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e119Use of leukocyte and platelet-rich fibrin(L-PRF)in periodontally accelerated osteogenic orthodontics(PAOO):Clinical effects on edema and painFrancisco Muoz 1,Constanza Jimnez 2,Daniela Espinoza 3,Alain Vervelle 4,Jacques Beugnet 5,Ziyad Haidar 61 DDS,certified Oral and MaxilloFacial Surgeon,Professor,Faculty of Dentistry,Universidad de los Andes,Santiago,Chile2 DDS,certified Periodontist and Implantologist,BioMATX-Centro de Investigacin Biomdica(CIB),Faculty of Dentistry,Universidad de los Andes,Santiago,Chile3 DDS,Oral and MaxilloFacial Surgeon,BioMATX-Centro de Investigacin Biomdica(CIB),Faculty of Dentistry,Universidad de los Andes,Santiago,Chile4 DDS,certified Oral and Maxillofacial Surgeon,(BioMATX-CIB UAndes Consultant),Private practice,Marseille,France5 DDS,certified Orthodontist,(BioMATX-CIB UAndes Consultant),Private practice,Marseille,France6 DDS,certified Implantologist,Oral and Maxillofacial Surgeon(M.Sc.),M.B.A.,PhD.Professor and Scientific Director,Faculty of Dentistry,UAndes.Founder and Head of BioMATX-CIB-PMI(Plan de Mejoramiento Institucional en Innovacin),Universi-dad de los Andes,Santiago,ChileCorrespondence:BioMATX(Biomaterials,Pharmaceutical Delivery and Cranio-Maxillo-Facial Tissue Engineering Laboratory)Centro de Investigacin Biomdica(CIB)Plan de Mejoramiento Institucional(PMI)en Innovacin-I+D+IFaculty of Dentistry,Universidad de los AndesAv.Monseor lvaro del Portillo12.455Las Condes,Santiago,Chilezhaidaruandes.clReceived:06/09/2015Accepted:02/10/2015Abstract Background:Demand for shorter treatment time is common in orthodontic patients.Periodontally Accelerated Osteogenic Orthodontics(PAOO)is a somewhat new surgical procedure which allows faster tooth movement via combining orthodontic forces with corticotomy and grafting of alveolar bone plates.Leukocyte and Platelet-Rich Fibrin(L-PRF)possess hard-and soft-tissue healing properties.Further,evidence of pain-inhibitory and anti-inflammatory potential is growing.Therefore,this study explores the feasibility,intra-and post-operative effects of using L-PRF in PAOO in terms of post-operative pain,inflammation,infection and post-orthodontic stability.Material and Methods:A pilot prospective observational study involving a cohort of 11 patients was carried out.A Wilckos modified PAOO technique with L-PRF(incorporated into the graft and as covering membrane)was performed with informed consent.Post-surgical pain,inflammation and infection were recorded for 10 days post-operatively,while the overall orthodontic treatment and post-treatment stability were followed up to 2 years.Results:Accelerated wound healing with no signs of infection or adverse reactions was evident.Post-surgical pain was either“mild”(45.5%)or“moderate”(54.5%).Immediate post-surgical inflammation was either“mild”(89.9%)or“moderate”(9.1%).Resolution began on day 4 where most patients experienced either“mild”or no in-flammation(72.7%and 9.1%,respectively).Complete resolution was achieved in all patients by day 8.The average orthodontic treatment time was 9.3 months.All cases were deemed stable for 2 years.Article Number:52760 http:/ Medicina Oral S.L.C.I.F.B 96689336-eISSN:1989-5488eMail:jcedjced.esIndexed in:PubmedPubmed Central(PMC)ScopusDOI SystemMuoz F,Jimnez C,Espinoza D,Vervelle A,Beugnet J,Haidar Z.Use of leukocyte and platelet-rich fibrin(L-PRF)in periodontally accelerated osteogenic orthodontics(PAOO):Clinical effects on edema and pain.J Clin Exp Dent.2016;8(2):e119-24.http:/ Clin Exp Dent.2016;8(2):e119-24.Effect of L-PRF in PAOOe120IntroductionDemand for shorter treatment time with none to mini-mal side effects(i.e.root resorption,gingival recession,tooth decalcification,etc)is a main request of adults seeking orthodontic treatment(1,2).Unlike children,adults have special biological conditions(i.e.slower cell mobilization and collagen conversion,increased risk of periodontal disease and almost inexistent alveolar and maxillary growth)which prevent speeding up treatment via conventional means(i.e.applying stronger forces)without increasing risk of hyalinization,among other complications(1).To overcome such limitations,di-fferent techniques are constantly explored and develo-ped over the years,to accelerate tooth movement,with surgical endeavors reporting the highest success rates.Indeed,such surgical attempts date back to 1959,when Kole theorized that cortical bone plates were the main resistance for tooth movement.Thereby,a corticotomy/osteotomy procedure which selectively sectioned the plates,was presented with promising results.Despite,it was not widely accepted due to subapical horizontal cuts penetrating full thickness of the alveolar ridge(1).Sub-sequent technical modifications included conservative corticotomies alongside the discovery that periodontal health could be maintained if the vertical cuts avoided the crestal bone area(1).This led the Wilcko brothers(a periodontist and an orthodontist)to introduce,in 2001 a new