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ISSN 2637-7764 Case Report

Successful Alliance of MTA and PRF for Treating

Young Permanent Tooth: A Case Report
Meeti Charan, Hind Pal Bhatia, Shveta Sood, Naresh Sharma and Akshara Singh*
Department of Pedodontics and Preventive Dentistry, Manav Rachna Dental College, India

*Corresponding author: Akshara Singh, Senior Lecturer, Department of Pedodontics and Preventive Dentistry, Manav Rachna Dental College, Sectort
43, Delhi Surajkund Road, Faridabad, Haryana, Pin- 121004, India
Submission: December 20, 2017; Published: March 19, 2018

Abstract
This case report describes the treatment of an immature permanent tooth (open apex) with periapical lesion which was treated with MTA
apexification and platelet rich fibrin (PRF) as an internal matrix. The root canal of immature permanent tooth was prepared and was disinfected with
2.5% Saline, NaOCl and EDTA. Triple antibiotic paste comprising Ciprofloxacin, Metronidazole and Tetracycline was given for intra radicular disinfection.
When the tooth became asymptomatic, PRF was prepared and placed in the apical end of tooth followed by Mineral Trioxide Aggregate (MTA) as a
sealing agent. It was obturated with thermoplasticized gutta percha and restored with Polycarbonate crown after 15 days. Progressive healing and
reappearance of normal trabaculae pattern in periapical area was seen in 3 months follow up. Our findings suggest that PRF can be used for accelerating
the healing process and for providing a barrier for the sealing agent like MTA in immature permanent teeth with periapical lesion.
Keywords: Immature permanent teeth; Mineral trioxide aggregate; Platelet rich fibrin; Triple antibiotic paste

Introduction
which are in need of supported or accelerated healing. This case
Young permanent teeth with pulpal necrosis require an
report describes the management of a necrosed young permanent
artificial material to induce the closure of an open apex as the
tooth with open apex using MTA for apexification and PRF as an
root development ceases. The closure of apex can be achieved
internal matrix.
by apexification which involves the formation of an apical
barrier at the root apex in order to prevent the leakage of any Case Presentation
microorganisms or toxic material to the surrounding periapical
A 10 year old female patient complained of pain in upper front
area, thus providing a hermetic seal [1]. Apexification with Mineral
tooth region since one month. On taking detailed history it was
Trioxide Aggregate (MTA) offers major advantage over traditional
revealed that the child had experienced dental trauma to anterior
Calcium hydroxide methods [2]. MTA is the preferred material for
teeth six months back. Two days after the trauma they had availed
apexification as it reduces the treatment time, doesn’t change the
dental services for the dental pain. However, the treatment was
mechanical properties of dentine, stimulates repair, restores the
discontinued and follow up wasn’t done by the guardians as the pain
tooth with a minimal delay and is highly biocompatible [3]. Despite
had subsided. After this anterior teeth remained asymptomatic until
the above mentioned advantages, overfill or under fill of MTA as an
last month. History of present illness revealed that the nature of
apical barrier may be disadvantageous. Lemon [4] introduced the
the pain was dull, constant, diffused with moderate severity which
“internal matrix concept” which involved the placement of hydroxyl
aggravated by intake of hot fluids. Intra-oral examination showed
apatite through the perforation to form an external barrier and
fracture involving the enamel in 11 and involving enamel, dentin
matrix, against which the perforation repair material (amalgam)
and exposing pulp in 21. A large access opening was seen on the
was condensed. He recommended the use of a matrix when the
lingual side of 11. On vertical percussion 21 was tender. Pulp vitality
diameter of the perforation is larger than 1mm to prevent the
tests were done, which elicited negative responses in 21. Based on
extrusion of sealing material. This concept was further modified by
the above clinical signs and symptoms, a provisional diagnosis of
Bargholz [5] who recommended the use of collagen as a completely
complicated crown fracture leading to chronic apical periodontitis
resorbable barrier material. The same concept is used for the
in 21 and uncomplicated crown fracture in 11 was proposed.
placement of MTA as an apical barrier. Platelet rich fibrin (PRF)
Intra oral periapical radiograph revealed an incompletely formed
which is a second generation platelet concentrate can be used as
apex with diffuse radiolucency (measuring 0.5x0.5cm) in greatest
a resorbable matrix material against which MTA apical barrier can
dimensions with respect to 21. It also showed radiopacity in 2/3rd
be placed. PRF is an easily accessible source of growth factors to
of the canal of 21 which was indicative of intracanal medicament
support bone and soft-tissue healing. It is added to surgical wounds
placed in the previous dental visit (Figure 1). Thus, a diagnosis of

