Clinical effect of autologousplatelet-rich fibrin in the treatmentof intra-bony defects: a controlledclinical trial

Thorat MK, Pradeep AR, Pallavi B. Clinical effect of autologous platelet-rich fibrin inthe treatment of intra-bony defects: a controlled clinical trial. J Clin Periodontol2011; 38: 925932. doi: 10.1111/j.1600-051X.2011.01760.x.

AbstractAim: Platelet-rich fibrin (PRF) may be considered as a second-generation plateletconcentrate widely used to accelerate soft and hard tissue healing because of presenceof many growth factors. The present study aimed to investigate the clinical andradiological effectiveness of autologous PRF in the treatment of intra-bony defects ofchronic periodontitis patients.

Material and Methods: Thirty-two intra-bony defects (one site/patient) were treatedeither with autologous PRF or a conventional open flap debridement alone. Clinicalparameters such as plaque index (PI), sulcus bleeding index (SBI), probing depth (PD),clinical attachment level (CAL) and gingival marginal level (GML) were recorded atbaseline and 9 months post-operatively. In both the groups, by using the image analysissoftware intra-bony defect fill was calculated on standardized radiographs (from thebaseline and 9 months).

Results: For all clinical and radiographic parameters test group was performed betterthan control group, and the difference was found to be statistically significant.Furthermore, images analysis revealed significantly greater bone fill in the test groupcompared with control (46.92% versus 28.66 %). Mean PD reduction(4.56 0.3743.56 0.27) and CAL gain (3.69 0.4442.13 0.43) in test groupwas found to be more compared with that of control group. In the test group, PD of44mm has highest percentage of PD reduction (68.9%) and CAL gain (61.6%). Onfrequency distribution analysis, there was no more difference for PD reduction in boththe groups but CAL gain was much more in the test group than the control group.

Conclusions: Within the limit of the present study, there was greater reduction in PD,more CAL gain and greater intra-bony defect fill at sites treated with PRF than theopen flap debridement alone.

Key words: intra-bony defects; periodontalregeneration; periodontitis; platelet-rich fibrin

Accepted for publication 3 June 2011

Regeneration has been defined as thereproduction or reconstitution of alost or injured part to restore the archi-tecture and function of the periodontium

(American Academy of Periodontology1992). When periodontal disease causesa loss of the attachment apparatus, opti-mal care seeks to regenerate the period-ontium to its pre-disease state. Theprimary goal of periodontal treatmentis the maintenance of the natural denti-tion in health and comfortable function(American Academy of Periodontology1992). To be considered a regenerativemodality, a material or technique must

histologically demonstrate that bone,cementum and a functional periodontalligament (a new attachment apparatus)can be formed on a previously diseasedroot surface (Zander et al. 1976).

Since 1923 [from Hegedus (1923)time], a number of techniques and variousgrafting materials have been in use forperiodontal tissue regeneration (Robinson1969, Schallhorn & Hiatt 1972, Carraroet al. 1976, Blumenthal et al. 1986,

ManojKumar Thorat1, A. R. Pradeep1

and Borse Pallavi2

1Department of Periodontics, Government

Dental College and Research Institute, Fort,

Bangalore, Karnataka, India 2SMBT Dental

College and Hospital, Sangamner,

Ahmednagar, Maharashtra, India

Conflict of Interests and Sources ofFunding Statement

The authors declare that they have noconflict of interests.The study was self-funded by the authors.

J Clin Periodontol 2011; 38: 925932 doi: 10.1111/j.1600-051X.2011.01760.x

925r 2011 John Wiley & Sons A/S

Bowers et al. 1986, Rosenberg & Cutler1994). However, among the graft materi-als only autogenous bone of extra-oral orintra-oral sources (Dragoo & Sullivan1973, Hiatt et al. 1978) and deminera-lized freeze-dried bone allograft (Bowerset al. 1989) have human histologicalevidence to include them as regenerativematerials (Cortellini & Bowers 1995).More recently, the use of platelet-richplasma (PRP) (Anitua et al. 2004), enam-el matrix derivative (EMD) (Sculeanet al. 1999), recombinant human bonemorphogenetic proteins (BMP)-2 (Ishika-wa et al. 1994), growth factors likeplatelet-derived growth factor (PDGF)and insulin-like growth factor-1 (IGF-1)(Lynch et al. 1989) and recombinanthuman basic fibroblast growth factor(bFGF) (Murakami et al. 2003) havebeen proposed as a source for periodontalregeneration. PRP is an autologous con-centration of platelets in a small volumeof plasma with high concentration of thefundamental protein growth factors likePDGF, transforming growth factor (TGF-1 and -2), vascular endothelial growthfactor (VEGF), IGF-1 and -2, bFGF andepithelial growth factor (EGF) secretedby platelets to initiate wound healing(Marx et al. 1998, Babbush et al. 2003).