technique for surgically-assisted tooth movement in orthodontics(3-6).Their technique combined clas-sic corticotomies/osteotomies of the alveolar bone with the use of bone grafts in order to maintain and increa-se the thickness of the cortical plates into which teeth were moved.Wilckos novel“Periodontally Accelerated Osteogenic Orthodontic or PAOO”technique gained acceptance and popularity given its safe,predictable and effective results as well as benefits versus traditio-nal orthodontics;which included:accelerated differen-tial tooth movement,reduced treatment time,less root resorption,enhanced expansion,increased traction of impacted teeth,increased post-treatment stability and increased robustness of the periodontum(including re-cently reported increase in the width of keratinized gin-giva)(1,4,7).With grafting,no more limits regarding pre-existing alveolar volume existed,allowing the teeth to be moved 2 to 3 times more(distance)and in almost Conclusions:L-PRF is simple and safe to use in PAOO.Combination with traditional bone grafts potentially accele-rates wound healing and reduces post-surgical pain,inflammation,infection without interfering with tooth movement and/or post-orthodontic stability,over a 2 years period;thus alleviating the need for analgesics and anti-inflammatory medications.Key words:Periodontally accelerated osteogenic orthodontics,leukocyte and platelet-rich fibrin,corticotomy,os-teogenesis,grafts.1/3rd of the conventional/traditional time(1,2,7).Today,main indications for PAOO include moderate to severe crowding,Class II malocclusions requiring expansion and/or extractions,mild Class III malocclusions,ex-trusion for open bite and intrusion for deep bite(1,7).Recently,PAOO has also been suggested to reduce the need and extension of orthognathic surgery in specific patients,opening new and exciting frontiers and possibi-lities within maxillofacial surgery(1,4,8).The rapid too-th movement and stability,as a result of PAOO,has been attributed to a localized and temporal osteoporosis-like/increased turnover state of the bone,referred to as Regio-nal Acceleratory Phenomenon or RAP(1).Briefly,RAP is a natural event within the bone healing process which usually follows fracture,osteotomy and/or grafting.The PAOO procedure,therefore,involves the activation and recruitment of precursor cells into the wounded/injured site,leading to subsequent two to ten-fold increase in hard and soft tissue healing(9).In PAOO,RAP begins within few days of the surgical intervention,peaks at 1 to 2 months post-surgery and usually lasts up to 4 mon-ths(though 6 and up to 24 months may be necessary to completely subside).However,as long as tooth move-ment continues,RAP follows(1).As any healing-related event,RAP requires a delicate combination of progeni-tor cells,extracellular signaling molecules and adequate extracellular matrix in order to succeed.In this“tissue engineering”context,biomaterials that support and en-hance the regenerative process may further improve the clinical outcomes of PAOO while reducing side-effects(which often include:slight interdental bone loss,loss of attached gingiva,periodontal defects,subcutaneous hematomas and postoperative pain and swelling for se-veral days)(1).Leukocyte and Platelet-Rich Fibrin or L-PRF is a second generation platelet hydrogel obtained through the simple and rapid centrifugation of whole blood samples in absence of anti-coagulants and bovine thrombin(10,11).The biomaterial is characterized by a dense fibrin mesh(similar to natural extracellular ma-trix)and rich platelet-,leukocyte-,growth factor-and stem cell-content(exceeding that of conventional blood clots and Platelet-Rich Plasma or PRP)(12).Accumu-lating evidence(13,14)demonstrates that L-PRF mem-branes actively produce and release abundant concentra-tions of growth factors and cytokines for up to 28 days J Clin Exp Dent.2016;8(2):e119-24.Effect of L-PRF in PAOOe121post-preparation;exerting:(a)dose-dependent osteoin-ductive effects over osteoblasts,periodontal ligament cells and bone marrow mesenchymal stem cells(which may be further increased via combination with autolo-gous bone)as well as potential(b)anti-inflammatory,(c)anti-infective and(d)pain inhibitory properties(15);all of which are attractive properties suitable for incor-poration into PAOO.Here in,we aimed to explore the clinical feasibility or effect of preparing and using L-PRF in PAOO in terms of post-operative inflammation,pain,infection and short-term orthodontic stability,as the study outcomes.Material and Methods-Study design and populationA cohort observational study was designed involving 11 patients who visited our clinics between June 2013 and June 2015.Inclusion criteria:(a)patients in need of orthodontic treatment whom desired a shorter treatment time and(b)patients whom(according to the Orthodontic and Periodontal specialists and consultants)were suita-ble candidates for PAOO.Exclusion criteria:(a)patients with systemic health illnesses incompatible with under-going surgery and(b)patients with active periodontal disease.Suitability for PAOO was confirmed after an ex-tensive series of examinations which included:mounted model casts,radiographic analysis(panoramic and la-teral radiographs),cephalometric analysis(Vicker Sas-souni)and both,intra and extra-oral photographs.This study complies with the guidelines of the World Medical Association-Helsinki Declaration 2000 for biomedical research and was reviewed,approved and supervised by the Ethics committee(Medicine/Dentistry Schools)of the University of the Andes in Santiago,Chile.