Journal of South Asian Association of Pediatric Dentistry
Volume 6 | Issue 3 | Year 2023

Choukroun’s Autologous Platelet Concentrate Used in Immature Necrotic Tooth during Revascularization: A Clinical and Radiological Report of a Case

Umapathy Thimmegowda1, Nagarathna Chikkanarasaiah2, Pragna S Vijaya3, Pallavi N Kuri4, Muhammed T ameem5

1–5Department of Pediatric and Preventive Dentistry, RajaRajeswari Dental College & Hospital, Bengaluru, Karnataka, India

Corresponding Author: Umapathy Thimmegowda, Department of Pediatric and Preventive Dentistry, RajaRajeswari Dental College & Hospital, Bengaluru, Karnataka, India, Phone: +91 9986478744, e-mail:

Received: 31 July 2023; Accepted: 25 August 2023; Published on: 30 December 2023


Aim: To discuss the management of an immature necrotic permanent tooth and the clinical and radiological outcome by utilizing platelet-rich fibrin (PRF).

Introduction: Traumatic injury to the teeth in children can lead to damage to the pulpal tissue and infection, and particularly in the underdeveloped teeth with immature and open apices, it restricts treatment possibilities. The process of revascularization has enabled increased root survival, symptom relief, and radiographic evidence of root thickening and lengthening with continuous root development. PRF as a scaffold material can be used in a necrotized, infected, immature tooth for regeneration of the pulp and tooth rejuvenation.

Case description: This case report displays a protocol of revascularization in which PRF was utilized as an autologous scaffold in an immature necrotized tooth that had undergone trauma with incomplete development of the root. Through examination, clinical, and radiographical investigations, lengthening of the root and thickened dentinal walls of the traumatized tooth were noted.

How to cite this article: Thimmegowda U, Chikkanarasaiah N, Vijaya PS, et al. Choukroun’s Autologous Platelet Concentrate Used in Immature Necrotic Tooth during Revascularization: A Clinical and Radiological Report of a Case. J South Asian Assoc Pediatr Dent 2023;6(3):134–138.

Source of support: Nil

Conflict of interest: None

Keywords: Case report, Open apex, Platelet-rich fibrin, Revascularization, Traumatized necrotic teeth


An immature tooth is a young or newly erupting permanent tooth with an incompletely developed root apex where the root growth is not complete for 3 more years after a permanent tooth develops in the oral cavity.1 Hertwig’s epithelial root sheath (HERS) is a two-layered cellular form that covers these emerging roots and affects their appearance.2 Any disruption in the blood supply to HERS can prevent the formation of roots by preventing cell division and proliferation.3

Traumatic dental injuries (TDIs) account for roughly 5% of all injuries and have a high prevalence in children and young people.4 Injury to developing permanent teeth can cause necrosis of the pulp, infection, and development of the root that is halted.5 Young permanent teeth with immature roots and necrotic pulps are recognized by wide root canals with an open apex and thin walls.6 Apexification, a conventional method of treating immature teeth, entailed coating the root canal with long-lasting calcium hydroxide dressings to create a calcified barrier at the root end. Treatment lengths ranging from 3 to 21 months, many visits, unavoidable increased expenses, poor compliance of the patient, and a high-risk of reinfection have all been connected to this technique.7 The protocol for treating such teeth changed from apexification to regenerative therapies as a result.8

The periapical tissues of immature teeth include stem cells that, in some circumstances, have the capacity to repair tissue and are highly vascularized. Regenerative endodontic procedures are thus a potent therapeutic choice.9 Platelet-rich fibrin (PRF) is a second-generation platelet concentrate that was developed in 2001 by Choukroun, hence, the name. The factors responsible for growth in PRF promote the proliferating and odontoblastogenesis of the stem cells of the apical papilla.9 These odontoblasts lay down tubular dentin at the apical and lateral walls of the canal, promoting continuity in the maturation of the root.10

The intent of the present case report is to emphasize the clinical and radiographical results of revascularization in an immature necrotized tooth using PRF.


