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CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 1  |  Page : 49-54

Platelet-rich fibrin (PRF) as an autologous biomaterial after an endodontic surgery: Case reports


1 Department of Conservative Dentistry and Endodontics, Sri Balaji Dental College and Hospital, Moinabad, Telangana, India
2 Department of Conservative Dentistry and Endodontics, SVS Institute of Dental Sciences, Mahboobnagar, Telangana, India

Date of Web Publication18-Mar-2016

Correspondence Address:
Kavitha Anantula
Department of Conservative Dentistry and Endodontics, Sri Balaji Dental College and Hospital, Moinabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.178979

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  Abstract 

The successful treatment of periapical inflammatory lesion depends on the reduction and elimination of the offending organism. Periapical surgery, one of the treatment alternatives, includes the curettage of all periapical soft tissues and sometimes application of different biomaterials to enhance the new bone formation in the defect site. The cases reported here present the management of the periapical inflammatory lesion using platelet-rich fibrin (PRF) which acts as a source of growth factors at the healing site. PRF features all the necessary parameters permitting optimal healing, but numerous perspectives of PRF have still to be clinically tested.

Keywords: Autologous growth factors, biomaterial, platelet concentrate, platelet-rich fibrin, platelet-rich plasma


How to cite this article:
Anantula K, Annareddy A. Platelet-rich fibrin (PRF) as an autologous biomaterial after an endodontic surgery: Case reports. J NTR Univ Health Sci 2016;5:49-54

How to cite this URL:
Anantula K, Annareddy A. Platelet-rich fibrin (PRF) as an autologous biomaterial after an endodontic surgery: Case reports. J NTR Univ Health Sci [serial online] 2016 [cited 2020 Mar 31];5:49-54. Available from: http://www.jdrntruhs.org/text.asp?2016/5/1/49/178979


  Introduction Top


Periapical lesion is a local response of bone around the apex of tooth that develops after the necrosis of the pulp tissue or extensive periodontal disease. The successful treatment of periapical inflammatory lesion depends on the reduction and elimination of the offending organism. Root canal therapy, periapical surgery, or extraction of the tooth might be the treatment alternatives. Periapical surgery includes the curettage of all periapical soft tissues and sometimes application of different biomaterials to enhance the new bone formation in the defect site. Bone grafts and barrier membrane have been used for optimal healing of the periapical defect area after degranulation of the lesion. [1],[2] All these approaches are known as regenerative therapies.[3]

Platelet-rich plasma (PRP), introduced by Whitmen et al. in 1997, is a natural source of growth factors (GF) used to enhance bone regeneration. It is an autologous concentrate of platelets suspended in plasma. It is well known that platelets have many functions beyond that of simple hemostasis. Platelets contain important GF that, when secreted, are responsible for increasing collagen production, recruiting other cells to the site of injury, initiating vascular ingrowth, and inducing cell differentiation. These are all crucial steps in early wound healing. [4]

On the other hand, platelet-rich fibrin (PRF), a second-generation platelet concentrate, has shown to be superior to PRP. [5] It was first developed in France by Choukroun et al. in 2001. [6] PRF allows one to obtain fibrin membranes enriched with platelets and GF after starting from an anticoagulant-free blood harvest. [7],[8],[9] Recently, studies have demonstrated that the PRF membrane has a very significant slow sustained release of many key GF for at least 1 week [10] and up to 28 days, [11] which means that PRF could release GF with its own biological scaffold for wound healing process.

