|Year : 2017 | Volume
| Issue : 1 | Page : 16-20
Recounting the advancement of platelet concentrates
Mrinalini Agarwal Bhatnagar, D Deepa
Department of Periodontology, Subharti Dental College and Hospital, Meerut, Uttar Pradesh, India
|Date of Submission||28-Nov-2016|
|Date of Acceptance||06-Apr-2017|
|Date of Web Publication||12-Jul-2017|
Department of Periodontology, Subharti Dental College and Hospital, Meerut, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Platelets play a crucial role in homeostasis and wound healing. Wound healing is a complex, multi-staged process that deals with multiple cell types such as platelets, leukocytes, and also growth factors. Growth factors present in platelets guide the regenerating cells to the area of healing. In the recent past, numerous techniques have been developed to utilize autologous platelet concentrates for the repair and regeneration of soft and hard tissues after periodontal surgical procedures. This review focuses on the evolution of platelet concentrates, and compares the widely used second-generation platelet concentrate, i.e., leukocyte platelet-rich fibrin (PRF) with a newer third-generation platelet concentrate, i.e., titanium-prepared PRF.
Keywords: Biocompatibility, growth factors, platelet-rich fibrin, platelet-rich plasma, titanium-prepared platelet-rich fibrin, wound healing
|How to cite this article:|
Bhatnagar MA, Deepa D. Recounting the advancement of platelet concentrates. J Curr Res Sci Med 2017;3:16-20
| Introduction|| |
One of the most interesting recent breakthroughs in the field of regenerative dentistry has been discovery of platelet concentrates which hold on to the growth factors enmeshed in the fibrin network resulting in their sustained release over a period of time, thus accelerating the wound healing process. Platelets are anucleate cytoplasmic fragments derived from bone marrow megakaryocytes measuring 2–3 μm in diameter. The α granules of platelets form an intracellular storage pool of proteins crucial for wound healing including platelet-derived growth factor, transforming growth factor, and insulin-like growth factor. After injury, platelets initiate the coagulation cascade and form a stable clot, releasing these growth factors that induce and support healing and tissue formation. Ross et al. were among the pioneers who first described a growth factor from platelets in 1974. Numerous techniques of autologous platelet concentrates have been developed and applied in the field of periodontal regenerative surgery.
| Evolution of Platelet Concentrates|| |
Platelet-rich plasma – first-generation platelet concentrate
Platelet-rich plasma (PRP) was introduced by Marx et al. in 1988. PRP was developed to combine the fibrin sealant properties with growth factor effects of platelets, thereby providing an ideal growth factor delivery system at the site of injury. These growth factors exhibit chemotactic and mitogenic properties that promote and modulate cellular functions involved in tissue healing, regeneration, and cell proliferation.
| Preparation of Platelet-Rich Plasma|| |
A volume of eight milliliters of venous blood is collected and subjected to centrifugation at 2400 rpm for 10 min. This results in formation of three fractions, plasma, buffy coat, and erythrocytes. The erythrocyte layer is discarded and then the remaining is subjected to second centrifugation cycle of 3600 rpm for 15 min. This results in formation of PRP and platelet-poor plasma (PPP). At the time of the application, the PRP is combined with an equal volume of a sterile saline solution containing 10% calcium chloride (a citrate inhibitor that allows the plasma to coagulate) and 100 U/mL of sterile bovine thrombin (an activator that allows polymerization of the fibrin into an insoluble gel, which causes the platelets to degranulate and release the indicated mediators and cytokines); the result is a sticky gel that is relatively easy to apply to the surgical defects [Figure 1].
| Clinical Applications|| |
PRP has been extensively used in periodontal regenerative procedures such as treatment of intrabony defects, furcation defects, and root coverage procedures. It has also been employed in sinus lift procedures, ridge augmentation, socket preservation, etc.
Anitua suggested that the application of PRP inside the extraction socket improved soft tissue repair and bone regeneration and that augmented sites could be future candidates for implant placement.
Lekovic et al. compared a combination of bovine porous bone mineral, PRP, and guided tissue regeneration for treatment of intrabony defects in humans. The results of the study suggested that PRP has strong regenerative potential and resulted in reduction of pocket depth and gain in clinical attachment level.
| Limitations of Platelet-Rich Plasma|| |
- Lack of uniformity in PRP preparation protocol as different platelet concentrations has different storage time
- Release of growth factors is for a shorter period of time
- Antibodies to bovine factor Va may cross-react with human factor Va and may produce coagulopathies and rare bleeding episodes.,
Platelet-rich fibrin – second-generation platelet concentrate
Platelet-rich fibrin (PRF) was developed by Dohan et al. in 2001. Unlike the PRP, this technique does not require the addition of anticoagulants, bovine thrombin, or any other gelifying agent, thereby eliminating the risk associated with them. The natural polymerization process during centrifugation yields the PRF clot. The fibrin architecture is responsible for slow release of growth factors and matrix glycoproteins.
| Preparation of Platelet Rich Fibrin|| |
Preparation of PRF follows the protocol developed by Choukron et al. The main advantages in preparation of PRF are the single centrifugation cycle at 3000 rpm for 10 min and absence of bovine thrombin. After centrifugation, the blood sample is separated into three layers: the lower fraction containing red blood cells (RBCs), middle fraction of fibrin clot, and the upper fraction containing the straw-colored acellular plasma. The upper portion of the test tube containing the acellular plasma is removed. The middle portion containing the fibrin clot is then removed and is scrapped off from the lower part containing the RBCs [Figure 2]. The natural and progressive polymerization results in a fibrin clot formation with substantial embedding of platelets and leukocyte growth factors into the fibrin matrix.
| Clinical Applications|| |
PRF has been successfully used in combination with bone grafts to hasten the healing process, ridge augmentation procedures, socket preservation, root coverage procedures, regeneration of intrabony defects, furcation defects, and palatal wound healing after free gingival grafts. PRF has been successfully used to treat gingival fenestrations along with coronally positioned flap. Satisfactory healing of the gingival fenestration defect with excellent color, texture match with the surrounding area along with the keratinized tissue formation was obtained, emphasizing the importance of using PRF as a membrane in esthetically demanding areas.
