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Platelet-Rich Fibrin with β-Tricalcium Phosphate—A Noval Approach for Bone Augmentation in Chronic Periapical Lesion: A Case Report

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Case Reports in Dentistry
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Introduction. This paper describes a case of bone augmentation with combination of Platelet-Rich Fibrin (PRF) and β-TCP for treatment of chronic periapical cyst. The case was followed for 12 months. Methods. Patient presented with chronic periapical lesion in maxillary anterior teeth with history of trauma 8 years back. Radiographically, a periapical cyst was seen in relation to maxillary left central and lateral incisors. Conventional endodontic treatment was started. Since it was not successful, apical surgery was performed. Bone augmentation was done using PRF in combination with β-TCP bone graft to achieve faster healing of the periapical region. Regular followups at 3, 6, 9, and 12 months were done. Results. Healing was uneventful. Follow-up examinations revealed progressive, significant, and predictable clinical and radiographic bone regeneration/healing without any clinical symptoms. Conclusions. Combined use of PRF and β-TCP for bone augmentation in treatment of periapical defects is a potential treatment alternative for faster healing than using these biomaterials alone.
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Hindawi Publishing Corporation
Case Reports in Dentistry
Volume 2012, Article ID 902858, 6pages
doi:10.1155/2012/902858
Case Report
Platelet-Rich Fibrin with β-Tricalcium Phosphate—A Noval
Approach for Bone Augmentation in Chronic Periapical Lesion:
ACaseReport
K. B. Jayalakshmi,1Shipra Agarwal,1M. P. Singh,1
B. T. Vishwanath,2Akash Krishna,1and Rohit Agrawal1
1Department of Conservative Dentistry and Endodontics, Peoples College of Dental Sciences & Research Centre, Bhopal 462037, India
2Century Dental College, Kerala, Poinachi 671541, India
Correspondence should be addressed to Shipra Agarwal, dentist.shipra@gmail.com
Received 19 August 2012; Accepted 25 September 2012
Academic Editors: A. C. B. Delbem, M. B. D. Gaviao, and P. Lopez Jornet
Copyright © 2012 K. B. Jayalakshmi et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Introduction. This paper describes a case of bone augmentation with combination of Platelet-Rich Fibrin (PRF) and β-TCP for
treatment of chronic periapical cyst. The case was followed for 12 months. Methods. Patient presented with chronic periapical
lesion in maxillary anterior teeth with history of trauma 8 years back. Radiographically, a periapical cyst was seen in relation
to maxillary left central and lateral incisors. Conventional endodontic treatment was started. Since it was not successful, apical
surgery was performed. Bone augmentation was done using PRF in combination with β-TCP bone graft to achieve faster healing
of the periapical region. Regular followups at 3, 6, 9, and 12 months were done. Results. Healing was uneventful. Follow-up
examinations revealed progressive, significant, and predictable clinical and radiographic bone regeneration/healing without any
clinical symptoms. Conclusions. Combined use of PRF and β-TCP for bone augmentation in treatment of periapical defects is a
potential treatment alternative for faster healing than using these biomaterials alone.
1. Introduction
Bacterial infection of the dental pulp may lead to periapical
lesions [1]. They are generally diagnosed either during
routine dental radiographic examination or following acute
pain and/or swelling in relation to the aected tooth
[2]. Most periapical lesions (>90%) can be classified as
dental granulomas, abscesses, or radicular cysts [3,4]. The
incidence of cysts within periapical lesions varies between
6 and 55% [5]. The occurrence of periapical granulomas
ranges between 9.3 and 87.1%, and of abscesses between 28.7
and 70.07% [6].
The ultimate goal of endodontic therapy is to return
the involved tooth to a state of health and function [7]. All
inflammatory periapical lesions should be initially treated
with conventional endodontic therapy [8] which has shown
success in 85% of cases [911]. However failure after con-
ventional root canal treatment calls for surgical intervention
[12]. Periapical Surgery has many limitations, like it is an
invasive procedure, has psychological impact on the patient,
andrequiresskilledandexperiencedoperator[13,14].