The present case reports describe the management of the periapical inflammatory lesion using PRF which acts as a source of GF at the healing site, thereby accelerating soft and hard tissue healing. [12],[13]


  Case reports Top


Case 1

A 23-year-old male patient presented to the Department of Conservative Dentistry and Endodontics with the complaint of pus discharge in relation to the right maxillary anterior region [Figure 1]a. The patient gave the history of trauma 7 years back. On clinical examination, there was grade I mobility in maxillary right lateral incisor and associated draining sinus.
Figure 1: Case 1: (a) preoperative clinical view; (b) a full-thickness Luebke Ochsenbein flap reflection and osteotomy; (c) after apicoectomy and retrograde MTA placement; (d) placement of PRF clot into the periapical defect; (e) PRF filled flat up to the brim of the defect; (f) postoperative clinical view after 3 months showing soft tissue healing

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Examination of the head and neck revealed no palpable lymph nodes. All vital signs were found to be within normal limits. Radiographic examination revealed a well-defined periapical radiolucency of about 1.2 × 1.0 cm around the apices of maxillary right central and lateral incisors [Figure 2]a. Both the teeth tested nonresponsive to thermal and electric pulp testing. There was only mild tenderness to percussion and palpation. The diagnosis was pulpal necrosis with chronic apical abscess with respect to maxillary right central and lateral incisors.
Figure 2: Radiographs of case 1: (a) preoperative radiograph showing the periapical lesion; (b) immediate postoperative radiograph; (c) 3 months postoperative radiograph showing enhanced bone healing; (d) 12 months postoperative radiograph showing the healed periapical lesion

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Management

The treatment plan was devised as nonsurgical root canal therapy in the maxillary right central and lateral incisors, but the lesion did not respond to the repeated calcium hydroxide dressings for 10 months. The dressing was changed at an interval of every 15 days as the canal was weeping at every subsequent visit. Later, it was decided to treat the lesion through endodontic surgery.

The canals were obturated with gutta-percha (Dentsply Maillefer, Ballaigues, Switzerland) and AH Plus sealer (Dentsply De Trey GmbH, Konstanz, Germany) under rubber dam isolation, 1 h prior to the surgery. After effective local anesthesia with 2% lignocaine, a full-thickness Luebke Ochsenbein flap was reflected. A small defect was visible in the cortical plate with the lateral incisor, which was enlarged to aid in complete curettage of the granulation tissue (which was sent for biopsy) and allowed room for retrograde instrumentation after root-end resection [Figure 1]b. This was followed by irrigation with betadine (Win Medicare; Win Medicare Dental Products, New Delhi, India) and sterile saline solution. The root-end resection was carried out followed by retrograde cavity preparation with ultrasonic tips (Mectron S.P.A, Carasco, Italia). The retrograde cavity was filled with mineral trioxide aggregate (MTA) (Pro Root MTA; Dentsply Maillefer) [Figure 1]c and [Figure 2]b.

PRF preparation was performed using the procedure described by Dohan et al. [7],[8],[9] The PRF protocol is very simple. A blood sample [Figure 3]a] was taken without anticoagulant in 10 ml tubes, which was immediately centrifuged at 3000 rpm for 10 min (Remi Centrifuge, Mumbai, India) [Figure 3]b. After PRF processing, three distinct samples were collected [Figure 3]c.

  • The supernatant represented acellular plasma (or) platelet-poor plasma (PPP)
  • The fibrin clot (PRF)
  • The exudates resulting from PRF clot corresponded to the solution trapped in the fibrin meshes
For collection, it was necessary to leave the PRF clots in a sterile metal cup for approximately 10 min to let slowly release the serum contained therein [Figure 3]d and e
Figure 3: PRF preparation technique: (a) collection of blood sample; (b) centrifuge machine (Remi Centrifuge); (c) a structured fibrin clot found after centrifugation in the middle of the tube, just between the red blood corpuscles at the bottom and acellular plasma at the top; (d) the fibrin clot with attached RBCs; (e) PRF clot placed in a sterile metal cup to allow the serum within the clot to drain

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.

The PRF clot was then packed into the defect to completely fill the bony crypt [Figure 1]d and e]. Wound closure was then obtained with 4-0 nylon sutures (Pearsalls Limited, Mumbai, India). Nonsteroidal anti-inflammatory analgesics (Ibuprofen 500 mg) were prescribed and the patient was advised to use chlorhexidine mouth wash for a week. The sutures were removed after 1 week, and satisfactory healing was observed. The patient was recalled at 3 and 12 months [Figure 1]f. Follow-up radiographs at these intervals showed satisfactory bone regeneration in the periapical defect [Figure 2]c and d.

