Accepted Manuscript

Autologous Platelet Rich Fibrin: Can it Secure a Better Healing ?

Sheetal Kapse , Sanidhya Surana , M. Satish ,

Syed Erfan Hussain , Sunil Vyas , Deepak Thakur

PII: S2212-4403(18)31154-4
DOI: https://doi.org/10.1016/j.oooo.2018.08.010
Reference: OOOO 2070

To appear in: Oral Surg Oral Med Oral Pathol Oral Radiol

Received date: 23 May 2018

Revised date: 22 June 2018
Accepted date: 22 August 2018

Please cite this article as: Sheetal Kapse , Sanidhya Surana , M. Satish , Syed Erfan Hussain ,
Sunil Vyas , Deepak Thakur , Autologous Platelet Rich Fibrin: Can it Secure a Better Healing ?,
Oral Surg Oral Med Oral Pathol Oral Radiol (2018), doi: https://doi.org/10.1016/j.oooo.2018.08.010

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 ACCEPTED MANUSCRIPT

Title – Autologous Platelet Rich Fibrin: Can it Secure a Better Healing ?

Authors –

Sheetal Kapse, MDS (Oral and Maxillofacial Surgery), Fellow (Maxillofacial Trauma)
(AOMSI), Private practitioner, Raipur, Chhattisgarh, India.

Sanidhya Surana, MDS, private practitioner at Swasthya Sanchay dental clinic, Balod,

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Durg, Chhattisgarh, India.

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M. Satish, MDS, Professor & HOD, Dept. of Oral & Maxillofacial surgery at Anil

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Neerukonda Institute of Dental Sciences, Visakhapatnam, Andhra Pradesh, India.

Syed Erfan Hussain, MDS (Oral and Maxillofacial Surgery), Private practitioner,
Raipur, Chhattisgarh, India. US
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Sunil Vyas, MDS (Oral and Maxillofacial Surgery), Private practitioner, Raipur,
Chhattisgarh, India.
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Deepak Thakur, MDS (Oral and Maxillofacial Surgery), Professor, Rungta College of
Dental Sciences and Research, Bhilai, Chhattisgarh, India.
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Mailing Address - Dr. Sheetal Kapse, House no. 1847, Pooja Niketan, Behind Touchtel
Tower, Near Swami Vivekanand English Medium School, Shanti Vihar Colony,
Danganiya, Raipur, Chhattisgarh, India. Pin – 492013.
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Contact no. - +91-9981298209, +91-8103987804. Email id - sheetal.kapse@yahoo.com

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Declarations of interest: none.

Word count for the abstract: 200
Word count for the manuscript: 2787
Number of references: 56
Number of figures: 7
Number of tables: 7
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Abstract

Objective: To evaluate the efficacy of platelet rich fibrin (PRF) in the healing of

impacted mandibular third molar (M3) extraction sockets.

Study Design: This study included 30 patients with bilaterally symmetrical impacted

M3 (total n = 60) requiring transalveolar extraction. All patients were randomly

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provided numbers; left-sided odd numbered M3 patients and right-sided even numbered

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patients were categorized into group A (test group), while the other side of the mouth

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was classified as ―Group B‖ (control group). Group A M3 extraction sockets received

PRF, while group B sockets were closed without PRF. Patients were evaluated for pain

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and swelling on post-operative days 1,3,7, and 14. Bone healing was compared on the

8th and 16th post-operative weeks. ANOVA and Tukey multiple comparison tests were
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applied for statistical analysis.

Results: A total of 30 patients between the age of 18 to 40 yearsparticipated in this

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study. The overall post-operative pain score (VAS) and facial swelling percentages were
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lower for group A compared to group B (p<0.05). Early bone healing was also evident

on the 8th and 16th week post-operative radiographs in group A (p < 0.001).
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Conclusion: Use of autologous PRF aids in earlier and better wound healing in a

controlled manner.
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The text

Introduction

Wound healing is a primary aspect of all injuries. The high vascularity of the oral and

maxillofacial region compared to other regions of the body results in faster wound

healing. The success of all surgical procedures performed in the specialty of oral and

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maxillofacial surgery including simple tooth extractions, implant placement, excision of

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pathologic tissues, complicated reconstruction work, cleft surgeries, aesthetic surgeries,

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etc. rely on an uneventful healing of hard and soft tissues. However, accomplishing

optimized wound healing can be challenging. Modern technological advances have

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spurred ongoing research work at the molecular level to develop biomaterials which can

control the associated inflammation and also aid wound healing.

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Extraction of the tooth is a routine procedure in the field of oral and

maxillofacial surgery and the transalveolar method is usually employed for the
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extraction of impacted third molars (M3). Pain, swelling, delayed bone healing, and a
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dry socket are the most common problems experienced by patients after the procedure.

