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Platelet-rich fibrin (PRF): A second-generation platelet concentrate.
Part IV: Clinical effects on tissue healing
Joseph Choukroun, MD, a^ Antoine Diss, DDS, MS, b^ Alain Simonpieri, DDS, c Marie-Odile Girard, DDS, c^ Christian Schoeffler, DDS, c^ Steve L. Dohan, d Anthony J. J. Dohan, e^ Jaafar Mouhyi, DDS, PhD, f^ and David M. Dohan, DDS, MS, g Nice and Paris, France, Los Angeles, Calif, and Go¨teborg, Sweden NICE UNIVERSITY, UNIVERSITY OF PARIS V, UNIVERSITY OF PARIS VI, UNIVERSITY OF SOUTHERN CALIFORNIA, AND GO¨ TEBORG UNIVERSITY
Platelet-rich fibrin (PRF) belongs to a new generation of platelet concentrates, with simplified processing and without biochemical blood handling. In this fourth article, investigation is made into the previously evaluated biology of PRF with the first established clinical results, to determine the potential fields of application for this biomaterial. The reasoning is structured around 4 fundamental events of cicatrization, namely, angiogenesis, immune control, circulating stem cells trapping, and wound-covering epithelialization. All of the known clinical applications of PRF highlight an accelerated tissue cicatrization due to the development of effective neovascularization, accelerated wound closing with fast cicatricial tissue remodelling, and nearly total absence of infectious events. This initial research therefore makes it possible to plan several future PRF applications, including plastic and bone surgery, provided that the real effects are evaluated both impartially and rigorously. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:E56-60)
Platelet-rich fibrin (PRF) is an immune and platelet concentrate collecting on a single fibrin membrane all the constituents of a blood sample favorable to heal- ing and immunity. 1-3^ Though platelet and leukocyte cytokines play an important part in the biology of this biomaterial, the fibrin matrix supporting them cer- tainly constitutes the determining element responsible for the real therapeutic potential of PRF. 4,
To understand the biologic effect of this fibrin matrix, it is important to divide clinical observations into 4 highly specific aspects of healing: angiogenesis, immune control, harnessing the circulating stem cells, and wound protection by epithelial cover.
ANGIOGENESIS, IMMUNITY,
AND EPITHELIAL COVER
These are the 3 keys to healing and soft tissue maturation. The membranes of PRF are able to simulta- neously support the development of these 3 phenomena.
Fibrin is the natural guide of angiogenesis Angiogenesis consists of the formation of new blood vessels inside the wound. It requires an extracellular ma- trix to allow migration, division, and phenotype change of endothelial cells. It has been clearly demonstrated that fibrin matrix leads directly to angiogenesis. 6 The angiogenesis property of fibrin matrix^7 is explained by the 3-dimentional structure of the fibrin gel and by the simultaneous action of cytokines trapped in the meshes. Furthermore, main angiogenesis soluble factors such as fibroblast growth factorebasic (FGFb), vascular endothelial growth factor (VEGF), angiopoı¨etin and platelet-derived growth factor (PDGF) are included in fibrin gel. Some studies 8,9^ indicate that FGFb and PDGF can bind to fibrin with high affinity. Therefore, direct fibrin angiogenesis induction could be explained by fibrin binding of numerous different growth factors. In vitro models developed by Nehl and Hermann 10 have shown that the structure and mechanical properties
This article is an English translation of: Choukroun J, Simonpieri A, Girard MO, Fioretti F, Dohan S, Dohan D. Platelet-rich fibrin (PRF): Un nouveau biomate´riau de cicatrisation. 4e`me partie: Implications the´rapeutiques. Implantodontie 2004;13:229-35. Published in the French journal Implantodontie, Elsevier SAS. All rights reserved. aPrivate Practice, Pain Clinic Center, Nice, France. bAssistant Professor, Laboratory of Surface and Interface in Odontol-
ogy, Odontology Faculty, Nice University; Department of Periodon- tology, Odontology Service, Hopital St Roch, Nice, France. cPrivate Practice, France. dStudent, Biophysics Laboratory, Faculty of Dental Surgery, Univer-
sity of Paris V; Odontology Service, Hopital Albert Chenevier, Paris. eStudent, Saint-Antoine Faculty of Medicine, University of Paris VI. fPrivate practice, Casablanca, Morocco; Assistant Professor, Advanced
Periodontology, University of Southern California; Researcher, Department of Biomaterials/Handicap Research, Institute for Surgical Sciences, Sahlgrenska Academy at Go¨teborg University. gAssistant Professor, Biophysics Laboratory, Faculty of Dental Sur-
gery, University of Paris V; Department of Oral Surgery, Odontology Service, Hopital Albert Chenevier, Paris. Received for publication Dec 7, 2004; returned for revision Jun 15, 2005; accepted for publication Jul 7, 2005. 1079-2104/$ - see front matter Ó 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2005.07.
