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Use of platelet-rich plasma in the cystic lesions of the jaws: a comparative study

Malik, Altaf H.a; Shah, Ajaz A.a; Tabasum, Rubeenab; Malik, Manzoor A.c

Egyptian Journal of Oral & Maxillofacial Surgery: April 2013 - Volume 4 - Issue 2 - p 27–31
doi: 10.1097/01.OMX.0000428092.16894.95
CLINICAL STUDY
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Background Platelet-rich plasma (PRP) is an autologous source of platelets that is obtained by sequestering and concentrating platelets by gradient density centrifugation. The healing characteristics and hemostatic properties of PRP enable it to support tissues and structures in desired configurations.

Purpose To evaluate the efficacy of PRP in regeneration of bone when mixed with tricalcium phosphate (TCP) in cystic defects of the oral and maxillofacial region and correlate this with that of a TCP graft in the same kinds of defects without PRP.

Materials and methods A comparative nonrandomized study including 30 patients with bony defects of 2–7.4 cm in the maxillofacial region was carried out in the Department of Oral and Maxillofacial Surgery. Patients were divided into two groups: group A received PRP with β-TCP and group B received only β-TCP. Postoperatively, the patients were monitored regularly by radiographs to evaluate new bone growth.

Statistical analysis The Mann–Whitney U-test and odds ratio were used for statistical analysis.

Results The graft dissolution was faster in the PRP group than in the non-PRP group. In the second month, it was 60 versus 40% of the dense–sparse pattern of bone trabeculae. The proportionate difference in the dense trabecular pattern at the sixth month was (73.3–46.7%=26.6%), which is greater than that observed at the 12th month (86.7–80.0%=6.7%), which is indicative of early consolidation, maturation of the graft material, and early osteogenesis.

Conclusion Defects filled with PRP and β-TCP showed comparatively earlier and faster bone regeneration.

aDepartment of Oral and Maxillofacial Surgery, Government Dental College

bDepartment of Ophthalmology, Government Medical College

cDepartment of ENT, Faculty of Medicine, University of Kashmir, Srinagar, Kashmir, India

Correspondence to Altaf H. Malik, MDS, Department of Oral and Maxillofacial Surgery, Sr Resident OMFS Government Dental College, Srinagar, 190010 Kashmir, India Tel: +91 94190 72925; e-mail: drmalikaltaf@gmail.com

Received September 23, 2012

Accepted February 12, 2013

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Introduction

Platelet-rich plasma (PRP) is a centrifugated blood fraction that contains high concentrations of platelets. Platelets contain a number of growth factors, namely, platelet-derived growth factor, transforming growth factor β, insulin-like growth factor, and vascular endothelial growth factor. There are, however, many other factors (e.g. basic fibroblast growth factor, coagulation factors, and vasoactive factors) that probably contribute toward tissue reactions. Surgeons are continually seeking ways to improve the success of bone grafting with either autogenous bone or other bone substitutes 1. PRP was first introduced to the oral surgery community by Whitman et al. in their 1997 article entitled ‘Platelet gel: an autologous alternative to fibrin glue with applications in oral and maxillofacial surgery’ 2.

PRP became increasingly popular in the oral and maxillofacial surgery community after the publication of a landmark article by Marx and colleagues in 1998 3. Marx’s study showed that combining PRP with autogenous bone in mandibular continuity defects resulted in significantly faster radiographic maturation and histomorphometrically denser bone regenerate 3. PRP is an autologous concentration of human platelets in a small volume of plasma. Therefore, the term PRP is preferred to an autologous platelet gel.

Enucleation of cystic lesions leads to bony defects. Many bone substitutes are available, which have advantages and disadvantages. Autologous bone grafts are without doubt the best bone substitutes for patients and can be harvested to fill the defects, but their harvesting is associated with donor-site morbidity and postoperative complications. Many times, sufficient bone volume might not be available for restoration of the bony defects by autologous methods. Because of these reasons, synthetic bone substitutes or grafts were developed, but even these synthetic materials have limitations in terms of the restoration of the continuity of the bony defect. Since antiquity many synthetic grafts have been used to fill the bony defects of the oral and maxillofacial region. PRP is autologous and does not elicit any significant immunological response and does not pose the risk of transmissible diseases such as HIV, hepatitis B, hepatitis C, etc. The aim of this study is to study the efficacy of PRP in wound healing and its advantage in bone regeneration.

