The Journal of Contemporary Dental Practice

Register      Login



Volume / Issue

Online First

Related articles

VOLUME 23 , ISSUE 7 ( July, 2022 ) > List of Articles


The Efficacy of Advanced Platelet-rich Fibrin in Revascularization of Immature Necrotic Teeth

Amr Yosry Abd El-Hady, Amany El-Said Badr

Keywords : Open apex, Randomized clinical trial, Revitalization

Citation Information : El-Hady AY, Badr AE. The Efficacy of Advanced Platelet-rich Fibrin in Revascularization of Immature Necrotic Teeth. J Contemp Dent Pract 2022; 23 (7):725-732.

DOI: 10.5005/jp-journals-10024-3367

License: CC BY-NC 4.0

Published Online: 10-11-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Aim: The present study aims to compare advanced platelet-rich fibrin (A-PRF) and conventional blood clot as scaffolds in the regenerative endodontic procedure (REP) and to evaluate their effectiveness in the development of traumatized nonvital immature teeth roots. Material and methods: Regenerative endodontic procedure was carried out on 20 traumatized nonvital immature maxillary incisors of 17 patients between the ages of 8 and 12 years. Irrigation with 1.5% sodium hypochlorite (NaOCl) and 17% ethylene diamine tetra-acetic acid was done following minimal mechanical debridement. Canal disinfection was achieved using calcium hydroxide paste. According to the scaffold type, teeth were randomly allocated into A-PRF (n = 10) and conventional blood-clot groups (n = 10). Apical width and root dimensions (length and thickness) were analyzed radiographically and statistically after 3-, 6-, and 12-month follow-up. Results: Fifteen patients with 18 teeth (A-PRF n = 9, blood clot n = 9) completed the follow-up, and 2 patients were excluded. Patients in both groups were asymptomatic. There was a significant increase within each group in respect to root length, root thickness at one- and two-thirds, and root apex width for all timepoints. While percent of change between the two groups was statistically insignificant. Conclusion: Regenerative endodontic procedure for traumatized immature nonvital teeth with either conventional blood clot or A-PRF as scaffold was comparable, except in cases where adequate bleeding cannot be achieved. Clinical significance: Advanced platelet-rich fibrin provides a suitable scaffold that can be used in REP of teeth with close proximity to vital structures such as inferior alveolar nerve (IAN) or mental nerve, where using a sharp instrument to induce bleeding can cause damage and also in cases where adequate bleeding cannot be achieved.

