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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 36-40

Management of periapical lesion using platelet-rich fibrin as a grafting material


Department of Conservative Dentistry and Endodontics, CSMSS Dental College and Hospital, Aurangabad, Maharashtra, India

Date of Submission24-Feb-2021
Date of Acceptance25-Aug-2021
Date of Web Publication30-Apr-2022

Correspondence Address:
Dr. Jivika Jitendra Matkar
Department of Conservative Dentistry and Endodontics, CSMSS Dental College and Hospital, Aurangabad - 431 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_8_21

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   Abstract 


The success of a periapical surgery is assessed by regeneration of functional periradicular tissues. The regenerative potential of platelets has been utilized in periradicular surgeries. 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 periapical lesion. A periapical endodontic surgery was performed on a 35-years-old male patient with a discoloration of 11. Open apex and bony defect were present radiologically with 11. Retrograde filling with mineral trioxide aggregate was done. The surgical defect was filled with PRF membrane and sutured. Follow-up was done after 8 weeks and 8 months. The present case report concluded that PRF can be recommended as an alternative to bone grafts and membranes in periapical lesions to enhance bone regeneration and to decrease the healing time.

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


How to cite this article:
Pawar KS, Matkar JJ, Daokar SG, Wahane KD. Management of periapical lesion using platelet-rich fibrin as a grafting material. J Interdiscip Dentistry 2022;12:36-40

How to cite this URL:
Pawar KS, Matkar JJ, Daokar SG, Wahane KD. Management of periapical lesion using platelet-rich fibrin as a grafting material. J Interdiscip Dentistry [serial online] 2022 [cited 2022 Aug 16];12:36-40. Available from: https://www.jidonline.com/text.asp?2022/12/1/36/344465




   Clinical Relevance to Interdisciplinary Dentistry Top


  • Platelet concentrates for surgical use are innovative tools of regenerative medicine, and were widely tested in oral and maxillofacial surgery
  • The use of platelet-rich fibrin defined new therapeutic principles for the treatment of periodontal intrabony lesions and for the reconstruction of the alveolar ridges
  • Mineral trioxide aggregate as a retrograde filling material has superior properties in terms of sealing ability, biocompatibility, and periradicular tissue regeneration.



   Introduction Top


Some of the periapical inflammatory lesions cannot be resolved by conventional root canal therapy, periapical surgery is an alternative. Regeneration of periapical bone defects is a great challenge to an endodontist.[1],[2]

Platelet-rich fibrin (PRF) is a second-generation platelet concentrate which is a rich source of growth factors and its application is an effective way for inducing tissue repair and regeneration.[3] PRF preparation generates a fibrin network similar to natural process. Such a network helps in more efficient cell migration and proliferation.[3] PRF has shown successful wound healing in periradicular bone defects.


   Case Report Top


A 35-year-old male patient reported to the department of conservative dentistry and Endodontics with the chief complaint of discolored tooth in the upper anterior region of jaw. The patient was asymptomatic. The patient reported a history of trauma in upper anterior teeth which had occurred more than 10 years back. The patient had consulted a private clinic 6 months prior for a similar complaint.

Clinical examination revealed discoloration with 11 [Figure 1]. No swelling was seen in the region. Sensitivity to percussion was absent with 11 and 12. No mobility was observed with these teeth. Pulp sensitivity tests revealed that 11 and 12 were nonvital. Periodontal pockets were absent and no abnormality was detected in the periodontium. Preoperative intraoral periapical radiograph of 11 and 12 was taken at exposure for 0.20 s, 200 Kvp at a vertical angle of + 55°. It revealed the presence of well-circumscribed periapical radiolucency (3 cm × 2 cm in size) involving 11 and open apex with 11 [Figure 2] and [Figure 3]. Access cavity preparation was done in 11 and 12 at a private clinic. Electric pulp test revealed no response with 11 and 12. This case was planned for conventional root canal treatment followed by periapical surgery. Treatment procedure was explained to the patient and informed consent from the patient was obtained.
Figure 1: Preoperative intraoral clinical photograph showing discoloration with 11

