Comparative Study of the Efficacy of Advanced Platelet-rich Fibrin and Standard Platelet-rich Fibrin in Mandibular Third Molar Surgery.

Background: Disimpaction of mandibular of third molar is one of the commonest minor oral surgical procedures. Platelet-rich fibrin (PRF) plays a vital role in both hard and soft tissue healing. There are various subtypes of PRF used for different surgical sites. Objective: The purpose of this study is to compare and evaluate the effectiveness of Advanced PRF (A-PRF) and Standard PRF (S-PRF) in the healing process of the surgical sites after the removal of mandibular third molars. Changes in swelling, pain, and mouth opening were evaluated. Materials and
Methods: 10 patients (3 men, 7 women; 18-35 years old) were selected for the removal of bilateral impacted mandibular third molar teeth. A-PRF and S-PRF were placed in the right-hand side for 5 patients in each group. In both the groups, the left side of the patients was taken as the control group. Postoperative pain was measured using a visual analogue scale (VAS), postoperative swelling was calculated using the distance between multiple facial landmarks (method) and mouth opening measured interincisally on the 1st postoperative day, 3rd day, and the 7th day, respectively. SPSS version 26.0 was used for data analysis.
Results: Advanced PRF group recorded noteworthy improvement in pain (P = 0.063), swelling (P = 0.001), and mouth opening (P = 0.013) when compared to the standard PRF group. There was statistically substantial variance between the advanced PRF and standard PRF groups.
Conclusion: Advanced PRF group showed decreased swelling, pain, and increased mouth opening compared to standard PRF group. Copyright:

INTRODUCTION

The disimpaction of bilateral impacted mandibular third molars are one of the most typical procedures in Oral and Maxillofacial surgery. Surgical abscission of mandibular third molars is usually accompanied by swelling, pain, trismus, and delayed healing of the sockets which may affect the patient's quality of life.[1] Meticulous surgical abscission and conscientious preoperative care can reduce the risk of complications and limit their intensity. Multiple medical and/or surgical modifications have been utilized to improve patients' quality of life. These comprise of drug therapies, laser treatment, steroids, ultrasound and modification of flap design. Unfortunately, the amount and the intensity of swelling, pain, trismus and delayed soft tissue healing cannot be completely eliminated. Platelet rich fibrin (PRF) is a second generation platelet concentrate adapted to simplify preparation without biochemical blood handling. It is an autogenous soluble biologic material vacuous of foreign material which is best suited for the surgical site. PRF was developed by Dohan D M et al. and comprises of platelet, cytokines, leucocytes and circulating stem cells that are enmeshed by a heterogeneous fibrin matrix.[2] These unique elements in PRF makes it a good biomaterial that permits superlative healing. The slow release of cytokines—vascular endothelial growth factor, transforming growth factor, epidermal growth factor and platelet-derived growth factor—are the key components which play an eminent role in neo-angiogenesis and tissue recuperation which makes this particular material extraordinary. Depending upon the centrifugation speed and time, various sub-types of PRF can be obtained, namely, leucocyte PRF (L-PRF),[3] standard PRF (S-PRF), advanced PRF (A-PRF), injectable PRF (I-PRF), and titanium PRF (T-PRF).

MATERIALS AND METHODS

This promising clinical investigation was implemented according to the Declaration of Helsinki (1975) regarding biomedical research involving human subjects and was carried out in the Department of Oral and Maxillofacial Surgery at Madha Dental College and Hospital (Kundrathur, Chennai, India) after procuring authorization from the Institutional Ethics Committee (Ref No: 013/MDC/IEC/2019). The investigation sample consisted of 10 adult subjects within the age group of 18–35 years with bilaterally impacted mandibular third molar indicated for surgical removal [Figures 1-10]. After noting their detailed case history, subjects were scrutinized clinically and the third molars were gauged radiographically.

Figure 1

Venipuncture

Figure 10

Pre-OP OPG

Inclusion criteria: Subjects who fit into the investigation requirements including periodic observations and hale and healthy subjects without significant systemic disorders; subjects with bilateral impacted mandibular third molars; Mesioangular, distoangular, horizontal and vertical impacted teeth; class I, class II and class III (Winter's classification); position A, position B and position C (Winter's classification).

