Pham et al.

BMC Oral Health (2024) 24:230 BMC Oral Health

https://doi.org/10.1186/s12903-024-03923-5

RESEARCH Open Access

Platelet rich fibrin and MTA in the treatment

of teeth with open apices
Van-Khoa Pham1*, Tran-Lan-Khue Pham1, An-Tran Pham1, Hoang-Lan-Anh Le1, Thi-Bich-Van Tran1,
Manh-Cuong Hoang1, Ta-Binh Vo1, Khanh-Ngoc Vy1, Minh-Hong Tran2, Thi-Anh-Thu Tran2, Minh-Anh Bui2,
Anh-Dung Hoang2, Ngoc-Phuc Nguyen3, Thi-Tam-Duyen Nguyen4, Phuc-Nguyen Nguyen4, Thi-Tuong-Vi Tran5 and
Cao-Hoai-Linh Nguyen5

Abstract
Background The present study aimed to evaluate the effectiveness of using platelet-rich fibrin (PRF) as the apical
matrix for the placement of MTA in nonsurgical endodontic therapy for teeth with periapical lesions and open apices.
Methods Twelve teeth from eleven patients with periapical periodontitis and open apices were enrolled in the study.
Nonsurgical endodontic therapy was performed with the PRF used as an apical barrier and the MTA manipulated as
an apical plug for further thermoplasticized gutta percha in the remaining part of the root canal. Clinical signs and
periapical digital radiographs were recorded and analyzed to evaluate the curing progress after periodical follow-
ups of 1, 3, and 6 months. The horizontal dimension of the periapical lesion was determined, and the changes in the
dimensions were recorded each time. The Friedman test was used for statistical analysis, with P < .05 serving as the
threshold for determining statistical significance.
Results All patients had no clinical symptoms after the first month of treatment, with a significant reduction in the
periapical lesion after periodical appointments.
Conclusions PRF is an effective barrier when combined with MTA for the treatment of teeth with periapical
periodontitis and open apices.
Keywords PRF, MTA, Apical barrier, Open apex, Periapical periodontitis

Background
Teeth with open apices and periapical lesions because of
traumatic or abnormal reasons have been endodontically
treated by many methods, from conventional apexifica-
tion with calcium hydroxide to modern application of
*Correspondence: MTA [1].
Van-Khoa Pham The traditional nonsurgical approach for apexification
[email protected] using calcium hydroxide Ca(OH)2 has certain drawbacks,
1
Faculty of Odonto-Stomatology, University of Medicine and Pharmacy at
Ho Chi Minh City, Ho Chi Minh City, Vietnam such as prolonged follow-up, multiple visits, patient com-
2
National Hospital of Odonto-Stomatology, Ho Chi Minh City, Vietnam pliance requirements, difficulty, and distinctive manipu-
3
Faculty of Dentistry, Van Lang University, Ho Chi Minh City, Vietnam lation [2]. Although this conventional method is not a
4
Faculty of Odonto-Stomatology, Tra Vinh University, Tra Vinh, Vietnam
5
Hospital of Odonto-Stomatology, Ho Chi Minh City, Vietnam sensitive technique, the weakened dentin structure could

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Pham et al. BMC Oral Health (2024) 24:230 Page 2 of 8