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Figure 2: Preoperative intraoral radiograph showing periapical lesion with 11

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Figure 3: Preoperative occlusal radiograph

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The root canal treatment was performed using step-back technique till an apical size of 45 in relation to 12. Biomechanical preparation was lightly carried out using 80 k-file with circumferential filing motion in 11. Three percent sodium hypochlorite solution (Prime Dental Products Pvt. Ltd. India) and normal saline (Infutec Healthcare Ltd. India) was used to irrigate the canals during the canal preparation. Calcium hydroxide intracanal medicament (Prime Dental Products Pvt. Ltd. India) was placed in 11 and 12. The patient was recalled after 7 days.

In the next appointment, canals were irrigated. As the root canals exhibited persistent discharge of exudates, periapical surgery was planned. Obturation was done using gutta-percha (Dentsply Maillefer, Switzerland) and AH 26 sealer (Dentsply, USA) by lateral compaction technique with 12 and by customized roll cone technique with 11. The access cavity was sealed with eugenol-free temporary cement (Maarc dental, India). Under local anesthesia (1:200,000 adrenaline, DJ Lab, India), a full-thickness mucoperiosteal flap was reflected [Figure 4]. A large periapical defect was seen with complete loss of labial cortical plate in relation to 11. The cystic lining was enucleated and sent for biopsy [Figure 5]. The histopathology report confirmed the provisional diagnosis of an infected dental cyst. Apicoectomy was not done in 11 because of the presence of an open apex. Root end cavity was prepared in the apical 3 mm in 11 and retrograde filling was done with mineral trioxide aggregate (MTA Xtreme, Gurumukh dental, India) [Figure 6].
Figure 4: Elevation of full-thickness mucoperiosteal flap

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Figure 5: Enucleated specimen

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Figure 6: Mineral trioxide aggregate retrograde filling with 11

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Around 5 ml of whole venous blood was collected in each of the two sterile tubes. The tubes are then placed in a centrifugal machine at 3000 revolutions per min for 10 min, after which it settles into 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 [Figure 7].
Figure 7: Middle fraction containing fibrin

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PRF was packed into the defect to the level of defect walls [Figure 8]. 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.
Figure 8: Platelet-rich fibrin placed into the surgical defect

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The patient was reviewed after 8 weeks during which there were no symptoms of pain, inflammation, or discomfort. These follow-up visits included routine intraoral, radiographic examinations, and professional plaque control [Figure 9]. A follow-up radiograph showed the appreciable healing of the lesion [Figure 10]. Another follow-up was done after 8 months in which radiograph of the periapical region of 11 and 12 was taken at an exposure for 0.20 seconds, 200 Kvp at vertical angle of + 550 which showed osseous healing in periapical region [Figure 11].
Figure 9: Postoperative intraoral clinical photograph

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Figure 10: Eight weeks follow-up radiograph showing decrease in size of periapical radiolucency

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Figure 11: Eight-month follow-up showing osseous healing in periapical region

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   Discussion Top


PRF was first used by Choukroun et al. in France and belongs to a second generation of platelet concentrate.[4] It is superior to platelet-rich plasma.[5] PRF can promote wound healing, bone growth, graft stabilization, hemostasis, and wound sealing.[4],[5] As the fibrin matrix is better organized, it is able to more efficiently direct stem cell migration and the healing program.[3],[6],[7]

The main component of PRF is a high concentration of growth factors present in the platelets which are required for wound healing.[8],[9],[10] Among the various growth factors, PRF contains platelet-derived growth factor (PDGF), transforming growth factor (TGF)-β1 and β2, insulin-like growth factor, epidermal growth factor, vascular endothelial growth factor, and fibroblast growth factor which are believed to play a major role in bone metabolism and potential regulation of cell proliferation.[11],[12] PDGF is an activator of collagenase which promotes the strength of healed tissue.[8] TGF-β activates fibroblasts to form procollagen which deposits collagen within the wound.[13] PRF facilitates healing by controlling the local inflammatory response.[10] Studies have shown that PRF can stimulate proliferation and differentiation of human osteoblasts.[14]

Factors leading to the popularity of this grafting material are the ease of obtaining it and the absence of risk such as rejection or allergy. The decision to use PRF as the sole grafting material in the present case report is because the lesion indicated the site of chronic infection. The introduction of alloplastic materials, allografts, or xenografts would have introduced the added risk of infection. PRF being an autologous fibrin scaffold did not carry this risk.

