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Table of Contents
Year : 2021  |  Volume : 11  |  Issue : 3  |  Page : 149-152

Use of platelet-rich fibrin membrane with tricalcium silicate in interdisciplinary management of fractured fused anterior teeth with periapical pathology

Department of Periodontology, GDCRI, Bengaluru, Karnataka, India

Date of Submission13-Aug-2020
Date of Decision30-May-2021
Date of Acceptance15-Jun-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Dr. C N Guruprasad
Department of Periodontology, GDCRI, Fort, Bengaluru - 560 002, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jid.jid_69_20

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The ultimate goal in modern dentistry is to achieve white and pink esthetics. Optimal periodontal health without encroaching biologic width is the foundation upon which reconstruction of teeth is based. This case report presents the multidisciplinary management of an orthodontic patient who reported with fractured fused endodontically treated upper right anterior teeth with periapical lesion. Crown lengthening procedure with apically displaced flap was done to preserve the band of keratinized tissue and to gain access to the apex of the teeth. Apicoectomy and placement of tricalcium silicate (Biodentine) along with platelet-rich fibrin membrane was done. For better esthetic composite, veneer was given and orthodontic treatment continued. One-year examination showed uneventful healing and reduction of the periapical lesion. PRF membrane and Biodentine yielded good benefits for regeneration. Thus, multidisciplinary approach emphasizes the importance and beauty of collaboration between various specialties to provide the best quality of care to the patient.

Keywords: Apically displaced flap, Biodentine, Crown lengthening, multidisciplinary approach, platelet-rich fibrin

How to cite this article:
Guruprasad C N, Shankareswari T R, Jeethu MT. Use of platelet-rich fibrin membrane with tricalcium silicate in interdisciplinary management of fractured fused anterior teeth with periapical pathology. J Interdiscip Dentistry 2021;11:149-52

How to cite this URL:
Guruprasad C N, Shankareswari T R, Jeethu MT. Use of platelet-rich fibrin membrane with tricalcium silicate in interdisciplinary management of fractured fused anterior teeth with periapical pathology. J Interdiscip Dentistry [serial online] 2021 [cited 2022 Oct 5];11:149-52. Available from: https://www.jidonline.com/text.asp?2021/11/3/149/333343

   Clinical Relevance to Interdisciplinary Dentistry Top

Interdisciplinary approach highlights the beauty and significance of collaboration between various dental specialties to provide the best quality of care to the patient.

   Introduction Top

Esthetic considerations have influenced the management of dental maladies in varying degrees for many years. The ultimate goal in modern dentistry is to achieve white and pink esthetics. Maintaining periodontal health without violating biologic width is the foundation upon which reconstruction of teeth is based. The concept of biologic width emerges from the classic histologic study by Gargiulo et al., yielding an average dimension of 2.04 mm and is the natural seal that protects the alveolar bone from infection and disease.[1]

Surgical crown lengthening increases the length of supragingival tooth structure for restorative or esthetic purposes by apically positioning the gingival margin, removing supporting bone, or both. Various techniques are available such as gingivectomy, displaced flap, and apically repositioned flap with or without resective osseous surgery, and orthodontic forced eruption with or without fibrotomy.[2] The selection criteria for any technique depend on several factors such as esthetics, clinical crown to root ratio, root proximity, root morphology, furcation location, individual tooth position, collective tooth position, and the ability to restore the teeth. It has become an essential component of the esthetic armamentarium to intensify the appearance and retention of restorations placed within the esthetic zone.

The relationship between periodontium and pulp was first discovered by Simring and Goldberg in 1964.[3] The success of both periodontal and endodontic therapy depends on halting disease process, whether they exist separately or as combined lesion. Apicoectomy with retrograde obturation is a commonly employed procedure to treat the periapical diseases. The main objective is to remove diseased tissue, debride the canal system, and reduce the spread of microorganism in the periradicular tissues, providing an environment conducive of regeneration of a normal periodontal apparatus.

