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

Abstract

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 affected 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 [9–11]. 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 differentiation 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
diffused 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 differentiate into
committed cells, (b) growth/differentiation factors as nec-
essary signals for attachment, migration, proliferation and
differentiation 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 [23–25].
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 efficacy 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
astrongerandmoredurableeffect 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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