Platelet Rich Fibrin - An Elixir in Endodontic Surgery- Original Research
Shazia Mahreen1, Deepyanti Dubey2, Dr Gurinder Kaur3, Tapan Kumar Mandal4, SongaSushmita Naidu5,Nitish Kumar Pandey6
1,4,6
Sr. Lecturer, Department of Conservative Dentistry and Endodontics, Hazaribag College of Dental Sciences and Hospital, Hazaribag,Jharkhand, India;
2,3,5
PGT,Department of Conservative Dentistry and Endodontics, Hazaribag College of Dental Sciences and Hospital, Hazaribag,Jharkhand, India
Corresponding author:
Dr.DeepyantiDubey, PGT, Department of Conservative Dentistry and Endodontics, Hazaribag College of Dental Sciences and Hospital, Hazaribag,Jharkhand, India
ABSTRACT:
Preservation of natural teeth is one of the ultimate goals of modern dentistry. The successful treatment of periapical inflammatory lesion depends on the reduction and elimination of offending organism.
Key words: Endodontic micro-surgery, Platelet Rich Fibrin, periapical inflammation.
INTRODUCTION
Endodontic micro-surgery is not only a predictable method to explore the cause of non healing in root canal treated teeth, but it is also a means to effectively eliminate persistent apical pathology. Radiographs as well as CBCT are important tools to determine if surgical intervention is the best option. Surgical success is dependent on ability to perform ideal protocols which includes:
Sufficient access to entire pathologic area with good visualization.
Proper resection amount and bevel.
Ultrasonic preparation of all portals of exit.
Placement of proper roots ends filling material.
Re-approximation of the surgical site with primary closure.
ASSESSMENT OF ETIOLOGY FOR PERSISTING PATHOLOGY IS ESSENTIAL When choosing endodontic microsurgery as a treatment option the following conditions that may be present that may not respond well to microsurgical treatment and have a questionable prognosis:
Lateral radiolucency with no apical radiolucency indicative of a strip perforation or vertical fracture
Primary periodontal lesions
Combined periodontal and endodontic lesions.
Root resorption affecting the middle or coronal third of the roots
Endodontic microsurgery requires significant accuracy at high magnification in order to visualize, access, prepare, and fill very small and difficult to reach areas with no margins for error. The following patient based factors affect the feasibility of performing successful endodontic microsurgery:
Adequate surgical access through patient position.
Proper maintenance of the patient’s position with minimal movement during.
Stated reaction to epinephrine, essential for adequate haemostasis.
Essential medication that affect bleeding and inhibit effective surgical site haemostasis.
CASE REPORT
The present case report describes the management of the periapical lesion using PRF. A 24 year old female patient reported to department of conservative dentistry and endodontics, Hazaribag College of dental sciences and hospitalwith a chief complaint of pus discharge and pain in relation to right maxillary anterior tooth since 1 week. Patient gave a history of trauma 5 years back.Clinical examination revealed that the patient has vestibular tenderness and Ellis class IV fracture with respect to 11. On Radiographic examination a frank pathology was evident that there was awell-definedradiolucency the right maxillary central incisor. Thermal and electric pulp testing showed no response
PROCEDURE CARRIED OUT WHILE SURGERY
The canals were cleaned and shaped. Calcium hydroxide was placed in to the canals after drying it paper points. The calcium hydroxide was removed by copious irrigation with 5%
sodium hypochlorite and normal saline. The canal was then obturated with ah plus sealer.Anaesthesia was performed with 2% lidocaine and 1:80.000 adrenaline
PREOPERATIVE CLINICAL PICTURE
PRE OPERATIVE RADIOGRAPH
CBCT EXAMINATION
Anterior region of maxilla 1.87 mm below the anterior nasal spine
A well-defined radiolucent lesion with corticated border measuring approximately 9.76x10.85 mm
Root resorption noted i.r.t 11
DIAGNOSIS : PERIAPICAL CYST
PUS DISCHARGE
OVER OBTURATION DONE BEFORE SURGERY PUS DISCHARGE
BUCCAL FLAP RAISED& EXTRUDED GUTTA PERCHA VISIBLE
CURETTAGE OF THE LESION DONE
ROOT END CAVITY PREPARED SAMPLE
CENTIGUGATION DONE PRF
SUTURES PLACED
SUTURE REMOVAL AFTER 1 WEEK
FOLLOW UP RADIOGRAPHS
FOLLOW UP PHOTOGRAPH
DISCUSSION
Apicoectomy is a well known surgical procedure, used when filled with gutta-percha and zinc oxide eugenol sealer by lateral conservative endodontic treatment has failed to retain natural condensation. The tooth was temporarily restored with zinc teeth. Endodontic surgery in anterior teeth is usually carried out without oxide eugenol. Hesitation, whereas in posterior regions endodontic surgery was not much preferred.