Biodentine, a novel dentinal substitute used as an apical plug is composed of tricalcium silicate, calcium carbonate, calcium chloride, zirconium oxide, and water.[4] The flowable consistency penetrates dentinal tubules, produces surface apatite crystals on contact with the phosphates available in tissue fluids, and helps in the mechanical properties at the interface by providing a good marginal seal.[5]

Platelet-rich fibrin (PRF) described by Choukroun et al. is a second-generation platelet concentrate containing platelets and growth factors in the form of fibrin membranes prepared from the patient's own blood, free of any anticoagulant, or other artificial biochemical modifications.[6] It is a powerful healing biomaterial with inherent regenerative capacity and used in various procedures such as the treatment of periodontal intrabony defects, furcation, sinus lift procedures, and in the field of tissue engineering as a scaffold for human periosteal cells.[7],[8],[9],[10]

   Case Report Top

A 19-year-old female participant reported to the Department of Periodontology, GDCRI Bangalore, with a fractured upper right anterior tooth at middle-third due to road traffic accident. She was under orthodontic treatment in the same institution for Class III malocclusion. On clinical examination, there was severe pain, inflamed gingiva, pus discharge, and tenderness on palpation. On radiographic examination, it was found to be an endodontically treated fused central and lateral incisors, showing periapical pathology. Gingival margins and attached gingiva level on right anterior teeth were at a lower level compared to the left side which was esthetically unacceptable [Figure 1]. Informed consent was obtained from the participant, and the use of her record for publication was explained. The surgical protocol included a routine medical and dental history followed by blood investigations.
Figure 1: Fractured upper right fused central-lateral incisors teeth at middle-third

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Preparation of platelet-rich fibrin

The protocol proposed by Choukroun et al.[6],[7] for preparation of PRF was employed. Before surgical procedure, blood was collected from the antecubital vein by venipuncture in 10 mL sterile glass tubes without anticoagulant and centrifuged at 3000 rpm for 10 min. Centrifugation led to the formation of structured meshed fibrin in the center of the glass tube, between red blood corpuscles (RBCs) settled at the base and platelet-poor plasma (PPP) above meshed fibrin. RBCs at the base were removed from PRF using sterile tweezers and scissors followed by PPP removal. Remaining meshed fibrin was placed onto sterile gauze pieces and compressed, squeezing serum out of meshed PRF, and forming a stabilized fibrin membrane [Figure 2].
Figure 2: Platelet-rich fibrin preparation

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After proper isolation, area was anesthetized with 2% lignocaine hydrochloride with adrenaline. To preserve the band of keratinized gingiva and to gain access to periapical area, apically displaced flap for crown lengthening was planned. The surgical procedure included reflection of a full-thickness mucoperiosteal flap beyond mucogingival junction by sulcular incision and two vertical releasing incisions. Debridement of tissues at the periapical site was followed by irrigation with sterile saline solution. Apicoectomy was done and retrograde filling material Biodentine containing tricalcium silicate (Biodentine, Septodont, Saint-Maur-des-Fosses, France) was used [Figure 3].
Figure 3: Apically displaced flap for apicoectomy, retrograde filling with tricalcium silicate (Biodentine), and sutures done

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Platelet-rich fibrin membrane was placed in the periapical osseous defect area, and flap was sutured. For the better esthetics, direct composite veneer was done to attain a natural color and form of the teeth, and orthodontic treatment was continued. The patient was followed up at 6 months [Figure 4] and at 12 months; the offending tooth was accepted both functionally and esthetically restoring the attached gingival level [Figure 5].
Figure 4: Clinical view showing uneventful healing at 1- and 6-month follow-up with composite veneer

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Figure 5: Clinical and radiological picture at 12-month follow-up with the continuation of orthodontic treatment

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   Discussion Top

The key to a successful outcome with long-term stability is the establishment of an accurate diagnosis and subsequent development of a comprehensive treatment plan. Using PRF membrane along with Biodentine yielded greater benefits. PRF membrane contains a tetramolecular structured leukocyte-PRF matrix having cytokines, platelets, and stem cells within it which acts as a biodegradable scaffold that guides epithelial cell to migrate to its surface. PRF releases growth factors for a period of 1 and 4 weeks from the cells involved in tissue regeneration.[11] Singh et al. conducted a study to treat periapical lesions using PRF and concluded that PRF improves early wound closure, bone maturation, and the final esthetic result of the periodontal soft tissues.[12]

