|Year : 2022 | Volume
| Issue : 3 | Page : 243-253
Evaluation of the efficacy of platelet-rich plasma (PRP) and injectable platelet-rich fibrin (i-PRF) in the acceleration of canine retraction: A randomized controlled trial
Rahaf Esam Naji, Talar Simon Zeitounlouian, Eyad Alomari, Mohamed Youssef
Department of Orthodontics and Dentofacial Orthopaedics, Faculty of Dentistry, Damascus University, Damascus, Syria
|Date of Submission||25-Nov-2021|
|Date of Decision||17-May-2022|
|Date of Acceptance||21-May-2022|
|Date of Web Publication||28-Jun-2022|
Dr. Eyad Alomari
35 Wrentham Rd, Worcester, MA 01602
Source of Support: None, Conflict of Interest: None
Aim: To compare the effectiveness of the intra-ligament injection of platelet-rich fibrin (i-PRF) and platelet-rich plasma (PRP) on canine movement rate during its orthodontic retraction. Materials and Methods: A randomized controlled trial with a split-mouth design included 40 patients (21.3 ± 1.8 years) whose all first premolars were indicated for extraction. Twenty patients were randomly allocated to each group (PRP vs. i-PRF). The Canine retraction was performed using Ricketts spring. PRP and i-PRF were injected twice in the intervention side with a 21-day interval. Saline was used likewise in the control side. Canine movement, rotation, and molar anchorage loss were measured on dental casts, whereas canine inclination was studied on cephalograms. Shapiro–Wilk normality test was performed, and a paired t-test was subsequently used for comparison within the same group. In addition, a two-sample t-test was used to compare the two groups. Results: A significantly higher rate of canine movement was observed in the PRP intervention group during the first month, unlike the i-PRF group in comparison with the control side. Besides, canine retracting rate was higher in the PRP group during the third month than in the i-PRF group. No statistical differences in canine inclination, rotation, and molar anchorage loss were found except for mandibular canine rotation in the PRP group and maxillary canine rotation between the two groups. Conclusion: PRP injection was probably better than the i-PRF in accelerating canine movement without avoiding the unwanted effects.
Keywords: Accelerated Orthodontics, Canine Inclination, Canine Retraction, Canine Rotation, Injectable Platelet-Rich Fibrin, Platelet-Rich Plasma
|How to cite this article:|
Naji RE, Zeitounlouian TS, Alomari E, Youssef M. Evaluation of the efficacy of platelet-rich plasma (PRP) and injectable platelet-rich fibrin (i-PRF) in the acceleration of canine retraction: A randomized controlled trial. J Int Oral Health 2022;14:243-53
|How to cite this URL:|
Naji RE, Zeitounlouian TS, Alomari E, Youssef M. Evaluation of the efficacy of platelet-rich plasma (PRP) and injectable platelet-rich fibrin (i-PRF) in the acceleration of canine retraction: A randomized controlled trial. J Int Oral Health [serial online] 2022 [cited 2022 Dec 2];14:243-53. Available from: https://www.jioh.org/text.asp?2022/14/3/243/348419
| Introduction|| |
The duration of orthodontic treatment is considered one of the main concerns for patients and orthodontists. The most prolonged treatment often accompanies extraction cases, which may require 2–3 years to finish, which usually has detrimental effects on teeth and supporting tissues: white spots, decays, gingival recession, and apical root resorption, especially among adults due to delayed metabolism and increased bone density., Various approaches have been applied to accelerate orthodontic tooth movement (OTM),,, such as lasers,, surgeries,,, medications, and vibratory stimulations. However, the most recent agents used to accelerate the OTM are the platelet-rich plasma (PRP) and the platelet-rich fibrin (PRF),,,, which have comparable results to some surgeries outcomes, with fewer adverse effects on periodontium.
PRP is a concentrate of autologous platelets, which is derived from plasma. PRP contains numerous proteins and growth factors essential in stimulating the healing process., Various animal experiments have been conducted to evaluate the impact of platelet concentrates on OTM. Some trials have reported an accelerated tooth movement through PRP application,,, whereas others have not., So far, there is a controversy regarding the effects of PRP on OTM in humans.,
Further, PRF is the second generation of platelet concentrates with many advantages over PRP. It does not contain anticoagulants and releases seven times more growth factors gradually and sustainably than PRP., PRF has a significant role in angiogenesis, collagen formation, and bone regeneration., Many studies have proven the effectiveness of PRF in accelerating tooth movement,,,, unlike some others,,
To the best of our knowledge, there is no trial in the literature compared PRP and i-PRF in orthodontics. Therefore, the purpose of this study was to evaluate the effectiveness of PRP versus i-PRF in accelerating orthodontic canine retraction. The second goal was to assess the dentoalveolar changes following canine movement, such as canine rotation, inclination, and molar anchorage loss.
| Materials and Methods|| |
This study was approved by The Ethics Committee at Damascus University – Faculty of Dentistry, Syria (UDDS-414-26042018/ SRC-2754).
