platelet rich fibrin

Introduction
• for years efforts have been made to find new
bioactive additives that promote and accelerate
healing, regulate inflammation, and improve
regeneration.
• to achieve these goals The impact of platelet
concentrates has been explored in sports medicine
and orthopedics
• platelet concentrates clearly improve wound healing
By facilitating recruitment, proliferation, and
maturation of cells participating in regeneration,
Based on the leukocyte content and fibrin
structure, platelet concentrates can be classified
into four main categories:
• Pure platelet-rich plasma (P-PRP) without
leukocytes and with a low-density fibrin network
after activation.
• Leukocyte- and platelet-rich plasma (L-PRP) with
leukocytes and with a low-density fibrin network
after activation.
• Pure platelet-rich fibrin (P-PRF) without leukocytes
and with a high-density fibrin network
• Leukocyte- and platelet-rich fibrin (L-PRF) with
leukocytes and a high-density fibrin network
 :Fibrin sealers are divided into two groups

• Homologous fibrin sealers: products made

from a combination of fibronectin, fibrinogen,
factor VIII, and a thrombin concentrate in calcium
chloride
• Autologous fibrin sealers: products of plasma
in which the fibrin polymerization is started by
the addition of thrombin of animal origin
 Action of these fibrin sealers
• stimulate local angiogenesis.
• minimize edema or hematoma.
• formation, and reduce postoperative pain.
• fibrin sealers upgraded platelet-derived
wound healing factor (PDWHF)
 The First Generation of Platelet
Concentrates: Platelet-Rich Plasma
• Whitman, Berry, and Green in 1997 and Marx
and colleagues in 1998 were the first to promote
the use of PRP in oral and maxillofacial surgery
 using PRP
in oral and
in medicine maxillofacial surgery
1-field of orthopedics and • after extraction of third molars,
sports medicine • in the treatment of periodontal
2-intra-articular injection of intrabony defects.
PRP in patients with • in sinus elevation techniques,
osteoarthritis of the knee • hard and soft tissue
augmentation.
The purpose of using PRP in these types of
surgeries was :
to accelerate the vascularization of the
graft, improve soft tissue healing and bone
regeneration, and reduce postoperative
morbidity
The Second Generation of Platelet
Concentrates: Platelet-Rich Fibrin
 PRF
• introduction of PRF by Choukroun and coworkers in 2001.
• autologous biomaterial made of a fibrin matrix that
contains the following:
1. The highest concentration of platelets
2. The highest concentration of growth factors, including
platelet-derived growth factor (PDGF),vascular
endothelial growth factor (VEGF), and transforming
growth factor (TGF)
3. A representative concentration of fibrin, fibronectin,
vitronectin, and thrombospondin
4. An approximately 65% concentration of leukocytes
 PRF
• PRF is classified according to its leukocyte
content as either L-PRF or P-PRF.
• L-PRF contains up to 90% of the platelets and
at least 75% of the leukocytes present in the
patient's blood.
Tubes for PRF Tubes for PRP
:Protocol for Preparation of L-PRF Clots
• Venipuncture: collect between four and eight 9-mL
tubes of blood
• Tubes have to be in the centrifuge within 60 seconds.
• Centrifuge at (2700 rpm) at least 12 min (Start timing
after the centrifuge has been loaded with the last two
tubes.)
• for patients taking anticoagulant medication, 15–18
min is recommended
• Take the clots out of the tubes and separate them from
the red blood cells
 Protocol for Preparation of L-PRF
:Membranes
• Place clots in Xpression kit (Intra-Lock) for
gentle compression by gravity (e.g., with light
metal plate)
• Five minutes later, the L-PRF membranes are
ready for use
• Membranes can be used during at least the
next 2 hours but should be prevented from
drying out.
 General Characteristics of L-PRF
Membranes
• Platelets in L-PRF
• Leukocytes in L-PRF
• Growth Factors in L-PRF
• Fibrin in L-PRF
• Stem Cells in L-PRF
Platelets in L-PRF
After centrifugation, at least 90% of the platelets derived from the
blood sample are present in the fibrin clot. The platelets are mainly
present in the lower portion of the clot, at the border between the
,RBCs and the clot itself. As a result, the lower portion of the clot
.also called the face, is considered to be the most biologically active
The platelet cytoplasm contains several granules. The content is
released at the time of activation. These granules contain many
