Platelet Rich Fibrin in Regenerative Dentistry

Biological Background and Clinical Indications

Richard J. Miron, Joseph Choukroun

• Publisher: Wiley-Blackwell
• Year: 2017
• ISBN:
  9781119406808
• Edition: 1
• Topic: Medicine
• Subtopic: Dentistry

The first book devoted exclusively to the subject, Platelet Rich Fibrin in Regenerative Dentistry offers comprehensive, evidence-based coverage of the biological basis and clinical applications of PRF in dentistry. Co-edited by a leading researcher in tissue regeneration and the inventor of the PRF technique, it brings together original contributions from expert international researchers and clinicians.

Chapters cover the biological foundation of PRF before addressing specific uses of the technology within clinical dentistry. Topics describe the use of PRF in many dental applications, including extraction socket management, sinus lifting procedures, root coverage, periodontal regeneration, soft tissue healing around implants, guided bone regeneration, and facial esthetics. The text is supplemented with color photographs and explanatory illustrations throughout.

Platelet Rich Fibrin in Regenerative Dentistry: Biological Background and Clinical Indications is an indispensable professional resource for periodontists, oral surgeons and oral and maxillofacial surgeons, as well as general dentists who use PRF or are interested in introducing it into their practices. It is also an excellent reference for undergraduate and postgraduate dental students.

1
Platelet Rich Fibrin: A Second-Generation Platelet Concentrate

Joseph Choukroun and Richard J. Miron

Abstract

Almost two decades have passed since platelet rich fibrin (PRF) was first introduced. Initially, the primary objective was to develop a therapy where platelet concentrates could be introduced into wounds by effectively utilizing the body's natural healing capacity. This was achieved by collecting growth factors derived from blood in a natural way. Platelet rich plasma (PRP) and platelet rich growth factor (PRGF) had been commercialized, yet both contained secondary byproducts that were both unnatural and known inhibitors of wound healing. By removing these anti-coagulants and modifying centrifugation protocols, PRF was introduced some years later with the potential to markedly impact many fields of medicine including dentistry. Many aspects important for tissue regeneration have since been revealed including the important role of fibrin as well as the preferential release of growth factors over longer periods of time from PRF. Furthermore, by introducing a new set of cells into platelet concentrates (namely leukocytes), a marked impact on tissue regeneration and wound healing was observed. Over the past 5 years, further modifications to centrifugation speed and time have additionally improved PRF into a concept now known as the “low-speed centrifugation concept.” Investigators began to modify surgical techniques to favorably treat patients with PRF with improved clinical outcomes. Together, many key opinion leaders from around the globe have been gathered to share their experiences and knowledge in many educational courses and seminars in what we now know as platelet rich fibrin. In this first chapter, we highlight the discovery of PRF and the studies leading to its first use in regenerative medicine. We focus specifically on its properties for wound healing and how its presented advantages over previous versions of platelet concentrates have favorably enhanced the regenerative potential of platelet concentrates in dentistry.

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Highlights

• Introduction of Platelet Rich Fibrin
• Reasons for its invention two decades ago
• Its variations from the formally known platelet concentrate “platelet rich plasma” or “PRP”
• The first case treated with PRF
• Properties important for wound healing

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1.1 Introduction

Wound healing is a complex biological process where many cellular events taking place simultaneously leading to the repair or regeneration of damaged tissues [1–4]. Many attempts have been made in the field of tissue regeneration with the aim of predictably repairing, regenerating, or restoring damaged and diseased tissues [1–4]. These include strategies with foreign materials often derived from allografts, xenografts, or synthetically produced alloplasts to regenerate host tissues [1–4]. While many of these materials have shown promise in various aspects of regenerative medicine, it is important to note that all create a “foreign body reaction,” whereby a foreign material is introduced into human host tissues.

Platelet concentrates collected from whole blood was first introduced over 20 years ago. The concept was developed with the aim of utilizing human blood proteins as a source of growth factors capable of supporting angiogenesis and tissue ingrowth based on the notion that blood supply is a prerequisite for tissue regeneration [5]. Four aspects of wound healing have since been described as key components for the successful regeneration of human tissues (Figure 1.1). These include 1) hemostasis, 2) inflammation, 3) proliferation, and 4) maturation. Each phase encompasses various cell types. One of the main disadvantages of currently utilized biomaterials in the field of tissue engineering is that the great majority are typically avascular by nature, and therefore do not provide the necessary vascular supply to fully obtain successful regeneration of either soft or hard tissues [5].