Healing of the extraction socket is mediated by the complex integration of molecular,

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cellular, biochemical, and physiological processes in order to restore the anatomic and

functional integrity of the injured tissues.1 In order to achieve early healing of

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extraction sockets, various autografts (mandibular symphysis, ramus, coronoid process,

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zygomaticomaxillary buttress maxillary tuberosity, calvarium, scapula, tibia and

fibula), allografts (mineralized freeze-dried bone graft and demineralized freeze-dried

bone graft), xenografts (deproteinized bovine bone mineral and coralline

hydroxyapatite) and synthetic materials (bioactive glasses, glass ionomers, aluminum

oxide, calcium sulfate, calcium phosphates, alpha and betatricalcium phosphate (TCP)
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and synthetic hydroxyapatite) can be used. Autografts are frequently associated with the

risk of donor site morbidity, while allografts and xenografts carry the risk of disease

transmission, and synthetic materials may provoke foreign body reaction leading to

graft rejection. Hence there is a need for biomaterials that can be used in the socket

which are easily accessible, cost effective, and strictly autologous.

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The first response to any injury is hemorrhage and clot formation. Being a

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biologic tissue, blood works as an attractive option for healing. The principal blood

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components, namely red blood cells (RBCs), white blood cells (WBCs), and platelets

assume a distinctive part in the organized wound healing cascade. RBCs oxygenate the

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tissues and configure the clot along with platelets and clotting factors; WBCs are
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amenable for clot immunity, while platelets initiate wound healing by forming the

platelet plug to seal the ruptured blood vessels. In addition, platelets also contribute in
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the sequential stages of healing by secretion and stimulation of various growth factors.1-
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Platelet- based therapy evolved in the early 1990’s after the identification of
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various growth factors released from the α granules of platelets.3 Initially fibrin

adhesives (fibrin glue)4 and platelet rich plasma (PRP)5 came into existence as first and
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second generation platelet concentrates respectively, but their popularity waned due to
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complicated preparation procedures. Fibrin glue is prepared from the blood of multiple

donors. In contrast, PRP is prepared from the patient’s own blood. The preparations of

both fibrin adhesives and PRP involve multistep procedures and require the addition of

anticoagulants, bovine-derived thrombin and gelling agents to the blood resulting in its

biochemical alteration. In 2001, Choukroun J et al6 introduced a new generation of

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platelet concentrate, the ―platelet rich fibrin (PRF)‖, a combination of WBCs and

platelets. Preparation of PRF from the patient’s own blood makes it strictly autologous,

easily accessible, and a gold standard graft material. It does not need the addition of any

chemical which overcomes all the legal issues of concern in handling blood or blood

products outside the body and their re-implantation.7

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In this randomized clinical trial, we evaluated how PRF can contribute a

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significant effect on the acceleration of the healing phase after surgical removal of

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impacted M3. By using the parameters ―pain‖, ―swelling‖, and ―bone healing‖ we

searched the literature to answer ―can PRF significantly improve the healing?‖ Based on

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the available knowledge in the literature (table 1),2,6,8-28 we hypothesized that PRF can
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act as an accelerating factor in wound healing, and possibly be used in other extraction

sockets to receive the implant comparatively earlier, as well as be utilized in other

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maxillofacial surgical procedures for enhanced healing.

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Materials and methods

A single-blind, randomized controlled trial was conducted among 30 patients between

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the age of 18 to 40 years with bilaterally symmetrical impacted M3 (total 60) requiring
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transalveolar extraction. We assessed the reciprocal symmetric impaction pattern by

using Pederson’s difficulty index.29 Patients with normal hematologic profile, without
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any systemic illness, good oral hygiene and surgical site free of active infection were

included in the study, while the consumption of tobacco or alcohol during the study

period and unwillingness to attend the long term follow-up programme were considered

as exclusion criteria. This study was approved by the institutional ethical committee and
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conducted from January 2013 to April 2014. All the participants signed an informed

consent agreement.

In this split-mouth study, all patients were randomly provided with numbers and

patients were categorized to two groups ─ Group A (test group, n=30) and Group B

(control group,n=30). The left-sided odd numbered M3 patients and right-sided M3 in

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even numbered patients were included in group A, while the other side of the mouth of

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the same patients acted as controls (group B). Group A M3 extraction sockets received

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PRF while group B sockets were closed without PRF. Primary closure of flap was

performed in both groups. The time interval between extractions of M3 in a patient was

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30 days. All patients were reviewed on 1st, 3rd, 7th, and 14th post-operative day to
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evaluate pain and swelling. Next, follow-up visits were scheduled on 8th and 16th post-

operative week to assess bone healing.