cytokines and many active substances such as serotonin, von
.Willebrand factor, factor V, osteonectin, and antimicrobial proteins
When platelets come in contact with the collagen of a damaged
blood vessel, they get activated. This activation is necessary for
.platelet aggregation and thus starts and maintains hemostasis
Activation of the platelets involves degranulation and the
sequential release of various cytokines. They stimulate cell
migration and proliferation into the fibrin matrix. The principal role
of the platelets is the maintenance of homeostasis; however, they
are capable of binding, aggregating, and internalizing
microorganisms, which enhances the clearance of pathogens from
the bloodstream. Platelets participate in antibody-dependent cell
cytotoxicity functions to kill protozoal pathogens and to release an
.array of potent antimicrobial peptides
Leukocytes in L-PRF
The presence of leukocytes in platelet concentrates is of great
importance. Leukocytes have potential antibacterial characteristics
but can also regulate cell proliferation and cell differentiation. In
addition, they are the basic cells responsible for the wound healing
process and the first cells to start neoangiogenesis. In fact, they
contain VEGF, which acts as a potent vascular growth factor. The
leukocytes are also a source of production of the aforementioned
.growth factors
Neutrophils are recruited to the site of injury within minutes after
trauma and are the hallmark of acute inflammation. They migrate
,toward the damaged site and get embedded in the fibrin network
forming a dense barrier against pathogens and preventing
infection. Their main function is the production of inflammatory
cytokines and growth factors.4
Monocytes are the largest type of leukocyte and can differentiate
into macrophages, playing a central role in healing. They have
.immunologic functions as antigen-presenting cells and phagocytes
.Macrophages have been implicated in inflammation processes
However, they also play an essential role in bone repair. The role of
monocytes and macrophages in bone repair has become an area of
.increased interest
 Macrophages apparently direct osteogenic cell
signals and promote mineralization during in vitro studies.20
During bone injury, monocytes and macrophages modulate the
acute inflammatory response, produce growth factors such as bone
morphogenetic protein 2 (BMP-2) and PDGF-BB, and induce
osteogenesis in mesenchymal stem cells.19,91,92,93 Macrophages
.secrete collagenase, which promotes the cleaning of the wound
,Additionally, they are a source of growth factors such as TGF
which stimulates the keratinocytes, and PDGF, which plays an
important role in angiogenesis. Granulocytes and macrophages
promote the production of inflammatory mediators such as
leukotriene B4 and platelet-activating factor, which stimulate the
expansion and increased permeability of blood vessels as well as
.the production of inflammatory cytokines and protolithic enzymes
,These factors also act on the endothelial cells of blood vessels
stimulating the adhesion of neutrophils and lymphocytes and their
migration out of blood vessels.4
Despite the release of activated oxygen species (free radicals)
from leukocytes during phagocytosis activity and the ischemia
reperfusion process, it seems that the inclusion of leukocytes in
.blood derivatives such as L-PRF may play a beneficial role
Growth Factors in L-PRF

Platelets have an important function in the release of growth

factors. The alpha-granules in platelets contain PDGF, insulin-like
growth factor-1 (IGF-1), epidermal growth factor (EGF), VEGF, and
TGF-β, which initiate wound healing by attracting and activating
macrophages, fibroblasts, and endothelial cells. L-PRF membranes
continuously release (≥7 days) a large quantity of growth factors. A
. significant amount of them are produced by the platelets
These growth factors are also present in PRP gel. However, their
release occurs specifically in the first hours, and they are completely
dissolved in the medium after 3 days due to the chemical activation
of the platelet content. This difference can be explained by the
differences in fibrin architecture between the PRF families. PRF has
,a natural polymerization with intrinsic growth factor enmeshment
whereas PRP gel families have an artificial provoked
polymerization with extrinsic growth factor enmeshment, leading
.to their immediate release and use or destruction
Fibrin in L-PRF

