Marsupialization for Treatment of Jaw Cysts

Marsupialization for treatment of jaw cysts … Rahpeyma A et al
Journal of International Oral Health 2016; 8(2):158-162
Received: 16th September 2015 Accepted: 19th December 2015 Conflict of Interest: None
Source of Support: Vice Chancellor of Research of Mashhad University of Medical Sciences
Original Research
Marsupialization for Treatment of Jaw Cysts: Indications and Limitations
Amin Rahpeyma1, Saeedeh Khajehahmadi2
Contributors:
1
Associate Professor, Department of Oral and Maxillofacial
Surgery, Oral and Maxillofacial Diseases Research Center, School
of Dentistry, Mashhad University of Medical Sciences, Mashhad,
Iran; 2Assistant Professor, Department of Oral and Maxillofacial
Pathology, Dental Research Center, School of Dentistry, Mashhad
University of Medical Sciences, Mashhad, Iran.
Correspondence:
Dr. Khajehahmadi S. Department of Oral and Maxillofacial
Pathology, Dental Research Center, Mashhad University of
Medical Sciences, Vakilabad Blvd, Mashhad, Iran. P.O. Box: 91735984. Tel.: +98(51)38829501. Email: [email protected]/
[email protected]
How to cite the article:
Rahpeyma A, Khajehahmadi S. Marsupialization for treatment
of jaw cysts: Indications and limitations. J Int Oral Health
2016;8(2):158-162
Abstract:
Background: Removal of jaw cysts that reach large sizes, result in
facial deformity, injury to the adjacent neurovascular bundles or jaw
fracture. Marsupialization means creating a window into the cyst
for decompression and is an adjuvant treatment. Limitations of this
technique are not explained completely.
Materials and Methods: Patients suffering from a variety of jaw
cysts that were managed by marsupialization with or without
subsequent enucleation were included in this study between 2007
and 2014. At the 3rd and 6th month, follow-up radiographs were
ordered.
Results: There were 16 patients (20 cysts) that were included in
this study. There were two cases (2/16) that decision was made to
change the treatment planning. Half the cysts were histologically
proven odontogenic keratocyst. Two-thirds of the patients, who
needs to enucleation subsequent to the successful marsupialization,
were managed under general anesthesia.
Conclusion: Limitations of this technique are: Inability to
examine the whole cyst microscopically, questionable eruption of
the permanent tooth involved with the cyst, dependency on the
patient cooperation, and difficulty of irrigation fluid circulation in
multilocular jaw cysts, and finally, if the created window has large
dimensions then soft tissue closure after final cyst enucleation is the
problem.
infection from pulpal or periodontal origin to the jaws.4 The
presence of inflammation within the jaw bones is a trigger for
beginning of the cysts in the alveolar process by itself.
Sometimes, jaw cysts reach large sizes and their removal
results in facial deformity, injury to the adjacent neurovascular
bundles, and permanent loss of nerve function.5,6 Probability
of mandibular fracture during removal of large cysts or in the
early period after surgery is a real danger if remaining cortical
bone is very thin.7,8 We call these features: “enucleation with
complication.”
Loss of permanent teeth when a large cyst occurs in the
mixed dentition and involves the teeth buds is the rule.
Marsupialization minimizes any disruption to future
dental development. Finally, elderly patients with severely
compromised health conditions and the presence of large
cyst within the jaw fall in this category. All above-mentioned
conditions are indications for marsupialization.
In most articles, benefits of this technique are noticed, and
drawbacks are in the shadow. In this article, experience of the
authors with the technique of marsupialization for the jaw cysts
is presented. Limitations of this technique are highlighted.
Materials and Methods
Patients suffering from jaw cysts that were managed by
marsupialization with or without subsequent enucleation were
included in this study between 2007 and 2014. An irrigation
port or two windows were placed into the cyst for twice daily
irrigation. After doing this surgery, the patients were recalled
every month. At the 3rd and 6th month after operation, follow-up
radiographs were ordered, and the further decision was made
about how to continue. If the considerable reduction in the
size of the lesion was obtained, then subsequent programed
enucleation was considered, and the marsupialization was
considered as successful.
Increase in the radiographic size of the cyst or static dimension,
as well as signs of soft tissue invasion, was considered as “not
responding” and subsequent enucleation was considered
without proposed benefits of marsupialization.
Key Words: Enucleation, jaw cyst, marsupialization
Introduction
Frequency of the cysts in mandible and maxilla is much
more than the other skeleton.1 The reason is the presence of
odontogenic epithelium in jaw bones that can proliferate to
the variety of the odontogenic cysts.2,3 The presence of the
teeth also is the other important factor, through the spread of
Results
Table 1 shows the results. There were 16 patients that
were included in this study. Mean age of the patients was
32.2 ± 26. 20% of the cysts were located in the maxilla.
158
Marsupialization for treatment of jaw cysts … Rahpeyma et al
Journal of International Oral Health 2016; 8(2):158-162
Table 1: ???.
N
Age Sex Maxilla/
(year)
mandible
Marsupialization Unfavorable Need to
device
result
enucleation
LA/GA
Type of cyst
Comment
1
2
78
8
M
F
Maxilla (ant)
Mandible (post)
Upper denture
Space maintainer
-
(+) LA
(+) LA
OKC
Dentigerous
3
82
M
Mandible
ant‑post (2)
Oral airway serum set
-
OKC
4
12
F
Mandible (post)
Hypodermic syringe
-
Radicular
-
5
80
F
Mandible
Serum set
-
(+) LA
(+) LA
Marsupialization
alone (‑)
Dead
Loss of permanent
tooth
Two separate cysts
-
6
7
14
10
F
F
Mandible (post)
Mandible (post)
Serum set
Serum set
-
Mural
ameloblastoma
Dentigerous
?