Exclusion criteria: Smokers, alcoholics and subjects with signs of pericoronitis and swelling.

All the patients were informed about the characteristics of the surgical procedure and prior formal consent was obtained. The entire course of action was explained in English and in their native language, and enough chance was given to clarify all their doubts. Orally, further explanation was given about the course of action, study, challenges and periodic observations. Patients who were obliging to participate in the study without any compulsion were documented. All the surgeries were accomplished by a sole operator strictly following the standard operating procedures. The chosen subjects underwent bilateral surgical removal of impacted mandibular third molars. Under sterile conditions, extra-oral and intra-oral regions were painted with povidone-iodine I. P 5% solution. 2% xylocaine with adrenaline inferior alveolar nerve block was given. Standard Ward's incision was placed with No. 15 blade and handle No. 3. Whole thickness mucoperiosteal flap was raised using Howarth's periosteal elevator; bone guttering was done using No. 703 bur in straight hand piece with copious amount of saline irrigation. At the of application, using straight elevator, the tooth was luxated and removed. The surgical sites in each subject were variably broadly divided into two analysis groups. The left side of the patient was the control group (38 region). The right side of the patient was the analysis group (48 region). These groups were further subdivided into subgroups, namely, A-PRF and S-PRF. For five patients, A-PRF was placed and for the rest of the five patients, S-PRF was placed in their corresponding sockets after the removal of impacted mandibular third molars [Figures 5 and 11]. Wound closure was done using 3-0 black braided surgical silk suture. Patients were explained about the postoperative instructions, guidance, and periodic follow-up.

Figure 5

Post-OP OPG

Figure 11

Post-OP OPG

Postoperative medications to be taken for five days were:

Cap Amoxicillin 500 mg thrice daily post meal

Tab Combiflam thrice daily post meal

Tab Flagyl 400 mg thrice daily post meal

Tab Ranitidine 150 mg thrice daily prior meal.

Methods of preparation of Advanced PRF: For procuring A-PRF [Figure 2], centrifugation commenced with 1500 rpm for 14 minutes with counter volume. The centrifuged blood was settled at three fractions: the upper fraction comprising of cellular plasma, the middle fraction comprising of the advanced fibrin clot, and the lower fraction comprising of red blood cells. The straw-colored cellular plasma was initially removed and the A-PRF clot was dissected from the red blood cells.[4] During dissection, adequate care was taken to minimize the number of red blood cells as minimum as possible. The final A-PRF clot thus obtained was placed into the surgical sites [Figure 3].

Figure 2

A-PRF centrifugation

Figure 3

A-PRF obtained

Method of preparation of Standard PRF: Following sterile conditions, 5 ml of venous blood was collected from the patient's left ante-cubital fossa [Figure 1] and placed in a glass test tube without adding any anti-coagulants. This was immediately placed in the centrifuge (REMI C-852, Remielektrotechnik Ltd, Vasai, India) with counter volume at 3000 rpm for 10 minutes [Figure 7]. The centrifuged blood was settled at three fractions: the upper fraction comprising of yellow cellular plasma, the middle fraction comprising of the standard platelet rich fibrin, and the lower fraction comprising of red blood cells.[5] The yellow-colored form of PRF was dissected from the residual red blood cells at the bottom of the test tube.[6] During dissection, adequate care was taken not to include the red blood cells. The final standard PRF clot thus obtained was placed into the surgical site [Figures 8 and 9].

Figure 7

S-PRF centrifugation

Figure 8

S-PRF obtained

Figure 9

S-PRF placed

Pain evaluation: Post-surgery pain was measured on the 1st, 3rd, and 7th postoperative day using visual analogue scale (VAS) with end point–marked scores of 0 (no pain) to 10 (extreme pain) [Figure 12].[7]

Figure 12

Mean pain score chart

Swelling evaluation: Postoperative facial swelling was evaluated by quantifying the distance from tragus—comissura labiorum, gonion-comissura labiorum and tragus. Lateral canthus measurements were performed preoperatively and on the 1st postoperative day, 3rd day, and 7th day using flexible tape proposed by Carrillo et al, [Figure 13] [Table 2].[8]

