Acta Odontologica Scandinavica

ISSN: 0001-6357 (Print) 1502-3850 (Online) Journal homepage: http://www.tandfonline.com/loi/iode20

Platelet rich fibrin combined with decalcified

freeze-dried bone allograft for the treatment
of human intrabony periodontal defects: a
randomized split mouth clinical trail

Ashish Agarwal, Narinder Dev Gupta & Avikal Jain

To cite this article: Ashish Agarwal, Narinder Dev Gupta & Avikal Jain (2016) Platelet rich fibrin
combined with decalcified freeze-dried bone allograft for the treatment of human intrabony
periodontal defects: a randomized split mouth clinical trail, Acta Odontologica Scandinavica,
74:1, 36-43, DOI: 10.3109/00016357.2015.1035672

To link to this article: http://dx.doi.org/10.3109/00016357.2015.1035672

Published online: 14 May 2015.

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 Acta Odontologica Scandinavica. 2016; 74: 36–43

ORIGINAL ARTICLE

Platelet rich fibrin combined with decalcified freeze-dried bone allograft

for the treatment of human intrabony periodontal defects: a randomized
split mouth clinical trail

ASHISH AGARWAL1, NARINDER DEV GUPTA2 & AVIKAL JAIN1

1
Deparment of Periodontics, Institute of Dental Sciences, Bareilly, India, and 2Department of Periodontics, Dr. Z. A.
Dental College, Aligarh, India
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Abstract
Objective. Polypeptide growth factors of platelet rich fibrin (PRF) have the potential to regenerate periodontal tissues.
Osteoinductive property of demineralized freeze-dried bone allograft (DFDBA) has been successfully utilized in periodontal
regeneration. The aim of the present randomized, split mouth, clinical trial was to determine the additive effects of PRF with a
DFDBA in the treatment of human intrabony periodontal defects. Materials and methods. Sixty interproximal infrabony
defects in 30 healthy, non-smoker patients diagnosed with chronic periodontitis were randomly assigned to PRF/DFDBA
group or the DFDBA/saline. Clinical [pocket depth (PD), clinical attachment level (CAL) and gingival recession (REC)] and
radiographic (bone fill, defect resolution and alveolar crest resorption) measurements were made at baseline and at a 12-month
evaluation. Results. Compared with baseline, 12-month results indicated that both treatment modalities resulted in significant
changes in all clinical and radiographic parameters. However, the PRP/DFDBA group exhibited statistically significantly
greater changes compared with the DFDBA/saline group in PD (4.15 ± 0.84 vs 3.60 ± 0.51 mm), CAL (3.73 ± 0.74 vs 2.61 ±
0.68 mm), REC (0.47 ± 0.56 vs 1.00 ± 0.61 mm), bone fill (3.50 ± 0.67 vs 2.49 ± 0.64 mm) and defect resolution (3.73 ±
0.63 vs 2.75 ± 0.57 mm). Conclusion. Observations indicate that a combination of PRF and DFDBA is more effective than
DFDBA with saline for the treatment of infrabony periodontal defects.

Key Words: Chronic periodontitis, intrabony defect, periodontal regeneration, platelet rich fibrin

Introduction approach to deliver high concentrations of PGFs to

periodontal surgical wounds [5,6].
Various regenerative modalities have been investi- Recent studies examining the effectiveness of
gated for the management of intrabony periodontal PGFs, used alone or in combination with other
defects, e.g. Bone grafts (BG) and substitutes, guided materials and techniques, have been conducted
tissue regeneration, growth factors, enamel matrix with autologous platelet-rich plasma (PRP) [7–9],
derivatives and combined approaches [1]. Decalcified recombinant platelet-derived growth factor [10,11]
freeze-dried bone allograft (DFDBA) contains and platelet rich fibrin (PRF) [12,13]. Among platelet
bone morphogenetic proteins (BMPs) that aid in concentrates, PRF belongs to a group of second-
mesenchymal cell migration, attachment and osteo- generation blood autologous preparations that was
genesis; have both osteoinductive as well as osteocon- originally described by Choukroun et al. [14]. The
ductive activity and the ability to create and maintain PRF preparation process creates a gel like matrix
the space. DFDBA has been proposed as an effective that contains high concentrations of non-activated,
regenerative material for osseous defects [2–4]. functional, intact platelets contained within a fibrin
Polypeptide growth factors (PGFs) revealed a matrix that release a relatively constant concentration
potential application in wound healing by promoting of growth factors over a period of 7 days [15,16].
periodontal regeneration via cell proliferation, angio- Dohan Ehrenfest et al. [17,18] demonstrated that
genesis, chemotaxis and differentiation. Autologous PRF induced a significant and continuous stimulation
blood concentrates constitute a safe and convenient and proliferation of human primary cultures of

