Combination of platelet rich fibrin, hydroxyapatite and PRF membrane in the management of large inflammatory periapical lesion
A 45-years-old male patient came to the Department of Endodontics with a chief complaint of swelling in the upper front teeth region (teeth #7 and #8). The patient had no medical contraindication to dental treatment. Dental history revealed an incident of trauma to the upper front teeth region 5 years ago. Clinical examination revealed discolored tooth #8 with an Ellis class 2 fracture. Both the teeth #7 and #8 were sensitive to percussion test. Upon radiographic examination gigantic periapical radiolucencies were observed at the apical region of teeth #7 and #8 [Figures and ].\nThe root canal treatment was performed using step back technique till an apical size of # 55 and #45 in relation to teeth #8 and #7 respectively. 5.25% sodium hypochlorite solution (Novo Dental Product Pvt Ltd, Mumbai, India) was used to irrigate the canals during the canal preparation. The root canal treatment was performed in three visits and calcium hydroxide was used as the intracanal medicament. The root canals were obturated using gutta percha (Dentsply maillefer Ballaigues) and AH 26 (Dentsply DeTrey GmbH, Philadelphia, USA) by the lateral condensation technique. After a review period of 6 months, expected healing did not occur. Hence, a periapical endodontic surgery was planned. Under local anesthesia (1:200000 adrenaline, DJ Lab, India), a full thickness mucoperiosteal flap was reflected by a sulcular incision starting from the distal of the tooth #9 to distal of the tooth #6. A large periapical defect was seen with complete loss of labial cortical plate. The lesion measured 15 mm × 16 mm × 16 mm corresponding to the length, width, and depth of the lesion []. Tissue curettage was done at the defect site followed by thorough irrigation using sterile saline solution. Using #702 tapered fissure bur (SS White burs), root end resection was performed in teeth #7 and #8 and Grey mineral trioxide aggregate (MTA) (ProRoot MTA; Dentsply, Tulsa, OK, USA) was used as the root end filling material. 20 mL of blood was drawn from the patient's antecubital vein and centrifuged (REMI centrifuge machine Model R-8c with 12 × 15 mL swing out head) for 10 min under 3000 revolutions (approximately 400 g) per minute to obtain the PRF. Commercially available HA bone graft crystals (Biograft HA, IFGL Bioceramics Ltd., India) were sprinkled over the PRF gel and together the mixture was placed into defect site []. PRF membrane was prepared with compresses and placed as two layers covering the edge of the defect []. Flap stabilization was done followed by suturing using 3-0 black silk suture material (Sutures India Pvt. Ltd, Karnataka, India). Patient was kept under the antibiotic (amoxycillin) coverage along with Affen PLUS Tab (Dr. Reddy's Lab, Andrapradesh, India) and 0.2% chlorhexidine gluconate solution as mouth rinse for a period of 5 days. Suture removal was done 1 week later and the healing was uneventful [].\nPatient was reviewed at 3 months [], 6 months [], 1 year [], and 2-year period during which there were no symptoms of pain, inflammation, or discomfort. These follow-up visits included routine intraoral examinations and professional plaque control. Radiographically, HA particles have been almost completely resorbed and replaced with new bone at the end of 2 years []. Patient was completely satisfied with the results of the treatment.