Influence of Platelet Rich Plasma in orthodontic tooth movement.

1. INFLUENCE OF PLATELET RICH
PLASMA ON ORTHODONTIC TOOTH
MOVEMENTDr. Ishfaq Ahmad
BDS. BCS. MCPS. MS
Resident

2. WITH KIND PERMISSION OF
Dr. Mukhlesur Rahman Pinu
BDS, BCS, DDS, MCPS, FCPS
Head of the Department
Department of Orthodontics and Dentofacial Orthopedics
Dhaka Dental College

3. INTRODUCTION
Acceleration of tooth movement is always a concern of
both orthodontist and patient. Demand for shorter
treatment time with none to minimal side effects is a
main request of orthodontic treatment. Several
noninvasive or invasive techniques have been proposed
clinically or experimentally for accelerating orthodontic
tooth movement. Currently, the surgical-assisted
approaches have been proved to be the most effective
technique in accelerating orthodontic tooth movement.

4. But in comparison to the noninvasive approaches, they
all have surgical insults to the bone that trigger a
higher osteoclastic activity, resorption of the alveolar
bone, decrease of the alveolar bone density, and loss
of alveolar bone of the target teeth. Which is not
friendly to both of the patients and orthodontists.
To simulate the effects of surgical insult without
surgery, the local injection of cytokines or hormone
could be a substitute for the surgical insults, but it is
not practical clinically due to its systemic effects and
the need of frequent injections. Injection of autologous
platelet rich plasma (PRP) could be a better substitute
for bone surgery.
Platelet rich plasma (PRP) is another approach in tissue
regeneration which has been widely used in various
surgical filds including dental surgical procedures.

5. THE PLATELET RICH PLASMA
PRP was introduced in dental literature, in
1998, by Robert Marx, as an adjunct in the
mandibular reconstructive procedure,
enhancing the radiographic maturation rate
of the graft alone. Platelet-rich plasma (PRP)
is an autologous concentration of human
platelets in a small volume of plasma. It
comprises of the concentration of platelets
and the seven-fundamental growth factor
which are actively secreted by platelets to
initiate wound healing.

6. HOW PRP WORKS
Platelets are one of the initiators both in the soft and hard
tissue wound healing processes. Platelets contain growth
factors such as the platelet-derived growth factor,
transforming growth factor, endothelium growth factor,
and the others. These growth factors are critical in the
regulation and stimulation of the wound healing process,
and they play an important role in regulating cellular
processes such as mitogenesis, chemotaxis,
differentiation, and metabolism. Peripheral blood contains
94% of red blood cells (RBCs), 6% of platelets, and <1% of
white blood cells (WBCs), while PRP contains 5% of RBCs,

7. PRP HAS SHOWN
Oral surgery- to speed alveolar bone repair after extraction of impacted third
molars.
Temporomandibular joint disorders- pain reduction.
Periodontal surgery- accelerate the healing process of wounds and reduce
healing time and more favorable clinical improvements in intraosseous
periodontal defects.
PRP applications in orthodontics include its potential use to accelerate tooth
movement without any other accelerators of treatment as well the use of PRF
to accelerate wound healing and reducing post-surgical pain in patients
treated with periodontally accelerated osteogenic orthodontics. It has also
been used to preserve alveolar ridge and potentially promote bone formation
in alveolar cleft repair patients.

8. TYPES OF PRP IN ORTHODONTICS
Considering the bioactive
properties of platelets in the
healing process, they can be used
as a valuable therapeutic adjunct
in medicine and dentistry.
Platelet-rich plasma (PRP) and
leukocyte platelet-rich fibrin
(LPRF) are the two main
autologous products derived from
platelets. They are both clinically
effective in accelerating the
healing process. They can be
used in injectable form and fibrin

9. THE PREPARATION OF PLATELET
RICH
PLASMA FOR ORTHODONTIC
PURPOSESThe autologous PRP should be prepared under
aseptic processing procedures [Figure 1].
A volume of 60 ml of whole blood is drawn from
the medial cubital vein of a patient using three 30
ml syringes that each contained 3 ml of 10%
sodium citrate solution as an anticoagulant.
Heparin is not recommended for using as the
anticoagulant due to its systemic effects and
inducing alveolar bone resorption. 1 ml of the
blood is used for checking the platelet counts.

