Application of advanced platelet-rich fibrin for through-and-through bony defect during endodontic surgery: Three case reports and review of the literature

Table 1 Brief description of the three mentioned cases

Tooth No.	Endodontic diagnosis	Coronal coverage	Periapical index using CBCT 47 (before surgery)	Periapical index using CBCT 47 (four months recall)
#15	Previously treated, symptomatic apical periodontitis	Fiber post and composite core build-up	5 + D: Cortical bone destruction	0: Intact periapical bone structure
#25	Previously treated, symptomatic apical periodontitis	PFM crown	4 + E: Cortical bone expansion	0: Intact periapical bone structure
#12	Previously treated, asymptomatic apical periodontitis	Metallic post and ceramic crown	5 + D: Cortical bone destruction	0: Intact periapical bone structure

The table shows a brief description of the three mentioned cases that include: The endodontic diagnosis, the coronal coverage, and the periapical index before the surgery and in 4 mo recall after the surgery. CBCT: Computed tomography; PFM: Porcelain fused to metal.

Table 2 Endodontic microsurgical protocol

Treatment phase	Steps performed
Before the surgery	The tooth is examined clinically and radiographically to assess the source of the pain and to diagnose the diseased tooth. Following the decision to perform surgical periapical treatment a CBCT scan was performed under the following standardized setting for a small field of view (90 kV, 6 mA, 5.0 cm × 5.5 cm, 160 μm, and 14 s). Using Planmeca device (ProMax 3D Mid, Helsinki, Finland)
	The treatment risks and benefits, and prognosis were discussed with the patient. The patient was asked to sign the surgical endodontic treatment consent form
	A clinical photograph of the surgical area is taken for surgical planning
	The CBCT scan is analyzed for the following details and measurements: (1) The quality of root canal obturation and the canal location; (2) the size of the lesion and its proximity to adjacent vital structures such as the maxillary sinus, nerves, and blood vessels; (3) the length of the dental root and the area of resection; (4) the thickness of the buccal plate; and (5) the condition of the dental supporting structure
	Surgical planning involved: The type and amount of local anesthesia, the design of the flap, the location and depth of osteotomy, the angle and length of root resection, the retro-filling material, the need for guided tissue regeneration, and the sutures type and technique
During the surgery	Based on the medical history and patient weight, the patient received local anesthesia to achieve analgesia and vasoconstriction
	The use of a microsurgical blade for the intrasulcular/submarginal incision and a 15c blade for the vertical incision. The vertical incision line is made over the healthy bone to include or exclude the papilla and frenum
	The use of a mucoperiosteal elevator to detach the dental flap from the underlying cortical bone while using a technique that minimizes trauma to the reflected flap
	The use of rear venting contra-angle handpiece and round bur to prepare the osteotomy while using a copious amount of water to prevent bone necrosis and trauma
	The use of the dental operating microscope and methylene blue to differentiate between the root and dental supporting structures and to detect any cracks
	The use of a long shank straight diamond or carbide bur to resect the apical 3 mm root tip in a perpendicular direction to the long access of the tooth
	The use of the back of a dental surgical curette to scrap and detach the lesion from the bone as a whole or in pieces
	The detached lesion is placed inside a 10% buffered formalin container to be sent for histological examination
	The area is filled with a hemostatic agent; cotton pellets filled with a high concentration of epinephrine or ferric sulphate. The hemostatic agent is properly removed before the end of the surgery
	The retro space is prepared using retrograde piezo ultrasonic tips to prepare a 3 mm retro space inside the canal
	The retro space is filled with a bioceramic material using a material carrier and a micro-plugger
	A dental radiograph of the surgical site is taken to determine the quality of root resection and retro filling
	The PRF membrane is prepared by withdrawing 10 mL of the patient blood within 15 s and placing the blood inside the A-PRF tube. The tube is inserted into the PRF centrifuge (PRF DUO Quatro Centrifuge, Biomedent, New South Wales, and Australia) in the setting recommended for A-PRF (1300 RPM for 14 min). After the centrifugation, the tube is placed in the tube holder for ten minutes. Then A-PRF clot is removed from the tube and placed inside the PRF box to be compressed by the tray for one minute to take the shape of a membrane. The membrane is then used to cover the osteotomy before suturing the flap. In the few cases where a bone graft is needed to support the membrane, Bio-gen cancellous granules xenograft (Biotech company, Italy) is used and mixed with the collected concentrated A-PRF blood clot. Subsequently, the xenograft is placed inside the osteotomy before covering the osteotomy with the membrane
	The flap is positioned back into its original position and is hydrated using sterile wet gauze. A non-resorbable monofilament suture is used to secure the flap into the original place using a reverse cutting needle that is 4-0 to 5-0 in diameter
	The sutured flap is gently compressed for few minutes using sterile wet gauze to reduce the bleeding and swelling
After the surgery	The patient is instructed to use an ice pack in the first eight hours for twenty minutes on and twenty minutes off. Then the patient is asked to apply wet warm towel intermittently for the next three days
	The patient is asked to minimize talking, avoid drinking hot drinks and food, and limit exercising in the first week. The dental cleaning has to be gentle and limited to the coronal area
	Analgesics are prescribed to manage pain in the first week after the surgery
	The patient is scheduled to be seen after one week for suture removal and to examine the surgical site. The patient first recall is four months after the surgery and annually

CBCT: Computed tomography; A-PRF: Advanced platelet-rich fibrin.