Correspondence: Dr Ashish Agarwal, Senior Lecturer, Department of Periodontics, Institute of Dental Sciences, Pilibhit Bypass Road, Bareilly 243006, India.
Tel: +91 94 5344 2418. E-mail: [email protected]
(Received 17 November 2014; accepted 25 March 2015)

ISSN 0001-6357 print/ISSN 1502-3850 online
2015 Informa Healthcare

DOI: 10.3109/00016357.2015.1035672
 Platelet rich fibrin in intrabony defect 37

gingival fibroblasts, dermal pre-keratinocytes, pre- weeks following phase I therapy, a periodontal
adipocytes and maxillofacial osteoblasts. re-evaluation was performed to confirm the suitability
Keeping the above facts in mind, the addition of of the sites for this periodontal surgical study. The
PRF to DFDBA may enhance periodontal regenera- study used a split-mouth design, in which two inter-
tion as compared with those sites treated with BG proximal sites were randomly (toss of a coin, per-
alone. At present, to the authors’ knowledge, there are formed by the study therapists) assigned to the
very few published clinical controlled trials on PRF DFDBA with saline or DFDBA with the PRF group.
that compare the results of PRF with DFDBA to the One operator (AA) performed all the surgeries,
outcomes of DFDBA alone in the treatment of infrab- whereas another operator (NDG) performed all the
ony periodontal defects. Therefore, the present study clinical and radiographic measurements without
was conducted for testing the hypothesis that PRF knowledge of the groups.
would augment the regenerative effects of DFDBA in
human intrabony defects.
Pre-surgical clinical measurements
Materials and methods Clinical parameters recorded before the surgical pro-
cedures and at 12 months post-operatively included
Thirty-two pairs of infrabony periodontal defects in
PD [measured from the gingival margin to the base of
32 patients (18 men and 14 women, mean age = 52 ±
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the pocket (tip of the probe in the pocket)], clinical

7 years), suffering from moderate-to-severe chronic
attachment level (CAL), measured from the cemen-
periodontitis, were selected for the study at the out-
toenamel junction (CEJ) to the base of the pocket (tip
patient Department of Periodontics, Dr Z. A. Dental
of the probe in the pocket) and gingival recession
College, Aligarh, India. The study was conducted
(REC, measured from the CEJ to the level of the
from April 2010 to January 2013. The research was
gingival margin), using customized acrylic stents with
designed as a randomized, double-blinded, parallel,
grooves to ensure a reproducible placement of the
controlled clinical trial that employed a split-mouth
University of North Carolina no. 15 (UNC-15, Hu
design for the comparison of periodontal outcomes
Friedy, Chicago, IL) periodontal probe. Plaque index
using DFDBA/saline and DFDBA/PRF preparation
(PI) [19] and modified sulcus bleeding index (mSBI)
in the treatment of intrabony periodontal defects.
[20] were also measured.
The inclusion criteria were the presence of a
matched pair of interproximal, intrabony defects
with probing depth (PD) ‡ 6 mm when evaluated Radiological assessments
8 weeks after phase I therapy with defect depth
‡ 4 mm, in asymptomatic posterior teeth. Osseous Pre-operatively and 12 months post-operatively,
defects needed to have two and/or three walls. The intra-oral standardized radiographs were taken for
plaque and gingival indices, associated with interested the evaluation of radiographic bone level (RBL) using
tooth, achieved following re-evaluation of initial ther- the paralleling technique and an individual film
apy had to be £ 1. Radiographic evidence of intrabony holder consisting of a bite block rigidly connected
defects had to exist as revealed by periapical films to an acrylic dental splint to achieve identical film
taken with the long-cone parallel technique. The placement at each evaluation. The differences
exclusion criteria for the study were the presence of between pre- and post-operative RBL measurements
any systemic disease, patients taking any medication, were considered as the radiographic bone loss/gain.
pregnancy or lactation, smokers, previously treated Radiographic measurements were done as (1)
for periodontal reasons, one-wall defects and furca- distance from the CEJ to the deepest point of the
tion involvement. vertical bone defect (BD), (2) distance from the CEJ
The study protocol, risks, benefits and procedures to the alveolar crest (AC) and (3) distance from
were explained and written informed consent was the AC to BD (Figures 1 and 2). Measurements
obtained from every patient. The study was approved were obtained utilizing an adhesive millimeter grid
by the ethical committee of Dr Z. A. Dental College, (Meyer-Haake, Oberursel, Germany).
Aligarh and all the examinations, treatment and pro- The most coronal area where the periodontal
cedures of this study followed the Declaration of ligament (PDL) maintained an even width was iden-
Helsinki of 1975, as revised in 2000. tified to measure the most apical extension of the
defect. The crossing of the silhouette of the alveolar
Initial therapy crest with the root surface was defined as the alveolar
crest. The differences between 12-month and baseline
Initial therapy consisted of detailed instructions values of CEJ-BD indicated the amount of bone fill.
regarding proper oral hygiene measures followed by The differences between CEJ-AC and AC-BD were
full mouth scaling and root planing using hand and identified as the amount of crestal bone resorption
ultrasonic instruments under local anesthesia. Eight and as the resolution of intrabony defect, respectively.
 38 A. Agarwal et al.

