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Table of Contents   
CASE REPORT  
Year : 2014  |  Volume : 25  |  Issue : 4  |  Page : 517-520
Use of second-generation platelet concentrate (platelet-rich fibrin) and hydroxyapatite in the management of large periapical inflammatory lesion: A computed tomography scan analysis


1 Department of Conservative Dentistry and Endodontics, SAIMS, Indore, Madhya Pradesh, India
2 Department of Oral and Maxillofacial Surgery, SAIMS, Indore, Madhya Pradesh, India
3 Department of Paediatric and Preventive Dentistry, SAIMS, Indore, Madhya Pradesh, India

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Date of Submission24-Mar-2014
Date of Decision19-Apr-2014
Date of Acceptance21-Aug-2014
Date of Web Publication10-Oct-2014
 

   Abstract 

Periapical surgery is required when periradicular pathosis associated with endodontically treated teeth cannot be resolved by nonsurgical root canal therapy (retreatment), or when retreatment was unsuccessful, not feasible or contraindicated. Endodontic failures can occur when irritants remain within the confines of the root canal, or when an extraradicular infection cannot be eradicated by orthograde root canal treatment. Foreign-body responses toward filling materials, toward cholesterol crystals or radicular cysts, might prevent complete periapical healing. We present here a case report wherein, combination of platelet-rich fibrin (PRF) and the hydroxyapatite graft was used to achieve faster healing of the large periapical lesion. Healing was observed within 8 months, which were confirmed by computed tomography, following improved bone density. PRF has many advantages over platelet-rich plasma. It provides a physiologic architecture that is very favorable to the healing process, which is obtained due to the slow polymerization process.

Keywords: Computed tomography, hydroxyapatite, platelet-rich fibrin, periapical lesion

How to cite this article:
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

How to cite this URL:
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 [serial online] 2014 [cited 2020 May 28];25:517-20. Available from: http://www.ijdr.in/text.asp?2014/25/4/517/142556
In modern endodontic practice, the number of indications for endodontic periapical surgery is decreasing. Still periapical surgery accounts for 3-10% of typical endodontic practice. [1] Cohn proposed periapical surgery as a predictable option when root canal treatment is either not possible or failed. [2]

Regenerative surgery, including the use of barrier membranes and graft materials, can reduce probing depths, support formation of the periodontal ligament and allow regenerative rehabilitation and functional reconstruction. [3] Surgical endodontic treatment is indicated in a limited number of cases of persistent periradicular pathosis. Selection between alternative treatments should be based on the assessment of individual case, as done in the present.


   Case report Top


A 20-year-old boy reported to the department of conservative dentistry and endodontics with pain and discharge in the upper front teeth, and swelling in the palatal region. On clinical examination, tooth 11, 21, and 22 were discolored, and they were tender on percussion [Figure 1]a. On radiographic examination, a large periapical lesion with a foreign material was observed in relation to 21 and 22, tooth 22 had an open apex [Figure 1]b. The patient gave a history of trauma 5 years prior and root canal treatment with tooth 21, 22, and 11 in a private dental clinic 1 year back. After analyzing the case radiographically, clinically and also considering the patient's history, it was decided to proceed with the surgical approach. The patient was explained in detail about surgical treatment planning and the regenerative modality to be used.
Figure 1: (a and b) Preoperative photograph and radiograph presenting a large periapical lesion on the upper left anterior region

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A computed tomography (CT) scan (Siemens Somatom, Mumbai, India) was advised to have the exact dimension of the lesion and to note the bone density of the diseased part, which measured 2.16 × 1.2 cm and 47 HU respectively [Figure 2]a and b. Modification mentioned by Christoph et al. was followed (collimation, 1 mm; pitch, 2; tube voltage, 80 kV; tube current, 40 mA). Using these guidelines, the effective radiation dosage produced by this method was 0.56-0.06 mGy, which is equivalent to a standard panoramic radiograph. This would help the clinician to perform accurately with the extent of surgical incision, as well as check for the bone formation postsurgery. Before proceeding with a surgical procedure, cleaning and shaping protocol was performed on tooth 11, 21, and 22 under rubber dam.
Figure 2: (a and b) Computed tomography scan axial view showing the size and HU measurement of the lesion before treatment