Another study by Malli Sureshbabu et al.[15] has shown successful osseous healing by using PRF in periapical surgery.

MTA was used in this case as a root-end filling material, as MTA prevents leakage better than glass ionomer cement and composite. The setting and subsequent leakage of MTA are not affected by the presence of blood. A layer of MTA would enhance the integrity of the apical barrier, making it more resistant to penetration by microorganisms and establishing a biologic barrier.[16] It also augments the formation of new cementum which is essential for periodontal healing.[17]


   Conclusion Top


We conclude that 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 esthetic result of the periodontal soft tissues.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his 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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Thanikasalam M, Ahamed S, Narayana SS, Bhavani S, Rajaraman G. Evaluation of healing after periapical surgery using platelet-rich fibrin and nanocrystalline hydroxyapatite with collagen in combination with platelet-rich fibrin. Endodontology 2018;30:25-31.  Back to cited text no. 1
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2.
Grossman's Endodontic Practice. Endodontic Surgery. In: Suresh Chandra B, Gopikrishna V, editors. 13th ed. India: Wolters Kluwer; 2010. p. 462-98.  Back to cited text no. 2
    
3.
Saluja H, Dehane V, Mahindra U. Plateletrich fibrin: A second generation platelet concentrate and a new friend of oral and maxillofacial surgeons. Ann Maxillofac Surg 2011;1:53-7.  Back to cited text no. 3
    
4.
Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part V: Histologic evaluations of PRF effects on bone allograft maturation in sinus lift. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:299-303.  Back to cited text no. 4
    
5.
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. 5
    
6.
Pierce GF, Mustoe TA, Altrock BW, Deuel TF, Thomason A. Role of platelet-derived growth factor in wound healing. J Cell Biochem 1991;45:319-26.  Back to cited text no. 6
    
7.
Bolander ME. Regulation of fracture repair by growth factors. Proc Soc Exp Biol Med 1992;200:165-70.  Back to cited text no. 7
    
8.
Prasanthi NN, Chittem J, Simpsy GS, Sajjan GS. Surgical management of a large inflammatory periapical lesion with platelet-rich fibrin. J Interdiscip Dent 2017;7:76-9.  Back to cited text no. 8
    
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. 9
    
10.
Corso MD, Toffler M, Ehrenfest DM. Use of autologous leucocyte and platelet rich fibrin (LPRF) in postavulsion sites: An overview of Choukran's PRF. J Implant Adv Clin Dent 2010;1:27-35.  Back to cited text no. 10
    
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. 11
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12.
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. 12
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13.
Shivashankar VY, Johns DA, Vidyanath S, Sam G. Combination of platelet rich fibrin, hydroxyapatite and PRF membrane in the management of large inflammatory periapical lesion. J Conserv Dent 2013;16:261-4.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
Dohan Ehrenfest DM, Diss A, Odin G, Doglioli P, Hippolyte MP, Charrier JB. In vitro effects of Choukroun's PRF (platelet-rich fibrin) on human gingival fibroblasts, dermal prekeratinocytes, preadipocytes, and maxillofacial osteoblasts in primary cultures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:341-52.  Back to cited text no. 14
    
15.
Malli Sureshbabu N, Selvarasu K, V JK, Nandakumar M, Selvam D. Concentrated growth factors as an ingenious biomaterial in regeneration of bony defects after Periapical surgery: A report of two cases. Case Rep Dent 2019;2019:7046203.  Back to cited text no. 15
    
16.
Parikh B, Navin S, Vaishali P. A comparative evaluation of healing with a computed tomography scan of bilateral periapical lesions treated with and without the use of platelet-rich plasma. Indian J Dent Res 2011;22:497-8.  Back to cited text no. 16
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17.
Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod 1993;19:591-5.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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