|Year : 2015 | Volume
| Issue : 1 | Page : 69-74
Treatment of infrabony defects with platelet-rich fibrin along with bone graft: Case report
Surekha Y Bhedasgaonkar, Janak Kapadia, Neha A Patil
Department of Periodontology, Vasantdada Patil Dental College and Hospital, Sangli, Maharashtra, India
|Date of Web Publication||18-Mar-2015|
Dr. Neha A Patil
Department of Periodontology, Vasantdada Patil Dental College and Hospital, Kavalapur, Miraj, Sangli - 416 306, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Although periodontitis is an infectious disease of periodontal tissues, changes that occur in the bone are crucial, because destruction of bone is responsible for tooth loss. Although horizontal bone loss is most common, vertical bone loss is more amenable to regenerative periodontal therapy. Recently, importance has been given to use of platelet-rich fibrin (PRF) for predictably obtaining periodontal regeneration. PRF is a concentrated suspension of growth factors found in platelets. These growth factors moderate the wound healing and promote tissue regeneration. This article includes case reports of two patients who showed infrabony defects that were treated with combining PRF with allograft. This case report tried to compare the clinical and radiographical outcome obtained by combination of PRF and allograft.
Keywords: Chronic periodontitis, PRF, Regeneration
|How to cite this article:|
Bhedasgaonkar SY, Kapadia J, Patil NA. Treatment of infrabony defects with platelet-rich fibrin along with bone graft: Case report. J Int Clin Dent Res Organ 2015;7:69-74
|How to cite this URL:|
Bhedasgaonkar SY, Kapadia J, Patil NA. Treatment of infrabony defects with platelet-rich fibrin along with bone graft: Case report. J Int Clin Dent Res Organ [serial online] 2015 [cited 2019 Jul 23];7:69-74. Available from: http://www.jicdro.org/text.asp?2015/7/1/69/153504
| Introduction|| |
The biologic goal of periodontal regeneration is restoration of the periodontium to its original form and function. Periodontal repair is "healing of the periodontium by tissue that does not fully restore the original function, anatomic and morphologic architecture." Following conventional surgical approaches, such as open flap debridement, repair of lost periodontal attachment occurs primarily through formation of a long junctional epithelium between the gingival flap and the previously diseased root surface.  Regeneration has been defined as "the reproduction or reconstitution of a lost or injured part to restore the architecture and function of the periodontium."  The aim of regenerative periodontal therapy is to restore the structure and function of the periodontium. Periodontal regeneration requires an orchestrated sequence of biologic events such as cell migration, adherence, growth and differentiation, to have the potential to increase the success and predictability of periodontal regenerative procedures. 
According to a position paper from the American Academy of Periodontology, periodontal regenerative procedures include soft tissue grafts, bone replacement grafts, root biomodifications, guided tissue regeneration (GTR), and combinations thereof for osseous, furcation, and recession defects. 
Platelet-rich fibrin (PRF) was first described by Choukroun et al. in 2004 in France. It has been referred to as a second generation platelet concentrate  because the natural concentrate is produced without any anticoagulants or gelifying agents. First biochemical analysis of the PRF composition indicated that this biomaterial consists of an intimate assembly of cytokines, glycanic chains, and structural glycoproteins enmeshed within a slowly polymerized fibrin network. This biologic activity of fibrin molecule is enough in itself to account for the significant cicatricial capacity of the PRF and the slow polymerization mode confers to the PRF membrane a particularly favorable physiological architecture to support the healing process. 
A recent innovation in the dentistry is the preparation and the use of PRF, a concentrated suspension of the growth factors found in platelets. These growth factors are involved in wound healing and are postulated as promoters of tissue regeneration. Platelet concentrate contains platelet-derived growth factor (PDGF), transforming growth factor (TGF), vascular endothelial growth factor (VEGF), etc. growth factors that modulate and up-regulate growth factor function. 
