Endodontic regeneration with A-PRF and I-PRF in a permanent tooth with immature apex: a clinical case report
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Published:
Nov 13, 2025
Keywords:
Dental pulp necrosis; Endodontics; Platelet-rich fibrin; Regeneration; Tissue engineering; Wound healing
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Abstract
Introduction: Dentoalveolar trauma (DAT), with reported incidence rates ranging from 6% to 59% (1), is one of the most frequent reasons for consultation today and is the cause of multiple injuries affecting different structures, including dental and pulpal involvement. One such case involves an immature apex, where the root portion never achieves closure, leading to pulpal pathologies. Objective: To evaluate the effectiveness of the combined use of A-PRF and I-PRF in the regeneration of a permanent tooth with an immature apex resulting from dentoalveolar trauma. Methodology: A clinical case with a diagnosis of pulpal necrosis accompanied by a chronic apical abscess and the presence of an open apex is presented. Regenerative endodontic therapy is performed using platelet concentrates A-PRF and I-PRF. Results: The combined use of platelet concentrates enhances the regenerative process of teeth with an immature apex. Radiographic and tomographic follow-ups showed considerable progress in bone formation and lesion repair, in addition to obtaining signs of pulpal revitalization. Conclusions: Regenerative endodontics with the use of platelet concentrates as a therapy represents one of the most promising innovations in the treatment of immature teeth with pulpal necrosis, as it aims to restore pulpal vitality, promote continuous root development, and achieve apical closure, appreciating scaffolding aspects (2), which offer an optimal microenvironment for the regeneration of pulpal tissue. General Area of Study: Odontology. Specific area of study: Endodontic. Type of study: Clinical case.
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González Guachizaca, G. V., Morocho Morocho, N. P., Lugo Pinto , M. A., & Rodriguez Reyes, F. G. (2025). Endodontic regeneration with A-PRF and I-PRF in a permanent tooth with immature apex: a clinical case report. Anatomía Digital, 8(4), 57-73. https://doi.org/10.33262/anatomiadigital.v8i4.3558
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Articulos de revisión bibliográfica
References
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11. Caruana A, Savina D, Macedo JP, Soares SC. From platelet-rich plasma to advanced platelet-rich fibrin: biological achievements and clinical advances in modern surgery. European Journal of Dentistry [Internet]. 2019 [cited 20 mayo 2025]; 13: 280–286. Available from: https://doi.org/10.1055/s-0039-1696585
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13. Farshidfar N, Amin Amiri M, Jafarpour D, Hamedani S, Niknezhad SV, Tayebi L. The feasibility of injectable PRF (I-PRF) for bone tissue engineering and its application in oral and maxillofacial reconstruction: from bench to chairside. Biomaterials Advances [Internet]. 2021 [cited 20 mayo 2025]; 134. Available from: https://doi.org/10.1016/j.msec.2021.112557
14. Duncan HF, El‐Karim IA, editors. Vital Pulp Treatment (first publication). John Wiley & Sons Ltd. [Internet]. Available from: https://onlinelibrary.wiley.com/doi/10.1002/9781119930419
15. Caldeira CL, Barletta FB, Ilha MC, Abrão CV, Gavini G. Pulse oximetry: a useful test for evaluating pulp vitality in traumatized teeth. Dental Traumatology [Internet]. 2016 [cited 20 mayo 2025]; 32(5):385–9. Available from: https://doi.org/10.1111/edt.12279
16. Grabliauskienė Ž, Zamaliauskienė R, Lodienė G. Pulp vitality testing with a developed universal pulse oximeter probe holder. Medicina [Internet]. 2021 [cited 20 mayo 2025]; 57(2): 101. Available from: https://doi.org/10.3390/medicina57020101
17. El-Kateb NM, Abdallah AM, ElBackly RN. Correlation between pulp sensibility and magnetic resonance signal intensity following regenerative endodontic procedures in mature necrotic teeth- a retrospective cohort study. BMC Oral Health [Internet]. 2024 [cited 20 mayo 2025]; 24(1):330. Available from:
https://doi.org/10.1186/s12903-024-04095-y
18. Sharma DS, Mishra S, Banda NR, Vaswani S. In vivo evaluation of customized pulse oximeter and sensitivity pulp tests for assessment of pulp vitality. Journal of Clinical Pediatric Dentistry [Internet]. 2019 [cited 20 mayo 2025]; 43(1):11–5. Available from: https://doi.org/10.17796/1053-4625-43.1.3
19. Zou X, Zheng X, Liang Y, Zhang C, Fan B, Liang J, et al. Expert consensus on irrigation and intracanal medication in root canal therapy. International Journal of Oral Science [Internet]. 2024 [cited 20 mayo 2025]; 16:23. Available from: https://doi.org/10.1038/s41368-024-00280-5
20. Usta SN, Erdem BA, Gündoğar M. Comparison of the removal of intracanal medicaments used in regenerative endodontics from root canal system using needle, ultrasonic, sonic, and laser-activated irrigation systems. Lasers in Medical Science [Internet]. 2024 [cited 20 mayo 2025]; 39(1):27. Available from: https://doi.org/10.1007/s10103-024-03980-w
21. Sunlakawit C, Chaimanakarn C, Srimaneekarn N, Osiri S. Effect of Calcium Hydroxide as an Intracanal Medication on Dentine Fracture Resistance: A Systematic Review and Network Meta-Analysis. Journal of Endodontics [Internet]. 2024 [cited 20 mayo 2025]; 50(12):1714-1724.e6. Available from: https://doi.org/10.1016/j.joen.2024.08.005
22. Yassen GH, Platt JA. The effect of nonsetting calcium hydroxide on root fracture and mechanical properties of radicular dentine: a systematic review. International Endodontic Journal [Internet]. 2013 [cited 20 mayo 2025]; 46(2):112–8. Available from: https://doi.org/10.1111/j.1365-2591.2012.02121.x
23. Andreasen JO, Farik B, Munksgaard EC. Long‐term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dental Traumatology [Internet]. 2002 [cited 20 mayo 2025]; 18(3):134–137. Available from: https://doi.org/10.1034/j.1600-9657.2002.00097.x
24. White JD, Lacefield WR, Chavers LS, Eleazer PD. The effect of three commonly used endodontic materials on the strength and hardness of root dentin. Journal of Endodontics [Internet]. 2002 [cited 20 mayo 2025]; 28(12):828–830. Available from: https://doi.org/10.1097/00004770-200212000-00008
25. Kawamoto R, Kurokawa H, Takubo C, Shimamura Y, Yoshida T, Miyazaki M. Change in elastic modulus of bovine dentine with exposure to a calcium hydroxide paste. Journal of Dentistry [Internet]. 2008 [cited 20 mayo 2025]; 36(11): 959-964. Available from: https://doi.org/10.1016/j.jdent.2008.08.003
26. Kahler B, Swain M V. The calcium hydroxide controversy: does calcium hydroxide weaken teeth? Dental Traumatology [Internet]. 2025 [cited 20 mayo 2025]; 41(S1):53–63. Available from: https://doi.org/10.1111/edt.13015
27. American Association of Endodontists [Internet]. AAE clinical considerations for a regenerative procedure. 2021 [cited 20 mayo 2025]; 1–8. Available from: https://www.aae.org/specialty/wp-content/uploads/sites/2/2018/06/ConsiderationsForRegEndo_AsOfApril2018.pdf
28. Venkatakrishnan HK, Kothari NR, Krishnappa S. Effectiveness of using platelet concentrate and blood clot in regenerative endodontic treatment: A systematic review and meta-analysis. Contemporary Pediatric Dentistry [Internet]. 2024 [cited 20 mayo 2025]; 5(1):1–14. Available from: http://doi.org/10.51463/cpd.2023.186
29. Fujioka-Kobayashi M, Schaller B, Mourão CFDAB, Zhang Y, Sculean A, Miron RJ. Biological characterization of an injectable platelet-rich fibrin mixture consisting of autologous albumin gel and liquid platelet-rich fibrin (Alb-PRF). Platelets [Internet]. 2021 [cited 20 mayo 2025]; 32(1): 74–81. Available from: https://doi.org/10.1080/09537104.2020.1717455
2. Gupta S, Sodhi SP, Brar G, Bansal R. Endodontic treatment of immature tooth – a challenge. Journal of Pre-Clinical and Clinical Research [Internet]. 2020 [cited 20 mayo 2025]; 14(3):73-79. Available from: https://doi.org/10.26444/jpccr/126280