A parallel two-arm randomized controlled trial with a split-mouth design. The sample was randomly divided into two groups: PRP and i-PRF(20:20). The comparisons were made between intervention and control sides within each group and between the two groups. The follow-up and the allocation of patients are given in [Figure 1]. The Cochrane risk of bias tool was used to assess the methodological quality of this trial.
|Figure 1: Consolidated standards of reporting trials (CONSORT) participants’ flow diagram|
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Sample size calculation
Results of a similar study were employed in G*Power software (Heinrich-Heine-Universität, Düsseldorf, Germany, V3.1.3) for sample size calculation. The effect size value was computed from the mean and the standard deviation of canine retraction in that study.
A paired sample t test was hired based on a (1:1) allocation ratio with a study power of 95% and 0.05 for alpha value.
Participants and eligibility criteria
The sample consisted of 40 patients (3 men, 37 women; 21.3 ± 1.8 years) seeking orthodontic treatment at the Department of Orthodontics at Damascus University – Faculty of Dentistry. The participants were chosen between September 2018 and March 2020 according to several inclusion and exclusion criteria. The inclusion criteria of the study included the patients aged (18–25 years), with an indication for extraction of all first premolars, complete permanent dentition (except third molars), no systemic diseases or drugs that affect teeth movement, healthy periodontium, and good oral hygiene. The exclusion criteria of the study included craniofacial anomalies, smokers, metallic restorations, and follow-up problems. An informed consent was obtained if the patient accepted the treatment plan.
Blinding and randomization
The sealed envelope technique was adopted to randomly allocate the groups (PRP or i-PRF) and choose the intervention side within each group (1:1). The envelopes contained either a right-upper, left-lower or a left-upper, right-lower sentence.
The participants were blinded for their allocation group, and the intervention side by using saline as a placebo on the other side. In addition, blinding was also applied to the assessment of outcomes.
The treatment was performed by the principal investigator (REN), under the supervision of the coauthor (MY) at the Department of Orthodontics at Damascus University – Faculty of Dentistry.
The intervention side of the mouth was randomly chosen to be injected with PRP or i-PRF, whereas the other side was considered as the control and injected with saline (placebo).
The injections were carried out twice: at the beginning of spring activation and after 21 days. The injections were done at five intra-ligament points of the canine: mid-distal, distobuccal, distopalatal, buccal, and palatal (4 units at each point) [Figure 2].
A fixed orthodontic appliance was used for retraction (Roth 0.018-inch brackets, Pinnacle, OrthoTechnology, Tampa, Florida) using Ricketts Retraction Spring (Blue-Elgiloy, 0.016*0.022 inches) to control canine tipping as much as possible while maintaining the elasticity of the spring [Figure 3].
Canine retraction was initiated after 14 days of premolars extraction by tipping the end of Ricketts spring 3 mm in the upper arch and 2 mm of Ricketts Delta spring in the lower arch to produce 150 g activation force. This process was repeated every 21 days until the end of canine retraction. In addition, anti-tip and anti-rotation bends were executed uniformly for all springs. Since the two-step retraction technique (canines followed by incisors) was employed in this study, the trans palatal arch (TPA) was used as a conventional anchorage device in addition to the lower lingual holding arch (LHA). Those anchorage mechanisms should be sufficient for the two-step retraction approach that usually reduces the anchorage needs.
Preparation of platelet-rich plasma and injectable platelet-rich fibrin
Twenty milliliters of the patient’s venous blood were drawn into vacuum blood collection tubes which contained Citrate-Phosphate Dextrose solution with Adenine (CPDA-1) as a platelet agglutination inhibitor.
Two blood separations were achieved: the first one was (1500 rpm for 10 min) to extract red blood cells from plasma. The second cycle (2800 rpm for 5 min) was performed for plasma containing blood platelets. Three milliliters of PRP were obtained after discarding the upper two-thirds of remaining plasma.
i-PRF was prepared at room temperature by separating 20 mL of venous blood (700 rpm for 3 min) in a dry tube. The upper 3 mL of the yellow-orange plasma was collected as the i-PRF.
