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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 45-47

Choukroun’s platelet-rich fibrin (L-PRF): A benevolence to surgical and reconstructive dentistry


1 Dental Unit in ARSMH, Pune, Maharashtra, India
2 Maharashtra Institute of Dental Sciences & Research Dental College, Latur, Maharashtra, India
3 Theerthanker Mahaveer Dental College and Research Centre, Rampur, Uttar Pradesh, India
4 Guru Teg Bahadur Hospital, Delhi, India

Date of Submission24-Jun-2020
Date of Acceptance24-Jul-2020
Date of Web Publication28-Sep-2020

Correspondence Address:
Dr. Ankit Agarwal
Guru Teg Bahadur Hospital, Dilshad Garden, Delhi.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJO.INJO_26_20

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  Abstract 

Platelet-rich fibrin (PRF) is a stringently autologous fibrin matrix containing a large quantity of platelets (thrombocytes) and leukocyte cytokines. PRF is an upcoming newer treatment modality used to augment healing process and has been in clinical use over the last decade within many disciplines, such as peri-implant defects, periodontal defects, exclusively as grafting material, in treatment of alopecia, orthopedic, oral-maxillofacial and cardiac surgery, and plastic and cosmetic surgeries. Choukroun in 2001 (France) and his coassociates were among the inventors for use of PRF in any reconstructive surgery to encourage and enhance the bone healing. PRF is found better than the previously used PRP (platelet-rich plasma) as it is easier to prepare and apply, cheaper, and there is no need to add bovine thrombin or anticoagulant in it. Thus in the current setup, it is proving to be benevolent to the surgical reconstructive dentistry.

Keywords: Growth factors, platelet-rich fibrin (PRF), regeneration, wound healing


How to cite this article:
Sahu K, Jadhav SU, Khan SM, Singh N, Khan M, Agarwal A. Choukroun’s platelet-rich fibrin (L-PRF): A benevolence to surgical and reconstructive dentistry. Int J Oral Care Res 2020;8:45-7

How to cite this URL:
Sahu K, Jadhav SU, Khan SM, Singh N, Khan M, Agarwal A. Choukroun’s platelet-rich fibrin (L-PRF): A benevolence to surgical and reconstructive dentistry. Int J Oral Care Res [serial online] 2020 [cited 2020 Oct 22];8:45-7. Available from: https://www.ijocr.org/text.asp?2020/8/3/45/296224




  Introduction Top


Reconstruction surgeries are needed to reshape and volumize the existing and remaining bone. Over the years, researchers are studying on the various reconstructive methodologies which are evolving in the medical field. Choukroun et al.’s[1] PRF is such one of the reconstructive methodologies, which was introduced as one of the adjunctive measures in bone augmentation. Apart from the choice of graft material (autograft, allograft, xenograft, alloplastic, bioresorbable, or nonresorbable) the conventional bone regeneration is reliant upon mainly four major biological principles: primary wound closure, sufficient blood supply, stable, and infection-free wound site.[2],[3] The bone graft should be provided the most vascularized environment to promote angiogenesis. Blood supply provides the necessary cells, growth factors, and inhibitors to initiate the osteogenic biomineralization cascade.[4],[5] Injury to blood vessels causes bleeding, consequent platelet collection at injury site, and clot formation. Fibrin clot plays a major role in hemostasis and also provides a template for the fibroblasts and endothelial cells that are necessary in angiogenesis and new tissue formation. According to Simonpieri et al.,[6],[7] use of platelet and immune concentrate during bone grafting offers mainly three advantages––first is that the fibrin clot plays an important mechanical role with the PRF membrane in maintaining and protecting the grafted biomaterials and also the PRF fragments serving as biological connectors joining bone particles, second advantage is the fibrin network that facilitates the cellular migration, mainly for the endothelial cells that are necessary for the neo-angiogenesis, whereas the third advantage is the leukocytes having role in the self-regulation of inflammatory and infectious phenomena within the grafted material.[2] The platelet number in PRF is three to seven times more concentrated than normally found (150–400 × 103/dL).[8]

