Second-generation Platelet Concentrate (Platelet-rich Fibrin) as a Scaffold in Regenerative Endodontics: A Case Series

Published:January 25, 2017DOI:



      The purpose of this case series was to report the clinical and radiographic results of a pulp regenerative procedure using platelet-rich fibrin (PRF), a second-generation platelet concentrate, in immature teeth with necrotic pulps.


      Root canal revascularization using PRF was performed on 4 immature teeth with necrotic pulps. After access cavity preparation, the root canals were irrigated with low concentration sodium hypochlorite solution (1.5% sodium hypochlorite [20 mL/canal, 5 minutes]) and then irrigated with saline (20 mL/canal, 5 minutes). Equal proportions (167 mg) of ciprofloxacin, metronidazole, and cefaclor were mixed and diluted to a final concentration of 1 g/mL. Finally, the canal was sealed with 3–4 mm of a temporary restorative material, and patients were dismissed for 2 to 3 weeks. At the second appointment, 9 mL of the patient's whole blood was obtained and centrifuged to prepare a PRF clot. Canals were irrigated with 17% EDTA, and a sharp spreader was inserted beyond the apex. Then, the PRF clot was placed inside the root canals, and Biodentine (Septodont, Saint-Maur, France) was placed directly over the PRF. The teeth were restored permanently with glass ionomer cement and composite resin.


      Clinical examinations revealed that all cases were asymptomatic at the recall appointments at 1, 3, 6, 12, and 18 months. Radiographs revealed resolution of the periapical lesions, further root development, and apical closure in all cases.


      On the basis of the short-term results up to 12 months, PRF clots acted as successful scaffolds for the regeneration of pulpal contents in immature teeth with necrotic pulps.

      Key Words

      To read this article in full you will need to make a payment


      Subscribe to Journal of Endodontics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bakhtiar H.
        • Vatanpour M.
        • Rayani A.
        • et al.
        The plasma-rich in growth factor as a suitable matrix in regenerative endodontics: a case series.
        N Y State Dent J. 2014; 80: 49-53
        • Keswani D.
        • Pandey R.K.
        Revascularization of an immature tooth with a necrotic pulp using platelet-rich fibrin: a case report.
        Int Endod J. 2013; 46: 1096-1104
        • Yassen G.H.
        • Platt J.A.
        The effect of nonsetting calcium hydroxide on root fracture and mechanical properties of radicular dentine: a systematic review.
        Int Endod J. 2013; 46: 112-118
        • Yassen G.H.
        • Eckert G.J.
        • Platt J.A.
        Effect of intracanal medicaments used in endodontic regeneration procedures on microhardness and chemical structure of dentin.
        Restor Dent Endod. 2015; 40: 104-112
        • Yassen G.H.
        • Sabrah A.H.
        • Eckert G.J.
        • Platt J.A.
        Effect of different endodontic regeneration protocols on wettability, roughness, and chemical composition of surface dentin.
        J Endod. 2015; 41: 956-960
        • Nosrat A.
        • Seifi A.
        • Asgary S.
        Regenerative endodontic treatment (revascularization) for necrotic immature permanent molars: a review and report of two cases with a new biomaterial.
        J Endod. 2011; 37: 562-567
        • Nosrat A.
        • Ryul Kim J.
        • Verma P.
        • S Chand P.
        Tissue engineering considerations in dental pulp regeneration.
        Iran Endod J. 2014; 9: 30-39
        • Law A.S.
        Considerations for regeneration procedures.
        Pediatr Dent. 2013; 35: 141-152
        • Banchs F.
        • Trope M.
        Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol?.
        J Endod. 2004; 30: 196-200
        • Bezgin T.
        • Yilmaz A.D.
        • Celik B.N.
        • Sonmez H.
        Concentrated platelet-rich plasma used in root canal revascularization: 2 case reports.
        Int Endod J. 2014; 47: 41-49
        • Jadhav G.R.
        • Shah N.
        • Logani A.
        Platelet-rich plasma supplemented revascularization of an immature tooth associated with a periapical lesion in a 40-year-old man.
        Case Rep Dent. 2014; 2014: 479584
        • Yeom K.H.
        • Ariyoshi W.
        • Okinaga T.
        • et al.
        Platelet-rich plasma enhances the differentiation of dental pulp progenitor cells into odontoblasts.
        Int Endod J. 2016; 49: 271-278
        • He L.
        • Lin Y.
        • Hu X.
        • et al.
        A comparative study of platelet-rich fibrin (PRF) and platelet-rich plasma (PRP) on the effect of proliferation and differentiation of rat osteoblasts in vitro.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 108: 707-713
        • Choukroun J.
        • Adda F.
        • Schoeffler C.
        • Vervelle A.
        Une opportunite en paroimplantologie: le PRF.
        Implantodontie. 2001; 42 (e62): 55-62
      1. American Association of Endodontists. AAE Clinical Considerations for a Regenerative Procedure. Available at: Accessed December 6th 2016.

