfate : 0,25 mg : IM, IV, sub-cutaneous or mouth floor If injected on mouth floor : inject fews drops of anesthetics before because atropine injection can be painful in this site