Fibrin is an insoluble clotting protein that plays a major role in

.platelet aggregation during hemostasis and wound healing
Fibrinogen, the precursor of fibrin, is converted by thrombin into
.fibrin, which forms long, nonsoluble strands that bind to platelets
Present in physiologic concentrations, thrombin allows the
formation of a fibrin matrix in a slow and physiologic manner. The
fibrin wires tend to polymerize and form a biochemical structure
with trimolecular or equilateral junctions, providing a fine and
flexible fibrin network that favors the entrapment of cytokines and
cell migration . This three-dimensional network has an important
function as a matrix, promoting the invasion of various
types of inflammatory, endothelial, and other cells. This matrix is
also able to capture glycosaminoglycans (originating from the blood
platelets). These glycosaminoglycans have a high affinity for
circulating peptides (e.g., cytokines) and a large capacity to support
.cell migration and healing processes
Stem Cells in L-PRF

Dohan and colleagues33 showed a significant stimulation of human

bone mesenchymal stem cells when in contact with L-PRF. This
effect was dose-dependent during the first weeks in normal
conditions and during the whole experiment in differentiation
conditions. The cultures without L-PRF in differentiation conditions
did not rise above the degree of differentiation of the cultures in
,normal conditions with L-PRF up to the 14th and 28th day
respectively. The scanning electron microscopy (SEM) culture
analysis at day 14 showed mineralization nodules more numerous
and more structured in the groups with L-PRF compared to the
.control groups
 Extraoral Applications of L-PRF
• L-PRF is used for the treatment of nonre sponding
skin ulcers, including diabetic foot ulcers (DFUs),
pressure ulcers (PUs), acute surgical wounds, and
venous leg ulcers (VLUs).
L-PRF in the Treatment of Periodontal
Bony Defects
The use of L-PRF in the treatment of periodontal or bone defects
can be described as natural tissue regeneration and natural bone
regeneration, analogous to guided tissue regeneration and guided
bone regeneration.23 The defect is filled with L-PRF (optionally
combined with a biomaterial to prevent collapse) and sealed with
.L-PRF membranes
These membranes have a protective function (induction of the
periosteum) and serve as a competitive barrier. Epithelium and connective
tissues are kept away from the
intrabony crater, so that the cells from the periodontal ligament or
.periosteum have time to regenerate cementum, bone, and ligament
These cells can also migrate through the membranes, which results
in fast neo-angiogenesis. L-PRF also promotes the proliferation and
differentiation of osteoblasts and bone marrow stromal cells in
vitro.31 This stimulation appears to be dose dependent, with
.leukocytes playing a key role
 L-PRF in the Treatment of Periodontal
Bony Defects protocol
• Intrasulcular incision with maximal preservation of gingival
complex.
• Minimal flap elevation and degranulation of intrabony defects.
Optimal root planing and conditioning
• Rinse defect with L-PRF fluid((The fluid is collected at the
bottom of the Xpression kit)
• Apply L-PRF membrane (or part of it) in the defect (preferably
with the face part of the membrane toward bone)
• Cover bony defect with at least two layers of L-PRF
membranes, running at least 2 mm over the bony borders
underneath the periosteum, in order to seal the socket and to
force the soft tissues to grow over instead of underneath the
membranes.
 L-PRF in the Treatment of Periodontal
Bony Defects
• Suture flap and try to provide primary closure
of the interdental papilla in the absence of
tension.
• Postoperative Care:
• Soft food intake; no biting in treated area; no
mechanical cleaning of the treated area.
• Use of 0.12% chlorhexidine mouthwash twice
daily for 1 min for at least 3 weeks.
• Painkillers.
 L-PRF for Ridge Preservation
• After tooth extraction and loss of the bundle bone, the
alveolar ridge undergoes a remodeling process in both vertical
and horizontal directions.
• Atraumatic tooth extraction with maximal preservation of
alveolar bone.
• Accurate removal of inflammation and granulation tissue.
• Preparation of envelope (approximately 2 mm in width)
between the bony borders of the socket and surrounding soft
tissues.
• use L-PRF exudate (aspirated in syringe)obtained after
compression of clots, to irrigate and clean the socket.
 L-PRF for Ridge Preservation
• Place three to five L-PRF plugs, one by one, into the socket,
compressing them vigorously with amalgam condenser and
absorbing superfluous serum with gauze.
• Cover the socket with at least a double layer of L-PRF
membranes, and slide their margins between soft and hard
tissues around the socket (envelope) to seal the socket and to
prevent epithelial infiltration.
• Suture
• Postoperative Care:
• No use of chlorhexidine during first 2 days, in order to not
disturb initial soft tissue healing.
 L-PRF and Sinus Floor Elevation
• filling material for the sinus (either alone or in
combination with a bone substitute).
• membrane to seal the lateral window, for
protection of the schneiderian membrane
after detachment from the underlying bone.
• used simultaneously with the placement of
implants (which act like tent posts to preserve
the space for bone regeneration).
Protocol for Lateral Window Technique and Simultaneous
Implant Placement Using L-PRF as Sole Bone Substitute