        • Shen J.
        • James A.W.
        • Zhang X.
        • et al.
        Novel Wnt regulator NEL-like molecule-1 antagonizes adipogenesis and augments osteogenesis induced by bone morphogenetic protein 2.
        Am J Pathol. 2016; 186: 419-434
      2. European Society of Endodontology position statement: revitalisation procedures.
        Int Endod J. 2016; 49: 717-723
        • Trevino E.G.
        • Patwardhan A.N.
        • Henry M.A.
        • et al.
        Effect of irrigants on the survival of human stem cells of the apical papilla in a platelet-rich plasma scaffold in human root tips.
        J Endod. 2011; 37: 1109-1115
        • Fouad A.F.
        • Verma P.
        Healing after regenerative procedures with and without pulpal infection.
        J Endod. 2014; 40: S58-S64
        • Thibodeau B.
        • Trope M.
        Pulp revascularization of a necrotic infected immature permanent tooth: case report and review of the literature.
        Pediatr Dent. 2007; 29: 47-50
        • Alkahtani A.
        • Alkahtany S.M.
        • Anil S.
        An in vitro evaluation of the cytotoxicity of varying concentrations of sodium hypochlorite on human mesenchymal stem cells.
        J Contemp Dent Pract. 2014; 15: 473-481
        • Yi T.
        • Jun C.M.
        • Kim S.J.
        • Yun J.H.
        Evaluation of in vivo osteogenic potential of bone morphogenetic protein 2-overexpressing human periodontal ligament stem cells combined with biphasic calcium phosphate block scaffolds in a critical-size bone defect model.
        Tissue Eng Part A. 2016; 22: 501-512
        • Diogenes A.
        • Henry M.A.
        • Teixeira F.B.
        • Hargreaves K.M.
        An update on clinical regenerative endodontics.
        Endod Topics. 2013; 28: 2-23
        • Yassen G.H.
        • Vail M.M.
        • Chu T.G.
        • Platt J.A.
        The effect of medicaments used in endodontic regeneration on root fracture and microhardness of radicular dentine.
        Int Endod J. 2013; 46: 688-695
        • Ruparel N.B.
        • Teixeira F.
        • Ferraz C.C.
        • et al.
        Direct effect of intracanal medicaments on survival of stem cells of the apical papilla.
        J Endod. 2012; 38: 1372-1375
        • Netea M.G.
        • Van der Graaf C.
        • Van der Meer J.W.
        • Kullberg B.J.
        Recognition of fungal pathogens by Toll-like receptors.
        Eur J Clin Microbiol Infect Dis. 2004; 23: 672-676
        • Sabrah A.H.
        • Yassen G.H.
        • Spolnik K.J.
        • et al.
        Evaluation of residual antibacterial effect of human radicular dentin treated with triple and double antibiotic pastes.
        J Endod. 2015; 41: 1081-1084
        • Torabinejad M.
        • Milan M.
        • Shabahang S.
        • et al.
        Histologic examination of teeth with necrotic pulps and periapical lesions treated with 2 scaffolds: an animal investigation.
        J Endod. 2015; 41: 846-852
        • Thibodeau B.
        • Teixeira F.
        • Yamauchi M.
        • et al.
        Pulp revascularization of immature dog teeth with apical periodontitis.
        J Endod. 2007; 33: 680-689
        • Lovelace T.W.
        • Henry M.A.
        • Hargreaves K.M.
        • Diogenes A.
        Evaluation of the delivery of mesenchymal stem cells into the root canal space of necrotic immature teeth after clinical regenerative endodontic procedure.
        J Endod. 2011; 37: 133-138
        • Shivashankar V.Y.
        • Johns D.A.
        • Vidyanath S.
        • Kumar M.R.
        Platelet rich fibrin in the revitalization of tooth with necrotic pulp and open apex.
        J Conserv Dent. 2012; 15: 395-398
        • Hargreaves K.M.
        • Giesler T.
        • Henry M.
        • Wang Y.
        Regeneration potential of the young permanent tooth: what does the future hold?.
        J Endod. 2008; 34: S51-S56
        • Yang Y.
        • Ge Y.
        • Chen G.
        • et al.
        Hertwig's epithelial root sheath cells regulate osteogenic differentiation of dental follicle cells through the Wnt pathway.
        Bone. 2014; 63: 158-165
        • Andreasen J.O.
        • Kristerson L.
        • Andreasen F.M.
        Damage of the Hertwig's epithelial root sheath: effect upon root growth after autotransplantation of teeth in monkeys.
        Endod Dent Traumatol. 1988; 4: 145-151
        • Nevins A.
        • Crespi P.
        A clinical study using the collagen gel Zyplast in endodontic treatment.
        J Endod. 1998; 24: 610-613
        • Preeja C.
        • Arun S.
        Platelet-rich fibrin: its role in periodontal regeneration.
        Saudi J Dent Res. 2014; 5: 117-122
        • Alsousou J.
        • Ali A.
        • Willett K.
        • Harrison P.
        The role of platelet-rich plasma in tissue regeneration.
        Platelets. 2013; 24: 173-182