Platelets when get activated, the growth factors are released and they get trapped within the fibrin matrix, which shows the mitogenic response during wound healing. Choukroun’s (2001) platelet-rich fibrin (PRF) is a fibrin membrane, which can serve as a resorbable membrane due to presence of platelets cytokines and some cells. In PRF clots/membranes, the platelets accumulate and release cytokines which play a significant role in the biology of PRF biomaterial. These cytokines are used and destroyed in a healing wound.[9]

Though PRF is a new generation of platelet concentrate, the granules present contain many proteins, which may be platelet specific (e.g., beta-thromboglobulins) or nonplatelet specific (fibronectin, thrombospondin, fibrinogen, and other coagulation, growth promoters, fibrinolysis inhibitors, and immunoglobulin’s) calcium, and serotonin. Also phospholipids double layer of platelet membrane constitute many receptors for other molecules.[10]

Considering the biological aspect, platelet-rich concentrates can be classified as follows:[11]

  • PRP (platelet-rich plasma)
    • P-PRP


    • L-PRP


  • PRF

    • A. P-PRF


    • B. L-PRF




Preparation of PRF

PRF preparation requires a centrifuge machine and a collection kit including a 24-gauge butterfly needle and 9mL blood collection tube. The procedure for preparing the PRF requires the blood to be drawn into the plain blood collecting tubes, that is, without anticoagulant and is immediately centrifuged at 3000rpm for 10–15 min, time period varies according to the room temperature. Absence of an anticoagulant allows the activation of a majority of platelets that are present in the sample which generate the coagulation cascade within a few minutes. The fibrinogen gets concentrated and remains in the upper part of the tube, until the effect of the circulating thrombin transforms it into a fibrin network.

The blood that is centrifuged in a tube contains the cellular plasma at the top, platelets in the middle part of it, whereas the bottom layer contains the red blood cells.

Unlike PRP, the PRF results from a natural and progressive polymerization which occurs during centrifugation. This clot is removed from the tube and the attached red blood cells are scraped off and discarded. Later the PRF clot is placed on the grid in the PRF Box and covered with the compressor and the lid.

The following are the methods of PRF membrane preparation:

  1. Dry gauge


  2. Compression device
    • PRF box


    • Spoon compressor


These methods produce an inexpensive autologous fibrin membrane in approximately 1 min, in which PRF box produces membranes of equal thickness. Another advantage of it is getting the serum exudates collected at the bottom of PRF box. This keeps the membrane hydrated for several hours and it is rich in the proteins vitronectin and fibronectin. The exudates collected at the bottom may also be used to hydrate bone graft materials and to rinse the surgical site.

The PRF clots are squeezed between the sterile cotton gauze or kept in PRF box to extract a membrane that can immediately be placed over surgical site. As the growth factor release is found to be the maximum in first 60 min, the membranes should be placed immediately over the surgical site which is exposed prior to the membrane preparation.

Shortcomings of platelet-rich fibrin

As the PRF membranes are prepared without the addition of anticoagulants they cannot be stored; the clinical benefits of the membranes depend on the speed of blood collection and the centrifugation that can make it more effective. Storage can shrink the membranes and alter the structural integrity of PRF. The dehydration of these membranes results in decreased growth factor content in PRF.[12] At the same time, the leukocyte viability will be adversely affected altering its biologic properties. PRF membranes cannot be stored in the refrigerator as they can contract the bacterial contamination.


  Discussion Top


PRF is first developed in France, by Choukroun et al.[1] and is being widely used for a decade in almost every part of the world. It is mostly accepted with an immense regenerative potential.[9] PRF makes it superior to PRP in having the ease of preparation/application, less expense, and no need of biochemical modification (i.e., bovine thrombin or anticoagulant). PRF can be successfully used to promote wound healing, bone regeneration, graft stabilization, wound healing, and hemostasis. This is because of the release of growth factors, cytokines, and fibrin matrix.[7]