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Preparation of PRF: Under aseptic conditions, 10 ml of venous blood was withdrawn

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from the antecubital region and collected into a sterile glass test tube without the

addition of any anticoagulant. It was immediately centrifuged in a bench-top centrifuge

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(R-4C DX, REMI, Mumbai, India (figure 1) at 2700 RPM for 12 min. Completion of

centrifugation produced three distinct layers in the test tube: RBCs clot at the base,
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whitish yellow colored clot (2 ml) in middle, and clear straw-colored acellular plasma at
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the top layer (figure 2). This middle clot is known as PRF which is a predominant

combination of platelets and WBCs collected in a fibrin matrix.6 In the absence of any

anticoagulant, blood starts coagulating as it comes in contact with the glass surface of

the test tube. Consequently, rapid collection and immediate centrifugation of blood is

the key to successfully prepare PRF.

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Operative technique: All patients with normal hematologic values and coagulation

profile were taken up for the procedure. Three facial measurements were taken

respectively from the lateral canthus to the angle of mandible, tragus of the ear to the

corner of mouth and the tragus of ear to the soft tissue pogonion. The arithmetic sum of

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these measurements (preoperative facial swelling or FSpreop) worked as the baseline data

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for calculation of post-operative swelling. Preparation of PRF preceded the surgical

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procedure in group A. Therefore, we utilized the preparation time (12 minutes) by

initiating the extraction procedure.

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Transalveolar extraction of impacted M3 was performed by a single operator
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under local anesthesia. Surgical procedure included mucoperiosteal flap reflection,

bone removal, tooth sectioning (if required), socket irrigation with normal saline (0.9%
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w/v), PRF placement (only in group A extraction sockets) (figure 3) and primary

closure of mucoperiosteal flap with 3-0 black braided silk suture with simple interrupted
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technique. An immediate post-operative digital intraoral periapical radiograph was

taken by using RVG (SOPIX2 DIGITAL SENSOR X-RAY SYSTEM, SOPRO,

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France) which was used as a baseline radiograph to compare the bone healing on
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follow-up visits.
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We evaluated the pain and swelling on 1st, 3rd, 7th, and 14th post-operative day.

Pain was scored on 100 points visual analogue scale (VAS) and swelling (percentage)

was calculated by using the method of Schultze et al30 modified by Ogundipe OK et al.1

All the evaluations were carried out by investigators other than the operating surgeon.

Facial swelling percentage was calculated as the difference of pre-operative and post-
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operative facial measurements divided by the pre-operative facial measurement and

multiplying it to 100 [(FSpreop - FSpostop)/FSpreop × 100]. Bone healing of extraction

sockets was assessed on post-operative 8th and 16th weeks by three investigators

manually, and the average of which was taken as the final score for each sub-parameter

namely lamina dura, bone density, and trabecular pattern based on modified Ogundipe

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OK et al1 criteria (table 2). Scores were awarded for gross and significant variations

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from the baseline radiograph score of 0 (zero) in which no significant changes were

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noticed. For the presentation of quantitative data, mean value ± standard deviation was

used. One-way Analysis of Variance (ANOVA) and Tukey multiple comparison tests

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were performed for statistical analysis. Inference of statistical significance was

represented by p-value as not significant (p>0.05), significant (p≤0.05), more significant

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(p≤ 0.01) and highly significant (p≤ 0.001).
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Results
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A total of 30 patients [males = 13 (43.3%) and females = 17 (56.76%)] between the

ages of 18 to 40 years (25.47 ± 0.90 years) participated in this study. The distribution
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pattern of M3 has been summarized in table 3. The quantitative data of three outcome

measures ―Pain‖, ―Swelling‖, and ―Bone healing‖ are summarized in tables 5, 6, and 7,
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respectively. The correlations among the age, gender, and type of impaction in both
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groups were not statistically significant.

The mean postoperative pain score (VAS) was highest at post-operative day 1

and gradually reduced over the following 14 days in both groups (figure 4). Although, it

was lower for group A at all time points (table 4) in comparison with group B (p<0.05).

The facial swelling percentage was highest at 3rd postoperative day and gradually
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reduced over the following days for the both groups (figure 5). The mean percentage

swelling (table 5) was lower for the PRF group at all time points (p<0.05). Higher bone

healing (lamina dura, bone density, and trabecular pattern) scores were observed

(p<0.001) in both groups (figure 6) at the 16th week as compared to 8th week, but it

was comparatively more for group A on both post-operative 8th and 16th weeks (table

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6). Group A revealed earlier attainment of bone healing. Intraoral periapical radiographs

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of one of the cases illustrate the comparison of bone healing between groups A and B

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(figure 7). Other unfavorable events like dry socket, infection at the surgical site,

septicemia, and prolong trismus were absent at all recall visits. Wound dehiscence was

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present in a total of 4 surgical sites (4/60), 3 (3/60) in group B and 1 (1/60) in group A.