Figure 13

Mean swelling score chart

Table 2

Paired samples t test to assimilate mean swelling value among study and control Groups in A-PRF and S-PRF materials separately

PRF	Time	Swelling	n	Mean	Std. Dev	P
A-PRF	1st day	Control	5	11.9320	0.56857	0.001
		Study	5	7.2760	0.88435
	3rd day	Control	5	10.7700	0.37537	<0.001
		Study	5	5.9640	0.46656
	1st week	Control	5	2.7940	0.30956	0.004
		Study	5	1.6500	0.33541
S-PRF	1st day	Control	5	11.9320	0.56857	0.002
		Study	5	8.2700	0.81077
	3rd day	Control	5	10.7700	0.37537	0.002
		Study	5	6.6860	0.95526
	1st week	Control	5	2.7940	0.30956	0.002
		Study	5	1.3880	0.17936

Mouth opening evaluation: Presurgical and postsurgical inter incisal distance was measured in centimeters in both the groups on the 1st postoperative day, 3rd day, and 7th day [Figure 14 and Tables 1 & 3].

Figure 14

Mean mouth opening chart

Table 1

Independent samples t test to assimilate mean mouth opening value among A-PRF and S-PRF materials in study and control groups separately

Group	Time	Mouth opening	n	Mean	Std. Dev	P
Control	1st day	A-PRF	5	19.20	3.271	0.196
		S-PRF	5	16.00	3.873
	3rd day	A-PRF	5	30.40	4.099	0.159
		S-PRF	5	26.20	4.438
	1st week	A-PRF	5	38.20	3.564	0.663
		S-PRF	5	37.20	3.421
	1st day	A-PRF	5	19.00	1.581	0.293
		S-PRF	5	17.20	3.114
	3rd day	A-PRF	5	34.60	3.847	0.016
		S-PRF	5	28.00	2.915
	1st week	A-PRF	5	44.20	1.304	0.002
		S-PRF	5	40.00	1.581

Table 3

Paired samples t test to assimilate mean mouth opening value among study and control groups in A-PRF and S-PRF materials separately

PRF	Time	Mouth opening	n	Mean	Std. Dev	P
A-PRF	1st day	Control	5	19.20	3.271	0.847
		Study	5	19.00	1.581
	3rd day	Control	5	30.40	4.099	0.083
		Study	5	34.60	3.847
	1st week	Control	5	38.20	3.564	0.013
		Study	5	44.20	1.304
S-PRF	1st day	Control	5	16.00	3.873	0.261
		Study	5	17.20	3.114
	3rd day	Control	5	26.20	4.438	0.295
		Study	5	28.00	2.915
	1st week	Control	5	37.20	3.421	0.135
		Study	5	40.00	1.581

RESULTS AND DISCUSSION

Results

The research consists a total of ten patients aged 18–35 years (mean age being 26.5). Among the ten patients, three were men and seven were women, all of whom underwent removal of bilaterally impacted mandibular third molars at different time intervals with A-PRF and S-PRF placed in their corresponding sockets. The A-PRF group recorded significant improvement in pain (P = 0.063), swelling (P = 0.001), and mouth opening (P = 0.013) compared to the S-PRF group. There was statistically consequential difference between the A-PRF and S-PRF group. In the A-PRF group, postoperative pain and swelling was less compared to their control group and correspondingly the same with S-PRF group; but when we compare the intergroup, the overall values are in favour of A-PRF group.