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A full-thickness mucoperiosteal flap under local anesthesia was reflected by a sulcular incision starting from distal of the maxillary right central to mesial of the maxillary left canine. The three-dimensional construction image revealed some loss of labial cortical plate, which is evident in the clinical photograph [Figure 3]a and b. Though the bone loss at the palatal area was larger when compared with the labial surface, the latter was chosen for surgical approach for easy accessibility and better retention of the graft material (placing against gravity would have been difficult). Total removal of the diseased soft tissue lining (which was sent for biopsy) and gutta-percha was done, followed by curettage of the defect [Figure 3]a and b. This was followed by irrigation with betadine and a sterile saline solution. Single-step apical barrier placement was done with tooth 22 (orthograde method) by placing 4-5 mm mineral trioxide aggregate (MTA) (ProRoot MTA; Tulsa Dental, Johnson City, TN, USA) apical plug, using Schilder pluggers (Dentsply Caulk, Milford, DE, USA). A wet cotton pellet with sterile water was then placed in the pulp chamber, and the access cavity was closed with temporary filling material Intermediate Restorative Material (Caulk Dentsply, Milford, DE, USA). Platelet-rich fibrin (PRF) was prepared by drawing the required amount of blood into a 10-mL test-tube without an anticoagulant and centrifuged immediately using a table top centrifuge (REMI Laboratories, Mumbai, Maharashtra, India) for 12 min at 571.54 g. The resultant product consisted of the following three layers [Figure 4]:
Figure 3: (a and b) Periapical defect with a foreign object, followed by complete debridement

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Figure 4: A structured fibrin clot in the middle of the tube, just between the red corpuscles at the bottom and acellular plasma at the top of the platelet-rich fibrin

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  • Acellular 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.


Then, 0.5 mg of hydroxyapatite (HA) granules (G-bone;

G Surgiwear Limited, Shahjahanpur, India) with an average pore size of 0.4-0.9 mm and a stomatal rate of 15% were mixed with the PRF preparation. PRF-HA mixture was carried and packed into the defect to the level of defect walls (flat) [Figure 5]a and b. Wound closure was then obtained with 4-0 silk sutures. Analgesics and antibiotics were prescribed, and the patient was advised to use chlorhexidine mouthwash for a week. After 3 days, tooth 22 was backfilled with thermo plasticized gutta-percha and tooth 11 and 21 were subsequently obturated with cold lateral condensation technique. Postoperative radiograph was taken [Figure 5]c to check the accuracy of obturations. Tooth 21 was not planned for root end resection since the apical end of the root did not exhibit any resorption. Later the sutures were removed after 7 days, and satisfactory healing was observed. His postoperative recovery was uneventful.
Figure 5: (a-c) The lesion after packing with platelet-rich fibrin- hydroxyapatite mixture and a postoperative occlusal radiograph

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The patient was recalled after 4, 8, and 18 months. At 8 th month, a CT scan was made to confirm the bone healing by measuring the bone density [Figure 6]b. At 18 th month the occlusal radiograph showed complete healing of the periapical lesion [Figure 6]a.
Figure 6: (a and b) Computed tomography scan axial view, HU values of bone tissue healing after 8 months and 18 month follow-up radiograph

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   Discussion Top


Microbial irritants of pulp and periradicular tissues include bacteria, bacterial toxins, bacterial fragments, and viruses. In addition to bacterial irritation, the periradicular tissues can be mechanically irritated and inflamed. Physical irritation of periradicular tissues can also occur during root canal therapy if the canals are instrumented or filled beyond their anatomic boundaries, root perforation, and overextension of filling materials. [4] In the present case, there was an over extended gutta-percha cone in the periapical region, which had to be retrieved since it was a cause for continuous irritation in the periapical area.

Fluid tight seal is a fundamental prerequisite for successful endodontic surgery. The possibility of achieving it with or without retrograde filling is controversial. [5] This case report demonstrates the favorable clinical outcomes that can be achieved following accurate judgment for the indication of retrograde filling.

Traditionally, the diagnosis of periapical lesion is based on clinical and radiographic presentations, which are only empiric methods. The final confirmatory diagnosis is performed by histopathological examination of the tissues, which is impractical in nonsurgical treatment cases. Once a biopsy is taken, the treatment is no longer a nonsurgical procedure. [6] The biopsy of the present case report confirmed the presence of radicular cyst. Moreover, the most common diagnostic tool, the intraoral periapical radiograph determines the mesiodistal extension and not the buccolingual. Hence, it just represents only the two-dimensional picture of a three-dimensional object. [7]

In the present case, CT scan was performed as per recommendations given by  Christopher et al. [8] The preoperative reading of bone density on the unaffected right side of the maxilla was 842 HU units, were as the lesion measured 47 HU. After 8 months again a CT scan was performed, and the bone density measured 817 HU, which gave an indication of bone formation, which could not have been possible to be analyzed accurately by conventional radiographic technique.

