Platelet Rich Fibrin and b-Tricalcium Phosphate for the Treatment of

Case Report
Platelet Rich Fibrin and -Tricalcium Phosphate for the
Treatment of Grade-II Furcation Defect – A Case Report
Sambhav Jain,1 Ranjana Mohan, 2 Karthik Krishna M., 3 Janardhana Amarnath BJ 4
Post Graduate Student, 1 Professor & Head, 2 Reader, 3 Professor, 4
Department of Periodontology, Teerthanker Mahaveer Dental College & Research Center, Moradabad
Abstract
Platelet-rich fibrin (PRF) is a second generation platelet concentrate, utilized for surgical procedures. The easy method
of collection allows the harvesting of a fibrin clot rich in growth factors making it safe and economical material for
regenerative procedures. This case report presents the treatment of a grade II furcation defect with a combination of
PRF and a newly-introduced bone graft consisting of multi-sized particles of tricalcium phosphate.
Key Words: - tricalcium phosphate, bone graft, furcation involvement, platelet rich fibrin, periodontal regeneration.
Introduction
Periodontal tissue is destroyed in the course of periodontitis
by disproportionate immunologic responses to a triggering
agent, such as bacteria in biofilm.1 It has been reported that
molars with furcation involvement have a higher rate of
periodontal breakdown and respond less favorably to
periodontal therapy than those without furcation
involvement or single-rooted teeth.2 The varied nature and
pattern of periodontal destruction in furcation area creates
situations in which routine periodontal procedures are
somewhat limited in efficacy and advanced procedures are
generally required. Various materials have been used to
resolve
furcation
defects
including
autografts,
demineralised freeze-dried bone allografts (DFDBAs),
bovine-derived xenografts, barrier membranes, and
combinations of membranes and bone grafts.3 The use of
biomimetic agents, such as enamel matrix derivatives4 and
platelet rich plasma (PRP),5 have been reported to further
enhance the treatment outcomes in furcation defects.
Platelet-rich fibrin (PRF) is a second generation platelet
concentrate widely used to accelerate soft and hard tissue
healing, composed of a strictly autologous fibrin matrix
containing a large quantity of platelet and leukocyte
cytokines. Its advantages over first generation concentrate,
platelet-rich plasma (PRP), include ease of preparation
/application, minimal expense, and lack of biochemical
modification (no bovine thrombin or anticoagulant is
required).6,7
Resorbable tissue replacement (RTRTM), is a biocompatible
synthetic alloplast material composed of ß-tricalcium
phosphate crystalline (ß-TCP) structure with particles sizes
ranging from 0.5 to 1 mm. The varying particle sizes tend
to form both macro- and micro-porosities in the material.
This unique property is claimed to make RTRTM promote
an in-depth colonization by osteogenic cells and release
calcium and phosphate slowly into the surrounding
environment thus promoting new bone formation. 8
Based on their properties, it can be assumed that the
application of PRF in combination with RTR in periodontal
regenerative therapy can be beneficial. However, till date,
no published data is available regarding the combination of
these two materials. This case report presents an attempt to
treat a grade II furcation defect with combination of PRF
and RTRTM.
Case Report
A 45 year old female was reported to the Department Of
Periodontology, Teerthanker Mahaveer Dental College and
Research Centre, with a chief complaint of severe
sensitivity, bleeding and food lodgement in lower left back
tooth since last 3 months. A thorough medical history was
taken and no significant findings were observed. On clinical
and radiographic examination advanced grade II buccal
furcation involvement and gingival recession on buccal
aspect in relation to lower left first molar was observed. On
measurement, the furcation had a vertical attachment loss of
7 mm and horizontal attachment loss of 6 mm (figure 1).
Figure 1: - Measuring horizontal depth of the furcation
defect with Nabers probe
Full-mouth scaling and root planning in the region of 36
were performed. Oral hygiene instructions were given,
patient was prescribed twice daily oral rinsing with 0.2%
chlorhexidine solution and recalled after one week. On the
second visit, based on the observations and probable
treatment outcome, surgical treatment of the furcation
defect with elevation of coronally advanced flap and
application of PRF with RTR granules was planned.
Preparation of Platelet Rich Fibrin
After application of tourniquet on the left upper arm of the
patient, the median cubital vein was located and 5 ml of
blood was drawn and inserted into sterile vacutainer tubes.
The tubes were loaded into the centrifugation machine and
TMU J. Dent Vol. – 1; Issue 1 Jan – Mar 2014 | 36
the blood was centrifuged for 15 min at 3000 rpm. Absence
of anticoagulant allows majority of platelets contained in
the sample to trigger a coagulation cascade after which it
settles into the following layers: red lower fraction
containing red blood cells, upper straw coloured cellular
plasma and the middle fraction containing the fibrin clot.
After draining the plasma layer, the middle PRF fraction
was separated with tissue pliers and compressed between
moist cotton gauze squares (figure 2).
month post-operative visit, complete root coverage could be
observed with thick, healthy gingival tissue covering the
defect (figure 3). Patient was recalled later to assess the
bone fill in the furcation area but she failed to report for
further visits.