Platelet-rich fibrin (PRF) may be con-sidered as a second-generation plateletconcentrate, using simplified protocol(Dohan et al. 2006, Dohan Ehrenfest etal. 2009a, b). Carroll et al. (2005) in vitrostudy demonstrated that the viable plate-lets in PRF released six growth factorslike, PDGF, VEGF, TGF, IGF, EGF andbFGF in about the same concentration forthe 7-day duration of their study. Morerecently, a canine study in mongrel dogsby Simon et al. (2009) determined theeffect of PRF in extraction sites treatedwith PRF matrix with or without mem-brane and found PRF exhibit enhancedhealing compared with sites treated withnon-viable materials and showed thathealing was more rapid in the PRF andPRF with membrane treated sites andfound by 3 weeks those sockets hadosseous fill. Again its beneficial effectin various surgical procedures like, sinusfloor augmentation during implant place-ment (Mazor et al. 2009); in multiplegingival recessions with coronally dis-placed flap (Del Corso et al. 2009) andin facial plastic surgical procedures (Scla-fani 2009) has been evaluated. The effectof PRF on human primary cultures ofgingival fibroblasts, dermal pre-keratino-cytes, pre-adipocytes and maxillofacialosteoblasts was evaluated in vitro (Dohan

et al. 2009a, b). He demonstrated that,PRF induced a significant and continuousstimulation and proliferation of all celltypes. The effect was dose dependentduring all the experiment with osteo-blasts, but only on day 14 with fibro-blasts. Moreover, PRF induced a strongdifferentiation in the osteoblasts. Theanalysis of osteoblasts cultures in differ-entiation conditions with PRF using lightand scanning electron microscopyrevealed a starting mineralization processin the PRF membrane (Dohan et al.2009a, b). Again, there are various advan-tages PRF over PRP. It requires less chairside time (12min.) for preparation thanPRP (Dohan et al. 2006); no need ofaddition of bovine thrombin-like PRP;long term effect of growth factors thanPRP (Carroll et al. 2005) and it can beeasily formulated into the membrane likeguided tissue regeneration (GTR) mem-brane. Because of the above-mentionedadvantages over the PRP (which is afirst-generation platelet concentrate, asit was developed first), PRF is consideredas a second-generation platelet concen-trate (Dohan et al. 2009a, b).

Keeping the above facts in mind andprolong release of various growth fac-tors, it would be expected that PRFtreatment of an intra-bony defect (IBD)may results in enhanced wound healingand periodontal regeneration comparedwith those sites treated with conven-tional open flap debridement. To testthis hypothesis, the present study wascarried out as a single-centre controlledclinical trial to investigate the clinicaland radiological (bone fill) effectivenessof autologous PRF in the treatment ofIBDs of chronic periodontitis patients.

Material and Methods

Patient selection

Forty systemically healthy subjects [22male and 18 female, age range: 2545(31.12 2.06) years] undergoing perio-dontal therapy at the Department ofPeriodontics, Government Dental Col-lege and Research Institute (from April2009 to January 2010) were selected forthe study. Intra-oral periapical radio-graphs (IOPAs) were taken to confirmthe presence of suitable IBDs for theselection of subjects.

The inclusion criteria were the pre-sence of inter-proximal IBDsX3mmdeep (distance between alveolar crestand base of the defect on IOPA) alongwith an inter-proximal probing depth(PD)X5mm following phase I therapy

(scaling and root planing, SRP) in vital,asymptomatic first and second mandib-ular molars without furcation involve-ment. Patients with present or pastsystemic illness that known to affectthe outcomes of periodontal therapy,insufficient platelet count (o200,000/mm3), immune compromised patients,pregnancy/lactation and smoking (anyother tobacco products), were excludedfrom the study. Patients taking medica-tions that may interfere with woundhealing, those allergic to other medica-tion and having unacceptable oralhygiene [if plaque index (PI) X3] afterthe re-evaluation of phase I therapywere excluded from the study.