be an unexpected outcome of this uncomplicated mea- as an apical barrier in the endodontic treatment of teeth
surement. Patient compliance is paramount for the suc- with open apexes and periapical lesions [14–16].
cess of this long-term process because of the possibility The aim of the present study was to evaluate the effec-
of reinfection of the root canal space resulting from inac- tiveness of the combination of A-PRF as an apical bar-
curate follow-up checks, accidentally broken temporary rier and MTA for the treatment of teeth with periapical
filling or even the remaining weak tooth structure [3]. lesions and open apices.
Apical closure using MTA on the canal cervical third
and a blood clot in the whole root canal space for revas- Methods
cularization of the pulp complex connective tissue is also This study was approved by the Research Ethics Com-
a promising option [4]. However, this sensitive technique mittee of the University of Medicine and Pharmacy at Ho
has unpredictable outcomes with certain unfavorable Chi Minh City, Vietnam, with the approval number 236/
consequences. ĐHYD-HĐĐĐ. Informed consent was obtained from all
Both of the above methods are not suitable for severely participants or their parents, and all methods were per-
missing dental structure teeth, where immediate require- formed in accordance with the relevant guidelines and
ments for restoration are urgently needed. Occlusal situ- regulations. Informed consent was also obtained from
ation and aesthetic issues are also important factors in all patients and/or their legal guardians for the publica-
determining the choice of these two treatment options. tion of identifying information/figures in an online open-
If these circumstances are unfavorable, apexification and access version.
apical closure with regeneration of the pulp complex are The sample size was calculated using G*Power ver-
not proper choices for the operator. sion 3.1.9.6 (Universität Kiel, Germany) with an effect
The prevention of apical extrusion of material is a size of 1.05, an alpha of 0.05, and a power of 0.9, leading
considerable challenge for teeth with wide apices and to a sample size of 12 teeth. The Wilcoxon signed-rank
periapical lesions. In addition to being wet and dark, test (matched pairs) in the software was chosen for the
substances are easily removed from the apex foramen reduction of the horizontal dimension of the periapical
because of the open space, especially for slurries and sub- radiolucent area before and after nonsurgical endodontic
stances with extensive setting times, such as calcium sili- therapy at the periodical appointments.
cate-based cement and endodontic sealers. Although the A total of eleven patients with teeth on both the maxil-
apical extrusion of MTA has an unconsiderable effect on lary and mandibular sides were recruited for the present
the healing process of periapical lesions, healing progress study. The inclusion criteria were teeth with a diagnosis
takes longer, and this outcome was not recommended by of symptomatic or asymptomatic apical periodontitis,
the authors of a previous study [5]. periapical lesions, and open apices. The exclusion crite-
Chemical or thermal gutta-percha for root canal obtu- ria were patients who had orofacial chronic pain, such
ration of the apical third is an ineffective and unreliable as migraine, sinusitis, temporomandibular pain, or tri-
technique for accessing teeth with open apices, especially geminal neuralgia. Teeth with severe structures that were
those with severe periapical lesions [1]. unrestorable, had unacceptable crown-to-root ratios, or
The formation of an apical barrier for a certain biologi- were cracked were also not included in the present study.
cal substance is necessary for predictable, favorable, and The subjects were recruited at the Department of
effective placement of calcium-silicate material such as Operative Dentistry and Endodontics, Faculty of Odonto-
MTA [1]. Hemostatic collagen membranes have been Stomatology, University of Medicine and Pharmacy at Ho
successfully applied to the barrier at the apical region to Chi Minh City, Vietnam, from November 2021 to April
prevent apical extrusion of substances in previous studies 2023.
[1, 6]. However, this material has not been an autogenous All endodontic procedures were performed by the
substance for ensuring a completely biocompatible heal- same endodontist via the same standard procedure. For
ing process. the first appointment, after completing the administra-
By introducing platelet-rich fibrin (PRF) [7], this tive procedure, a putty silicone bite registration impres-
strong fibrin membrane enriched with platelets and sion was made to capture the first long cone periapical
growth factors has become popular in dentistry, espe- digital radiograph using the X-Mind unit and the phos-
cially in endodontic therapy [8–10]. The PRF membrane phor plate (Satelec, Acteon Group, France) with a
has been successfully used as an apical barrier for safe 16-inch position device.
MTA or Biodentine placement in previous studies [11, Local anesthesia was administered using 2% lidocaine
12]. Leukocyte PRF (L-PRF) [13] has been used in these (Lignospan standard, Septodont, France), followed by
case reports with promising results. However, to date, rubber dam isolation (Ash Rubber Dam, Dentsply Sirona,
advanced PRF (A-PRF) [13] has not been manipulated Switzerland). A 3D dental operating microscope (Prom-
ise Vision 3D, Seiler, St. Louis, MO, USA) was used for
Pham et al. BMC Oral Health (2024) 24:230 Page 3 of 8