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Patients and methods

The study was carried out as a comparative nonrandomized study in the Department of Oral and Maxillofacial Surgery, Government Dental College, Srinagar. Thirty patients were enrolled for the study after all the clinical and histological examinations were carried out. Patients with cystic defects ranging from 2 to 7.4 cm in size were studied. All patients with underlying systemic compromise were excluded from the study. Patients were divided into two groups: group A received PRP with a tricalcium phosphate (TCP) mixture, whereas group B received only TCP. Formal consent was obtained from the patients. The assessment criteria used postoperatively to assess the outcome of treatment were pain, swelling, infection, graft rejection, and radiographic interpretations of the trabecular pattern of bone in the first-, second-, sixth-, and 12th-month follow-up.

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Surgical procedure

The surgical procedure was planned under local anesthesia or general anesthesia depending on extension of the lesion and patient factors. Standard draping procedures were used for the patient and part preparation was carried out. A standard incision was used to raise the full-thickness mucoperiosteal flap and access to the lesion was gained. Full enucleation of the lesion was performed. The root canal treatment was performed wherever indicated and the defect left was filled with an equal volume of PRP and graft in GP-A and only with a graft in the case of GP-B. The graft used was β-TCP. The small pore size of the graft of 0.4–1.7 μm prevents migration of pluripotent cells. The replacement of TCP to bone is dependent on the osteoclastic and osteoblastic matrix remodeling kinetics of the host wound. TCP has a stoichiometry similar to that of amorphous biologic precursors to bone. It acts as an osteoconductive scaffold and is highly biocompatible. Proper closure of the defect was performed after hemostasis was achieved. A layerwise closure was carried out wherever needed. All the patients were administered intravenous antibiotics in the form of augmentin 1.2 g intravenously three times daily for 3 days, followed by oral augmentin 625 mg for 4 more days. A stat dose of 8 mg dexona (intravenously) and vovern (intramuscularly) was administered. Suture removal was performed on the seventh day.

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Preparation of platelet-rich plasma

PRP was prepared using the centrifuge. Patients’ blood was drawn from the antecubital area and was dispensed into 10 ml vacutainer tubes [Becton, Dickinson and Company (BD); Franklin Lakes, New Jersey, USA] containing a citrate phosphate dextrose solution (1.5 ml). The contents in the vacutainer tubes were mixed well before they were placed in the centrifuge. Centrifugation was performed for 20 min at 5600 rpm. This resulted in a separation of whole blood into a lower red blood cell region and an upper straw-colored plasma region. A relatively high concentration of platelets was found in the boundary layer between these two regions (buffy coat). The upper straw-colored plasma layer (platelet poor plasma) and 1–2 mm of the top part of the red blood cell layer along with buffy coat were aspirated with a micropipette and transferred into another container (sterile plan vacutainer) and again centrifuged for 10 min at 2400 rpm. This resulted in an upper portion of a clear yellow supernatant serum containing fibrinogen and a very low concentration of platelets and a bottom red-tinged layer consisting of highly concentrated platelet-rich plasma. The liquid was drawn out of the tube with a 5 ml syringe and a 63 mm blunt needle until the syringe drew air. This left ∼1.5 ml of serum and concentrated platelet-rich plasma in the tube. The remaining contents were mixed thoroughly and expressed out. The contents of the tube were mixed well and transferred into another sterile plan vacutainer tube. At the time of the application, the PRP was combined with an equal volume of a sterile saline solution containing 10% calcium chloride and sterile bovine thrombin (an activator that allows polymerization of the fibrin into an insoluble gel, which causes the platelets to degranulate and release the indicated mediators and cytokines). This resulted in the formation of a sticky gel that was relatively easy to apply to the surgical defects along with the synthetic porous graft material. Sufficient volume of blood was drawn depending on the size of the defect. PRP (0.2 ml) can be prepared from 10 ml blood. The ratio of graft and PRP was maintained constant, that is, to every 2 ml of PRP, 2 cm3 of graft was mixed: the amount of graft and volume of blood required depended on the size of the defect. The assessment criteria used were as follows:

