Understanding Platelet-Rich Fibrin, Richard Miron, Editör, Quintessence Publishing Co, Inc. , Illinois, ss.89-100, 2021
Study 6: Tunali et al. Improving PRF membrane mechanical strength through change in material characterization and an introduction to titanium-PRF(T-PRF) tubes.
Titanium represents an extremely bioinert material with excellent hydrophilic properties. In addition, titanium is resistant to corrosion and has the property of osteointegration. Because of this feature, it has been used in dental implants as well. Little is known about the blood compatibility of metals, but we know that titanium and derivatives thereof are among the most thrombogenic materials which may explain its outstanding osteointegrating properties. (Biomaterials. 2005 Apr;26(12):1397-403. Material-specific thrombin generation following contact between metal surfaces and whole blood. Hong J1, Azens A, Ekdahl KN, Granqvist CG, Nilsson B.) The coagulation activation caused by titanium was triggered by the intrinsic pathway because the generation of FXIIa-AT/C1 esterase inhibitor paralleled that of thrombin-antithrombin, and both thrombin-antithrombin complex and FXIIa-AT/C1 esterase inhibitor generation were abrogated by corn trypsin inhibitor, which is a specific inhibitor of FXIIa. The binding of platelets was increased on the titanium surface compared to the other biomaterial surfaces and the state of platelet activation was much more pronounced as reflected by the levels of beta-thromboglobulin and PDGF. Furthermore, PDGF and other alpha-granule proteins e.g. TGF-beta, are known to be potent promotors of osteogenesis which suggests that the pronounced thrombogenic properties of titanium might contribute to the good osteointegrating properties. (Thromb Haemost. 1999 Jul;82(1):58-64. Titanium is a highly thrombogenic biomaterial: possible implications for osteogenesis. Hong J1, Andersson J, Ekdahl KN, Elgue G, Axén N, Larsson R, Nilsson B.)
Because of these properties of titanium, titanium induced platelet aggregation is better than glass. Titanium prepared platelet-rich fibrin (T-PRF) has stronger and thicker fibrin carpet than that of the glass tube prepared platelet-rich fibrin. (Tunalı M, Özdemir H, Küçükodacı Z, et al. A Novel Platelet Concentrate: Titanium Prepared Platelet-Rich Fibrin (T-PRF). Biomed Res Int 2014; 209548.) Strong fibrin structure is important to extend the time for resorption of fibrin in-vivo, and increase the release time of growth factors. (Tunalı M, Özdemir H, Küçükodacı Z, et al. In vivo evaluation of titanium-prepared platelet-rich fibrin (T-PRF): a new platelet concentrate. Br J Oral Maxillofac Surg 2013; 5:438-43.)
Along with the experimental studies that reveal the properties of T-PRF, many successful clinical studies have also been conducted with this second generation blood product. T-PRF has been shown to be an important alternative to connective tissue grafts in the treatment of gingival recessions. (Effectiveness and predictability of titanium-prepared platelet-rich fibrin for the management of multiple gingival recessions. Uzun BC, Ercan E, Tunalı M. Clin Oral Investig. 2018 Apr;22(3):1345-1354.) In addition, it has been used alone as a hard tissue graft material in the treatment of periodontal defects, sinus lifting applications and crest preservation techniques, by utilizing the length of in-vivo resorption time. (Comparison of GTR, T-PRF and open-flap debridement in the treatment of intrabony defects with endo-perio lesions: a randomized controlled trial. Ustaoğlu G, Uğur Aydin Z, Özelçi F. Med Oral Patol Oral Cir Bucal. 2020 Jan 1;25(1):e117-e123.) Comparison of the clinical, radiographic, and histological effects of titanium-prepared platelet rich fibrin to allograft materials in sinus-lifting procedures.Olgun E, Ozkan SY, Atmaca HT, Yalim M, Hendek MK. J Investig Clin Dent. 2018 Nov;9(4):e12347.
Successful results of T-PRF in previous clinical trials caused the birth of many new research topics. The most important one of these new research topics is relate to how the process progressed after the T-PRF was inserted into the soft and hard tissues. In particular, which is more important, the growth factors that are released more than 30 days from T-PRF, or the long resorption period of T-PRF's natural strong matrix structure, which activates bone healing mechanisms? It still be an important question.
Clinical significance: Titanium-PRF tubes have therefore been developed and utilized in clinical practice. We can say that the titanium surface gives the PRF important properties by strengthening the structure of the fibrin. After T-PRF, first question to be asked is what purpose we can use platelet-rich products for: 1. For soft tissue healing? 2. As a biological material in addition to the graft material used in the hard tissue healing, for providing to faster healing rates and enhanced tissue regeneration? 3. As a biological barrier membrane in the hard tissue
healing? 4. As a scaffold to the stem cells, growth factors, or other biological materials in applications? 5. As a hard tissue graft material alone? 6. Or for all these goals? Future research is ongoing.