Nevertheless, periapical surgery remains the last resort when
root canal treatment either fails or is not possible.
Traditional surgical approaches to treat periapical defects
include debridement of apical lesions along with reshaping
of the surrounding bone, resection, and retro filling of root
apex, where healing is almost always by repair [15]. Repair
is defined as the healing of a wound by tissue that does
not fully restore the architecture or the function of the
part [16]. Since this is not ideal, newer approaches such as
regenerative procedures that aim to restore lost tissue have
been introduced.
Beta-tricalcium phosphate (β-TCP) is an alloplast widely
used in periapical surgery to enhance new bone formation.
It is an osteoconductive bone graft which gets chemically
resorbed with a concomitant release of bioactive ions [15].
2Case Reports in Dentistry
Figure 1: Preoperative radiograph of 21 and 22 showing a large
periapical radiolucency.
More number of platelets deliver an increased number
of polypeptide growth factors that regulate cell proliferation,
chemotaxis, and dierentiation to the surgical area [17].
Platelet rich plasma (PRP), first generation of autologous
platelet concentrate, has been used for the purpose of tissue
regeneration [17,18]. Although its use has shown clinical
success its complex preparation protocol and moderate
benefits limit its usage in regenerative surgeries [19,20].
Platelet rich fibrin (PRF), introduced by Choukroun et al.
in the year 2001, is a second-generation platelet concentrate
enriched with platelets and growth factors which promote
periapical tissue regeneration and healing. Unlike PRP, it is
obtained from a anticoagulant and thrombin free blood har-
vest making it free from the risk of disease transmission [20].
PRP has been successfully used with bone grafts like β-
TCP for bone regeneration in the treatment of periodontal
defects [17,21].
In the present case an innovative idea of combining PRF
with a β-tricalcium phosphate was used. Indeed, separate
studies have shown clinical success in bone formation with
the use of both these materials used separately. This case
report presents an attempt to evaluate the healing kinetics
of the combination of PRF and β-tricalcium phosphate as
opposed to using these materials alone.
2. Case Report
A 25-year-old female reported to the Department of Con-
servative Dentistry and Endodontics with chief complaint of
swelling and pus discharge from upper front tooth region
since 1 month. Past dental history revealed trauma which
she sustained 8 yrs back in the same region. On intraoral
examination, there was a draining sinus, in relation to the
apex of 21. On Electric pulp testing, tooth number 22 was
also found nonvital. Periapical radiograph revealed a large
diused periapical radiolucency in relation to 21 and 22
measuring 1.4 cm in diameter (Figure 1).
Figure 2: Periapical defect after flap reflection.
2.1. Management. Culture and sensitivity test revealed pres-
ence of Pseudomonas aeruginosa. Accordingly an antibiotic
course of cefixime 400 mg twice daily and metronidazole
200 mg thrice daily were advised to the patient for 7 days.
Conventional RCT was started with 21 and 22. Since it
was not successful it was decided to surgically debride the
lesion, with root resection followed by retrograde restora-
tion. In order to achieve optimal healing and regeneration
of bone, it was planned to use PRF in combination with
bone graft. An ethical clearance was obtained from the
institutional ethical committee. Patient consent was taken
after careful explanation of the surgical procedure used and
the risks and benefits.
Before the surgery, patient’s complete hemogram was
done and all the parameters were found to be within normal
limits.
Intraoral and extraoral antisepsis was performed using
0.2% chlorhexidine digluconate rinse and povidone iodine
solution, respectively. Following administration of local
anaesthesia, submarginal incision was given 3 mm apical
the marginal gingiva and mucoperiosteal flap was reflected
(Figure 2). Meticulous defect debridement was done; 21 and
22 were then obturated using lateral and vertical condensa-
tion technique.