  • Painon a scale of 1–10 assessed by the visual analogue scale method.
  • Swelling (present/absent).
  • Infection (present/absent).
  • Graft rejection (present/absent).
  • Radiographic interpretations were performed using Christina Lindh analysis (dense/dense sparse/sparse) in the first, second, sixth, and 12th month. The data were entered into a master chart and subjected to statistical analysis using the Mann–Whitney U-test and odds ratio (OR).
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Results

The study showed that there was less swelling in the PRP group. The OR of 5.1 (Table 1) at the 1-week follow-up period showed a higher risk of swelling in group B (the non-PRP group). The results also showed less pain in the PRP group than in the non-PRP group. Pain was significantly less, with a P value 0.058 at 1 week in the follow-up period, and pain reduced significantly in the follow-up period in both the groups (Table 2). The risk of infection at the 1-month follow-up was greater in the non-PRP group along with a greater risk of graft rejection with an OR of 2.1 after the 1-week follow-up (Table 3). The trabecular pattern on radiographic analysis showed more favorability for bone deposition in the PRP group with a dense pattern of trabeculae 73.3% at the sixth month and 86.7% at the 12th month of follow-up (Table 4). The graft dissolution was faster in the PRP group than in the non-PRP group. At the second month, it was 60 versus 40% of the dense–sparse pattern of bone trabeculae. The proportionate difference in the dense trabecular pattern in the 6-month period was (73.3–46.7%=26.6%),which is greater than that observed at the 12th month (86.7–80.0%=6.7%), which is indicative of early consolidation, maturation of the graft material, and early osteogenesis.

Table 1

Table 1

Table 2

Table 2

Table 3

Table 3

Table 4

Table 4

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Discussion

Platelet gel can act as a wound sealant and dural waterproofing agent. The presence of platelets and leukocytes leads to hemostatic and antimicrobial support, thereby reducing dehiscence and infection in the graft 4. In our study, pain was present in both the groups at the 1-week follow-up. In group A, only 46.7% of patients had pain compared with 80% of patients in group B. There was no pain at 1 month until the 12-month follow-up in both the groups. Pain reduction in both the groups was significant at follow-up (P=0.000). Our observation was in accordance with the study of Anitua 5,6, Man et al. 7, and Gilberto etal. 8,9, who found that there was a reduction in pain and swelling in the PRP group of patients postoperatively. This finding was also consistent with that of Mancuso et al. 10, who found a lower rate of osteitis and pain postoperatively in the patients in the PRP group.

The swelling of the patients in group A was less (73.3%) than that of the patients in group B (93.3%), and reduced significantly in the follow-up period in both the groups (P=0.000). In group B, one patient developed an infection. There was significant swelling in the patients in group B at 1 week and the reduction in swelling until the 12-month follow-up period was significant in the rest of the patients, almost similar to group A. There was about a 5.1-fold greater risk of swelling in group B (OR=5.1) and less probability of swelling in group A. The same finding was also reported by Anitua 5 and Fennis et al. 11, who evaluated the modulation of wound healing and soft tissue ingrowths in synthetic and allogenic implants with platelet gel. This finding is also in agreement with that of Man et al. 7, who reported that PRP is very effective in stopping capillary bleeding and aids hemostasis and wound healing, thereby reducing the postoperative swelling.

The healing was uneventful and there was no graft rejection in group A, whereas there was graft rejection in one patient in group B. At 1 week, the OR was 2.1, which indicates a higher risk of infection in group B. About 6.7% of the patients in group B developed an infection. This finding was in agreement with that of Green and Klink 4, who found that the platelet gel acts as a wound sealant and dural waterproofing agent and the presence of platelets and leukocytes leads to hemostatic and antimicrobial support, thereby reducing dehiscence and infection in the graft.