An 8-year-old male child visited the department with a complaint of pain in his upper front teeth region for the past 2 weeks. The child stated a history of traumatic injury to the upper anterior teeth caused by a fall 1 month ago. Upon clinical examination, the maxillary right central incisor was positive for the percussion test with grade I mobility. The tooth was unresponsive to the electric pulp test (EPT). A radiographic investigation it revealed an incomplete root formation with thin dentinal walls and a wide, open apex. The diagnosis of apical periodontitis was reached for tooth in relation to (irt) 11 based on clinical and radiographic presentations, and revascularization was planned to be performed with PRF.

Written consent was obtained after the treatment modalities were explained to the parent and the patient. The teeth were splinted with composite resin and a 0.7-inch orthodontic wire from canine to canine for 2 weeks. The anesthesia was administered using 2% lidocaine with 1:100,000 epinephrine. With a round bur and Endo-Z bur (Dentsply Maillefer, Tulsa, Oklahoma) irt 11, an access cavity was prepared, followed by minimal instrumentation, and copious irrigation of the canal was done using 20 mL of 1.5% sodium hypochlorite solution (NaOCl) followed by 20 mL of saline. Determination of the working length by a 50-size K file (Mani, Japan) was done (Fig. 1). The canals were dried using paper points. Triple antibiotic paste (TAP) (a mixture of metronidazole, ciprofloxacin, and minocycline) was prepared and placed using an endodontic plugger (Dentsply Maillefer) into a canal depth of 2–3 mm short of the radiographic apex. Following this, a pellet of cotton was placed, and the opening of access was temporized using thick zinc oxide eugenol (ZOE-Prime Dental, India). After 1 week, at the next visit, the tooth was symptom free. The cavity was reopened and thoroughly irrigated to flush out the TAP, and the canal was dried with sterile paper points.

Fig. 1: Working length determined irt 11

Under aseptic conditions, from the patient’s medial cubital vein, 10 mL of blood was withdrawn (Figs 2 and 3). Without using an anticoagulant, the blood sample was immediately collected into a test tube and placed on a centrifugal machine for 10 minutes at 3000 revolutions per minute (RPM) (Figs 4 and 5). The formation of three well-defined layers in the tube was noted. At the top level, a straw-colored acellular platelet-poor plasma, intermediately, PRF liquid, and at the base, a red fraction of red blood cells, were observed (Fig. 6). The PRF clot was compressed in between the dry sterile gauge to release the fluids entrapped in the fibrin matrix. Apical bleeding was induced using a sterile hand file past the apex of the tooth. The obtained autologous fibrin membrane was fragmented and placed using an endodontic hand plugger (Dentsply Maillefer, Switzerland) until the cementoenamel junction (CEJ) (Fig. 7). A white mineral trioxide aggregate (MTA) with a thin layer was placed, followed by a moist cotton pellet, and the tooth was temporized with ZOE (Fig. 8).

Fig. 2: A 5 mL sample of whole venous blood was drawn from the patient’s forearm

Fig. 3: A 5 mL sample of whole venous blood was drawn from the patient’s forearm

Fig. 4: The blood sample was transferred into a test tube without anticoagulant

Fig. 5: Blood sample was centrifuged immediately using a tabletop centrifuge at 3000 RPM for 10 minutes

Fig. 6: Formation of PRF after centrifugation of peripheral blood with clot (top layer) and red blood cells (bottom layer)

Fig. 7: The PRF fragments placed incrementally in the canal using a endodontic hand plugger

Fig. 8: The MTA was placed directly over the PRF membrane

The next day, the patient was recalled, and composite restoration with respect to 11 was done (3M ESPE, United States of America). At 3, 6, 9, and 12 months, the patient was recalled for follow-up. In the recall visit, the treated tooth responded positively to the EPTs, and the responses to percussion and palpation were normal and also noted. At 6 months, radiographic analysis of 11 revealed continuous growth of the root and complete closure of the root apex (Fig. 9). At 12 months, tooth 11 revealed advanced growth of the root end, dentin walls had enhanced thickness with narrowed canal space, the apex showed faster closure, and normal architecture of periradicular tissues was observed (Fig. 10). Clinically, tooth 11 showed no discoloration, and the tooth was vital (Fig. 11).