PDF Share
  1. Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet 2007;369(9555):51–59. DOI: 10.1016/S0140-6736(07)60031-2.
  2. Dye BA, Thornton-Evans G, Li X, et al. Dental caries and sealant prevalence in children and adolescents in the United States, 2011-2012. NCHS Data Brief 2015;(191):1–8. PMID: 25932891.
  3. Hintze H. Approximal caries prevalence in Danish recruits and progression of caries in the late teens: A retrospective radiographic study. Caries Res 2001;35(1):27–35. DOI: 10.1159/000047427.
  4. Hecova H, Tzigkounakis V, Merglova V, et al. A retrospective study of 889 injured permanent teeth. Dent Traumatol 2010;26(6):466–475. DOI: 10.1111/j.1600-9657.2010.00924.x.
  5. Narang I, Mittal N, Mishra N. A comparative evaluation of the blood clot, platelet-rich plasma, and platelet-rich fibrin in regeneration of necrotic immature permanent teeth: A clinical study. Contemp Clin Dent 2015;6(1):63–68. DOI: 10.4103/0976-237X.149294.
  6. Kerezoudis NP, Valavanis D, Prountzos F. A method of adapting gutta-percha master cones for obturation of open apex cases using heat. Int Endod J 1999;32(1):53–60. DOI: 10.1046/j.1365-2591.1999.00180.x.
  7. Thomson A, Kahler B. Regenerative endodontics–biologically-based treatment for immature permanent teeth: A case report and review of the literature. Aust Dent J 2010;55(4):446–452. DOI: 10.1111/j.1834-7819.2010.01268.x.
  8. Rafter MJDT. Apexification: A review. Dent Traumatol 2005;21(1):1–8. DOI: 10.1111/j.1600-9657.2004.00284.x.
  9. Kerekes K, Heide S, Jacobsen I. Follow-up examination of endodontic treatment in traumatized juvenile incisors. J Endod 1980;6(9):744–748. DOI: 10.1016/S0099-2399(80)80186-5.
  10. Lv H, Chen Y, Cai Z, et al. The efficacy of platelet-rich fibrin as a scaffold in regenerative endodontic treatment: A retrospective controlled cohort study. BMC Oral Health 2018;18(1):139. DOI: 10.1186/s12903-018-0598-z.
  11. Huang FM, Yang SF, Zhao JH, et al. Platelet-rich fibrin increases proliferation and differentiation of human dental pulp cells. J Endod 2010;36(10):1628–1632. DOI: 10.1016/j.joen.2010.07.004.
  12. Freed LE, Vunjak-Novakovic G, Biron RJ, et al. Biodegradable polymer scaffolds for tissue engineering. Biotechnology (NY) 1994;12(7):689–693. DOI: 10.1038/nbt0794-689.
  13. Torabinejad M, Corr R, Buhrley M, et al. An animal model to study regenerative endodontics. J Endod 2011;37(2):197–202. DOI: 10.1016/j.joen.2010.10.011.
  14. Torabinejad M, Faras H. A clinical and histological report of a tooth with an open apex treated with regenerative endodontics using platelet-rich plasma. J Endod 2012;38(6):864–868. DOI: 10.1016/j.joen.2012.03.006.
  15. Kim SG, Zhou J, Solomon C, et al. Effects of growth factors on dental stem/progenitor cells. Dent Clin North Am 2012;56(3):563–575. DOI: 10.1016/j.cden.2012.05.001.
  16. Shivashankar VY, Johns DA, Vidyanath S, et al. Platelet rich fibrin in the revitalization of tooth with necrotic pulp and open apex. J Conserv Dent 2012;15(4):395–398. DOI: 10.4103/0972-0707.101926.
  17. Ehrenfest DMD, Rasmusson L, Albrektsson T. Classification of platelet concentrates: From pure platelet-rich plasma (P-PRP) to leucocyte-and platelet-rich fibrin (L-PRF). Trends Biotechnol 2009;27(3):158–167. DOI: 10.1016/j.tibtech.2008.11.009.
  18. Kawazoe T, Kim HH. Tissue augmentation by white blood cell-containing platelet-rich plasma. Cell Transplant 2012;21(2–3):601–607. DOI: 10.3727/096368911X605538.
  19. Fujioka-Kobayashi M, Miron RJ, Hernandez M, et al. Optimized platelet-rich fibrin with the low-speed concept: Growth factor release, biocompatibility, and cellular response. J Periodontol 2017;88(1):112–121. DOI: 10.1902/jop.2016.160443.
  20. Dohan Ehrenfest DM, Pinto NR, Pereda A, et al. The impact of the centrifuge characteristics and centrifugation protocols on the cells, growth factors, and fibrin architecture of a leukocyte- and platelet-rich fibrin (L-PRF) clot and membrane. Platelets 2017;29(2):171–184. DOI: 10.1080/09537104.2017.1293812.