        • Del Corso M.
        • Mazor Z.
        • Rutkowski J.L.
        • Dohan Ehrenfest D.M.
        The use of leukocyte- and platelet-rich fibrin during immediate postextractive implantation and loading for the esthetic replacement of a fractured maxillary central incisor.
        J Oral Implantol. 2012; 38: 181-187
        • Nagaveni N.B.
        • Kumari K.N.
        • Poornima P.
        • Reddy V.
        Management of an endo-perio lesion in an immature tooth using autologous platelet-rich fibrin: a case report.
        J Indian Soc Pedod Prev Dent. 2015; 33: 69-73
        • Lolato A.
        • Bucchi C.
        • Taschieri S.
        • et al.
        Platelet concentrates for revitalization of immature necrotic teeth: a systematic review of the clinical studies.
        Platelets. 2016; 27: 383-392
        • Borie E.
        • Olivi D.G.
        • Orsi I.A.
        • et al.
        Platelet-rich fibrin application in dentistry: a literature review.
        Int J Clin Exp Med. 2015; 8: 7922-7929
        • Ji B.
        • Sheng L.
        • Chen G.
        • et al.
        The combination use of platelet-rich fibrin and treated dentin matrix for tooth root regeneration by cell homing.
        Tissue Eng Part A. 2015; 21: 26-34
        • Chang Y.C.
        • Zhao J.H.
        Effects of platelet-rich fibrin on human periodontal ligament fibroblasts and application for periodontal infrabony defects.
        Aust Dent J. 2011; 56: 365-371
        • Woo S.M.
        • Kim W.J.
        • Lim H.S.
        • et al.
        Combination of mineral trioxide aggregate and platelet-rich fibrin promotes the odontoblastic differentiation and mineralization of human dental pulp cells via BMP/Smad signaling pathway.
        J Endod. 2016; 42: 82-88
        • Sunitha Raja V.
        • Munirathnam Naidu E.
        Platelet-rich fibrin: evolution of a second-generation platelet concentrate.
        Indian J Dent Res. 2008; 19: 42-46
        • Hiremath H.
        • Saikalyan S.
        • Kulkarni S.S.
        • Hiremath V.
        Second-generation platelet concentrate (PRF) as a pulpotomy medicament in a permanent molar with pulpitis: a case report.
        Int Endod J. 2012; 45: 105-112
        • Mishra N.
        • Narang I.
        • Mittal N.
        Platelet-rich fibrin-mediated revitalization of immature necrotic tooth.
        Contemp Clin Dent. 2013; 4: 412-415
        • Keswani D.
        • Pandey R.K.
        • Ansari A.
        • Gupta S.
        Comparative evaluation of platelet-rich fibrin and mineral trioxide aggregate as pulpotomy agents in permanent teeth with incomplete root development: a randomized controlled trial.
        J Endod. 2014; 40: 599-605
        • Smith A.J.
        • Murray P.E.
        • Sloan A.J.
        • et al.
        Trans-dentinal stimulation of tertiary dentinogenesis.
        Adv Dent Res. 2001; 15: 51-54
        • Toffler M.
        • Holtzclaw D.
        • Toscano N.
        • et al.
        Introducing Choukroun's platelet rich fibrin (PRF) to the reconstructive surgery milieu.
        J Implant Adv Clin Dent. 2009; 1: 21-31
        • Malkondu O.
        • Karapinar Kazandag M.
        • Kazazoglu E.
        A review on biodentine, a contemporary dentine replacement and repair material.
        Biomed Res Int. 2014; 2014: 160951
        • Zanini M.
        • Sautier J.M.
        • Berdal A.
        • Simon S.
        Biodentine induces immortalized murine pulp cell differentiation into odontoblast-like cells and stimulates biomineralization.
        J Endod. 2012; 38: 1220-1226
        • Rathinam E.
        • Rajasekharan S.
        • Chitturi R.T.
        • et al.
        Gene expression profiling and molecular signaling of dental pulp cells in response to tricalcium silicate cements: a systematic review.
        J Endod. 2015; 41: 1805-1817
        • Shokouhinejad N.
        • Nekoofar M.H.
        • Pirmoazen S.
        • et al.
        Evaluation and comparison of occurrence of tooth discoloration after the application of various calcium silicate-based cements: an ex vivo study.
        J Endod. 2016; 42: 140-144
        • Kohli M.R.
        • Yamaguchi M.
        • Setzer F.C.
        • Karabucak B.
        Spectrophotometric analysis of coronal tooth discoloration induced by various bioceramic cements and other endodontic materials.
        J Endod. 2015; 41: 1862-1866
        • Bose R.
        • Nummikoski P.
        • Hargreaves K.
        A retrospective evaluation of radiographic outcomes in immature teeth with necrotic root canal systems treated with regenerative endodontic procedures.
        J Endod. 2009; 35: 1343-1349
        • Diogenes A.
        • Ruparel N.B.
        • Shiloah Y.
        • Hargreaves K.M.
        Regenerative endodontics: a way forward.
        J Am Dent Assoc. 2016; 147: 372-380