Apicoectomy versus apical curettage in combination with or without L-PRF application: a randomized clinical trial

This study compared the efficacy of apicoectomy and apical curettage with and without leukocyte- and platelet-rich fibrin (L-PRF) in treating large periapical lesions. Sixty-four adults (30 male, 34 female) with a previously endodontically treated tooth and a large periapical lesion were randomized into four groups (n = 16): retrograde obturation (RG), orthograde obturation (OG), RG + L-PRF, and OG + L-PRF. All participants underwent root canal retreatment in two sessions. The RG group underwent root-end resection and retrograde MTA obturation, the RG + L-PRF group underwent L-PRF application to the bone defect following the RG protocol, the OG group underwent orthograde MTA obturation and periapical curettage without root-end resection, and the OG + L-PRF group underwent L-PRF application following the OG protocol. Clinical and radiographic assessments were performed preoperatively, and at 1 week and 1, 3, 6, 9, and 12 months postoperatively. At follow-up visits, pain scores, swelling, tooth mobility, tenderness to percussion (T-PER), tenderness to palpation (T-PAL), and the presence of fistula were clinically assessed. Periapical radiography determined the periapical index (PAI) score and measured the periapical lesion area (PALA). The Kruskal–Wallis test was performed to test the effect of a single independent variable (factor) on a dependent variable. No statistically significant differences were identified between the groups for preoperative PAI scores, pain scores, swelling, tooth mobility, fistula, T-PER, or T-PAL (p > 0.05). At postoperative week 1, the RG + L-PRF group showed a significantly lower T-PER. The RG + L-PRF group showed significantly lower PALA values and significantly higher PALA healing rates at postoperative 1, 6, and 9 months. Both L-PRF groups achieved PALA healing rates of over 90% at 9 months. It was concluded that a combination of apicoectomy and L-PRF effectively treats periapical lesions and promotes both short- and long-term healing and that a combination of periapical curettage and L-PRF offers a less invasive alternative, especially when the crown-to-root ratio is a concern. Trial registration: The protocol was registered at ClinicalTrials.gov (NCT05847647).