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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 309-313

Multidisciplinary approach in the management of large infected periapical cystic lesion in the mandibular anterior region with platelet-rich fibrin


1 Department of Pedodontics and Preventive Dentistry, Meghna Institute of Dental Sciences, Nizamabad, Telangana, India
2 Department of Oral and Maxillofacial Surgery, Meghna Institute of Dental Sciences, Nizamabad, Telangana, India
3 Department of Pedodontics and Preventive Dentistry, KLE VK Institute of Dental Sciences, Belagavi, Karnataka, India

Date of Submission26-Apr-2022
Date of Acceptance16-May-2022
Date of Web Publication17-Sep-2022

Correspondence Address:
Dr. Kiranmayi Thote
Department of Pedodontics and Preventive Dentistry, Meghna Institute of Dental Sciences, Mallaram, Nizamabad - 503 230, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_315_22

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  Abstract 


Periapical cysts are considered as the most prevalent odontogenic cystic lesions of the jaws. These cystic lesions are usually asymptomatic; however, once infected, they result in tumefaction of the affected region. Current noninvasive diagnostic methods such as computed tomography, magnetic resonance imaging, and cone-beam computed tomography help in accurate assessment of size and nature of these lesions, which determine proper treatment planning and prognosis of the affected tooth. Management of these cystic lesions depends upon their extent. Periapical localized cysts can be managed by nonsurgical root canal therapy, whereas large periapical cysts require multidisciplinary approach involving an endodontist and an oral surgeon. Accelerated healing of soft and hard tissues near these lesions can be done using tissue engineering scaffolds such as platelet-rich fibrin and platelet-rich plasma. This case report presents successful multidisciplinary management of a large infected periapical cyst which was associated with mandibular incisors.

Keywords: Cone-beam computed tomography, endodontic therapy, enucleation, infected radicular cyst, plasma-rich fibrin, tissue regeneration


How to cite this article:
Thote K, Reddy P V, Teji P A, Hugar SM. Multidisciplinary approach in the management of large infected periapical cystic lesion in the mandibular anterior region with platelet-rich fibrin. Indian J Health Sci Biomed Res 2022;15:309-13

How to cite this URL:
Thote K, Reddy P V, Teji P A, Hugar SM. Multidisciplinary approach in the management of large infected periapical cystic lesion in the mandibular anterior region with platelet-rich fibrin. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 Sep 25];15:309-13. Available from: https://www.ijournalhs.org/text.asp?2022/15/3/309/356276




  Introduction Top


The most commonly occurring odontogenic cystic lesions of the jaws are radicular cysts.[1] Based on the size, location of the lesion, and its proximity to vital structures, the management of these lesions varies, i.e., it might be conservative nonsurgical or surgical procedure.[2] Proper diagnosis of the extent of these lesions plays a major role in their treatment planning. Recent advancements in radiographic diagnostic aids such as cone-beam computed tomography (CBCT) helps in diagnosing the lesion in all three dimensions providing undistorted information of the hard tissues.[3] Along with proper diagnosis and treatment planning, regenerative biomaterials such as platelet-rich fibrin (PRF), platelet-rich plasma, and bone grafts help in accelerated bone regeneration and healing process.[4] The following case report presents multidisciplinary approach in the treatment of radicular cyst both endodontically and surgically along with using PRF.


  Case Report Top


A 12-year-old female patient reported to the outpatient department of pediatric and preventive dentistry with the chief complaint of swelling and pain near the chin region. The patient gave a history of trauma to lower front tooth 1 year back. On extraoral examination, a diffuse swelling was present near the mandibular anterior region extending anterioposteriorly which on palpation was firm in consistency and tender with slight rise in temperature [Figure 1]. On intraoral examination, grade I mobility of the mandibular incisors (tooth no. 31, 32, and 41) was present, and no swelling or sinus tract opening was noticed near the buccal vestibule [Figure 2]. Lymph nodes were not palpable.
Figure 1: Preoperative images: Extraoral swelling noticed near chin region

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Figure 2: Preoperative images: No swelling or sinus tract opening noticed intraorally. Significance of red arrow indicates resorption area of periapical cyst

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The patient was advised a CBCT of the mandibular anterior region. On radiographic evaluation, large unilocular radiolucency with well-defined borders was seen. CBCT evaluation helped in assessing the lesion in all three dimensions including the extent of the lesion which was about 1.5 cm mesiodistally, about 2 cm superior-inferiorly, and about 2 cm labiolingually [Figure 3], [Figure 4], [Figure 5]. On carrying out the electric pulp testing, negative response was noticed in relation to the mandibular right and left incisors (tooth no. 31, 32, and 41), indicating that pulp is nonvital for these teeth.
Figure 3: Preoperative images: Cone-beam computed tomography showing radiolucency near periapical region of 31, 32, and 41 – sagittal plane. Significance of red arrow indicates resorption area of periapical cyst

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Figure 4: Preoperative images: Cone-beam computed tomography showing radiolucency near periapical region of 31, 32, and 41- coronal plane. Significance of red arrow indicates resorption area of periapical cyst

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Figure 5: Preoperative images: Cone-beam computed tomography showing radiolucency near periapical region of 31, 32, and 41. Significance of red arrow indicates resorption area of periapical cyst

