USE OF PLATELET RICH PLASMA IN Clinical Report

BONE REGENERATION AFTER CYST ENUCLEATION:

SACHIN DALAL* , PARTH RAVAL** , SAURABH JAIN*** , NEHA VYAS****

ABSTRACT
Platelet rich plasma (PRP) is a wonderful tissue engineering product and has gained much popularity due its promising
results in wound healing. PRP being a rich source of autologous growth factors can be used in many areas of oral and
maxillofacial surgery. In the last 5 years, many studies about autogenous platelet-rich plasma have been undertaken
pointing out its regenerative and reparative properties on tissues. The features of this product are an attribute of platelet
cells, which, after cellular interactions, release growth factors. These molecules promote tissue healing and also induce
cellular regeneration. Autologous platelet gel or concentrate (PRP) can be used alone or in association with bone graft
for the treatment of bony defect, cystic lesions, alveolar bone defects, and periodontal pockets and particularly in
patients with coagulation diseases. We present a case illustrating the use of PRP in bony regeneration after enucleation
of dentigerous cyst in anterior maxilla.

KEY WORDS: PRP ( Platelet rich plasma ), Dentigerous cyst, Growth factors, wound healing.

INTRODUCTION approximately 20-24% of all epithelial lined jaw

1
Marx et al. (1998) have proposed the use of PRP as
a viable technique to obtain a high concentration of
growth factors (GFs). Autologous Platelet Rich
Plasma is a novel method for obtaining autologous
platelet growth factors (PGFs), especially for
platelet derived growth factor (PDGF) and
transforming growth factor ß (TGF ß). PRP use is a
way to accelerate and enhance body’s natural
wound-healing mechanisms. The added benefit of
PRP is its ability to form a biologic gel that may
provide containment, clot stability and function as
an adhesive. An important decrease in healing time
of bone grafts was shown when they are used in
combination with PRP.1,2
PRP is well known for its advanced healing
properties and when mixed with bone graft
enhances the bony regeneration compared to the use
of bone grafts alone. Numerous reports have shown
that the use of PRP facilitates clinical handling of
3,4
graft material.
Dentigerous cyst is common developmental
odontogenic cyst of jaws and accounts for
cyst. The predilection site of dentigerous cyst is the
mandibular third molar. Other frequent sites include
maxillary canines, maxillary third molars and
mandibular second premolar. It is always associated
with any unerupted teeth, usually attached to the
tooth at the cemento-enamel junction.5
Radiographically, the dentigerous cyst typically
shows a unilocular radiolucent shadow with a well-
defined sclerotic border associated with the crown
of an unerupted tooth, but an infected cyst will show
ill-defined borders.5
Here, we describe a case of dentigerous cyst in
anterior maxilla (in relation to impacted right
maxillary canine) treated with its enucleation
followed by filling the defect with autologous bone
graft and platelet rich plasma.
CASE REPORT
A 21 yrs old female patient reported to the
Department Of Oral And Maxillofacial Surgery,
Ahmedabad Dental College with chief complain of

*Reader (Dept of Oral and Maxillofacial Surgery) **Post graduate (Dept of Oral and Maxillofacial Surgery)
***Senior Lecturer (Dept of Oral and Maxillofacial Surgery) ****Professor & Head (Dept of Oral and Maxillofacial Surgery)
AHMEDABAD DENTAL COLLEGE & HOSPITAL, BHADAJ-RANCHHODPURA ROAD, TA:- KALOL DIST:-GANDHINAGAR.

The Journal of Ahmedabad Dental College and Hospital; 2(1), March 2011 - August 2011 35
 SACHIN DALAL et. al. : Use of Platelet Rich Plasma in Bone Regeneration After Cyst Enucleation:

swelling in upper right front tooth region since last 2

months. The patient was relatively asymptomatic
some 2 months back when she noticed a non- tender
swelling present at upper right vestibule region.
Patient gives history of pus discharge from upper
right deciduous canine region since last 1 month.
No relevant dental, medical, & family history was
found. Vitals were within normal limit.

On extra oral examination, there was a single,

diffuse swelling with smooth overlying skin,
extending antero-posteriorly from right ala of nose
to the lateral canthus of eye and superior-inferiorly
from right ala of nose to right commisure of lip. Figure-2: Bony defect after cyst enucleation
Obliteration of right Nasolabial fold was evident.
There was no anaesthesia/paresthesia of associated with peripheral osteotomy was done. Defect was
region. On palpation swelling was firm, non filled with the mixture of autologous bone graft and
fluctuant, non pulsatile, non tender, non translucent. platelet rich plasma.
Both right and left submandibular lymphnodes
were enlarged, tender on palpation, and not fixed to
underlying structures.

On intraoral inspection, there was obliteration of

vestibule from 11 to 15 region with single, well
defined, oval swelling of size 2×1cm, with normal
overlying mucosa. Mouth opening was recorded as
38 mm. 13 was clinically missing. On palpation
buccal plate was found to be expanded. The
swelling was firm, non pulsatile and non fluctuant.