Shivashankar et al. reported a case where in PRF membrane was used as a barrier membrane over a large periapical bony defect to maintain a confined space for the purpose of guided tissue regeneration and rapid bone formation. [9] PRF was first described by Choukroun et al. It has been referred to as a second-generation platelet concentrate, which has been shown to have several advantages over traditionally prepared platelet-rich plasma (PRP). Its chief advantages include ease of preparation and lack of biochemical handling of blood, which makes this preparation strictly autologous.

Platelet-rich fibrin contains a lot of platelets and leucocyte cytokines. Clinical trials suggest that the combination of bone grafts and growth factors contained in PRP and PRF may be suitable to enhance bone density. In an experimental trial, the growth factor content in PRP and PRF aliquots was measured using ELISA kits. The results suggest that the growth factor content (platelet derived growth factor and transforming growth factor-β) was comparable in both. Another experimental study used osteoblast cell cultures to investigate the influence of PRP and PRF on proliferation and differentiation of osteoblasts. In this study, the affinity of osteoblasts to the PRF membrane appeared to be superior.

Platelet-rich fibrin is in the form of platelet gel and can be used in conjunction with bone grafts, which offers several advantages including promoting wound healing, bone growth and maturation, graft stabilization, wound sealing and hemostasis, and improving the handling properties of graft materials. [10]


   Conclusion Top


In the current case, repair and regeneration of a large periapical lesion, was achieved by using a combination of growth factors and HA bone graft. Healing was observed within 8 months which were confirmed by CT, following improved bone density.

The conversion of fibrinogen into fibrin in PRF takes place slowly with small quantities of physiologically available thrombin present in the blood sample itself. Thus, a physiologic architecture that is very favorable to the healing process is obtained due to this slow polymerization process.

 
   References Top

1.Johnson BR, Witherspoon DE. Periradicular surgery. In: Cohen S, Hargreaves KM, editors. Pathways of the Pulp. 9 th ed. Missouri: Mosby; 2006. p. 724-85.  Back to cited text no. 1
    
2.Cohn SA. When all else fails. Aust Endod J 1998;24:128-9.  Back to cited text no. 2
    
3.Gruber R, Kandler B, Fischer MB, Watzek G. Osteogenic differentiation induced by bone morphogenetic proteins can be suppressed by platelet-released supernatant in vitro. Clin Oral Implants Res 2006;17:188-93.  Back to cited text no. 3
    
4.Masillamoni CR, Kettering JD, Torabinejad M. The biocompatibility of some root canal medicaments and irrigants. Int Endod J 1981;14:115-20.  Back to cited text no. 4
    
5.Rahbaran S, Gilthorpe MS, Harrison SD, Gulabivala K. Comparison of clinical outcome of periapical surgery in endodontic and oral surgery units of a teaching dental hospital: A retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:700-9.  Back to cited text no. 5
    
6.Nair PN. New perspectives on radicular cysts: Do they heal? Int Endod J 1998;31:155-60.  Back to cited text no. 6
    
7.Kaffe I, Gratt BM. Variations in the radiographic interpretation of the periapical dental region. J Endod 1988;14:330-5.  Back to cited text no. 7
    
8.Christoph GD, Wilfried GH, Britta R, Hermann KP, Oestmann JW. Must radiation dose for ct of the maxilla and mandible be higher than that for conventional panoramic radiography? Am Soc Neuroradiol 1996;96:1709-58.  Back to cited text no. 8
    
9.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. 9
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10.Hiremath H, Gada N, Kini Y, Kulkarni S, Yakub SS, Metgud S. Single-step apical barrier placement in immature teeth using mineral trioxide aggregate and management of periapical inflammatory lesion using platelet-rich plasma and hydroxyapatite. J Endod 2008;34:1020-4.  Back to cited text no. 10
    

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Correspondence Address:
Hemalatha Hiremath
Department of Conservative Dentistry and Endodontics, SAIMS, Indore, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.142556

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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