Fig. 9: Follow-up at 6 months revealed the accelerated root growth

Fig. 10: Radiographic follow-up at 12 months revealed accelerated root end growth, enhanced thick dentinal walls with narrowing of the canal space, faster closure of the apex, and normal periradicular architecture

Fig. 11: Clinical follow-up at 12 months showed no discoloration irt 11 and the tooth was vital


A biological method called the regenerative endodontic treatment approach is intended to restore the impaired structure of the tooth, which includes the dentin, root, and dentin–pulp complex. Revascularization of the root canal is one of the techniques used in regenerative endodontics to restore the vitality of nonvital teeth.11 Traditional treatment of immature teeth included apexification, which involved placing calcium hydroxide [Ca(OH)2] dressings for a longer period of time to create a calcified barrier at the apex of the root prior to filling root canals. The Ca(OH)2 apexification method is linked to unpredictable treatment durations (between 3 and 21 months), numerous visits, large expenses, poor patient cooperation, and possible reinfection, as it is a challenge to create long-lasting seals with temporary restorations.7 Furthermore, the action of Ca(OH)2 tends to weaken the bonds between collagen fibers and hydroxyapatite crystals, thereby decreasing the organic support of dentine. As a result of this decrease in the microhardness of dentine, the teeth are very vulnerable to root fracture.5 The vitality of the apical papilla cells is the basis for the revascularization of the teeth that proliferate into the canal space.

A proper scaffold is necessary for stem cell differentiation and proliferation in order to place the factors responsible for growth and stem cells in the root canal area. In revascularization procedures, scaffolding materials that include collagen, platelet-rich plasma (PRP), PRF, and blood clots are employed.12,15 In our case, autologous-PRF (A-PRF) was used as a scaffold. The traditional method of revitalization was done mechanically, causing the induction of bleeding into the pulp canal.16 The blood clot that is generated acts as a matrix for new tissues to develop into the pulp canal. The periapical tissues will be mechanically irritated, which will cause discomfort to the patient.17 Additionally, collagen has been applied as a matrix or scaffold to promote the growth of tissue inside root canals. However, collagen serves as a passive scaffold and has no advantages in promoting the revascularization process since it lacks the components that promote cell proliferation and differentiation.18

Platelet-rich plasma (PRP), a first-generation platelet concentrate, contains growth factors that can promote synthesis, recruit more cells to the injury site, and stimulate vascular development, all of which hasten the healing process. The development of antibodies may also increase the fatality risk associated with coagulopathies.19,20 A-PRF, a platelet concentrate of the second generation, combines growth factors, cytokines, and platelets that may improve hard and soft repair with the healing.21 A-PRF enhances cellular differentiation, promotes angiogenesis, and increases the proliferation of numerous types of cells. Lastly, the self-regulation of inflammatory and infectious processes can be considerably altered by leukocytes, cytokines, and moderate numbers of lymphocytes in PRF.22 With the guidance of HERS and once the inflammation has subsided, these pulp cells transform into odontoblast-like cells.7

