Open Access Case Report Published via Manav Rachna Dental College

Surgical Management of a Large Endodontic

Periapical Lesion With Bone Putty and Platelet-
Received 08/25/2024
Rich Fibrin: A Case Report With a Two-Year
Review began 09/05/2024
Review ended 09/10/2024 Volumetric Follow-Up
Published 09/13/2024
Rajat Sharma 1, Monika Tandan 1, Sonal Soi 1 , Alpa Gupta 1
© Copyright 2024
Sharma et al. This is an open access article
distributed under the terms of the Creative 1. Conservative Dentistry and Endodontics, Manav Rachna Dental College, Faridabad, IND
Commons Attribution License CC-BY 4.0.,
which permits unrestricted use, distribution,
Corresponding author: Rajat Sharma, [email protected]
and reproduction in any medium, provided
the original author and source are credited.

DOI: 10.7759/cureus.69355
Abstract
The present case report evaluates the surgical management of a large periapical lesion with palatal
perforation using platelet-rich fibrin (PRF) and bone putty material, with a two-year follow-up. A 15-year-
old male presented with persistent swelling and pain in the right maxillary anterior region, having a history
of trauma and recurrent swelling. Cone beam computed tomography (CBCT) imaging revealed a large
periapical lesion extending from teeth #11 to #15 with a palatal breach. Initial non-surgical root canal
treatment (RCT) failed due to persistent exudation from teeth #11, #12, and #13. This led to the decision for
periradicular surgery involving cystic lesion enucleation, apicoectomy, retrofill with mineral trioxide
aggregate (MTA), and placement of bone putty and PRF. Follow-up assessments, including volumetric
analysis with ITK-SNAP software (www.itksnap.org), showed a 97% reduction in lesion volume, from 4055 to
132 cubic millimeters. The palatal perforation was successfully repaired, with no clinical symptoms
reported. Substantial reduction in lesion size and successful repair of the perforation highlight the potential
of this approach in complex surgical endodontic cases.

Categories: Dentistry
Keywords: bone putty, itk-snap, palatal perforation, periradicular surgery, platelet-rich fibrin, volumetric analysis

Introduction
Most periapical radiolucent lesions can typically be resolved with standard root canal treatment (RCT) [1].
However, periradicular surgery is indicated if RCT has failed or when orthograde RCT cannot be completed
due to persistent exudation into the root canal despite repeated chemo-mechanical debridement [2]. The
success of endodontic therapy ranges from 53% to 98% when performed for the first time [3], while the
success rate for retreatment cases with periapical lesions is lower [4].

Bone defects after apicoectomy are often large and complicated, resulting from extensive apical lesions,
endo-periodontal lesions, and through-and-through lesions [5]. In cases involving large through-and-
through lesions associated with labial and palatal perforations of endodontic origin, the effectiveness of the
surgical intervention depends on several factors, including appropriate case selection, the surgical
proficiency of the practitioner, and the materials used to seal the enucleated periapical defect [6]. In such
lesions, a 25% healing rate has been documented [7]. Based on limited evidence, a systematic review and
meta-analysis demonstrated that if a large or through-and-through lesion exists, guided tissue regeneration
procedures may lead to better outcomes, with resorbable membranes being more effective than non-
resorbable ones [8].

Autologous platelet-rich concentrates, such as platelet-rich plasma and platelet-rich fibrin (PRF), are
effective agents for bone regeneration [9]. However, if these concentrates are not properly supported by
scaffolds, they may push through palatal perforations in large periapical lesions, making it challenging to
maintain their precise placement. Therefore, in addition to platelet-rich concentrates, bone graft/putty
materials contribute to the successful healing of such bony defects.

The present case report describes the surgical management of a large periapical lesion of endodontic origin
associated with a palatal perforation using platelet-rich fibrin and bone putty material with a two-year
follow-up. Healing was evaluated by ITK-SNAP software (www.itksnap.org) for cone beam computed
tomography (CBCT) analysis.