PRF was prepared in accordance with the protocol devel-
oped by Freymiller and Aghaloo [19]. Intravenous blood
(by venipuncturing of the antecubital vein) was collected
(Figure 3) in a 10 mL sterile tube without anticoagulant and
immediately centrifuged at 3,000 rpm for 10 minutes. Blood
centrifugation allowed the formation of a structured fibrin
clot in the middle of the tube, just between the red corpuscles
at the bottom and acellular plasma (platelet-poor plasma)
at the top. PRF was easily separated from red corpuscles
base (preserving a small RBC layer) using sterile tweezers
(Figure 4) just after removal of PPP (platelet-poor plasma)
and then transferred into a sterile dappen dish.
PRF was mixed with β-tricalcium phosphate and aug-
mented into the intrabony defect upto the surrounding bone
level (Figure 5). The mucoperiosteal flap was repositioned
and simple interrupted sutures were given using 3–0 non-
absorbable black silk suture.
Case Reports in Dentistry 3
Figure 3: Blood collection from anticubital vein.
Figure 4: PRF clot obtained after centrifugation.
Figure 5: PRF mixed with β-tricalcium phosphate placed into the
defect.
Post-operative care was explained to the patient, with
instructions to report back after a week for suture removal.
Recall examinations after 3-, 6-, 9-, and 12-month interval
were done to evaluate the healing kinetics of the periapical
defect.
3. Discussion
Regeneration is defined as reproduction or reconstitution of
a lost or injured part which fully restores the architecture or
function of the part [16].
Regeneration of tissue after periapical surgery requires
(a) recruitment of progenitor/stem cells to dierentiate into
committed cells, (b) growth/dierentiation factors as nec-
essary signals for attachment, migration, proliferation and
dierentiation of cells, and (c) local-microenvironmental
cues like adhesion molecules, extra cellular matrix, associated
non-collagenous protein molecules, and so forth. Lack of
any of these elements would result in repair rather than
regeneration [22].
Perhaps the most commonly used technique for regen-
eration is the use of bone replacement grafts. These grafts
can promote tissue or bone regeneration through variety of
mechanisms.
Bone grafting materials include autografts, allograft,
xenografts, and alloplasts. Alloplasts such as osteoconductive
calcium phosphate have been widely used in periapical
surgery to enhance new bone formation [15]. Several case
reports have demonstrated healing with mature bone and
haemopoietic marrow in periapical areas by using this bone
graft [2325].
To promote periapical tissue regeneration and healing,
local application of growth factors and host modulating
agents is being used to maximize the body’s healing potential.
TGF-beta and PDGF are the typical two growth factors which
promote healing of soft tissue and bone through stimulation
of collagen production to improve wound strength and
initiation of callus formation [15]. PDGF is aregulator for
migration, proliferation, and survival of mesenchymal cell
lineages. TGF-beta constitutes the most powerful fibrosing
agent among all cytokines. It induces massive synthesis of
matrix molecules such as collagen-I and fibronectin either by
osteoblasts or fibroblasts. Although its regulation mechanism
is particularly complex, it is considered as an inflammation
regulator through its capacity to induce fibrous cicatrization.
Basic studies have demonstrated that specialized secretory
granules of platelets, such as alpha-granules, contain these
growth factors [26,27]. Growth factors are known to attract
stem cells present in apical tissues [28].
Platelet-rich plasma (PRP) has been used clinically to
stimulate bone regeneration although its real ecacy is
debated [17]. It has been suggested to mediate only the early
aspects of bone regeneration [29]. Its long-term predictabil-
ity remains questionable, and the anticipated benefits are
moderate [29].
PRF helps to obtain fibrin membranes enriched with
platelets and growth factors. PRF by Choukroun’s technique
is produced in a natural manner, without using an antico-
agulant, bovine thrombin, or calcium chloride for platelet
activation and fibrin polymerization [20].