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of the fibrin clot are also important factors. The rigidity of the matrix considerably influences the capillary formation by endothelial cells in response to FGFb or VEGF stimulation. These differences in the fibrin matrix configuration are crucial for understanding the differences of biologic kinetics between fibrin glue, concentrated platelet-rich plasma (cPRP), and PRF. Finally, an important phase of angiogenesis is avb 3 integrin expression by endothelial cells, allowing the cells to bind to fibrin, fibronectin, and vitronectin. Impor- tant regulation of this integrin expression could be direct, brought on by the fibrin itself. In endothelial human cell culture, fibrin stimulates avb3 integrin expression. This is not the case with collagen. 8
Fibrin constitutes a natural support to immunity Fibrin and fibrinogen degradation products (FDP) stimulate the migration of neutrophil and increase the membrane’s expression of CD11c/CD18 receptor. This receptor permits adhesion of the neutrophil to endothe- lium and fibrinogen as well as the transmigration of neutrophils. 11 Moreover, the phagocytosis of neutrophils and the enzymatic degradation process are modulated by FDP. 12 Monocytes arrive at the injury site later than neutro- phils. It has been demonstrated that the wound coloniza- tion by macrophages is controlled by fibronectin via the chemical and physical properties of fibrin and by che- motactic agents trapped in its meshes. 13 For example, FDP D-dimer added to the culture medium of human promonocytic cell lines increases the interleukin (IL)-1 and plasminogen activator (uPA) secretion.^14 This implies a positive feedback of fibrin in inflammatory events.
Fibrin and wound coverage Fibrin matrix guides the coverage of injured tissues, af- fecting the metabolism of epithelial cells and fibroblasts. Around the wound’s margins, epithelial cells lose their basal and apical polarity and produce basal and lateral extensions toward the wound side. The cells subsequently migrate on the transitory matrix made by fibrinogen, fibronectin, tenascin, and vitronectin. This migration is more like a genuine matrix degradation than a simple translation. Fibrin, fibronectin, PDGF, and transforming growth factors (TGF-b) are essential to modulate integrin expression, fibroblast proliferation, and their migration inside the wound. 15 These can be bound directly with fibrin by different integrins, of which avb3 integrin is primary. Thanks to the expression of 2 plasminogen activators, fibroblasts develop an important proteolytic activity to move within the fibrin clot. Furthermore, the in vitro migration of rat fibroblasts in fibrin gel is
optimal when there is a maximum number of crossed connections between a-chains. 16 This fact represents one of the most important differences between swift polymerization of fibrin glues (and by extension, cPRP) and slow gelation of PRF. After migration and degradation of fibrin, fibroblasts start the collagen synthesis as described in the in vitro healing model.^17
Clinical implications With these fundamental considerations, PRF can be considered as a natural fibrin-based biomaterial favor- able to the development of a microvascularization and able to guide epithelial cell migration to its surface. The interest of such a membrane is evident, namely, to protect open wounds and accelerate healing. Further- more, this matrix contains leukocytes and promotes their migration. Its utilization seems to be of high inter- est in the case of infected wounds. A current clinical example deals with the filling of a tooth socket by PRF. Quickly, a neovascularization forms through the PRF clot and the epithelial covering developed. Finally, in spite of the infectious and inflam- matory statement of such sockets, rapid healing of the wound is observed without pain, dryness, or purulent complications (Fig. 1).
ANGIOGENESIS AND HARNESSING
OF STEM CELLS
During any phenomenon of hemostasis and healing, the fibrin clot traps the circulating stem cells brought to the injured site thanks to initial neovasculariza- tion. Set in fibrin matrix, these cells converge on a secretory phenotype, allowing the vascular and tissue restoration. 18, PRF, as a physiologic fibrin matrix, serves as a net to stem cells, especially when an accelerated angiogenesis develops in the fibrin membrane. 7 This aspect is of particular interest in the case of wide osseous defects. Indeed, such healing requires accumulation of medullar stem cells and their conversion toward the osteoblast phenotype.
