Overview and Future of Hemo-Components and Natural Guided Regeneration
Andrea Mascolo1 and Elio Boschetti1,2
1Ludes Foundation HEI, Malta
2Institute of Dentistry, University of Cagliari, Italy
Submission: February 28, 2017; Published: March 03, 2017
*Corresponding author: Andrea Mascolo, Associate Professor of Dental Medicine, LUDES Foundation HEI Malta, Email: andrea.mascolo@ludes.edu.mt
How to cite this article: Mascolo A, Boschetti E, Overview and Future of Hemo-Components and Natural Guided Regeneration. Open Access J Surg. 2017; 2(4): 555593. DOI: 10.19080/OAJS.2017.02.555593
Abbreviations: PRP: Platelet-Rich Plasma; PRF: Platelet-Rich Fibrin; P-PRP: Pure Platelet-Rich Plasma; PRGF: Plasma Rich in Growth Factors; L-PRP: Leukocyte-and Platelet-Rich Plasma; P-PRF: Pure Platelet-Rich Fibrin
Mini Review
The History of Platelet Rich Fibrin (hemocomponents) started in 1970, when Matras described a fibrin glue, formed by polymerizing fibrinogen with thrombin and calcium, which was used to improve skin wound healing in a rat model in 1970 [1]. Because of the low concentration of fibrinogen in plasma, the stability and quality of fibrin glue were low. A few years later several research works proposed an upgraded concept for the use of blood extracts, termed “platelet-fibrinogen-thrombin mixtures” or “gelatin platelet - gel foam” [2,3]. In this new concept, the fibrin glues were presenting a significant concentration of platelets within the final preparation. The idea was first to reinforce naturally the fibrin gel, and also to combine the healing properties of the platelets with those of the fibrin. This improvement allowed to prepare more natural products, integrating more natural blood constituents as it should.
These products were the first platelet-rich plasma gels. These new strategies insisted in the role of platelets within the fibrin gel, and offered excellent preliminary results in ophthalmology, neurosurgery and general surgery. Whitman proceeded to develop this technique in 1997 and particularly Marx et al. [4,5] in 1998. The Leukocyte- and Platelet-Rich Fibrin L-PRF clot was often described as “optimized blood clot” that can be surgically handled and used. The rationale to use this glue/membrane and its success is due to fibrin, platelets, growth factors slow release, leukocytes and other cells: all these components are the key active actors of the natural healing process and combined together are forming a kind of engineered tissue extracted from the blood circulating tissue [6].
Unfortunately at the moment there is a lack of an international standard for characterization, classification and identification of surfaces in implantable materials [7,8], in particular a standardization is needed to obtain an optimal and reproducible results, however the current classification of platelet-rich concentrates is based on their fibrin architecture and cell content. It consists in two main groups of products, platelet-rich plasma (PRP) and platelet-rich Fibrin (PRF), both of which are available in a pure or leukocyte-enriched form (L-PRP and L-PRF) [9]. Each product has an unique biological profile that dictates its clinical applications. L-PRF concentrates provide slow release of many growth factors and can be easily prepared during surgery [10-14]. They are inexpensive and autologous; therefore, they avoid the complications associated with allogenic blood use.
Pure Platelet-Rich Plasma (P-PRP) products are preparations without leukocytes and with a low density fibrin network after activation. One largely advertised method of P-PRP is known under the commercial name PRGF [Plasma Rich in Growth Factors or Preparations Rich in Growth Factors or EndoRet, Biotechnology Institute BTI (dental implant company), Vitoria, Spain] and was tested in many clinical situations, particularly in sports medicine. P-PRP gel released most of its growth factors in the first hours and completely dissolved in the medium after 3 days, even after a maximum artificial fibrin polymerization.
Leukocyte-and Platelet-Rich Plasma (L-PRP) products are preparations with leukocytes and with a low-density fibrin network after activation. The methods to prepare the PRP membranes require two or one centrifugations, there are, infact, some new faster machines like Arthrex ACP®, nevertheless an anticoagulant is always needed. PRP families are not adapted (complicated, expensive, with mixed clinical relevance) for daily oral applications. PRP families are substitutions to fibrin glues in most other surgeries, particularly to improve skin wound healing. The use of gelling of the PRP on the surgical site makes it adequate surgical adjuvants in many clinical situations, even if the exact effects - in comparison to fibrin glues - remain largely debated.