In vitro studies have proved that PRF releases autologous
growth factors gradually for at least 1 week and up to 28
days [30]. The natural and slow polymerization occurring
during centrifugation process of PRF leads to formation
of a homogenous 3-dimensional organization of the fibrin
network. The absence of anticoagulant in the test tube leads
to massive platelet activation, bolstered by the presence of
a mineral phase on the tube walls (residual glass parti-
cles). A progressive polymerization mode signifies increased
incorporation of the circulating cytokines in the fibrin
4Case Reports in Dentistry
Figure 6: Postoperative radiograph after 3 months.
Figure 7: Follow-up radiograph after 6 months (with intracoronal
bleaching agent).
meshes (intrinsic cytokines). This configuration increases
the lifespan of these cytokines, as they are released and used
only at the time of initial cicatricial remodeling [31]. PRF has
astrongerandmoredurableeect than PRP [20].
Marx et al. in their study added PRP to bone grafts
used in mandibular bone defects and evidenced that radio-
graphically the maturation rate was better than that of grafts
without platelet-rich plasma [17]. Wiltfang et al. reported
8% to 10% more bone formation when PRP was added to
tricalcium phosphate [32].
In another study Goyal et al. compared the healing
responses of PRP with guided tissue regeneration Membrane
and found significant healing in the treatment of apico-
marginal defects [18]. In addition Taschieri et al. also used
combination of autologous growth factors with xenogenic
Figure 8: Follow-up radiograph after 9 months.
Figure 9: Follow-up radiograph after 12 months.
bone grafts in treatment of through and through bone lesions
and observed a fast and predictable tissue healing [21].
The healing potential of PRF combined with β-TCP has
not been studied in endodontics. Kim et al. combined PRF
with β-TCP and observed rapid bone formation, remodeling,
and calcification in the second week than the β-TCP alone in
rabbits [33].
In the present case, it was observed that at 3- (Figure 6),
6- (Figure 7), 9- (Figure 8), and 12- (Figure 9) month fol-
lowup after the surgical treatment of large chronic periapical
lesion, PRF combined with beta-tricalcium resulted in signif-
icant, progressive, and predictable clinical and radiographic
bone regeneration.
Besides promoting wound healing, bone growth, and
maturation, PRF mixed with β-tricalcium phosphate bone
Case Reports in Dentistry 5
graft has the advantages of graft stabilization, wound sealing,
hemostasis, and improved handling properties [34].
However, like other clinical studies this study also has few
limitations like short follow-up period of 12 months and a
need for histological evaluation to confirm regeneration.
4. Conclusion
From the present case report, where PRF and β-Tricalcium
Phosphate allograft were used for periapical healing, follow-
ing conclusions can be drawn.
(i) Addition of PRF to β-Tricalcium Phosphate allograft
accelerates regenerative capacity of bone.
(ii) When used in combination, they give a predictable
clinical and radiographic evidence of bone forma-
tion.
Conflict of Interests
The authors deny any conflict of interests.
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... Bone defect due to periapical lesion is of a surgical importance in the field of the maxillofacial surgery because of higher regional susceptibility to cyst, tumor, trauma, and/or fracture (1,2) . The periapical surgery to removes this periapical lesion in combination with the use of various graft material to enhances new bone formation at the defective site is of prime clinical importance (3) . ...
... Many studies supported the grafting of critical size bony defects after enucleation of periapical lesions (1)(2)(3)(4)(5) . The use of different bone grafts include autogenous and alloplastic bone grafts were recommended as bone grafting materials that could help with healing of the periapical bone defects and reducing the risk of possible fractures of the jaws and shorten the recovery period (9) . ...
... Thus, the result of this case report suggests that a combination of sticky bone and PRF barrier membrane promotes bone healing and bone growth in apico-marginal and periapical bone defects. Similar case reports presented by Dhiman et al. 23 and Jayalakshmi KB et al. 24 concluded that the use of PRF along with bone graft might hasten bone regeneration in apico-marginal defects. Sureshbabu et al. 25 concluded that the combination use of sticky bone along with an autologous barrier membrane promotes rapid bone healing and bone regeneration in large periapical defects. ...