The canine retraction rate was our primary outcome, whereas measurements of first molar anchorage loss, canine rotation, and inclination were counted as secondary outcomes. Alginate impressions (Cavex Impressional, Cavex, the Netherlands) were taken after 21 days (T1), 42 days (T2), 63 days (T3), and 84 days (T4) following the onset of canine retraction.
The canine retraction, rotation, and molar anchorage loss were measured on each side of the upper and lower casts at a 21-day interval between T0 (pre-treatment) and T4. However, the canine inclination was evaluated on cephalograms.
The studied casts were photographed using the same camera and stand following a standardized method. Each time, a specific holder was used with the same adjustments (level and height) while capturing all dental casts [Figure 4]. The camera settings were also the same for each photo. All images were taken under exactly identical conditions.
The reference points, lines, and angles are shown in [Figure 5][Figure 6][Figure 7]. Canine and first molar movement were measured directly on casts using a symmetry gauge by calculating the distance between a tangent line to the third palatal rugae to the tip of the canine, and the central fossa of the first molar on the upper arch. On the lower arch, the distance was measured between a horizontal plane from the central fossa of the second molar to the tip of the canine and the central fossa of the mandibular first molar, respectively.
|Figure 5: Cast models reference points (according to Ziegler and Ingervall, 1989a). (A) Tip of the canine. (B) Central fossa of the first molar. (C) The median palatal suture line. (D) The third palatal rugae. (E) The fossa of the second molar. (F) The median bony line of the mandible. (G and H) Mesial and distal margins of the canine|
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|Figure 6: Cast models reference lines: (A) Distance of upper canine retraction. (B) Distance of upper molar movement. (C) Distance of lower molar movement. (D) Distance of lower canine movement|
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|Figure 7: Cast models reference angles. (A and B) Angles between the median bony line and a line passing through the mesial to the distal margins of canine to evaluate canine rotation|
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The velocity was calculated as follows: v = d/t, where v is the velocity of canine movement, d is the amount of this movement in millimeters, and t is the total time needed to complete the retraction.
The angle of canine rotation was measured between the midline and a line passing through the distal and mesial margins of the canine. The cephalograms were analyzed to assess the inclination of canines at T0 and TF (end of canine retraction). The angle of inclination was calculated between the palatal and mandibular planes and their respective canine [Figure 8].
|Figure 8: Cephalometric reference lines and angles. (A) ANS–PNS (SPP), the maxillary plane. (B) Go–Me, mandibular plane. (C) UC: ANS–PNS, the angle between the upper canine axis and maxillary plane. (D) LC: Go–Me, the angle between the lower canine axis and mandibular plane|
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The IBM-SPSS Software was used for statistical analysis (SPSS, Chicago, Illinois, v22.0). The normality was detected by the Shapiro–Wilk normality test. As a result, the paired sample t tests and the two-sample t test were implemented to assess the differences between mouth sides and the two groups, respectively. P Values ≤ 0.05 were considered statistically significant accompanied by 95% of confidence interval.
The error of the method
Twenty model casts and twenty cephalometric radiographs were randomly chosen, then all the reference points were reidentified, and all measurements were recalculated using the previously mentioned method. Those measurements were carried out after a 4-week interval by the same investigator (REN). The intraclass correlation coefficient test (ICC) was made to assure the reportability of the used method, i.e., intra-observer reliability or (random error). At the same time, the paired t-tests were used to find any systematic error. Bland and Altman plots were also used to determine the correspondence between the two measurements. The Dahlberg’s formula was adopted to confirm the reliability of the measurements:
, where d is the difference between measurements.
| Results|| |
Forty patients were involved in this study without any patient loss.