The PRP solutions have also the advantage to be liquid before activation, and can therefore be used as injection or placed during gelling on a skin wound or suture (similar to the use of fibrin glues) in various sports medicine or orthopedic applications. In this strategy of regenerative medicine, the platelet suspensions are injected like other pharmaceutical preparations. The results of this method remain however largely debated in the literature, probably because of the large quantity of different protocols [14-16]. Pure Platelet-Rich Fibrin (P-PRF) - or Leukocyte- Poor Platelet- Rich Fibrin preparations without leukocytes and with a high-density fibrin network. These products only exist in a strongly activated gel form, and cannot be injected or used like traditional fibrin glues. However, because of their strong fibrin matrix, they can be handled like a real solid material for other applications.
L-PRF membrane remains solid and intact after 7 days and relases continuously a large quantity of growth factors, a significant part of it being produced by the cell population within the membrane. L-PRF family fits the needs of the applications in oral and maxillofacial surgery, as L-PRF clots and membranes present a volume and shape easy to combine with most surgical techniques, as filling and interposition healing biomaterial or as protection healing membrane. The fibrin architecture of L-PRF is constitued by connected trimolecular junctions, due to a slow polymerization of the platelet concentrate and due to the absence of heterologous thrombin. The results of this process is a flexible fibrin network, able to promote the gradual release of growth factors and leukocytes migrationduring extended period.
It is easy to prepare in large quantity and inexpensive, what makes it particularly adapted for daily clinical practice. PRF families in general are usable in other disciplines with interesting results, particularly for the treatment of skin chronic wounds and ulcers. The methods to prepare PRF never require an anticoagulant and a lower G-force is needed (around 400G). PRF products cannot be used as injectable products in sports medicine for example [12,17]. Some groups advocated that the presence of leukocytes may be negative for the therapeutic outcome, due to a potential risk of stimulation of the inflammatory process after the membrane placement in a wounded site [18]. Other researchers insisted on the need of some leukocyte population in the injectable PRP in order to increase the growth factors production, the release of anti-pain mediators and the natural anti-infectious activity.
Some kind of leukocytes, lymphocytes in particular, are playing a key function as regulation turntable of the healing and inflammatory process, and there is no reason to discard them. Leukocytes are not only inflammatory cells: they also present anti-nociceptive effects through different chemokines, anti-inflammatory cytokines (IL-4, IL-10 and IL-13) and opioid peptides (b-endorphin, metenkephalin, and dynorphin-A) and can therefore promote a clinically relevant inhibition of pathological pain [19-21]. The classification previously described is the only nomenclature which considers all forms of platelet concentrates for surgical use. However, other classifications systems were proposed in the recent years, but are limited because they only refer to Platelet-Rich Plasma products and sports medicine applications. Both proposals are not significantly evidence-based and do not allow to improve the current terminology [22].
Most publications about growth factors and platelet concentrations showed the relative lack of significance of these parameters, due to the many inter-individual variations and the short-term effects of these parameters: platelets being activated and active during a very short time and the growth factors being released, consumed locally or dissolved in the blood circulation in few minutes or hours after their release [23,24]. Platelet concentrates for surgical use are a system of all blood elements within a logical healing platform including the fibrin matrix, the platelets, the mediators and the cells all together to reach a clear and reproducible clinical result [25]. Castro in a systematic review founded favorable effects on hard and soft tissue healing and postoperative discomfort reduction were often reported when L-PRF was used, nevertheless, they found a lack of standardization of the protocol in regenerative procedure [26].
