AIMS Bioengineering, 10(2): 175–182.

DOI: 10.3934/bioeng.2023012
Received: 03 April 2023
Revised: 16 May 2023
Accepted: 23 May 2023
Published: 13 June 2023
http://www.aimspress.com/journal/Bioengineering

Review

Advanced platelet rich fibrin in periodontal regeneration

Aishwarya Rathod*, Priyanka Jaiswal and Deepika Masurkar

Department of Periodontics, Sharad Pawar Dental College and Hospital, Datta Meghe institute of
Higher Education and Research (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra
442001, India

* Correspondence: Email: [email protected].

Abstract: Regenerating periodontal tissue is the main goal of periodontal therapy. Periodontal tissue
regeneration involves the development of new bone, cement, and periodontal ligaments on damaged
tooth root surfaces in order to restore anatomy and function. In order to further enhance PRF (Platelet
rich fibrin) and develop advanced platelet-rich fibrin, a slower rotating speed is proposed (A-PRFs).
Cell dispersion is affected by centrifugation rate. The majority of the leukocytes in the PRF are
concentrated near the bottom of the tube due to centrifugation rate. By switching the centrifugation
process to 1,500 rpm for 14 minutes, granulocyte neutrophils and the fibrin matrix are more evenly
distributed in the A-PRF created. Hence, a periodontal evaluation of this subject is required.

Keywords: centrifugation; growth factors; platelets; regeneration

1. Introduction

An inflammatory condition of the periodontal tissues known as periodontitis causes the affected
teeth to become less stable, particularly the periodontal ligaments and the bone into which they are
embedded. The predicted healing outcome after periodontal therapy is regeneration or repair. This is
dependent on two important occurrences: the availability of the required cell types and the presence or
absence of the signals required to draw in and activate the cells. Clot development starts the process
of healing any wound, which is then followed by the proliferative and maturative stages. Growth
factors aid wound healing by encouraging cell migration (chemotaxis), cell proliferation (mitogenesis),
and the development of new blood vessels (angiogenesis) [1].
Platelet rich fibrin (PRF) is considered as a platelet concentrate of 2nd generation evolved by
Choukroun et al. (2001) [2]. It is centrifuged blood with lack of any other inclusions and avoid using
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any type of biochemical blood handling. PRF contains vascular endothelial growth factor (VEGF),
transforming growth factor β-(TGFβ-1), and platelet derived growth factor (PDGF). The new
modifications of PRF preparation lead to evolution of Advanced platelet rich fibrin (A-PRF). For
getting more growth factor in A-PRF, there is minimum G forces as compared to PRF [3]. Because
polymerization happens naturally, no bovine thrombin is needed. When compared to other platelet
concentrates, it demonstrates prolonged growth factor release. High elasticity and flexibility can be
found in A-PRF membrane. A-PRF is prepared by adhering to the 14-minute centrifugation time
and 1500 rpm spinning rate technique. It consists of hematopoietic stem cells, T and B lymphocytes,
and more (HSCs). The monocytes needed for bone production are more concentrated in it and are
distributed further in an equivalent manner. The platelets are distributed equally across the entire clot
as well [4].

2. Properties of A-PRF

Researcher are looking to mix bone grafts and platelet concentrates containing a range of growth
factors in periodontal regenerative surgery to enhance the ability of local bone induction and tissue
healing in an effort to increase the effectiveness of periodontal regeneration therapy. Among them, A-
PRF the most recent generation of autologous platelet concentrate, is high in autologous growth factors
that encourage cell migration and proliferation, which can speed up tissue remodelling and new
angiogenesis. Results from A-PRF have been superior to those from PRP (Choukroun et al. 2006) [5].
This biomaterial, which is based on the low speed centrifugation concept (LSCC), provides
macrophages in addition to growth factors to support the sustainability of A-PRF for a duration of 7
to 28 days. A-PRF favours a higher growth factor release than conventional PRF, and this may have a
direct impact on tissue regeneration by boosting levels of collagen mRNA and fibroblast migration
and proliferation [6].
There were more neutrophils and PRF. According to studies, gel-like A-PRF contains collagen
fibres that are nearly in their physiological state. These collagen fibres can serve as a natural
component that induces vascularization, supports the immune system, and serves as a three-
dimensional scaffold for cell proliferation. TGF-, VEGF, and other growth factors can promote
angiogenesis, inhibit osteoclasts, aid in the migration and proliferation of gingival fibroblasts, and
create an environment that is conducive to the regeneration and repair of injured tissue. A-PRF
generates significantly more of the chemotactic molecules CCL-5 and eotaxin, as well as the growth
factors TGF-, PDGF, and VEGF than does conventional PRF [3].
The process of angiogenesis, which promotes endothelial cell migration and proliferation and
maintains the creation of blood vessels, depends heavily on VEGF. By promoting osteoblast migration,
proliferation, and differentiation, VEGF also aids in bone production. In order to promote bone
regeneration, PDGF stimulates osteoblast precursor cells and aids in tissue repair [7]. TGF gathers
osteoblast precursor cells, promotes osteoblast development, and boosts mesenchymal cell
proliferation [8]. Furthermore, A-PRF contains more neutrophils than normal. Despite the identical
total number of leukocytes, these inflammatory cells aid in the differentiation of monocytes and
macrophages. A-PRF is a great medium for forming new vessels and repairing damaged tissue.