The error of the method
There was no significant difference between the two measurements (P > 0.05); thus, the systematic errors were found to be insignificant ([Supplementary Table 1]).
|Supplementary Table 1: Additional file 1: Evaluation of the systematic error in the study (n = 20)|
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The ICCs were higher than 0.995, meaning that the intraexaminer reliability was also high ([Supplementary Table 2]).
|Supplementary Table 2: Intraclass correlation coefficients of repeated measurements in the current study for the assessment of random error (n = 20)|
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In addition, Bland and Altman plots showed a good correspondence between the two measurements ([Supplementary Table 3]).
|Supplementary Table 3: Levels of agreement of the performed measurements in this current study according to Bland and Altman’s analysis (n = 20)|
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The velocity of canine retraction
Regarding the PRP group, the retraction velocity of the upper and lower canines was not significantly greater in the intervention side compared to the control, except for the maxillary canine during the (T0–T1) period (P < 0.05). The mean amount of the upper canine retraction was (1.95 ± 1.47 mm, 1.15 ± 1.04 mm)/21 days, in the intervention and the control sides, respectively, with an acceleration rate of 41% [Table 1].
|Table 1: Descriptive statistics of the rate of canine retraction (mm/21 days) along with the P-values of significance tests|
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Despite a noted decrease in the rate of canine retraction in the i-PRF group, no statistical differences were recorded compared to the control side [Table 1].
There was no statistical difference in comparison between the two groups (PRP vs. i-PRF; P > 0.05) except for the PRP intervention side of the upper arch (T2–T3; P = 0.005), where 1.36 ± 0.92 mm/21 days velocity was recorded in the PRP group versus 0.53 ± 0.88 mm/21 days in the i-PRF group, with an acceleration rate of 61% [Table 1].
Canine rotation was more noticeable in the PRP intervention side related to the control one with no statistical difference (P > 0.05) except for the lower arch at T0–T1 and at T0–TF, where the mean value of lower canine rotation was 22.65° ± 6.56° and 15.5° ± 10.76° in the intervention and control side, respectively (P < 0.05) [Table 2].
|Table 2: Descriptive statistics of the canine rotation rate (degrees/21 days) as along with P–values of significance tests|
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However, there were no statistical differences within the i-PRF group in the context of canine rotation rate (P > 0.05). The values of upper canine rotation between T3–T4 and T0–TF were the only significant variables (P < 0.05) in the PRP group compared to the i-PRF group where the mean rotation amount at T0–TF was 22.02° ± 10.72° and 17.80° ± 7.76° for the PRP and i-PRF, respectively [Table 2].
Canine inclination on cephalogram was greater on the intervention side within the PRP group and the control side in the i-PRF group. At the same time, the amount of inclination was higher in PRP group compared to the i-PRF group without any significant differences [Table 3]. No significant differences were found in molar anchorage loss between any group (P > 0.05) [Table 4].
|Table 3: Descriptive statistics of the canine inclination rate (degree) along with the P–values of significance tests|
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|Table 4: Descriptive statistics of the molar movement rate (mm/21 days) as well as the P–values of significance tests|
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| Discussion|| |
Some biological materials have been introduced to shorten orthodontic treatment.[14-16],,,, To the best of our knowledge, this is the first trial comparing the effectiveness of two biological materials (the PRP and the i-PRF) in terms of canine retraction. Therefore, this research aimed to compare the effects of PRP, which was already approved by the FDA, and used in several studies, and the injectable platelet-rich fibrin (i-PRF) in accelerating OTM. The use of a placebo in the control side reduces the confounding factors by evaluating the effectiveness of the studied material, whereby the injection procedure and the twitch that happens may excite an inflammatory process and activate the stem cells in the area, on the intervention side. The injections were performed into the dentoalveolar ligament of the canines which were helpful at the same time in inducing coagulation cascade and producing thrombin to create a thrombus layer rich with platelets in contact with alveolar bone. Hence, a continuous releasing of growth factors begins to leach into the alveolar bone.
This study showed that PRP injection accelerated the canine retraction rate during the first month of intervention, and this was perhaps the increased release of growth factor that heightened bone regeneration., Besides, the rich content of cytokine-19 might have mediated differentiation, activation, and bone cell survival. Some trials on dogs and rats studied the effect of PRP on tooth movement, but the mechanism of action was not interpreted.
Rashid et al. reported an increase in osteoclast counts at the compression sites during the ninth week. On the contrary, Gulec et al. showed that the PRP accelerated tooth movement on days 7, 14, 21, and 60 regardless of osteoclasts count drop at compression sites compared to the control group. According to Akbulut et al., 80% of growth factors were reported to be released 24 hours after application and be finished in 2 weeks. Therefore, 14 days is enough to observe the early effects of PRP on tooth movement.
El-Timamy et al.’s study revealed that canine retraction was faster in the PRP intervention side than the control one during the first 2 months. However, the movement had slowed down during the third month by 40%, which was plausibly attributed to the use of calcium chloride as an anticoagulant which might have affected the results negatively.