Here, we present a 6-month follow-up report of an intrabony defect treated with an autologous PRF by assessing clinical and radiological parameters. The bone graft used in this case is demineralized freeze-dried bone allografts (DFDBA), an allograft which has osteogenic potential.
| Case Report|| |
Patients reported to the Department of Periodontics, with the complaint of food lodgement and pain in the gingiva. They did not give any relevant medical history, no history of dental trauma, orthodontic treatment, and no injurious habit was reported.
A 45-year-old Indian male complained of food lodgement and pain in the lower left mandibular molar region. On intraoral examination, there was bleeding on probing present no swelling and no pus exudation were noticed. The probing pocket depth (PD) on the distobuccal aspect of tooth #38 was 9 mm and no mobility was detected. A periapical radiograph was taken. Radiographs were standardized by using paralleling technique and holder, which revealed presence of interproximal angular bone loss [Figure 1]. This intraoral peri-apical radiograph (IOPA) was scanned through X digi USB* and grid was applied and the defect was measured and it was 7 mm.
A 35-year-old Indian female complained of food lodgement and bleeding in the right upper maxillary premolar region. The probing PD on the distobuccal aspect of #15 was 12 mm, whereas no mobility was detected. A periapical radiograph was taken. Radiographs were standardized by using paralleling technique and holder, which revealed presence of interproximal angular bone loss [Figure 10]. This IOPA was scanned through X digi USB and grid was applied and defect was measured and it was 9 mm.
Keeping all the findings in the mind, the periodontal therapy was planned.
- Non-surgical periodontal therapy by means of conventional scaling and root planning using ultrasonic instrument and curettes.
- Patients were recalled after every week and re-examination was done for 4 weeks, even after non surgical periodontal therapy pocket persist after 4 weeks.
- So surgical periodontal therapy was planned.
Before that patients platelet count, hemoglobin, bleeding time, and clotting time were assessed and found to be within normal limits.
The PRF was prepared in accordance with the protocol developed by Choukroun et al. just prior to surgery, intravenous blood from antecubital vein was collected in the 10 ml of sterile tube without an anticoagulant and centrifuged† immediately. Blood was centrifuged using a tabletop centrifuging machine for 12 min at 2,700 rpm [Figure 2].
The resultant product consists of three layers:
- Topmost layer consist of acellular platelet poor plasma (PPP).
- PRF clot in the middle.
- Red blood cells (RBCs) at the bottom.
PRF was easily separated from RBCs using a sterile tweezer just after removal of PPP and then transferred on to the sterile dapen dish. The PRF was then mixed with DFDBA bone graft** [Figure 3].
Intraoral antisepsis were performed using 0.2% chlorhexidine digluconate rinse and iodine solution was used to carry out extra oral antisepsis for both the patients. Following administration of local anesthesia, sulcular incisions were made, and mucoperiosteal flap were reflected [Figure 4]. Meticulous defect debridement and root planning was carried out with the help of area specific curettes. The direct examination after debridement, confirmed the presence of three walled bony defect. PRF + DFDBA bone graft was filled into the infrabony defect [Figure 5]. The mucoperiosteal flap were repositioned and secured in place using 3-0 non-absorbable black silk surgical suture. The simple interrupted sutures were placed. Periodontal dressing was placed [Figure 6] and [Figure 7]. Same procedure was done for patient 2 [Figure 11], [Figure 12], [Figure 13], [Figure 14]. After that immediate post operative IOPAs were taken for both the patients [Figure 8] and [Figure 15].
The suitable antibiotics and analgesics (amoxicillin 500 mg three times a day for 5 days and piroxicam two times a day for 5 days) were prescribed along with 0.2% chlorhexidine mouth wash twice daily, for 1week. Periodontal pack and sutures were removed after 1 week postoperatively. Surgical wound were cleaned with iodine and patients were instructed for gentle brushing with soft toothbrush. Patients were instructed for oral hygiene maintenance and examined weekly for 1 month and then 3 and 6 months.