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Figure 1. Centrifugation Machine used for preparation of A-PRF.

Figure 2. Advanced platelet rich fibrin.

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3. Advantages

It is simple, safe and inexpensive process which required patient’s own blood. It accelerates the
wound healing and minimizes the discomfort [9].

4. Evidence of A-PRF in Periodontal regeneration

4.1. In vitro studies

Pitzurra et al. (2019) [10]. The efficacy of leukocyte-platelet-rich fibrin (L-PRF) and (A-PRF+)
to promote the proliferation and migration of periodontal fibroblasts in vitro was examined. The
researchers arrived to the conclusion that both L-PRF and A-PRF+ stimulate periodontal fibroblast
migration and proliferation, with A-PRF+ maintaining artificial wound closure for a longer amount
of time than L-PRF.
Nguyen et al. (2022) [11]. based on the in-vitro release of growth factors, examined the effects
of a mixture of A-PRF and xenogenic bone replacement material (XBSM) on the proliferation and
migration of human periodontal ligament stem cells (hPDLSCs). According to the findings, 20%
APRF+XBSM greatly raised hPDLSC proliferation compared to treatments with 4% and 100%
APRF+XBSM at different time periods. The authors came to the conclusion that combining APRF
with XBSM releases growth factors, such as PDGF-AB and VEGF, for up to 7 days. The scientists
came to the conclusion that APRF+XBSM would be useful for healing and periodontal regeneration
as a result of the fact that APRF+XBSM further encouraged the proliferation and migration of
hPDLSCs in vitro.

4.2. Animal studies

Masahiro et al. (2019) [12]. clarified how advanced PRF (A-PRF) affected the growth of bone
in tooth sockets after extraction in beagle dogs. In this investigation, six female beagle dogs with
clinically sound periodontal tissues were employed. Compared to the A-PRF group, bone
development in the control group was inferior. At 30 days after extraction, dense bone growth was
seen in the extraction socket of the A-PRF group. The authors came to the conclusion that A-PRF
administration may increase new bone development and may speed up bone growth. By boosting
osteoblast activity, A-PRF induced bone growth more quickly than a self-limiting process and may
be helpful for bone production in clinical medicine.

4.3. Human clinical studies

Upadhyay et al. (2020) [4]. evaluated and compared PRF and A-PRF in the treatment of human
periodontal infrabony defects (IBDs) both clinically and radiographically. Twenty-eight patients
having IBDs were divided into Group A (PRF) and Group B (A-PRF). Comparison between both
groups revealed statistically insignificant differences. Authors came to conclusion that individually,
both the materials have shown promising results. Statistically, PRF group (Group A) showed better
treatment outcome in terms of bone fill and A-PRF group (Group B) in terms of soft tissue healing.

