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Table of Contents
CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 2  |  Page : 76-79

Surgical management of a large inflammatory periapical lesion with platelet-rich fibrin


1 Department of Conservative Dentistry and Endodontics, GSL Dental College and Hospital, Rajahmundry, Andhra Pradesh, India
2 Department of Conservative Dentistry and Endodontics, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India

Date of Web Publication9-Aug-2017

Correspondence Address:
Nalam N. V. D. Prasanthi
Department of Conservative Dentistry and Endodontics, GSL Dental College and Hospital, Rajahmundry - 533 296, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_77_15

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   Abstract 

Periapical inflammatory lesion is the local response of bone around the apex of tooth that develops after the necrosis of the pulp tissue or extensive periodontal disease. The final outcome of the nature of wound healing after endodontic surgery could be repair or regeneration depending on the nature of the wound, the availability of progenitor cells, signaling molecules and microenvironmental cues. The purpose of this case report is to add knowledge to the existing literature about the use of platelet-rich fibrin (PRF) in the treatment of large periapical lesion. A periapical endodontic surgery was performed on a 33-years-old female patient with a swelling in the palatal region of upper front teeth with a large bony defect radiologically. The surgical defect was filled with PRF membrane and sutured. The present case report concluded that PRF produced by high-speed centrifugation accelerated the wound healing and induced the rapid rate of bone formation.

Keywords: Mineral trioxide aggregate, periapical inflammatory lesion, periapical surgery, platelet-rich fibrin, wound healing


How to cite this article:
Prasanthi NN, Chittem J, Simpsy GS, Sajjan GS. Surgical management of a large inflammatory periapical lesion with platelet-rich fibrin. J Interdiscip Dentistry 2017;7:76-9

How to cite this URL:
Prasanthi NN, Chittem J, Simpsy GS, Sajjan GS. Surgical management of a large inflammatory periapical lesion with platelet-rich fibrin. J Interdiscip Dentistry [serial online] 2017 [cited 2019 Sep 15];7:76-9. Available from: http://www.jidonline.com/text.asp?2017/7/2/76/212606


   Clinical Relevance to Interdisciplinary Dentistry Top


  • Vital pulp therapies are aimed to maintain the health of pulp tissue by eliminating bacteria from the dentin-pulp complex
  • PRF which has high concentration of growth factors plays a major role in wound healing
  • Biodentine is a new bioactive calcium silicate based material that is used in vital pulp therapies.



   Introduction Top


Successful endodontic therapy depends on complete periapical repair and regeneration. In cases where conventional root canal therapy fails to eliminate the lesion, surgery is the last alternative.[1] Periapical surgery aims to remove periapical pathology followed by achieving complete wound healing and regeneration of the bone and periodontal tissue.[2],[3] In modern endodontic practice, the number of indications for endodontic periapical surgery is decreasing, but still periapical surgery accounts for 3%–10% of typical endodontic practice.[4]

Platelet-rich fibrin (PRF) is coming up as a biological revolution in dental field which is an immune and platelet concentrate with specific composition, three-dimensional architecture, and associated biology that collects all the constituents of a blood sample to favor wound healing and immunity.[5] PRF contains multitude of growth factors such as platelet-derived growth factor (PDGF), transforming growth factor β1 (TGF β1), insulin-like growth factor (IGF), and exhibiting varied potent local properties such as cell migration, cell attachment, cell proliferation, and cell differentiation.[6] Usage of PRF is a way to accelerate and enhance the body's natural wound healing mechanisms. Enhancement of the regenerative process of human body by utilizing the patient's own blood is a unique concept in dentistry. Postsurgically, blood clots initiate the healing and regeneration of the hard and soft tissues.[4],[7],[8]

PRF is both a healing and an interpositional biomaterial. As a healing material, it accelerates wound closure and mucosal healing due to fibrin bandage and growth factor release. PRF as an interpositional material, avoids the early invagination of undesired cells, thereby behaves as a compet itive barrier between desired and undesired cells. An easy, cost-effective way to obtain high concentrations of growth factors for tissue healing and regeneration is autologous platelet storage through PRF. The purpose of this case report is to add knowledge to the existing literature about the use of PRF in the treatment of large periapical lesion.[5]