enhanced vision and illumination during the entire non- MTA Angelus (Angelus, Brazil) was mixed following
surgical root canal procedure. the manufacturer’s instructions and inserted into the
The endodontic access cavity was prepared using Mar- MTA carrier by digging the gun into the prepared MTA
tin and Endo-Z burs (Dentsply Sirona, Maillefer, Switzer- material mass. The MTA material was delivered into the
land) under copious sterile water spray. The root canal apical region by triggering the piston of the carrier. The
length was subsequently measured via the synthesis of plugger was used to gently pack the material against the
information from an electronic apex locator (ProPex PRF barrier until 5 mm of MTA was placed. The place-
PiXi, Dentsply Sirona, Maillefer, Switzerland), a periapi- ment of MTA was checked for appropriateness or any
cal digital radiograph, and observation under a dental material extrusion by digital radiography.
microscope. The working length was shorter than the The remaining canal space was obturated with thermo-
root canal length at 2 mm. The root canal was prepared plastic gutta-percha (EQV, Meta Biomed, Korea) and AH
using K-files (Dentsply Sirona, Maillefer, Switzerland) Plus sealer (Dentsply Sirona, Maillefer, Switzerland). A
with gentle, circumferential motion. A Max-i-Probe nee- composite and bonding system (GC, Tokyo, Japan) was
dle (Dentsply Sirona, Maillefer, Switzerland) was used used to restore the access cavity after ensuring obturation
to deliver 3% sodium hypochlorite (Canal Pro, Coltene quality via digital radiography.
Whaledent, Altstätten, Switzerland) into the root canal Periodical follow-up periods of 1 month, 2 months, 3
space for copious irrigation. months, and 6 months were scheduled for collecting the
Root canal preparation was performed with the pur- clinical and radiographical findings (using the individual
pose of at least dentin removal and as much content bite registration impressions). Clinical symptoms such as
cleaning as possible. Saline solution was used for final postoperative pain and analgesic consumption, pain upon
irrigation of the root canal. After being parched by ster- palpation or percussion, and sinus tract were recorded.
ile paper points, the root canal was filled with calcium Treatment failure was confirmed if any of the above clini-
hydroxide paste (Endo Cal, Septodont, France), which cal symptoms existed. Certain dimensions of the periapi-
was subsequently gently condensed using a proper plug- cal lesion were measured to obtain the data for analysis.
ger (Dentsply Sirona, Maillefer, Switzerland), ensuring The dimension was determined as the largest distance
that the paste fully occupied the entire root canal, from of the segment from the two intersections between the
the apical end to the cemento-enamel junction. The Cavit lesion circumferential and the line drawn perpendicular
(GC, Tokyo, Japan) was used to fill the access cavity with to the root axis (Fig. 1). Radiographic success was con-
an underlying sterile cotton pellet. firmed if the dimension was reduced or unchanged. All
The next appointment was scheduled for one week measurements were conducted by the same operator, and
after the first visit. The apical plug procedure was pre- the Kappa (for clinical symptoms) or Intra-class correla-
pared after the completion of the root canal content tion (for radiographic dimensions) coefficient was used
removal and drying. Ten milliliters of venous blood was to evaluate intra-examiner agreement. All horizontal
drawn from the subjects’ venae brachia and centrifuged dimensions of the periapical lesions were remeasured by
at 1300 rotations per minute (RPM) for 8 min at a maxi- the same examiner after each two-week period, following
mal relative centrifugal force (RCF-max) of 208 g [13] the periodic examinations to calculate the intra-class cor-
using an apparatus (PRF Duo Quattro, Nice, France). The relation coefficients.
fibrin clots containing the platelets were extracted. The All the statistical analyses were performed using IBM
PRF block was then placed under the cover of the box, SPSS Statistics version 27 (IBM, Armonk, NY, US), with
over the flat plane inside the box, for 120 s to allow the a significance level of p < .05. The data were first tested
formation of the PRF membrane. The PRF membrane for normality by the Shapiro–Wilk test or paired t test.
was subsequently cut into 3 mm × 3 mm pieces, inserted, If the data were not normally distributed, they were ana-
and gently condensed into the apical apex region with an lyzed using the Friedman and Dunn–Bonferroni post hoc
appropriate plugger. Under the microscope, the pieces correction.
of the cut PRF membrane were condensed incremen-
tally through the canal into the periapical area using the Results
proper condenser until a firm barrier was established The Kappa and Intra-class correlation coefficients were
at the apex of the root. The procedure was performed greater than 0.9 for the examiner.
rapidly and easily because of the widening of the apical The horizontal dimensions of the periapical lesions on
portion of the root. The position and texture of the PRF the radiographs are displayed and analyzed in Table 1.
barrier were checked for stability with a plugger under There was a width of nearly ten millimeters at the diag-
a dental operating microscope, and additional pieces of nostic stage, and the patient was completely cured after
PRF could be further condensed into place if needed. all at 6 months. In fact, the patient healed within the first
few months because of the continuous reduction in the
Pham et al. BMC Oral Health (2024) 24:230 Page 4 of 8