Case Presentation
A 15-year-old male patient reported to the department of conservative dentistry and endodontics in March
2022, with the chief complaint of pain in the right upper lip region and swelling on the right cheek and
palatal region. The swelling had persisted for five months, and it continued to increase. He had taken over-
the-counter (OTC) medications multiple times, but the swelling persisted. The pain became severe in the

How to cite this article

Sharma R, Tandan M, Soi S, et al. (September 13, 2024) Surgical Management of a Large Endodontic Periapical Lesion With Bone Putty and
Platelet-Rich Fibrin: A Case Report With a Two-Year Volumetric Follow-Up. Cureus 16(9): e69355. DOI 10.7759/cureus.69355
 Published via Manav Rachna Dental College

last three days and was not relieved by the medications prescribed by a dental health professional. The
patient had a history of trauma to the upper front teeth five to six years ago, which was followed by swelling
in the upper lip for 15 days. The swelling subsided after taking medications from a nearby primary health
center. There was no history of fever or weight loss, and no significant medical history was obtained. An
extra-oral clinical examination revealed diffuse hard swelling in the right maxillary anterior region, lateral
to the nose. Intra-oral examination showed a discolored and labially inclined right central incisor, as well as
a swelling on the palate in the region of teeth #11, #12, and #13 (Figures 1a, 1b). The swelling was oval-
shaped and diffuse, extending from the distal aspect of tooth #11 to the mesial aspect of tooth #14. It was
hard, non-tender, and non-fluctuant. Electric pulp testing (EPT) indicated that teeth #11, #12, #13, #14, and
#15 were non-responsive. Based on the history and clinical findings, a provisional diagnosis of pulp necrosis
with symptomatic apical periodontitis (according to diagnostic terminology approved by the American
Association of Endodontists and the American Board of Endodontics) involving teeth #11, #12, #13, #14, and
#15 was made. The patient presented with CBCT reports, which had been advised by a dental health
professional three days prior. The CBCT revealed a large, well-defined periapical lesion with a well-defined
bony outline in relation to teeth #11, #12, #13, #14, and #15, with a breach in the continuity of the palatal
cortical plate in the right maxillary anterior region (Figures 2a, 2b). Volumetric analysis using ITK-SNAP
software showed a lesion volume of 4055 cubic millimeters (Figure 3).

FIGURE 1: Labial and palatal view on intra-oral examination

1a: Discolored and labially inclined right central incisor are noted; 1b: Palatal swelling was observed in the region
of teeth #11, #12, and #13.

FIGURE 2: Cone-beam computed tomography (CBCT) findings

2a. A large, well-defined periapical lesion with a well-defined bony outline affecting teeth #11, #12, #13, #14, and
#15; 2b. A breach in the continuity of the palatal cortical plate is noted.

2024 Sharma et al. Cureus 16(9): e69355. DOI 10.7759/cureus.69355 2 of 10

 Published via Manav Rachna Dental College

FIGURE 3: Volumetric analysis conducted using ITK-SNAP software

shows a periapical lesion volume of 4055 cubic millimeters
ITK-SNAP software: www.itksnap.org

Endodontic procedure
A treatment plan was initially developed for non-surgical RCTs on teeth #11, #12, #13, #14, and #15. The
procedural steps were explained to the patient, and written informed consent was obtained. After applying a
rubber dam, access openings were made using a large round (314 G) bur (SS White Burs, Inc., Lakewood, NJ),
and working length was estimated using a size 10 K file. Chemo-mechanical preparation was performed with
hand K files and Ni-Ti rotary files (Dentsply Maillefer, Ballaigues, Switzerland). Canals were irrigated with
5.25% sodium hypochlorite (CanalPro, Coltene, Switzerland), normal saline (0.9% sodium chloride, Otsuka,
India), and 2% chlorhexidine (CanalPro). After drying the canal, a calcium hydroxide intracanal dressing was
placed for one week. Root canal obturation of teeth #14 and #15 was completed using Gutta-percha
(Dentsply Maillefer) and Bioceramic Sealer (BioRoot RCS, Septodont, Saint-Maur-des-Fosses, France) with
lateral condensation technique during the next appointment (Figure 4). However, dry canals could not be
obtained in teeth #11, #12, and #13 despite multiple dressings. Consequently, the treatment plan was
revised to include periradicular surgery and obturation of teeth #11, #12, and #13 on the day of surgery.