possible. Complete debridement of the defects, as

well as scaling and root planing to ensure root
smoothness, were achieved with the use of an ultra-
sonic device and hand instruments.
DFDBA (LifeNet Health, Virginia Beach, VA) was
mixed with PRF or saline at a proportion of 1:1 (v/v)
and filled into the defect to the same level as the most
coronal existing bony defect wall during the surgical
procedures according to treated group. Care was
taken not to overfill defects. A membrane of com-
pressed PRF was trimmed and adapted over the
grafted defects in both of the groups. Membranes
were extended over the periphery of the defect in
the buccal and lingual directions and secured in place
using 5–0 gut sutures anchored to the adjacent teeth.
Figure 1. Pre-operative radiograph.
Flaps in both groups were repositioned and sutured
PRF preparation with 3–0 non-absorbable black silk surgical suture
(Ethicon, Johnson & Johnson, Somerville, NJ) using
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The PRF was produced according to the protocol an interrupted technique (Figures 3, 4, 5 and 6).
developed by Choukroun et al. [14]. On the day of Periodontal dressing was placed over the surgical
surgery, 10 ml of blood was drawn from each patient area; 500 mg amoxicillin, three times daily for
by venipuncture of the antecubital vein. Blood was 7 days; 800 mg ibuprofen, three times daily were
collected in a sterile glass test tube without any anti- prescribed, along with chlorhexidine digluconate
coagulant. The test tube was immediately centrifuged (CHX) rinses (0.12%) twice daily for 2 weeks.
using a refrigerated centrifugal machine at 400 g for
12 min. Because of differential densities, it resulted in Post-operative follow-up care
the separation of three basic fractions: a base of red
blood cells at the bottom, acellular plasma on the Periodontal dressing and sutures were removed
surface and, finally, a PRF clot between the two. The 2 weeks post-operatively. Surgical wounds were
top layer was pipetted out with the sterile dropper; the gently cleansed with 0.2% CHX on a cotton swab.
middle layer (PRF) was removed and placed in a Thereafter, gentle brushing with a soft toothbrush was
sterile dappen dish. This clot was either minced recommended. At 8 weeks post-operatively, each
into small pieces and mixed with graft material or patient was reinstructed about proper oral hygiene
pressed between two sterile compresses to obtain a measures. Patients were examined weekly for 1 month
membrane. after surgery and then at 3, 6 and 9 months. Post-
operative care included reinforcement of oral hygiene
and mechanical plaque control whenever necessary.
Surgical procedure

Following administration of local anesthesia, buccal Post-surgical measurements

and lingual sulcular incisions were made and the
mucoperiosteal flaps were elevated. Care was taken PI, SBI, PD, CAL and REC were recorded 12 months
to preserve as much inter-proximal soft tissue as after the initial surgery. Soft tissue measurements
were repeated with previously used acrylic stents.
A second IOPA (after 12 months) of the same treated
sites was taken and radiographical measurements
were performed from the baseline and 12-month
radiographs.

Primary and secondary outcome measures

The primary outcome measure of the study was CAL

gain and secondary outcomes included PD, defect
resolution, bone fill, PI and mSBI.

Statistical analysis

The results were averaged (mean ± SD) for each

Figure 2. 12 months post-operative radiograph. clinical and radiographic parameter at baseline and
 Platelet rich fibrin in intrabony defect 39

Table I. Demographical data of the study. Table II. Clinical and radiographic measurements (in mm;
mean ± SD) at baseline and 12 months (n = 30 for DFDBA/saline
Characteristics DFDBA with DFDBA with
and PRF/DFDBA group).
PRF (30 sites in saline (30 sites in
15 patients) 15 patients) Baseline 12 months Change p-value

Male 10 7 DFDBA/saline group

Female 5 8 PPD 7.12 ± 0.78 3.52 ± 0.79 3.60 ± 0.51 < 0.001*
Osseous wall CAL 8.18 ± 0.99 5.57 ± 1.17 2.61 ± 0.68 < 0.001*
3 wall defects 7 9 REC 1.07 ± 0.41 2.07 ± 0.86 –1.00 ± 0.61 < 0.001*
2 wall defects 6 3 CEJ-AC 4.03 ± 1.21 4.30 ± 1.30 –0.26 ± 0.25 < 0.001*
Combined 2 and 17 18 AC-BD 5.20 ± 0.71 2.45 ± 0.63 2.75 ± 0.57 < 0.001*
3 wall defects
CEJ-BD 9.23 ± 1.30 6.75 ± 1.28 2.49 ± 0.64 < 0.001*
Teeth treated
PI 0.62 ± 0.22 0.58 ± 0.23 0.03 ± 0.10 < 0.001*
Mandibular premolars 3 4
BOP 0.95 ± 0.27 0.89 ± 0.30 0.07 ± 0.15 0.02
Maxillary premolars 8 8
PRF/DFDBA group
Maxillary molars 10 8
PPD 7.13 ± 0.88 2.98 ± 0.46 4.15 ± 0.84 < 0.001*
Mandibular molars 9 10
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CAL 8.18 ± 1.04 4.45 ± 0.80 3.73 ± 0.74 < 0.001*