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Csifó-Nagy et al. (2021) [13]. clinically evaluated enamel matrix derivative regeneration of
intrabony defects following treatment with a new generation of platelet-rich fibrin (A-PRF+) (EMD).
Thirty intrabony defects were treated randomly with either A-PRF+ (test, n=15) or EMD (control,
n=15) in 18 patients (9 men, 9 women). The new generation platelet-rich fibrin appears to be equally
therapeutically effective as EMD during surgical therapy of intrabony defects, according to the authors’
findings. Clinical outcomes from A-PRF+ or EMD treatment were consistent. A-PRF+, an autologous
human product, can have a beneficial effect on periodontal repair.
Zahid et al. (2019) [14]. A-PRF was examined for its potential as a regenerative biomaterial for
bone regeneration and postoperative complications following extraction of an impacted third molar.
This clinical experiment was a split-mouth, double-blind, randomised study. The study enrolled a total
of 10 female patients with bilaterally impacted third molars. Visual comparisons revealed that on the
seventh postoperative day, pain and swelling were much lower in the A-PRF group than in the control
group. Between the two groups, there was no statistically significant difference in healing scores. The
authors came to the conclusion that A-PRF might potentially be used as a biomaterial to lower the
intensity of pain and swelling following third molar surgery. The authors proposed that to acquire more
significant outcomes on periodontal regeneration, long-term trials with a bigger sample size and
methodologically solid assessment tools are required.
Yüce et al. (2019) [15]. The application of APRF+ based on the low speed centrifugation concept
(APRF+) in cases of delayed wound healing due to alveolar osteitis following extraction of the third
molar in the mandible was examined. This randomised prospective controlled clinical examination
was conducted on 40 patients between the ages of 18 and 40 years [female (55%) to male (45%)] three
days following the excision of mandibular third molars of classes A and 1 according to the Pell-
Gregory classification. Hard tissue and epithelium statistically recovered statistically more faster in
the APRF+ application group than in the control group. The authors report that by promoting faster
wound healing, the use of APRF+ in the management of alveolar osteitis has reduced patient
discomfort and pain intensity.
Chekurthi et al. (2021) [16]. In order to repair gingival recession abnormalities, advanced
platelet-rich fibrin (A-PRF) in conjunction with a coronally advanced flap (CAF) was examined for
its clinical efficacy. In 18 instances, total root coverage was attained. GTH, CAL, WAG, and KTH
all saw significant increases at six months. The average RES and VAS aesthetic scores were,
respectively, 8.54 mm and 8.83 mm and 1.17 mm. The authors came to the conclusion that A-PRF
could be employed as a therapy option for cases of recession.
Tadepalli et al. (2022) [17]. The therapeutic effectiveness of L-PRF and A-PRF combined with
CAF in correcting anomalies of gingival recession was assessed and compared. For systemically
healthy subjects with 30 Miller’s class I or II gingival recession anomalies in their maxillary anteriors
and premolars, treatment options comprised CAF + L-PRF or CAF + A-PRF. Between the therapy
groups, there was no appreciable variation in the mean clinical indicators after six months. When
compared to the mean baseline values, the CAF + L-PRF and CAF + A-PRF locations showed
statistically significant improvement in all clinical parameters at 6 months. The authors’ findings
suggest that both L-PRF and A-PRF can effectively treat gingival recession in the maxilla.
Clark et al. (2018) [18] investigated how well A-PRF alone or in combination with freeze-dried
bone allograft (FDBA) improved alveolar dimensional stability and vital bone growth during ridge
preservation. A-PRF alone or combined with FDBA can be a promising biomaterial for ridge
preservation, according to the authors’ findings.

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In the treatment of infrabony pockets, Suwondo et al. (2018) [19]. investigated the variations in
periodontal tissue regeneration following the administration of A-PRF and PRF based on probing
depth (PD), relative attachment loss (RAL), and alveolar bone height. 20 infrabony pockets were
separated into two groups; 10 individuals from each group received treatment with OFD+A-PRF and
OFD+PRF. On days 0, 30, and 90, measures of periodontal depth and RAL were taken. CBCT X-rays
were used to measure bone height on days 0 and 90. According to the authors, applying A-PRF results
in increased probing depth and a relative attachment loss reduction when compared to PRF, as well as
an increase in bone height equal to that seen when treating infrabony pockets.
A-PRF use in various periodontal regeneration treatment modalities has been demonstrated by
several researchers to produce better clinical results. A-PRF and bone grafts together have shown to
significantly correct periodontal abnormalities clinically.

5. Conclusions

The autogenous nature of A-PRF makes it simple to use and manipulate. According to the studies
in the literature stated above, A-PRF is utilised successfully and without any complications in the
periodontal regeneration and healing process.

Use of AI tools declaration

The authors declare they have not used Artificial Intelligence (AI) tools in the creation of this
article.

Conflict of interest

The authors declare no conflict of interest.

Acknowledgment

Authors acknowledge the immense help received from the scholars whose articles are cited and
included in references to this manuscript. The authors are also grateful to authors/editors/publishers of
all those articles, journals and booksfrom where the literature for this article has been reviewed and
discussed.

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AIMS Bioengineering Volume 10, Issue 2, 175–182.