   Case Report Top


A 33-years-old female patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of swelling on the inner surface of gum region in relation to upper front teeth for the past 10 days. Swelling was initially small, then gradually progressed and was associated with discomfort while taking food. Clinical examination revealed Ellis Class IV fracture in 21 with a swelling of 2.5 cm × 2 cm size seen over the palatal mucosa in relation to 21, 22, and 23 [Figure 1]a. Tenderness was felt on palpation over the apical mucosa in relation to 21, 22, and 23. These three teeth were sensitive to percussion tests. Pulp sensitivity tests revealed that 11, 21, 22, and 23 were nonvital. Preoperative intraoral periapical radiograph of 21, 22, and 23 reveals presence of large irregular periapical radiolucency (3 cm × 2 cm in size) at the apex of 21, 22, and 23 [Figure 2]a and [Figure 2]b. This case was planned for conventional root canal treatment followed by periapical surgery.
Figure 1: (a) Preoperative intraoral clinical photograph showing palatal swelling of 2.5 cm × 2 cm. (b) Preoperative maxillary occlusal radiograph showing periapical lesion of 3 cm × 2 cm. (c) Preoperative intraoral radiograph of 11, 21, 22 and 23

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Figure 2: Surgical management: (a) Elevation of full thickness mucoperiosteal flap. (b) Enucleation of the lesion. (c) Enucleated specimen. (d) After root resection. (e) Platelet-rich fibrin placement into the surgical defect

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The root canal treatment was performed using step back technique till an apical size of #50, # 55, #45, and #60 in relation to teeth 11, 21, 22, and 23, respectively. Sodium hypochlorite (5.25%) solution (Prime Dental Products Pvt. Ltd., Thane, India) was used to irrigate the canals during the canal preparation. Nearly 2% chlorhexidine solution (ICPA Health Products Ltd, India) was used as the final irrigant after biomechanical preparation. The root canal treatment was performed in three visits, and calcium hydroxide was used as the intracanal medicament. The root canals were obturated using gutta-percha (Dentsply Maillefer, Ballaigues, Switzerland) and AH 26 sealer (Dentsply DeTrey GmbH, Philadelphia, USA) by lateral compaction technique. Before planning for the surgical procedure, patient's platelet count (4 lakh/mm3), hemoglobin (12 g/dl), bleeding time (2.5 min), and clotting time (4.5 min) were assessed and found to be within normal limits. Informed consent was obtained from the patient. Under local anesthesia (1:200,000 adrenaline, DJ Lab, India), a full thickness mucoperiosteal flap was reflected by a sulcular incision starting from the distal aspect of the tooth 12 to distal aspect of the tooth 25 [Figure 2]a. A large periapical defect was seen with complete loss of labial cortical plate. The lesion measured 2.5 cm, 2 cm, and 2 cm corresponding to the length, width, and depth of the lesion. Tissue curettage was done at the defect site followed by thorough irrigation using sterile saline solution [Figure 2]b and [Figure 2]c. Using #702 tapered fissure bur (SS White Burs), root end resection was performed in teeth 11, 21, 22, and 23 [Figure 2]d. Root end cavity of 3 mm depth was prepared with diamond-coated ultrasonic surgical tip S12 90ND (Satelec/Acteon, Merignac, France) at high-power setting of ultrasonic device. White mineral trioxide aggregate (MTA) (ProRoot MTA; Dentsply, Tulsa, USA) was used as the root end filling material. A volume of 10 mL of blood was drawn from the patient's antecubital vein and centrifuged (REMI centrifuge machine Model R-8c with 15 mL swing out head) for 10 min under 3000 revolutions (approximately 400 g) per minute to obtain the PRF. The resultant product consisted of the following three layers:

  • A cellular platelet poor plasma at the top of the tube
  • Fibrin clot (PRF) in the middle of the tube and
  • Red blood corpuscles at the bottom of the tube.


