|Year : 2013 | Volume
| Issue : 2 | Page : 61-66
Regenerative periapical surgery: A case report
Sonam Bhandari1, TS Ashwini1, Reshma Naik2, Tushar Bandiwadekar3, Saleem Makandar1
1 Department of Conservative Dentistry and Endodontics, Maratha Mandal's NGH Institute of Dental Sciences and Research Centre, Belgaum, India
2 Department of Periodontology, Maratha Mandal's NGH Institute of Dental Sciences and Research Centre, Belgaum, India
3 Department of Oral and Maxillofacial Surgery, Maratha Mandal's NGH Institute of Dental Sciences and Research Centre, Belgaum, India
|Date of Web Publication||5-Jun-2013|
Maratha Mandal's NGH Institute of Dental Sciences and Research Centre, R.S. NO. 47A/2, Bauxite Road, Belgaum- 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Periapical surgery is an important treatment alternative in the presence of a large periapical cyst. To achieve optimal healing and regeneration of the bone different bone substitutes can be used. Case Report: A 35 year old male patient reported with the soft diffuse swelling in anterior palatal region and drainings in us with 21 labially. He had a history of trauma 5 years back. The clinical and radiographic diagnosis of infected periapical cyst with 11,21; invasive cervical root resorption with 21 and internal root resorption with 11 was made. Endodontic treatment was performed with11,2 followed by periapical curettage. A picectomy and retrograde filling with white mineral trioxide aggregate (MTA) was carried out with 11,21. The cervical resorption defect with 21 was restored with white MTA. Platelet rich fibrin (PRF) was mixed with demineralised bone matrix (Osseograft) and used as a regenerative biomaterial in the periapiacl defect. 14 months follow up shows satisfactory healing and regeneration of periapical region. Discussion: There is considerable clinical interest in using PRF alone or in combination with graft materials as it is a reservoir of many growth factors and have potential for accelerated soft-and hard tissue healing. PRF is a new generation of platelet concentrate, derived from patients own blood.
Keywords: Bonegraft, invasive cervical resorption, mineral trioxide aggregate, platelet-rich fibrin
|How to cite this article:|
Bhandari S, Ashwini T S, Naik R, Bandiwadekar T, Makandar S. Regenerative periapical surgery: A case report. Dent Hypotheses 2013;4:61-6
| Introduction|| |
Regeneration of periapical bone defects continue to present formid able challenges to the endodontists. 
Especially in cases of large periapical boned effects or through and through lesions, conventional surgery results in less predictable healing with extensive fibrous connective tissue fill that is unreliable repair. 
Adopting a patient's own regenerative tools for bone regeneration is a relatively new approach as vehicles for growth factor (GF) delivery are continually optimized for preclinical and clinical applications. Recently tissue engineering has gained attraction in different fields such as orthopedics, sports medicine, oral and maxillofacial surgery, periodontics, implantology etc. To accelerate bone regeneration. 
Platelet rich fibrin (PRF) was developed in France by Choukroun J et al., 2001. It is a second generation platelet concentrate widely used to accelerate
soft- and hard tissue healing. Its advantages over the better known platelet rich plasma (PRP) include ease of preparation/application, minimal expense and lack of biochemical modification that is no bovine thrombin or anticoagulant is required, sustained release of G Fovera longer period of time. 
The scientific rationale behind the use of these preparations lies in the fact that the platelet α granules area reservoir of many GF that are known to play a crucial role in hard and soft tissue repair mechanism. PRF is a strictly autologous fibrin matrix containing a large quantity of platelet and leukocytecytokines. 
Clinical data reveal that this biomaterial would be a favourable matrix for the development of a coherent healing without inflammatory excess. 
Invasive cervical resorption is an insidious and often aggressively destructive form of external root resorption, which may occur as a late complication following dental trauma particularly where it involves damage to cementum and supporting tissues. While this resorption may be evident clinically as a pink coronal discolouration, later with cavitation of the enamel, often there are no obvious external signs and the condition is only detected radiographically. It is characterized by the invasion of the cervical region of the root by fibro vascular tissue, which progressively resorbs dentine, enamel and cementum. Diagnosis of lesions at a nearly stage of development is highly desirable.  Clinical case reports in which mineral trioxide aggregate (MTA) has been used to repair invasive cervical root resorption, with both clinical and radiographic success have been reported. ,
When used as retrograde root filling material, MTA demonstrated high success rate when compared to other materials such as zinc oxide eugenol cement, glassionomer cement, Super ethoxy benzoic acid, Composite. 