The results of this study showed that i-PRF caused a slowdown of canine movement during the entire treatment period. This slowdown might have been due to insufficient duration or concentration of growth factor release during the second month. The i-PRF shortly turns into a fibrin thrombus characterized by a comparatively long retention period but only a 28-day gradual release of growth factors.
We agreed with Pacheco, who concluded that the canine distalization rate was faster on the control side than the PRF one. However, our results were not consistent with Zeitounlouian et al. outcomes which indicated a faster canine retraction in the i-PRF side during the second month. This could be related to the injection protocol. The current study was not compatible with Erdur’s and Karakasli’s studies,, which showed an acceleration of tooth movement when treatment combined with i-PRF., These differences could be explained by the timing of injections, the amount of injected substance, a different methodology, and the different types of tooth movement.
Our study’s results did not follow Nemtoi’s and Tehranchi’s studies, which assumed that PRF clots accelerated tooth movement., This disagreement might be related to the different forms of PRF used and the dissimilarity in retraction techniques, in addition to the arbitrary calculation in their measurements.
In comparison between our two groups, the results of this study showed that PRP injection led to an acceleration of canine retraction during the third month of intervention. Hence, PRP achieved more acceleration than i-PRF since the PRP releases a rapid and higher initial concentration of growth factors, whereas the i-PRF requires a longer time to do so. Besides, fibrin increases cell maturity, whereas PRP increases cell proliferation.
This study showed that PRP did not affect canine rotation rate except for the mandibular canine at (T0–T1, T0–TF), and these findings were in disagreement with El-Timamy et al.’s study.
It has also been found that the effect of the i-PRF on canine rotation was very limited, and a little higher on the control side without any significant difference (P > 0.05). This conclusion was similar to Zeitounlouian’s study, and it may be contributed to the limited amount of injected material.
Overall, the canine rotation rate was higher in the PRP group than the i-PRF group, except for the upper canine during the fourth month; This can be interpreted by that the faster canine movement is associated with a greater amount of rotation.
No statistical differences were detected concerning canine inclination within each group or between the two groups. However, our clinical results showed a higher inclination rate on the intervention side in the PRP group which coincide with the higher distalization rate, and on the control side of the i-PRF group, which support Pacheco et al. regarding i-PRF.
There were no statistical differences in the first molar anchorage loss in or between the two groups (P > 0.05), which might be due to an insufficient infiltration of the injected material or the spread of its growth factors to the molar region because of the thickness of bone. In other words, this insignificant difference could be attributed to the limited distribution of the material that was mainly located and concentrated at the canine region and far away from the molar (it has to spread for a long span) and this may hinder the effect of the material in the posterior area. These results are compatible with Zeitounlouian et al.’s study.
The follow-up period should have been longer to evaluate the effect of the PRP and the i-PRF more accurately. Further, the current trial did not assess the possible sex-related differences in tooth movement rate or even bone quality. However, the generalizability of these findings might be representative to some extent. Therefore, these limitations should be used to conduct further rigorous studies about the biomaterial use in orthodontic treatment in the future.
Based on the research findings, it can be concluded that:
- 1. The intra-ligament injected PRP could accelerate canine retraction during orthodontic treatment, but did not show long-term acceleration effects, so we disapproved the null hypothesis.
- 2. The injected PRF did not enhance the rate of canine retraction during orthodontic treatment, leading us to accept the null hypothesis.
- 3. The PRP is possibly superior to the i-PRF in accelerating canine retraction rate.
- 4. Neither PRP nor i-PRF could reduce the unwanted associated effects such as canine rotation, inclination, and molar anchorage loss.
Financial support and sponsorship
This study was self-funded by the author (REN) and was supported by the Scientific Research and Graduate Studies Council at Damascus University.
Conflict of interest
There are no conflicts of interest.
RN: Concept, design, data collection, clinical studies, analysis, literature search and article writing. MY: Concept, study design, supervision of data acquisition, analysis, and article writing. TZ and EO: Study developing, interpretation of the results, article preparation, and editing of the manuscript.
Ethical policy and institutional review board statement
This randomized study was approved by the institutional review board and ethical review committee of Damascus University (Damascus, Syria; institutional review board; Approval Number: no. 2754 on April 26, 2018).
Patient declaration of consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Data availability statement
The datasets used and/or analyzed during the current study are available from the corresponding author (Dr. Eyad Alomari, e-mail: [email protected]) on reasonable request.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]