We planned the follow-up visit at postoperative 6th month also which revealed near to
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equal bone healing parameters for groups A and B extraction sockets. Here, our idea

was to observe the evidence of bone healing at its earliest so that PRF can be used
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similarly in the extraction sockets other than M3 to reduce the time interval between
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extractions and implant placement. Therefore, we have not compared the radiographs

taken at the 6th postoperative month.

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Discussion
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Wound healing is an orchestrated complex sequence of physiological and biochemical

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mechanisms at cellular and molecular levels. Usually, extraction sockets take 12 to 16

months for complete healing.31 A minimum of 4 to 6 months of post-extraction time

period is utilized by any extraction socket to receive endosseous prosthetic

rehabilitation like implants.32 Various graft materials are applied in practice to

accelerate the healing phase of extraction sockets among which ―autografts‖ are
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considered as ―gold standard‖. Human blood is the most potent biomaterial ever,

inculcating all the qualities of autologous grafts. Since the 1990s, the recognition of

growth factors in blood, especially in platelets, started a revolutionary era in the field of

regenerative medicine.33 Ross R et al8 were one of the pioneers to explore the growth

potential of platelets. Again in 2001, Choukroun J et al6 developed a new generation of

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platelet concentrate, from the patient’s own blood, and termed it as ―PRF‖. The

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consequent studies of Choukroun J et al10 and Dohan DM et al34 pointed PRF as a major

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combination of WBCs and platelets, responsible for the secretion of various growth

factors. In this study, we have evaluated the healing efficacy of PRF by applying it in

the impacted M3 extraction sockets.

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The results of this study revealed significantly less pain scores and facial

swelling percentages in PRF group (p<0.05) similar to the study conducted by Singh A
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et al2 and Ogundipe OK et al1. During preparation of PRF, the platelets get activated as

soon as they come in contact with the wall of the test tube and begin a massive release
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of their secretions (platelet-specific proteins, non-platelet specific proteins, Ca++,

serotonin, cytokines and growth factors). These platelet products get incorporated into
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the fibrin matrix along with the glycanic chain and play a significant role in modulation
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of inflammation. The α granules of platelets progressively release the cytokines and

growth factors (table 7) in the PRF clot at implanted sites during the remodeling phase
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of fibrin matrix.7 This serves as a suitable justification for the reduced pain, swelling,

and the risk of post-operative infection and inflammation in group A. Moreover, the

WBCs content of PRF provides its immune property despite the fact that PRF contains

fewer WBCs in per unit of blood compared to platelets. Our study also revealed higher

bone healing scores in group A (p<0.001) on the post-operative 8th and 16th week
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radiographs. The earlier attainment of bone density and organized trabecular pattern in

group A were similar to the results of the studies conducted on human2,28 and animal

models35. The accelerated bone healing property of PRF causes faster onset of

mineralization process as early as the 14th day.14,21,24 Sustained and continuous release

of growth factors is responsible for increased quality of newly formed bone35 and

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decreased inflammation induced bone resorption. PRF can be used in the form of a

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membrane, plug, or particles. It can be applied alone or in combination with other bone

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grafts.

Transalveolar extraction is a very common surgical procedure performed for

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patients of all age groups in any population. Post-operative pain and swelling are the
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two most common bothersome factors for patients. The third factor for concern is the

dry socket;36 long considered a nightmare for both patient and the surgeon, but can be
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efficiently managed with PRF application.37 Although the overall complication rates

with transalveolar extraction are low36; but at a larger scale, morbidity becomes
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significant when a large population is considered. To overcome these complications

associated with extractions, Bui CH et al36 advocated the need for a filling material into
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the extraction sockets to stabilize the clot and accelerate tissue healing. The need is
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prudent especially at the infected sites or in the patients with compromised medical

conditions (e.g. diabetes mellitus, immunosuppression, thrombocytopenia etc.) which

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may delay healing.25 Early healing of M3 extraction sockets can be utilized to shorten

the time period between extraction and orthognathic procedures where sagittal split

osteotomies of the mandible are required. PRF has proven its efficacy in the field of

implantology, periodontal surgery, management of periapical lesions, and other bony

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defects. For bony defects, the time taken for complete healing depends on the size of the

defects.

Shivashankar VY et al38 successfully treated a periapical lesion of 15 mm x 16

mm x 16 mm size in relation to teeth 11 and 12 by adding PRF along with

hydroxyapatite crystals and applying PRF membrane over it. Jayalakshmi KB39 et al

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also reported good healing with the application of PRF in a periapical bony defect of 1.4

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cm in relation to teeth 21 and 22. Acceptable results have been documented in the field

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of implantology as PRF reduces the time taken by the implant to osseointegrate, and

outcome was good in sinus lift procedures as well.6,10,32 Platelet-based therapy has also

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been tried in combination with cancellous cellular marrow grafts for reconstruction of
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mandibular defects in animal models which resulted in approximately double the

radiographic maturity and a significantly greater trabecular bone density than those
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without the therapy.40 Further research is required to utilize these advantageous features

of PRF in the oral and maxillofacial domain.

