Platelet-rich fibrin-mediated revitalization of immature necrotic tooth
An 11-year-old boy was referred to the department of conservative dentistry and endodontics for evaluation and treatment of left maxillary central incisor. The patient gave the history of bicycle fall 2 years ago. The medical history was non-contributory. The extraoral examination showed no significant changes. The intra-oral examination showed absence of any soft tissue abnormalities. Clinical examination of teeth revealed slight discoloration in tooth #21. It was sensitive to percussion and palpation tests. It did not respond to 1, 1, 1, 2-tetrafluoroethane (Endo-Ice; Hygenic Corp., Akron, OH, USA) and electric pulp test (Analytic Technology, Redmond, WA, USA). The adjacent teeth were caries free, asymptomatic, and tested positively. The periodontal examination of all teeth showed probing depths within normal limits. An intraoral radiograph was taken with paralleling technique using XCP positioner (extension cone paralleling technique) (Dentsply) showed an immature root with periapical pathology and open apex in tooth #21 and an associated immature supernumerary tooth []. On the basis of clinical and radiographic findings, the pulpal diagnosis of necrotic pulp with symptomatic apical periodontitis was made for tooth #21. Various treatment options were explained and the parents gave the consent for regenerative endodontic procedures with the aid of PRF.\nLocal anesthesia was obtained by using 2% lignocaine with 1:200000 epinephrine. Access preparation was done in tooth #21 under rubber dam isolation. Minimal instrumentation was done and the canal was irrigated with 10 mL of 2.5% NaOCl. It was dried with paper points. Equal proportions of ciprofloxacin (Bayer, Leverkusen, Germany), metronidazole (Shionogi and Co, Ltd, Osaka, Japan), and minocycline (Aurobindo, Andhra Pradesh, India) were ground and mixed with distilled water to a thick paste consistency. This antibiotic mixture was placed in the canal using an amalgam carrier and packed with large endodontic pluggers. The access cavity was sealed with Cavit (ESPE, Chergy Pontoise, France). After 4 weeks, tooth #21 was asymptomatic and showed no sensitivity to percussion and palpation. A 5 ml of whole blood was collected from the median cubital vein of the patient for the preparation of PRF clot []. Under rubber dam isolation, temporary restoration was removed. The triple antibiotic mixture was washed out with saline. After drying the canal with paper points, the fibrin membrane was pushed [] with Buchanan Hand Plugger Size #2 (Sybron Endo, Orange, CA) 1 mm beyond the confines of working length and coronally to the level of cementoenamel junction. Three millimetres of MTA was placed directly over the PRF clot and tooth was temporarily restored. After 72 hours, permanent restoration was done with composite (Esthet.X HD, Dentsply, UK). The patient was kept on follow-up at 6 and 12 months [] for re-evaluation. Tooth #21was asymptomatic and was not sensitive to percussion or palpation tests. Sensitivity tests with cold and Electric Pulp Tester elicited a positive response. Radiographic examination showed resolution of the periapical lesion, further root development and continued apical closure in tooth #21 and associated supernumerary tooth.