• Crestal incision (and one or two releasing incisions).

• Reflection of the flap
• Preparation of lateral window.
• Meticulous elevation of the schneiderian membrane, pushing
the bone window inside (to prevent sharp edges)
• implant osteotomy preparation.
• before implant placement, L-PRF membranes should be
placed covering the schneiderian membrane.
• Place some membranes against the palatal/mesial/distal walls
of the uncovered sinus.
• Insert implants
• Add extra L-PRF membranes around the
implants in the sinus and buccally.
• Cover the window with at least two layers of
L-PRF membranes (with the L-PRF face toward
the sinus).
• Close flap and suturing .
• Postoperative Care
Protocol for Transalveolar Sinus Floor Augmentation and
Simultaneous Implant Placement Using L-PRF as Sole Bone
Substitute
• Crestal incision to expose the crestal bone
• Reflection of the flap.
• Osteotomy preparation up to 1 mm away from the schneiderian
membrane.
• Placement of L-PRF membrane in osteotomy (to act as a cushion
for the next step
• Carefully fracture the remaining floor of the sinus with
osteotomes
• Elevate the schneiderian membrane carefully
• Make sure that at least four L-PRF membranes are placed in the
sinus
• Insert implants&Suture
 L-PRF and Implant Surgery
• higher Implant Stability(Öncu and Alaaddinoglu).
• Implant Coating With L-PRF:
Prepare implant osteotomy following the implant
protocol.
• Use L-PRF exudate, obtained after compression of L-
PRF clots to irrigate and clean the osteotomy.
• Option 1:
• Option 2:
• Option 3:
• Option 4:
 L-PRF for Periodontal Mucogingival
Surgery
• PRF can be helpful in mucogingival surgery because
of its strong three-dimensional fibrin network,
which provides the possibility of its use as a
membrane but allows its use (alone) as a soft tissue
graft.
• It slowly releases growth factors and matrix
proteins that stimulate healing for more than 7
days.
• Impregnation:
• Induction:
Protocol for Gingival Recession Coverage With Coronally Advanced Flap
(CAF) Procedure Using L-PRF as Graft Material

• Incision
• de-epithelialization of papilla.
• Fix at least three L-PRF membranes (with correct
dimensions) together with resorbable 6-0 sutures.
• Place L-PRF graft on exposed connective tissue
(receptor bed) and over the recession, and fix it to the
periosteum.
• Suture with a coronal advancement of the flap for
coverage of the graft.
• Postoperative Care
 L-PRF and Medication-Related
Osteonecrosis of the Jawbone
• L-PRF membranes used to stimulate the
healing of MRONJ lesions.
 PRF-Block
• relatively strong bone substitute blocks that
can resist some pressure.
• By combining
• chopped L-PRF membrane parts
• fibrinogen-rich liquid
• a bone substitute