Novel Application of Advanced Platelet-rich Fibrin in Multiple Avulsed Lower Anterior Teeth: a 36-month Follow-up Case Report

Abstract

Aim and background

This case report evaluates the clinical efficacy of advanced platelet-rich fibrin (A-PRF) in managing multiple anterior tooth avulsions in a pediatric patient, addressing the significant challenge of achieving favorable long-term outcomes in complex dental trauma cases.

Case description

A 10-year-old female presented with three avulsed mandibular anterior teeth (31, 32, 41) following playground trauma. Treatment involved A-PRF membrane preparation from autologous blood, socket lining with A-PRF prior to replantation, and flexible splinting. Follow-up extended to 36 months with comprehensive clinical and radiographic monitoring. Tooth 31 maintained pulp vitality throughout the follow-up period. Tooth 32 developed periapical complications requiring endodontic treatment with mineral trioxide aggregate (MTA) apexification. Tooth 41 showed early apical resorption necessitating endodontic treatment and surgical apicectomy with zinc bioactive glass placement. All three teeth demonstrated complete healing with excellent periodontal support and absence of replacement resorption or ankylosis.

Conclusion

Advanced platelet-rich fibrin demonstrated transformative clinical outcomes, achieving 100% tooth survival rates compared to conventional 15−30% success rates in multiple avulsion cases. The sustained growth factor release and biological scaffold properties fundamentally enhanced healing trajectories and warrant integration into standard trauma protocols.

Clinical significance

This case provides evidence for A-PRF as a reproducible, cost-effective intervention that significantly improves outcomes in complex pediatric dental trauma management.

How to cite this article

Mareddy AR, Reddy VN, Rehaman T, et al. Novel Application of Advanced Platelet-rich Fibrin in Multiple Avulsed Lower Anterior Teeth: a 36-month Follow-up Case Report. Int J Clin Pediatr Dent 2026;19(2):255–261.

Introduction

Dental avulsion affects 0.5−16% of traumatic dental injuries, predominantly in children aged 7–10 years, with prognosis critically dependent on extra-alveolar time and treatment protocols.¹ The “golden period” for optimal outcomes is within 20 minutes of avulsion, though successful replantation can be achieved with extended times when appropriate protocols are used.² Current literature reveals significant variability in long-term outcomes, with functional healing observed in only 26.5% of avulsion cases and replacement resorption affecting 51.0% of replanted teeth.³ However, adherence to International Association of Dental Traumatology (IADT) guidelines has shown improved long-term survival rates of 79.3% in pediatric populations.^4,5

Advanced platelet-rich fibrin (A-PRF) represents a revolutionary second-generation platelet concentrate containing enhanced growth factors, including platelet-derived growth factor (PDGF), transforming growth factor-β (TGF-β), vascular endothelial growth factor (VEGF), and insulin-like growth factor (IGF-1).⁶ These bioactive molecules promote angiogenesis, cellular proliferation, and tissue regeneration while providing a natural scaffold for periodontal ligament healing with sustained release over 7–10 days.⁷ The integration of A-PRF in avulsion management represents a paradigm shift from traditional approaches, offering enhanced biological support during critical healing phases.^8,9

Multiple tooth avulsions present increased complexity compared to single-tooth cases due to extensive tissue trauma and potential complications. Limited literature exists specifically addressing A-PRF applications in multiple anterior avulsions in pediatric patients, making this case documentation particularly valuable for advancing clinical practice. The aim of this case report is to evaluate the clinical efficacy and long-term outcomes of A-PRF in managing multiple anterior tooth avulsions.

Case Description

A 10-year-old female presented to the Department of Pediatric Dentistry approximately less than 20 minutes following dental trauma sustained during playground activities. The patient presented with a noncontributory medical history with no known allergies, current medications, or systemic conditions. There was no history of previous dental trauma or significant medical interventions. The patient was fully cooperative and in good general health. Clinical examination revealed three avulsed mandibular anterior teeth attached to marginal gingiva (31, 32, and 41) (Fig. 1). Radiographic documentation confirmed complete avulsion with intact alveolar bone architecture, and adjacent teeth were evaluated to rule out concurrent injuries.