Written informed consent was ob-tained from those who were agreed toparticipate. Ethical clearance (No:GDCB/143/12 March 2009) was recei-ved from the Institutional Committeeof Government Dental College andResearch Institute, Bangalore.

Pre-surgical therapy

Before the surgery, each patient wasgiven careful instructions on properoral hygiene measures. Full-mouth supraand subgingival SRP procedures (withultrasonic instrument, EMS V-Dent,Guangdong, China) were performedunder local anaesthesia.

Six to 8 weeks following phase Itherapy, periodontal evaluation was per-formed to confirm the suitability of thesites for this study. The selected siteswere divided randomly (coin toss) intothe control and test groups. The controlgroup consisted of the sites treated withconventional flap surgery, whereas thetest group sites were treated with con-ventional flap surgery with autologousPRF. In both the groups Kirklandsmodified flap operation (Kirkland1931) procedure was performed fol-lowed by suturing and periodontal dres-sing for 714 days. In the control andtest group one site/subject was treated.

Clinical parameters recorded beforethe surgical procedures included PD[measured from the gingival margin tothe base of the pocket (tip of the probein the pocket)], clinical attachment level(CAL), measured from the cemento-enamel junction (CEJ) to the base ofthe pocket (tip of the probe in thepocket) and gingival marginal level(GML, measured from the CEJ to thelevel of the gingival margin), usingcustomized acrylic stents with groovesto ensure a reproducible placement of

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the University of North Carolina no. 15(UNC-15, HuFriedy, Chicago, IL, USA)periodontal probe. Site-specific PI (Sil-ness & Loe 1964) and sulcus bleedingindex (SBI) (Muhlemann & Son 1971)were also measured.

Radiographic evaluation of IBDs

IBD was evaluated at baseline and after 9months (Figs. 1 and 2). The radiographicIBD depth (vertical distance from thecrest of the alveolar bone to the base ofthe defect) was measured by means ofcomputer aided program (Scion imageCorporation, Fedrick, MD, USA) used

in our previous study (Pradeep & Thorat2010). Individually customized biteblocks and parallel angle technique wasused to obtain standardized radiographs.A review of all the radiographs wasperformed in a single reference centerby a blind evaluator. For evaluation,radiographs were scanned at 800 dpiwith a scanner (HP Scanjet 3c/I, HewlettPackard, Palo Alto, CA, USA).

PRF preparation

The PRF was produced according to theprotocol Process protocol, Nice,France; developed by Choukroun et al.

(2001). PRF was prepared without bio-chemical manipulation of blood. On theday of surgery, 10ml of blood wasdrawn from each patient by venipunc-ture of the antecubital vein. Blood wascollected in a sterile glass test tube(10ml) without any anti-coagulant.Immediately test tube was centrifugedusing a refrigerated centrifugal machine at400g for 12min. Because of differentialdensities, it resulted in the separation ofthree basic fractions: a base of red bloodcells at the bottom, acellular plasma on thesurface, and finally a PRF clot between thetwo. A total of 23ml of the top layer waspipetted out with the sterile dropper; themiddle layer (PRF) was removed andplaced in a sterile dappen dish.

Surgical procedure

Following administration of local anaes-thesia, buccal and lingual sulcular inci-sions were made and the mucoperiostealflaps were elevated. Care was taken topreserve as much inter-proximal softtissue as possible. Meticulous defectdebridement and root planing was car-ried out with the use of curettes. Noosseous recontouring was performed.

PRF gel was prepared according to themethod described above. One part of PRFwas placed in the IBD and the other partwas used to prepare the membrane whichwas used to cover the defect as a GTRmembrane. To avoid the displacement ofPRF, a suture was passed through thebuccal and lingual flap before the place-ment of PRF. The mucoperiosteal flapswere repositioned and secured in placeusing 3-0 non-absorbable black silk surgi-cal suture (Ethicon, Johnson & Johnson,Somerville, NJ, USA). The Modified ver-tical mattress and interrupted sutures wereplaced. The surgical area was protectedand covered with periodontal dressing(Coe-Pak, GC America, Alsip, IL, USA).Later, suitable antibiotics (amoxicillin,500mg, every 8h) and 0.2% chlorhexi-dine digluconate (CHX) rinse (twice dailyfor 2 weeks) was prescribed. Surgicalprocedures in test and control groupswere differed for PRF treatment only.

