PMC4979353_01
Clinical image (a) extraoral swelling. (b) intraoral swelling
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F1
Skin over the swelling was normal [Figure 1a]. Intraorally also, there was large swelling which was about 2 cm x 5 cm and it was attached to the gingiva from the right lower second molar (47) to the left lower canine (33) with obliteration of the sulcus [Figure 1b].
Preoperative (a) orthopantomogram (b) computed tomography - mandible (labial expansion) (c) computed tomography - mandible lingual perforation (d) computed tomography - lateral view of the Mandible
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F2
The orthopantomogram (OPG) revealed a well-defined radiolucent area extending from the left lower lateral incisor (32) to the right lower second premolar (45) of about 3 cm x 3 cm dimension with an impacted canine tooth 43 seen at the apex of tooth 45 and impacted 32 seen on the left side inferior border of mandible [Figure 2a]. A three-dimensional computed tomography (CT) scan of the mandible was taken and showed expansion of both buccal and lingual cortical plates of mandible with perforation [Figure 2b, c and d].
(a) Curetting the lesion (b) removed mandible (c) placing the mesh (d) mesh carrying the SyboGrafts
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F3
The affected buccal cortical plate from lesional area from 46 to 33 regions was removed [Figure 3]. The lower border of the mandible was maintained and lingual cortical plate was not disturbed even in the perforated area [Figure 3a and b]. The height of the buccal side of the mesh was less than the lingual cortical plate and a 1 cm of gap was maintained between lingual cortical plate and the mesh from 47 to 33 regions [Figure 3c]. Before placing the mesh over the operated area, five Sybografts (SyboGraft-T-plug is a sterile synthetic beta-tricalcium phosphate-Eucare Pharmaceuticals (P) Ltd., Chennai, India) scaffold measuring 25 mm in length with a diameter of 12 mm were placed inside the mesh and fixed with resorbable sutures [Figure 3d].
Intraoperative procedure (a) syringes with stromal vascular fraction and dental pulp stem cell (b) placing stromal vascular fraction and dental pulp stem cell in SyboGraft. (c) Stromal vascular fraction mixed with granules. (d) Placing mixed granules over lingual cortex
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F4
The prepared 20 million stem cells cultured from DPSC and the fat SVF containing 45 million cells mixed with platelet-rich plasma (PRP) were placed over the graft [Figure 4a and b]. The stem cells were mixed with the granules and were packed inside the mesh and placed over the lingual cortex [Figure 4c and d].
Postoperative (a) orthopantomogram at 10th month (b) computed tomography mandible at 10th month AP view (c) Mandible lateral view
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F5
Postoperative days were uneventful. Postoperative OPG and CT scan of the mandible were taken during the 10 months, it showed satisfactory bone formation [Figure 5].