It must further be noted that in general, wound healing demands the complex interaction of various cell types with a three-dimensional extracellular matrix as well as soluble growth factors capable of facilitating regeneration [6]. Certainly, one area of research in dentistry that has gained tremendous momentum in recent years is that of recombinant growth factors where a number have been used to successfully regenerate either soft or hard tissues [7–9]. Table 1.1 provides a list of currently approved growth factors along with their individual roles in tissue regeneration and clinical indications supporting their use. Similarly, a number of barrier membranes with various functions and resorption properties have also been commonly utilized in regenerative dentistry formulated from either synthetic or animal-derived materials [10]. Lastly, many bone-grafting materials are brought to market every year, all characterized by their specific advantages and disadvantages during tissue regeneration. While each of the above-mentioned biomaterials have been shown to carry properties necessary for the repair and regeneration of various tissues found in the oral cavity, very few possess the potential to promote blood supply/angiogenesis directly to damaged tissues.

Wound healing has therefore previously been characterized as a four-stage process with overlapping phases [7–9]. What is noteworthy is the fact that platelets have been described as key components affecting the early phases of tissue regeneration important during hemostasis and fibrin clot formation [6]. Platelets have also been shown to secrete a number of important growth factors including platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), coagulation factors, adhesion molecules, cytokines/chemokines, and a variety of other angiogenic factors capable of stimulating the proliferation and activation of cells involved in the wound healing process including fibroblasts, neutrophils, macrophages, and mesenchymal stem cells (MSCs) [11].

Interestingly, in the mid- to late 1990s, two separate strategies were adopted to regenerate human tissues based on these concepts. First, the main growth factor secreted from platelets (PDGF) was commercialized into a recombinant growth factor (rhPDGF-BB). This has since been FDA-approved for the regeneration of numerous tissues in the human body including intrabony defects in the field of periodontology. A second strategy was proposed around the same time to collect supra-physiological doses of platelets by utilizing centrifugation. Since blood is naturally known to coagulate within minutes, the additional use of anti-coagulants was added to this process to maintain a liquid consistency of blood throughout this procedure. A positive correlation between platelet count and the regenerative phase was therefore observed for tissue wound healing. In fact, it has also been shown that the simple combination of bone grafting materials with blood alone is known to enhance angiogenesis and new bone formation of bone grafts when compared to implanted bone grafts alone that are not pre-coated [12]. Based on these findings, several research groups across many fields of medicine began in the 1990s to study the effects of various platelet concentrates for tissue wound healing by adapting various centrifugation techniques and protocols with the aim of improving tissue regeneration.

1.2 Brief history of platelet concentrates

It is interesting to point out that the use of platelet concentrates have dramatically increased in popularity over the past decade since the discovery of PRF. Despite this, it is important to understand that growth factors derived from blood had been used in medicine for over two decades [13]. These first attempts to use concentrated platelet growth factors was derived from the fact that supra-physiological doses could be obtained from platelets to promote wound healing during and following surgery [14, 15]. These concepts were later established into what is now known as “platelet rich plasma” (PRP), which was later introduced in the 1990s in dentistry with leading clinician-scientists such as Whitman and Marx [16, 17]. The main goal of PRP was to isolate the highest quantity of platelets and ultimately growth factors associated with their collection and re-use them during surgery. Typical protocols ranged in time from ...

Table of contents

• Cover
• Title Page
• Copyright Page
• Dedcation
• About the Authors
• Foreword
• Preface
• 1 Platelet Rich Fibrin: A Second-Generation Platelet Concentrate
• 2 Biological Components of Platelet Rich Fibrin: Growth Factor Release and Cellular Activity
• 3 Introducing the Low-Speed Centrifugation Concept
• 4 Uses of Platelet Rich Fibrin in Regenerative Dentistry: An Overview
• 5 Use of Platelet Rich Fibrin for the Management of Extraction Sockets: Biological Basis and Clinical Relevance
• 6 Maxillary Sinus Floor Elevation in the Atrophic Posterior Maxillae: Anatomy, Principles, Techniques, Outcomes, and Complications
• 7 Maxillary Sinus Floor Elevation Procedures with Platelet Rich Fibrin: Indications and Clinical Recommendations
• 8 Use of Platelet Rich Fibrin for the Treatment of Muco-Gingival Recessions: Novel Improvements in Plastic Aesthetic Surgery Utilizing The Fibrin Assisted Soft Tissue Promotion (FASTP) Technique
• 9 Use of Platelet Rich Fibrin for Periodontal Regeneration/Repair of Intrabony and Furcation Defects
• 10 Platelet Rich Fibrin as an Adjunct to Implant Dentistry
• 11 Guided Bone Regeneration with Platelet Rich Fibrin
• 12 Modern Approach to Full Arch Immediate Loading: The Simonpieri Technique with PRF and i-PRF
• 13 Use of Platelet Rich Fibrin in Facial Aesthetics and Rejuvenation
• 14 Use of Platelet Rich Fibrin in Other Areas of Medicine
• 15 Future Research with Platelet Rich Fibrin
• Index
• EULA