Fibrin and mesenchymal stem cells Mesenchymal stem cells from bone marrow contrib- ute to regeneration of whole-type bone cells and many other tissues. These undifferentiated cells are recruited from blood to injured tissues, 20,21^ where they are able to differenti- ate themselves into several different cell types. This initial differentiation occurs necessarily in a transitory scar matrix formed by fibrin and fibronectin. That is why fibrin is preferentially used as support matrix for
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Nevertheless fibrin is a recognized support matrix for bone morphogenetic protein (BMP) transplants. Therefore, the fibrin matrix associated with BMPs has angiotrophic, hemostatic, and osseous conductive proper- ties.^26 BMPs enmeshed in the fibrin matrix are progres- sively released, and when transplanted intramuscularly they are able to induce bone. This progressive release of cytokines is a common feature of in vivo natural fibrin clot and likely of PRF.
Clinical implications These fundamental elements are illustrated during maxillary cystic ablation. After complete cystic abla- tion, the cavity fills quickly with blood. This blood clot is nothing more than a ‘‘light’’ version (physiologic version) of PRF. The fibrin clot matrix is a trap for the circulating stem cells. Thus, physiologic healing time of this cystic cavity lies between 6 months and 1 year. When the cystic cavity is filled with PRF, this physi- ologic healing phenomenon is accelerated. Because the PRF fibrin matrix is better organized, it is able to more efficiently direct stem cell harnessing and the healing program.
A cystic cavity filled with PRF will be totally healed in 2 months instead of the 6 to 12 months required for physiologic healing (Fig. 2).
DISCUSSION: WHICH FIELDS OF
APPLICATION FOR PRF?
PRF has to be considered as a fibrin biomaterial. Its molecular structure with low thrombin concentration is an optimal matrix for migration of endothelial cells and fibroblasts. It permits a rapid angiogenesis and an easier remodeling of fibrin in a more resistant connec- tive tissue. Therefore, these PRF membranes can be used for all types of superficial cutaneous and mucous healing. But PRF is not only a simple fibrin membrane. It is also a matrix containing all the molecular and cellular elements permitting optimal healing. The matrix carries all the favorable constituents present in a blood sample. That is why this biomaterial can be considered a physi- ologic concentrate. It is obtained without any addition or manipulation. Numerous extraoral applications might be imagined. In plastic surgery, the esthetic result of cutaneous wound
Fig. 2. During massive cystic ablation of the maxillary (A and B), residual cavity is filled with PRF (C). Two and a half months later, the osseous defect is replaced by a dense and cortical bone (D) instead of the average 10 months naturally. The use of PRF allows acceleration of the physiologic phenomena.
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healing constitutes a recurrent problem. In this respect, fibrin glues are still used in this discipline for their ca- pacities to prevent formation of keloid scars. The use of PRF in this type of surgery has to be tested. Nevertheless, only a limited volume of PRF can be used. Because it is obtained from an autologous blood sample, the quantities produced are low. This fact limits the systematic utilization of PRF for general surgery. PRF tissue banks are unfeasible. The fibrin matrix con- tains all the circulating immune cells and all the highly antigenic plasmatic molecules. That is why PRF mem- branes are totally specific to the donor and cannot con- stitute an allogenic graft tissue.
CONCLUSIONS The clinical experience confirms that PRF can be considered as a healing biomaterial. It features all the necessary parameters permitting optimal healing. These consist of a fibrin matrix polymerized in a tetramolecu- lar structure, the incorporation of platelets, leukocyte, and cytokines, and the presence of circulating stem cells. Despite the fact that cytokines trapped in PRF are gradually released and able to accelerate the cellular phenomenon, the structure of the fibrin network is the key element of all improved PRF healing processes. Finally, from a clinical standpoint, this biomaterial appears to accelerate physiologic healing and the nu- merous perspectives of PRF have still to be clinically tested.
REFERENCES
- Choukroun J, Adda F, Schoeffler C, Vervelle A. Une opportunite´ en paro-implantologie: le PRF. Implantodontie 2001;42:55-62. French.
- Dohan D, Donsimoni J-M, Navarro G, Gaultier F. [Platelet con- centrates. Part 1: Technologies.] Implantodontie 2003;12:5-16. French.
- Dohan D, Donsimoni J-M, Navarro G, Gaultier F. [Platelet con- centrates. Part 2: Associated biology.] Implantodontie 2003;12: 17-25. French.
- Gaultier F, Navarro G, Donsimoni J-M, Dohan D. [Platelet con- centrates. Part 3: Clinical applications.] Implantodontie 2004;13: 3-11. French.
- Simonpieri A, Choukroun J, Girard MO, Ouaknine T, Dohan D. [Immediate post-extraction implantation: interest of the PRF.]. Implantodontie 2004;13:177-89. French.
- Dvorak HF, Harvey VS, Estrella P, Brown LF, McDonagh J, Dvorak AM. Fibrin containing gels induce angiogenesis. Impli- cations for tumor stroma generation and wound healing. Lab Invest 1987;57:673-86.