PRF was carried and packed into the defect to the level of defect walls [Figure 2]e. Flap stabilization was done followed by suturing using 3-0 black silk suture material (Sutures India Pvt. Ltd, Karnataka, India). Analgesics and antibiotics were prescribed, and the patient was advised to use 0.2% chlorhexidine mouthwash for a week. Suture removal was done 1 week later and the healing was satisfactory.

Patient was reviewed at 3 months [Figure 3]a and [Figure 3]b and 12 months [Figure 3]c during which there were no symptoms of pain, inflammation, or discomfort. These follow-up visits included routine intraoral, radiographic examinations, and professional plaque control. Radiographically, periapical bone regeneration was evident at the end of 12 months [Figure 3]d.
Figure 3: Follow-up: (a) Three months' follow-up clinical photograph showing complete resolution of palatal swelling. (b) Three months' follow-up radiograph showing decrease in the size of periapical radiolucency to 1.5 cm × 1.2 cm. (c) Ten months' follow-up clinical photograph. (d) Twelve months' follow-up radiograph showing maximum resolution of periapical radiolucency

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   Discussion Top


Orthograde root canal therapy should be the first option for treatment of all inflammatory periapical lesions which have 85% of success rate. Periapical surgery remains the last resort when orthograde treatment fails or is not possible. After a surgical procedure, healing usually occurs by repair or regeneration.[5] Regeneration has been defined as the reproduction or reconstitution of a lost or injured part to restore the architecture and function of the periodontium. Regenerative surgery with the use of barrier membrane and graft material can support the formation of new tissue and allows for regenerative rehabilitation with functional reconstruction.[9] The four critical factors that influence bone regeneration after the periapical surgery are primary wound closure, angiogenesis as a blood supply and source of undifferentiated mesenchymal cells, space maintenance, and stability of the wound (PASS principle).[10]

The present case report evaluated the clinical efficacy of PRF in the treatment of intrabony defect. PRF is a matrix of autologous fibrin with a large quantity of platelet and leukocyte cytokines embedded in it. As the network of fibrin disintegrates, the intrinsic incorporation of cytokines within the fibrin mesh allows their progressive release over time (7–11 days).

The main component of PRF is high concentration of growth factors present in the platelets which are required for wound healing.[11],[12],[13],[14] Among the various growth factors, PRF contains PDGF, TGF-β1 and β2, IGF, epidermal growth factor (EGF), vascular EGF-, and fibroblast growth factors which are believed to play a major role in bone metabolism and potential regulation of cell proliferation.[2],[4],[5] PDGF is an activator of collagenase which promotes the strength of healed tissue. TGF-β activates fibroblasts to form procollagen which deposits collagen within the wound. PRF facilitates healing by controlling the local inflammatory response.[2],[12]

According to Simonpieri et al.,[15] the use of this platelet and immune concentrate during bone grafting offers the following four advantages:First, the fibrin clot plays an important mechanical role and serves as biological connectors between the bone particles. Second, the integration of this fibrin network into the regenerative site facilitates cellular migration, particularly for endothelial cells necessary for the neoangiogenesis, vascularization and survival of the graft. Third, the platelet cytokines (PDGF, TGF-α, IGF-1) are gradually released as the fibrin matrix is resorbed, thus creating a perpetual process of healing. Finally, the presence of leukocytes and cytokines in the fibrin network also plays a significant role in the self-regulation of inflammatory and infectious phenomena within the grafted material.