2024 Sharma et al. Cureus 16(9): e69355. DOI 10.7759/cureus.69355 3 of 10

 Published via Manav Rachna Dental College

FIGURE 4: Root canal treatment

Obturation performed on teeth #14 and #15

Surgical procedure
The patient's surgical region was painted with 5% povidone-iodine and draped under sterile conditions.
Local anesthesia was achieved with 2% lignocaine (1:80000 adrenaline) (Lignospan Special, Septodont). A
crevicular incision was made from the distal aspect of tooth #16 to the mesial aspect of tooth #22, with
releasing incisions given bilaterally (Figure 5a), thus raising a rectangular mucoperiosteal flap (Figure 5b).
The cystic lesion was enucleated and sent for histopathological examination (Figures 5c-5e). Bur #701 (SS
White Burs, Inc.) was used in a straight handpiece of the physiodispenser (Implantmed, W & H, Bürmoos,
Austria) at a slow speed of 40,000 rpm with an adequate water jet to cut 3 mm of root tips of teeth #11, #12,
and #13 (Figure 5f). A straight ultrasonic tip No. F00106/F00079 (Satelec Acteon, Mérignac, France) was used
to remove gutta-percha and prepare the retrocavity (Figure 5g). After mixing ProRoot mineral trioxide
aggregate (MTA) (Dentsply Maillefer) according to the manufacturer’s instructions, MTA was placed into the
retrocavity and condensed using a microsurgical retrofilling DE plugger (Hu-Friedy, Chicago, IL) in two to
three increments (Figure 5h). Sharp margins were rounded off, and the cavity was thoroughly lavaged with
normal saline (Figure 5i). Clinically, the nasal floor remained intact, and the palatal perforation was sealed
using bone putty material (NovaBone, NovaBone Products, Bangalore, India) (Figure 5j). To prepare the PRF,
venous blood was drawn from the patient into 10 mL sterile tubes without anticoagulants and centrifuged
immediately at 3000 rpm for 10 minutes. The fibrin clot formed in the middle layer was then isolated from
the red blood cell layer and applied over the bone putty in the osteotomy site, filling the bony cavity

2024 Sharma et al. Cureus 16(9): e69355. DOI 10.7759/cureus.69355 4 of 10

 Published via Manav Rachna Dental College

completely (Figure 5k). The mucoperiosteal flap was then repositioned, and the surgical site was closed with
multiple interrupted sutures using 4-0 silk (Mersilk, Ethicon, Somerville, NJ) (Figure 5l) and a periodontal
dressing (Coe-Pak Automix, GC America Inc., Alsip, IL) (Figure 5m). A postoperative intra-oral periapical
radiograph (IOPAR) was taken (Figure 6), and a custom-made acrylic palatal splint was fitted in the patient's
mouth to support the palatal perforation site. Postoperative instructions were given, and antibiotics and
analgesics were prescribed for five days. The patient was recalled after five days for evaluation, palatal splint
adjustment, and suture removal. Histopathological examination revealed a cyst wall lined by stratified
squamous epithelium, with dense inflammatory infiltrates, including lymphocytes, plasma cells, and
histiocytes, as well as inflamed granulation tissue. The presence of cholesterol clefts was noted. No hyaline
bodies, metaplasia, calcification, granuloma, or atypia were identified. These findings are consistent with
the diagnosis of a periradicular cyst associated with teeth #11, #12, #13, #14, and #15.

