|CLINICAL SCIENCE AND TECHNIQUES/CASE REPORT WITH DISCUSSION
|Year : 2014 | Volume
| Issue : 2 | Page : 134-138
Platelet-rich plasma and bi-phasic tri calcium phosphate in the management of periodontally compromised teeth with hopeless prognosis: A case report with six-year follow-up and surgical re-entry
Subramoniam Sundaram, Suresh Ranga Rao
Department of Periodontics, Faculty of Dental Sciences, Sri Ramachandra University, Porur, Chennai, Tamil Nadu, India
|Date of Web Publication||28-Oct-2014|
Suresh Ranga Rao
Department of Periodontics, Faculty of Dental Sciences, Sri Ramachandra University, Porur, Chennai - 600 116, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
One of the main objectives of periodontal therapy is to prolong the lifespan of dentition as there is no ideal substitute for natural dentition even in the era of dental implants. Treatment of teeth with advanced periodontal disease with hopeless prognosis is always extraction. However in this case report, we discuss a novel regenerative strategy using a combination of platelet rich plasma and bi-phasic tri calcium phosphate for a lower central incisor that was considered for extraction. Clinical and radiographic examination during the six-year follow-up postoperatively revealed stable periodontal health in the lower right central incisor. The surgical re-entry done in the sixth year postoperatively revealed good periradicular healing and alloplastic bone graft incorporation within the host bone.
Keywords: Bi-phasic-tri calcium phosphate, chronic periodontitis, platelet-rich plasma, prognosis, surgical re-entry
|How to cite this article:|
Sundaram S, Rao SR. Platelet-rich plasma and bi-phasic tri calcium phosphate in the management of periodontally compromised teeth with hopeless prognosis: A case report with six-year follow-up and surgical re-entry. J Int Clin Dent Res Organ 2014;6:134-8
|How to cite this URL:|
Sundaram S, Rao SR. Platelet-rich plasma and bi-phasic tri calcium phosphate in the management of periodontally compromised teeth with hopeless prognosis: A case report with six-year follow-up and surgical re-entry. J Int Clin Dent Res Organ [serial online] 2014 [cited 2019 May 20];6:134-8. Available from: http://www.jicdro.org/text.asp?2014/6/2/134/143517
| Introduction|| |
Tooth that is lost once is lost forever. One of the main goals of periodontal therapy is prolonging the lifespan of periodontally diseased dentition and to preserve the tooth in good esthetic and functional health. A number of attempts have been made to replace the missing natural tooth (implants, dentures) but reports from previous literature and clinical experiences have shown that there is no substitute for natural dentition. Various prognostic and risk factors are taken into consideration in selecting an appropriate periodontal surgical technique for a periodontally compromised tooth. However, extraction and replacement is preferred commonly over conventional periodontal therapy for patients with advanced periodontal destruction. The prognosis of teeth with advanced bone loss, attachment loss up to the apex and mobility is often considered hopeless and is frequently extracted. Therefore treatment of teeth with advanced periodontal disease with hopeless prognosis still remains an elusive goal of periodontal therapy.
Even though various studies presenting successful outcomes using regenerative osseous surgical techniques exists in the literature, it is still a challenging task to salvage a periodontally compromised teeth with hopeless prognosis using regenerative modalities. More over long-term clinical follow-ups of these regenerative attempts is scarce in the literature. This is a report of a case using a regenerative periodontal surgical technique combining platelet-rich plasma (PRP) and bi-phasic tri calcium phosphate bone graft to achieve admirable clinical and radiographic outcome with a six-year follow-up and surgical re-entry thus saving a periodontally compromised teeth from extraction.