Preparation of PRF is quite easy, fast, and simplified process when compared to platelet-rich plasma (PRP) where artificial biochemical modification is required. It eliminates the redundant process of adding anticoagulant as well as the need to neutralize it. The addition of bovine-derived thrombin to promote conversion of fibrinogen to fibrin in PRP is also eliminated. The elimination of these steps considerably reduces biochemical handling of blood as well as risks associated with the use of bovine-derived thrombin.[7] PRF preparation process creates a gel-like fibrin matrix polymerized in a tetramolecular structure, which incorporates platelets, leukocyte, cytokines, and circulating stem cells. PRF is a by-product of the patient's own blood; therefore, chances of infectious disease transmission are rare. Since PRF harvesting is done with only 8-10 ml of blood, the patients' need not bears the expense of the harvesting procedure in hospital or at the blood bank.[2],[4],[5],[7],[16]


   Conclusion Top


PRF is a healing biomaterial as it contains all the factors required for optimal wound healing. Previous research and clinical experience indicate that PRF improves early wound closure, maturation of bone, and the final aesthetic result of the periodontal soft tissues. Long-term follow-up of the present case and long-term controlled clinical trials will be required to evaluate the final treatment outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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Mazumbar P, Bhunia S. Treatment of periapical lesion with platelet rich fibrin. Indian Med Gazette 2013:28-33.  Back to cited text no. 1
    
2.
Singh S, Singh A, Singh S, Singh R. Application of PRF in surgical management of periapical lesions. Natl J Maxillofac Surg 2013;4:94-9.  Back to cited text no. 2
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Mazumdar S, Joshi S, Ansari S. Experiences with the use of PRF (Plasma Rich Fibrin) in enucleated cystic cavity. J Indian Dent Assoc 2014;8:19-26.  Back to cited text no. 3
    
4.
Hiremath H, Motiwala T, Jain P, Kulkarni S. Use of second-generation platelet concentrate (platelet-rich fibrin) and hydroxyapatite in the management of large periapical inflammatory lesion: A computed tomography scan analysis. Indian J Dent Res 2014;25:517-20.  Back to cited text no. 4
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Sunitha Raja V, Munirathnam Naidu E. Platelet-rich fibrin: Evolution of a second generation platelet concentrate. Indian J Dent Res 2008;19:42-6.  Back to cited text no. 7
    
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Kiran NK, Mukunda KS, Tilak Raj TN. Platelet concentrates: A promising innovation in dentistry. J Dent Sci Res 2011;2:50-61.  Back to cited text no. 8
    
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Bhandari S, Ashwini TS, Naik R, Bandiwadekar T, Makandar S. Regenerative periapical surgery: A case report. Dent Hypotheses 2013;4:61-6.  Back to cited text no. 9
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Boyapati L, Wang HL. The role of stress in periodontal disease and wound healing. Periodontol 2000 2007;44:195-210.  Back to cited text no. 10
    
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Gassling V, Douglas T, Warnke PH, Açil Y, Wiltfang J, Becker ST. Platelet-rich fibrin membranes as scaffolds for periosteal tissue engineering. Clin Oral Implants Res 2010;21:543-9.  Back to cited text no. 11
    
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Corso MD, Toffler M, Ehrenfest DM. Use of autologous leucocyte and platelet rich fibrin (L-PRF) in post-avulsion sites: An overview of Choukran's PRF. J Implant Adv Clin Dent 2010;1:27-35.  Back to cited text no. 12
    
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Deenadayalan E, Kumar A, Tewari RK, Mishra SK, Iftekhar H. Management of large periapical lesion with the combination of second generation platelet extract and hydroxyapatite bone graft: A report of three cases. J Clin Diagn Res 2015;9:D24-7.  Back to cited text no. 13
    
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Nagaveni NB, Kumari KN, Poornima P, Reddy V. Management of an endo-perio lesion in an immature tooth using autologous platelet-rich fibrin: A case report. J Indian Soc Pedod Prev Dent 2015;33:69-73.  Back to cited text no. 14
    
15.
Simonpieri A, Del Corso M, Sammartino G, Dohan Ehrenfest DM. The relevance of Choukroun's platelet-rich fibrin and metronidazole during complex maxillary rehabilitations using bone allograft. Part II: Implant surgery, prosthodontics, and survival. Implant Dent 2009;18:220-9.  Back to cited text no. 15
    
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[PUBMED]  [Full text]  


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  [Figure 1], [Figure 2], [Figure 3]



 

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