Re-examination after 6 month revealed reduction in pocket depth for case 1 was 4 mm, with bone fill of 5 mm and for case 2 was 5.5 mm and bone fill was 6 mm. There was no sign of bleeding on probing and significant radiographic bone fill was observed in both the patients [Figure 9] and [Figure 16].
| Discussion|| |
The ideal goal for periodontal therapy is the reconstitution of bone and connective tissue attachment that has been destroyed by the disease process.  The complete regeneration of the periodontium after periodontal treatment modalities has been difficult to achieve because of differences in the healing abilities among periodontal tissues. During the last 12 years, the field of periodontics has made great strides in developing techniques to regenerate the lost tissues. There are a broad range of treatment options available, but only some may be regarded as truly regenerative procedures. Consequently, dental research and industry have been increasingly concerned over the past two decades with biologically inert, synthetic, and autologous materials for implantation into periodontal infrabony defect.
The present case report evaluates the clinical efficacy of PRF + DFDBA allograft in the treatment of infrabony defects in patients with chronic periodontitis and showed a significant improvement in clinical and radiographic parameters. Also the 3-wall infrabony defects provided the best spatial relationship for defect bridging by vascular and cellular elements from the periodontal ligament and adjacent osseous wall. 
PRF is in the form of a platelet gel and can be used in conjunction with bone graft, which offers several advantages including promoting wound healing, bone growth and maturation, graft stabilization, wound sealing and hemostasis, and improving the handling properties of graft material.
When platelets in a concentrated form are added to graft materials, a more predictable outcome is derived.  The growth factors present in PRF are PDGF and TGF-β. They help in the protein synthesis in osseous tissues, stimulates angiogenesis, and enhance woven bone formation, etc. 
DFDBA have been used in periodontal therapy for years together. It is known to have an osteogenic potential that is manifested by exposing bone morphogenic protein (BMPs) which presumably have the ability to induce host cells to differentiate into osteoblast. They have been successfully used to reconstruct intraosseous periodontal defects.
Anuj Sharma et al. (2011)  and Thorat et al. (2011)  have done a study to explore the clinical and radiographic effectiveness of autologous PRF in the treatment of intrabony defects in patients with chronic periodontitis. There was greater pocket depth reduction, clincal attachment level (CAL) gain, and bone fill at the sites treated with PRF with conventional open-flap debridement compared to conventional open-flap debridement alone.
Mellonig et al. (1987)  carried out a study to evaluate DFDBA in human periodontal defects. Group 1 was treated with DFDBA and Group 2 was treated with only open-flap debridement. All defects were evaluated after 6 months postoperatively. Re-entry showed that there was 64.7% of bone fill in the sites which were treated with DFDBA. They concluded that DFDBA has definite potential as a graft material in periodontal regenerative therapy.
Simonpieri et al. (2009)  described the four advantages of the use of PRF during bone grafting. First, fibrin clot plays an important mechanical role in maintaining and protecting the graft and PRF fragments serve as biological connectors between bone particles. Second, fibrin network facilitates cellular migration, vascularization, and survival of the graft. Third, the growth factors (PDGF, TGF-β, IGF-1) are gradually released as the fibrin matrix is resorbed, thus creating a perpetual process of healing. Lastly, the presence of leukocytes and cytokines in the fibrin network can play a important role in the self-regulation of inflammatory and infectious phenomena within the grafted material.
Bansal et al. (2013)  and Khattar Sakshi et al. (2014)  had done a study to evaluate the efficacy of autologous PRF with the DFDBA, in the treatment of periodontal intrabony defects. They concluded that a combination of PRF and DFDBA demonstrated significant improvement in the clinical probing depth, relative attachement level, and radiographical bone fill.