Figure 3: - One-month post-operative view shows complete
root coverage.
# RTR, Septodont, USA
Discussion
Figure 2: - Harvesting the PRF membrane from the
vacutainer tube after centrifugation
Surgical Procedure
After the patient was prepared, inferior alveolar and long
buccal nerve blocks and supplementary local infiltration
were administered using an anesthetic solution (2%
xylocaine hydrochloride with adrenaline). Two vertical
incisions, one at mesial line angle of the second molar and
the other on the distal line angle of the second pre-molar,
extending from the gingival margin and beyond the
mucogingival junction (MGJ) were given and joined by a
crevicular incision. A full-thickness flap was raised to
expose the furcation area and continued as a partial
thickness flap beyond the MGJ to enable the coronal
repositioning of the flap. The furcation area was debrided
thoroughly and any residual calculus deposits were
removed.
RTR granules# was mixed with normal saline to form a
thick paste and the furcation defect region was slightly
overfilled with this paste. The PRF membrane was trimmed
and placed over the bone graft such that it extended at least
2mm beyond the margins of the furcation defect. The flap
was then coronally advanced taking care not to expose the
membrane and ligated with a sling suture around the first
molar. Vertical incisions were approximated with
interrupted direct loop sutures. Patient was given postoperative instructions, prescribed amoxicillin with
clavulanic acid, 500mg, TID for 10 days, advised to use
0.2 % chlorhexidine mouthwash twice daily and recalled
after a week.
In the recall appointment, healing was observed to be
uneventful. Mild apical migration of the flap margin was
noted but without any exposure of the membrane. At the 1
In the present case, an attempt was made to achieve the
twin objectives of root coverage and defect fill in the
furcation area of the first molar. Complete root coverage
with gain in clinical attachment could be observed
clinically at the 1 month post-operative visit. However, the
extent of bone fill could not be assessed as the patient failed
to report further.
Several studies performed to evaluate the efficacy of PRF
in treating periodontal defects have demonstrated
favourable results. Joseph et al,9 Thorat et al10 and Sharma
et al11 reported higher gains in clinical attachment levels
and radiographic bone fill in infrabony defects when
utilizing PRF with open flap debridement. Bajaj et al12
reported higher gains in vertical clinical attachment levels
in mandibular grade II furcation defects treated with PRF
and OFD.
In the present case PRF was combined with bone graft
material composed of multi-sized particles of -tricalcium
phosphate. Combination of PRF with bone graft materials
has been reported to enhance its regenerative potential.
Pradeep et al13 observed that hydroxyapatite when added to
PRF, increased its regenerative effects when treating three
wall intrabony defects. Lekovic et al14 stated that
combining bovine porous bone mineral (BPBM) with PRF
resulted in significantly greater pocket depth reduction,
attachment gain and bone fill in infrabony defects. Bansal
et al15 demonstrated significantly higher pocket depth
reduction and attachment gain in infrabony defects on
combining PRF with decalcified freeze-dried bone allograft
(DFDBA).
The concept of using PRF for regenerative procedures is
based on the presence of multiple growth factors within the
membrane. During the centrifugation process, slow
polymerization in the collected blood results in
TMU J. Dent Vol. – 1; Issue 1 Jan – Mar 2014 | 37
development of a homogenous, 3-dimensional organization
of fibrin meshwork that entraps circulating cytokines such
as Inteleukins-1, -4, and -6, and growth factors such as
bone morphogenetic proteins, transforming growth factor1, platelet derived growth factor-AB etc. When placed in
the periodontal defect, this meshwork acts as a bio-scaffold
with an integrated reservoir of growth factors which are
released over prolonged periods thus enhancing the
regenerative potential of the surrounding tissues.16, 17
Using PRF instead of PRP eliminates the need for adding
anticoagulant as prior to centrifugation. Also, the risk
associated with the biochemical handling of bovine derived
thrombin is minimized.18 According to the manufacturer,
RTR can form macropores (100-400 m) as well as
micropores (<10 m) after it is implanted into the defect.8
These multisized porosities can enhance the in-depth
colonization of osteogenic cells and promote new bone
formation. Also, the release of multiple growth factors from
the PRF membrane may further enhance the regenerative
potential of the bone cells, resulting in significant bone fill
and attachment gain.
Conclusion
PRF in combination with RTR granules was observed to be
a successful approach for obtaining significant root
coverage associated with grade II furcation defect in a
mandibular first molar. Further studies investigating the
efficacy of a combination of these two materials are
recommended to gain further insight on their regenerative
potential.
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Corresponding Address:
Dr. Karthik Krishna M.
Department of Periodontology
Teerthanker Mahaveer Dental College & Research
Center,
Moradabad, Uttar Pradesh
Email Id: - [email protected]
TMU J. Dent Vol. – 1; Issue 1 Jan – Mar 2014 | 38