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 Mod Res Dent Copyright © Akshara Singh

chronic periapical abscess in 21 was made. The treatment plan Preparation of PRF
presented was to perform apexification in 21. Informed consent
For the preparation of PRF membrane 10ml of venous blood was
was taken by the guardians after explaining them the treatment
drawn from venipuncture of antecubital vein half an hour before
planned in detail.
the procedure. Blood was collected in a 10ml sterile glass tube
without an anticoagulant and was immediately centrifuged at 3000
revolutions per minute for 10 minutes. After centrifugation three
layers were seen the tube-topmost layer consisting of a cellular
platelet poor plasma, PRF clot in the middle and red blood cells at
the bottom (Figure 3a). The PRF clot was retrieved using tweezer
and was placed on a sterile gauze piece to squeeze the excess fluid
and obtain the PRF membrane (Figure 3b). An approximate size of
the membrane was cut and placed in the canal using tweezer and
hand pluggers. The matrix was placed at the apex, estimating its
placement by the working length.

Figure 1: Periapical region of 21 showing open apex with

radiolucency indicative of chronic apical periodontitis. The canal
showed radiopacity in 2/3rd of the canal, indicating intra-canal
dressing in the canal.
Treatment
Local anaesthesia was administered after rubber dam
application. Previously placed restoration and intra canal dressing
was removed from the canal by saline irrigation. No.10 hand K file
(Mani Inc., Tochigi, Japan) was used to check the patency of the canal.
Biomechanical preparation was done using step back technique
with stainless steel H files (Mani Inc., Tochigi, Japan) along with
copious irrigation with saline, 2.5% sodium hypochlorite solution
and EDTA (RC Help, Prime Dental, Thane, India) to ensure complete Figure 3a: Centrifugation of blood showed three layers-topmost
removal of the necrotic pulp tissue. Intracanal dressing of triple layer consisting of acellular platelet poor plasma, PRF clot in the
middle and red blood cells at the bottom.
antibiotic paste consisting of Ciprofloxacin (250mg), Metronidazole
(400mg) and Minocycline (100mg) in the ratio of 1:1:1 was placed
according to the method followed by Prabhakar et al. [6] (Figure 2).
After 40 days the tooth was asymptomatic but the periapical area
showed no significant change in the periapical radiolucency. At this
appointment, it was decided to enhance periapical healing by using
PRF membrane as an internal matrix against which MTA would be
placed as an apical barrier.

Figure 3b: The PRF clot after squeezing the excess fluid.

MTA placement
MTA (Angelus, Londrina, Brazil) was mixed as per the
manufacturer’s instructions and introduced into the canal and
compacted using Schilder’s pluggers (DENTSPLY Caulk, Milford, DE)
Figure 2: Triple antibiotic paste placed as an intra canal dressing against the PRF membrane. Digital radiograph was used to confirm
in 21. adequate placement of MTA to form an apical stop approximately

Volume 2 - Issue - 1
How to cite this article: Meeti C, Hind Pal B, Shveta S, Naresh S, Akshara S. Successful Alliance of MTA and PRF for Treating Young Permanent Tooth: A 103
Case Report. Mod Res Dent. 2(1). MRD.000527.2018. DOI: 10.31031/MRD.2018.02.000528
 Mod Res Dent Copyright © Akshara Singh

