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Case Report

Treatment of Periapical Lesion with Platelet Rich Fibrin

Paromita Mazumdar, Assoc. Professor,
Dept. of Conservative Dentistry & Endodontics,
Debabrata Nag, Professor, HOD,
Dept. of Biochemistry,
Sanjib Bhunia, Post Graduate Student,
Dept. of Conservative Dentistry & Endodontics
Gurunanak Institute of Dental Sciences & Research, Kolkata.
Abstract
Periapical surgery aims to remove periapical pathology
to achieve complete wound healing and regeneration of bone
and periodontal tissue. Platelet rich fibrin (PRF) is a
wonderful tissue engineering product and has gained much
popularity due its promising results in wound healing bone
induction. The features of this product are an attribute of
platelet cells, which, after cellular interactions, release
growth factors. This case report illustrates the use of PRF
in bony regeneration after enucleation of cyst in anterior
maxilla.
Keywords
PRF (platelet rich fibrin), growth factors, wound healing
Introduction
The primary goal of dental treatment is the maintenance
of the natural dentition in health and for optimum comfort,
function, and esthetic. After surgical procedure healing
usually occurs by repair or regeneration. Regeneration has
been defined as the reproduction or reconstitution of a lost
or injured part to restore the architecture and function of
the periodontium. It is possible to achieve bone regeneration
by using autografts and biomaterials. Both have presented
high rates of success. Regenerative surgery including the
use of barrier membrane, graft material, can support the

formation of tissue and allow regenerative rehabilitation and

also functional reconstruction.
Successful treatment for periapical lesion depends on
removal of lesion along with causative microorganism. In
cases where conventional root canal therapy fails to
eliminate the lesion surgery is the last alternative. Periapical
surgery includes removal of diseased soft tissue and
sometimes application of different graft material to enhance
new bone formation at the defective site.
Enhancement of the regenerative process of human body
by utilizing the patients own blood is a unique concept in
dentistry. Post-surgically, blood clots initiate the healing and
regeneration of hard and soft tissues. Platelet rich fibrin
(PRF) is coming up as a biological revolution in dental field.
Using platelet-rich fibrin, or PRF, is a way to accelerate
and enhance the bodys natural wound-healing mechanisms.
Platelets primarily are involved in wound healing through
clot formation and the release of growth factors that initiate
and support wound healing1. PRF represents a similarity to
the natural healing process, with the application of multiple
growth factors. Growth factors are the biologically active
substances that are involved in tissue-repair mechanism
such as chemotaxis, cell proliferation, angiogenesis,
extracellular matrix deposition, and remodelling. PRF
contains and releases (through degranulation) at least seven

Address for correspondence: Dr Paromita Mazumdar, MDS, Assoc. Professor, Dept. of Conservative Dentistry & Endodontics, Gurunanak
Institute of Dental Sciences & Research, 157/F, Panihati, Sodepur, Kolkata 700 114. E-mail: pm.evershine@gmail.com

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different growth factors (cytokines) that stimulate bone

and soft tissue healing. An easy, cost-effective way to obtain
high concentrations of growth factors for tissue healing
and regeneration is autologous platelet storage via PRF.
PRF was first introduced in France by Choukroun et al
in 2001. The PRF production protocol attempts to
accumulate platelets and released cytokines in a fibrin clot.
The use of PRF has been restricted to hospital setting. This
was mainly due to the cost of separating the platelets from
the blood (thousands) and the large amount of blood needed
(one unit) to produce suitable quantity of platelets. New
technology permits to safely harvest and produce a sufficient
quantity of platelets from only 8-10 ml of blood drawn
from patients in dental office. Surgical sites enhanced with
PRF have been shown to heal at rates two to three times
that of normal surgical sites3. Thus, PRF can be a great
adjunct to many periodontal and oral surgical procedures
such as bone grafts, implants and maxillofacial
reconstructions.
This case report describes the healing of a defect which
was treated using PRF and followed over a period of 1
year. Post-operative healing was checked by clinical &
radiographcal parameter.
Case Report
A 28-year-old Indian female complaining of occasional
pain in the upper right anterior region reported to the
Department of Conservative Dentistry and Endodontics.
On intraoral examination, central incisor was slight