-L-PRF preparation.Peripheral blood samples were drawn into 10 mL glass-coated tubes without anti-coagulants(6-8 tubes per pa-tient).Samples were immediately table-top centrifuged at 3000 rpm for 10 mins,according to the protocol de-veloped by Choukroun et al.in 2001(11).Clots were then carefully separated from red blood cell precipitants using scissors.Half of the clots were minced and incor-porated into the bone graft while the other half prepared as a membrane using L-PRF box.-Surgical procedureAll surgeries(N=11)were performed by the same team.Following an informed and written consent,a modified“Wilcko”technique incorporating the use of L-PRF(60 to 80 mL of blood per patient)as grafting material and barrier membrane,with antibiotic treatment.After ad-ministration of anesthesia,full-thickness envelope flap is carefully raised preserving the interdental papillae.Vertical corticotomy patterns are performed using either rotary(ESCAROM n2 round burs at 500 rpm)or piezo-electric(ESCAROM,BS1 tip)instruments.Cuts extend from 2 mm below the bone crest to approximately 2-3 mm past the teeth apices,penetrating 1.5 to 2 mm into the cortical plate until reaching the cancellous bone evi-dence suggest that corticotomy pattern,depth,extent and means of creation(either rotary or piezoelectric)are not crucial factors for the success of PAOO(4).After con-trolling the bleeding,minced pieces of L-PRF(4 clots)are grafted with a 3:2 combination of Puros cortico-can-cellous(Zimmer Dental Inc,CA,USA)and Bio-Oss(Geistlich Pharma North America Inc,Princeton,USA),respectively;with the addition of two(250 mg each)Metronidazole capsules(total of 500 mg mixed into the graft).It is noteworthy that final graft volume varies ac-cording to individual patient needs in terms of tooth mo-vement,bone thickness and labial support.L-PRF mem-branes(3 to 4 per patient)are then placed over the graft in order to contain it on the buccal aspect of the alveolar plate.Finally,the flap is repositioned and sutured using tension-free trans-papillary Donati Blair stitches(4-0 vicyrl).The recommended post-operative management regimen typically includes:Chlorhexidine mouthwash(0.12%,every 6 hrs for 10 days),Amoxicillin(2 g every 24 hrs for 7 days),Cortisol(30 mg every 24 hrs for 2 days)and Ibuprofen(400 mg every 8 hrs,as needed).Sutures are removed 10 days post-operatively.-Data collectionAll 11 patients were monitored at days 1,2,4,8 and 10 post-op.At each time-point,complete clinical evalua-tions with intra-and extra-oral photographs were perfor-med.Post-surgical inflammation,infection and pain were recorded using clinical parameters and patient feedback.Briefly,inflammation was measured by means of pre-sence and extension of clinical edema using a customi-zed scale.Infection was measured as either“present”(+)or“absent”(-)upon presence of abscesses,suppuration and/or fistulae.Finally,quantification and measurement of pain was made by patients via a customized scale to report extent and need for post-operative analgesics.-Orthodontic procedureAll patients(N=11)were treated by the same orthodon-tist.Full maxillary and mandibular braces with self-liga-ting brackets were placed 7 days pre-surgery,followed by a 0.12,0.14 or 0.16 NiTi arch protocol,according to the individual need of each patient;with activation every two weeks.Total treatment time(from placement of appliances until removal)and post-treatment stability were documented using rigid night guard splints.Stabi-lity was recorded as either“stable”(if the splint fitted correctly)or“unstable”(if it did not fit).No post-or-thodontic contentions were utilized.-Statistical analysisDescriptive statistics for baseline patient characteristics(age,gender,diagnosis,response to treatment and post-orthodontic stability)were applied.Further testing was deemed un-necessary.J Clin Exp Dent.2016;8(2):e119-24.Effect of L-PRF in PAOOe122ResultsEleven patients were enrolled in this study(3 males and 8 women;average age:34.8 years).All subjects com-pleted the 2-years follow-up.Baseline demographic data and diagnosis are summarized in table 1.L-PRF preparation was done intra-operatively(15 minutes)while performing corticotomy patterns;(Fig.1).From clinicians stand-point,the biomaterial was simple to prepare,handle and suture.In this technique,minced pieces of L-PRF mixed into the graft provide increased stability when placed on the buccal aspect of the surg