Case 2

A 22-year-old male patient presented with pus discharge in relation to the right maxillary anterior region for the past 2 weeks. The patient gave a history of trauma 5 years ago. On clinical examination, grade I mobility in right maxillary central and lateral incisors was observed and there was a sinus tract associated with the central incisor. Both the incisors were tender on vertical percussion and gave no response on thermal and electric pulp testing [Figure 4]a.
Figure 4: Case 2: (a) preoperative clinical view; (b) a rectangular full-thickness flap reflection and visible defect after enucleation; (c) placement of PRF clot into the periapical defect; (d) PRF filled flat up to the brim of the defect; (e) sutures given with 4-0 silk suture material; (f) postoperative clinical view after 3 months showing soft tissue healing

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Examination of the head and neck revealed no palpable lymph nodes. All vital signs were found to be within normal limits. Radiographic examination revealed a well-defined radiolucency of about 2.2 × 2.4 cm around the apices of right maxillary incisors [Figure 5]a. The diagnosis was pulpless infected root canal system with a secondary acute apical abscess with respect to maxillary right central and lateral incisors.
Figure 5: Radiographs of case 2: (a) preoperative radiograph showing the periapical lesion; (b) working length determination; (c) obturation of the canals; (d) immediate postoperative radiograph after apicocetomy and retrograde MTA placement; (e) 3 months postoperative radiograph showing enhanced bone healing; (f) 12 months postoperative radiograph

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Management

The treatment plan was root canal therapy in the right central and lateral incisors, followed by surgical enucleation of the lesion and root-end surgery because of the time constraint of the patient toward nonsurgical approach. After effective local anesthesia with 2% lignocaine, the rubber dam was placed and both teeth were accessed. Instrumentation of the canals was accomplished utilizing K-files (Mani Prime Dental, Mumbai, India) and was followed by irrigation with 3% sodium hypochlorite and 17% ethylenediaminetetraacetic acid (EDTA). The canals were obturated with gutta-percha (Dentsply Maillefer) and AH Plus sealer (Dentsply De Trey GmbH) [Figure 5]b and c.

A full-thickness rectangular flap was raised and loss of labial cortical plate was seen. Total removal of the granulomatous tissue (which was sent for biopsy) was followed by irrigation with betadine and sterile saline solution [Figure 4]b]. The root-end resection was followed by retrograde cavity preparation with ultrasonic tips (Mectron S.p.A) and obturation with MTA [Figure 5]d.

PRF was processed from 20 ml of the patient's blood and packed into the defect to completely fill the bony defect [Figure 4]c and d. The flap was repositioned and closed with 4-0 silk suture (Pearsalls Limited) [Figure 4]e. The biopsy report gave the diagnosis of periradicular cyst. The patient was recalled after 3 and 12 months [Figure 4]f. Follow-up radiographs at these intervals showed satisfactory healing and bone regeneration in the periapical defect [Figure 5]e and f.


  Discussion Top

"The richest of resources in nature lie in the nature itself." The world seems to be going back to natural substitutes for all its queries and dilemmas. Modern day medicine and surgery are certainly no exception to this rule.

PRP is a natural source of GF that is used to enhance bone regeneration. [4] But PRF, a second-generation platelet concentrate, has shown to be superior to PRP. [11] Advantages of PRF over PRP include: [14]

  1. Ease of preparation (blood centrifuged only once)
  2. Ease of application
  3. Minimal expense (sophisticated equipment not required)
  4. Lack of biomechanical modification (anticoagulant or thrombin or calcium chloride not required unlike PRP)
The major role of fibrin in wound repair is hemostasis, but fibrin also provides a matrix for the migration of fibroblasts and endothelial cells that are involved in angiogenesis and are responsible for remodeling of new tissue.