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PRF can be concluded as an ―immunized hemostatic plug‖ which is purely

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autologous and free of any chemical (anticoagulant or gelling agent). It is cost effective,

easy to prepare, and assures early healing. The only disadvantage is its low quantity,
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i.e., 10 ml of blood can produce only 2 ml of PRF. This study proves our hypothesis and
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concludes that PRF assures a good and controlled hard and soft tissue healing in

surgical procedures. It also opens new avenues to conduct further research to evaluate

the practical use of PRF in other oral and maxillofacial surgical procedures; and also to

popularize this simple and low-cost material in routine clinical practice.

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Statement of Clinical Relevance

In this randomized clinical trial, we evaluated the effect of PRF on soft and hard tissue
healing by applying it in the extraction socket of impacted mandibular third molar teeth
after their surgical extraction.

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Lithner, B: Immediate and Delayed Implant Placement Into Extraction Sockets:

A 5‐Year Report. Clinical implant dentistry and related research 2:93, 2000.
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33. Yelamali T, Saikrishna D: Role of Platelet Rich Fibrin and Platelet Rich Plasma
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Med Oral Pathol Oral Radiol Endod 101:e51, 2006.

35. Ozdemir H, Ezirganli S, Isa Kara M, Mihmanli A, Baris E: Effects of platelet

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36. Bui CH, Seldin EB, Dodson TB: Types, Frequencies, and Risk Factors for

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38. Shivashankar VY, Johns DA, Vidyanath S, Sam G. Combination of platelet rich
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inflammatory periapical lesion. J Conserv Dent 16:261, 2013.

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39. Jayalakshmi K. B., Agarwal S, Singh M. P., Vishwanath B. T., Krishna A,

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Agrawal R. ―Platelet-Rich Fibrin with β-Tricalcium Phosphate—A Noval

Approach for Bone Augmentation in Chronic Periapical Lesion: A Case

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40. Fennis, J. P. M., Stoelinga, P. J. W., and Jansen, J. A. Mandibular

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41. Bose B. and Balzarini M. A. Bone graft gel: Autologous growth factors used

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42. Eppley BL, Pietrzak WS, Blanton M. Platelet-rich plasma: a review of biology

and applications in plastic surgery. Plastic and reconstructive surgery 118:147e,

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43. O’Connell SM, Impeduglia T, Hessler K, Wang X-J, Carroll RJ, Dardik H.

Autologous platelet-rich fibrin matrix as cell therapy in the healing of chronic

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46. Toffler M, Toscano N, Holtzclaw D, Corso MD, Ehrenfest DD: JIACD

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the Reconstructive Surgery Milieu. The Journal of Implant & Advanced Clinical
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Dentistry 1:21, 2009.

47. Matras H, Dinges H, Lassmann H, Mamoli B, Zur N: interfaszikularen nerven

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transplantation im tierexperiment, Wein Med. Wochenschr 112, 1972.

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48. Gibble JW, Ness PM: Fibrin glue: the perfect operative sealant? Transfusion

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49. Whitman DH, Berry RL, Green DM: Platelet gel: an autologous alternative to

fibrin glue with applications in oral and maxillofacial surgery. J Oral Maxillofac

Surg 55:1294, 1997

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50. Man D, Plosker H, Winland-Brown JE: The use of autologous platelet-rich

plasma (platelet gel) and autologous platelet-poor plasma (fibrin glue) in

cosmetic surgery. Plast Reconstr Surg 107:229, 2001.

51. H. Schliephake: Bone growth factors in maxillofacial skeletal reconstruction.

Int. J. Oral Maxillofac. Surg 31: 469, 2002.

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53. Bajaj P, Rao NS, Agarwal E, Pradeep AR: Treatment of Intrabony Defect with

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Platelet Rich Fibrin: A Case Report. AOSR 1:90, 2011.

54. Zhang Y, Tangl S, Huber CD, Lin Y, Qiu L, Rausch-Fan X: Effects of

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histological and histomorphometric study. J Craniomaxillofac Surg 40:321,

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55. H Yuasa, T Kawai, M Sugiura: Classification of surgical difficulty in extracting

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impacted third molars. Br J Oral Maxillofac Surg 40:26, 2002.

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Potential of Platelet Rich Fibrin In Dentistry: Literature Review. Asian Journal

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Figure legends

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Figure 1: Immediate centrifugation of blood at 2700 RPM for 12 minutes.

Figure 2: Final product: PRF (Platelet Rich Fibrin).

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Figure 3: PRF in extraction socket of group A.