3. Flanagan TA. What can cause the pulps of immature, permanent teeth with open apices to become necrotic and what treatment options are available for these teeth? Australian Endodontic Journal [Internet]. 2014 [cited 20 mayo 2025]; 40(3): 95–100. Available from: https://doi.org/10.1111/aej.12087
4. Luzón Caigua KL, Sánchez Robles BA, González Eras SP, Gahona Carrión DI. Apicoformación en dientes necróticos. RECIMUNDO [Internet]. 2020 [cited 20 mayo 2025]; 4(4):134–43. Available from: https://doi.org/10.26820/recimundo/4.(4).octubre.2020.134-143
5. Chang MC, Chao YC, Chen YC, Chang HW, Zhong BH, Pan YH, et al. Bone morphogenetic protein-4 induced matrix turnover and osteogenic differentiation-related molecules of stem cells from apical papilla and its associated ALK/Smad signaling. Journal of Dental Sciences [Internet]. 2024 [cited 20 mayo 2025]. Available from: https://doi.org/10.1016/j.jds.2024.11.002
6. Singh G, Kumari B, Grover HS, Mahajan A, Jabeen F, Kumar A. Application of platelet rich fibrin, platelet rich plasma, plasma rich growth factors in different fields of dentistry: an overview. Journal of Complementary and Alternative Medical Research [Internet]. 2020 [cited 20 mayo 2025];11(3):12–23. Available from: https://doi.org/10.9734/jocamr/2020/v11i330186
7. Bucchi C. Tratamiento del diente permanente necrótico. un cambio de paradigma en el campo de la endodoncia. International Journal of Odontostomatology [Internet]. 2020 [citado 2025 mayo 20]; 14(4): 670-677. Disponible en: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0718-381X2020000400670&lng=es. http://dx.doi.org/10.4067/S0718-381X2020000400670
8. Murray PE. Review of guidance for the selection of regenerative endodontics, apexogenesis, apexification, pulpotomy, and other endodontic treatments for immature permanent teeth. International Endodontic Journal [Internet]. 2023 [cited 20 mayo 2025]; 56(2): 188–199. Available from: https://doi.org/10.1111/iej.13809
9. Das S, Srivastava R, Thosar NR, Khubchandani M, Ragit R, Malviya N. Regenerative endodontics-reviving the pulp the natural way: a case report. Cureus [Internet]. 2023 [cited 20 mayo 2025]; 15(3). Available from: https://doi.org/10.7759/cureus.36587.
10. Prado Camargo K, Quispe Águila I. Endodoncia quirúrgica con aplicación de fibrina rica en plaquetas por fracaso de cirugía endodóntica previa. Revista Científica de Odontología UNITEPC [Internet]. 2022 [citado 15 mayo 2025];1(1):16-23. Disponible en: https://investigacion.unitepc.edu.bo/revista/index.php/revista-odontologia/article/view/38
11. Caruana A, Savina D, Macedo JP, Soares SC. From platelet-rich plasma to advanced platelet-rich fibrin: biological achievements and clinical advances in modern surgery. European Journal of Dentistry [Internet]. 2019 [cited 20 mayo 2025]; 13: 280–286. Available from: https://doi.org/10.1055/s-0039-1696585
12. Pereira VBS, Lago CAP, Almeida R de AC, Barbirato D da S, Vasconcelos BC do E. Biological and cellular properties of advanced platelet-rich fibrin (A-PRF) compared to other platelet concentrates: systematic review and meta-analysis. International Journal of Molecular Sciences [Internet]. 2024 [cited 20 mayo 2025]; 25. Available from: https://doi.org/10.3390/ijms25010482
13. Farshidfar N, Amin Amiri M, Jafarpour D, Hamedani S, Niknezhad SV, Tayebi L. The feasibility of injectable PRF (I-PRF) for bone tissue engineering and its application in oral and maxillofacial reconstruction: from bench to chairside. Biomaterials Advances [Internet]. 2021 [cited 20 mayo 2025]; 134. Available from: https://doi.org/10.1016/j.msec.2021.112557
14. Duncan HF, El‐Karim IA, editors. Vital Pulp Treatment (first publication). John Wiley & Sons Ltd. [Internet]. Available from: https://onlinelibrary.wiley.com/doi/10.1002/9781119930419
15. Caldeira CL, Barletta FB, Ilha MC, Abrão CV, Gavini G. Pulse oximetry: a useful test for evaluating pulp vitality in traumatized teeth. Dental Traumatology [Internet]. 2016 [cited 20 mayo 2025]; 32(5):385–9. Available from: https://doi.org/10.1111/edt.12279