Fig. 2
Pre-operative radiograph

discolored but there was no mobility, no swelling and no

pus exudation was noticed. There was history of dental
trauma which occurred in her childhood but no orthodontic
treatment, and no injurious habit was reported by the patient.
A periapical radiograph was taken using the standardized
techniques, which revealed presence of interproximal
intrabony defects with tooth 21 and 22 (Fig. 2). The patient
was healthy and no other medical complication was there.
So it was decided to do root canal treatment in 21 &22 and
remove the lesion surgically. Before planning for the surgical
procedure, patients platelet count (3.5 lac/mm 3),
Haemaglobin (11.5 gm/dl), Bleeding time (2.5 min) and
Clotting time (4.5 min) were assessed and found to be within
normal limits. Root canal therapy of 21 & 22 done in
conventional way using k files and obturated with
guttapercha and AH Plus sealer (Fig. 3). Access cavity was
filled up by glass ionomer cement.
PRF Preparation

Fig. 1
Pre-operative view

The PRF was prepared in accordance with the protocol

developed by Choukroun et al. Just prior to surgery, 8 ml
intravenous blood (by venipuncturing of the antecubital vein)
was collected in a 10-ml sterile tube without anticoagulant
and immediately centrifuged in centrifugation machine at

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Fig. 5
Enucleation of lesion

Fig. 3
Post-obturation radiograph

3,000 revolutions per minute for 10 minutes. Blood

centrifugation immediately after collection allows the
composition 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

Fig. 6
Cystic cavity after removal of lesion

results from a natural and progressive polymerization which

occurs during centrifugation. PRF was easily separated from
red corpuscules base [preserving a small red blood cell
(RBC) layer] using a sterile tweezers and scissors just after
removal from the tube and then transferred onto a sterile
dapen dish and stored in refrigerator.
Surgical Procedure

Fig. 4
Flap elevation

Iodine solution was used to carry out extraoral

antisepsis. Following administration of local anaesthesia,
buccal sulcular incisions were made and full thickness
mucoperiosteal flaps were reflected (Fig. 4). The loss of
labial cortical plate was evident in relation to the left central

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Fig. 7
Platelet rich fibrin

Fig. 9
Suture given

Fig. 8
PRF in cystic cavity

and lateral incisor. The cystic lining was enucleated

(Figs. 5 & 6) and sent for biopsy. The PRF prepared and
stored prior to surgery was filled into the intrabony defect
to cover the defect (Figs. 7 & 8). The mucoperiosteal flaps
were repositioned and secured in place using 3-0 nonabsorbable black silk surgical suture (Fig. 9). The simple
interrupted sutures were placed.
Post-operative Care
The suitable antibiotics (Cefixime and Clavulanate
Potssium) and analgesics (Diclofenac) for 5 days were
prescribed, along with warm saline mouthbath times daily

Fig. 10
Two month Post-operative radiograph

for 2 weeks. Sutures were removed 1 week postoperatively. Patient was re-instructed for proper oral hygiene
measures post-operatively and examined weekly up to
1 month after surgery and then 2 and 6 months.
Discussion
The exact mechanism by which periapical lesions are
formed is not clearly understood. An inflammatory reaction

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may be evoked due to egress of irritants from infected root

canal into the periradicular tissue which can initiate the
formation and perpetuation of periapical lesion. Depending
upon the nature and quantity of irritants, duration of
exposure the lesions may varies from simple periodontitis,
granulomas, cysts or various fibro-osseous lesion.
Nonsurgical root canal therapy often fails to remove the
lesion and then surgery is the last option by which lesion is
removed followed by placement of suitable graft material.

role in the self-regulation of inflammatory and infectious

phenomena within the grafted material.

The present case report evaluated the clinical efficacy

of PRF in the treatment of Intrabony defect. PRF is a matrix
of autologous fibrin, in which are embedded a large quantity
of platelet and leukocyte cytokines during centrifugation.
The intrinsic incorporation of cytokines within the fibrin
mesh allows for their progressive release over time (7-11
days), as the network of fibrin disintegrates6. The main
component of PRF is high concentration of growth factor
present in the platelets which are required for wound
healing7. The PRF acts much like a fibrin bandage8, serving
as a matrix to accelerate the healing of wound .
Amongst the various growth factors that PRF contains,
platelet derived growth factor (PDGF), Transforming
growth factor b (TGF b-1 & b-2), and insulin like growth
factor (IGF), epidermal growth factor, vascular endothelial
factor, and fibroblast growth factors are believed to play a
major role in bone metabolism and potential regulation of
cell proliferation. PDGF is an activator of collagenase which
promotes the strength of healed tissue. TGF-B activates
fibroblasts to form procollagen which deposits collagen
within the wound. PRF facilitates healing by controlling
the local inflammatory response4,9.
According to Simonpieri et al2, the use of this platelet
and immune concentrate during bone grafting offers the
following 4 advantages: First, the fibrin clot plays an
important mechanical role, with the PRF membrane
maintaining and protecting the grafted biomaterials and PRF
fragments serving as biological connectors between bone
particles. Second, the integration of this fibrin network into
the regenerative site facilitates cellular migration, particularly
for endothelial cells necessary for the neo-angiogenesis10,
vascularization and survival of the graft. Third, the platelet
cytokines (PDGF, TGF- , IGF-1) are gradually released
as the fibrin matrix is resorbed, thus creating a perpetual
process of healing6,11. Lastly, the presence of leukocytes
and cytokines in the fibrin network can play a significant

