PMC6343149_01
(a) Clinical aspect of left mandibular vestibule (premolar and molar regions). (b) Aspiration syringe yielding blood and pus from the radiolucent image. (c) OPG of the patient displaying the radiolucent image in left mandible (34 to 37).
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Aspiration of the lesion was performed under local analgesia and it released pus and blood and a presumptive diagnosis of infected radicular cyst was made (Figures 1(a)-1(c)).
CBCT reconstruction of the left mandible. (a) The sagittal reconstruction with the approximative measurement of the bone destruction (30.7 mm x 19.7 mm). (b) Para-axial cut showing the discontinuity of the buccal cortical bone. (c) Para-axial cut showing the position of the mandibular canal.
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(a) Clinical aspect of alveolar cavities of 35 and 36, immediately after their extraction. (b) Plastic tubes secured in alveolar cavities of teeth 35 and 36 with sutures. A disposable syringe (with needle) injecting a normal saline solution (sodium chloride in water) in distal tube in order to regularly irrigate the lesions. After injection of antiseptic solution in distal tube (A), irrigating liquid is evacuated from mesial tube (B).
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Gingival healing around decompressing devices (tubes), 3 weeks after their placement and suturing.
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At biweekly intervals, the length of the tube was monitored and cut in order to keep it far from occlusion (Figure 4).
(a) Panoramic radiograph 7 months after decompression, showing a reduction of the volume of the lesion. (b) CBCT of the same time period time, the para-axial cut shows a bone healing toward the center of the lesions with approximately +-4 mm buccally and +-2.4 mm lingually. (c) Sagittal reconstruction of the CBCT shows a volume reduction of the lesion approximately.
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Indeed, 6 months after the first lesion's irrigation, a panoramic radiograph was taken in order to evaluate the bone apposition: bone formation took place within the lesion as observed on CBCT performed after 7 months, with an almost complete formation of buccal cortical and bone apposition buccally (+-4 mm) and lingually (+-2.4 mm) as shown on the para-axial cut and lesion volume reduction as shown on the sagittal reconstruction (+-25.1 mm x 15.2 mm), all along the lesion (Figures 5(a)-5(c)).
(a) Six months after the beginning of decompression, a mucoperiosteal flap was performed and decompression tubes removed, leading to the roof of the radiolucent lesion. (b) Upper aspect of the bony pathological cavity, immediately after the lesion's enucleation. Notice that the bone was formed all around external surfaces of both decompression devices (tubes). (c) The pathological cavity filled with Puros  cortico-cancellous particulate allograft, a mixture of 70% cortical and 30% cancellous bone particulate. (d) Puros  biomaterial covered with collagen cones (CollaPlug ) and mucosal wound sutured with 5/0 nylon sutures.
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The flap was relocated with 5/0 nylon interrupted sutures, and tube opening locations were covered with collagen (CollaTape ) over bone graft (Figures 6(a)-6(d)).
(a) Clinical mucosal healing after one week. (b) Radiological aspect of the graft and surrounding bone.
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Histopathology of the cyst. (a) Stratified squamous nonkeratinized epithelium with rete ridges and inflamed connective tissue wall (H&E x 20). (b) Cystic lumen is filled with liquid containing cholesterol crystals (H&E x 40). Mucoperiosteal flap showing the buccolingual thickness of mandibular ridge before implant placement.
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Para-axial cuts of a control CBCT before implant placement showing a complete bone regeneration of the cyst area.
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(a) Clinical view of the bone healing before implant placement. (b) Two Swiss Plus Zimmer  implants placed in postalveolar locations of teeth 35 and 36. (c) Clinical aspects of cover screws and sutures, immediately after implants placement. (d) Clinical aspect of restored implants (35 and 36). (e) Panoramic radiograph showing the final situation of the bone and the restored implants.
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