Temmerman et al. [27] compared bone ridge preservation L-PRF socket filling and natural healing following tooth extraction after 3 months; the results showed the use of L-PRF as a socket filling material in order to achieve ridge preservation is beneficial for all parameters considered (vertical height changes, width reduction, mineralized bone) during a 3 month observation period. Furthermore, the use of L-PRF results in less post-operative discomfort and pain for the patients. Multiple surgical specialties have recognized the potential advanatges of platelet-rich concentrates. Their use has been described in ophthalmology, neurosurgery, general surgery [22] orthopedic surgery, sports medicine [28] and oral and maxillofacial surgery [29]. Several applications of L-PRF concentrate have been described in the literature including postoperative hand wound healing yielding faster re-epithelialization and in the treatment of androgenic alopecia diminishing hair loss among others [30- 32].
The role of L-PRF in endoscopic endonasal skull base surgery defect reconstruction was investigated by Soldatova et al. [33] who demonstrated the potential benefits of L-PRF membranes for the reconstruction of skull base defects with encouraging rate of healing progression as measured by the crusting score. During the lasts years the production of platelet concentrates for surgical use from the PRF (Platelet-Rich Fibrin) family are becoming very popular in some surgical fields. The main product is classified as L-PRF and is used in oral and maxillofacial applications in particular. Many systems are available on the global market, but only one system to date is duly CE-marked and FDA-cleared (Intra-Spin System, Intra-Lock, Boca-Raton, FL, USA) [34].
The impact of the centrifuge characteristics and centrifugation protocols on the cells, growth factors and fibrin architecture of L-PRF was investigated comparing 4 different centrifuges. The results showed significant differences in the vibrations level at each rotational speed between the 4 tested machines. The CE-marked and FDA-cleared device was the most stable machine in all configurations and it remains under the threshold of resonance, unlike the 3 other tested machines [35]. In another study M.F-Kobayashi demonstrated in vitro that reducing the centrifugation speed favored an increase in growth factor release from PRF clots which in turn may directly influence tissue regeneration by increasing fibroblast migration, proliferation and collagen mRNA levels [36].
Conclusion
L-PRF treatment offers additional advantages: favorable effects on hard and soft tissue healing, postoperative discomfort reduction, simple harvesting, simplicity in use, no need for primary closure, and no risk for early membrane exposure. The economic implication in the final cost of a treatment has also to be taken into consideration. The vitro and molecular biology studies are very useful to understand which molecules are present in the clot and to hypothesize their role in the healing and regenerative process, however more clinical standardized studies are needed to demonstrate the quantity of growth factor is actually necessary to significantly improve the regenerative processes. Literature’s results are often discordant, several practitioners report different clinical experiences and mixed clinical outcomes. These unpleasant facts are due to a chaotic market and a lack of standardization of the procedure. Further researches and clinical trial under a rigid protocol are needed to fully understand the potential and optimal effect of L-PRF in regenerative procedures.
References
- Matras H (1970) Die Wirkungen verschiedener Fibrinpräparate auf Kontinuitat-strennungen der Rattenhaut. Osterr Z Stomatol 67: 338- 359.
- Rosenthal AR, Egbert PR, Harbury C, Hopkins JL, Rubenstein E (1978) Use of platelet-fibrinogen-thrombin mixture to seal experimental penetrating corneal wounds. Albrecht Von Graefes Arch Klin Exp Ophthalmol 207(2): 111-115.
- Knighton DR, Ciresi KF, Fiegel VD, Austin LL, Butler EL (1986) Classification and treatment of chronic nonhealing wounds. Successful treatment with autologous platelet-derived wound healing factors (PDWHF). Ann Surg 204(3): 322-330.
- Whitman DH, Berry RL, Green DM (1997) Platelet gel: an autologous alternative to fibrin glue with applications in oral and maxillofacial surgery. J Oral Maxillofac Surg 55(11): 1294-1299.
- Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, et al. (1998) Platelet-rich plasma: Growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 85(6): 638- 646.
- Dohan Ehrenfest DM, Del Corso M, Diss A, Mouhyi J, Charrier JB (2010) Three-dimensional architecture and cell composition of a Choukroun’s platelet-rich fibrin clot and membrane. J Periodontol 81(4): 546- 555.
- DM Dohan Ehrenfest, JL Rutkowski (2012) Evolution of the dental implant market: an african tale revisited. Journal of Oral Implantology 38(3): 201-202.