The conventional root-end cavity preparation technique using rotary burs in a micro-hand piece poses several problems for the surgeon (1, 2, 3, 4, 5, 6):
1. Access to the root-end is difficult, especially with limited working space 2. There is a high risk of a perforation of the lingual root-end or cavity preparation, when it does not follow the original canal path 3. There is insufficient depth and retention of the root-end filling material 4. The root-end resection procedure exposes dentinal tubules 5. Necrotic isthmus tissue cannot be removed.
These clinical dilemmas were never questioned in the past, rather it was an accepted fact, because the standard tools at that time were too large for the surgical site and the true complexity of the root-end anatomy was not known. Many articles and textbooks of that time contain extensive descriptions how to retro-prepare with burs shows a generation change in root-end preparation tools from burs to microbus to ultrasonic tips. The aim of the root-end preparation is to remove the intracanal filling material and irritants and to create a cavity that can be properly filled.
The ideal root-end preparation can be defined as a class 1 cavity at least 3 mm into root dentine, with walls parallel to and coincident with the anatomic outline of the root canal space (5). Richman first introduced the use of ultrasonic’s in endodontics in 1957, using a modified ultrasonic periodontal chisel scaler for root canal debridement and apicoectomy(7).
Eventually Carr (4) introduced retro tips designed specifically for root-end cavity preparation during endodontic surgery. Several authors later reported superior operator control, decreased risk of perforation by increased ability to stay centered in the canal when using the ultrasonic retro tips as compared to the microhandpiece(6).thus in the current study we used ultrasonic tips for root end resection.
An ultrasonically prepared 3 mm class I cavity preparation must be filled with a material that guarantees a hermetic seal. , a review article by Torabinejad and Pitt Ford (8) provides an excellent review. There are several root-end filling materials now used in conjunction with apical surgery. Amalgam has been and still is to some extent a widely used material.
However, in the past decade amalgam has slowly given way to ZOE containing materials, such as IRM and SuperEBA as a favourite root-end filling materials. Numerous studies show that these ZOE containing materials are superior to amalgam in terms of saleability and biocompatibility (9, 10, 11).
More recently, mineral trioxide aggregate (MTA) has been suggested as having many of the properties of the ideal root-end filling material. Although the exact composition of MTA is proprietary, the main ingredients are tricalcium silicate (Ca3 Si), tricalcium aluminate (Ca3 Al), and tricalcium oxide (Ca3O2). Because of its superior sealing ability and biocompatibility over conventional filling materials, MTA is gaining popularity among endodontists(13, 14, 15, 16).
In vivo studies haves shown that MTA has the capacity to induce bone, dentin and cementum formation in vivo (16, 17, 18).
In comparison to amalgam and SuperEBA as root-end filling materials, MTA consistently resulted in regeneration of periapical tissues including periodontal ligament andcementum.Thus in current study we have used mta as a root end filling material.
Platelet rich fibrin (PRF) is a fibrin matrix in which platelet cytokines, growth factors, and cells are trapped .This stimulate the mitogenic response in the bone periosteum during normal wound healing for repair of the bone.Choukrounet al. were amongst the pioneers for using PRF protocol in surgery to improve bone healing.PRF membrane has a very significant slow
sustained release of many key GF for at least 1 week and up to 28 days . In the present case report, the periapical defects after the surgical procedure were filled with PRF to accelerate the physiologic healing mechanismIn the present case reports, the periapical defects after the surgical procedure were filled with PRF to accelerate the physiologic healing mechanism. In the current study ,the post-operative clinical and radiographic assessments revealed an enhanced healing of the bony lesion at 6 months follow-up.
The ideal healing response after periradicular surgery is the re-establishment of an apical attachment apparatus and osseous repair. (19, 20) However, histological examination of biopsy specimens reveals three types of tissue response; (21). Healing with reformation of the periodontal ligament; healing with fibrous tissue (scar); and moderate-to-severe inflammation without scar tissue. The deposition of cementum on the cut root face is considered a desired healing response and a prerequisite for the reformation of a functional periodontal attachment. (19)Cementum deposition occurs from the circumference of the root end and proceeds centrally toward the resected root canal. The cementum provides a ‘biological seal,’
in addition to the ‘physical seal’ of the root end filling, thereby creating a ‘double seal’. (23) CONCLUSION
Apical surgery is now considered a predictable treatment option to save a tooth with apical pathology that cannot be managed by conventional, non-surgical endodontics. The use of magnification and illumination, preferably a surgical microscope, and the application of microsurgical principles are also important requirements for obtaining successful outcomes after apical surgery.
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