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ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 1  |  Page : 37-41

Efficacy of autologous platelet-rich fibrin in osseous regeneration after mandibular third molar surgery: A comparative study


1 Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Vijayawada, Andhra Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Kamineni Institute of Dental Sciences, Narketpally, Nalgonda, Telangana, India
3 Consultant Surgeon, Visakhapatnam, Andhra Pradesh, India
4 Vishnu Dental College and Hospital, Bhimavaram, Andhra Pradesh, India

Date of Submission22-Mar-2018
Date of Acceptance28-Apr-2018
Date of Web Publication26-Apr-2019

Correspondence Address:
Dr. Sudhakar Gudipalli
Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Vijayawada, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_25_18

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  Abstract 


Aims and Objectives: To evaluate the efficacy of soft tissue healing and bone regeneration in mandibular third molar extraction sockets after placement of platelet-rich fibrin (PRF).
Patients and Methods: A split-mouth study was carried out in 15 patients requiring extraction of bilateral impacted mandibular third molars. Patients were divided into group I (test group) and II (control group) of 15 sites in each. Results were compared within the parameters of postoperative pain, facial swelling, soft tissue healing and bone density. Radiological assessment of the extraction site was done.
Results: This study clearly indicates a definite improvement in the wound healing, decrease in postoperative edema, wound dehiscence, and increase in the bone density, which signifies and highlights the use of PRF certainly as a valid method inducing hard tissue regeneration.
Conclusion: The procedure of PRF preparation is simple, cost-effective, and has demonstrated good results.

Keywords: Bone density, mandibular third molars, platelet-rich fibrin, wound healing


How to cite this article:
Surekha K, Gudipalli S, Peramulla P, Prathima T, Kumar Y N, Budumuru A. Efficacy of autologous platelet-rich fibrin in osseous regeneration after mandibular third molar surgery: A comparative study. J NTR Univ Health Sci 2019;8:37-41

How to cite this URL:
Surekha K, Gudipalli S, Peramulla P, Prathima T, Kumar Y N, Budumuru A. Efficacy of autologous platelet-rich fibrin in osseous regeneration after mandibular third molar surgery: A comparative study. J NTR Univ Health Sci [serial online] 2019 [cited 2019 Dec 14];8:37-41. Available from: http://www.jdrntruhs.org/text.asp?2019/8/1/37/257160




  Introduction Top


Mandibular third molars are frequently impacted teeth that can be found in humans.[1] Surgical removal is the ultimate treatment for most impacted third molars.[2] Successful regeneration and healing can be accelerated by bone regenerative techniques. There are several allografts, xenografts, or alloplasts used for bone regeneration possessing good osteoinductive and osteoconductive properties.[3]

Platelet-rich fibrin (PRF) is superior to bone grafts because it regulates inflammation and stimulates the immune process of chemotaxis. It is a second-generation platelet concentrate with cicatricial properties.[4] The purpose of the study is to understand the bone healing of mandibular third molar socket, to assess the soft tissue healing, and to evaluate the facial swelling with the application of PRF.


  Patients and Methods Top


A split-mouth study was carried out among 15 patients requiring extraction of bilateral impacted mandibular third molars after obtaining clearance from the ethical committee.

Sample size:Thirty (15 control group, 15 test group)

Type of study: A randomized controlled comparative study.

Inclusion criteria

  1. Patient aged between 18 and 50 years.
  2. Patients requiring bilateral impacted mandibular third molar extraction.
  3. Nonsmoker and nonalcoholic patients.
  4. Platelet count more than 150,000/mm3.


Exclusion criteria

  1. Patients in whom the second molar was missing or was indicated for extraction.
  2. Patients with any underlying systemic disease or compromised immunity.
  3. Pregnant women and lactating mother.


Preparation of platelet-rich fibrin

Collection of blood: Under aseptic techniques, 10 ml of blood was drawn intravenously from the anticubital region of patient's forearm using 10 ml syringe, as shown in [Figure 1]. This was transferred to centrifugal vials.
Figure 1: Drawing of blood

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Preparation of platelet-rich fibrin

  1. 10 ml autologous blood was collected in a vial and immediately centrifuged at 3000 rpm for 10 min, as shown in [Figure 2].
  2. The absence of anticoagulant implies activation in a few minutes of most platelets of the blood sample in contact with the tube walls as well as the release of the coagulation cascades.
  3. A fibrin clot is then obtained in the middle of the tube just between the red corpuscles at the bottom and acellular plasma at the top, as shown in [Figure 2].
Figure 2: Entrifugation and collection of Platelet-rich fibrin

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In the following, extraction PRF was placed in one of the extraction sockets as shown in [Figure 3], and the other socket was taken as the control site with no PRF. The patients were assessed for postoperative pain, facial swelling, soft tissue healing, and bone density. Radiological assessment of the extraction site was done for a period of 3 months to evaluate the change in bone density.
Figure 3: Placement of platelet-rich fibrin

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All patients were evaluated on 1st, 3rd, and 7th postoperative day and followed for 1 month and 3 months postoperatively.