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Endodontic treatment of 31, 32, and 41 was planned under local anesthesia followed by enucleation procedure [Figure 6]. Under proper sterile conditions and adequate anesthesia, crevicular incisions were placed from the right mandibular canine to the left mandibular canine. After the incision, full-thickness mucoperiosteal flap was elevated, leading to the identification of cystic lesion. The cystic fluid was drained out and the cystic lining was completely removed [Figure 7] and [Figure 8]. Removal of the diseased bone was carried out using bone rongeur. As the cystic lesion was larger in size, PRF with freeze-dried bone graft was planned to be placed. As the patient's socioeconomic status was poor, they did not gave consent for bone graft placement. Hence, PRF was placed in the residual socket and suturing was done using vicryl 3-0 suturing material [Figure 9] and [Figure 10].
Figure 6: Intraoral periapical radiograph of endodontically treated 31, 32, and 41

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Figure 7: After enucleation procedure

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Figure 8: Cystic lesion

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Figure 9: Platelet-rich fibrin placement done

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Figure 10: Suturing done

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Protocol followed for preparation of platelet-rich fibrin

First step for preparation of PRF was to collect whole venous blood into vacutainer tubes (6 ml), with no anticoagulant placed in these tubes. These tubes were then placed in a centrifuge machine at 3000 revolutions per minute for 10 min. After this, the blood in the tubes settled as three layers, upper layer consisting of straw-colored acellular plasma, middle layer consisting of fibrin clot, and lower layer consisting of red blood cells. The middle layer consisted of numerous platelets embedded in the fibrin mesh work which was used as PRF.

The patient was kept under antibiotics and analgesics and recalled for follow-up after 1 week, 1 month, and 3, 6, and 12 months. During follow-up, the patient was symptomless and showed healing on radiographic evaluation [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15].
Figure 11: Reduced swelling noticed near chin region

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Figure 12: Complete healing of surgical site postoperatively after 1 month

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Figure 13: Orthopantamogram after 6 months of follow-up

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Figure 14: Mandibular occlusal view radiograph after 9 months of follow-up

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Figure 15: IOPA of 31, 32,41 after 12 months of follow-up

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  Discussion Top


Radicular cysts are considered as one of the most commonly occurring cystic lesions of the jaw.[1] The main etiological factors for these lesions are trauma or dental caries. In the present case, the patient gave a history of trauma 1 year back. The management of these lesions includes conventional nonsurgical root canal therapy when lesions are localized, or if the lesions are larger in size, procedures such as enucleation, marsupilization, or decompression techniques can be performed.[5] In the present case report, multidisciplinary approach was followed starting with root canal treatment of offending tooth 31, 32, and 41 followed by surgical enucleation procedure and placement of PRF in the bony defect.

In the present case, diagnosis of the lesion was done using CBCT which helped in assessing cystic lesion three-dimensionally with undistorted hard tissue findings. Thus, accurate assessment of the size, shape, width, and depth of the lesion was done which helped in proper treatment planning.[6] However, there are some limitations of using it in soft tissue imaging and high radiation dose.

PRF consists of natural framework of fibrin, with a specific property of slow release of growth factors.[7] Growth factors such as platelet-derived growth factor and transforming growth factors are released from PRF.[8] PRF can guide healing process as it can upregulate phosphorylated extracellular signal-regulated protein kinase expression, and it also suppresses osteoclastogenesis by promoting the secretion of osteoprotegerin.[9] By considering these properties of PRF, it was used as a biomaterial for periapical tissue regeneration in the present study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given their consent for her images and other clinical information to be reported in the journal. The patient's parents understand that her name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nair PN. New perspectives on radicular cysts: Do they heal? Int Endod J 1998;31:155-60.  Back to cited text no. 1
    
2.
Bodner L. Cystic lesions of the jaws in children. Int J Pediatr Otorhinolaryngol 2002;62:25-9.  Back to cited text no. 2
    
3.
Simon JH, Enciso R, Malfaz JM, Roges R, Bailey-Perry M, Patel A. Differential diagnosis of large periapical lesions using cone-beam computed tomography measurements and biopsy. J Endod 2006;32:833-7.  Back to cited text no. 3
    
4.
Borie E, Oliví DG, Orsi IA, Garlet K, Weber B, Beltrán V, et al. Platelet-rich fibrin application in dentistry: A literature review. Int J Clin Exp Med 2015;8:7922-9.  Back to cited text no. 4
    
5.
Ribeiro PD, Gonçalves ES, Neto ES, Pacenko MR. Surgical approaches of extensive periapical cyst. Considerations about surgical technique. Salusvita 2004;23:317-28.  Back to cited text no. 5
    
6.
Scarfe WC, Farman AG, Sukovic P. Clinical applications of cone-beam computed tomography in dental practice. J Can Dent Assoc 2006;72:75-80.  Back to cited text no. 6
    
7.
Dohan Ehrenfest DM, Diss A, Odin G, Doglioli P, Hippolyte MP, Charrier JB. In vitro effects of Choukroun's PRF (platelet-rich fibrin) on human gingival fibroblasts, dermal prekeratinocytes, preadipocytes, and maxillofacial osteoblasts in primary cultures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:341-52.  Back to cited text no. 7
    
8.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part II: Platelet-related biologic features. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e45-50.  Back to cited text no. 8
    
9.
Chang IC, Tsai CH, Chang YC. Platelet-rich fibrin modulates the expression of extracellular signal-regulated protein kinase and osteoprotegerin in human osteoblasts. J Biomed Mater Res A 2010;95:327-32.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]



 

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