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Year : 2016  |  Volume : 19  |  Issue : 5  |  Page : 688-691

Platelet-rich fibrin combined with synthetic nanocrystalline hydroxy apatite granules in the management of radicular cyst

1 Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal, Karnataka, India
2 Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal, Karnataka, India

Date of Acceptance20-Apr-2015
Date of Web Publication19-Aug-2016

Correspondence Address:
K Pradeep
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal - 576 104, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1119-3077.188711

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Radicular cysts are inflammatory jaw cysts confined to the apices of teeth with infected and necrotic pulp. They arise from the epithelial residues in the periodontal ligament as a result of inflammation, following the death of pulp. The treatment of such lesions vary with regard to their sizes; the small cystic lesions heal after an endodontic therapy, but larger lesions, may require additional treatment. Apical surgery for radicular cysts generally involves apical root resection and sealing with endodontic material. This case report, describes the treatment of a cyst related to the maxillary central and lateral incisors using platelet rich fibrin along with synthetic nanocrystalline hydroxyapatite granules for the regeneration of lost tissues. A follow-up evaluation at 6 months and 1-year revealed a significant radiographic bone fill with satisfactory healing at the surgical site.

Keywords: Hydroxyapatite granules, platelet rich fibrin, radicular lesion

How to cite this article:
Pradeep K, Kudva A, Narayanamoorthy V, Cariappa K M, Saraswathi M V. Platelet-rich fibrin combined with synthetic nanocrystalline hydroxy apatite granules in the management of radicular cyst. Niger J Clin Pract 2016;19:688-91

How to cite this URL:
Pradeep K, Kudva A, Narayanamoorthy V, Cariappa K M, Saraswathi M V. Platelet-rich fibrin combined with synthetic nanocrystalline hydroxy apatite granules in the management of radicular cyst. Niger J Clin Pract [serial online] 2016 [cited 2022 Oct 6];19:688-91. Available from:

   Introduction Top

Radicular cysts are common inflammatory cystic lesions that develop in the apical tissues as a consequence of an infected and necrotic pulp.[1] Most of them are asymptomatic and are noticed when teeth with nonvital pulp are subjected to periapical radiographs. However, some patients may complain of a slowly progressive swelling. The radiographic appearances of most radicular cysts are round or pear shaped unilocular radiolucent lesions enclosing the periapical region of the affected tooth/teeth. The cyst may displace adjacent teeth or cause mild root resorption.[2] Although in most cases small cystic lesions heal after endodontic therapy while, in larger lesions, additional treatment may be needed.[3]

Traditional surgical approach to treating periapical defects include debridement of apical lesions along with reshaping of the surrounding bone, resection, and retro filling of root apex, where healing is almost always by repair.[4] Repair is defined as the healing of a wound by tissue that does not fully restore the architecture or the function of the part.[5] Since, repair is not an ideal outcome of wound healing, newer approach such as regenerative procedures aimed to restoring lost tissue have been introduced. Regenerative therapies involving the use of osseous grafts and barrier membranes have been considered for optimal healing of the periapical lesions.[6]

Porous hydroxyapatite (HA) has been used to fill the periodontal intrabony defects resulting in clinically acceptable response.[5] There is evidence that porous HA bone grafts have excellent bone conductive properties, which promotes the outgrowth of osteogenic cells from existing bone surfaces into the adjacent bone material.[6] Barrier membranes are an inert material that maintains a confined space, which is one of the key biological requirements for bone regeneration.[7] Platelet rich fibrin (PRF) is both a healing and a barrier biomaterial. As a healing material, it accelerates wound closure and mucosal healing due to fibrin bandage and growth factor release. As a barrier material, it avoids the early invagination of undesired cells, thereby behaving as a competitive barrier between desired and undesired cells.[8] Hence, this case is being reported to provide additional scientific information related to the combined use of graft material and barrier membrane in the treatment of periapical lesions.