  21. Kobayashi E, Flückiger L, Fujioka-Kobayashi M, et al. Comparative release of growth factors from PRP, PRF, and advanced-PRF. Clin Oral Investig 2016;20(9):2353–2360. DOI: 10.1007/s00784-016-1719-1.
  22. Rizk HM, Salah Al-Deen MS, Emam AA. Pulp revascularization/revitalization of bilateral upper necrotic immature permanent central incisors with blood clot vs platelet-rich fibrin scaffolds – A split-mouth double-blind randomized controlled trial. Int J Clin Pediatr Dent 2020;13(4):337–343. DOI: 10.5005/jp-journals-10005-1788.
  23. Cehreli ZC, Isbitiren B, Sara S, et al. Regenerative endodontic treatment (revascularization) of immature necrotic molars medicated with calcium hydroxide: A case series. J Endod 2011;37(9):1327–1330. DOI: 10.1016/j.joen.2011.05.033.
  24. Trope M. Treatment of the immature tooth with a non-vital pulp and apical periodontitis. Den Clin North Am 2010;54(2):313–324. DOI: 10.1016/j.cden.2009.12.006.
  25. Nosrat A, Seifi A, Asgary S. Regenerative endodontic treatment (revascularization) for necrotic immature permanent molars: A review and report of two cases with a new biomaterial. J Endod 2011;37(4):562–567. DOI: 10.1016/j.joen.2011.01.011.
  26. Chang YC, Huang FM, Tai KW, et al. The effect of sodium hypochlorite and chlorhexidine on cultured human periodontal ligament cells. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92(4):446–450. DOI: 10.1067/moe.2001.116812.
  27. Kontakiotis EG, Filippatos CG, Tzanetakis GN, et al. Regenerative endodontic therapy: A data analysis of clinical protocols. J Endod 2015;41(2):146–154. DOI: 10.1016/j.joen.2014.08.003.
  28. Zeng Q, Nguyen S, Zhang H, et al. Release of growth factors into root canal by irrigations in regenerative endodontics. J Endod 2016;42(12):1760–1766. DOI: 10.1016/j.joen.2016.04.029.
  29. Huang X, Zhang J, Huang C, et al. Effect of intracanal dentine wettability on human dental pulp cell attachment. Int Endod J 2012;45(4):346–353. DOI: 10.1111/j.1365-2591.2011.01982.x.
  30. Martin DE, De Almeida JFA, Henry MA, et al. Concentration-dependent effect of sodium hypochlorite on stem cells of apical papilla survival and differentiation. J Endod 2014;40(1):51–55. DOI: 10.1016/j.joen.2013.07.026.
  31. Diogenes A, Ruparel NB. Regenerative endodontic procedures: Clinical outcomes. Dent Clin North Am 2017;61(1):111–125. DOI: 10.1016/j.cden.2016.08.004.
  32. Tanase S, Tsuchiya H, Yao J, et al. Reversed-phase ion-pair chromatographic analysis of tetracycline antibiotics: Application to discolored teeth. J Chromatgr B Biomed Sci Appl 1998;706(2):279–285. DOI: 10.1016/s0378-4347(97)00563-x.
  33. Eymirli A, Nagas E, Uyanik MO, et al. Effect of laser-activated irrigation with ethylene diaminetetraacetic acid and phytic acid on the removal of calcium hydroxide and triple antibiotic paste from root dentin. Photomed Laser Surg 2017;35(1):43–48. DOI: 10.1089/pho.2016.4146.
  34. Zhou R, Wang Y, Chen Y, et al. Radiographic, histologic, and biomechanical evaluation of combined application of platelet-rich fibrin with blood clot in regenerative endodontics. J Endod 2017;43(12):2034–2040. DOI: 10.1016/j.joen.2017.07.021.
  35. Jiang X, Liu H, Peng C. Clinical and radiographic assessment of the efficacy of a collagen membrane in regenerative endodontics: A randomized, controlled clinical trial. J Endod 2017;43(9):1465–1471. DOI: 10.1016/j.joen.2017.04.011.
  36. Denio D, Torabinejad M, Bakland LK. Anatomical relationship of the mandibular canal to its surrounding structures in mature mandibles. J Endod 1992;18(4):161–165. DOI: 10.1016/S0099-2399(06)81411-1.
  37. Scarano A, Di Carlo F, Quaranta A, et al. Injury of the inferior alveolar nerve after overfilling of the root canal with endodontic cement: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104(1):e56–e59. DOI: 10.1016/j.tripleo.2007.01.036.
  38. Ulusoy AT, Turedi I, Cimen M, et al. Evaluation of blood clot, platelet-rich plasma, platelet-rich fibrin, and platelet pellet as scaffolds in regenerative endodontic treatment: A prospective randomized trial. J Endod 2019;45(5):560–566. DOI: 10.1016/j.joen.2019.02.002.