Fig. 1 The horizontal dimension was defined as the largest distance of the segment from the two intersections between the lesion circumferential and
the line drawn perpendicular to the root axis

Table 1 The horizontal dimensions of the periapical lesions on the digital radiographs through periodic examinations
Minimum 25th percentile Median 75th percentile Maximum Friedman test
T0 3.5400 4.667 5.815 7.142 9.870 < 0.00001*
T1 0.6700 3.277 3.455 3.907 4.890
T2 0.0000 0.200 1.715 2.817 3.480
T3 0.0000 0.000 0.000 0.830 2.500
T6 0.0000 0.000 0.000 0.000 1.390
T0, T1, T2, T3, and T6 Periapical lesion width at the beginning of treatment and at 1, 2, 3, and 6 months, respectively
* P < .05, Friedman test

periapical lesion width. The lesion width reached a small pairs of values at the examined periodic measurements
value at 3 months and nearly reached zero at 6 months of (P < .05). This result proves that the curing process has
follow-up, which indicated that all lesions had progressed been continuously occurring in a positive direction, with
and cured during the investigated examinations. significant improvement occurring through every succes-
The results revealed that there were significant differ- sive periodical examination.
ences among the horizontal dimensions of periapical The dimensional differences between the two succes-
lesions on digital radiographs at the different investigated sive periodic examinations are displayed in Table 3.
time points (P < .05). There were significant differences in the width of the
The horizontal dimensions were successively reduced periapical lesions among the periods of periodic exami-
at each periodic radiographic measurement. This proves nation (P < .05).
that the healing process has successfully and firmly The differences in the width of the periapical lesion
progressed. between the two successive periodic examinations are
The differences in the width of the periapical lesions are further analyzed in Table 4.
displayed and analyzed in Table 2. The Dunn–Bonferroni post hoc correction revealed
The Dunn–Bonferroni post hoc correction revealed that there was a significant difference in one pair of
that there were significant differences among the five measurements between the two successive periodic
Pham et al. BMC Oral Health (2024) 24:230 Page 5 of 8