FIGURE 5: Surgical procedure

5a. Crevicular incision from the distal aspect of #16 to mesial aspect of #22 with bilateral releasing incisions; 5b.
Raised mucoperiosteal flap; 5c. A window was created to enucleate the periradicular cyst; 5d. The periradicular
cyst was enucleated; 5e. The periradicular cyst was sent for histopathological examination; 5f. Apicoectomy
performed on teeth # 11, #12, and #13; 5g. Gutta-percha was removed and retrocavities were prepared in teeth
#11, #12, and #13 using retro-ultrasonic tips; 5h. Retrofilling with mineral trioxide aggregate (MTA) completed in
teeth #11, #12, and #13 using a microsurgical plugger; 5i. Bony cavity cleaned after enucleation of periradicular
cyst and MTA retrofilling; 5j. Palatal perforation was sealed with NovaBone putty material; 5k. Platelet-rich fibrin
was placed into the bony cavity till it was filled; 5l. The surgical site closed with multiple interrupted sutures using
4-0 silk; 5m periodontal dressing (Coe-Pak)

2024 Sharma et al. Cureus 16(9): e69355. DOI 10.7759/cureus.69355 5 of 10

 Published via Manav Rachna Dental College

FIGURE 6: Postoperative intra-oral periapical radiograph (IOPAR) of

retrofilled teeth #11, #12, and #13

Regular follow-up was maintained, and the periapical healing was assessed using IOPAR and ITK-SNAP
software for CBCT volumetric analysis (in terms of reduction in the lesion volume). Postoperative follow-up
evaluation after two years revealed near-complete healing of the periapical lesion (Figure 7), with an almost
97% reduction in lesion volume from 4055 cubic millimeters to 132 cubic millimeters (Figure 8).

2024 Sharma et al. Cureus 16(9): e69355. DOI 10.7759/cureus.69355 6 of 10

 Published via Manav Rachna Dental College

FIGURE 7: Intra-oral periapical radiograph (IOPAR) performed at the

two-year follow-up revealed near-complete healing of the periapical
lesion.

FIGURE 8: Cone beam computed tomography (CBCT) done at the two-

year follow-up showed a reduction in lesion volume to 132 cubic
millimeters.
ITK-SNAP software: www.itksnap.org

Discussion
According to the guidelines for periradicular surgery (2020) provided by the Royal College of Surgeons in
collaboration with the British Endodontic Society, the indications for periradicular surgery include: (a) When
orthograde root canal treatment cannot be completed due to persistent exudation into the root canal despite
repeated chemo-mechanical debridement; (b) When previous treatment has been carried out to guideline
standards but symptomatic or progressing periradicular disease persists in an optimally root-filled tooth; (c)
Symptomatic or progressing periradicular disease associated with a well root-filled tooth where root canal

2024 Sharma et al. Cureus 16(9): e69355. DOI 10.7759/cureus.69355 7 of 10

 Published via Manav Rachna Dental College

retreatment has failed, or where retreatment may compromise the structural integrity of the tooth, be
destructive to a restoration or fixed prosthesis, or involve the removal of a post with a high risk of root
fracture; (d) Symptomatic or progressive periradicular disease associated with a tooth in which iatrogenic or
developmental anomalies prevent orthograde root canal treatment; (e) when a biopsy of periradicular tissue
is required; and (f) when visualization of the periradicular tissues and tooth root is necessary if perforation
or root fracture is suspected [1].

In the present case, the large size of the lesion and persistent pus discharge from teeth #11, #12, and #13,
even after multiple appointments, led to the decision to proceed with periradicular surgery. Apicoectomy of
teeth #14 and #15 was not performed to preserve the adjacent healthy buccal cortical plate.