In this case, Regenerative periapical surgery using PRF and demineralised bone matrix has been attempted to overcome the disadvantage of unreliable repair in conventional surgery and achieve optimal and accelerated soft- and hard tissue healing.
| Case Report|| |
A 35-year-old male patient reported to the Department of Conservative Dentistry and Endodontics with the chief complaint of draining pus from upper front region. He had a history of trauma 5 years back. Clinically, 11,21 were discolored. A soft diffuse swelling was present in anterior palatal region [Figure 1] and drainings in us present with 21 labially.
|Figure 1: Pre-operative photograph showing swelling in anteriorpalatal region|
Click here to view
Upon radio graphic evaluation, two large periapical radiolucencies seen at the apex of 11,21. Furthermore, the radiolucency was seen in the cervical region of 21 and the middle-third of root canal with 11 [Figure 2]. The clinical and radiographic diagnosis of infected periapical cyst with 11,21; invasive cervical root resorption with 21and internal root resorption with 11 was made.
|Figure 2: Occlusal radiograph showing large periapical radiolucency with 11,21; white arrow shows internal resorption with 11, yellow arrow shows invasive cervical resorption with 21|
Click here to view
Multiple visit endodontic treatment was performed with 11,21 with calcium hydroxide placed as an intra canal medicament for 3 weeks. Obturation of 11 carried out with thermo plasticized gutta-percha technique (E & Q plus, Meta Biomed Co. Ltd, CHOONG CHONG BUKDO, Korea) to fill the irregularities of internal resorption defect and that of 21 was carried out with cold lateral compaction [Figure 3].
|Figure 3: Thermo plasticised gutta-percha obturation with 11, cold lateral compaction with 21|
Click here to view
For the surgical procedure, labial rectangular [Figure 4] and palatal triangular full thickness mucoperiosteal flap was raised [Figure 5]. Complete loss of palatal cortical bone was seen. Labially the bony window was enlarged, and curettage of the cyst lining carried out and sent for biopsy. Histopathological examination further confirmed the diagnosis of radicular cyst.
Apicectomy was carried out with 11, 21, retrograde filling done with white MTA (Angelus, Londrina, Brazil); [Figure 6]. The cervical resorption defect was debrided with curettes and restored with white MTA [Figure 7].
|Figure 6: Curettage of cystdone, root resection with 11,21; retrograde cavity prepared and root end filling done with white mineral trioxide aggregate with 11,21|
Click here to view
|Figure 7: Invasive cervical resorption defect on the distopalatal aspect of 21 was debrided thoroughly and restored with white mineral trioxide aggregate|
Click here to view
The palatal flap was sutured. The regenerative biomaterial used here is PRF. PRF was mixed with demineralised bone matrix (Osseograft, Advanced Biotech products (P) LTD, USA) in the approximate ratio of 5:1 and the combination placed in the bony defect [Figure 8] and [Figure 9] and labial sutures placed [Figure 10]. Post-operatively antibiotics, Augmentin (combination of Amoxicillin and Clavulanate potassium) 625 mg tablet every 8 hourly for 5 days, Metrogyl (Metronidazole) 400 mg twice a day for 3 days and anti inflammatory drug i.e., Enzoflam (combination of Diclofenac, Paracetamol (Acetaminophen) and Serratio peptidase) 8 hourly for 3dayswereprescribed.At the followup visit after 10 days, vitality testing was performed with 12,22 was diagnosed non-vital and endodontic treatment was performed. The patient was followed-up after 3, 6, 9, and 14 months.
|Figure 8: Three separate layers were formed after centrifugation of patients' blood: top arrow shows platelet poor plasma (PPP) centerone is platelet-rich fibrin (PRF) and bottom arrow shows red blood cells (RBC's)|
Click here to view
|Figure 9: Fibrin clot was separated from attached red blood cells and mixed with bonegraft|
Click here to view
|Figure 10: The combination of fibrin clot and bone graft placed in the defect|
Click here to view
Fourteen months follow-up radiograph shows satisfactory bone fill in the periapical area [Figure 11].