REC 1.05 ± 0.46 1.52 ± 0.60 –0.47 ± 0.56 < 0.001*
12 months. The difference between each pair of CEJ-AC 4.17 ± 1.29 4.40 ± 1.34 –0.23 ± 0.25 < 0.001*
measurements was calculated (baseline–12 months). AC-BD 5.32 ± 0.69 1.58 ± 0.49 3.73 ± 0.63 < 0.001*
The paired t-test was applied to assess the statistical CEJ-BD 9.50 ± 1.29 6.00 ± 1.15 3.50 ± 0.67 < 0.001*
significance between time points within each group for
PI 0.63 ± 0.20 0.60 ± 0.24 0.03 ± 0.11 < 0.001*
the clinical and radiographic parameters. Inter-group
BOP 1.01 ± 0.27 0.98 ± 0.26 0.03 ± 0.08 0.03
comparison was made by unpaired t-test. The Chi-
square test was used for the assessment of frequency *p < 0.001; highly significant.
distribution between groups. Statistical significance
was set at p < 0.05. Power calculations were performed
before the study was initiated. To achieve a 90% power resorption, PI and BOP were determined in DFDBA +
and detect mean differences of 1 mm for clinical PRP (Table III).
parameters (PD, CAL, bone fill) between groups, The frequency distribution table (Table IV) shows
25 sites per group were required. The mean intra- more CAL gain and bone fill for the PRF associated
examiner standard deviation of differences in repeated group than the DFDBA with saline. For PRF/
PD measurements and CAL measurements was
obtained using single passes of measurements with a
periodontal probe (correlation coefficients between Table III. Inter-group comparison of clinical and radiographical
duplicate measurements; r = 0.95). parameters (mean ± SD) from baseline to 12 months after
treatment.

Results DFDBA/saline PRF/DFDBA p-value

(changes in (changes in
12 months) 12 months)
A total of 30 of 32 patients completed the study, while
two patients (four sites) did not return for follow-up Mean Mean Mean
examinations. The type and number of teeth and
bone defects evaluated are shown in Table I. Over PPD 3.60 ± 0.51 4.15 ± 0.84 < 0.05**
the course of the study, there were no infectious CAL 2.61 ± 0.68 3.73 ± 0.74 < 0.001*
episodes and no other adverse complications in any REC –1.00 ± 0.61 –0.47 ± 0.56 0.001*
treatment site. During the study period the oral CEJ-AC –0.26 ± 0.25 –0.23 ± 0.25 0.613NS
hygiene level and the number of bleeding sites (–6.8 ± 7.6)% (–6.4 ± 9.9)%
remained stable or improved with respect to the AC-BD 2.75 ± 0.57 3.73 ± 0.63 < 0.001*
values detected at baseline. (53.0 ± 8.5)% (70.3 ± 8.3)%
At the 12-month examination (Table II) statistically CEJ-BD 2.49 ± 0.64 3.50 ± 0.67 < 0.001*
significant treatment effects were observed in both (27.2 ± 7.3)% (37.2 ± 7.1)%
groups in terms of clinical and radiographical para- PI 0.03 ± 0.10 0.03 ± 0.11 0.885NS
meters (p < 0.001). On inter-group comparison, there
BOP 0.07 ± 0.15 0.03 ± 0.08 0.320NS
was a statistically significant greater PPD reduction,
CAL gain, REC, defect resolution and bone fill; while **p < 0.05; significant; *p < 0.001; highly significant.
there was a non-significant reduction in alveolar crest NS, non-significant.
 40 A. Agarwal et al.

Table IV. Frequency distribution of clinical attachment gain and

bone fill.
CAL change Control group n (%) Test group n (%)

£ 2 mm 10 (33.3%) —
> 2–3 mm 14 (46.7%) 9 (30%)
> 3–4 mm 6 (20%) 14 (46.7%)
> 4 mm — 7 (23.3%)
CEJ-BD change (bone fill)
£ 2 mm 11 (36.7%) —
> 2–3 mm 16 (53.3%) 12 (40%)
> 3–4 mm 3 (10%) 14 (46.7%)
> 4 mm — 4 (13.3%)

careful patient selection was also responsible for the

positive outcomes obtained in both groups.
DFDBA, most of the sites [14 (46.7%), seven
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Outcomes of this clinical trial have suggested that