16. Grabliauskienė Ž, Zamaliauskienė R, Lodienė G. Pulp vitality testing with a developed universal pulse oximeter probe holder. Medicina [Internet]. 2021 [cited 20 mayo 2025]; 57(2): 101. Available from: https://doi.org/10.3390/medicina57020101
17. El-Kateb NM, Abdallah AM, ElBackly RN. Correlation between pulp sensibility and magnetic resonance signal intensity following regenerative endodontic procedures in mature necrotic teeth- a retrospective cohort study. BMC Oral Health [Internet]. 2024 [cited 20 mayo 2025]; 24(1):330. Available from:
https://doi.org/10.1186/s12903-024-04095-y
18. Sharma DS, Mishra S, Banda NR, Vaswani S. In vivo evaluation of customized pulse oximeter and sensitivity pulp tests for assessment of pulp vitality. Journal of Clinical Pediatric Dentistry [Internet]. 2019 [cited 20 mayo 2025]; 43(1):11–5. Available from: https://doi.org/10.17796/1053-4625-43.1.3
19. Zou X, Zheng X, Liang Y, Zhang C, Fan B, Liang J, et al. Expert consensus on irrigation and intracanal medication in root canal therapy. International Journal of Oral Science [Internet]. 2024 [cited 20 mayo 2025]; 16:23. Available from: https://doi.org/10.1038/s41368-024-00280-5
20. Usta SN, Erdem BA, Gündoğar M. Comparison of the removal of intracanal medicaments used in regenerative endodontics from root canal system using needle, ultrasonic, sonic, and laser-activated irrigation systems. Lasers in Medical Science [Internet]. 2024 [cited 20 mayo 2025]; 39(1):27. Available from: https://doi.org/10.1007/s10103-024-03980-w
21. Sunlakawit C, Chaimanakarn C, Srimaneekarn N, Osiri S. Effect of Calcium Hydroxide as an Intracanal Medication on Dentine Fracture Resistance: A Systematic Review and Network Meta-Analysis. Journal of Endodontics [Internet]. 2024 [cited 20 mayo 2025]; 50(12):1714-1724.e6. Available from: https://doi.org/10.1016/j.joen.2024.08.005
22. Yassen GH, Platt JA. The effect of nonsetting calcium hydroxide on root fracture and mechanical properties of radicular dentine: a systematic review. International Endodontic Journal [Internet]. 2013 [cited 20 mayo 2025]; 46(2):112–8. Available from: https://doi.org/10.1111/j.1365-2591.2012.02121.x
23. Andreasen JO, Farik B, Munksgaard EC. Long‐term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dental Traumatology [Internet]. 2002 [cited 20 mayo 2025]; 18(3):134–137. Available from: https://doi.org/10.1034/j.1600-9657.2002.00097.x
24. White JD, Lacefield WR, Chavers LS, Eleazer PD. The effect of three commonly used endodontic materials on the strength and hardness of root dentin. Journal of Endodontics [Internet]. 2002 [cited 20 mayo 2025]; 28(12):828–830. Available from: https://doi.org/10.1097/00004770-200212000-00008
25. Kawamoto R, Kurokawa H, Takubo C, Shimamura Y, Yoshida T, Miyazaki M. Change in elastic modulus of bovine dentine with exposure to a calcium hydroxide paste. Journal of Dentistry [Internet]. 2008 [cited 20 mayo 2025]; 36(11): 959-964. Available from: https://doi.org/10.1016/j.jdent.2008.08.003
26. Kahler B, Swain M V. The calcium hydroxide controversy: does calcium hydroxide weaken teeth? Dental Traumatology [Internet]. 2025 [cited 20 mayo 2025]; 41(S1):53–63. Available from: https://doi.org/10.1111/edt.13015
27. American Association of Endodontists [Internet]. AAE clinical considerations for a regenerative procedure. 2021 [cited 20 mayo 2025]; 1–8. Available from: https://www.aae.org/specialty/wp-content/uploads/sites/2/2018/06/ConsiderationsForRegEndo_AsOfApril2018.pdf
28. Venkatakrishnan HK, Kothari NR, Krishnappa S. Effectiveness of using platelet concentrate and blood clot in regenerative endodontic treatment: A systematic review and meta-analysis. Contemporary Pediatric Dentistry [Internet]. 2024 [cited 20 mayo 2025]; 5(1):1–14. Available from: http://doi.org/10.51463/cpd.2023.186
29. Fujioka-Kobayashi M, Schaller B, Mourão CFDAB, Zhang Y, Sculean A, Miron RJ. Biological characterization of an injectable platelet-rich fibrin mixture consisting of autologous albumin gel and liquid platelet-rich fibrin (Alb-PRF). Platelets [Internet]. 2021 [cited 20 mayo 2025]; 32(1): 74–81. Available from: https://doi.org/10.1080/09537104.2020.1717455