- JP Davidas (2014) Looking for a new international standard for characterization, classification and identification of surfaces in implantable materials: the long march for the evaluation of dental implant surfaces has just begun. POSEIDO 2(1): 1-5.
- Del Corso M, Dohan Ehrenfest DM (2013) Immediate implantation and peri-implant natural bone regeneration (NBR) in the severely resorbed posterior mandible using leukocyte- and platelet-rich fibrin (L-PRF): a 4-year follow up. POSEIDO 1(2): 109-116.
- Dohan Ehrenfest DM, Sammartino G, Shibli JA, Wang HL, Zou DR, et al. (2013) Guidelines for the publication of articles related to platelet concentrates (platelet-rich plasma - PRP, or platelet-rich fibrin - PRF): the international classification of the POSEIDO. POSEIDO 1(1): 17-27.
- Toeroek R, Dohan Ehrenfest DM (2013) The concept of screw-guided boneregeneration(S-GBR). Part2: S-GBR in the severely resorbed preimplant posterior mandible using bone xenograft and leukocyteandplatelet- richfibrin (L-PRF); a 5-year follow-up. POSEIDO 1(2): 85- 92.
- Dohan Ehrenfest DM (2010) How to optimize the preparation of leukocyte- and platelet-rich fibrin (L-PRF, Choukroun’s technique) clots and membranes: introducing the PRF Box. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 110(3): 275-280.
- Everts PA, Hoogbergen MM, Weber TA, Devilee RJ, van MonftortG, et al. (2012) Is the use of autologous platelet-rich plasma gels in gynecologic, cardiac, and general, reconstructive surgery beneficial? Curr Pharm Biotechnol 13(7): 1163-1172.
- Yuan T, Guo SC, Han P, Zhang CQ, Zeng BF (2012) Applications of leukocyte- and platelet-rich plasma (L-PRP) in trauma surgery. Curr Pharm Biotechnol 13(7): 1173-1184.
- Del Corso M, Vervelle A, Simonpieri A, Jimbo R, Inchingolo F, et al. (2012) Current knowledge and perspectives for the use of platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) in oral and maxillofacial surgery part 1: Periodontal and dentoalveolar surgery. Curr Pharm Biotechnol 13(7): 1207-1230.
- Simonpieri A, Del Corso M, Vervelle A, Jimbo R, Inchingolo F, et al. (2012) Current knowledge and perspectives for the use of platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) in oral and maxillofacial surgery part 2: Bone graft, implant and reconstructive surgery. Curr Pharm Biotechnol 13(7): 1231-1256.
- Cieslik-Bielecka A, Choukroun J, Odin G, Dohan Ehrenfest DM (2012) L-PRP/L-PRF in esthetic plastic surgery, regenerative medicine of the skin and chronic wounds. Curr Pharm Biotechnol 13(7): 1266-1277.
- Anitua E, Sanchez M, Orive G, Andia I (2007) The potential impact of the preparation rich in growth factors (PRGF) in different medical fields. Biomaterials 28(31): 4551-4560.
- Mishra A, Harmon K, Woodall J, Vieira A (2012) Sports medicine applications of platelet rich plasma. Curr Pharm Biotechnol 13(7): 1185-1195.
- Bielecki T, Dohan Ehrenfest DM, Everts PA, Wiczkowski A (2012) The role of leukocytes from L-PRP/L-PRF in wound healing and immune defense: new perspectives. Curr Pharm Biotechnol 13(7): 1153-1162.
- Moojen DJ, Everts PA, Schure RM, Overdevest EP, van Zundert A, et al. (2008) Antimicrobial activity of platelet-leukocyte gel against Staphylococcus aureus. J Orthop Res 26(3): 404-410.
- Dohan Ehrenfest DM, Rasmusson L, Albrektsson T (2009) Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L- PRF). Trends Biotechnol 27(3): 158-167.
- Weibrich G, Hansen T, Kleis W, Buch R, Hitzler WE (2004) Effect of platelet concentration in platelet-rich plasma on peri-implant bone regeneration. Bone 34(4): 665-671.