(23.3%)] showed > 3–4 mm and > 4 mm of CAL
both treatment groups presented with significant
gain. For DFDBA/saline, 14 (46.7%) and seven
improvement in clinical and radiographical para-
(23.3%) sites observed > 2–3 mm and > 3–4, respec-
meters between baseline and 12 months. However,
tively, while no site involved > 4 mm of CAL gain.
on inter-group comparison, DFDBA + PRP treat-
ment showed significant advantages in terms of PPD,
Discussion CAL, REC, alveolar crest resorption, defect resolu-
tion and bone fill.
The present study was designed to evaluate PRF as an In a previous study [9], DFDBA/saline demon-
adjunct to DFDBA for the management of human strated similar improvement in PD, CAL and defect
periodontal infrabony defects. All baseline parameters fill, but more defect resolution than in the present
were recorded with non-significant differences in both study. Bender et al. [24] evaluated lesser PD reduc-
groups. The uneventful healing in all the sites was tion, CAL gain and bone fill, while greater mean
in agreement with previous studies [9,13,21], thus percentage bone fill (37.0 ± 18.7%) and percent
supporting the excellent properties of involved defect resolution (47.2 ± 25.3%). Improvement in
biomaterials for periodontal wound healing. Plaque clinical parameters (PD and CAL) of a recent trial
accumulation and smoking are important factors that [25] were less in magnitude as compared to the
were shown to significantly influence the outcomes of present study; possible reasons could be involvement
regenerative periodontal surgery [22,23]. Because the of smokers and one wall defects. The data of our
present study excludes smokers and the patients previous study [26] concluded similar changes in
maintained an acceptable oral hygiene throughout parameters as in the present study, despite involving
the study, therefore, it may be assumed that the non-contained one wall defects.
For PRF + BG, recent histological studies showed
more benefits during bone healing in comparison to
BG alone during augmentation in maxillary sinus, as
revealed in this trial [27,28]. Bolukbasi et al. [29]
 Platelet rich fibrin in intrabony defect 41

study [26]. Piemontese et al. [9] determined more

improvement for DFDBA + PRP in PD (4.6 ±
1.3 mm), but less in CAL (3.6 ± 1.8 mm), REC
(–1.0 ± 1.3 mm), crestal resorption (–0.3 ± 1.3 mm),
defect resolution (3.6 ± 1.7 mm) and bone fill (3.3 ±
1.5 mm).
Trials with no additive advantages of PGFs with
bone graft in bony defects are also present in the
literature. Choi et al. [33] histologically suggested
that addition of PRP to autogenous bone graft retards
new bone formation in osseous defects after 6 weeks
of post-operative period. Variations in the PRP con-
centrations might influence the bone formation within
the PRP-treated bone grafts. Growth factors present
in high concentrations at inappropriate times or for an
extended duration can adversely affect cell behavior.
Viability and proliferation of alveolar bone cells are
suppressed by high PRP concentrations, but are
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observed a histomorphometric increase in bone for- stimulated by low PRP concentrations [34].
mation with the addition of PRF to BG for bone Combining PRF with DFDBA resulted in signifi-
regeneration in surgically created bone defects in cantly greater improvement in PD, CAL, REC, defect
sheep tibia. Simon et al. [30] demonstrated that sites resolution and defect fill than DFDBA used with
treated with platelet-rich fibrin matrix and DFDBA saline. However, the findings observed between the
healed faster than those grafted with DFDBA and a two treatment groups could not be attributed to
membrane during clinical and histological compari- significantly different resorption of alveolar crest, PI
son for 12 weeks of extraction socket healing. The and BOP. Therefore, the differences in parameters
present observations are not corroborated by a recent observed between the two treatment groups in this
trial that proposed no additive benefits of PRF with trial can be explained due to the use of PRF with a
BG for maxillary sinus augmentation [31]. During high degree of certainty. The clinical superiority of the
correlation of the results of above studies it should PRF involvement can also be confirmed by the
keep in mind that bone healing in infrabony peri- frequency distribution data of CAL gain and bone
odontal defect is different as compared to mentioned fill supporting an additional significant benefit in
bony cavities due to the chance of oral fluid contam- terms of periodontal regeneration.
ination, lack of exact standardization, presence of less Magnitude of regenerative outcomes of other regen-
osteoprogenitor cells, and adjacent avascular tooth erative technologies like guided tissue regeneration,
surface. enamel matrix derivatives, combined approaches and
Scanty data is available regarding the use of autol- PRP are comparable to the results of our modalities
ogous PRF in combination with BG in the treatment [35]. PRF is a biocompatible, bioresorbable, three-
of infrabony defects. Thus, a direct comparison with dimensional polymerized fibrin meshwork in which
other studies was not much. As similar to PRF, the the platelet, leukocytes, cytokines, growth factors
first generation autologous platelet preparation (PRP) (such as transforming growth factor-b1, platelet-
also supplies an elevated concentration of polypeptide derived growth factor, vascular endothelial growth
growth factors at the surgical site. While monitoring factor) and matrix glycoproteins (such as thrombos-
changes in clinical and radiographic measurements in pondin-1) are trapped and may be delivered for a
PRP with BG associated randomized trials [32], certain time to play an essential role in wound repair,
diverse inferences have been reported with respect and provides a matrix for migration of tissue-forming
to the present findings. cells like fibroblasts and endothelial cells, which are
The recent findings with surgical re-entry support involved in angiogenesis and are responsible for
our results in terms of significant improvement with re-modeling of the new tissue [36]. In vitro, PRF
PRF/BG associated group in intrabony defects after significantly improved proliferation of human osteo-
6 months [13]. In our previous study DFDBA + PRP blasts in a dose-dependent manner and the expression
showed lesser improvement after 12 months in PD of alkaline phosphatase activity was enhanced in a time-
(3.65 ± 0.63 mm), CAL (3.15 ± 0.50 mm), REC dependent manner with PRF [37]. The enhancement
(–0.54 ± 0.59 mm), crestal resorption (–0.27 ± of phosphorylated extracellular signal-regulated pro-
0.25 mm), defect fill (3.02 ± 0.50 mm) and defect tein kinase, osteoprotegerin and ALP may provide
resolution (3.29 ± 0.53 mm) than DFDBA + PRF in benefits for periodontal regeneration [38]. PRF
the present study; the difference is more likely due to entraps circulating stem cells due to which it leads to
involvement of non-contained osseous defects in that superior healing of large osseous defects where there is
 42 A. Agarwal et al.