The radiological findings showed that the dense trabecular pattern was present in a higher percentage of patients at the 12th-month follow-up in group A (86.7%) than group B (80%), which shows that bone deposition was higher and faster in group A than in group B. This is in agreement with the observation of Lee et al.12, who concluded that at the 12-month follow-up, bone density was greater in the PRP group than in the non-PRP group in their study of alveolar clefts grafted with bone and PRP. At the 1-month follow-up, the dense–sparse pattern appeared earlier in group A (13.3%) compared with group B (6.7%). At 2 months, the dense–sparse pattern was present in a higher percentage of patients in group A (60.0%) compared with group B (40.0%), which shows that the dissolution of the graft and uptake of graft or graft maturity was higher in group A. This is almost in agreement with the study of Aghaloo et al.13. Aghaloo et al.13 observed increased tendency of bone formation at 1 and 2 months in his study on rabbit cranial defects and he observed histomorphometric and radiographic tendency toward increased bone formation with PRP 3. The decreased density of grafted material at 2 months in our study and increase in the dissolution of grafted material are in agreement with the observation of Lee et al.12, who observed a rapid decrease in the density of grafted bone in the early postoperative period and concluded that PRP may lead to higher bone density in the long postoperative period. Our findings at 1 and 2 months were in agreement with those of Kim et al., who studied the use of Bio-Oss and PRP in cranial defects and observed increased bone density on plain radiographic and computed tomography scans 14. In our study, at 1 month, the dense pattern was found in 80.0% of patients in group A compared with 86.7% of patients in group B. The same observation was made by Gerard et al. 15, who found that at 1 month, the non-PRP grafts were more dense compared with PRP grafts (P<0.05).

The higher density at 1 month is because of the graft material, but the value is less in group A which indicates early dissolution of the graft material, in agreement with the study of Lee et al.12. Dense–sparse pattern was more in group A at 1 month (13.3%) and 2 months (60%) compared with group B, in which it was 6.7 and 40% at 1 and 2 months, respectively, which indicates early takeup of graft and its early dissolution in group A compared with group B. We observed, in the second month, sparse pattern was maximum in group B (33.3%) compared with group A (13.3%), indicating more favourability for bone formation in group A. This indicates that PRP enhances new bone formation by its early healing potential 15. The same observations, in terms of radiographic changes in the grafts from radio-opacity to radiolucency, with radiolucency indicating new bone formation, have been reported by Silva et al.16. Kanno et al.17 also observed that PRP exerts a favorable effect on human osteoblast-like cells and acts both to enhance bone regeneration and as an activator in wound healing.

At the sixth-month follow-up, the dense pattern was present in a higher percentage of patients in group A (73.3%) compared with group B (46.7%) in contrast to the sparse pattern, which was more in group B (33.3%) compared with group A (6.7%), which shows that bone maturation was faster in the patients in group A in comparison with the patients in group B. This is almost in agreement with the study of Marx et al. 3 on mandibular continuity defects that were grafted with autogenous bone with PRP and autogenous bone without PRP. A maturity index of about 1.62 was obtained in his study, with a P value 0.001. The increased trabeculation with PRP is in agreement with the observation of Weibrich et al. 18 in their in-vitro studies 19.

In our study, the dense pattern was more in group A at 6 and 12 months than in group B. The proportionate difference in the dense trabecular pattern between group A and group B at 6 months (73.3–46.7%=26.6%) is higher compared with 12 months (86.7–80%=6.7%); this indicates that PRP plays an early role in bone formation and induces earlier maturation of the graft 3.

The clinical and radiographic interpretations in our study conclude that the defectsthat were filled with a PRP+TCP graft combination healed faster compared with the defects filled with a TCP graft alone.

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Conclusion

The following conclusions can be drawn from our study on the use of PRP in cystic bony defects of the maxillofacial region.

PRP is autologous and does not induce any significant immunological response and does not pose a risk of transmissible diseases such as HIV, hepatitis B, hepatitis C, etc. PRP improved the handling characteristics of the graft. PRP promoted early consolidation of the graft. PRP promoted earlier maturation of the graft. PRP improved trabecular bone density. PRP provides earlier availability of growth factors and thereby enhances the osteoconductive properties of the graft.