Single surgeon (M. T.) performed allsurgeries. An examiner (A. R. P.) otherthan the operator performed all clinicalmeasurements without knowledge of thetreatment groups.

Post-operative care

Periodontal dressing and sutures wereremoved 2 weeks post-operatively.

Fig. 1. Baseline radiograph showing IBD5 6.0mm with linear measurement by Scionimage analyzer.

Fig. 2. Radiograph after 9 month showing IBD5 1.8mm with linear measurement by Scionimage analyzer.

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Surgical wounds were gently cleansedwith 0.2% CHX on a cotton swab. There-after, gentle brushing with a soft tooth-brush was recommended. At 8 weekspost-operatively, each patient was rein-structed about proper oral hygiene mea-sures. Patients were examined weeklyfor 1 month after surgery and then at 3,6 and 9 months. No subgingival instru-mentation was attempted at any of theseappointments. Post-operative care inclu-ded reinforcement of oral hygiene and

mechanical plaque control whenevernecessary.

Post-surgical measurements

PI, SBI, PD, CAL and GML wererecorded 9 months after the initial sur-gery. Soft and hard tissue evaluationwas performed. Soft tissue measure-ments were repeated with previouslyused acrylic stents. A second IOPA(after 9 months) of the same treated

sites was taken, and IBD measurementswere performed from the baseline and9-month radiographs.

Statistical analysis

The results were averaged (mean SD)for each clinical and radiographic para-meter at baseline and 9 months. Thedifference between each pair of mea-surements was calculated (baseline 9months). The paired t-test was appliedto assess the statistical significancebetween time points within each groupfor the clinical and radiographic para-meters. One-way analysis of variance(ANOVA) was used to test the differencebetween the groups. SBI and PI wereexpressed as absolute and relativecounts. Comparison of indices betweentest and control groups was carried outusing the MannWhitney test. The datawere analysed using statistical software(SPSS version 10.5, SPSS, Chicago, IL,USA). A small scale study called a pilotstudy was conducted 6 months before,based on the pilot study results, thestandard deviation of a parameter (GIor PI or CAL) is in first groups is 0.40and second group is 0.42, the meandifference was calculated between thetwo groups was 0.45. Using this infor-mation, the sample size was calculatedunder 5% error (to tolerate) and powerof the test was about 85% and consider-ing two-sided test. The required samplesize was found to 15 in each group.

The mean intra-examiner standarddeviation of differences in repeated PDmeasurements and CAL measurementsobtained using single passes of measure-ments with a conventional probe (corre-lation coefficients between duplicatemeasurements; r5 0.730).

Results

Out of 40, 32 patients (control group30.3 4.3 years, nine males, sevenfemales; test group 31.12 4.9 years,11 males, five females) were completedthe study. Four patients were notreported to the clinic as they eitherrefused to participate due to reasonsunrelated to this study or not meet theinclusion criteria. After interventionaltherapy, four more patients (two fromtest group and two from control group)were either not followed up or dis-continued the treatment. Thirty-twotreatment sites (one site/subject) wereevaluated and analysed for clinical(PD, CAL and GML) and radiological

Table 1. Sulcus bleeding index (SBI) and plaque index (PI) at Baseline and 9 months

Baseline, n (%) 9 months, n (%)

control test control test

SBI0 0 0 10 (62.5) 11(68.8)1 9 (56.2) 10 (62.5) 5 (31.3) 5 (31.3)2 7 (43.8) 6 (37.5) 1 (6.2) 0p-value o 0.001n o 0.001n

0.05n

PI0 0 0 11 (68.8) 13 (81.3)1 12 (75.0) 12 (75.0) 5 (31.3) 3 (18.7)2 4 (25.0) 4 (25.0) 0 0p-value 0.003n o0.001n

0.01n

nStatistically significant at po0.05.

Table 2. Comparison of two groups and baseline and 9 months in both the groups with respect toPD (in mm)

Group Mean SD %changebaseline 9 months baseline 9 months

Group I 6.75 1.69 3.19 1.52 3.56 1.09 52.78nwGroup II 7.88 2.19 3.19 1.05 4.69 1.45 59.52nwF-value 2.6471 3.2301p-value 0.1142z 0.0827

npo0.01.wPaired t-test.zOne-way ANOVA.Analysis of covariance (ANCOVA) by taking baseline values as a covariate.