migration of stem cells differentiating into the osteo- References

blast phenotype [27].
[1] Darby I. Periodontal materials. Aust Dent J 2011;56:107–18.
The formability into the membrane, no require-
[2] Froum S, Cho SC, Rosenberg E, Rohrer M, Tarnow D.
ment of bovine thrombin or other exogenous activa- Histological comparison of healing extraction sockets
tors in the preparation process, slow release of growth implanted with bioactive glass or demineralized freeze-dried
factors during ‡ 7 days, antibacterial effects due to the bone allograft: A pilot study. J Periodontol 2002;73:
presence of leukocytes, easy and fast processing as 94–102.
[3] Gajiwala AL, Kumar BD, Chokhani P. Evaluation of demi-
well as inexpensive chair side preparation make PRF
neralised, freeze-dried, irradiated bone allografts in the treat-
the material of choice over other platelet concentrates ment of osseous defects in the oral cavity. Cell Tissue Bank
[39]. On the other hand, the short shelf-life can be 2007;8:23–30.
considered as a drawback of PRF. PRF membrane [4] Ilgenli T, Dündar N, Kal BI. Demineralized freeze-dried bone
should be used immediately after preparation as it will allograft and platelet-rich plasma vs platelet-rich plasma alone
in infrabony defects: A clinical and radiographic evaluation.
shrink, resulting in dehydration and altering the struc-
Clin Oral Invest 2007;11:51–9.
tural integrity of PRF. Dehydration also results in the [5] Caceres M, Hidalgo R, Sanz A, Martinez J, Riera P,
decreased growth factor content in PRF and leuko- Smith CP. Effect of platelet rich plasma on cell adhesion,
cyte viability will be adversely affected, altering its cell migration, and myofibroblastic differentiation in human
biologic properties [37]. gingival fibroblasts. J Periodontol 2008;79:714–20.
[6] Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR,
In clinical practice, pure two or three wall angular
Downloaded by [Tokyo Ika Shika University] at 21:31 05 January 2016

