|Year : 2016 | Volume
| Issue : 1 | Page : 27-31
A comparative clinical study to evaluate the healing of large periapical lesions using platelet-rich fibrin and hydroxyapatite
Prashant Monga, Ruma Grover, Pardeep Mahajan, Vanita Keshav, Navkesh Singh, Gurbant Singh
Baba Farid University of Health Sciences and Research, Faridkot; Department of Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab, India
|Date of Web Publication||21-Jun-2016|
Department of Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab
Source of Support: None, Conflict of Interest: None
Aims: To evaluate and compare the effectiveness of periapical surgery using mineral trioxide aggregate (MTA) as a retrograde filling material with/without using hydroxyapatite or platelet-rich fibrin (PRF) in curetted periapical defect and to evaluate the patients clinically and radiographically at each recall visit.
Subjects and Methods: The study was conducted on thirty patients having periapical radiolucency in maxillary anterior teeth. The selected teeth were divided into three groups: Group A, Group B, and Group C having 10 teeth each. All the teeth were treated with single visit root canal treatment. The periapical curettage along with apicoectomy was followed thereafter. In all the groups, root end cavity was prepared. In Group A, root end cavity was filled with MTA. In Group B, root end cavity was filled with MTA followed by placement of hydroxyapatite in the curetted periapical defect. In Group C, root end cavity was filled with MTA followed by placement of PRF in the curetted periapical defect. In all the three groups, patient recall visits were scheduled after 1, 3, 6, and 9 months time interval for clinical and radiological examination.
Results: A significantly higher rate of healing was observed after 9 months in Group C (82.36%) followed by Group B (65.16%) and Group A (60.12%).
Conclusions: Placement of root end filling material contributes greatly to the success of surgical treatment. To enhance the healing of periapical defect, use of host modulating agents such as PRF is preferred over grafts as these are autologous and contain growth factors that promote faster healing of periapical defects.
Keywords: Hydroxyapatite; platelet-rich fibrin; retrograde filling material.
|How to cite this article:|
Monga P, Grover R, Mahajan P, Keshav V, Singh N, Singh G. A comparative clinical study to evaluate the healing of large periapical lesions using platelet-rich fibrin and hydroxyapatite. Endodontology 2016;28:27-31
|How to cite this URL:|
Monga P, Grover R, Mahajan P, Keshav V, Singh N, Singh G. A comparative clinical study to evaluate the healing of large periapical lesions using platelet-rich fibrin and hydroxyapatite. Endodontology [serial online] 2016 [cited 2019 Mar 26];28:27-31. Available from: http://www.endodontologyonweb.org/text.asp?2016/28/1/27/184336
| Introduction|| |
Periapical lesions in teeth can occur due to long-standing untreated endodontic infection. When indicated periapical surgery removes diseased soft tissue and with application of different graft material enhances new bone formation at the defective site. 
Formation of new bone can occur with repair or regeneration. The most commonly used technique for regeneration is the use of bone replacement grafts. These grafts can promote tissue or bone regeneration through variety of mechanisms. Bone grafting materials include autografts, allografts, xenografts, and alloplasts. The ideal bone replacement material should be inert, noncarcinogenic, easy maneuverable, and should be dimensionally stable. It should serve as a scaffold for bone formation and slowly resorb to permit the formation of the new bone.  Biphasic calcium phosphate ceramic is one of the promising biomaterials for bone healing and regeneration.  Several case reports have demonstrated healing with the formation of mature bone using this bone graft.
To further enhance the healing of periapical defects, host modulating agents such as platelet concentrates - platelet-rich fibrin (PRF) is used. It collects all constituents of a blood sample favorable for healing and immunity.  It contains growth factors necessary for cell migration, attachment, proliferation, and differentiation that promote the healing of hard and soft tissues. 
The need of surgical endodontic treatment is to remove any associated extraradicular infection such as periapical granulomas and cysts. The purpose of this clinical study was to evaluate and compare the healing of periapical defect after periapical surgery using white mineral trioxide aggregate (MTA) as retrograde filling material with/without using hydroxyapatite (BioGraft CPC putty) or PRF in curetted periapical defect.
| Subjects and Methods|| |
The present in vivo study was conducted on thirty patients having periapical radiolucency in maxillary anterior teeth taken from the Outpatient Department of Genesis Institute of Dental Sciences and Research, Ferozepur. Ethical clearance was taken from the Ethical Committee of the Institute with approval number: GIDSR-15/EC//1865-68.
The intraoral periapical radiographs were taken following bisecting technique.
Teeth selected had (i) definitive radiolucency at the apex (minimum 0.5 cm) or in periapical area (ii) healthy periodontal status.