Biodentine, a tricalcium silicate base material employed to repair root perforations, apexification, and as a retrograde filling material has a good marginal sealing ability and produces surface apatite crystals when in contact with the phosphates available in tissue fluids.[5],[13] Kokate and Pawar compared the microleakage of glass ionomer cement, mineral trioxide aggregate (MTA), and Biodentine when used as a retrograde filling material and found Biodentine exhibited the least microleakage when compared to other materials used.[14] Sulthan et al. in their study evaluated the pH and calcium ion release of MTA and Biodentine when used as root-end fillings and found Biodentine presented alkaline pH and had ability to release calcium ions similar to that of MTA.[15]

For better esthetics, soft-tissue management is very vital which is achieved here with apically displaced flap to gain access to apex of the fused teeth and to preserve the width of attached gingiva. Thus, multidisciplinary approach has become an integral part of everyday dentistry. This case report emphasized the importance and beauty of collaboration of work between periodontics, endodontics, and orthodontics specialties to treat and provide the best quality of care to the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Gargiulo AW, Wentz FM, Orban B. Dimensions and relations of the dentogingival junction in humans. J Periodontol. 1961;32:261-7.  Back to cited text no. 1
Nemcovsky CE, Artzi Z, Moses O. Preprosthetic clinical crown lengthening procedures in the anterior maxilla. Pract Proced Aesthet Dent 2001;13:581-8.  Back to cited text no. 2
Simring M, Goldberg M. The pulpal pocket approach: Retrograde periodontitis. J Periodontol 1964;35:22-48.  Back to cited text no. 3
Laurent P, Camps J, De Méo M, Déjou J, About I. Induction of specific cell responses to a Ca3SiO5-based posterior restorative material. Dent Mater 2008;24:1486-94.  Back to cited text no. 4
Atmeh AR, Chong EZ, Richard G, Festy F, Watson TF. Dentin-cement interfacial interaction: Calcium silicates and polyalkenoates. J Dent Res 2012;91:454-9.  Back to cited text no. 5
Choukroun J, Adda F, Schoeffer C, Vervelle A. PRF: An opportunity in perio-implantology (in French). Implantodontie 2000;42:55-62.  Back to cited text no. 6
Pradeep AR, Pai S, Garg G, Devi P, Shetty SK. A randomized clinical trial of autologous platelet-rich plasma in the treatment of mandibular degree II furcation defects. J Clin Periodontol 2009;36:581-8.  Back to cited text no. 7
Sharma A, Pradeep AR. Autologous platelet-rich fibrin in the treatment of mandibular degree II furcation defects: A randomized clinical trial. J Periodontol 2011;82:1396-403.  Back to cited text no. 8
Mazor Z, Horowitz RA, Del Corso M, Prasad HS, Rohrer MD, Dohan Ehrenfest DM. Sinus floor augmentation with simultaneous implant placement using Choukroun's platelet-rich fibrin as the sole grafting material: A radiologic and histologic study at 6 months. J Periodontol 2009;80:2056-64.  Back to cited text no. 9
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. 10
Borie E, Oliví DG, Orsi IA, Garlet K, Weber B, Beltrán V, et al. Platelet-rich fibrin application in dentistry: A literature review. Int J Clin Exp Med 2015;8:7922-9.  Back to cited text no. 11
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. 12
[PUBMED]  [Full text]  
Wang X, Sun H, Chang J. Characterization of Ca3SiO5/CaCl2 composite cement for dental application. Dent Mater 2008;24:74-82.  Back to cited text no. 13
Kokate SR, Pawar AM. An in vitro comparative stereomicroscopic evaluation of marginal seal between MTA, Glass Inomer Cement and Biodentine as root end filling materials using 1% methylene blue as tracer. Endodontics 2012;2:3642.  Back to cited text no. 14
Sulthan IR, Ramchandran A, Deepalakshmi A, Kumarapan SK. Evaluation of pH and calcium ion release of mineral trioxide aggregate and a new rootend filling material. E J Dent 2012;2:1669.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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