Above studies show that when PRF is used alone or in combination with bone graft, demonstrate significant amount of pocket depth reduction, CAL gain, and radiographic bone fill, yet PRF with DFDBA gave more predictable results.
There are wide range of regenerative procedures that have been developed over the years. It is important to recognize and harness the benefits of each process and use them in indicated situations. The patients could be benefited in such situations, by maximum possible regeneration, ideally reaching physiological levels.
| Conclusion|| |
From the presented case, it can be concluded that PRF is efficacious clinically and radiographically in the periodontal infrabony defect. PRF is an autologous preparation and found to be clinically effective and economical than any other available regenerative material. However, long-term, multicenter randomized, controlled clinical trials will be required.
* X digi USB, Jolly computers, Surat
† X digi USB, Jolly computers, Surat
† Centrifuge machine of company REMI
† DFDBA bone graft from Tata Memorial Tissue Bank Mumbai
| References|| |
Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL. Regeneration of Periodontal Tissue: Bone replacement grafts. Dent Clin North Am 2010;54:55-71.
Bajaj P, Rao NS, Agarwal E, Pradeep AR. Treatment of intrabony defect with platelet rich fibrin: A case report. Arch Oral Sci Res 2011;1:90-4.
Pradeep AR, Shetty SK, Garg G, Pai S. Clinical effectiveness of autologous platelet-rich plasma and Peptide-enhanced bone graft in the treatment of intrabony defects. J Periodontol 2009;80:62-71.
Greenwell H; Committee on Research, Science and Therapy. American Academy of Periodontology. Position paper: Guidelines for periodontal therapy. J Periodontol 2001;72:1624-8.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al
. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part II: Platelet-relate biologic features. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e45-50.
Wartiovara U, Salven P, Mikkola H, Lassila R, Kaukonen J, Joukov V, et al
. Peripheral blood platelets express VEGF C and VEGF which are released during platelets activation. Thromb Haemost 1998;80:171-5.
Choukroun J, Adda F, Schoeffler C, Vervelle A. An opportunity in perio-implantology: The PRF. Implantodontie 2000;42:55-62.
Zander HA, Polson AM, Heijl LC. Goals of periodontal therapy. J Periodontol 1976;47:261-6.
Blumenthal NM, Alves ME, Al-Huwais S, Hofbauer AM, Koperski RD. Defect Determined regenerative options for treating periodontal intrabony defects in Baboons.
J Periodontol 2003;74:10-24.
Sunitha Raja V, Munirathnam Naidu E. Platelet rich fibrin: Evolution of a second generation platelet concentration. Indian J Dent Res 2008;19:42-6.
Sharma A, Pradeep AR. Treatment of 3-wall intrabony defects in patients with chronic periodontitis with autologous platelet-rich fibrin: A randomized controlled clinical trial. J Periodontol 2011;82:1705-17.
Thorat MK, Pradeep AR, Pallavi B. Clinical effect of autologous platelet-rich fibrin in the treatment of intra-bony defects: A controlled clinical trial. J Clin Periodontol 2011;38:925-32.
Mellonig JT. Decalcified freeze-dried bone allograft as an implant material in human periodontal defects Int J Periodontics Restorative Dent 1984;4:40-55.
Simonpieri A, Del Corso M, Sammartino G, Dohan Ehrenfest DM. The relevance of choukroun's platelet-rich fibrin and metronidazole during complex maxillary rehabilitations using bone allograft. Part II: Implant Surgery, prosthodontics and survival. Implant Dent 2009;18:220-9.
Bansal C, Bharti V. Evaluation of autologous platelet rich fibrin with the demineralized freeze dried bone allograft in the treatment of periodontal intrabony defects. J Indian Soc Periodontol 2013;17:361-6.
Khattar S, Kaushik M, Tomar N. The use of platelet rich fibrin and demineralized freeze dried bone allograft in the treatment of intrabony defect-A case report. Sch J Med Case Rep 2014;2:563-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]