Therefore, PRP, when combined with a graft, is superior in comparison with the plain graft used in filling bony defects of oral and maxillofacial regions.

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Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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References

1. Turvey FM Oral & Maxillofacial Surgery.2nd ed. St Louis, Missouri The WB Saunders, Elsevier:501–510
2. Issa JPM, Tiossi R, Mello ASDS, Lopes RA, Di Matteo MAS, Iyomasa MM. PRP: a possibility in regenerative therapy. Int J Morphol. 2007;25:587–590
3. Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;85:638–646
4. Green DM, Klink B. Platelet gel as an intraoperatively procured platelet-based alternative to fibrin glue. Plast Reconstr Surg. 1998;101:1161–1162
5. Anitua E. Plasma rich in growth factors: preliminary results of use in the preparation of future sites for implants. Int J Oral Maxillofac Implants. 1999;14:529–535
6. Von Lindern JJ, Niederhagen B, Appel T, Berg S. Investigation of platelet-rich plasma in rabbit cranial defects: a pilot study. J Oral Maxillofac Surg. 2002;60:1176–1181
7. Man D, Plosker H, Windland-Brown JE, Saltz R. The use of autologous platelet-rich plasma (platelet gel) and autologous platelet-poor plasma (fibrin glue) in cosmetic surgery. Plast Reconstr Surg. 2001;107:238–239
8. Gilberto S, Mariano T. Use of autologous platelet-rich plasma (PRP) in periodontal defect treatment after extraction of impacted mandibular third molars. J Oral Maxillofac Surg. 2005;63:766–770
9. Sammartino G, Tia M, Marenzi G, Espedito Di Lauro A, D’Agostino E, Claudio PP. Use of autologous platelet-rich plasma (PRP) in periodontal defect treatment after extraction of impacted mandibular third molars. J Oral Maxillofac Surg. 2005;63:766–770
10. Mancuso JD, Bennion JW, Hull MI. PRP. A preliminary report on routine impacted mandibular third molar surgery and the prevention of alveolar osteitis. J Oral Maxillofac Surg. 2003;61:40
11. Fennis JPM, Stoelinga PJW, Jansen JA. Reconstruction of the mandible with an autogenous irradiated cortical scaffold, autogenous corticocancellous bone-graft and autogenous platelet-rich-plasma: an animal experiment. Int J Oral Maxillofac Surg. 2005;34:158–166
12. Lee C, Nishihara K, Okawachi T, Iwashita Y, Majima HJ, Nakamura N. A quantitative radiological assessment of outcomes of autogenous bone graft combined with platelet-rich plasma in the alveolar cleft. Int J Oral Maxillofac Surg. 2009;38:117–125
13. Aghaloo TI, Moy P, Freymiller EG. Investigation of platelet-rich plasma in rabbit cranial defects: a pilot study. Int J Oral Maxillofac Surgery. 2002;60:1176–1181
14. Freymiller EG, Aghaloo TL. Platelet-rich plasma: ready or not? J Oral Maxillofac Surg. 2004;62:484–488
15. Gerard D, Carlson ER, Gotcher JE, Jacobs M. Effects of platelet-rich plasma on the healing of autologous bone grafted mandibular defects in dogs. J Oral Maxillofac Surg. 2006;64:443–451
16. Silva RV, Camilli JA, Bertran CA, Moreira NH. The use of hydroxyapatite and autogenous cancellous bone grafts to repair bone defects in rats. Int J Oral Maxillofac Surg. 2005;34:178–184
17. Kanno T, Takahashi T, Tsujisawa T, Ariyoshi W, Nishihara T. Platelet-rich plasma enhances human osteoblast-like cell proliferation and differentiation. J Oral Maxillofac Surg. 2005;63:362–369
18. Weibrich G, Hansen T, Kleis W, Buch R, Hitzler WE. Effect of platelet concentration in platelet rich plasma on preimplant bone regeneration. Bone. 2004;34:665–671
19. Anitua E, Sánchez M, Nurden AT, Nurden P, Orive G, Andía I. New insights into and novel applications for platelet-rich fibrin therapies. Trends Biotechnol. 2006;24:227–234
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