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Apico-marginal defects are localized bony defects encompassing the total root length. The presence of apico-marginal defects has accounted for the failure of endodontic treatment in many cases. The best treatment option for such defect is to perform endodontic surgery using Guided Tissue Regeneration (GTR) membranes. Recently, platelet-rich fibrin (PRF), has been suggested as a better alternative to the conventional practice of using guided tissue regeneration (GTR) barrier membranes for the treatment of these defects. This case report presents clinical management of apico-marginal defect allied with extensive peri-radicular destruction in a maxillary central incisor subjected to periapical surgery using sticky bone and PRF as a barrier membrane. The patient was followed up for 1 year. Clinically, there was a reduction in probing pocket depth, and an increase in attached gingiva, and radiographically a resolution of periapical radiolucency and a significant amount of bone fill was evident.
... Additionally, studies have shown that PRF lowers postoperative pain and infections because of enhanced soft-tissue repair and the presence of immune cells that fight microbes [39]. Because bone graft material only has an osteoconductive impact and PRF's growth factors stimulate osteoinduction, the combination of PRF and bone graft material boosts the regenerative effect of osseous tissue [40,41]. In a histological study, bone regenerative effects of PRF mixed with Tri-Calcium Phosphate (TCP), and TCP alone were compared, and the results showed that PRF-TCP resulted in more rapid bone healing compared with the other group [25]. ...
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... PRF enhances bone healing [7] by providing a sustained release of endogenous fibrogenic factors which are important for wound healing [8] and causes a rapid reduction in pain [7] and swelling [7,9]. HA [10], βTCP [11], and DFDB [12] have been combined with PRF independently for use in osseous defects to achieve faster bone regeneration and repair. Being a dynamic bone scanning modality that provides functional information is sensitive to subtle changes in bone perfusion and bone turnover, and provides highly sensitive, three-dimensional imaging of the skeleton, 99mTc methyl diphosphonate scanning provides a quantitative measurement of bone blood flow and regeneration after surgical intervention [13]. ...
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Introduction: This study was conducted to clinically compare a commercially available combination of 70:30 nanocrystalline hydroxyapatite (HA) and beta tricalcium phosphate (βTCP) along with platelet-rich fibrin (PRF) with demineralized freeze-dried bone (DFDB) grafts along with PRF in small maxillofacial osseous defects. Materials and methods: Thirty patients with one osseous defect were randomly distributed into two groups of 15 each: Group A and Group B. Group A patients received HA+βTCP+PRF while Group B received DFDB + PRF. Postoperative pain, swelling, wound dehiscence, and the presence or absence of infection were evaluated at various intervals up to seven postop days and compared between the two groups and within either group. A technetium 99m methylene diphosphonate (MDP 99mTc) scan was also done for a representative patient of either group at the end of three months to evaluate the fate of the graft. Results: We found no significant difference between the two groups for any of our parameters. Significant improvements were noted for pain and swelling within either group at various intervals. The MDP 99mTc scan showed increased tracer uptake for the representing patient of either group. Conclusions: HA+βTCP is more inexpensive than DFDB and more readily available and has no host incompatibility or infection potential, resulting in similar clinical postoperative states as DFDB when either is used with PRF.
... Selain mendukung pertumbuhan dan pematangan tulang baru, platelet-rich fibrin dengan β-TCP juga memiliki sifat yaitu stabilitas pada bone graft, wound sealing dan hemostasis yang lebih baik. 34 ...
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... [17] PRF acts as an immune regulator due to presence of leukocytes and immune cytokines like IL 1β, IL 6, IL 4 and TNF α. [18] TGF-beta and PDGF induce collagen production to improve wound strength which promotes healing. [19] Fibrin matrix directs the wound coverage. PRF aids in trapping circulating stem cells and these are brought to the wound site. ...