OPG shows well defined radiolucency with

sclerotic borders, of size approximately 2x1cm in
relation to 11,12,53,14,15. Impacted right maxillary Figure-3: Cystic cavity filled with mixture of PRP and autologous bone grafts
canine and resorption of root of 53 was also evident.
METHOD OF PREPARATION OF PRP

Figure-1: Orthopantomograph of the patient showing cystic lesion

associated with the right impacted canine

Patient was operated under general anaesthesia and

enucleation of cyst
Figure-4: Method of preparation of platelet rich plasma

The Journal of Ahmedabad Dental College and Hospital; 2(1), March 2011 - August 2011 36
 SACHIN DALAL et. al. : Use of Platelet Rich Plasma in Bone Regeneration After Cyst Enucleation:

10 ml patient’s blood was taken from median first month ,

cephalic vein of right arm with the help of 18 gauze
needle and 10 ml syringe which was then added in
test tube containing anticoagulant solution (Sodium
citrate). These test tubes were then centrifuged at
1200rpm for 10 mins. After the first centrifugation,
plasma and RBC’s were separated. Plasma, layer of
buffy coat and some amount of RBC’s were
aspirated with the help of spinal needle and 10cc
syringe and were emptied in plain test tube without
any anti- coagulant. This test tube was again
centrifuged at 2400rpm for 10 mins. After second
centrifugation platelet poor plasma and platelet rich
rd
plasma got separated. Upper 2/3 of the solution
containing platelet poor plasma was aspirated out. Figure-6: IOPA at one month
Platelet rich plasma was made into gel form with the
help of addition of 3-4 drops of Calcium chloride. and third month .

The prepared PRP gel and autologous bone graft

were mixed and placed in the defect. Postoperative
antibiotics were prescribed for 7 days.

Histopathological analysis was suggestive of the

lesion being dentigerous cyst.

Regular follow up with IOPA x-rays were taken at

immediate postoperative day,

Figure-7: IOPA at 3 month

Promising result with fast and good quality bony

regeneration was observed.

DISCUSSION

The dentigerous cyst is the second most common

Figure-5 : IOPA at immediate post operative day
odontogenic cyst of jaws. It presents mostly in the
second or third decade of life in the maxillary or
mandibular third molar or maxillary canine regions.
Most of the times it is found to be quite large in size,
resulting in large bony defects following
enucleation which takes long time for bony
regeneration and filling of the defect. Till this
4
happens the risk of pathologic fracture is also high.

Researchers continuously strive to improve bone-

grafting techniques and to provide the means to
obtain a faster and denser bony regeneration. Marx

The Journal of Ahmedabad Dental College and Hospital; 2(1), March 2011 - August 2011 37
 SACHIN DALAL et. al. : Use of Platelet Rich Plasma in Bone Regeneration After Cyst Enucleation:
1
et al. (1998) have proposed the use of platelet-rich
plasma (PRP) as a viable technique to obtain a high
concentration of growth factors (GFs). These
authors observed that autogenous bone grafts
matured faster when combined with PRP to treat
mandibular defects resulting from the removal of
benign and malignant tumours.
PRP is a blood derivative, generated by differential
centrifugation, in which platelets are concentrated
in a small plasma volume (Roussy et al. 2007).2 The
use of PRP is based on the premise that platelets
constitute a reservoir of critical GFs, such as
platelet-derived growth factor (PDGF),
transforming growth factor-b (TGF-b), insulin-like
growth factor-I (IGF-I) and vascular endothelial
growth factor (VEGF), which, once released, may
positively regulate the wound-healing process
(Marx 2001, 2004, Roussy et al. 2007).1,2
Bone is a dynamic tissue subject to balanced
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The Journal of Ahmedabad Dental College and Hospital; 2(1), March 2011 - August 2011
processes of bony formation and resorption;
autologous platelet gel or concentrate PRP can be
used alone or in association with bony graft for the
6,7
treatment of bony defect, cystic lesions ,
8 10
periodontal pockets and extraction sockets .
Rutkowski et al10 conducted study on extraction
sockets and found that the control sites required 16
weeks to reach the same degree of radiographic
density for the total extraction socket as the PRP
treatment achieved in 8 weeks. This is of clinical
significance because it indicates more rapid healing
at the PRP-treated sites
Present case is an excellent example of benefits of
PRP on autologous bone grafts. This case also
provides us alternative reconstructive option over
routine treatment procedure in management of
odontogenic cysts. This method is simple, reliable
and can be used routinely as it does not consume
much time.
7. Piotr PE , Marcin, Hanna, Grzegorz, Andrzej: Treatment of solitary bone
cysts with allogenic bone graft and platelet-rich plasma. A preliminary
report: Acta Orthop. Belg., 2010, 76, 374-379
8. Sammartino et al: Use of Autologous Platelet-Rich Plasma (PRP) in
Periodontal Defect Treatment After Extraction of Impacted Mandibular
Third Molars; J Oral Maxillofac Surg 63:766-770, 2005
9. Nagata et al: Effect of platelet-rich plasma on bone healing of
autogenous bone grafts in critical-size defects: Clin Periodontol 2009;
36: 775–783
10. Rutkowski et al: Platelet Rich Plasma to Facilitate Wound Healing
Following Tooth Extraction: Journal of Oral Implantology 2010; 11-23
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