| Case report|| |
A 32-year-old male patient reported to the outpatient Department of Periodontology and Implantology, Sri Ramachandra University with chief complaint of bleeding gums and pain since one year. Dental history revealed that the patient had undergone root canal treatment in relation to 31 and 41, one year earlier. Upon clinical examination, it was noted that the patient was suffering from chronic localized severe periodontitis in relation to 31, 41 with Miller's Grade III mobility in relation to 41 and Grade II in relation to 31 and 42. Intra-oral periapical radiograph (IOPA) revealed advanced bone loss beyond the apical third of the root in relation to 41 on both the mesial and distal sites [Figure 1]. The prognosis of 41 was hopeless.
|Figure 1: Preoperative intraoral periapical radiograph showing bone loss up to apical third in relation to 41 (Lower right central incisor)|
Click here to view
Patient insisted to retain his natural tooth and denied for extraction of 41. Considering the mobility of 41, 42 and 31, it was decided to initiate non-surgical periodontal therapy after placing an extra coronal 0.010” ligature braided wire splinting secured with light cured composite resin extending from 33 to 43 [Figure 2]. Full mouth scaling and root planing was carried out. Although, the inflammation resolved, residual pockets of probing depth 10 mm existed in all the six sites in relation to 41 at the six-week follow-up re-evaluation [Figure 3]. Therefore, surgical therapy was discussed with the patient. The authors decided to use a sandwich regenerative osseous surgery technique of placing PRP and pi-phasic tri calcium phosphate (Ossify TM ) to which the patient agreed and signed a written consent form for the same.
|Figure 3: Preoperative probing depth of more than 10 mm in relation to mesial aspect of 41|
Click here to view
Preparation of platelet-rich plasma
A two-stage centrifugation procedure was used to obtain PRP.  An hour before the surgery, 10 ml of venous blood was drawn from the median cubital vein of the patient using Vacutainer blood collection tube coated with 3.2% sodium citrate as the anticoagulant (Vacutainer, Becton and Dickinson, USA). This tube was centrifuged at a speed of 2,400 rpm for 10 minutes. After centrifugation, three layers were obtained - the upper layer consisting of platelet poor plasma, the middle buffy coat layer that is rich in platelets and the lower layer of red blood cells. The red blood cells and the middle buffy coat comprising platelets and leukocytes were transferred to an empty Vacutainer tube and centrifuged for 15 minutes at 3,600 rpm to obtain PRP. Before placing the PRP to the surgical site in order to activate the degranulation of the platelets, 10% calcium chloride solution and 100 U/ml of bovine thrombin were mixed to the PRP. This resulted in the formation of a sticky gel that was mixed with the bi-phasic tri calcium phosphate graft (Ossify TM ) in a sterile cup.
The patient was asked to rinse with Listerine TM for one minute before the surgical procedure. The surgical site was anesthetized with 2% lignocaine containing 1:80,000 adrenaline. Crevicular incision was given with a bard parker #15 blade directed toward the alveolar crest in relation to 31, 41 and 42. Full thickness mucoperiosteal flap was raised buccally and lingually. Significant bone loss extending circumferentially and also beyond the apical third of the root was seen in relation to 41 [Figure 4]. The granulation tissue was removed from the defects by manual debridement and root surfaces were thoroughly planned. Root biomodification was done using tetracycline HCl (50 mg/ml) for four minutes and was washed with saline [Figure 5].
|Figure 4: Kirkland flap refelected in relation to 32 to 42 showing bone loss up to the apical third|
Click here to view
Intra marrow penetration was done using micro motor straight hand piece with No.10 Tungsten carbide round bur (SS White). A layered increment of PRP was applied to the osseous defect [Figure 6]a. Briefly, a layer of PRP gel alone placed on the osseous defect followed by a second layer of PRP mixed with the bone graft (bi-phasic tri calcium phosphate)[Figure 6]b and a third layer of PRP gel alone was applied thus sandwiching the PRP bone graft combination [Figure 6]c. The flap was stabilized with 3-0 black braided silk using simple interrupted sutures. Periodontal dressing was placed (Coe Pak TM ). The patient was prescribed 500 mg Amoxicillin three times a day for one week along with Ibuprofen four times a day for three days. Patient was instructed to rinse with Chlorhexidine gluconate 0.2% (Hexidine TM ) for two months twice daily.