  39. Wang Y, Cox MK, Coricor G, et al. Inactivation of Tgfbr2 in Osterix-Cre expressing dental mesenchyme disrupts molar root formation. Dev Biol 2013;382(1):27–37. DOI: 10.1016/j.ydbio.2013.08.003.
  40. Masuki H, Okudera T, Watanebe T, et al. Growth factor and pro-inflammatory cytokine contents in platelet-rich plasma (PRP), plasma rich in growth factors (PRGF), advanced platelet-rich fibrin (A-PRF), and concentrated growth factors (CGF). Int J Implant Dent 2016;2(1):19. DOI: 10.1186/s40729-016-0052-4.
  41. Shivashankar VY, Johns DA, Maroli RK, et al. Comparison of the effect of PRP, PRF and induced bleeding in the revascularization of teeth with necrotic pulp and open apex: A triple blind randomized clinical trial. J Clin Diagn Res 2017;11(6):ZC34–ZC39. DOI: 10.7860/JCDR/2017/22352.10056.
  42. Murray PE. Minireview of the clinical efficacy of platelet-rich plasma, platelet-rich fibrin and blood-clot revascularization for the regeneration of immature permanent teeth. 2018;6(1):1–5. DOI: 10.5321/wjs.v6.i1.1.
  43. Nazzal H, Kenny K, Altimimi A, et al. A prospective clinical study of regenerative endodontic treatment of traumatized immature teeth with necrotic pulps using bi-antibiotic paste. Int Endod J 2018;51(Suppl 3):e204–e215. DOI: 10.1111/iej.12808.
  44. Saoud TMA, Zaazou A, Nabil A, et al. Clinical and radiographic outcomes of traumatized immature permanent necrotic teeth after revascularization/revitalization therapy. J Endod 2014;40(12):1946–1952. DOI: 10.1016/j.joen.2014.08.023.
  45. Nagata JY, de Almeida Gomes BPF, Rocha Lima TF, et al. Traumatized immature teeth treated with 2 protocols of pulp revascularization. J Endod 2014;40(5):606–612. DOI: 10.1016/j.joen.2014.01.032.
  46. Estefan BS, El Batouty KM, Nagy MM, et al. Influence of age and apical diameter on the success of endodontic regeneration procedures. J Endod 2016;42(11):1620–1625. DOI: 10.1016/j.joen.2016.06.020.
  47. Yajamanya SR, Chatterjee A, Babu CN, et al. Fibrin network pattern changes of platelet-rich fibrin in young versus old age group of individuals: A cell block cytology study. J Indian Soc Periodontol 2016;20(2):151–156. DOI: 10.4103/0972-124X.176390.
  48. Nazzal H, Ainscough S, Kang J, et al. Revitalisation endodontic treatment of traumatised immature teeth: A prospective long-term clinical study. Eur Arch Paediatr Dent 2020;21(5):587–596. DOI: 10.1007/s40368-019-00501-0.
  49. Chen MY, Chen KL, Chen CA, et al. Responses of immature permanent teeth with infected necrotic pulp tissue and apical periodontitis/abscess to revascularization procedures. Int Endod J 2012;45(3):294–305. DOI: 10.1111/j.1365-2591.2011.01978.x.
  50. Ou KL, Chang CC, Chang WJ, et al. Effect of damping properties on fracture resistance of root filled premolar teeth: A dynamic finite element analysis. Int Endod J 2009;42(8):694–704. DOI: 10.1111/j.1365-2591.2009.01570.x.
  51. Yang J, Yuan G, Chen Z. Pulp regeneration: current approaches and future challenges. Front Physiol 2016;7:58. DOI: 10.3389/fphys.2016.00058.
  52. Torabinejad M, Turman M. Revitalization of tooth with necrotic pulp and open apex by using platelet-rich plasma: A case report. J Endod 2011;37(2):265–268. DOI: 10.1016/j.joen.2010.11.004.
  53. Wang X, Thibodeau B, Trope M, et al. Histologic characterization of regenerated tissues in canal space after the revitalization/revascularization procedure of immature dog teeth with apical periodontitis. J Endod 2010;36(1):56–63. DOI: 10.1016/j.joen.2009.09.039.
  54. Lei L, Chen Y, Zhou R, et al. Histologic and immunohistochemical findings of a human immature permanent tooth with apical periodontitis after regenerative endodontic treatment. J Endod 2015;41(7):1172–1179. DOI: 10.1016/j.joen.2015.03.012.
  55. Tomson PL, Grover LM, Lumley PJ, et al. Dissolution of bio-active dentine matrix components by mineral trioxide aggregate. J Dent 2007;35(8):636–642. DOI: 10.1016/j.jdent.2007.04.008.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.