Figure 4: Post-operative pain scores within the two groups (bar diagram).
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Figure 5: Post-operative swelling scores within the two groups (bar diagram).
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Figure 6: Post-operative bone healing scores within the two groups (bar diagram).
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Figure 7: Comparison of bone healing between groups A and B by intraoral periapical

radiographs.
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Tables

Table 1: Milestones of PRF in the literature

Author Study

Prepared platelet concentrate by centrifugation of fresh venous blood without the

Choukroun J et al
addition of any chemical. The process involved a slow polymerization of fibrin network
(2001)6
very similar to the natural one.
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Quantified growth factors PDGF-BB, TGFβ-1, and cytokine IGF-1 within the platelet
poor plasma (PPP), platelet rich plasma (PRP) and PRF. PDGF-BB and TGFβ-1 were
Dohan DM et al (2006)7 significantly high in PRP, and IGF-1 was higher in PRF. They observed a more
organized incorporation of cytokines and glycanic chain in the fibrin mesh of PRF
giving it a more healing property .

Compared the effect of plasma serum (dialyzed serum prepared from recalcified
platelet-poor plasma) and blood serum (dialyzed serum from clotted blood) on
Ross R et al (1974)8 proliferation of monkey’arterial smooth muscle cells in culture. They observed addition
of platelet and calcium or platelet frees supernatant to plasma serum makes it better
growth promoter.

Mentioned four fundamental events of cicatrization delivered by PRF, namely,

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Dohan DM et al (2006)9 angiogenesis, immune control, circulating stem cells trapping, and wound-covering
epithelialization, which are responsible for uneventful wound healing.

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Observed for bone regeneration in sinus floor elevation using Freeze-Dried Bone
Allograft (FDBA). 6/9 sites were treated with FDBA+PRF and 3/6 sites were treated
Choukroun J et al

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with only FDBA. After 4 months of healing time, histologic maturation of the test
(2006)10
group appears to be identical to that of the control group after a period of 8 months
which gives an idea that with the use of PRF, healing can be reduced to 4 months.

Compared PRF with PRP on technical and histological basis, and concluded that
Sumitha RV &
Munirathnam NE
(2008)11 US
growth factors and bone density were similar in both. But they found the PRF strictly
autologous and free of any biochemical alteration of blood (addition of anticoagulant,
bovine-derived thrombin, and gellifying agents). They observed the PRF preparation
procedure was less time-consuming and cost effective.
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Radiographically evaluated the change in apical bone levels in microthreaded implant
placed in subsinus bone height after sinus floor elevation with PRF as grafting material.
Diss A et al (2008)12 Sufficient bone was observed to resist a torque of 25 N.cm applied during tightening at
healing period of 2-3 months. At 1 year, a new recognizable bone structure delimiting
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the sinus floor and predictable for implant function was identified.

Examined the growth factor released from PRP and PRF in vitro. Blood samples were
collected from 10 patients to prepare PRP and PRF. Human osteoblasts, human
Gassling VL et al
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fibroblasts, and human osteoblast-derived osteosarcoma cells were used for cell culture
(2009)13
and growth factors and were analyzed by ELISA. They concluded the PRP application
in cell cultures led to high level of growth factors than PRF application.

Evaluated the effects PRP and PRF prepared from human blood on proliferation and
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differentiation of rat calvarial osteoblasts in vitro. PRP released the highest amount of
PDGF-AB and TGF-β1 on the 1st day, followed by a significantly decreased release.
PRF had the highest amount of PDGF-AB at day 7 and TGF-β1 at day 14.
He L et al (2009)14
Mineralization was at the peak with PRF exudate culture at day 14, which concluded
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that PRF was a better growth factor than PRP. This was because PRF released
autologous growth factors gradually and expressed stronger and more durable effect on
proliferation and differentiation of osteoblasts.
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Compared the bone healing potentials of PRF with Demineralized Freeze-Dried Bone
Allograft (DFDBA) in dog’s extraction sockets. The sockets were filled with osseous
Simon BI et al (2009)15 new bone by 3 weeks with PRF. But with DFDBA at 6 weeks very little new bone was
present in the sockets and were filled with new bone only at 12 weeks. They concluded
that PRF alone was the best graft material for ridge preservation procedures.

Analyzed the effect of PRF on human gingival fibroblasts, dermal prekeratinocytes,

preadipocytes, and maxillofacial osteoblasts in vitro. Cells were evaluated on days 3, 7,
Dohan DM et al (2009)16 14, and 21, and even 28 days for osteoblasts. PRF induced a significant and continuous
stimulation of proliferation in all cell types. Starting mineralization process was
observed in osteoblasts after 14 days.