- van Hinsbergh VW, Collen A, Koolwijk P. Role of fibrin matrix in angiogenesis. Ann N Y Acad Sci 2001;936:426-37.
- Feng X, Clark RA, Galanakis D, Tonnesen MG. Fibrin and collagen differentially regulate human dermal microvascular endothelial cell integrins: stabilization of alphav/beta3 mRNA by fibrin1. J Invest Dermatol 1999;113:913-9.
- Sahni A, Odrljin T, Francis CW. Binding of basic fibroblast growth factor to fibrinogen and fibrin. J Biol Chem 1998;273: 7554-9. 10. Nehls V, Herrmann R. The configuration of fibrin clots deter- mines capillary morphogenesis and endothelial cell migration. Microvasc Res 1996;51:347-64. 11. Loike JD, Sodeik B, Cao L, Leucona S, Weitz JI, Detmers PA, et al. CD11c/CD18 on neutrophils recognizes a domain at the N terminus of the A alpha chain of fibrinogen. Proc Natl Acad Sci U S A 1991;88:1044-8. 12. Kazura JW, Wenger JD, Salata RA, Budzynski AZ, Goldsmith GH. Modulation of polymorphonuclear leukocyte microbicidal activity and oxidative metabolism by fibrinogen degradation products D and E. J Clin Invest 1989;83:1916-24. 13. Lanir N, Ciano PS, Van de Water L, McDonagh J, Dvorak AM, Dvorak HF. Macrophage migration in fibrin gel matrices. II. Ef- fects of clotting factor XIII, fibronectin, and glycosaminoglycan content on cell migration. J Immunol 1988;140:2340-9. 14. Hamaguchi M, Morishita Y, Takahashi I, Ogura M, Takamatsu J, Saito H. FDP D-dimer induces the secretion of interleukin-1, urokinase-type plasminogen activator, and plasminogen activator inhibitor-2 in a human promonocytic leukemia cell line. Blood 1991;77:94-100. 15. Gray AJ, Bishop JE, Reeves JT, Laurent GJ. A alpha and B beta chains of fibrinogen stimulate proliferation of human fibroblasts. J Cell Sci 1993;104(Pt 2):409-13. 16. Brown LF, Lanir N, McDonagh J, Tognazzi K, Dvorak AM, Dvorak HF. Fibroblast migration in fibrin gel matrices. Am J Pathol 1993;142:273-83. 17. Tuan TL, Song A, Chang S, Younai S, Nimni ME. In vitro fibro- plasia: matrix contraction, cell growth, and collagen production of fibroblasts cultured in fibrin gels. Exp Cell Res 1996;223: 127-34. 18. Bonucci E, Marini E, Valdinucci F, Fortunato G. Osteogenic response to hydroxyapatite-fibrin implants in maxillofacial bone defects. Eur J Oral Sci 1997;105:557-61. 19. Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: growth factor enhance- ment for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:638-46. 20. Bucala R, Spiegel LA, Chesney J, Hogan M, Cerami A. Circulat- ing fibrocytes define a new leukocyte subpopulation that medi- ates tissue repair. Mol Med 1994;1:71-81. 21. Badiavas EV, Abedi M, Butmarc J, Falanga V, Quesenberry P. Participation of bone marrow derived cells in cutaneous wound healing. J Cell Physiol 2003;196:245-50. 22. Bensaid W, Triffitt JT, Blanchat C, Oudina K, Sedel L, Petite H. A biodegradable fibrin scaffold for mesenchymal stem cell trans- plantation. Biomaterials 2003;24:2497-502. 23. Yamada Y, Boo JS, Ozawa R, Nagasaka T, Okazaki Y, Hata K, Ueda M. Bone regeneration following injection of mesenchymal stem cells and fibrin glue with a biodegradable scaffold. J Cra- niomaxillofac Surg 2003;31:27-33. 24. Boo JS, Yamada Y, Okazaki Y, Hibino Y, Okada K, Hata K, et al. Tissue-engineered bone using mesenchymal stem cells and a biodegradable scaffold. J Craniofac Surg 2002;13:231-9; discussion 240-3. 25. Soffer E, Ouhayoun JP, Anagnostou F. Fibrin sealants and plate- let preparations in bone and periodontal healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:521-8. 26. Kawamura M, Urist MR. Human fibrin is a physiologic delivery system for bone morphogenetic protein. Clin Orthop 1988;235: 302-10.
Reprint requests: David M. Dohan, DDS, MS Faculty of Dental Surgery Biophysics Laboratory 1 Rue Maurice Arnoux 92120 Montrouge France drdohand@hotmail.com
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