Vitality of the tooth was checked before starting treatment using pulp vitality tests. If the tooth was found to be nonvital and met the above-mentioned criteria; then, it was selected for periapical surgical procedure.
Prior consent was taken from the patient before the start of the procedure. Preoperative radiograph of the tooth was taken, and size of the radiolucency of the concerned tooth was measured using X-ray Mesh Gauge (Dentech Corporation, Tokyo, Japan). Vitality of the tooth was checked using thermal and electric tests. Injection Dexona (Zydus Alidac, India) and Voveran (Novartis India Ltd.) were given to the patients intramuscularly ½ h before the procedure to relieve the stress and increase the pain threshold of the patient. Surgical area was anesthetized by giving infraorbital and nasopalatine nerve blocks using 2% lignocaine with 1:200,000 adrenaline (LOX 2% adrenaline) before endodontic procedure. The tooth was isolated using rubber dam application. Access cavity was prepared, and working length of canal was measured following Ingle's method. Root canal was prepared using crown-down technique. During instrumentation, copious irrigation was done with 3% sodium hypochlorite (NaOCl) solution (Prevest Dentpro Ltd., India) alternating with normal saline (Beryl Drugs Ltd., India). After thorough biomechanical preparation, tooth was obturated with gutta-percha cones (Dentsply, Maillefer, Ballaigues, Switzerland) following cold lateral condensation technique using AH Plus Sealer (Dentsply, Maillefer, Ballaigues, Switzerland). Finally, access cavity was sealed with composite resin restoration (3M ESPE Dental, USA).
Periapical surgery was performed under strict aseptic conditions. A crevicular incision accompanied by two releasing vertical incisions was given using a No. 3 Bard-Parker Scalpel and a No. 15 blade. A full thickness flap was reflected using periosteal elevator exposing the cortical bone. The exposed cortical bone over the periapical surgical site was removed with the help of No. 6 Round Bur (SS White, USA) in a Straight Handpiece (NSK, Nakanishi Inc., Japan) revolving at slow speed. Constant irrigation was done with sterile normal saline solution throughout the cutting process. Adequate cortical bone was removed so as to have optimum access to periradicular area. Curettage of the infected periapical tissue was done using curettes, and bony cavity was cleaned. Apical 3 mm of the root was resected using a straight fissure bur. Root end cavity was prepared using a round bur. The MTA (MTA Angelus, Londrina, PR, Brazil) was mixed according to manufacturer's instructions and inserted as a root-end filling material using MTA carrier (Dentsply, Maillefer, Ballaigues, Switzerland).
In Group A, after the placement of MTA, no graft material was added in the periapical defect. In Group B, the same procedure was carried out till the placement of MTA, followed by placement of Hydroxyapatite (BioGraft CPC putty; IFGL Refractories Ltd., Odisha, India) in the periapical defect. In Group C, the same procedure was carried out till the placement of MTA; then, PRF was freshly prepared at this stage. Whole venous blood (around 5 ml) of patient was collected in vacutainer tube without anticoagulant. It was then placed in a centrifugal machine and rotated at 3000 rpm for 10 min. After centrifugation, upper straw-colored layer was removed. The middle part consisting of fibrin clot was removed from the tube using tissue holding forceps and the attached red blood cells were scraped off from it and discarded [Figure 1]. PRF was placed in the bony cavity using tissue holding forceps and adapted to the cavity walls.
Interrupted suturing (CNW 5028, Centisilk) was done further. Postoperative radiograph was taken. The patient was discharged after giving postoperative instructions. Patient was instructed to report immediately in case of swelling and/or pain. Sutures were removed 1 week after surgery.
In all the three groups, patient recall visits were scheduled after 1, 3, 6, and 9 months for clinical and radiological examination. On each recall, patient was examined clinically regarding postoperative discomfort, pain, sensitivity to percussion, and presence/absence of swelling. Radiographically, an intraoral periapical radiograph with X-ray Mesh Gauge placed onto the IOPA film (Carestream, Kodak Dental X-ray Films) was taken on each follow-up visit. Size of the radiolucency was measured each time and compared with preoperative radiograph. A number of boxes corresponding with the extent of lesion were calculated to measure the size of the lesion and relative increase/decrease/no change in the size of the lesion was measured.