DISCUSSION

Disimpaction of impacted mandibular third molars is one of the customary approaches in minor oral surgery. Disimpaction may cause damage to the soft tissues and underlying bony structures in the oral cavity. Postoperative signs and manifestation of edema and pain might occur as a result of muscle spasm.[9] PRF is considered a fibrin bio-material; it enables a rapid angiogenesis and an uncomplicated remodeling of fibrin in better resistant connective tissue and protects the growth factors from proteolysis.[10] PRF described by Kumar et al. is produced naturally without the inclusion of thrombin. PRF releases different kinds of growth factors like pain transforming growth factors P-1 (TGF), pain, and platelet-derived growth factor AB (PDGF-AB). NF-α obtained by effortless centrifugation procedure stimulates several biological functions of the sort proliferation, angiogenesis, modulation, chemotaxis, differentiation. Consequently, it has more swift and productive regeneration of both hard and soft tissues.[11] Singh et al.[12] in their research concluded that use of PRF in bilateral third molar surgeries brought about decreased pain compared to the control side. Thorat MK et al.[13] in their study found out that when PRF was used for the management of infrabony defects of chronic periodontitis, showed improved wound healing. Lee et al.[14] in their animal study found out that when PRF was used for reconstruction of peri implant defects in rabbit, it showed improved healing at the site of application. The differentiation of monocyte/macrophages depends on the number of neutrophils which are abundant in leucocytes present in A-PRF.[15] When A-PRF placed in the mandibular third molar socket, growth factors are liberated in 10 days which in turn increases angiogenesis, cellular conduction & natural healing of tissues. The potential benefits of fibrin and leucocytes are the mutual stimulation “troupers” in the healing process.[16] A-PRF releases elevated quantity of growth factors and increases the level of cellular differentiation which results in tissue repair and vessel formation.[17] Local vascularization and tissue repair occurs mainly due to the extended release of anti-inflammatory cytokines namely IL-4, IL-6, IL-1, and L-10 which in addition has potential antimicrobial effect.[18]

PRF preparation protocol is simple and similar to that of platelet-rich plasma (PRP) preparation. It includes collection of whole venous blood from the patient's median cubital vein of approximately 5 ml each in sterile vacutainer tubes (6 ml) without any additives like anticoagulants or bovine thrombin [Figure 6]. These vacutainer tubes are balanced and placed in centrifugal machine at 3000 rpm for 10 minutes. Due to the difference in weight and gravity, three layers are formed, namely, the upper straw-colored a-cellular plasma, middle layer of fibrin clot, and lower layer containing red blood cells. The upper layer is removed. The fibrin clot or the middle layer thus collected 2 mm below the lower dividing line is called the platelet-rich fibrin.[19] Surgical removal of mandibular third molars is usually accompanied by pain, swelling, trismus and delayed healing of the sockets which may affect the patient's quality of life. PRF comprises of platelet, cytokines, leucocytes and circulating stem cells that are entangled by a complex fibrin matrix. These unique components in PRF make it a good healing biomaterial that permits optimal healing.[20] PRF is used in immediate implant placement to accelerate the healing of both soft and hard tissues. One of the major complications after implant placement is marginal bone loss which is inevitable. S-PRF is unique in its nature because of the slow and gradual release of growth factors from one week to four weeks.[21] PRF as a graft material is beneficial for increasing bone mineral density, shortening healing time, and no donor site morbidity.[22]

Figure 6

Venipuncture

D11c/CD18 receptors function in phagocytosis, cell migration, and cytokine production by monocytes/macrophages as well as induction of T cell proliferation by Langerhans cells.[23] In platelets, various growth factors such as chemokines, coagulation factors, cytokines and adhesion molecules are present in abundant numbers. Cytokines play a vital role in the biology of this biomaterial in which the fibrin matrix forms the skeletal framework.[24]

CONCLUSION

In our study we found that A-PRF decreases the postoperative swelling, pain and increases mouth opening for subjects who underwent disimpaction of bilaterally impacted mandibular third molars in contrast to the standard PRF group. The routine application of A-PRF is not only restricted to dentistry but is also used as co-adjuvants in musculoskeletal lesions, in the management of plastic surgery, chronic ulcers, and even bone and joint surgery. To obtain more good results, future research should use a larger sample with different investigative methods for all variables (i.e., pain, swelling, and mouth opening).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Statistical analysis was accomplished using SPSS 26.0 (for Windows, Armonk, NY: IBM Corp., r2019), significance level was fixed as 5% (α = 0.05). To assimilate pain score values between A-PRF and S-PRF, Mann–Whitney U test was utilized. As the study was of split-mouth design, to assimilate the pain score values between the study and control groups, Wilcoxon Signed Rank Sum test was applied. To assimilate mean values (swelling and mouth opening) between A-PRF and S-PRF, independent samples t test was used. To assimilate mean values (swelling and mouth opening) between study and control groups, paired t test was used.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.