Strauss JE, Georgeff RN. Platelet rich plasma: Growth factor

defects are uncommon, whereas the majority of the enhancement for bone grafts. Oral Surg Oral Med Oral Pathol
defects are present in combination manner [40]. Oral Radiol Endod 1998;85:638–46.
Defects treated in this study were two wall, three [7] Lekovic V, Camargo PM, Weinlaender M, Vasilic N,
wall or a combination of two and three wall defects. Kenney EB. Comparison of platelet-rich plasma, bovine
porous bone mineral, and guided tissue regeneration versus
Regenerative potential of vertical defects depends on
platelet-rich plasma and bovine porous bone mineral in the
the defect topography. Therefore, due to the inher- treatment of intrabony defects: A reentry study. J Periodontol
ently low bone fill character, one wall defects have 2002;73:198–205.
been excluded from the present study. [8] Markou N, Pepelassi E, Vavouraki H, Stamatakis HC,
Heterogeneous regenerative outcomes are present Nikolopoulos G, Vrotsos I, et al. Treatment of periodontal
endosseous defects with platelet-rich plasma alone or in
in DFDBA-related previous studies due to variation
combination with demineralized freeze-dried bone allograft:
in osteoinductive potential. Possible reasons for this A comparative clinical trial. J Periodontol 2009;80:
could be the insufficient amount of bone morpho- 1911–19.
genic proteins and the inactivity of BMPs. Research- [9] Piemontese M, Aspriello SD, Rubini C, Ferrante L,
ers have demonstrated that different preparations of Procaccini M. Treatment of periodontal intrabony defects
with demineralized freeze-dried bone allograft in combination
allograft material, both from inter and intra distri-
with platelet-rich plasma: A comparative clinical trial.
butors, may have different biological activity [41]. J Periodontol 2008;79:802–10.
Assuming that the processing methods are standard- [10] Del Fabbro M, Bortolin M, Taschieri S, Weinstein R. Is
ized at individual bone banks, the fact that there was platelet concentrate advantageous for the surgical treatment
considerable variation in bone-induction ability of periodontal diseases? A systematic review and meta-
analysis. J Periodontol 2011;82:1100–11.
among the samples suggests that there is an
[11] Nevins M, Giannobile WV, McGuire MK, Kao RT,
underlying difference in the inherent capacity of Mellonig JT, Hinrichs JE, et al. Platelet derived growth factor
the bone to promote osteogenesis. These differences stimulates bone fill and rate of attachment level gain: Results of
may be a function of donor age, previous exposure a large multicenter randomized controlled trial. J Periodontol
of pathology and/or drug therapy or genetic 2005;76:2205–15.
[12] Thorat MK, Pradeep AR, Pallavi B. Clinical effect of autol-
variation [41].
ogous platelet-rich fibrin in the treatment of intra-bony
In conclusion, for human periodontal infrabony defects: A controlled clinical trial. J Clin Periodontol 2011;
defects, addition of PRF to DFDBA significantly 38:925–32.
enhanced the regenerative output obtained compared [13] Lekovic V, Milinkovic I, Aleksic Z, Jankovic S, Stankovic P,
with bone graft alone. Kenney EB, et al. Platelet-rich fibrin and bovine porous bone
mineral vs. platelet-rich fibrin in the treatment of intrabony
periodontal defects. J Periodont Res 2012;47:409–17.
[14] Choukroun J, Adda F, Schoeffler C, Vervelle A. An oppor-
Acknowledgments tunity in perio-implantology: The PRF. Implantodontie 2001;
42:55–62.
The authors are highly grateful to Dr Vatika Agarwal, [15] Davis VL, Abukabda AB, Radio NM, Witt-Enderby PA,
Dental graduate, for her support and help in prepar- Clafshenkel WP, Cairone JV, et al. Platelet-rich preparations
ing this manuscript. to improve healing. Part II: Platelet activation and enrich-
ment, leukocyte inclusion, and other selection criteria. J Oral
Implantol 2014;40:511–21.
Declaration of interest: The authors report no [16] Dohan Ehrenfest DM, Choukroun J, Diss A, Dohan SL,
conflicts of interest. The authors alone are responsible Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF):
for the content and writing of the paper. A second-generation platelet concentrate. Part I: Technological
 Platelet rich fibrin in intrabony defect 43
concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:
Radiol Endod 2006b;101:37–44. 583–92.
[17] Dohan Ehrenfest DM, Diss A, Odin G, Doglioli P, [29] Bolukbasi N, Yeniyol S, Tekkesin Mm S, Altunatmaz K. The
Hippolyte MP, Charrier JB. In vitro effects of Choukroun’s use of platelet-rich fibrin in combination with biphasic cal-
PRF (platelet-rich fibrin) on human gingival fibroblasts, cium phosphate in the treatment of bone defects: A histologic
dermal prekeratinocytes, preadipocytes, and maxillofacial and histomorphometric study. Curr Ther Res 2013;75:
osteoblasts in primary cultures. Oral Surg Oral Med Oral 15–21.
Pathol Oral Radiol Endod 2009;108:341–52. [30] Simon BI, Zatcoff AL, Kong JJW, O’Connell SM. Clinical
[18] Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classi- and histological comparison of extraction socket healing fol-
fication of platelet concentrates: From pure platelet-rich lowing the use of autologous platelet-rich fibrin matrix
plasma (P-PRP) to leucocyte- and platelet-rich fibrin (PRFM) to ridge preservation procedures employing demi-
(L-PRF). Trends Biotechnol 2009;27:158–67. neralized freeze dried bone allograft material and membrane.
[19] Silness J, Loe H. Periodontal disease in pregnancy. II. Cor- Open Dent J 2009;3:92–9.
relation between oral hygiene and periodontal condition. Acta [31] Zhang Y, Tangl S, Huber CD, Lin Y, Qiu L, Rausch-Fanb X.
Odontol Scand 1964;22:121–35. Effects of Choukroun’s platelet-rich fibrin on bone regener-
[20] Muhlemann HR, Son S. Gingival sulcus bleeding – A leading ation in combination with deproteinized bovine bone mineral
symptom in initial gingivitis. Helv Odontol Acta 1971;15: in maxillary sinus augmentation: A histological and histomor-
107–13. phometric study. J Cranio-Maxillofac Surg 2012;40:321–8.
[21] Sharma A, Pradeep AR. Treatment of 3-wall intrabony defects [32] Kotsovilis S, Marou N, Pepelassi E, Nikolidakis D. The
in patients with chronic periodontitis with autologous platelet- adjunctive use of platelet rich plasma in the therapy of peri-
rich fibrin: A randomized controlled clinical trial. J Periodontol odontal intraosseous defects: A systemic review. J Periodontol
Downloaded by [Tokyo Ika Shika University] at 21:31 05 January 2016