Toffler M et al (2010)17
Lucarelli E et al (2010)18
Dohan DM et al (2010)19
Corso MD et al (2010)20
Dohan DM et al (2010)21
Simon BI et al (2011)22
Thorat MK et al (2011)23
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Alhijazi AY &
Mohammed SA (2011)24
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Sammartino G et al
(2011)25
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Triveni MG et al (2012)26
27
Jankovic S et al (2012)
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Placed 138 implants in 110 patients using osteotome-mediated sinus floor elevation
with PRF where the residual subantral bone height of alveolar ridge was 4-8 mm. They
obtained a 2.5-5 mm increase in bone height within 3-5 months. Average functional
loading time of 5.2 months was achieved.
Documented the poor mechanical property of PRP as difficulties in handling and
securing in the implantation site. Otherwise, when released, growth factors could be
washed out during an operation. They compared it with platelet-rich fibrin matrix
(PRFM) with a tear elastic modulus of 937.3 ± 314.6 kPa, stress at a break of 1476.0 ±
526.3 kPa, and an elongation at break of 146.3 ± 33.8 %. PRFM preserved its
mechanical properties throughout the testing procedure.
Microscopically analyzed the cell composition and 3-D organization of PRF clot.
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Approximately 97% of the platelets and >50% of the leukocytes were concentrated in
the PRF clot and showed a specific 3-D distribution. A well matured and dense cluster
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of platelets and fibrin was observed in the first millimeters of the membrane beyond the
red blood cell base.
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Concluded PRF as one of the best autologous inexpensive material which provided
optimized and usable blood clot for healing by early closures of wound margins,
stabilization of graft materials, and protection of surgical site from external aggression.
They found the PRF when mixed with graft materials, it served as biologic cement
between the particles and enhanced neoangiogenesis and bone regeneration.
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Analyzed the in vitro effects of PRF on human bone mesenchymal stem cells (BMSC)
harvested in the oral cavity after preimplant endosteal stimulation. BMSCs from
primary cultures were cultivated with or without a PRF membrane. The scanning
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electron microscope culture analysis was performed at days 3, 7, 14, 21, and 28. Day 14
showed more numerous and more structured mineralization nodules in the PRF group.
Placed PRF matrix in 21 extraction sockets and observed the width resorption by 0.32
mm to 0.57 mm and a mean height resorption by 0.67 mm at the fourth month. Rapid
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clinical healing, minimal flap reopening, and excellent bone density was also evident.
Treated 32 intra-bony defects with autologous PRF or a conventional open flap
debridement alone and compared the effects. They found significantly greater bone fill
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(46.92%), probing depth reduction (4.56 ± 0.37), clinical attachment level gain (3.69 ±
0.44) in the PRF group at the end of 9 months postoperatively.
Extracted maxillary right and left central incisors of 24 rabbits. The left socket was
filled with PRF matrix material and the right socket was left for normal healing as the
control group. Histological examination under light microscopy revealed an
acceleration of bone formation and more rapid healing process at 2 nd, 3rd and 4th week
post-operatively, and radiographically assessed ossification of the socket started by the
second week and was completed by the fourth week in PRF group.
Placed leucocyte-PRF as a hemostatic agent in the extraction sockets of 50 patients
taking oral anticoagulants with the mean INR 3.16 ± 0.39. Patients were treated without
alteration in the anticoagulants dose. 38 patients (76%) showed an adequate hemostasis
while 2 required compression and hemostatic topical agents for few hours and 10
required only mild compression for 2 hours to arrest hemorrhage.
Placed 100% beta tricalcium phospahate (β-TCP) and PRF in extraction sockets of
grade III mobile teeth with periodontal pocket at all surfaces and diffuse periapical
radiolucency. The 10th-day follow-up revealed no pain at the operated site. Complete
soft tissue coverage was revealed on the 14th day. Radiographically, the alveolar socket
appeared to be filled with radiodense bone at the 4th month.
Compared the clinical result found with the use of PRF and connective tissue graft
(CTG) in the treatment of gingival recession. Enhanced wound healing and decreased
subjective patient discomfort were observed in PRF cases. While greater gain in
keratinized tissue width was obtained in the CTG group.
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Conducted a comparative study to evaluate the efficacy of PRF in soft and hard tissue
healing in 20 patients after transalveolar extraction of impacted mandibular 3 rd molars.
Singh A et al (2012)2
They observed less and better soft tissue healing in PRF group. The 3 rd month follow-
up radiograph revealed a comparatively higher bone density level in the PRF group.

Compared the healing of mandibular 3rd molar extraction sockets treated with and
without PRF. They observed better soft tissue healing in PRF at 1 week post-
Rao SG et al (2012)28
operatively. One month, 3 and 6 months post-operative radiographs revealed better
bone healing in the PRF group but it was not statistically significant.