   Case Report Top

A 32-year-old female patient visited the Department of Endodontics with a chief complaint of pain of 3 months duration in the premaxilla region. The pain was explained as dull and nonradiating in nature. The patient had no contributory medical condition. Dental history revealed that fixed restorations were provided for teeth in the premaxilla region 5 years prior. Clinical examination revealed an ill-fitting acrylic bridge in relation to teeth no. 11, 21, 22 and a dislodged acrylic crown in relation tooth no. 23 [Figure 1]a. Radiographic evaluation of the maxillary anterior teeth, revealed a large periapical unilocular radiolucency with sclerotic border in relation to teeth no. 11 and 21 [Figure 1]b. Further, the acrylic prostheses was removed to determine the vitality of teeth no. 11, 21, 22 and 23; they all presented negative response to the test [Figure 1]c.
Figure 1: (a) Preoperative clinical picture. (b) preoperative, intra oral radiography. (c) Stabilization with splints

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Teeth no. 11, 21 and 22 were nontender to percussion but grade II mobility was elicited. Based on the details obtained from the patient's history, clinical examination and investigations, a provisional diagnosis of infected radicular cysts in tooth no. 22 was made.

A treatment plan was constituted, in which the affected teeth would undergo root canal therapy followed by surgical intervention. However, prior to the commencement of treatment, the mobile teeth were splinted using a 24 gauuge wire and composite resin [Figure 1]c to ensure stability during healing. The root canal treatment was performed teeth no. 11, 21, 22 and 23, using the step back technique until an apical size of no. 50 was obtained. Sodium hypochlorite solution (Novo Dental Product Pvt Ltd., Mumbai, India) of concentration 5.25% was used as canals irrigant during the biomechanical preparation. The root canal treatment was performed in three visits and calcium hydroxide paste with iodoform (Diapex plus, Diadent group International, South Korea) was used as intracranial medicament between appointments. The root canals were obturated using gutta percha (Dentsply Maillefer Ballaigues) and AH 26 (Dentsply DeTrey GmbH, Philadelphia, USA) by the cold lateral compaction technique [Figure 2]a.
Figure 2: (a) Completion of root canal treatment. (b) Full thickness flap elevated. (c) Root end sealing completed using mineral trioxide aggregate

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The patient was scheduled for surgery at the following visit, prior to which a complete hemogram was done, with all the parameters within normal limits. The surgery was performed under aseptic conditions. Under local anaesthesia (1:2,00,000 adrenaline, Neon Lab, India), a full thickness mucoperiosteal flap was reflected by a sulcular incision extending from Sdistal to tooth no. 11 to the distal aspect of tooth no. 23 [Figure 2]b. The defect was debrided and a large periapical cystic lesion was observed with complete loss of labial cortical plate. The enucleated cystic specimen was sent for histo-pathologic examination. Following which a no. 702 tapered fissure bur (SS White burs) was used to the root end of teeth no. 21 and 22. Gray mineral trioxide aggregate (MTA) (ProRoot MTA; Dentsply, Tulsa, OK, USA) was used as the root end filling material [Figure 2]c.

Platelet rich fibrin was prepared in accordance with the protocol developed by Freymiller and Aghaloo [9] from 20 mL of blood drawn from the patient's antecubital vein and centrifuged (REMI centrifuge machine Model R-8c) for 10 min under 3000 revolutions (approximately 400 g) per min to obtain the PRF.

Commercially available HA nanocrystal granules (Biograft HA, Nano, IFGL Bioceramics Ltd., India) were mixed with PRF and placed into the defect [Figure 3]a and [Figure 3]b. The flap was approximated and sutured with a 3–0 black silk suture material (Sutures India Pvt. Ltd, Karnataka, India) [Figure 3]c. The patient was prescribed antibiotic (Augmentin – 625 mg BD for 5 days) along with anti-inflammatory (Combiflam Tab, Sanofi India TID for 5 days). The patient was also advised to use 0.2% chlorhexidine gluconate mouth rinse for a week. At recall appointment after 1-week the sutures were removed; revealing an uneventful healing process.
Figure 3: (a) Hydroxy apatite nano crystalline graft material mixed with platelet rich fibrin (PRF). (b) Hydroxy apatite nano crystalline graft material along with PRF by placing over the defect. (c) Sutures placed

