# MRONJ Treatment Strategies: A Systematic Review and Two Case Reports
## 4 Discussion
### Fluorescence-Guided Bone Surgery
Another strategy that might be used is the use of autologous preparations made from the patient's blood, platelet-concentrate products, such as platelet-rich plasma (PRP), platelet-rich fibrin (PRF), and concentrated growth factor (CGF), that release large amounts of growth factors playing an important function in bone biology by speeding up and improving bone repair or regeneration [75, 76, 77, 78, 79]. Autologous platelet concentrates (APC) are employed in various fields of dentistry since their role in bone and soft tissue regeneration has been demonstrated [80, 81, 82]. APC induces target cells to synthesize growth factors (GF) such as TGF-\(\beta\)1, PDGF-BB, VEGF-A, and IGF-I which influence important processes involved in tissue healing, chemotaxis, cell proliferation, differentiation, and extracellular matrix production [83,84]. They promote healing by bringing in leukocytes, increasing collagen production, generating anti-inflammatory agents, and beginning internal vascular development [85]. The amount and rate of GF release have been demonstrated to differ between CGF, PRF, and PRP: PRP enables faster delivery of GFs to the target site, even if using PRF or CGF leads to a considerable increase in GFs, compared to PRP [86, 87, 88]. PRP, PRF, and CGF have been utilized therapuctically for various purposes, including the treatment of MRONJ, and have shown extremely promising outcomes in several trials [89, 90]. According to researchers, APCs might help cure osteonecrosis by increasing patients' quality of life and decreasing pain and postoperative infections [91, 92, 93]. Including PRP in surgical therapy for MRONJ patients tends to improve the recurrence rate, with good healing in 85-90% of instances [94,95]. The use of PRP has been proposed in several studies to treat osteonecrosis caused by BPs. In a study by [PERSON] et al., patients with BRONJ were treated with surgical necrotic bone resection and PRP discovering that full wound healing was achieved in most patients and that the BRONJ treatment duration was reduced [96]. [PERSON] et al. used PRP in the surgical treatment of BRONJ, allowing quicker mucosal healing, less analgesic use, and better clearance of oral lesions [97]. Moreover, the study of [PERSON] et al. showed positive results in terms of preservation or regeneration of bone with the use of PRP in BRONJ treatment [75]. PRP has been proposed as a first-generation platelet concentrate, but anticoagulants have been shown to interfere with platelet-mediated angiogenic and regenerative responses [98]. [PERSON] developed a second-generation platelet concentrate, termed platelet-rich fibrin (PRF), that required no manipulation after blood collection and centrifugation as a substitute for PRP [99,100]. The fibrin clot's slow and continuous release of various proangiogenic growth factors and cytokines promotes the proliferation and differentiation of osteoblasts, endothelial cells, chondrocytes, and fibroblasts, improving soft tissue and bone regeneration [101]. So far, literature regarding the use of PRF in the surgical treatment of MRONJ is scarce. [PERSON] et al. compared the surgical treatment according to current guidelines to the addition of PRF in patients with stage I-III MRONJ, finding no statistically significant differences between the two groups in terms of wound healing, disease downstaging, pain reduction, and quality of life [45]. A different result has been reported by [PERSON] et al. that used PRF for the surgical treatment of osteonecrosis of the jaw, showing its use in grade 2 ONJ may be a factor In favorable outcomes [102]. In the study by [PERSON] et al., seventy patients with MRONJ were treated surgically with local debridement and PRP placement, finding a recurrence rate of 18.6% of the patients [38]. In a randomized control trial of patients with stage II and III MRONJ, [PERSON] et al. compared a control group to which surgical removal of necrotic bone was performed and an experimental group in which surgical removal with the addition of PRF was performed.