Table 2 Differences in the width of the periapical lesions on the Table 4 Differences in the width of the periapical lesion on the
radiographs obtained through periodic examinations radiographs obtained through periodic examinations
Test Standard Significance Adjusted Test Standard Significance Adjusted
Statistic Test Significance⁑ Statistic Test Signifi-
Statistic Statistic cance⁑
T6 -T3 0.500 0.775 0.439 1.000 T3 − 6 - T2 − 3 0.583 1.107 0.268 1.000
T6 -T2 1.250 1.936 0.053 0.528 T3 − 6 - T1 − 2 0.958 1.818 0.069 0.414
T6 -T1 2.583 4.002 < 0.001 0.001* T3 − 6 - T0 − 1 1.958 3.716 0.000 0.001*
T6 -T0 3.583 5.551 < 0.001 0.000* T2 − 3 - T1 − 2 0.375 0.712 0.477 1.000
T3 -T2 0.750 1.162 0.245 1.000 T2 − 3 - T0 − 1 1.375 2.609 0.009 0.055
T3 -T1 2.083 3.227 0.001 0.012* T1 − 2 - T0 − 1 1.000 1.897 0.058 0.347
T3 -T0 3.083 4.777 < 0.001 0.000* T0 − 1, T1 − 2, T2 − 3, and T3 − 6 differences in lesion width between the two
successive periodic examinations at the beginning and the first month, the first
T2 -T1 1.333 2.066 0.039 0.389
and the second month, the second month and the third month, and the third
T2 -T0 2.333 3.615 < 0.001 0.003* month and the sixth month, respectively
T1 -T0 1.000 1.549 0.121 1.000 ⁑ Significance values were adjusted by the Bonferroni correction for multiple
T0, T1, T2, T3, and T6 Periapical lesion width at the beginning of treatment and at tests
1, 2, 3, and 6 months, respectively *P < .05, Dunn-Bonferroni post hoc correction
⁑ Significance values were adjusted by the Bonferroni correction for multiple
tests
* P < .05, Dunn-Bonferroni post hoc correction
Discussion
The results of the present study showed that all treated
patients healed at different levels at periodical evaluations of
examinations for each period of periodic examination. both periapical digital radiographs and clinical signs.
The results demonstrated that the lesion dimensions Table 1 reveals that there are significant differences in
decreased rapidly in the first month and then decreased lesion width among the different examination times accord-
at a slower rate in the last month. ing to the digital radiographs, and these measurements were
Between the 3- and 6-month periodic examinations, continuously reduced throughout the investigated periods.
the mean difference in the reduction in lesion width was The difference in lesion width occurred immediately after
nearly zero, which indicated that there was no further the first month, regardless of sex, age, or tooth type. The
room for reduction in lesion width. The differences in the results of Table 2 reveals that the amplitude of this differ-
decreases in the first period are greater than those in the ence is greater than that of the other fluctuations during
last period, which means that the healing process is rapid the following periodic examinations. These results prove
in the first month. the strong reaction of periapical lesions to the combina-
The first signs of continuing formation of the root end tion of the two modalities of PRF and MTA and indicate
were observed in the second month after completion another proper treatment option for teeth with open api-
of the procedure. The continuing creation of the root ces and periapical radiolucent lesions. On the radiographs,
end in the present study has proven that this nonsurgi- not only was the horizontal dimension reduced but also the
cal endodontic procedure is definitely the regenerative vertical dimension decreased. The periapical lesion image
approach, according to contemporary knowledge. This was changed from a radiolucent area to a radiopaque area
firm evidence has been fundamental for modern knowl- throughout the examination period. Along with the change
edge in the evaluation of certain approaches to regenera- in the periapical digital radiograph, clinical symptoms did
tive concepts in root canal therapy. not occur immediately after the first month, and there were
no other negative clinical signs on subsequent periodic
examinations. Therefore, the success rate of nonsurgical
endodontic procedures can reach 100%.

Table 3 The dimensional differences in the horizontal dimensions of the periodontal lesion on the digital radiographs between the
two successive periodic examinations
Minimum 25th percentile Median 75th percentile Maximum Friedman test
T0 − 1 0.8000 1.382 2.095 3.897 6.480 < 0.001817*
T1 − 2 0.1100 0.677 1.285 2.457 4.090
T2 − 3 -0.9500 0.000 0.865 2.482 3.480
T3 − 6 0.0000 0.000 0.000 0.830 2.450
T0 − 1, T1 − 2, T2 − 3, and T3 − 6 differences in lesion width between the two successive periodic examinations at the beginning and the first month,the first and the second
month, the second month and the third month, and the third month and the sixth month, respectively
* P < .05, Friedman test
Pham et al. BMC Oral Health (2024) 24:230 Page 6 of 8