There are differing views on the use of collagen membranes and bone grafts in surgical endodontics for
treating extensive buccal perforations with periapical diseases [10]. Calcium phosphosilicate (CPS) particles
with a bimodal size distribution are combined with binders like glycerine and polyethylene glycol to create
the NovaBone putty substance. The binders improve handling characteristics and aid in maintaining particle
separation, which facilitates quicker revascularization. After application, the binders dissolve and absorb
within 24 to 72 hours, forming a three-dimensional porous scaffold that allows blood and tissue fluids to
diffuse throughout the matrix [11]. NovaBone putty has both osteoconductive and osteostimulative
properties. Following implantation, the absorption of the graft material and the controlled release of silicon,
calcium, and phosphorus ions increase the osteocalcin and alkaline phosphatase levels, which promote new
bone growth [12]. Both cellular and non-cellular components are bound within the gel matrix by the silica
and calcium-rich surface gel; additionally, hydroxyl carbonate/apatite nucleates crystallize and interact with
collagen, glycoproteins, mucopolysaccharides, and osteocellular components [13]. A vital component called
carbonate apatite is resorbed by osteoclasts in mildly acidic environments and replaced by new bone via
remodeling. It has better osteoconductive qualities than hydroxyapatite (HA) and accelerates osteoblast
differentiation alongside the rate at which new bone tissue is deposited. Furthermore, microstructural
examination demonstrating new bone growth inside the grafting material indicates that carbonate apatite
promotes bone deposition without fibrotic tissue formation [14].

When combined with bone grafts, platelet-rich concentrates help promote improved bone repair. Growth
factors such as insulin-like growth factor-1 (IGF-1), platelet-derived growth factor (PDGF), transforming
growth factor beta (TGF-β), epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), and
basic fibroblast growth factor (FGF) are abundant in PRF and effectively contribute to new bone production
[15]. Platelet-rich fibrin functions as a biological link between the bone graft materials and the cytokine
release from PRF is crucial for the graft material's ability to self-regulate the inflammatory process [16].
Additionally, PRF demonstrates significant chemotactic and mitogenic potential, promoting cell
proliferation, differentiation, angiogenesis, and tissue regeneration, further enhancing bone healing and
regeneration [17].

As a newer alternative to PRF, concentrated growth factor (CGF) could also be used, which is a second-
generation platelet concentrate prepared by centrifuging blood samples at alternating and controlled speeds
using a specialized centrifuge. This method results in a denser fibrin matrix that is richer in growth factors
compared to PRF and PRP. The three-dimensional network of fibrin in CGF allows for a slower and more
sustained release of growth factors [18].

Given the osteostimulative and osteoconductive qualities of the NovaBone putty material and the
characteristics of autologous PRF, it was hypothesized that these factors would work synergistically to
manage the extensive periapical lesions with palatal perforations in this case.

For teeth with endodontic involvement, Huumonen and Ørstavik examined alterations in the 2D periapical
index (PAI) score to evaluate treatment results and periapical healing [19]. With the increasing use of CBCT
in endodontics, lesion volume has been assessed in several studies to gauge periapical healing [20, 21].
Estrela et al. reported that the greatest diameter of each lesion determined the CBCT PAI score [22].
Boubaris et al. introduced a novel volume-based CBCT periapical volume index (PAVI) with scores ranging
from 1 to 6 in 2021 [23]. In the current case, the lesion is rated at 6 (>100 mm³) according to the newly
developed CBCT PAVI, indicating that a thorough volumetric study is required to obtain meaningful results.
The effective lesion volume decrease was computed using ITK-SNAP software version 4.0.1, an open-source
image analysis technique supported by the US National Library of Medicine [24]. The bubble cluster and
polygonal form fill methods were considered, with the latter being chosen for its higher accuracy and
reproducibility.