Recent research suggests that the PRF, with its own biological scaffold, could release factors responsible for growth in the process of wound healing, which includes platelet-derived growth factor (PDGF) and transforming growth factor-β1 (TGF-β1).23 For at least 1 week and as long as 28 days, PRF has an extremely significant, slow, sustained release of numerous crucial growth factors. Its key advantages are its ease of preparation and the absence of blood biochemical processing, which restricts this preparation to only autologous use.24 Infection control in the canal area is a crucial first step in revascularization procedures. In our case, to disinfect the canal area, 1.5% NaOCl and TAP were used, as suggested by other researchers.25 To completely eradicate canal infections and overcome the pathogenic bacteria’s resistance, a combination of medicines such as ciprofloxacin, metronidazole, and minocycline is necessary.26 The research on revascularization with PRF demonstrated continuing root lengthening, dentinal wall thickening, decline of periapical lesions, and radiographical closure of the root apex.11 In our case, radiographically visible root lengthening, thickness in the dentinal wall, and closure of the root apex were seen without any clinically detectable sensitivity to percussion or palpation. Electric and cold pulp tests on teeth produced positive results. In our case, the good response to cold testing and EPT testing was caused by the position of MTA just below the level of the CEJ. This might be because there is a good possibility of generating a favorable response if MTA is placed close to CEJ. Any negative vitality testing findings may have been caused by the MTA thickness, which prevents the growth of fresh tissue in front of it.14 In histologic sections, the soft tissues are likely to be periodontal ligaments rather than pulp tissue, with the hard tissues being heterogeneous mineralized tissue resembling bone or cementum.11 The PRF-mediated delivery of factors of growth into the cleaned root canal region served as a bioscaffold, which is the most likely explanation for these observations. It has been shown that the apical papilla’s mesenchymal stem cells express cell membrane receptors for growth factors found in platelets. These receptors are expressed by osteoblasts, endothelial cells, fibroblasts, and epithelial cells. This can cause these cells to proliferate into the canal space from the periapical region and produce a matrix in the canal space.24 Therefore, it acts as a storage space for components that aid in tissue repair, and PRF promotes new hard and soft tissue generation within the canal area.5


This case report elucidates the application of PRF in pediatric dentistry. Growth factors found in abundance in PRF promote cellular differentiation, angiogenesis, and proliferation. It controls inflammatory responses and permits the gradual and continuous release of growth factors for revascularization. Therefore, this makes it a suitable scaffold for the regeneration of vital tissue in necrotic, immature teeth. Pediatric dentists may use this during revascularization operations. To evaluate the advantages of employing PRF in revascularization treatments, extensive clinical trials, histological research, and studies supporting the usage, clinical effectiveness, and stability over the long term in pediatric patients are required.


Umapathy Thimmegowda

Pragna S Vijaya


1. Fouad AF. Endodontic microbiology: John Wiley & Sons; 2017.

2. Xiong J, Gronthos S, Bartold PM. Role of the epithelial cell rests of M alassez in the development, maintenance and regeneration of periodontal ligament tissues. Periodontology 2000 2013;63(1):217–233. DOI: 10.1111/prd.12023

3. Li J, Parada C, Chai Y. Cellular and molecular mechanisms of tooth root development. Development 2017;144(3):374–384. DOI: 10.1242/dev.137216

4. Levin L, Day PF, Hicks L, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: general introduction. Dent Traumatol 2020;36(4):309–313. DOI: 10.1111/edt.12574

5. Keswani D, Pandey RK. Revascularization of an immature tooth with a necrotic pulp using platelet-rich fibrin: a case report. Int Endod J 2013;46(11):1096–104. DOI: 10.1111/iej.12107

6. Singh RK, Shakya VK, Khanna R, et al. Interventions for managing immature permanent teeth with necrotic pulps. Cochrane Database System Rev 2017;(6):CD012709. DOI: 10.1002/14651858.CD012709

7. Cehreli ZC, Isbitiren B, Sara S, et al. Regenerative endodontic treatment (revascularization) of immature necrotic molars medicated with calcium hydroxide: a case series. J Endod 2011;37(9):1327–1330. DOI: 10.1016/j.joen.2011.05.033

8. 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. Aust Endod J 2014;40(3):95–100. DOI: 10.1111/aej.12087

9. Ray Jr HL, Marcelino J, Braga R, et al. Long-term follow up of revascularization using platelet-rich fibrin. Dent Traumatol 2016;32(1):80–84. DOI: 10.1111/edt.12189

10. Neelamurthy PS, Kumar RA, Balakrishnan V, et al. Revascularization in immature and mature teeth with necrotic pulp: a clinical study. J Contemp Dent Pract 2018;19(11):1393–1399. DOI: 10.5005/jp-journals-10024-2438