3-4mm thick. Moist cotton pellet was placed in the chamber and Discussion
the access cavity was sealed with Intermediate Restorative Material
The American Association of Endodontists defines apexification
(IRM) (Caulk/DENTSPLY, Milford, DE).
as a method to induce a calcified barrier in a root with an open apex
Obturation and restoration or the continued apical development of an incomplete root in teeth
with necrotic pulp [7]. Calcium hydroxide has been the material
After the patient remained asymptomatic for twenty four hours
of choice for apexification and few studies have shown a 100%
the tooth was isolated and accessed as before. A hand plugger was
success rate with it but previous literature also states that Calcium
lightly tapped against the MTA plug to confirm a hardened set.
Hydroxide can cause radicular dentin fracture when in contact with
The canal was obturated with thermoplasticized gutta percha-
it for a long time [8]. Also the mean time required for the barrier
Obtura III (Obtura Spartan Endodontics, Algonquin, USA) and AH
formation is approximately 12-19 months [9]. Such long term
Plus sealer (Dentsply DeTrey, Konztanz, Germany). The tooth was
treatment with multiple appointments reduces the compliance
restored with resin composite (Figure 4). After one month recall
of the patients. Due to the above reasons the newer concept of
the radiograph showed reappearance of normal trabaculae pattern
single sitting apexification is now preferred. Triple antibiotic paste
in the periapical region of 21. Considering the age of the child a
can be used as a dressing before the placement of MTA as the
temporary crown, Polycarbonate crown (3M, ESPE) was given in 21
combination of Ciprofloxacin, Metronidazole and Minocycline is an
(Figure 5).
effective for intra radicular disinfection. MTA has shown successful
clinical and radiographic outcomes [10]. It also has shown good
healing characteristics, like lack of inflammation, no ankylosis,
cellular cementum formation (over growth), and PDL regeneration
between the cementum and alveolar bone [11]. It takes an average
of 3 to 4 hours for MTA to form a solid barrier thus allowing single
sitting procedure. However; its complete setting may take up to
21 days [12]. The manipulation of MTA is difficult due to which its
placement in the wide apical area is difficult to achieve [13]. A matrix
can be used as a scaffold and a barrier for apexification procedures
against which MTA can be placed and condensed. Calicum sulfate,
hydroxyapatite, resorbable collagen, and platelet-rich fibrin are few
materials that be used as a matrix for apexification [14]. PRF was
chosen as an internal matrix because it is of an autogenous source
Figure 4: Internal matrix of PRF, 3-4mm thick MTA and and would have a favourable host tissue response. PRF produces
thermoplasticized gutta percha placed in 21. leukocyte and platelets cytokine (PDGF, TGF and IGF-1) which are
released as the matrix resorbs. These growth factors stimulate
collagen production, induces anti-inflammatory reaction, recruits
cells to the site of healing, increases vascular proliferation which
in turn accelerates wound healing [15]. Thus in apexification
procedure PRF can be used to promote wound healing and act as a
barrier for the sealing material at the apical end. The combination
of PRF and MTA is a revolutionary concept that should be preferred
over the conventional apexification techniques for treating
periapical lesions especially in children as it requires lesser clinical
visits and accelerates wound healing. This also aids in developing a
positive dental attitude in young children.

References
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How to cite this article: Meeti C, Hind Pal B, Shveta S, Naresh S, Akshara S. Successful Alliance of MTA and PRF for Treating Young Permanent Tooth: A 104
Case Report. Mod Res Dent. 2(1). MRD.000527.2018. DOI: 10.31031/MRD.2018.02.000528
 Mod Res Dent Copyright © Akshara Singh

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Volume 2 - Issue - 1
How to cite this article: Meeti C, Hind Pal B, Shveta S, Naresh S, Akshara S. Successful Alliance of MTA and PRF for Treating Young Permanent Tooth: A 105
Case Report. Mod Res Dent. 2(1). MRD.000527.2018. DOI: 10.31031/MRD.2018.02.000528