Table 3. Comparison of two groups and baseline and 9 months in both the groups with respect toclinical attachment level (CAL) (mm)

Group Mean SD % changebaseline 9 months baseline 9 months

Group I 6.50 1.75 4.38 2.16 2.13 1.71 32.69nwGroup II 7.69 1.82 3.56 2.06 4.13 1.63 53.66nwF-value 3.5462 7.8416p-value 0.0694z 0.0090n

npo0.01.wPaired t-test.zOne-way ANOVA.Analysis of covariance (ANCOVA) by taking baseline values as a covariate.

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parameters (IBD fill) at baseline and 9months in 32 treatment sites. The meanPD and CAL at baseline and 9 month incontrol and test group was 6.75 1.69,6.50 1.75 and 3.19 1.52, 4.38 2.16mm, respectively, and was foundto be significant (po0.01) at 9 months.When IBD at baseline (4.40 1.04)and test group (4.52 1.11) was com-pared, it was found to be non-significantat baseline (p40.05) and was signifi-

cant at 9-month comparison (po0.05)(Table 6).

Healing of all the control and testsites was uneventful and not a singlecase of post-operative infection wasobserved. Reductions in the SBI and PIwere observed in both groups at 9months post-operatively and are statis-tically not significant. The differencesbetween two groups were statisticallyinsignificant when compared at baseline

and 9 months (p40.05) and was foundto be significant when compared withbaseline versus 9 months (po0.05)(Table 1).

Changes in the clinical parameters arereported in Tables 24. When the meandifference was found to be significant(po0.01) when compared in boththe groups at baseline and 9 months(Table 2). CAL gain was found to besignificantly greater in the test site(3.56 2.06) compared with controlsite (2.13 0.43) at 9-month visit (Table3). When GML were compared betweenthe groups, it was significant (po0.05)with less marginal tissue recession in testgroup (0.81 0.75) compared with con-trol site (1.50 1.03) after 9 months ofexamination (Table 4).

Changes in the radiographic para-meters are reported in Table 6. Testsites presented with a mean defect fill(distance from alveolar crest to the baseof the defect at baseline and 9 monthspost-operatively) of 2.12 0.69mmand the percentage defect fill of46.92%, which was higher than thecontrol sites (1.24 0.69; 28.66%).This difference was significantly greaterin the test group than in the controlgroup (po0.05). Out of 16 treatedIBDs, 11 (68.75%) defects were three-walled and five (31.25%) were two-walled in the control group, and in thetest group 12 (75.0%) defects werethree-walled and four (25.0%) weretwo-walled. On observation, the datarepresented in Table 5 shows that com-pared with two-walled the three-walledIBD had more defect fill.

Frequency distribution table (Table 6)shows more PD reduction, less residualPD and more CAL gain for the PRFtreated group than the control group(Table 7).

Discussion

The present study was aimed to evaluatethe clinical effectiveness of PRF in thetreatment of IBD in chronic perio-dontitis patients. In total, 32 subjects(16 subject per group, one site/subject)was treated either with the conventionalperiodontal flap surgery alone or con-ventional flap surgery with autologousPRF. To the best of our knowledge, tilldate there is no published data on theuse of PRF in the IBD of periodontitispatients.

Reconstructive dental surgeons areconstantly looking for an edge that

Table 4. Comparison of two groups and baseline and 9 months in both the groups with respect togingival recession (GML)

Group Mean SD %changebaseline 9 months baseline 9 months

Group I 0.19 0.40 1.50 1.03 1.31 1.01 700.00nwGroup II 0.50 0.82 0.81 0.75 0.31 0.95 62.50nwF-value 1.8844z 5.8548p-value 0.1800 0.0220n

npo0.01.wWilcoxons matched paired test by ranks t-test.zOne-way ANOVA.Analysis of covariance (ANCOVA) by taking baseline values as a covariate.