11. Poornima, Sulakshana P, Srinath SK, et al. Revascularization of immature permanent teeth via blood clot or PRF Platelet rich fibrin: a review. RGUHS J Dent Sci 2022;14(3):2–12. DOI: 10.26715/rjds.14_3_2

12. Vemuri S, Kotha RS, Raghunath RG, et al. Root canal revascularization via blood clotting in regenerative endodontics: essentials and expectations. J Dr NTR Univer Health Sci 2013;2(4):235–238. DOI: 10.4103/2277-8632.122156

13. Abd El-Hady AY, Badr AE. The efficacy of advanced platelet-rich fibrin in revascularization of immature necrotic teeth. J Contemp Dent Pract 2022;23(7):725–732. DOI: 10.5005/jp-journals-10024-3367

14. Torabinezad M, Turman M. Revitalization of tooth with necrotic pulp and open apex by using platelet rich plasma: a case report. J Endod 2011;37(2):265–268. DOI: 10.1016/j.joen.2010.11.004

15. Mishra N, Narang I, Mittal N. Platelet-rich fibrin mediated revitalization of immature necrotic tooth. Contemp Clin Dent 2013;4(3):412–415. DOI: 10.4103/0976-237X.118379

16. Tomer AK, Mangat P, Behera A, et al. Revascularisation of an immature permanent tooth using platelet rich fibrin and biodentin as a matrix a case report. Int J Med Biomed Stud 2019;3(7):273–277. DOI: 10.32553/ijmbs.v3i7.431

17. Ramachandran N, Singh S, Podar R, et al. A comparison of two pulp revascularization techniques using platelet-rich plasma and whole blood clot. J Conserv Dent 2020;23(6):637–643. DOI: 10.4103/JCD.JCD_221_20

18. Singhal P, Kadian B, Midha P, et al. Regenerative endodontic therapy using platelet-rich fibrin in children. Saudi J Oral Sci 2020;7(3):210–215. DOI: 10.4103/sjos.SJOralSci_76_19

19. Eshwar SS, Victor DJ, Sangeetha S, et al. Platelet rich plasma in periodontal therapy. J Pharmaceut Sci Res 2017;9(6):965–971.

20. Mohanty R, Satpathy A, Panda M. Platelet rich plasma (PRP). The game changer in periodontal therapy. 2021;42–49.

21. Pavlovic V, Ciric M, Jovanovic V, et al. Platelet-rich fibrin: basics of biological actions and protocol modifications. Open Med 2021;16(1):446–454. DOI: 10.1515/med-2021-0259

22. Alharith DN, Altuwaijri S, Alshaman LM, et al. Updates in regenerative endodontics for young general practitioners: a literature. 2022;6(1):193–200. DOI: 10.24911/IJMDC.51-1634562991

23. Manhas M, Mittal S, Sharma AK, et al. Biological approach in repair of partially inflamed dental pulp using second-generation platelet-rich fibrin and mineral trioxide aggregate as a pulp medicament in primary molars. J Indian Soc Pedodont Prevent Dent 2019;37(4):399–404. DOI: 10.4103/JISPPD.JISPPD_133_19

24. Egle K, Salma I, Dubnika A. From blood to regenerative tissue: how autologous platelet-rich fibrin can be combined with other materials to ensure controlled drug and growth factor release. Int J Molecul Sci 2021;22(21):11553. DOI: 10.3390/ijms222111553

25. Orduña JF, Caviedes-Bucheli J, Céspedes MC, et al. Use of platelet-rich plasma in endodontic procedures in adults: regeneration or repair? A report of 3 cases with 5 years of follow-up. J Endod 2017;43(8):1294–1301. DOI: 10.1016/j.joen.2017.04.010

26. Mohammadi Z, Jafarzadeh H, Shalavi S, et al. A review on triple antibiotic paste as a suitable material used in regenerative endodontics. Iranian Endod J 2018;13(1):1–6. DOI: 10.22037/iej.v13i1.17941

© The Author(s). 2023 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.