Dr. Jaspreet Kaur, Dr. Shalu Chandna, Dr. Kimpreet Kaur, Dr. Sanjeev Kumar Salaria

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1 Case Report Choukroun's Platelet-rich Fibrin As The Sole Grafting Material In Grade II Furcation Defect: A Case Report Dr. Jaspreet Kaur, Dr. Shalu Chandna, Dr. Kimpreet Kaur, Dr. Sanjeev Kumar Salaria Kaur J, Chandna S, Kaur K, Salaria SK. Choukroun's Platelet-Rich Fibrin As The Sole Grafting Material In Grade II Furcation Defect: A Case Report. J Periodontal Med Clin Pract 2015;02:91-97 Affiliation 1. PG student, Department of Periodontology and Oral Implantology, MMCDSR, Mullana, Ambala, India. 2. Professor, Department of Periodontology and Oral Implantology, MMCDSR, Mullana, Ambala, India 3. PG student, Department of Periodontology and Oral Implantology, MMCDSR, Mullana,Ambala, India 4. Head of the department & Professor, Surendra Dental College and Research Institute Sri Ganganagar, India. Corresponding Author: Jaspreet Kaur Address: Near S.P.S School Sangrur, Patiala-dhuri byepass road, Sangrur, India address: dr.jaspreetdhimaan@gmail.com Conflict of Interest declared- Nil ABSTRACT Treatment of furcation defects becomes complicated due to its anatomy and difficulty in instrumentation. Several treatment modalities such as furcation plasty, guided tissue regeneration, bone grafts and growth factor shave been proposed based on the grade of furcation involvement. Recently, importance has been given to the use of Platelet Rich Fibrin (PRF) for predictably obtaining periodontal regeneration. PRF belongs to a new generation of platelet concentrates, with simplified processing and without biochemical blood handling. All of the known clinical applications of PRF highlight an tissue remodeling and nearly total absence of infectious events. The purpose of this case report is to present clinical and radiographic results in relation to soft and hard tissue healing with the use of the PRF as a sole grafting material in grade II furcation defects. Key words: furcation defect, platelet rich fibrin, growth factors Introduction Furcation areas present one of the greatest challenge to success of periodontal regeneration due to its plaque retentive nature, anatomical factors and [1] accelerated tissue cicatrisation due to the difficulty in instrumentation. Reports in the development of effective neovascularization, accelerated wound closing with fast cicatricial 91 literature show that, when compared to other teeth, molars are more vulnerable to attachment loss and

2 [2,3] [13,14] are more prone to extraction. Methods for the as an autologous leukocyte and PRF biomaterial. treatment of furcation involved molars have shown varying degrees of success. Grade I early furcation involvements are generally treated well with effective plaque control, scaling and root planing procedures. Surgical management of Grade II and III furcations includes furcation plasty, guided tissue regeneration (GTR), tunnel preparation, root resection and often tooth extraction. The biological principle of GTR using resorbable barriers and bone replacement grafts have been successfully used for the periodontal regeneration of Grade II furcation [4] involvements. In recent times, biologic modifiers, including enamel [5] matrix derivative (EMD), platelet derived growth PRF consists of an intimate assembly of cytokines, glycanic chains, and structural glycoproteins enmeshed within a slowly polymerized fibrin network. The biologic activity of the 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 favourable physiologic architecture to support the healing process. Hence, the purpose of the present case report was to assess the regenerative capacity of autologous PRF, clinically and radiographically in a patient with Grade-II furcation defect. [6] factor (PDGF), bone morphogenetic protein CASE DESCRIPTION [7] [8] (BMP), platelet-rich plasma (PRP), platelet-rich A 45-year-old male patient reported to the [9] fibrin (PRF) have all shown promising results in department of Periodontology and Oral enhancing regeneration. These agents act by augmenting the wound healing process through anabolic bone formation, angiogenesis, cementogenesis, osteoblast differentiation, mitosis, chemotaxis, and other processes that improve the healing environment. The use of polypeptide growth factors (PGFs) to regenerate the periodontium and to accelerate the healing has recently attracted the attention of researchers. Vast studies and research has been carried out on transforming growth factor-á (TGFá) and platelet derived growth factor (PDGF), among Implantology, with a chief complaint of bleeding gums and sensitivity in the right lower back tooth region since 7-8 months. On examination, there was generalized bleeding on probing but no swelling or exudation, and varying degree of probing depths. The patient was diagnosed with chronic periodontitis along with furcation involvement. The probing pocket depth (PPD) on the mid-buccal aspect of the tooth #46 (right first molar) was 6 mm and relative attachment level (RAL) was11 mm(fig1)a Grade II furcation involvement on the buccal side of #46 with a horizontal probing depth of 8 mm was detected [10] all the PGFs. A simplest method to obtain using 2QN Naber'sprobe (Hu-Friedy) (Fig 2).The autologous TGFá and PDGF is the use of PRF that can be easily prepared from patient's own blood by [11] centrifugation. Choukroun's platelet-rich fibrin (PRF),which is a tooth was vital. For radiographically assessment, periapical radiographs and 3D Computed Tomographic Dentascan were obtained which revealed the [12] second-generation platelet concentrate, is defined presence of radiolucency in the furcation area #46 [15] 92