JANUARY 2013

Preparation of PRF is quite easy and fast and simplified

processing minus artificial biochemical modification than
PRP, which takes more time. The PRF preparation process
creates a gel like fibrin matrix polymerized in a
tetramolecular structure, that incorporates platelets,
leukocyte, and cytokines, and circulating stem cells. PRF
is a by-product of the patients own blood; therefore,
chances of infectious disease transmission is rare. Since
PRP harvesting is done with only 8-10 ml of blood, the
patient need not bear the expense of the harvesting
procedure in hospital or at the blood bank.
Conclusions
From the presented case, it can be concluded that PRF
is efficacious clinically and radiographically in the treatment
of intrabony defect. PRF is an autologous preparation and
found to be clinically effective and economical than any
other available regenerative materials. Although the growth
factors, ideal ratios of the components and exact
mechanisms, still are being investigated, and more clinical
research with long-term results is needed. PRF with its
beneficial outcomes will definitely revolutionize the surgical
dentistry in the near future.
References
1.

Nathan E. Carlson, D.M.D.; Robert B. Roach Jr.,

D.D.S. Platelet-rich plasma Clinical applications
in Dentistry JADA. Vol. 133, October 2002.

2.

Simonpieri A., Del Corso M., Sammartino G., Dohan

Ehrenfest D.M. The Relevance of Choukrouns
Platelet-Rich Fibrin and Metronidazole during Complex
Maxillary Rehabilitations Using Bone Allograft. Part
II: Implant Surgery, Prosthodontics, and Survival.
Implant Dent. 18:220229, 2009.

3.

Marx R.E., Carlson E.R., Eichstaedt R.M., Schimmele

S.R., Strauss J.E. Georgeff K.R. Platelet-rich
plasma: growth factor enhancement for bone grafts.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
85: 638-646, 1998.

4.

Palwinder Kaur, Puneet, Varun Dahiya. PlateletRich Plasma: A Novel Bioengineering Concept Trends
Biomater. Artif. Organs. 25(2), 86-90, 2011.

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5.

Choukroun J., Adda F., Schoeffler C., Vervelle A.

A opportunite in paroimplantology: the PRF.
Implantodontie. 42:55-62, 2001.

6.

Simonpieri A., Del Corso M., Sammartino G., Dohan

Ehrenfest D.M. The Relevance of Choukrouns
Platelet-Rich Fibrin and Metronidazole during Complex
Maxillary Rehabilitations Using Bone Allograft. Part
I:M A New Grafting Protocol. Implant Dent. 18:102
111, 2009.

7.

8.

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Marx R.E., Carlson E.R., Eishstaed R.M., Schimmele

S.R., Strauss J.E., Georgeff K.R. Platelet rich
plasma; Growth factor enhancement for bone grafts;
Oral Surg Oral Med Oral Path Oral Radiol Endod.
96; 638-646, 1998.
Wang H.L., Boyapati L. PASS principles for
predictable bone regeneration. Implant Dent. 15(1):817, 2006.

9.

Parikh B., Navin S., Vaishali P. A comparative

evaluation of healing with a computed tomographiy
scan of bilateral lesions treated with and without the
use of platelet rich plasma; Indian Journal of Dental
Research. 22(3), 2011.

10. Dohan D.M., Choukroun J., Diss A., Dohan S.L.,

Dohan A.J., Mouhyi J., Gogly B. Platelet-rich fibrin
(PRF): a second-generation platelet concentrate. Part
I: technological concepts and evolution. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 101:e3744, 2006..
11. Mazor Z., Peleg M., Garg A.K., Luboshitz J.
Platelet-rich plasma for bone graft enhancement in
sinus floor augmentation with simultaneous implant
placement: patient series study. Implant Dent. 13:6572, 2004.