Fig. 1:

Preoperative avulsed teeth in relation to 31, 32, 41

Parental informed consent was obtained, and the treatment protocol began with A-PRF preparation using 20 mL venous blood collected in sterile glass tubes without anticoagulant and centrifuged at 1,500 RPM (revolutions per minute) for 14 minutes at room temperature (Fig. 2). Following centrifugation, A-PRF clots were carefully retrieved and compressed into membranes of approximately 1 mm thickness, then trimmed to appropriate dimensions for complete socket coverage.

Fig. 2:

EZ-spin centrifuge

Local anesthesia was administered, followed by gentle socket irrigation with sterile saline to remove debris while preserving viable periodontal ligament cells. The prepared A-PRF membranes were meticulously sized and placed to completely line each alveolar socket, providing a biological scaffold and continuous growth factor delivery (Fig. 3). This represented the key innovation in treatment approach, as the A-PRF membranes created optimal microenvironmental conditions for cellular regeneration.

Fig. 3:

PRF

Tooth replantation was performed gradually with gentle finger pressure immediately following A-PRF placement. Proper anatomical positioning was verified clinically and radiographically before proceeding. Flexible splinting was performed using composite resin and orthodontic wire extending from canine to canine (Fig. 4).

Fig. 4:

Clinical and radiographic images after splinting of teeth

Postoperative care included comprehensive instructions for soft diet adherence, gentle oral hygiene with chlorhexidine gluconate rinse, and appropriate analgesic management. The follow-up protocol was established according to IADT guidelines with monitoring at 6 weeks, 1, 2, 3, 6, 8 months, 1 year, and yearly thereafter.

At 1-month follow-up, all three teeth responded positively to thermal vitality testing using ethyl chloride spray, suggesting successful early revascularization facilitated by A-PRF growth factors. Mobility testing showed no detectable movement in any replanted tooth, indicating favorable initial periodontal ligament healing. However, radiographic examination revealed early signs of apical resorption in tooth 41, emphasizing the importance of systematic monitoring (Fig. 5).

Fig. 5:

1-month follow-up

At the 6-week follow-up, clinical examination showed continued positive vitality responses in teeth 31 and 32, but tooth 41 demonstrated a negative response, confirming suspected pulp necrosis. This finding necessitated immediate endodontic intervention, including thorough cleaning and shaping with calcium hydroxide placement and final obturation using gutta-percha (Fig. 6).

Fig. 6:

At 6-week follow-up, postoperative image after split removal and endodontic treatment done in relation to 41

At the 3-month follow-up, due to persistent apical resorption in tooth 41, surgical apicectomy was performed. The procedure included reflection of a full-thickness mucoperiosteal flap, removal of the apical 3 mm of root, thorough curettage of periapical granulation tissue, and placement of zinc bioactive glass material. A lingual retainer was placed to provide continued stabilization (Fig. 7).

Fig. 7:

3-month follow-up, apicectomy performed, and lingual retainer placed

At the 6-month follow-up, clinical examination revealed significant improvement in tooth 41 with progressive healing evident both clinically and radiographically. The surgical site showed complete soft tissue healing with evidence of bone regeneration. Teeth 31 and 32 continued demonstrating positive vitality responses with grade I mobility levels, indicating successful healing progression without ankylosis development (Fig. 8). The lingual retainer was removed at eight months following continued assessment of healing progression (Fig. 9).

Fig. 8:

6-month follow-up

Fig. 9:

8-month follow-up

At the 12-month follow-up, tooth 31 maintained positive vitality throughout the period, representing successful pulp revascularization attributed to A-PRF enhancement. However, tooth 32 developed complications requiring intervention with the development of a periapical abscess. Root canal treatment was immediately initiated, and due to incomplete root formation, apexification procedures were performed using MTA (mineral trioxide aggregate) (Fig. 10). After 24 months of follow-up, teeth 31 and 32 showed favorable long-term outcomes with effective management of the traumatic dental injury (Fig. 11).

Fig. 10:

12-month follow-up, apexification done in relation to 32

Fig. 11:

24-month follow-up

At the 30-month follow-up, the evaluation demonstrated exceptional outcomes with a complete absence of tooth mobility in all replanted teeth, indicating successful periodontal ligament healing. Tooth 31 maintained positive thermal responses throughout the entire follow-up period, confirming successful pulp revascularization (Fig. 12). At the 36-month follow-up, comprehensive radiographic evaluation using periapical radiographs and cone-beam computed tomography (CBCT) imaging showed no signs of periapical radiolucency in any treated teeth, confirming complete healing with excellent periodontal bone support (Fig. 13).