3 tooth(fig 3). Clinical and radiographic evaluation plastic tube without an anticoagulant and revealed Grade-II furcation defect. immediately centrifuged at rpm for 12 A full mouth supra and sub gingival scaling and root planing was performed. After assessment of the pre- treatment records and satisfactory response to Phase I therapy, the patient was subjected to surgical procedure under aseptic conditions. The patient was comfortably seated on a dental chair and extra oral surface of the patient was swabbed with 5% povidone iodine solution, and asked to rinse the mouth with 10 ml of 0.2% chlorhexidine digluconate solution. The operative site was anaesthetized with min. A fibrin clot formed in the middle part of the tube, whereas the upper part contained acellular plasma, and the bottom part contained red corpuscles (Fig5). The fibrin clot was easily separated from the lower part of the centrifuged blood. The PRF clot was gently pressed with sterile dry gauze. The PRF was placed using a condenser instrument in furcation defect upto the roof of the furcation defect (Fig6). The flap was sutured securely to its original position using 3-0 direct sutures. The patient was 2% xylocaine HCL with adrenaline (1:80000).Under provided with postoperative and home care inferior alveolar nerve block anesthesia, sulcular incisions were made using Bard Parker knife with blade no. 12 and a mucoperiosteal flap was reflected using periosteal elevator on teeth #47 to #45 to expose the furcation defects and gain access to the underlying attachment apparatus (Fig4). The area was properly debrided, scaled and root planed using sonic, and hand instrumentation and the flap trimmed to remove the granulation tissue tags and minimise bleeding. The area was irrigated using normal saline.. Preparation of PRF follows the protocol developed instructions and a prescription for rinse with Chlorhexidine gluconate 0.12% (twice a day) for a period of 3 to 4weeks, antibiotics (500 mg Novamox-LB, 8 hourly for 5 days) and analgesics (500 mg, paracetamol 6 hourly for 3 days). Sutures were removed 1 week after the surgery. Healing was uneventful. Postoperatively at 6 months follow up there was reduction in probing pocket depth from 6mm to 2mm and gain in attachment level of 3mm (Fig 7). There was substantial defect fill in the furcation area with residual horizontal depth of 3 mm (Fig 8). After 6 months there was [16] 3 [3] by Choukroun et al. Blood sample was taken from volumetric reduction from 6.8mm to 4.6mm at the antecubital vein of the patient in 5-ml glass coated defect site (Fig 9). Fig 1: Preoperative midbuccal relative attachment level# 46 Fig 2:Preoperative Grade II furcation defect #46 93

4 Fig 3: Preoperative Dentascan #46 showing interradicular lesion Fig 4: Nabers probe in the furcation defect after flap reflection Fig 5: Preparation of platelet rich fibrin Fig 6: Platelet rich fibrin (PRF) placed in furcation defect 94

5 DISCUSSION PRF consists of a fibrin matrix polymerized in a Fig 9:- Post-operative Dentascan after 6 months periosteal cells and induces the proliferation of various cells in vitro, with the strongest induction [18] tetra-molecular structure with platelets, leukocytes, effect on osteoblasts. Thus in the present case, cytokines, growth factors and circulating stem PRF afforded a great improvement in soft and hard [17] cells. Dohan et al reported the presence of IL 1â, tissue with reduction in horizontal probing depth IL 6, TNF- á, IL-4, VEGF in a PRF clot which play a crucial role in the delicate balance of tissue homeostasis. The healing cytokines like IL-4 &VEGF inhibit inflammatory signal pathways and from 6mm to 2mm.The findings in the presented case were in accordance with those of previous [9] studies done by Sharma et al. in the treatment of mandibular Grade II furcation and those of Aroca et 14 [19] support and coordinate neovascularisation. This al. in the treatment of multiple adjacent gingival explains the uneventful healing seen in this case report. PRF act as a suitable scaffold for breeding human recession. Conventional radiographs are a 2-dimensional mapping of 3-dimensional periodontal structures 95

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7 which underestimate the defect fill and the deepest Periodontol 1988;15: portion of the defect fill may be obscured by facial and lingual bony cortices. To overcome the 2. Chace R Sr, Low SB. Survival characteristics of periodontally involved teeth: A 40 year difficulties, in the present case radiographic study. J Periodontol 1993; 64: parameters were taken using multi slice spiral computed tomography equipped with a 3-3. Ramford SP, Knowles JW, Morrison EC. Results of periodontal therapy related to dimensional image reconstruction software tooth type. J Periodontol 1980; 51: [20] package, Dentascan. Future-prospective is that being an effective and regenerative and viable cost effective material, the use of PRF can be further explored as a sole filling 4. Bowers GM, Schallhorn RG, McClain PK, Morrison GM. Factors influencing the outcome of regenerative therapy in mandibular class 11 furcations: Part I. J material and its incorporation into various Periodontol 2003;74: membranous scaffolds and bone grafts. Histologic studies can be carried out to maximize the growth factor delivery while using PRF. CONCLUSION PRF as a natural and optimized blood clot has been shown to be effective modality to stabilize a high 5.Giannobile WV, Somerman MJ. Growth and amelogenin-like factors in periodontal wound healing. A systematic review. Ann Periodontol 2003;8: Nevins M, Giannobile WV, McGuire MK, et al. Platelet-derivedgrowth factor stimulates bone fill and rate of attachment level gain: Results of a large multicenter randomized volume of natural bone and as a sole filling material controlled trial. J Periodontol 2005;76:2205- in furcation defect References 7. Jung RE, Glauser R, Scharer P, Hammerle CH, Sailer HF, WeberFE. Effect of rhbmp-2 1. Martin M, Gantes B, Garrett S, Egelberg J. on guided bone regeneration in humans. Clin Treatment of periodontal furcation defects. Oral Implants Res 2003;14: (I) Review of the literature and description of a regenerative surgical technique. J Clin 8. Bajaj P, Pradeep AR, Agarwal E, Rao NS, Naik SB, Priyanka N, Kalra N.Comparative Competing interest / Conflict of interest The author(s) have no competing interests for financial support, publication of this research, patents and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript. Source of support: NIL Copyright 2014 JPMCP. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 97