|Figure 6: (a) Placement of layer of platelet-rich plasma (b) Placement of bi-phasic tri calcium phospate bone graft mixed with PRP (c) Placement of bi-phasic tri calcium phosphate layer alone|
Click here to view
Patient reported to the department after one week for suture removal with no complaints of any pain or discomfort. The operated site had healed well and the patient was kept on maintenance phase every month for the next three months. Only visual clinical examination was done at first and second month postoperatively. Oral hygiene was reinforced to the patient and patient was instructed to use a multi-tufted interdental brush (Thermoseal NS TM ) twice daily. At three months postoperatively, the involved teeth (41) was clinically and radiographically evaluated. There was absence of bleeding on probing and the periodontal condition had improved dramatically. Reduction in pocket depth and gain in clinical attachment level was observed. There was a significant reduction in probing depth from 10 mm to 3 mm in the distal surface of 41 and from 9 mm to 2 mm in the mid-buccal site. IOPA at 3 months demonstrated an increase in radio-opacity suggesting of significant bone fill in relation to the above-mentioned teeth compared to the pre-operative radiographs.
After six years, the probing depth was 3 mm, with a gain in attachment of 7 mm in the mesial site of 41 [Figure 7]. IOPA radiographs revealed a significant bone fill in the sixth-year follow-up and this can been appreciated when it is compared with the pre operative radiographs [Figure 8]a-c. Since the extra coronal splint had to be replaced as it had debonded it was possible to examine the mobility of 41, 31 and 42. The mobility had decreased to Grade I in relation to 41, 31 and 42. The extra coronal splint was redone as a surgical re-entry procedure was scheduled with the consent of the patient. The surgical re-entry revealed a significant bone fill in the osseous defect. However, the bone fill was seen only up to the middle third of the root in relation to 41 [Figure 9]. It was decided to further increase the bone level by placing PRP gel mixed with bioactive glass (Perioglas TM ) after root biomodification with tetracycline (50 mg/ml) and the same surgical protocol was followed again.
|Figure 7: Postoperative probing depth (sixth-year follow-up examination)|
Click here to view
|Figure 8: (a) Preoperative radiograph, (b) One year postoperative radiograph showing extra coronal splint in relation to 43 to 33 and bone fill up to middle third of the root assessed with a radiographic grid, (c) Sixth-year postoperative radiograph showing bone fill up to middle third|
Click here to view
|Figure 9: Surgical re-entry after six years at the defect site revealing incorporation of grafts particles into the host bone|
Click here to view
| Discussion|| |
Untreated periodontal disease may cause destruction of the periodontal tissues to an extent that it becomes functionally and aesthetically compromised. Recent advances in the regenerative therapeutic modalities and maintenance have allowed the periodontally compromised tooth to continue as a functional unit of the masticatory apparatus. The available literature indicates that PRP alone, or when combined with bone grafts, exerts positive outcomes in the management of intrabony defects. PRP contains significant amount of growth factors such as transforming growth factor, platelet-derived growth factor, insulin-like growth factor and fibrin, which can promote periodontal regeneration and early graft consolidation and maturation. 
Although the prognosis of the involved tooth can be clinically and radiographically categorized as "hopeless," the decision to retain the tooth was made based on the patient's strong desire to retain the periodontally compromised teeth. The other major determinants that were favorable for retaining the compromised tooth are as follows:
- The involved tooth was not compromised esthetically;
- Periodontal health of rest of the dentition was stable without any attachment loss;
- Presence of adequate width of keratinized tissue with absence marginal gingival recession and
- Good oral hygiene and non-smoking status of the patient.