The data were collected and put to statistical analysis. Paired t-test and one-way ANOVA with post hoc Scheffe test were employed to measure change in the size of radiolucency between groups.
| Results|| |
A significantly higher rate of healing was observed after 9 months when apicoectomy was done using retrograde filling materials with PRF as a graft material in Group C (82.36%) followed by hydroxyapatite (BioGraft CPC putty) in Group B (65.16%) as compared to Group A, where no graft material was added in the curetted periapical defect (60.12%). However, no significant difference was observed when comparing Group A with Group B (P = 0.831) and Group B with Group C (P = 0.134). A significant difference was observed when comparing Group A with Group C (P = 0.040) [Table 1] and [Figure 2],[Figure 3] and [Figure 4].
|Figure 2: Radiographs for Group A (a) postoperative (b) postsurgery (c) after 3 months (d) after 6 months (e) after 9 months (f) after 12 months|
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|Figure 3: Radiographs for Group B (a) postoperative (b) postsurgery (c) after 3 months (d) after 6 months (e) after 9 months (f) after 12 months|
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|Figure 4: Radiographs for Group C (a) postoperative (b) postsurgery (c) after 3 months (d) after 6 months (e) after 9 months (f) after 12 months|
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|Table 1: Comparison of percentage change in size of radiolucency at different time intervals between three groups|
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| Discussion|| |
Periapical surgery promotes healing by removing most of the pathological tissue.  To increase the success rate of surgical treatment, it is important to maintain a good quality apical seal. Apical seal can be obtained by the use of root-end filling materials.  MTA is preferred as retrograde filling material over other materials. MTA has shown the highest healing rates (91.4%) in comparison to other root-end filling materials.  MTA also shows less leakage than other root-end filling materials. 
In the present study, single visit root canal treatment was done as it offers various advantages such as immediate obturation, avoids repeated instrumentation, and prevents the occurrence of pain resulting from reinfection of canals from a leaky temporary restoration.  Cleaning and shaping of the canals were done following crown-down technique. It permits straight access to the apical region, eliminates coronal interferences, removes the bulk of tissue and microorganisms before apical shaping, allows deeper penetration of irrigants, and allows better control over working length. 
NaOCl was used as an irrigant because of its broad-spectrum antimicrobial activity as well as its capacity to dissolve necrotic tissue remnants.  AH Plus sealer known for its adhesive properties can achieve an adequate seal when used. It has the advantages of lesser solubility, high radiopacity, lesser toxicity, and can be removed from canal if necessary. 
After the completion of root canal treatment, surgical procedure was performed. During root end resection, root end cavity was prepared. It has been found that if we remove this apical 3mm part, 98% of canal ramifications and 93% of accessory canals are removed.  Following root end resection, apical 3 mm of root was prepared. It increases the contact length of the material in the cavity and decreases the probability of apical leakage. 
Osteoconductive calcium phosphates have been widely used in periapical surgery to enhance new bone formation. Calcium phosphate cement is bioactive cement that sets as hydroxyapatite when moistened.  The histological examinations confirm the excellent bone biocompatibility and osteoconductive properties of calcium phosphate cement. The material did not evoke any inflammatory response and allows new bone formation. In vivo studies reveal that it sets into an osteoconductive apatite that has chemical and physical characteristics similar to bone, which is further replaced by natural bone. 
PRF is an autologous concentrate of platelets on a fibrin meshwork that contains cytokines, leukocytes, and growth factors such as platelet-derived growth factor (PDGF), transforming growth factor-beta (TGF-beta), vascular endothelial growth factor, and epidermal growth factor. TGF-beta and PDGF promote healing of soft tissue and bone through stimulation of collagen production. PDGF promotes angiogenesis, activates macrophages that initiate the release of growth factors from host tissue which enhances bone repair and regeneration. TGF-beta activates fibroblasts to induce collagen formation, endothelial cells for angiogenesis, chondroprogenitor cells for cartilage and mesenchymal cells to increase the population of wound healing cells. Fibrin serves as a scaffold for cell migration and platelet entrapment.  Use of PRF has certain advantages over bone grafting materials. Being autologous, it is indispensable in tissue wound healing and acts as better space filler.  PRF is easy to obtain and is inexpensive. Its slow polymerization leads to favorable healing. 
Clinically, some patients complained of pain and swelling 1-2 days postoperatively after the surgical procedure. These findings are in concurrence with study done by Christiansen et al.,  who demonstrated that pain following periapical surgery tends to peak on the operational day, may get pronounced 1-2 days postoperatively. When patients treated with PRF were evaluated for clinical signs of pain/swelling, postoperative discomfort, and/or sensitivity to percussion all the treated patients were comfortable. The present study is also in concurrence with the study conducted by Del Fabbro et al., who suggested that use of platelet concentrates is related to lower levels of pain, swelling, and other symptoms. 