10. The remaining 59 ml of whole blood is
first centrifuged under 1000 rpm for 12
min at room temperature. The blood is
then separated into its 3 basic
components as the RBCs at the bottom,
the buffy coat (platelets) in the middle,
and the platelet poor plasma (PPP) at the
top.
The RBCs is discarded, and the
remaining buffy coat and PPP are
collected and centrifuged again under
3000 rpm for 8 min. After the second
centrifugation, the PPP is removed until
4 ml remained and then the remaining
PPP is mixed with the buffy coat to
become PRP. One ml of the PRP is
analyzed for its platelet count.
Under such a preparation, the PRP
contains anticoagulant, high
concentration of platelets, and a few of

12. PREPARATION OF LEUKOCYTE
PLATELET-RICH FIBRIN
Preparation of leukocyte platelet-rich fibrinThe protocol for LPRF preparation was
simple and included the collection of whole venous blood from the brachial vein using a
10 mL syringe. The collected blood was transferred into two sterile vacutainer tubes (9
mL) without anticoagulant and were placed symmetrically into the centrifuge device.
The intraspin tubes were immediately centrifuged (PCO2 Process) at 2700 rpm for 12
min, after which, three layers were formed: red blood cells at the bottom, upper straw-
colored cellular plasma, and the middle fraction containing the fibrin clot and platelets.
The upper straw-colored layer was discarded, and the middle fraction was collected, 2
mm below the lower dividing line, which was LPRF. Fibrinogen which is initially
concentrated in the upper part of the tube is combined with the circulating thrombin
following centrifugation to form fibrin. A fibrin clot is then formed in the middle of the
tube, right between the red corpuscles at the bottom and acellular plasma at the top.
Platelets are trapped massively in the fibrin mesh Collection of venous blood from the
brachial vein using a 10 mL syringe. (b) Platelets are trapped massively in the fibrin
meshThe central part includes platelets trapped massively in the fibrin mesh. The
success of this technique entirely depends on the time interval between blood collection
and its centrifugation, which should be minimized. The blood sample without
anticoagulant starts to coagulate almost immediately upon contact with the glass and
decreases the required centrifugation time to concentrate fibrinogen. Adherence to the
correct preparation protocol and quick handling are critical to obtain clinically usable
LPRF clot charged with serum and platelets. Resistant autologous fibrin membranes may
be available by driving out the fluids trapped in the fibrin matrix.

13. PREPARATION OF LEUKOCYTE
PLATELET-RICH FIBRIN

15. THE SUBMUCOSAL INJECTION OF
PLATELET
RICH PLASMA FOR ORTHODONTIC
PURPOSESThe PRP together with the
containing anticoagulant is injected
submucosally. Due to the presence
of anticoagulant,we surmised that
after injection of PRP, only part of
the platelets adhere and aggregate
little by little on the surfaces
of collagen fibers, the intrinsic and
extrinsic pathways of hemostasis
initiate to generate thrombin
gradually, platelet clots lay down
little by little above the
periosteum, and
then the growth factors release and
infiltrate little by little into the
periosteum and alveolar bone. The
procedures of

16. • Before the injection of PRP, local anesthesia
(Xylocaine) should be injected at the target sites for
the pain control.
• For each target site, 0.7 ml of PRP could be
injected. It is better to inject through the attached
gingivae into the oral mucosa using a 27-gauge
dental needle to avoid leakage of the PRP.
• It is a submucosal injection rather than a
sub-periosteal injection. It is just similar to the
injection of local anesthesia, and it has no certain
injection pattern.
• Acetaminophen (500 mg) could be prescribed for
the post injection pain control. Nonsteroidal anti
inflmmatory drug will neutralize the effects PRP
and is not appropriated for the post injection pain
control.

17. THE CLINICAL APPLICATIONS FOR
PLATELET
RICH PLASMA SUBMUCOSAL
INJECTIONThe injection of PRP could be applied for accelerating orthodontic
tooth alignment and leveling in anterior crowding [Figure 3], and
space closure in en masse anterior
retraction [Figure 3] or molar protraction [Figure 4]. It could also be
used for preserving the pressure side alveolar bone of en masse
anterior retraction.
• The target sites of injection are the labial and lingual/palatal sides
of the anterior teeth when the purpose of injection is to accelerate the
alignment and leveling.
• The target site is the lingual/palatal side of anterior teeth when the
purpose is to accelerate anterior retraction or to preserve the
pressure side alveolar bone.
• The target sites could be the buccal, lingual/palatal, and mesial
sides of the posterior teeth when the purpose is to accelerate the
protraction of posterior teeth or preserve the alveolar bone of the

20. THE DOSAGE AND EFFECTS OF
SUBMUCOSAL INJECTION OF
PLATELET RICH PLASMA
A single injection of PRP lasts for 5–6 months clinically. It has been
observed clinically that the fastest rate of acceleration is during the
second to fourth month after the injection. The applied regimen for
different purposes is summarized:
• Single injection of PRP in the beginning of treatment for the
purpose of alignment and leveling.
• One injection of PRP in the beginning and another boost of injection
6 months after the fist injection for the purpose of anterior retraction.
• One injection of PRP in the beginning and another boost of injection
6 months after the fist injection for the purpose of protraction of
posterior teeth.