Clinical evaluation

Pain was evaluated in the postoperative period using a visual analog scale score of 100 mm. After the surgery, the patients were instructed to note their postoperative discomfort and/or pain on a scale designed as 0 indicating no pain while 100 indicating the worst pain ever experienced. The evaluation of the postoperative pain was carried out at 1st, 3rd, and 7th day after the procedure.[5]

Evaluation of the facial swelling was done using a horizontal and vertical guide with a flexible ruler. For a horizontal guide, two points are marked at the ear tragus and soft tissue pogonion, which is the most prominent point at the midline on the chin. Vertical guide at lateral canthus of the eye and gonion. The distance between them was measured and recorded as shown in [Figure 4]. The evaluation of the postoperative facial swelling was carried out at 24 h, 72 h, and 7 days after the procedure. The swelling was evaluated by subtracting the value obtained at each postoperative period by the values obtained at baseline.[6] Soft tissue healing was assessed at the end of 1st, 3rd, and 7th postoperative day using the healing index given by Landry et al.[7]
Figure 4: Measurement of swelling

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Bone density

A digital orthopantomograph (OPG) was taken on Carestream (Kodak) OPG Machine. All exposures were standardized at 66 kV and 9 mA. The images were viewed on a monitor; contrast and brightness were adjusted to enhance the image quality. The first postoperative radiographic image parameters were standardized and recorded. The same were applied for subsequent radiographs at 3 postoperative months for every patient.

Digital OPG radiographs were taken for all the patients at the end of the 1st and 3rd month of follow-up. The digitalized OPG images were viewed on a screen using Adobe Photoshop CS, as shown in [Figure 5]. The area of the extracted third molar socket was marked on each side.
Figure 5: Digitalized digital orthopantomograph image

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The marked area on each side represents the area of bone formation at the end of 1st and 3rd month postoperatively. The mean gray-scale values of the area bounded within the borders of extracted third molar socket on the PRF and control side were then measured using the Histogram Tool and tabulated. These gray-scale values were then recorded in a similar manner for all 15 patients and 30 sites of PRF and control groups, respectively, and tabulated. The mean gray-scale values of the two sides were then compared, which represent the bone healing capabilities of PRF and control sides.[7]


  Results Top


The evaluation of the postoperative pain was carried out at 1st, 3rd, and 7th day after the procedure.[8] Mean values of postoperative pain in both control and PRF sides were compared using Mann–Whitney U-test. Our results showed that there was no significant difference between the two groups in terms of postoperative pain after 1st (P = 0.06), 3rd (P = 0.62), and 7th day (P = 0.08) of follow-up.

The evaluation of the postoperative facial swelling was carried out at 24 h, 72 h, and 7 days after the procedure. Mean values of swelling in both control and PRF sides were compared on 1st postoperative day using Mann–Whitney U-test. The results obtained in our study showed significantly lesser dimensions of swelling for the PRF group on both 1st (<0.05) and 3rd (<0.05) postoperative days. On 7th (P = 0.23) postoperative day, the swelling dimensions in both control and PRF groups were comparable with no significant difference.

Soft tissue healing was assessed at the end of 1st, 3rd, and 7th postoperative day using the healing index proposed by Landry et al.[7]

Our results showed that the soft tissue healing was significantly faster in the PRF group on the 3rd postoperative day (P = <0.05) compared to the control side. Healing in both groups did not show any significant difference on the 7th postoperative day (P = 0.08).

The evaluation of the postoperative bone density was carried out at 1st and 3rd month after the procedure. The digitalized OPG images were viewed on a screen using Adobe Photoshop CS [Figure 3]. The area of the extracted third molar socket was marked on each side.

Our results showed highly significant values of bone density radiographically for the PRF group at the end of the 1st month postoperative follow-up. At 3-month postoperative follow-up, there was significant difference (P ≤ 0.01) in bone density on PRF side compared to the control side in all patients.