Procedure for preparation of PRF 40 ml of patient's blood was collected without any anticoagulant and immediately centrifuged at 2700 rpm for 18 min. The result was a fibrin clot containing the platelets located in the middle of the tube, just between the red blood cell layer at the bottom and a cellular plasma at the top [Figure 12]. This clot was removed from the tube and the attached red blood cells scraped off and discarded. Then PRF was mixed with demineralised bone matrix (Osseograft, Advanced Biotech products (P) LTD, USA) in the approximate ratio of 5:1 and combination placed in the defect.
|Figure 12: Fourteen month follow up radiograph shows satisfactory bone regeneration|
Click here to view
| Discussion|| |
The understanding of how normal wound healing and tissue formation occurs together with recent advances in materials science, stem cell research and developmental biology have helped to find target molecules and pathways, which can restore a patient's regenerative capacity. 
PRF is a matrix of autologous fibrin, in which are embedded a large quantity of platelet and leukocyte cytokines during centrifugation. Platelet alpha (α) granules for man intra cellular storage pool of GF including platelet derived growth factor (PDGF), transforming growth factor-β (TGF-β, including β−1 and β−2 -isomers), vascular endothelial growth factor (VEGF), and epidermal growth factor.  Platelet GF exhibit chemotactic and mitogenic properties that promote and modulate cellular functions involved in tissue healing and regeneration and cell proliferation.  Insulin-like growth factor-1 (IGF-1), which is present in plasma, can exert chemotactic effects towards human osteoblasts. 
PRF contains all key immune cytokines such as interleukins IL1β,IL-6,IL-4 and tumour necrosis factor. PRF has a supportive effect on the immune system because it is able to stimulate defense mechanisms. This could be important in the case of wound infection.  PRF may act as a supportive matrix for bone morpho genetic proteins as well-Kawamura and Urist. 
Though platelets and leukocyte cytokines play an important part in the biology of this biomaterial, the fibrin matrix supporting them certainly constitutes the determining element responsible for the real therapeutic potential of PRF.  A progressive polymerization mode signifies increased incorporation of the circulating cytokines the fibrin meshes. This result would imply that PRF, unlike the other platelet concentrates would be able to release cytokines during fibrin matrix remodelling i.e., when they have to be stimulated to launch injured site reconstruction that is it has along term effect. 
According to Simonpieri  et al., 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 maintaining and protecting the bone grafts and 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-angiogenesis,  vascularisation and survival of the graft. Third, the platelet cytokines (PDGF, TGF-β,IGF1) are gradually released as the fibrin matrix is resorbed, thus creating a perpetual process of healing. , Lastly, the presence of leukocytes and cytokines in the fibrin network can play a significant role in the self-regulation of inflammatory and infectious phenomena within the grafted material.
Osseograft consists of demineralised bone matrix that is prepared from bovine cortical bone sample resulting in non immunogenic flow able particles of approximately 250 μm. It possess good osteo conductive properties, is well integrated into bone tissue and has good bio compatibility.  The clinical results with Bovine Derived Xeno graft were comparable with those obtained with demineralised freeze dried bone allograft. ,
Clinical studies have shown PRF in combination with bone graft showed enhanced bone formation. 
Root canal obturation was carried out with thermo plasticized gutta per chain case of internal resorption with 11 asith as advantages like obtaining a homogenous obturating mass, successfully filling irregularities in the root canals and promoting a better apical seal. 
MTA was used as a root-end filling material and restoration with the invasive cervical resorption because of its advantage s such as biocompatibility, antibacterial action, less micro leakage.  There is evidence of healing of the surrounding tissues as osteoblast shave a favorable response to MTA.  With longer duration, new cementum formation appears on the surface of the material. 