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Table 2: Bone healing criteria

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Scores Description of radiographic observations¥

Lamina dura Bone density Trabecular pattern

+3 Absence of lamina dura US

Significant increase in
density
Well organized trabecular
pattern
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+2 Presence of lamina dura in Comparatively coarser yet not
Moderate increase in density
isolated areas organized trabecular pattern

+1 Thinning of lamina dura, may Presence of some coarse

Mild increase in density
absent at certain areas trabecular pattern
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0 No significant changes No significant changes No significant changes

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-1 Mild thickening of lamina dura Mild decrease in density Very fine trabecular pattern

-2 Moderate to severe thickening of Moderate decrease in

Random trabecular pattern
lamina dura density
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Thickening of lamina dura, Significant decrease in

-3 associated with pathologic density with pathologic Absence of trabeculations
features features
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¥
Qualitative observations are scored in contrast with immediate postoperative radiograph.

Table 3: Distribution pattern of impacted mandibular third molars (M3).

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Age Gender and no. of No. of Impaction pattern

group participants M3
M* H€ V£ D¥
Male 6 12 10 - - 2
18-20
Female 5 10 10 - - -
21-25 Male 2 4 2 - 2 -
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Female 8 16 8 2 6 -
Male 3 6 2 - 4 -
26-30
Female 3 6 2 - 4 -
Male 1 2 - - 2 -
31-35
Female 1 2 2 - - -
Male 1 2 - 2 - -
36-40

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Female 0 0 - - - -

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Total 30 60 36 4 18 2
* € £ ¥
M = mesioangular ; H = horizontal; V = vertical; D = distoangular

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Table 4: Post-operative pain level (Mean ± SD, n=30) of the two groups
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Post-operative
Group A Group B p-value
periods

1st day 20.77 ± 1.74 30.17 ± 2.28 0.001*

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3rd day 11.17 ± 1.70 34.60 ± 2.32 <0.001*

7th day 3.30 ± 0.80 18.90 ± 1.35 <0.001*

14th day 0.73 ± 0.22 9.47 ± 1.12 0.003

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* Highly significant (p<0.001).

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Table 5: Post-operative swelling score (Mean ± SD, n=30) of the two groups

Post-operative
Group A
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periods

1st day 2.41 ± 0.27 4.43 ± 0.32 <0.001*

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3rd day 5.16 ± 0.32 8.80 ± 0.51 <0.001*

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7th day 1.19 ± 0.10 3.55 ± 0.28 <0.001*

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14th day 0.13 ± 0.04 1.49 ± 0.16 0.017

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* Highly significant (p < 0.001).

Table 6: Post-operative bone healing score (Mean ± SD, n=30) of the two groups
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Post- p-value
Bone Group Group (Group
operative A vs.
healing
A B
parameters Group
periods
B)
Lamina 8 wk 1.23 ± 0.40 ± <0.001*
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dura 0.10 0.09

1.80 ± 0.90 ±
16 wk <0.001*
0.07 0.12

p value
<0.001 <0.001 -
(8 wk vs.
16 wk)

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1.23 ± 0.27 ±

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8 wk 0.09 0.08 <0.001*

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1.83 ± 0.63 ±
Bone
16 wk <0.001*
0.07 0.09
density

p value
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<0.001 0.001 -
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(8 wk vs.
16 wk)

1.20 ± 0.30 ±
M

8 wk 0.11 0.09 <0.001*

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Trabecular 1.87 ± 0.50 ±

16 wk <0.001*
pattern 0.06 0.09
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p value
<0.001 0.116 -
(8 wk vs.
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16 wk)
* Highly significant (p<0.001).
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Table 7: Important inflammation modulators secreted by α granules of platelets,

and their mechanism of action.8,14, 28

Inflammation modulators Mechanism of action

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Cytokines
 Stimulates T-helper lymphocytes.
Interlukin-1 (IL-1)
 Along with TNF-α, activates osteoclasts.

 Activation factor for T-lymphocytes.

Interlukin-6 (IL-6)  Differentiation factor for B-lymphocytes.
 Stimulates antibody secretion by B-Lymphocytes.
 Activates monocytes.
Tumor necrosis
 Stimulates remodeling capacity of fibroblasts.
factor-alpha (TNF-
α)  Increases phagocytosis and neutrophil induced cytotoxicity.


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Modulates expression of IL-1 and IL-6.
Growth Transforming

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Factors  Most powerful fibrosis agents.
growth factor-beta 1
 Massive synthesis of collagen and fibronectin.
(TGF-β1)

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Platelet derived  Proliferation of arterial smooth muscle cells in animal models.
growth factor  Regulation of migration, proliferation and survival of mesenchymal
(PDGF) cell lineage.

Vascular endothelial
growth factor
(VEGF)
 US
Promotes angiogenesis.
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Epithelial growth
 Promotes epithelialization.
factor (EGF)
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 Stimulation of cell multiplication.

Insulin like growth
 Induction of survival signaling during apoptosis.
factor (IGF)
 Exerts chemotactic effect towards human osteoblasts.
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