[Table 1] and [Figure 6] depicts the minimum and maximum values, mean values, and standard deviations of various parameters evaluated in this study (bone density, swelling, soft tissue healing, postoperative pain).
Table 1: Statistical Analysis Of Collected Data Done Using Mann-Whitney U-Test

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Figure 6: Statistical analysis of collected data from both the PRF side and Control side in a 3 months follow up period

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  Discussion Top


The surgical removal of impacted third molars causes trauma of the soft tissue and bony structures in the oral cavity that may result in a large bony defect. Repair of a large bony defect requires the surgical transfer of bone from donor to the wound site, which is considered to be the clinical “gold standard.”

The present study was undertaken to determine the efficacy of autologous PRF in soft tissue healing and bone regeneration in mandibular impacted third molar extraction sockets.

Rapid and effective regeneration of hard and soft tissues using PRF can be attributed to its property to release high quantities of three main growth factors, i.e. transforming growth factor β-1, platelet-derived growth factor AB (PDGF-AB), vascular endothelial growth factor, and an important coagulation multidomain matrix glycoprotein (thrombospondin-1) during 7 days of placement in the study site. In addition, PRF also secretes endothelial growth factor, fibroblast growth factor, and three important proinflammatory cytokines: interleukin (IL)-1b, IL-6, and tumor necrosis factor-α. These secretory products stimulate several functions such as chemotaxis, angiogenesis, proliferation, differentiation, and modulation.[6]

PDGF increases the population of wound healing cells and recruits other angiogenic growth factors to the wound site. Therefore, it is a reasonable hypothesis that increasing the concentration of platelets in a bone defect may lead to improved healing.[9] In addition, the PRF clot provides a matrix scaffold for the recruitment of tissue cells to an injured site. Specifically, fibrin is the end product of the coagulation cascade, an excellent matrix which has been used to deliver various human cells to a wound in suspension. It has been shown to be natural in growth matrix for fibroblasts and endothelial cells and is a flexible platform. Fibrin in conjunction with fibronectin acts as a provisional matrix for the influx of monocytes, fibroblasts, and endothelial cells. Besides growth factors and chemotactic factors, an appropriate extracellular matrix is also necessary for angiogenesis.[10]


  Conclusion Top


This study clearly indicates a definite improvement in postoperative facial swelling, soft tissue healing, and bone regeneration after third molar surgery cases treated with PRF compared to the control group postoperatively. This improvement in wound healing, decrease in postoperative edema, wound dehiscence, and increase in the bone density signifies and highlights the use of PRF, which is definitely a valid method inducing hard tissue regeneration. The procedure of PRF preparation is simple, cost-effective, and has demonstrated good results. As the present study was conducted with a limited sample of 15 patients, further clinical trials with larger sample size are required for more affirmative and conclusive results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials 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 Top

1.
Patil S. Prevalence and type of pathological conditions associated with unerupted and retained third molars in the Western Indian population. J Craniomaxillofac Surg 2013;2:10.  Back to cited text no. 1
    
2.
Khan A. Impacted mandibular third molars: Pattern of presentation and postoperative complications. Pak Oral Dent J 2010;30.  Back to cited text no. 2
    
3.
Singh A, Kohli M, Gupta N. Platelet rich fibrin: A novel approach for osseous regeneration. J Maxillofac Oral Surg 2012;11:430-4.  Back to cited text no. 3
    
4.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part I: technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e37-44.  Back to cited text no. 4
    
5.
Obiechina AE, Arotiba JT, Fasola AO. Third molar impaction: Evaluation of the symptoms and pattern of impaction of mandibular third molar teeth in Nigerians. Odontostomatol Trop 2001;24:22-5.  Back to cited text no. 5
    
6.
Ozgul O, Senses F, Er N, Tekin U, Tuz HH, Alkan A, et al. Efficacy of platelet rich fibrin in the reduction of the pain and swelling after impacted third molar surgery: Randomized multicenter split-mouth clinical trial. Head Face Med 2015;11:1.  Back to cited text no. 6
    
7.
Yelamali T, Saikrishna D. Role of platelet rich fibrin and platelet rich plasma in wound healing of extracted third molar sockets: A comparative study. J Maxillofac Oral Surg 2015;14:410-6.  Back to cited text no. 7
    
8.
Abu-Mostafa NA. The effects of primary and secondary wound closure following surgical extraction of lower third molars on post-operative morbidity: A prospective randomized clinical trial. J Dent Oral Hyg 2015;7:168-74.  Back to cited text no. 8
    
9.
Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part IV: clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e56-60.  Back to cited text no. 9
    
10.
Martínez CE, Smith PC, Alvarado VA. The influence of platelet-derived products on angiogenesis and tissue repair: A concise update. Front Physiol 2015;6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 5], [Figure 6], [Figure 4]
 
 
    Tables

  [Table 1]



 

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Introduction
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