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Abstract The aim of this study was to evaluate clinically and radiographically the long-term results of endodontic therapy. A total of 172 mature teeth with periapical radiolucencies with and without symptoms were treated endoclontically using calcium hydroxide paste as the intracanal medicament and a calcium hydroxide containing root canal sealer. In 58 teeth, the dressing-was accidentally or intentionally extruded into the lesions. All cases were followed up for a period of 2–5 years. The teeth in which the dressing was extruded did not show a different healing pattern from the ones treated conventionally. The complete healing rate for all cases was 80.8% while incomplete healing had taken place in 7.6% of the cases.
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The objective of this histologic study was to evaluate platelet-rich fibrin (PRF)-mixed tricalcium phosphate (TCP) and recombinant human bone morphogenic protein 2 (rhBMP-2)-coated TCP in their potential to enhance bone regeneration in sinus elevation in rabbits as well as in their inflammatory features. Bilateral round-shaped defects (diameter 8.0 mm) were formed in the maxillary anterior sinus walls of 36 New Zealand white rabbits. The defects were grafted with TCP only (control group), with rhBMP-2-coated TCP (experimental group A) and with PRF-mixed TCP (experimental group B). Each group included 12 rabbits. The animals were killed at 3 days, 1 week, 2 weeks, 4 weeks, 6 weeks, and 8 weeks. The specimens underwent decalcification and were stained for histologic analysis. There were no significant differences in inflammatory features among the groups at 3 days or the first week after operation. In a histomorphometric analysis, the new bone formation ratio showed significant differentiation between groups A and B. The TCP-only control group showed a relatively lower bone formation ratio rather than the experimental groups. The PRF-mixed TCP group showed a larger bone formation area, compared with both the control group and group A. In the results of the histologic evaluation (hematoxylin-eosin, Masson trichrome stain), the experimental groups A and B showed rapid bone formation, remodeling, and calcification in the second week. Moreover, there was a significant difference between those experimental groups and the control group in the new bone formation area at the fourth, sixth, and eighth weeks. The PRF-mixed TCP showed more rapid bone healing than the rhBMP-2-coated TCP or the TCP-only control.
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This study was based on the microscopic examination of 800 periapical lesions received as routine biopsy specimens. The specimens were contributed by students and faculty of the University of Kentucky College of Dentistry, by private general practitioners, and by specialists, most of whom were oral surgeons.Periapical granulomas constituted 45.2 per cent of the lesions and radicular cysts 43.8 per cent. Thus, the diagnosis of periapical granuloma or radicular cyst was made for 89 per cent of the 800 periapical lesions submitted. The remaining 11 per cent of the lesions were related inflammatory lesions of various types. Therefore, clinicians can expect that nine out of ten periapical lesions will be periapical granulomas or radicular cysts and that these two lesions should occur with almost equal frequency.The frequency of both cysts and granulomas was one and one-half times greater in the maxilla than in the mandible. The most commonly involved teeth were maxillary incisors, mandibular first and second molars, and maxillary first molars.Radicular cysts were found to be almost as common as granulomas in both posterior and anterior areas of the mouth. Since posterior lesions resolve without surgical endodontic therapy as frequently as anterior lesions, many of which are treated surgically, perhaps much apical surgery should be avoided.
