## 4 Discussion  
In this series of patients, one patient (patient #2) received autogenous free fat graft (AFFG) transplant combined with L-PRF for management of ORN. This patient was previously managed with multiple sessions of surgical debridement over a period of two years but failed to show any satisfactory healing. There was recurrent infection with suppuration at the ORN defect. AFFG was used to obliterate the osseous defect with PRF lining the recipient bed as there was inadequate soft tissue to cover the defect. The remaining cases in this series have adequate soft tissue to allow primary closure. In the MRONJ group, drug holiday was not advised in patients #5 and #6 due to the high fracture risk, while in patients #7 and #8, decision of treatment break for three months was made in view of low to moderate fracture risk. The administration of pentoxifiline and \(\alpha\)-tocopherol post-operatively in patients #7 and #8 for management of MRONJ was similar to previous report by [PERSON] et al. 2010 [31]. The medications were well tolerated, and no adverse effects were reported. The use of autologous platelet concentrates in the management of both ORN and MRONJ has immense therapeutic potential. L-PRF, a second-generation APC, is preferred to PRP in the management of such lesions for a few reasons. Firstly, elimination of anticoagulants during its preparation ensures that it is strictly autologous with no additional chemicals. This reduces the possibility of any immunogenic reaction. Secondly, its improved formulation allows it to be used in either a liquid or solid form. Three layers are formed after centrifugation: the red blood cell base layer, acellular plasma top layer, and a PRF clot in the middle. The L-PRF clot is a strong fibrin matrix with a complex three-dimensional architecture containing a dense concentrate of platelets and leucocytes, as well as a variety of growth factors and cytokines, including transforming growth factor beta 1 (TGF-\(\beta\)1), platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), interleukin (IL)-1\(\beta\), IL-4, and IL-6 [34]. Thirdly, unlike PRP, L-PRF does not dissolve quickly after use, leading to an increased lifespan for cytokines. It also shows a substantial embedding of the growth factors of platelets and leucocytes into the \begin{table}
\begin{tabular}{c c c c c c c c c c c c c} \hline \hline
**No** & **Age** & **(y)** & **Sex** & **Primary** & **Disease** & **Details of BP** & **Smoker** & **MH** & **Stage** & **Max/Mand** & **Site** & **Procedure** & **Follow-Up** & **Outcome** \\ \hline
5 & 77 & F & Osteoporosis & \begin{tabular}{c} Ibandronate \\ (IV) 2 months \\ \end{tabular} & No & \
\begin{tabular}{c} DM, \\ HPT, \\ CKD \\ \end{tabular} & 2 & Mand & 34 to 44 &
\begin{tabular}{c} Sequestrectomy, \\ PRF application \\ and PC \\ \end{tabular} & 3 years & Failed \\ \hline
6 & 69 & F & \begin{tabular}{c} Rheumatoid \\ arthritis \\ \end{tabular} & \begin{tabular}{c} Alendronate (oral) 15 years & No & \
\begin{tabular}{c} HPT, \\ CS, \\ OA, \\ PE, \\ DLP \\ \end{tabular} & 2 & Mand & 33, 34 &
\begin{tabular}{c} Sequestrectomy, \\ extraction 34, \\ PRF application \\ and PC \\ \end{tabular} & 2 years & Healed \\ \hline
7 \({}^{\dagger}\) & 78 & F & \begin{tabular}{c} Left breast \\ carcinoma \\ \end{tabular} & \
\begin{tabular}{c} Zoledronate \\ (IV) 3 years \\ \end{tabular} & No & DLP & 2 & Mand & 36 &
\begin{tabular}{c} Sequestrectomy, \\ PRF application \\ and PC \\ \end{tabular} & 4 months & Healed \\ \hline
8 \({}^{\dagger}\) & 68 & F & Osteoporosis & \begin{tabular}{c} Alendronate (oral) 2 years & No & \
\begin{tabular}{c} DM, \\ HPT, \\ HDF \\ DLP \\ \end{tabular} & 2 & Mand & 36 to 38 &
\begin{tabular}{c} Sequestrectomy, \\ PRF application \\ and PC \\ \end{tabular} & 3 months & Healed \\ \hline \hline \end{tabular}
\end{table} 
Table 3: Clinical characteristics of patients with medication-related osteoneogenesis of the jaws (MRONJ) treated with PRF as adjunct. more favorable architecture of the physiological fibrin matrix [35].