2011;82:1705–12. Res 2010;45:428–43.

[22] Trombelli L, Kim CK, Zimmerman GJ, Wikesjo UM. Ret- [33] Choi BH, Im CJ, Huh JY, Suh JJ, Lee SH. Effect of platelet-
rospective analysis of factors related to clinical outcome of rich plasma on bone regeneration in autogenous bone graft.
guided tissue regeneration procedures in intrabony defects. Int J Oral Maxillofac Surg 2004;33:56–9.
J Clin Periodontol 1997;24:366–71. [34] Choi BH, Zhu SJ, Kim BY, Huh JY, Lee SH, Jung JH. Effect
[23] Tonetti MS, Prato GP, Cortellini P. Factors affecting the of platelet-rich plasma (PRP) concentration on the viability
healing response of intrabony defects following guided tissue and proliferation of alveolar bone cells: An in vitro study. Int J
regeneration and access flap surgery. J Clin Periodontol 1996; Oral Maxillofac Surg 2005;34:420–4.
23:548–56. [35] Kao RT, Nares S, Reynolds MA. Periodontal regeneration –
[24] Bender SA, Rogalski JB, Mills MP, Arnold RM, intrabony defects: A systematic review from the AAP regen-
Cochran DL, Mellonig JT. Evaluation of bone mineralization eration workshop. J Periodontol 2015;86(Suppl):S77–S104.
paste and putty in periodontal intraosseous defect. [36] Kang YH, Jeon SH, Park JY, Chung JH, Choung YH,
J Periodontol 2005;76:768–77. Choung HW, et al. Platelet-rich fibrin is a bioscaffold and
[25] Hoidal MJ, Grimard BA, Mills MP, Schoolfield JD, reservoir of growth factors for tissue regeneration. Tissue Eng
Mellonig JT, Mealey BL. Clinical evaluation of demineralized Part A 2011;17:349–59.
freeze-dried bone allograft with and without enamel matrix [37] Dohan Ehrenfest DM, de Peppo GM, Doglioli P,
derivative for the treatment of periodontal osseous defects in Sammartino G. Slow release of growth factors and
humans. J Periodontol 2008;79:2273–80. thrombospondin-1 in Choukroun’s platelet-rich fibrin
[26] Agarwal A, Gupta ND. Platelet rich plasma combined with (PRF): A gold standard to achieve for all surgical platelet
decalcified freeze dried bone allograft for the treatment of non concentrates technologies. Growth Factors 2009;27:63–9.
contained human infrabony periodontal defects: [38] Chang YC, Zhao JH. Effects of platelet-rich fibrin on human
A randomized controlled split mouth study”. Int J Perio Resto periodontal ligament fibroblasts and application for periodon-
Dent 2014;34:705–11. tal infrabony defects. Aust Dent J 2011;56:365–71.
[27] Choukroun J, Diss A, Simonpieri A, Girard MO, [39] Kumar RV, Shubhashini N. Platelet rich fibrin: A new par-
Schoeffler C, Dohan SL, et al. Platelet-rich fibrin (PRF): adigm in periodontal regeneration. Cell tissue bank 2013;14:
A second- generation platelet concentrate. PartV: Histologic 453–63.
evaluations of PRF effects on bone allograft maturation in [40] Selvig KA, Kersten BG, Wikesjö ULFME. Surgical treatment
sinus lift. Oral Surg Oral Med Oral Pathol Oral Radiol Endod of intrabony periodontal defects using expanded polytetra-
2006;101:299–303. fluoroethylene barrier membranes: Influence of defect
[28] Kim BJ, Kwon TK, Baek HS, Hwang DS, Kim CH, configuration on healing response. J Periodontol 1993;64:
Chung IK, et al. A comparative study of the effectiveness 730–3.
of sinus bone grafting with recombinant human bone [41] Wang HL, Greenwell H, Fiorellini J, Giannobile W,
morphogenetic protein 2-coated tricalcium phosphate and Offenbacher S, Salkin L, et al. Periodontal regeneration.
platelet-rich fibrin-mixed tricalcium phosphate in rabbits. J Periodontol 2005;76:1601–22.