21. Our clinical data revealed that the submucosal injection of
PRP accelerated orthodontic tooth alignment and
decreased the alveolar bone loss on the pressure side of
orthodontic tooth movement. The injection of PRP
accelerated the mandibular or maxillary anterior teeth
alignment 1.7 folds in average (range from 1.3 to 2.1
folds), and the acceleration was dose-dependent when the
PRP fold (platelet count in PRP/platelet count in blood) was
<12.5. The optimal PRP fold for a more than 2-fold of
acceleration of orthodontic alignment was found to be 9.5
to 12.5 folds. On the other hand, the submucosal injection
of PRP in the pressure side of en masse anterior retraction
decreased 71–77% of alveolar bone loss, and this was PRP
dose-dependent. The pressure side was found having no
alveolar bone loss when the PRP fold was higher than 11.0.
In summary, the optimal PRP fold for a higher than 2-fold
acceleration of orthodontic tooth movement and no

23. Objective:
The aim of this study was to evaluate the effect of LPRF, placed in
extraction sockets, on orthodontic tooth movement (OTM).
Materials and Methods:
Thirty extraction sockets from eight patients (five males, three females,
with a mean age of 17.37 years; range 12–25 years) requiring extraction
of first premolars based on their orthodontic treatment plan
participated in this split-mouth clinical trial. In one randomly selected
quadrant of each jaw, the extraction socket was preserved as the
experimental group by immediate placement of LPRF in the extraction
socket. The other quadrant served as the control group for secondary
healing. Immediately, the teeth adjacent to the defects were pulled
together by a NiTi closed-coil spring with constant force. A piece of
0.016 × 0.022-inch stainless steel wire was used as the main arch wire.
The amount of OTM was measured on the study casts at eight time
points with 2-week intervals for 3 months. Analysis of random effect
model was performed for the purpose of comparison between the
experimental and control groups.

24. Results:
According to the random effect model, a statistically
significant difference was found between the experimental
and control group in rate of OTM (P = 0.006).
Conclusion:
According to the results, application of LPRF, as an
interdisciplinary approach combining orthodontics and
surgery, may accelerate OTM, particularly in extraction
cases.

26. Effcts of PRP on the rate of orthodonti tooth movement have been
investiated by [35] in six skeletally mature male mongrel dogs. The
maxillary second premolar in each dog was extracted bilaterally. PRP
was prepared and injected around the fist premolar in one randomly
selected maxillary quadrant while the other quadrant served as the
control. Coil springs (150 g) were used to distalise the fist premolars
for 63 days using temporary anchorage devices. The results showed
total maxillary tooth movement was signifiantly faster on the
experimental side compared to the control side (mean movement of
15.60mm versus 9.46mm). Local injectin of PRP in this animal study
resulted in accelerated orthodonti tooth movement with no obvious
clinical or microscopic side effcts.

28. Seventy-six rats were divided into 2 groups: A moderate
concentration PRP injection group and a high concentration PRP
injection group. In each group, 5-tie points were studied: 3, 7,
14, 21, and 60 days. Before orthodontic mesializatin of the
maxillary fist molar, moderate and high concentrations of PRP
were injected on the right sides of the molar buccal sulcus, and
the lef sides served as the controls. Tooth movements were
measured on 3-dimensional digital models. Alveolar bone
volume density and osteoclastic actiity in the fist molar
intraradicular areas were evaluated by histomorphometric
analysis.
The results showed alveolar bone density was decreased in the
experimental groups compared with the control groups at 3, 7,
14, and 21 days. On day 3, the osteoclastic actviity of the
experimental groups was higher than that of the controls. On
day 21, the amount of tooth movement in the high-
concentration experimental group were 1.7 ties greater than in
the high-concentration control group and 1.4 ties greater than
in the moderate-concentration experimental group. On day 60,
alveolar bone density increased to original levels in all groups.
The study found injection of both moderate and high
concentrations of PRP might accelerate orthodontic tooth
movement by decreasing alveolar bone density on para-dental
tissues by enhancing osteoclastic activity in a transient way.

29. EFFECT ON ROOT RESORBTION
There is no data or research found on the effect of Pletelet Rich
Plasma and Fibrin on Root resorbtion under orthodontic force. So tere
is a scope of further research On this perspective.

30. CONCLUSIONS
PRP has the potential and capability to promote
periodontal regeneration through various mechanisms.
The effect of PRP in localized acceleration of tooth
movement is dependent on the concentration used.
However, the method of synthesis is critical to the success
of PRP based acceleration of tooth movement. The use of
injectable PRP at a different stage of orthodontic treatment
can improve the quality of the treatment outcome by
influencing the bone quality and enhancing the rate of
tooth movement.

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