- Weibrich G, Kleis WK, Kunz-Kostomanolakis M, Loos AH, Wagner W (2001) Correlation of platelet concentration in platelet-rich plasma to the extraction method, age, sex, and platelet count of the donor. Int J Oral Maxillofac Implants 16(5): 693-699.
- Dohan Ehrenfest DM, Del Corso M, Diss A, Mouhyi J, Charrier JB (2010) Three-dimensional architecture and cell composition of a Choukroun’s platelet-rich fibrin clot and membrane. J Periodontol 81(4): 546- 555.
- Castro A, Meschi N, Temmerman A, Pinto N, Lambrechts P, et al. (2017) Regenerative potential of leucocyte- and platelet-rich fibrin. Part A: intra-bony defects, furcation defects and periodontal plastic surgery. A systematic review and meta-analysis. J Clin Periodontol 44(1): 67-82.
- Temmerman A, Vandessel J, Castro A, Jacobs R, Teughels W, et al. (2016) The use of leucocyte and platelet-rich fibrin in socket management and ridge preservation: a split-mouth, randomized, controlled clinical trial. J Clin Periodontol 43(11): 990-999.
- Pinto NR, Pereda A, Jiménez P (2014) The impact of the centrifuge characteristics and centrifugation protocols on the cells, growth factors and fibrin architecture of a leukocyte- and platelet-rich fibrin (L-PRF) clot and membrane. Part 2: macroscopic, photonic microscopyand scanning electron microscopy analysis of 4 kinds of L-PRF clots and membranes. POSEIDO (2): 141-154.
- Dohan Ehrenfest DM, Bielecki T, Jimbo R, Barbé G, Del Corso M, et al. (2012) Do the fibrin architecture and leukocyte content influence the growth factor release of platelet concentrates? An evidence-based answer comparingapureplatelet-richplasma(PPRP) gelandaleukocyte-and platelet-rich fibrin (L-PRF). Curr Pharm Biotechnol 13(7): 1145-1152.
- Cieslik-Bielecka A, Choukroun J, Odin G, Dohan Ehrenfest DM (2012) LPRP/L-PRF in esthetic plasticsurgery, regenerative medicine of the skin and chronic wounds. Curr Pharm Biotechnol 13(7): 1266-1277.
- Chignon-Sicard B, Georgiou CA, Fontas E, David S, Dumas P, et al. (2012) Efficacy of leukocyte- and platelet-rich fibrin in wound healing: a randomized controlled clinical trial. Plast Reconstr Surg 130(6): 819e-829.
- Schiavone G, Raskovic D, Greco J, Abeni D (2014) Platelet-rich plasma for androgenetic alopecia: a pilot study. Dermatol Surg 40(9): 1010- 1019.
- Soldatova L, Campbell RG, Elkhatib AH, Schmidt TW, Pinto NR, et al. (2017) Role of Leukocyte-Platelet-Rich Fibrin in Endoscopic Endonasal Skull Base Surgery Defect Reconstruction. J Neurol Surg B Skull Base 78(1): 59-62.
- David M Dohan Ehrenfest, Adriano Piattelli, Gilberto Sammartino, Hom-Lay Wang (2017) New Biomaterials and Regenerative Medicine Strategies in Periodontology, Oral Surgery, Esthetic and Implant Dentistry 2016. BioMed Research International 2017: 3.
- David M Dohan Ehrenfest, Byung-Soo Kang, Marco Del Corso, Mauricio Nally, Marc Quirynen, et al. (2014) The impact of the centrifuge characteristics and centrifugation protocols on the cells, growth factors and fibrin architecture of a Leukocyte- and Platelet-Rich Fibrin (L-PRF) clot and membrane. Part 1: evaluation of the vibration shocks of 4 models of table centrifuges for L-PRF. POSEIDO 2(2).
- Fujioka-Kobayashi M, Miron RJ, Hernandez M, Kandalam U, Zhang Y, et al. (2017) Optimized Platelet-Rich Fibrin With the Low-Speed Concept: Growth Factor Release, Biocompatibility, and Cellular Response. J Periodontol 88(1): 112-121.