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The patient was reviewed at 6 months and 1-year period during which there were no reports of pain, inflammation, or discomfort [Figure 4]a. The follow-up visits, included routine intraoral examinations and professional plaque control measures. Radiographic examination revealed satisfactory bone fill [Figure 4]b and [Figure 4]c. The patient was completely satisfied with the results of the treatment and is still on maintenance and recall schedule. The histopathology report confirmed the provisional diagnosis of an infected radicular cyst.
Figure 4: (a) Postoperative clinical picture. (b) 6 months follow-up orthopantomogram (OPG). (c) 1 year follow-up OPG

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   Dicussion Top

The regeneration of bone after periapical surgery depends primary wound closure, angiogenesis of vessels, source of undifferentiated mesenchymal cells, space maintenance and stability of the wound.[10] The most commonly used technique for regeneration involves the use of osseous grafts which aids in tissue or bone regeneration through a variety of mechanisms. HA has shown very good results with respect to periodontal and periapical bone regeneration. Literature review reported that a combination of HA and PRF resulted in greater pocket depth reduction, a gain in clinical attachment and better defect fill than PRF used alone.[11] Thus, HA was selected, to enhance the effects of PRF by maintaining the space for tissue regeneration and osteoconductive effects in the bony defect area. Bone grafts alone without a blood clotting factor are unlikely to promote periapical wound healing.[12] Biologically, blood clot is a better space filler than all bone grafting materials. A blood clot is the host's own biologic product which plays a major role in wound healing.[13]

When PRF is used along with bone grafts, it offers several advantages like promoting wound healing, bone growth and maturation, graft stabilization, wound sealing, haemostasis and improving the handling properties of graft materials.[13] The PRF is a concentrate of growth factors like platelet-derived growth factor (PDGF), transforming growth factor (TGF)-beta and insulin-like growth factor (IGF), which play a major role in wound healing.

In vivo application of PDGF increased bone regeneration in calvarial defects when a bio-absorbable membrane is used as a carrier.[14] The growth factor TGF-stimulates bio-synthesis of type I collagen and induces deposition of bone matrix in vitro,[15] but when applied with a biodegradable osteogenic material, bone growth around calvarial defects increased significantly.[16] The IGF-I is synthesized and secreted by osteoblasts;[17] stimulating bone formation by proliferation and differentiation.[18] Since the surface of PRF membrane is smoother, it can cause superior proliferation of human cells, which enhances bone regeneration.[19] The progressive polymerization mode of coagulation in PRF helps in the increased incorporation of the circulating cytokines into the fibrin meshes (intrinsic cytokines) which helps in wound healing by moderating the inflammation.[20],[21]

The advantages of PRF amongst others lies in its preparation; which is simple, easy, less time consuming and cost effective. As a by-product of patient's own blood, the chances of infectious diseases transmission are rare. It promotes a more efficient cell migration and proliferation. It also helps in haemostasis. The PRF prevents early invagination of undesired cells as interpositional material; eliminating the need for a separate barrier membrane at the time of closure.[21] The PRF used in this case report has proven to be a favourable bone regeneration material along with an interpositional material. This eliminates the use of expensive bone grafts and barrier membranes, which makes the treatment cost for patients prohibitive. When compared to bone grafts, PRF has shown good results which enhance accelerate and organize bone regeneration.[21]