The procedure that was described in the present study Indirect vision in the dark, wet, complicated apical region
is independent of root canal enlargement, which requires requires a powerful light source and suitable magnifica-
rotary nickel-titanium instruments [11, 12]. The irrigation tion that cannot be achieved by conventional dental light
protocol is important for this kind of nonsurgical endodon- or a normal head loupe even with enhanced illumination.
tic procedure. All disinfected solutions were kept inside This procedure is not difficult if the operator has been fully
the root canal space to ensure no further irritation of the trained in a reasonable amount of time [17, 18, 20].
periapical tissue. This is a difficult task because of the wide Blood sample preparation is a rather uncomfortable issue
open apical foramen facilitating the outflow of the irrigation for adolescents and their parents in Vietnamese culture.
solution at all times. These irrigation solutions should be A sample of ten millimeters of blood is a barrier to paren-
sufficiently and properly activated to obtain enough water. tal consensus because of the fear of disease. An increase
The concentration of the irrigation solution should not have in the amount of blood is uncomfortable for parents [21].
been high, as approximately 2% is reasonable. Several patients declined to enrol in the study because of
A dental operating microscope with proper magnifica- the ten millimeters of blood sample needed for nonsurgi-
tion is essential, indispensable, and invaluable in this deli- cal endodontic procedures. For fresh and immediate PRF
cate, complicated, and difficult procedure. Almost normal blocks to manipulate the process, blood is withdrawn from
routine instruments could have been used for this special the patient simultaneously with the endodontic progress to
procedure, as long as the field of view was clear and illu- ensure a smooth journey from the beginning of the proce-
minated enough. Unless the MTA carrier is used for inser- dure to the insertion of pieces of PRF membranes into the
tion into the apical region, there is no further need for any periapical region [21].
other special instruments, as with microsurgical procedures Once the PRF block was extracted, it was then placed
under a dental operating microscope, where special micro- under the cover of the box for two minutes to cre-
instruments are indispensable [17]. Manipulation of a dental ate the PRF membrane. Preparation of the root canal
operating microscope for the present procedure has made and periapical region was accomplished before the PRF
working length determination less complicated [18]. The membrane was cut into 3 mm × 3 mm pieces for easier
operator could clearly observe the length of the root canal insertion into the periapical region.
from the occlusal surface through the apical foramen. The The PRF membrane used in the present study was con-
length of the root canal could be measured directly using a structed with a box instrument accompanied by a centri-
proper plugger and reconfirmed via periapical digital radi- fuge machine [22]. The steel plane is properly designated for
ography. The electronic apex locator becomes redundant in the formation of the PRF membrane once the membrane
these circumstances. is withdrawn from the vacuum sterile tube. The dimension
Illumination has been a very important factor in this of the piece of the PRF membrane correlates with the size
nonsurgical endodontic procedure. Manipulation of the of the apical foramen for each circumstance and facilitates
periapical region in the present protocol requires maximum the manipulation of the insertion through the foramen. The
light intensity to ensure clear vision in the field of view [17, size of the plugger is suitable for the apical foramen because
19]. However, periapical tissue should not be illuminated it does not further damage the delicate dentinal wall of the
with high light intensity because this is a living tissue; much apical third [11, 12].
or less, it has been affected by high light intensity. There- The patient posture during the procedure is certainly
fore, the field of view was intermittently illuminated by the uncomfortable because of the time-consuming nature
on and off buttons or by the light intensity change knob on of the procedure and the unfavorable mandibular tooth
the body of the dental operating microscope. Sometimes, position [19].
the right direction of the light into the periapical region is The results of the present study revealed that although
modified simply by changing the angle of the dental mirror PRF is an autogenous substance, the healing process
whenever the operator desires it. The contrast filter of the time is not rapid enough compared with that of the col-
dental operating microscope is sometimes used for tem- lagen membrane used in a previous study [1]. Although
porarily adjusting the light intensity. Because almost all the PRF has certain advantages over collagen membranes,
teeth recruited into the study were lower teeth, the posture the manipulation of this autogenous material requires
of the mandibular and, therefore, the position of the head a strictly sterilized environment [11], leading to diffi-
of the patient was adjusted to the uncomfortable location. culty in normalizing the procedure in common clinical
However, patient cooperation has been very good for non- situations.
surgically sensitive endodontic treatment [17, 20]. Once the apical barrier of the PRF membrane has been
The fluid squeezed from the PRF membranes was clearly confirmed, the insertion of MTA into the desired posi-
observed by the operator and could be evaluated exactly tion in the apical third of the root canal has not been
until the PRF membranes were sufficient for the beginning further complicated. MTA could be carried out using an
of MTA placement.
Pham et al. BMC Oral Health (2024) 24:230 Page 7 of 8

