Comparative histological evaluation of two PRF formulations (PRF High and PRF Medium) on quality of life and healing outcome of apicomarginal defects: A randomized clinical trial

The objective of this randomized clinical trial was to investigate the effects of two PRF formulations (PRF High and PRF Medium) on quality of life and healing outcome (2D and 3D) of apicomarginal defects. Patients presenting with endodontic lesions and concomitant periodontal communication were randomly allocated to PRF High and PRF Medium groups. The treatment protocol in each group included a periapical surgical procedure with placement of PRF clot and membrane in the bony defect and on the denuded root surface, respectively. Quality of life was assessed for 1 week after surgery following a modified version of the patient's perception questionnaire. Postoperative pain was assessed using a visual analog scale. Clinical and radiographic evaluations were performed using Rud and Molven 2D criteria and Modified PENN 3D criteria. Buccal bone formation was assessed using sagittal and corresponding axial sections in CBCT. Histological analysis was performed using hematoxylin and eosin (H and E) staining and attaching primary antibodies to tissue sections. In total, 40 patients were enrolled in the trial (N = 20 per group). PRF Medium group patients reported significantly less swelling on the 1st (p = 0.036), 2nd (p = 0.034), and 3rd (p = 0.023) days, and average pain on the 2nd (p = 0.031), 3rd (p = 0.03), and 4th (p = 0.04) days postoperatively. The difference in success rate for periapical healing was non-significant between the PRF Medium group (89.5%) and PRF High group (90%), in both 2D and 3D imaging (p = 0.957). The formation of buccal bone was observed in five cases (26.3%) and four cases (20%) in the PRF Medium and PRF High groups, respectively, with a non-significant difference (p = 0.575). PRF Medium clots had a loose fibrin structure with a significantly higher number of neutrophils (473.79 ± 82.89 per mm²) than PRF High clots, which had a dense structure and fewer neutrophils (253.15 ± 63.86 per mm²) (p = 0.001). Autologous platelet concentrates (APCs) promoted satisfactory periapical healing, with no significant difference between the groups. Within the limitations of the study, it seems that PRF Medium should be preferred over PRF High when the patients' quality of life is the priority.

Combined endodontic therapy and peri-radicular regenerative surgery in the treatment of dens invaginatus type III associated with apicomarginal defect

Dens invaginatus (DI) is a dental developmental abnormality, probably resulting from an infolding of the dental papilla during tooth development. The following case report presents a case of Type III DI with apicomarginal defect and peri-radicular lesion, diagnosed with cone-beam computed tomography scan and treated with combined orthograde endodontic therapy and peri-radicular regenerative surgery. Follow-up examination at 2 years revealed uneventful healing and improvement in the status of the tooth-supporting structures.

Management of a Previously Treated, Calcified, and Dilacerated Maxillary Lateral Incisor: A Combined Nonsurgical/Surgical Approach Assisted by Cone-beam Computed Tomography

Teeth with calcified canals, dilacerated roots, and associated large periradicular lesions involving both cortical plates pose a challenge to dentists. In addition to the nonsurgical endodontic treatment, such teeth may require surgical intervention with concomitant use of bone grafting materials and barrier techniques. These techniques, when combined with the use of a host modulating agent such as platelet-rich fibrin (PRF), may improve the chances of success. A 26-year-old woman was referred for dental treatment with a recurrence of an intraoral sinus tract 2 months after periradicular surgery in the upper anterior region. Clinical and radiographic examinations revealed a calcified and perforated maxillary left lateral incisor with a severely dilacerated root as well as an associated large radiolucent lesion surrounding the roots of the maxillary left central and lateral incisors. A cone-beam computed tomographic scan of the anterior maxilla showed erosion of the labial and palatal cortical plates in the same region. A calcified canal in the lateral incisor was negotiated up to the straight line portion of the canal. Periradicular surgery with root-end resection was performed, and root-end filling was performed with mineral trioxide aggregate. The perforation present on the middle third of the labial surface of the root was repaired with mineral trioxide aggregate, and the canal was cleaned, shaped, and obturated. A PRF scaffold was prepared and used with a collagen membrane and a freeze-dried bone allograft. Follow-up visits after 3 months, 6 months, and 1 year revealed satisfactory clinical and radiographic healing. The combined use of nonsurgical and surgical modes of treatment cannot be overemphasized in this case. The use of PRF along with a bone graft and a barrier membrane may have enhanced the speed of healing and the resolution of periradicular radiolucency by enhancing bone regeneration.

Endodontic-periodontal microsurgery for combined endodontic-periodontal lesions: An overview

Endodontic and periodontal microsurgery has surpassed the success rates for traditional endodontic and periodontal surgical procedures. Excellent healing results are being attributed to both the techniques, when employed, for isolated endodontic or periodontal defects. Combined endodontic-periodontal lesions have been referred to as a true challenge, requiring not only endodontic microsurgical management but also concurrent bone grafting and membrane barriers techniques. The prevention of epithelial downgrowth and regeneration of periodontal cementum, fiber, and bone seals the fate of these cases. Achieving primary closure with submergence of grafts has a positive effect on GTR outcome. New techniques of periodontal microsurgery, such as minimally invasive papilla preserving flaps with passive internal mattress suturing, have managed to obtain 90% primary flap closure over grafted sites. Root surface treatment and conditioning has also shown to be beneficial for GTR. Endodontic microsurgery for the combined lesion has not integrated these advances yet. These advances, along with a recently suggested treatment strategy, are ushering in the level next in management of the combined lesions. This article offers an overview of the combined lesion, the disease, its classification, treatment strategy, regenerative tools, microsurgical recommendations, and outcome studies.