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Tissue regeneration by using membrane barriers and bone grafting materials in periapical surgery is an example of tissue engineering technology. Membrane barriers and/or bone grafts are often used to enhance periapical new bone formation. However, the periapical tissues also consist of the periodontal ligament (PDL) and cementum. For regeneration of the periapical tissues after periapical surgery, one of the important requirements is recruitment and differentiation of progenitor/stem cells into committed pre-osteoblasts, pre-PDL cells, and pre-cementoblasts. Homing of progenitor/stem cells into the wounded periapical tissues is regulated by factors such as stromal cell-derived factor 1, growth factors/cytokines, and by microenvironmental cues such as adhesion molecules and extracellular matrix and associated noncollagenous molecules. Tissue regeneration after injury appears to recapitulate the pathway of normal embryonic tissue development. Multiple tissue regeneration involves a complex interaction between different cells, extracellular matrix, growth/differentiation factors, and microenvironmental cues. Little is known concerning the biologic mechanisms that regulate temporal and spatial relationship between alveolar bone, PDL, and cementum regeneration during periapical wound healing. Simply applying a membrane barrier and/or bone graft during periapical surgery might not result in complete regeneration of the periapical tissues. It has not been clearly demonstrated that these biomaterials are capable of recruiting progenitor/stem cells and inducing these undifferentiated mesenchymal cells to differentiate into PDL cells and cementoblasts after periapical surgery.
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The purpose of this study was to evaluate the effect of biologic characteristics of platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) on proliferation and differentiation of rat osteoblasts. Blood samples were collected from 14 healthy volunteers (7 male) with a mean age of 23.2 +/- 2.24 years. PRP and PRF were prepared with standard protocols. The exudates of PRP and PRF were collected at the time points of 1, 7, 14, 21, and 28 days. The levels of platelet-derived growth factor AB (PDGF-AB) and transforming growth factor beta1 (TGF-beta1) were quantified in PRP and PRF. Then the exudates of PRP and PRF were used to culture rat calvaria osteoblasts. The biologic characteristics of osteoblasts were analyzed in vitro for 14 days. PRP released the highest amounts of TGF-beta1 and PDGF-AB at the first day, followed by significantly decreased release at later time points. PRF released the highest amount of TGF-beta1 at day 14 and the highest amount of PDGF-AB at day 7. Exudates of PRP collected at day 1 and exudates of PRF collected at day 14 expressed maximum alkaline phosphatase (ALP) activity, though no significance was shown. Cells treated with exudates of PRF collected at day 14 reached peak mineralization significantly more than both negative control and positive control groups. PRF is superior to PRP, from the aspects of expression of ALP and induction of mineralization. PRF released autologous growth factors gradually and expressed stronger and more durable effect on proliferation and differentiation of rat osteoblasts than PRP in vitro.
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The aim of this was to evaluate the histology of periapical lesions in teeth treated with periapical surgery. After root-end resection, the root tip was removed together with the periapical pathological tissue. Histologic sectioning was performed on calcified specimens embedded in methylmethacrylate (MMA) and on demineralized specimens embedded in LR White (Fluka, Buchs, Switzerland). The samples were evaluated with light and transmission electron microscopy (TEM). The histologic findings were classified into periapical abscesses, granulomas, or cystic lesions (true or pocket cysts). The final material comprised 70% granulomas, 23% cysts and 5% abscesses, 1% scar tissues, and 1% keratocysts. Six of 125 samples could not be used. The cystic lesions could not be subdivided into pocket or true cysts. All cysts had an epithelium-lined cavity, two of them with cilia-lined epithelium. These results show the high incidence of periapical granulomas among periapical lesions obtained during apical surgery. Periapical abscesses were a rare occasion. The histologic findings from samples obtained during apical surgery may differ from findings obtained by teeth extractions. A determination between pocket and true apical cysts is hardly possible when collecting samples by apical surgery.
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Guided tissue regeneration (GTR) is effective in halting tissue and bone destruction and promoting new tissue and bone formation. Although the goal of complete and predictable regeneration still remains elusive, many techniques and materials have been developed that show good clinical and histologic outcomes. The most commonly used materials in GTR include bone replacement grafts from numerous sources, nonresorbable and bioabsorbable membranes, and recently growth hormones/cytokines and other host modulating factors. This article reviews the biologic rationale behind current techniques used for tissue/bone regeneration, reviews the most common materials and techniques, and attempts to explain the factors that influence the outcomes of these therapies.