Platelet activation in response to tissue damage and vascular exposure results in the formation of a platelet plug and blood clot, as well as the secretion of biologically active proteins. [15] Platelet alpha (α) granules form an intracellular storage pool of GF including platelet-derived growth factor (PDGF), transforming growth factor ß (TGF-ß, including ß-1 and ß-2-isomers), vascular endothelial growth factor (VEGF), and epidermal growth factor (EGF). [5] Insulin-like growth factor-1 (IGF-1), which is present in plasma, can exert chemotactic effects toward human osteoblasts. [16] After platelet activation, the α granules fuse with the platelet cell membrane, transforming some of the secretory proteins to a bioactive state. [17],[18] Active proteins are secreted and bind to transmembrane receptors of the target cells to activate intracellular signaling proteins. [19] This results in the expression of a gene sequence that directs cellular proliferation, collagen synthesis, and osteoid production. [20]

It has been reported that PRF clot forms a strong natural fibrin matrix and shows a complex architecture as a healing matrix. It is an autologous biomaterial and not improved fibrin glue. Unlike the PRP, PRF developed by Choukroun's technique does not dissolve quickly after application; instead, the strong fibrin matrix is slowly remodeled in a similar way to a natural blood clot. [10],[21] In vitro studies have demonstrated that PRF has shown no cytotoxicity toward many cells including preadipocytes, dermal prekeratinocytes, osteoblasts, oral epithelial cells, dental pulp cells, periodontal ligament cells, and gingival fibroblasts. [22],[23],[24],[25]

In view of the above-mentioned characteristics of platelets and advantages of PRF, in the present case reports, the periapical defects after the surgical procedure were filled with PRF to accelerate the physiologic healing mechanism. The postoperative clinical and radiographic assessments revealed an enhanced healing of the bony lesion at the 3 month follow-up.

Previously, many case reports have been published on using PRP or PRP in combination with other graft materials in the periapical defects after endodontic surgery. [3],[26],[27] But PRP requires two centrifuging processes and addition of bovine thrombin and calcium chloride to it to form a gel. PRF does not require any modification after collection and is easy to process and carry to the operating site. We believe this is probably the first case report in which the periapical defects after endodontic surgery were filled with PRF to enhance bone regeneration and soft tissue closure. Nevertheless, only a limited volume of PRF can be used because it is obtained from an autologous blood sample and, thus, the quantities produced are low. This fact limits the systematic utilization of PRF for general surgery. PRF tissue banks are unfeasible. The fibrin matrix contains all the circulating immune cells and all the antigenic plasmatic molecules. That is why PRF membranes are totally specific to the donor and cannot constitute an allogenic graft tissue.

The clinical experience confirms that PRF can be considered as a healing biomaterial and it features all the necessary parameters permitting optimal healing, but numerous perspectives of PRF have still to be clinically tested.

 
  References Top

1.
Stassen LF, Hilsop WS, Still DM, Moos KF. Use of anorganic bone in periapical defects following apical surgery-a prospective trial. Br J Oral Maxillofac Surg 1994;32:83-5.  Back to cited text no. 1
    
2.
Uchin RA. Use of a bioresorbable guided tissue membrane as an adjunct to bony regeneration in cases requiring endodontic surgical intervention. J Endod 1996;22:94-6.  Back to cited text no. 2
    
3.
Demiralp B, Keçeli HG, Muhtaroðullar M, Serper A, Demiralp B, Eratalay K. Treatment of periapical inflammatory lesion with the combination of platelet-rich plasma and tricalcium phosphate. J Endod 2004;30:796-800.  Back to cited text no. 3
    
4.
Freymiller EG, Aghaloo TL. Platelet-rich plasma: Ready or not? J Oral Maxillofac Surg 2004;62:484-8.  Back to cited text no. 4
    
5.
Su CY, Kuo YP, Tseng YH, Su CH, Burnouf T. In vitro release of growth factors from platelet rich fibrin (PRF): A proposal to optimize the clinical applications of PRF. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:56-61.  Back to cited text no. 5
    
6.
Choukroun J, Adda F, Schoeffler C, Vervelle A. Une opportunite´ en paro-implantologie: le PRF. Implantodontie 2000;42:55-62.  Back to cited text no. 6
    