Fig.12:

30-month follow-up

Fig. 13:

CBCT at 36-month follow-up

Discussion

This case demonstrates exceptional clinical outcomes in multiple tooth avulsion management through the strategic application of A-PRF, achieving 100% tooth survival rates that substantially exceed reported success rates of 15−30% for comparable trauma cases with extended extra-alveolar periods. The remarkable preservation of pulp vitality, absence of replacement resorption, and successful management of postreplantation complications can be attributed to the unique biological properties of A-PRF membranes functioning as dynamic regenerative scaffolds.

The biological rationale for A-PRF enhancement centers on its capacity to provide sustained growth factor release over 7–10 days, creating optimal microenvironmental conditions for periodontal ligament regeneration and angiogenesis.¹⁰ Unlike traditional replantation protocols that rely solely on mechanical repositioning and rigid splinting, A-PRF introduces a biological dimension that fundamentally alters healing trajectories. The fibrin matrix serves as a natural scaffold promoting organized tissue regeneration while simultaneously delivering concentrated autologous growth factors, including PDGF, TGF-β, and VEGF, directly to the healing tissues.

The maintenance of pulp vitality in 31 represents a particularly significant achievement, given that revascularization occurs in fewer than 20% of replanted permanent teeth under similar clinical circumstances.¹¹ This success correlates directly with A-PRF's ability to enhance angiogenesis through sustained VEGF release and provide the cellular scaffolding necessary for successful pulpal revascularization. The growth factor concentration within A-PRF membranes creates conditions that promote endothelial cell proliferation and capillary formation essential for pulpal healing.

The systematic management of complications in teeth 32 and 41 through A-PRF-enhanced interventions transformed potential treatment failures into long-term successes. The biological enhancement provided by A-PRF during intentional replantation procedures created microenvironmental conditions that supported tissue regeneration even when conventional healing was compromised.¹² The concurrent use of zinc bioactive glass during apicectomy procedures provided additional antimicrobial and osteoconductive properties, enhancing periapical healing through controlled ion release and bioactive surface interactions. This dual biological enhancement approach demonstrates the synergistic potential of combining advanced biomaterials in complex dental trauma management. This finding supports the concept that biological enhancement can overcome traditional limitations in complex replantation scenarios.

The absence of replacement resorption and ankylosis across all replanted teeth suggests that A-PRF fundamentally altered the inflammatory response and healing cascade typically associated with delayed replantation. Contemporary research demonstrates that platelet-rich fibrin (PRF) applications consistently reduce complications and enhance tissue regeneration through modulation of inflammatory cytokines and promotion of anti-inflammatory mediators.¹³ The bioactive molecules within A-PRF appear to create conditions favoring organized tissue repair over pathological healing responses.

Recent advances in PRF technology, including injectable formulations with enhanced clinical handling characteristics, suggest potential for further optimization of these protocols.¹⁴ The versatility of PRF across multiple dental applications, from alveolar osteitis management to complex oral surgery procedures, supports its broader integration into contemporary dental trauma protocols.¹⁵

Conclusion

This case demonstrates A-PRF as a transformative intervention in multiple tooth avulsion management, achieving unprecedented 100% survival rates and maintaining pulp vitality. The sustained growth factor release fundamentally enhanced healing outcomes, providing clinicians with a reproducible, cost-effective method for complex trauma cases. These exceptional results strongly support A-PRF integration into standard protocols and warrant randomized controlled trials to establish evidence-based clinical guidelines.

Clinical Significance

This case demonstrates exceptional clinical significance by achieving 100% tooth survival vs conventional 15−30% success rates in multiple avulsion management. The preservation of pulp vitality, occurring in <20% of similar cases, and the complete absence of ankylosis represent remarkable biological enhancement. This provides critical evidence for standardized A-PRF protocols in pediatric dental trauma management

Orcid

Tarannum Rehaman https://orcid.org/0009-0007-7773-3973

Abhishta Kanugula https://orcid.org/0009-0006-9491-2490