MTA carrier, a hand spiral instrument, or even ultrasonic The firm evidence of root apex development in the
energy, with the hope of a better result [23]. present study contributes to the contemporary knowl-
The MTA used for the apical plug was chosen for discol- edge of the regenerative approach in endodontics.
oration of the dental structure, especially for the anterior The limitations of the present study include the small
tooth. Although calcium silicate-based cement is placed sample size, short follow-up period, small number of
only in the apical third, discoloration of the coronal portion teeth, and the use of only periapical digital radiographs.
of the tooth should be considered an adverse effect during Further investigations should be performed using other
this procedure [10]. Modern MTA erases the discoloration calcium silicate-based materials, other PRF forms, and
of teeth and is a reasonable reason for its use in the clini- a broader range of teeth and ages. Fluid separation from
cal setting. The moisture environment required for the set- the PRF membrane should be investigated to confirm
ting of the conventional MTA was eliminated during the that there is no considerable effect on the quality of the
manipulation of this modern MTA; therefore, the following PRF membrane compared to that of the PRF block.
appointment for treatment completion was unnecessary. The PRF membrane is a good autogenous substance
Water is rapidly separated from the PRF membrane; there- for the apical barrier formation procedure for preventing
fore, this substance should be manipulated as soon as pos- apical extrusion of material used in the apical region.
sible to establish a parched region, facilitating subsequent
Abbreviations
MTA placement. The volume of the PRF barrier should be PRF platelet-rich fibrin
extended further into the apical region to compensate for RCF relative centrifugal force
the shrinkage of the PRF block after compression by sterile RPM Rotations Per Minute
L-PRF Leukocyte Platelet Rich Fibrin
cotton. A-PRF Advanced platelet-rich fibrin
The apical MTA barrier combined with the PRF mem- MTA mineral trioxide aggregate
brane offers a high chance of successful restoration of CBCT Cone-beam computed tomography
ALARA As Low As Reasonably Achieve
extremely weakening tooth structure compared with other
long-term, multiple visits, such as calcium hydroxide apexi- Author contributions
fication and apical closure regeneration. Once the tooth has V-K.P. designed, conceived, wrote the original, reviewed, and approved the
manuscript. M-H.T., N-P.N., and T-A-T.T. performed, data collected, review, and
been fully restored on time, its functional, aesthetic, and approved the manuscript. A-T.P. and T-L-K.P. wrote the original manuscript,
stable abilities can be restored and enhanced in terms of data collected, reviewed, and approved the manuscript. All authors have read
both function and aesthetics, ensuring the best outcome for and approved the manuscript.

this kind of nonsurgical conservative endodontic procedure Funding

[24]. There was no funding for this study.
The texture of the PRF membrane seems tougher than
Data availability
that of the collagen membrane under the conditions of No datasets were generated or analysed during the current study.
these PRF extraction parameters. This characteristic
facilitates the manipulation of PRF pieces in the delicate Declarations
apical region, although fluid separates from the com-
pressed substance during placement [22]. Ethics approval and consent to participate
This study was approved by the Research Ethics Committee of the University
The estimation of the blood volume needed for PRF of Medicine and Pharmacy at Ho Chi Minh City, Viet Nam, with the approval
extraction is not an issue if a previous cone-beam com- number of 236/ĐHYD-HĐĐĐ, the informed consent was obtained from
puted tomography image is available. The dimensions of parents of all participants, or participant herself, and all methods were
performed in accordance with the relevant guidelines and regulations.
the periapical lesion could be estimated more exactly via
CBCT than via conventional periapical digital radiogra- Consent for publication
phy, as described in the present study. CBCT is a very good Informed consent had been obtained from all subjects and/or their legal
guardian(s) for publication of identifying information/images in an online
method for evaluating the reduction of periapical lesions in open-access publication.
all three dimensions in space. Further investigations using
CBCT should be performed to obtain additional details on Competing interests
The authors declare no competing interests.
the healing process of this nonsurgical endodontic proce-
dure. However, there is concern as to the radiation exposure Received: 14 December 2023 / Accepted: 21 January 2024
used in CBCT capture to ensure the As Low As Reasonably
Achieve (ALARA) principle [25].
PRF loaded with antibiotics after oral surgery has
been advocated for in recent studies because of its many References
advantages [26]. 1. Pham KV, Tran TA. Effectiveness of MTA apical plug in dens evaginatus with
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