Table 5. Intra-bony defect (IBD) depth in mm

Subject no. Baseline 9 months

control test control test

1 3.4n 4.2w 2.5 2.12 5.1n 6.2n 4.0 2.73 6.5n 4.7n 4.9 2.74 4.8n 3.4n 3.6 1.95 3.7w 6.2n 2.8 3.76 3.8n 5.6n 2.5 3.67 3.2n 3.2n 2.3 1.98 4.5w 4.5w 3.5 2.39 3.3n 4.6n 2.3 2.810 6.0n 4.6n 3.2 2.011 4.1w 4.0n 3.2 2.112 5.1n 6.0n 3.5 1.813 4.4w 4.5w 3.4 2.614 3.4n 3.0n 1.8 1.815 3.7n 3.3w 1.5 1.716 5.8w 4.2n 4.5 1.9Mean SD 4.41 1.02 4.52 1.11 3.08 0.92 2.35 0.52nThree-wall defect.wTwo-wall defect.

Table 6. Comparison of mean and percentage reduction of IBD (mm) from baseline to 9 months

Groups Mean SD Mean SDreduction

Percentage ofIBD reduction

t-value F-value p-value

Test (n5 16)Baseline 4.52 1.11 2.12 0.69 46.92 12.12 13.31 o0.001n9 months 2.39 0.71

Control (n5 16)Baseline 4.40 1.04 1.24 0.69 28.66 7.11 o0.001n9 months 3.08 0.92

F-value: analysis of variance.nStatistically significant at po0.001.

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jumps starts the healing process to max-imize predictability as well as thevolume of regenerated bone. Manygrowth factors like BMP-2, bFGF,recombinant PDGF-BB and PRP havebeen studied in animals and are in use inthe clinical practice to treat the suprab-ony or IBDs due to periodontitis.

Reduction in PD, IBD and gain inCAL are the major clinical outcomesmeasured to determine the success ofany periodontal treatment. In the presentstudy, a significant reduction in PD andCAL gain were found in both groupswhen compared with baseline and 9months. However, there was more PDreduction (4.56 0.37) and CAL gain(3.69 0.44) in the PRF-treated groupcompared with the subjects treated withconventional periodontal flap surgeryalone. The present study also reflectsthe percentage of IBD fill in the PRFgroup (46.92%) is higher than the con-ventionally treated subjects (28.66%),supporting the significance and advan-tage of various growth factors present inthe PRF may accelerate the soft andhard tissue healing (Choukroun et al.2001, Dohan et al. 2007). Also, Simonet al. (2009) observed that the healingwas more rapid in the PRF and PRFwith membrane treated sites with sig-nificant osseous fill in sockets by 3weeks. In vitro study by He et al.(2009) on rat osteoblasts showed thatcells treated with exudates of PRF col-lected at day 14 reached peak miner-alization significantly more than bothnegative control and positive (PRP)control groups and concluded that PRFis superior to PRP, from the aspects ofexpression of alkaline phosphatase

(ALP) and induction of mineralization,because of markedly released TGF-b1and PDGF-AB. Again, by using lightand scanning electron microscopyrevealed that osteoblasts cultured indifferentiation conditions with PRFshowed a starting mineralization processin the PRF membrane itself (after 14days) and PRF leucocytes seemed toproliferate and interact with osteoblasts(Dohan Ehrenfest et al. 2009a, b). Mazoret al. (2009) by radiologic and histologicanalyses showed that the use of PRFduring a simultaneous sinus lift andimplantation stabilizes a high volumeof natural regenerated bone in the sub-sinus cavity, up to the tip of theimplants.

There are many advantages of usingPRF, a second-generation platelet con-centrate, over the PRP. First, PRF dif-fers from other commercially availablePRP systems in that it does not usebovine thrombin or other exogenousactivators in the preparation process.The PRF preparation process creates agel-like matrix that contains high con-centrations of non-activated, functional,intact platelets, contained within a fibrinmatrix, that release, a relatively constantconcentration of growth factors over aperiod of 7 days (Carroll et al. 2005).Second, it can be squeezed to form amembrane and can be used as fibrinbandage serving as a matrix to acceler-ate the healing of wound edges (Gablinget al. 2009, Vence et al. 2009). Third,the chair side preparation of PRF isquite easy and fast and simplified pro-cessing minus artificial biochemicalmodification than PRP, which takesmore time (Dohan et al. 2006). Fourth,

this produces an inexpensive autologousfibrin membrane in approximately1min. and hence no cost for membraneand bone graft to the patients.