7.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second generation platelet concentrate-part I: Technological concept and evolution. Oral Surg Oral Med Oral Path Oral Radiol Endod 2006;101:E37-44.  Back to cited text no. 7
    
8.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate-part II: Platelet-related biologic features. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:E45-50.  Back to cited text no. 8
    
9.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate-part III: leucocyte activation: A new feature for platelet concentrates? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:E51-5.  Back to cited text no. 9
    
10.
Dohan Ehrenfest DM, de Peppo GM, Doglioli P, Sammartino G. Slow release of growth factors and thrombospondin-1 in Choukroun's platelet-rich fibrin (PRF): A gold standard to achieve for all surgical platelet concentrates technologies. Growth Factors 2009;27:63-9.  Back to cited text no. 10
    
11.
He L, Lin Y, Hu X, Zhang Y, Wu H. A comparative study of platelet-rich fibrin (PRF) and platelet-rich plasma (PRP) on the effect of proliferation and differentiation of rat osteoblasts in vitro. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:707-13.  Back to cited text no. 11
    
12.
Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL, et al. Platelet-rich fibrin (PRF): A second generation platelet concentrate-part IV: Clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:E56-60.  Back to cited text no. 12
    
13.
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:E299-303.  Back to cited text no. 13
    
14.
Toffler M, Toscano N, Holtzclaw D, Corso MD, Dohan Ehrenfest D. JIACD Continuing education. Introducing Choukroun's platelet rich fibrin (PRF) to the reconstructive surgery milieu. J Implants Advan Cl Dent 2009;1:21-31.  Back to cited text no. 14
    
15.
Hamdan AA, Loty S, Isaac J, Bouchard P, Berdal A, Sautier JM. Platelet-poor plasma stimulates proliferation but inhibits differentiation of rat osteoblastic cells in vitro. Clin Oral Implants Res 2009;20:616-23.  Back to cited text no. 15
    
16.
Lind M. Growth factor stimulation of bone healing. Effects on osteoblasts, osteomies, and implants fixation. Acta Orthop Scand Suppl 1998;283:2-37.  Back to cited text no. 16
    
17.
White JG, Krumwiede M. Further studies of the secretory pathway in thrombin-stimulated human platelets. Blood 1987;69:1196-203.  Back to cited text no. 17
[PUBMED]    
18.
Zucker-Franklin D, Benson KA, Myers KM. Absence of a surface-connected canalicular system in bovine platelets. Blood 1985;65:241-44.  Back to cited text no. 18
[PUBMED]    
19.
Gaßling VL, Açil,Y, Springer IN, Hubert N, Wiltfang J. Platelet-rich Plasma and Platelet-rich fibrin in human cell culture. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:48-55.  Back to cited text no. 19
    
20.
Marx RE. Platelet-rich plasma: Evidence to support its use. J Oral Maxillofac Surg 2004;62:489-96.  Back to cited text no. 20
    
21.
Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: From pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF). Trends Biotech 2009;27:158-67.  Back to cited text no. 21
    
22.
Huang FM, Yang SF, Zhao JH, Chang YC. Platelet-rich fibrin increases proliferation and differentiation of human dental pulp cells. J Endod 2010;36:1628-32.  Back to cited text no. 22
    
23.
Tsai CH, Shen SY, Zhao JH, Chang YC. Platelet-rich fibrin modulates cell proliferation of human periodontally related cells in vitro. J Dent Sci 2009;4:130-5.  Back to cited text no. 23
    
24.
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. 24
    
25.
Chang IC, Tsai CH, Chang YC. Platelet-rich fibrin modulates the expression of extracellular signal-regulated protein kinase and osteoprotegerin in human osteoblasts. J Biomed Mater Res A 2010;95:327-32.  Back to cited text no. 25
    
26.
Hemalatha 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. 26
    
27.
Shashikiran ND, Reddy VV, Yavagal CM, Zakirulla M. Applications of platelet rich plasma in contemporary pediatric dentistry. J Clin Pediatr Dent 2006;30:283-6.  Back to cited text no. 27
    


    Figures

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



 

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