Conclusions
This case report demonstrates that the use of PRF and bone putty material effectively managed a large
periapical lesion with a palatal perforation. The treatment resulted in a 97% reduction in lesion volume over
two years and successful repair of the palatal defect. This outcome underscores the efficacy of integrating
advanced biomaterials in complex endodontic surgical cases and highlights the importance of precise case
selection and skilled surgical intervention in achieving successful outcomes. Future studies should continue
to explore and validate these techniques to further improve the management of challenging periapical

2024 Sharma et al. Cureus 16(9): e69355. DOI 10.7759/cureus.69355 8 of 10

 Published via Manav Rachna Dental College

lesions.

Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.

Concept and design: Rajat Sharma, Monika Tandan, Sonal Soi, Alpa Gupta

Acquisition, analysis, or interpretation of data: Rajat Sharma, Monika Tandan, Sonal Soi, Alpa Gupta

Drafting of the manuscript: Rajat Sharma, Monika Tandan, Sonal Soi, Alpa Gupta

Critical review of the manuscript for important intellectual content: Rajat Sharma, Monika Tandan,
Sonal Soi, Alpa Gupta

Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial
relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.

Acknowledgements
We thank Dr Pravin Kumar, Professor and Head of Department, Department of Dentistry, All India Institute
of Medical Sciences (AIIMS), Jodhpur.

References
1. Del Fabbro M, Corbella S, Sequeira-Byron P, Tsesis I, Rosen E, Lolato A, Taschieri S: Endodontic procedures
for retreatment of periapical lesions. Cochrane Database Syst Rev. 2016, 10:CD005511.
10.1002/14651858.CD005511.pub3
2. Guidelines for periradicular surgery 2020. (2020). Accessed: July 24, 2024: https://www.rcseng.ac.uk/-
/media/files/rcs/fds/publications/periradicular_surgery_guidelines_2020.pdf.
3. Saunders WP, Saunders EM: Coronal leakage as a cause of failure in root-canal therapy: a review . Endod
Dent Traumatol. 1994, 10:105-8. 10.1111/j.1600-9657.1994.tb00533.x
4. Gorni FG, Gagliani MM: The outcome of endodontic retreatment: a 2-yr follow-up . J Endod. 2004, 30:1-4.
10.1097/00004770-200401000-00001
5. Yoshikawa G, Murashima Y, Wadachi R, Sawada N, Suda H: Guided bone regeneration (GBR) using
membranes and calcium sulphate after apicectomy: a comparative histomorphometrical study. Int Endod J.
2002, 35:255-63. 10.1046/j.1365-2591.2002.00473.x
6. Dhamija R, Tewari S, Sangwan P, Duhan J, Mittal S: Impact of platelet-rich plasma in the healing of
through-and-through periapical lesions using 2-dimensional and 3-dimensional evaluation: a randomized
controlled trial. J Endod. 2020, 46:1167-84. 10.1016/j.joen.2020.06.004
7. Hirsch JM, Ahlström U, Henrikson PA, Heyden G, Peterson LE: Periapical surgery. Int J Oral Surg. 1979,
8:173-85. 10.1016/s0300-9785(79)80016-2
8. Tsesis I, Rosen E, Tamse A, Taschieri S, Del Fabbro M: Effect of guided tissue regeneration on the outcome
of surgical endodontic treatment: a systematic review and meta-analysis. J Endod. 2011, 37:1039-45.
10.1016/j.joen.2011.05.016
9. Metlerska J, Fagogeni I, Nowicka A: Efficacy of autologous platelet concentrates in regenerative endodontic
treatment: a systematic review of human studies. J Endod. 2019, 45:20-30.e1. 10.1016/j.joen.2018.09.003
10. Schloss T, Sonntag D, Kohli MR, Setzer FC: A comparison of 2- and 3-dimensional healing assessment after
endodontic surgery using cone-beam computed tomographic volumes or periapical radiographs. J Endod.
2017, 43:1072-9. 10.1016/j.joen.2017.02.007
11. Wang W, Yeung KW: Bone grafts and biomaterials substitutes for bone defect repair: a review . Bioact Mater.
2017, 2:224-47. 10.1016/j.bioactmat.2017.05.007
12. Gupta V, Bains VK, Singh GP, Jhingran R: Clinical and cone beam computed tomography comparison of
NovaBone Dental Putty and PerioGlas in the treatment of mandibular class II furcations. Indian J Dent Res.
2014, 25:166-73. 10.4103/0970-9290.135912
13. Dohan Ehrenfest DM, Rasmusson L, Albrektsson T: Classification of platelet concentrates: from pure
platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF). Trends Biotechnol. 2009,
27:158-67. 10.1016/j.tibtech.2008.11.009
14. Yotsova R, Peev S: Biological properties and medical applications of carbonate apatite: a systematic review .
Pharmaceutics. 2024, 16:291. 10.3390/pharmaceutics16020291
15. Parmar PD, Dhamija R, Tewari S, Sangwan P, Gupta A, Duhan J, Mittal S: 2D and 3D radiographic outcome
assessment of the effect of guided tissue regeneration using resorbable collagen membrane in the healing of