The popularity of this material and manifold advantages along with in-depth details in publications provided by the pioneers as well as in vitro, in vivo, clinical trials, and histological evaluations from the other parts of the world after understanding of this second-generation autologous Choukran’s PRF has revolutionized the field of regenerative dentistry and motivated the researchers and clinicians further to apply this procedure along with tissue engineering protocol.[13],[14] Certain issues that include the relationships between quantity and quality of PRF with aging, systemic diseases (thrombocytopenia, afibrinogenemia, bleeding disorders, diabetes, and leukocyte adhesion syndromes) or conditions, socioeconomic status or nutrition, ethnic or racial groups, environmental, blood profile, autoimmunity, and genetic predisposition, besides standardized PRF preparation protocol, may be answered in the coming few years.[1]


  Conclusion Top


The previously published articles and clinical experience seem to indicate that PRF is having dental and para-dental applications such as it helps in early wound healing, maturation of bone grafts, and optimum soft tissue health for a better esthetic result of the peri-implant and periodontal soft tissues, extracted sockets, periapical surgeries, periodontal surgeries, cosmetic surgeries, and preprosthetic surgeries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Choukroun J, Adda F, Schoeffler C, Vervelle A Une opportunité en paro-implantologie: le PRF. Implantodontie 2001;42:55-62.  Back to cited text no. 1
    
2.
Raghoebar GM, Timmenga NM, Reintsema H, Stegenga B, Vissink A Maxillary bone grafting for insertion of endosseous implants: Results after 12-124 months. Clin Oral Implants Res 2001;12:279-86.  Back to cited text no. 2
    
3.
Wallace SS, Froum SJ Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review. Ann Periodontol 2003;8:328-43.  Back to cited text no. 3
    
4.
Tulasne JF [Commentary on maxillary pre-implant rehabilitation. A study of 55 cases using autologous bone graft augmentation]. Rev Stomatol Chir Maxillofac 1999;100:265-6.  Back to cited text no. 4
    
5.
Wang HL, Boyapati L “PASS” principles for predictable bone regeneration. Implant Dent 2006;15:8-17.  Back to cited text no. 5
    
6.
Simonpieri A, Del Corso M, Sammartino G, Dohan Ehrenfest DM The relevance of Choukroun’s platelet-rich fibrin and metronidazole during complex maxillary rehabilitations using bone allograft. Part I: A new grafting protocol. Implant Dent 2009;18:102-11.  Back to cited text no. 6
    
7.
Simonpieri A, Del Corso M, Sammartino G, Dohan Ehrenfest DM The relevance of Choukroun’s platelet-rich fibrin and metronidazole during complex maxillary rehabilitations using bone allograft. Part II: Implant surgery, prosthodontics, and survival. Implant Dent 2009;18:220-9.  Back to cited text no. 7
    
8.
Marx RE Platelet-rich plasma (PRP): What is PRP and what is not PRP? Implant Dent 2001;10:225-8.  Back to cited text no. 8
    
9.
Ross R, Glomset J, Kariya B, Harker L A platelet-dependent serum factor that stimulates the proliferation of arterial smooth muscle cells in vitro. Proc Natl Acad Sci U S A 1974;71:1207-10.  Back to cited text no. 9
    
10.
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 Sci2011;1:22-8.  Back to cited text no. 10
    
11.
Gassling VL, Açil Y, Springer IN, Hubert N, Wiltfang J Platelet-rich plasma and platelet-rich fibrin in human cell culture. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:48-55.  Back to cited text no. 11
    
12.
Marx RE Platelet-rich plasma: Evidence to support its use. J Oral Maxillofac Surg 2004;62:489-96.  Back to cited text no. 12
    
13.
Jung RE, Glauser R, Schärer P, Hämmerle CH, Sailer HF, Weber FE Effect of rhbmp-2 on guided bone regeneration in humans. Clin Oral Implants Res 2003;14:556-68.  Back to cited text no. 13
    
14.
Nevins M, Giannobile WV, McGuire MK, Kao RT, Mellonig JT, Hinrichs JE, et al. Platelet-derived growth factor stimulates bone fill and rate of attachment level gain: Results of a large multicenter randomized controlled trial. J Periodontol 2005;76: 2205-15.  Back to cited text no. 14
    




 

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