The healing results were radiographically evaluated at 1, 3, 6, and 9 months postoperatively and compared with preoperative radiograph. There was a decrease in the size of radiolucency with every follow-up in all the three groups with maximum decrease in size of radiolucency in Group C (82.36%) > Group B (65.16%) > Group A (60.12%). However, no significant difference was observed when comparing Group A with Group B (P = 0.831) and Group B with Group C (P = 0.134). A significant difference was observed when comparing Group A with Group C (P = 0.040). Healing results are in concurrence with a study conducted by Jayalakshmi et al. where there was a predictable clinical and radiographic bone regeneration after using the combination of PRF with beta tricalcium after follow-up period of 3, 6, 9, and 12 months. 
| Conclusion|| |
It was concluded from the study that a good quality apical seal can be obtained using root-end filling materials contributing to the success of the treatment. To further enhance the success rate, grafts, and various host modulating agents can be used. Calcium phosphate cements used as grafts are bioactive materials that promote the formation of new bone. However, PRF is preferred over grafts as it is autologous and promote faster healing by release of growth factors needed for the formation of bone.
The authors would like to thank the institution for their support during the conductance of the study. Authors are also thankful to Mr. Aman for his material help.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Manoj K, Lora M, Asmita GS, Swagatika N. Management of a large non healing periapical lesion by combined endodontic-periodontic approach: A case report. J Endodontol 2015;27:77-9.
Sreedevi P, Varghese N, Varugheese JM. Prognosis of periapical surgery using bonegrafts: A clinical study. J Conserv Dent 2011;14:68-72.
Gusiyska A, Dyulgerova E. Remodeling of periapical lesions scaffolding by biphase calcium phosphate ceramics - A pilot study. J IMAB 2009;15:113-8.
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.
Singh S, Singh A, Singh S, Singh R. Application of PRF in surgical management of periapical lesions. Natl J Maxillofac Surg 2013;4:94-9.
Evans GE, Bishop K, Renton T. Royals College for Surgeons Guidelines for Surgical Endodontics Faculty of Dental Surgery 2012;2:1-9.
Johnson BR. Considerations in the selection of a root-end filling material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:398-404.
von Arx T, Peñarrocha M, Jensen S. Prognostic factors in apical surgery with root-end filling: A meta-analysis. J Endod 2010;36:957-73.
Eliyas S, Vere J, Ali Z, Harris I. Micro-surgical endodontics. Br Dent J 2014;216:169-77.
Rao KN, Kandaswamy R, Umashetty G, Rathore VP, Hotkar C, Patil BS. Post-Obturation pain following one-visit and two-visit root canal treatment in necrotic anterior teeth. J Int Oral Health 2014;6:28-32.
Carrotte P. Endodontics: Part 7. Preparing the root canal. Br Dent J 2004 27;197:603-13.
Maity I, Meena N, Kumari RA. Single visit nonsurgical endodontic therapy for periapical cysts: A clinical study. Contemp Clin Dent 2014;5:195-202.
Ingle JI, Bakland LK, Baumgartner JC. Endodontics 6. Hamilton: BC Decker Inc.; 2008.
Al-Sanabani JS, Madfa AA, Al-Sanabani FA. Application of calcium phosphate materials in dentistry. Int J Biomater 2013;2013:876132.
Dumitrescu AL. Bone Grafts and Bone Graft Substitute in Periodontal Therapy: Chemicals in Surgical Periodontal Therapy. Springer-Verlag: Berlin Heidelberg; 2011.
Mehta S, Watson JT. Platelet rich concentrate: Basic science and current clinical applications. J Orthop Trauma 2008;22:432-8.
Deenadayalan E, Kumar A, Tewari RK, Mishra SK, Iftekhar H. Management of large preiapical lesion with the combination of second generation platelet extract and hydroxyapatite bone graft. J Clin Diagn Res 2015;9:24-7.
Naik B, Karunakar P, Jayadev M, Marshal VR. Role of Platelet rich fibrin in wound healing: A critical review. J Conserv Dent 2013;16:284-93.
Christiansen R, Kirkevang LL, Hørsted-Bindslev P, Wenzel A. Patient discomfort following periapical surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:245-50.
Del Fabbro M, Ceresoli V, Lolato A, Taschieri S. Effect of platelet concentrate on quality of life after periradicular surgery: A randomized clinical study. J Endod 2012;38:733-9.
Jayalakshmi KB, Agarwal S, Singh MP, Vishwanath BT, Krishna A, Agrawal R. Platelet-rich fibrin with â-tricalcium phosphate-a noval approach for bone augmentation in chronic periapical lesion: A case report. Case Rep Dent 2012;2012:902858.
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