In this case, the radiograph reveals satisfactory bone regeneration after 14 months. Thus, it can be concluded that PRF is a healing biomaterial, as it features all the necessary parameters permitting optimal wound healing. Long-term follow-up of the case is essential to evaluate the treatment outcome.
| Acknowledgments|| |
We would like to thank Dr. Kishor Bhatt, Department of microbiology, principal and the head of the Department of Conservative Dentistry And Endodontics, MMNGHIDS for their support.
| References|| |
|1.||Chen FM, Zhang J, Zhang M, An Y, Chen F, Wu ZF. A review on endogenous regenerative technology in periodontal regenerative medicine. Biomaterials 2010;31:7892-927. |
|2.||Pecora G, De Leonardis D, Ibrahim N, Bovi M, Cornelini R. The use of calcium sulphate in the surgical treatment of a 'through and through' periradicular lesion. Int Endod J 2001;34:189-97. |
|3.||Toffler M, Toscano N, Holtzclaw D, Corso MD, Ehrenfest DD. Introducing Choukroun's Platelet Rich Fibrin (PRF) to the Reconstructive Surgery Milieu. J Implant Adv Clin Dent 2009;1:21-32. |
|4.||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. |
|5.||Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL, Dohan AJ, Mouhyi J, Dohan DM. 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;101:299-303. |
|6.||Heithersay G. Invasive cervical resorption. Endod Top 2004;7:73-92. |
|7.||Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197-205. |
|8.||White C Jr, Bryant N. Combined therapy of mineral trioxide aggregate and guided tissue regeneration in the treatment of external root resorption and an associated osseous defect. J Periodontol 2002;73:1517-21. |
|9.||Roberts HW, Toth JM, Berzins DW, Charlton DG. Mineral trioxide aggregate material use in endodontic treatment: A review of the literature. Dent Mater 2008;24:149-64. |
|10.||Anitua E, Sánchez M, Orive G, Andía I. The potential impact of the preparation rich in growth factors (PRGF) in different medical fields. Biomaterials 2007;28:4551-60. |
|11.||Lind M. Growth factor stimulation of bone healing. Effects on osteoblasts, osteomies, and implants fixation. Acta Orthop Scand Suppl 1998;283:2-37. |
|12.||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. |
|13.||Kawamura M, Urist MR. Human fibrin is a physiologic delivery system for bone morphogenetic protein. Clin Orthop Relat Res 1988;235:302-10. |
|14.||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. |
|15.||Simonpieri A, Del Corso M, Sammartino G, Dohan Ehrenfest DM. The relevance of Choukroun's platelet-rich fibrin and metronidazole during complex maxillary rehabilitations using bone allograft. Part II: Implant surgery, prosthodontics, and survival. Implant Dent 2009;18:220-9. |
|16.||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 concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e37-44. |
|17.||Simonpieri A, Del Corso M, Sammartino G, Dohan Ehrenfest DM. The relevance of Choukroun's platelet-rich fibrin and metronidazole during complex maxillary rehabilitations using bone allograft. Part I: A new grafting protocol. Implant Dent 2009;18:102-11. |
|18.||Berglundh T, Lindhe J. Healing around implants placed in bone defects treated with Bio-Oss. An experimental study in the dog. Clin Oral Implants Res 1997;8:117-24. |
|19.||Mellonig JT. Human histologic evaluation of a bovine-derived bone xenograft in the treatment of periodontal osseous defects. Int J Periodontics Restorative Dent 2000;20:19-29. |
|20.||Richardson CR, Mellonig JT, Brunsvold MA, McDonnell HT, Cochran DL. Clinical evaluation of Bio-Oss: A bovine-derived xenograft for the treatment of periodontal osseous defects in humans. J Clin Periodontol 1999;26:421-8. |
|21.||Lekovic V, Milinkovic I, Aleksic Z, Jankovic S, Stankovic P, Kenney EB, et al. Platelet-rich fibrin and bovine porous bone mineral vs. platelet-rich fibrin in the treatment of intrabony periodontal defects. J Periodontal Res 2012;47:409-17. |
|22.||Yee FS, Marlin J, Krakow AA, Gron P. Three-dimensional obturation of the root canal using injection-molded, thermoplasticized dental gutta-percha. J Endod 1977;3:168-74. |
|23.||Koh ET, Torabinejad M, Pitt Ford TR, Brady K, McDonald F. Mineral trioxide aggregate stimulates a biological response in human osteoblasts. J Biomed Mater Res 1997;37:432-9. |
|24.||Baek SH, Plenk H Jr, Kim S. Periapical tissue responses and cementum regeneration with amalgam, Super EBA, and MTA as root-end filling materials. J Endod 2005;31:444-9. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]