We preferred regenerative procedure over extraction as studies have shown that regenerative therapy has the potential to save hopeless teeth from extraction. The results of the five-year randomized control trial by Cortellini et al.  concluded that regenerative therapy can be applied at hopeless teeth and has the potential to change their prognosis. Another factor that was considered was the effect of the hopeless teeth on proximal periodontium as in the past it was thought that retaining them would have a deleterious effect on the adjacent teeth. But recently it has been established that retaining periodontally hopeless teeth had no detrimental effect on proximal periodontium of adjacent teeth prior to and following treatment. 
The rationale behind using bi-phasic tri calcium phosphate is that it has good osteoconductive potential and has the capacity to form carbonate apatite compared to pure Hydroxyapatite itself.  One of the main limitations associated with particulate bone graft like bi-phasic tri calcium phosphate is that it is not very effective when bone defect morphology falls in the category of hemiseptum and horizontal osseous defects.  Although various particulate graft materials are available autogenous bone grafts are considered as the gold standard. 
We selected particulate bone graft primarily to avoid secondary donor site and considered the combination of PRP with bone graft as a viable alternative to autogenous bone graft. The emerging concept of tissue engineering has renewed interest in using particulate bone grafts. These graft materials acts as a scaffold for the various cells such as periodontal ligament fibroblast, osteoblast these when induced or signaled with appropriate growth factors can enhance periodontal tissue regeneration. The combination of PRP and particulate bone graft identifies itself with the tissue engineering triad. Adding PRP to particulate bone grafts not only improves handling properties of the bone graft particles and facilitates graft placement at the defect site but also enhances bone regeneration. 
There was a significant improvement in probing depth, mobility from grade III to grade I and radiographic bone fill at one-year and sixth-year follow-up visit. Factors that explain this positive outcome could be attributed to the presence of sufficient overlying gingival tissue that provided an adequate coverage for the grafted site during the early healing phase and the other major factor is the placement of PRP gel alone over the overlying osseous defect in an incremental manner. Although there was no residual probing pocket depth at the sixth-year follow-up, it was decided to perform a surgical re-entry with an objective to evaluate the bone levels clinically Although there was no residual probing pocket depth at the sixth-year follow-up, it was decided to perform a surgical re-entry with an objective to evaluate the bone levels clinically.
| Conclusion|| |
The outcome of this case report indicates that periodontally compromised teeth even with hopeless prognosis can be salvaged with regenerative periodontal therapy. This novel approach of saving and maintaining hopeless teeth clearly shows a changing trend in favor of regenerative periodontal therapy over prosthetic replacement of natural teeth.
| References|| |
Weibrich G, Kleis WK, Kunz-Kostomanolakis M, Loos AH, Wagner W. Correlation of platelet concentration in platelet-rich plasma to the extraction method, age, sex, and platelet count of the donor. Int J Oral Maxillofac Implants 2001;16:693-9.
Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: Growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:638-46.
Cortellini P, Stalpers G, Mollo A, Tonetti MS. Periodontal regeneration versus extraction and prosthetic replacement of teeth severely compromised by attachment loss to the apex: 5-year results of an ongoing randomized clinical trial. J Clin Periodontol 2011;38:915-24.
Machtei EE, Hirsch I. Retention of hopeless teeth: The effect on the adjacent proximal bone following periodontal surgery. J Periodontol 2007;78:2246-52.
Cho JS, Lee JH, Kang YC. Large scale production of yolk-shell β-tricalcium phosphate powders, and their bioactivities as novel bone substitutes. Phys Chem Chem Phys 2014;16:16962-7.
Finkemeier CG. Bone-grafting and bone graft-substitutes. J Bone Joint Surg Am 2002;3:454-64.
Coradazzi LF, Garcia IR Jr, Manfrin TM. Evaluation of autogenous bone grafts, particulate or collected during osteotomy with implant burs: Histologic and histomorphometric analysis in rabbits. Int J Oral Maxillofac Implants 2007;22:201-7.
Marx RE. Platelet-rich plasma: Evidence to support its use. J Oral Maxillofac Surg 2004;62:489-96.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]