   References Top

Sagit M, Guler S, Tasdemir A, Akf Somdas M. Large radicular cyst in the maxillary sinus. J Craniofac Surg 2011;22:e64-5.  Back to cited text no. 1
Shear M. Radicular and residual cysts. In: Bristol W, editor. Cyst of the Oral Region. 3rd ed. UK: John wright and son;1992. p. 136-62.  Back to cited text no. 2
Martin SA. Conventional endodontic therapy of upper central incisor combined with cyst decompression: A case report. J Endod 2007;33:753-7.  Back to cited text no. 3
Bashutski JD, Wang HL. Periodontal and endodontic regeneration. J Endod 2009;35:753-7.  Back to cited text no. 4
American Academy of Periodontology. Glossary of Periodontal Terms. Chicago, Ill, USA: American Academy of Periodontology; 2001.  Back to cited text no. 5
Demiralp B, Keçeli HG, Muhtarogullar M, Serper A, Demiralp B, Eratalay K. Treatment of periapical inflammatory lesion with the combination of platelet-rich plasma and tricalcium phosphate: A case report. J Endod 2004;30:796-800.  Back to cited text no. 6
Carranza FA, Newman MG, Takei HH, Klokkevold PR. Carranza's Clinical Periodontology. 10th ed. Saunders, Elsevier publication St Louis Mo: Localized bone augmentation and implant site development; 2006. p. 1134.  Back to cited text no. 7
Del Corso M, Sammartino G, Dohan Ehrenfest DM. Re: Clinical evaluation of a modified coronally advanced flap alone or in combination with a platelet-rich fibrin membrane for the treatment of adjacent multiple gingival recessions: A 6-month study. J Periodontol 2009;80:1694-7.  Back to cited text no. 8
Freymiller EG, Aghaloo TL. Platelet-rich plasma: Ready or not? J Oral Maxillofac Surg 2004;62:484-8.  Back to cited text no. 9
Boyapati L, Wang HL. The role of stress in periodontal disease and wound healing. Periodontol 2000 2007;44:195-210.  Back to cited text no. 10
Pradeep AR, Bajaj P, Rao NS, Agarwal E, Naik SB. Platelet-rich fibrin combined with a porous hydroxyapatite graft for the treatment of three-wall intrabony defects in chronic periodontitis: A randomized controlled clinical trial. J Periodontol 2012;83:1499-507.  Back to cited text no. 11
Laurell L, Gottlow J. Guided tissue regeneration update. Int Dent J 1998;48:386-98.  Back to cited text no. 12
Sunitha Raja V, Munirathnam Naidu E. Platelet-rich fibrin: Evolution of a second-generation platelet concentrate. Indian J Dent Res 2008;19:42-6.  Back to cited text no. 13
Chung CP, Kim DK, Park YJ, Nam KH, Lee SJ. Biological effects of drug-loaded biodegradable membranes for guided bone regeneration. J Periodontal Res 1997;32:172-5.  Back to cited text no. 14
Pfeilschifter J, Oechsner M, Naumann A, Gronwald RG, Minne HW, Ziegler R. Stimulation of bone matrix apposition in vitro by local growth factors: A comparison between insulin-like growth factor I, platelet-derived growth factor, and transforming growth factor beta. Endocrinology 1990;127:69-75.  Back to cited text no. 15
Arnaud E, Morieux C, Wybier M, de Vernejoul MC. Potentiation of transforming growth factor (TGF-beta 1) by natural coral and fibrin in a rabbit cranioplasty model. Calcif Tissue Int 1994;54:493-8.  Back to cited text no. 16
Hock JM, Centrella M, Canalis E. Insulin-like growth factor I has independent effects on bone matrix formation and cell replication. Endocrinology 1988;122:254-60.  Back to cited text no. 17
Baker NL, Carlo Russo V, Bernard O, D'Ercole AJ, Werther GA. Interactions between bcl-2 and the IGF system control apoptosis in the developing mouse brain. Brain Res Dev Brain Res 1999;118:109-18.  Back to cited text no. 18
Gassling V, Douglas T, Warnke PH, Açil Y, Wiltfang J, Becker ST. Platelet-rich fibrin membranes as scaffolds for periosteal tissue engineering. Clin Oral Implants Res 2010;21:543-9.  Back to cited text no. 19
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part III: Leucocyte activation: A new feature for platelet concentrates? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e51-5.  Back to cited text no. 20
Toffler M, Toscano N, Holtzclaw D, Corso MD, Dohan Ehrenfest DM. Introducing Choukron's platelet rich fibrin (PRF) to the reconstructive surgery. Milieu J Implant Adv Clin Dent 2009;1:21-30.  Back to cited text no. 21


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