A recent 6-month study evaluated theuse of PRF in the treatment of multiplegingival recessions with coronallyadvanced flap procedure and found thesignificant improvement during theearly periodontal healing phase with athick and stable final remodelled gingiva(Del Corso et al. 2009). In the presentstudy, it has been found that there wasless marginal tissue recession in testgroup compared with control sites after9 months of examination (test site,0.81 0.75; control site, 1.56 0.96).A recent in vivo dog study showed that,sites treated with PRF and deminera-lized freeze-dried bone allograft(DFDBA) healed slower than thosewith PRF alone or with a membrane,but faster than those grafted withDFDBA and a membrane (Simon et al.2009). A 9 months human clinical trialusing high dose (150mg/ml) recombi-nant human PDGF/recombinant humanIGF-1 revealed 2.08mm of new boneand 43.2% defect fill, compared with0.75mm vertical bone height and 18.5%bone fill in controls (Howell et al. 1997).Study by Heijl et al. (1997) showed themean radiographic bone fill was greaterfor the EMD treated defects that for thecontrol sites (2.7 versus 0.7mm, respec-tively) with mean PD (3.1 versus2.3mm, respectively) and mean CALgain (2.2 versus 1.7mm), respectively.The present study is also in accordancewith respective to the defect fill, gain inCAL and reduction in PD when com-pared with that of control. However,long-term and large sample studiesshould be carried out to affirm theobservations of our study.

Two recent reviews by Laurell et al.(1998) and Lang (2000), reported theweighted mean bone defect fill in theangular defect by open flap debridementis 1.1 and 1.5mm, respectively. In thepresent study, the results of controlgroup is in accordance with these recentreviews showing the mean angulardefect fill of 1.24 0.69mm. Most ofthe defects treated in the present studyare three wall and two wall. One alsohas to consider that the potential forbone fill may differ depending on themorphology of the angular bone defect.Most angular defects appear as combi-nations of one-, two- and three-walldefects and whereas the two- andthree-wall component of an angular

Table 7. Frequency distribution tables for probing depth (PD) reduction, residual PD and clinicalattachment level (CAL) gain

Parameter In mm Frequency % Mean SDPD reductionControl group 43 7 43.9 3.56 0.27

46 9 56.1Test group 43 5 31.3 4.56 0.37

46 10 62.6X7 1 6.3

CAL gainControl group 43 11 68.9 2.13 0.43

46 5 31.3Test group 43 6 37.6 3.69 0.44

46 8 49.1X7 2 12.5

Reduced PDControl group 43 11 68.8 3.19 1.51

46 5 31.3Test group 43 10 62.6 3.19 1.04

46 6 37.5

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bone defect may show great potentialfor bone fill during healing, the one-wallcomponent will rarely demonstrate thistype of healing.

Growth factors like recombinantPDGF-BB and allograft like DFDBAwere found to be more effective thanother xenografts, alloplasts and GTR inthe periodontal regeneration. As, PRF isan autologous preparation from patientsown blood like PRP, it decreases thecost of the regeneration therapy and alsoless time consuming, both for the sur-geon and patient. Again placement ofPRF does not require a skill and it is lesstechnique sensitive than GTR and bonegraft placement. However, long-term,randomized, controlled clinical trialwill be needed to know its effect overthe other treatment modalities.

Conclusions

Within the limit of this study, there wasgreater reduction in PD, and more CALgain with significant IBD filled withPRF in IBDs. However, long-term andlarge sample studies should be carriedout to affirm the observations of ourstudy. Use of PRF in the periodontalregeneration procedures would be thecost effective and less technique sensi-tive treatment both for the patients andclinician.

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Address:

Dr. Manoj Kumar Thorat

Department of Periodontics

Government Dental College and

Research Institute

Fort

Bangalore 560002

Karnataka

India

E-mail: manojpals@gmail.com or

manojthoratmds@rediffmail.com

Clinical relevance

Scientific rationale for the study:This is the first clinical trial to studythe clinical effectiveness of PRF inthe treatment of IBDs in chronicperiodontitis patients.Principal findings and practical impli-cations: Treatment of IBDs with auto-logous PRF placement in adjunct to

conventional flap procedures showedthat a significant improvement in theclinical parameters and significantbone fill same as the use of PDGFand EMD, however further studies arerequired.Advantages of PRF: Not requiredbiochemical modification like PRP,cost effective than other growth fac-

tors (PDGF, EMD), faster healing,and elimination of disadvantagesinvolved in using barrier membranes,release of constant concentration ofgrowth factors for prolonged periodof time than PRP.

932 Thorat et al.

r 2011 John Wiley & Sons A/S