Aim of the study
The aim of the study was to evaluate the efficacy of the tube decompression procedure in treatment of mandibular dentigerous cysts.
Cystic lesions of the jaw can be treated by either enculation or marsupialization depending on their size, location, and proximity to the vital structures such as teeth, maxillary sinus, nasal cavity, and mandibular canal as well as on the continuity of bone margins 1. Small cysts are enucleated, whereas large cysts are marsupialized initially and then enucleated at a later stage 2.
The choice depends on the topography of the cyst and the integrity and proximity of the adjacent structures. Dentigerous cysts are the most ideal indication for the marsupialization procedure, mainly to preserve the associated tooth and minimize surgical trauma in pediatric population 3.
Another important factor is the accessibility of the cystic cavity for surgical intervention and regular irrigation. A new technique (tube decompression procedure) used in this study facilitates surgical deroofing and frequent irrigation of inaccessible areas such as the mandibular ramus region.
Materials and methods
The study included eight patients suffering from large mandibular dentigerous cysts (size in OPG 4×6 cm on average in the greatest dimensions) who were attending the Department of Oral and Maxillofacial Surgery, Specialized Dental Teaching Hospital. All patients signed an informed consent form before undergoing any procedure included in this study. The mean age ranged from 7 to 45 years, five male patients and three female patients. Histopathology confirmed their diagnosis of dentigerous cyst. Marsupialization was performed under local anesthesia as sole treatment of the lesions. All patients were treated with a primary intervention with an exception of patient number 8, where a residual cystic cavity in 45-year-old female was marsupialized and followed up for 6 months.
After induction of profound regional anesthesia, the cystic lesions were marsupialized by creating a soft-tissue opening in the facial aspect of the cystic cavity (about 1 cm in diameter, taken as incisional biopsy). The cyst wall was sutured to the oral mucosa. After that, a plastic tube catheter was introduced into the depth of the cystic cavity through the soft-tissue opening. The cystic cavity was irrigated with povidone iodine solution and isotonic saline using the plastic tube. The distal end of the tube was fixed using stainless wire into the adjacent tooth or Erich arch bar (Fig. 1). The patient or his parents were instructed to irrigate the tube after each meal and at least three times daily with the same irrigation solution.
Postoperative medications including mild analgesic and short course of oral antibiotic were prescribed. Patients were instructed to irrigate the cyst cavity using the plastic tube five times daily with isotonic saline and bovidine iodide. All patients were recalled every 2 weeks to assure the wound condition and adequate irrigation of the cystic cavity. All patients were evaluated using digital panorama (OPG) (Nile company for pharmaceuticals and chemical industries, Cairo, Egypt) preoperatively and 3 months and 6 months postoperatively until complete resolution of the lesion (Fig. 2).
The surgical procedure was well tolerated by all patients. No reported complications were encountered except accidental tube displacement in two pediatric patients; the tube was reinserted and fixed. Complete resolution of the cystic lesion was achieved during the follow-up period (Fig. 3).
No affection of the inferior alveolar nerve was reported. The associated impacted tooth could be preserved in four patients, even erupted in two patients, and the other four patients were associated with impacted third molar, which have been extracted at the end of the treatment. Postoperative radiograph revealed successful new bone formation within the cystic cavity with re-establishment of the mandibular outline (Fig. 3).
Marsupialization is a surgical technique by which a window is created in the wall of the cyst to relieve the intracystic pressure, enabling the cavity to decrease gradually in size. This approach was first introduced by Partsch 4 and has become known as the Partsch I technique. The difference in the bone healing mechanism after enculation and marsupialization is the key to plan the treatment strategy for cystic lesion. Actually, after cyst enculation and primary closure, bone was formed through the cavity with a ground-glass appearance, whereas after marsupialization when the center of the cavity is opened it can only do so by creeping substitution from the adjacent bone with longer healing time 5,6.
Therefore, if the cystic lesion is so large or inaccessible that primary closure is questionable, marsupialization alone or marsupialization with secondary enculation is the treatment of choice. In another words, primary cyst enculation with primary closure should be the first treatment option for small accessible lesions 7.
Another factor affecting the treatment plan of the odontogenic cyst is the histopathology of the lesion itself. Actually dentigerous and residual cysts are the ideal indications for marsupialization, whereas odontogenic keratocyst and unicystic ameloblastoma are not amenable for such technique 8,9.
Marsupialization is considered a well-established nonaggressive treatment strategy for large odontogenic cysts. It offers the advantages of preservation of the vital structures, minimal surgical trauma, and less risk for pathologic fracture; the patient, however, should be compliant and able to accept the prolonged treatment period 10.
The principle of marsupialization is to create an opening in the cyst wall to decrease the intracystic pressure and hence reverse the resorptive bone activity; however, the maintenance of this opening requires the use of cyst bulge, which needs frequent adjustment and is not practical especially in pediatric population 11. The tube decompression procedure offers a better tool to keep the cystic cavity patent and facilitates regular irrigation by the patient. The present technique minimizes the disadvantages of the marsupialization procedure, especially in the inaccessible regions and in pediatrics.
The current technique provides a simple surgical procedure suitable for inaccessible large cystic lesions in the areas such as the mandibular ramus region. The use of arch bar and possible tube displacement are the only disadvantages of the technique.
Conflicts of interest
There are no conflicts of interest.
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