2024 Sharma et al. Cureus 16(9): e69355. DOI 10.7759/cureus.69355 9 of 10

 Published via Manav Rachna Dental College

through-and-through periapical lesions - a randomized controlled trial. Int Endod J. 2019, 52:935-48.
10.1111/iej.13098
16. Naqvi A, Gopalakrishnan D, Bhasin MT, Sharma N, Haider K, Martande S: Comparative evaluation of
bioactive glass putty and platelet rich fibrin in the treatment of human periodontal intrabony defects: a
randomized control trial. J Clin Diagn Res. 2017, 11:ZC09-13. 10.7860/JCDR/2017/23831.10149
17. Yotsova R, Peev S, Kolarov R: Application of platelet-rich plasma for alveolar ridge preservation. A review
article. Scr Sci Med Dent. 2022, 8:18-37. 10.14748/ssmd.v8i1.8493
18. Qin J, Wang L, Zheng L, Zhou X, Zhang Y, Yang T, Zhou Y: Concentrated growth factor promotes Schwann
cell migration partly through the integrin β1-mediated activation of the focal adhesion kinase pathway. Int J
Mol Med. 2016, 37:1363-70. 10.3892/ijmm.2016.2520
19. Huumonen S, Ørstavik D: Radiographic follow-up of periapical status after endodontic treatment of teeth
with and without apical periodontitis. Clin Oral Investig. 2013, 17:2099-104. 10.1007/s00784-013-0926-2
20. Metska ME, Parsa A, Aartman IH, Wesselink PR, Ozok AR: Volumetric changes in apical radiolucencies of
endodontically treated teeth assessed by cone-beam computed tomography 1 year after orthograde
retreatment. J Endod. 2013, 39:1504-9. 10.1016/j.joen.2013.08.034
21. Zhang MM, Liang YH, Gao XJ, Jiang L, van der Sluis L, Wu MK: Management of apical periodontitis: healing
of post-treatment periapical lesions present 1 year after endodontic treatment. J Endod. 2015, 41:1020-5.
10.1016/j.joen.2015.02.019
22. Estrela C, Bueno MR, Azevedo BC, Azevedo JR, Pécora JD: A new periapical index based on cone beam
computed tomography. J Endod. 2008, 34:1325-31. 10.1016/j.joen.2008.08.013
23. Boubaris M, Chan KL, Zhao W, Cameron A, Sun J, Love R, George R: A novel volume-based cone-beam
computed tomographic periapical index. J Endod. 2021, 47:1308-13. 10.1016/j.joen.2021.04.027
24. ITK-SNAP. (2023). Accessed: July 24, 2024: http://www.itksnap.org/pmwiki/pmwiki.php.

2024 Sharma et al. Cureus 16(9): e69355. DOI 10.7759/cureus.69355 10 of 10