A 6-month randomized controlled clinical study to compare PRF membrane or connective tissue graft (CTG) in the treatment of gingival recession found that use of a PRF membrane provided acceptable clinical results, followed by enhanced wound healing and decreased subjective patient discomfort compared to CTG-treated gingival recessions.
Another study evaluating the clinical and radiographic effectiveness of autologous PRF and PRP in the treatment of intrabony defects in chronic periodontitis concluded that PRF is less time consuming and less technique sensitive and a better treatment option than PRP.
PRF has also been used in the management of complicated oral wounds. It has proved to be effective in reducing donor site morbidity after free grafts.
Limitations of platelet-rich plasma
Owing to the fact that PRF is an autologous product, the availability of this biomaterial in larger amounts is a concern. PRF possesses the circulating immune cells and antigenic molecules that prevent its use as an allogenic material. Furthermore, there is an increased risk of transmitting infectious agents.
Apart from the above-mentioned limitations, the success of the PRF procurement technique totally relies on the speed of blood collection and its transfer into the centrifuge machine. Furthermore, the absence of anticoagulant, the blood samples start to coagulate as soon as it comes in contact with the glass tubes. This suggests that quick handling is the only means to obtain a clinically usable leukocyte PRF (L-PRF) clot.
In an attempt to solve the problems associated with L-PRF, third-generation platelet concentrate has been developed.
| Platelet-Rich Fibrin Releasate|| |
The PRF clot can be squeezed between two-gauge pieces to obtain an inexpensive autologous fibrin membrane. PRF Box (Process Ltd., Nice, France) is commercially available to prepare the PRF membrane. The PRF clot is placed on the grid in the PRF Box and covered with compressor lid which squeezes out the fluid from the clot. The serum exudate expressed from the clot is called as PRF releasate and is rich in proteins such as vitronectin and fibronectin. This exudate may be used to hydrate graft materials, rinse the surgical site, and store autologous graft.
Titanium-prepared platelet-rich fibrin – third-generation platelet concentrate
Titanium-prepared platelet-rich fibrin (T-PRF) is the third-generation platelet concentrate. It was developed by Tunali et al. in 2011. The T-PRF method is based on the hypothesis that titanium may be more effective in activating platelets than the silica activators used with glass tubes in Choukroun's L-PRF method. L-PRF has been successfully used for regenerative procedures, but there has been an issue about the possible health hazard associated with the use of glass-evacuated blood collection tubes with silica activators. O'Conell described the unavoidable silica contact. The silica particles in the glass tube, although dense enough to sediment with the RBCs are small enough for a fraction to remain colloidally suspended in the buffy coat, fibrin and PPP (Platelet poor plasma) layers. Thus there is a potential risk of these silica particles reaching the patient when the L-PRF material is used for treatment.
| Preparation of Titanium-Prepared Platelet-Rich Fibrin|| |
T-PRF is prepared in Grade IV titanium tubes. Blood samples are drawn from the antecubital vein and collected in titanium tubes. The tubes are then centrifuged at 2800 rpm for 12 min.
| Differences between Leukocyte Platelet-Rich Fibrin and Titanium-Prepared Platelet-Rich Fibrin|| |
Light microscopy reveals that the T-PRF samples have a highly organized network with continuous integrity compared to the PRF samples. The fibrin border between the cellular structures and the fibrin network is thicker and more prominent in the T-PRF samples than in the L-PRF samples. Fluorescence microscopy shows that the fibrin network is mature and dense in both the T-PRF and L-PRF groups. However, the fibrin is thicker and better organized in the T-PRF samples. T-PRF has well-organized matrix and fibrin maturation and also fibrin network of T-PRF occupies larger area than the L-PRF.
Platelet activation by titanium offers some improved characteristics to T-PRF. Titanium has the highest corrosion resistance and strength-to- weight ratios among metals. It also possesses excellent biocompatibility due to its noncorrosive nature. The material passivates itself in vivo by forming an adhesive oxide layer. Titanium also displays a unique property of osseointegration and is commonly used in total joint replacements and dental implants. It is also hemocompatible, an important property for biomaterials that come in contact with blood. T-PRF has a histologic structure similar to that of L-PRF, however, as discussed above the fibrin of T-PRF seems to be more tightly woven and thicker than that of L-PRF. This can be attributed to better hemocompatibility of titanium compared to glass, leading to the formation of more polymerized fibrin. This may also result in longer life of T-PRF in the tissue [Figure 3].
| Conclusion|| |
The application of autologous PFR could present new possibilities for enhanced healing and regeneration. The advantages of T-PRF over L-PRF are still debatable, and more research is required for better understanding of this new platelet-rich product in terms of its resorption time and clinical applications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]