8
11
M
Maxilla (post)
Serum set
-
9
10
28
34
M
F
Mandible
Mandible
Acrylic device
Acrylic device
11
11
M
Mandible
Serum set
Recurrence
Not reduction
in size
-
12
13
13
15
F
M
Acrylic device
Acrylic device (4)
14
15
52
43
M
M
Mandible
Mandible‑ (2)
Maxilla (2)
Mandible
Mandible
16
24
F
Maxilla
(+) GA
Marsupialization
alone (‑)
(+) GA
Dentigerous
OKC/T
OKC/T
Increase in cyst
size
(+) GA
Change the
treatment plane
Marsupialization
alone (‑)
(+) LA
Change the
treatment plane
Serum set
Serum set
-
(+) LA
(+) GA
Acrylic device
-
(+) GA
Radicular cyst
Glandular
odontogenic cyst
COC
?
OKC/T
OKC/T
Window
management
Dehiscence
Dehiscence
-
Eruption of the
involved premolar
Loss of permanent
tooth
-
-
Eruption of the
tooth
Four separate cyst
-
-
-
-
Lateral slinding flap
Buccinator flap
-
Buccinator flap
M: Male, F: Female, Ant: Anterior, Post: Posterior, GA: General anesthesia, LA: Local anesthesia, OKC/T: Odontogenic keratocyst/tumor, COC: Calcifying odontogenic cyst
31% of the patients were in mixed dentition. Sex distribution
was equal. Two patients had more than one cyst (2 and
4 cysts), one of them with Gorlin-Goltz syndrome. 20
jaw cysts were managed by marsupialization while 15/20
needed to subsequent enucleation, two-thirds under general
anesthesia. Marsupialization was done under local anesthesia
in all cases.
cyst, and mural ameloblastoma, each with one case, were in the
minority. In two cases, the exact pathologic diagnosis was not
possible because any specimen had been send to the laboratory.
One patient developed recurrence of the cyst (OKC) in the
same site 3 years after the surgery.
The most common method for marsupialization was acrylic
devices and infusion set that was prepared by the surgeon,
each with eight cases.
From five cysts that were in the preadolescence, one was
radicular cyst correlates with the remnant roots of the
mandibular first molar. The other four cysts were involved
with the tooth germ that half of them respond ideally to
the marsupialization with the spontaneous eruption of the
tooth buds into the mouth without the need for orthodontic
treatment. The other two cases responded to this procedure by
dramatic decrease in the size of the cyst but needed to further
enucleation with the loss of permanent tooth involved with
the cyst.
Acrylic resin extension, penetrating into the cystic cavity and
attached to the upper denture or space maintainer was the
other tool. Oral airways, and cut hypodermic syringe each with
one case, were the other used devices, for marsupialization
(Figure 1).
Discussion
Considering the marsupialization as a conservative surgical
approach in the management of large jaw cysts has many
beneficial effects.9 Marsupialization in jaw cysts means creating
a window into the cyst for decompression. This window in
the maxillary cysts can open into the nose, maxillary sinus, or
oral cavity.10,11 For mandibular cysts, the intraoral window is
the sole choice.
There were two cases (2/16) that decision was made to change
the treatment planning. In a case, toward “enucleation with
complication,” other case toward resection.
Half the cysts were histologically proven odontogenic
keratocyst/tumor (OKC). Dentigerous cyst with (15%) and
a radicular cyst with (10%) were in the second and third place.
Glandular odontogenic cyst, calcifying epithelial odontogenic
Removal of the cyst in the mandible and maxilla, when the cyst
encroaches into the neurovascular bundles. Inferior alveolar
159
Marsupialization for treatment of jaw cysts … Rahpeyma et al
Journal of International Oral Health 2016; 8(2):158-162
nerve in the mandible and infraorbital nerve in the maxilla
will results in the lost sensibility of the lips after surgery.12
This condition aggravates if the cyst needs to adjunctive
treatments such as curettage and peripheral ostectomy as well
as the application of Carnoy’s solution or cryotherapy that is
recommended in the cysts with high recurrence rates such as
OKC and glandular odontogenic cyst.13-15 Successful treatment
by marsupialization will reduce this possibility by depositing
bone above the neurovascular bundle after cyst decompression
(Figure 2).
a
Another advantage of marsupialization is the prevention of
pathologic fracture in weak mandible.16
General anesthesia in geriatric patients with severely
compromised medical conditions has high risks.
Marsupialization followed by secondary enucleation of the
cyst under local anesthesia can reduce these risks although the
probability of medical emergencies will increase during this
procedure that the surgeon should be ready to confront it.17
Two-thirds of the patients, who needs to enucleation
subsequent to successful marsupialization, were managed
under general anesthesia. This is because of the young age of
the patients in some cases and the fact that despite the reduction
in the size of the cyst in comparison with the beginning of the
treatment, yet the size of the lesion is so large that needs to
general anesthesia for complete cystectomy.
b
There was a case of huge mural ameloblastoma that had
endangered the airway. After decompression, this condition
improved (Figure 3).
Facial bulging is the other reason for using this technique. After
regression of the facial bony expansion, the cyst can be removed
without excessive loss of the bony contours of the maxilla.
c
Figure 1: Appliances for marsupialization. (a) Infusion set,
(b) oral airway secured with miniscrews, and (c) hypodermic
syringe.
a
Marsupialization had been recommended in the treatment
of the high recurrent cysts (mainly OKC).18 The proposed
theory is metaplasia of the epithelium in these cases
(Figure 4).19,20 Study of Pogrel and Jordan on the OKCs
treated by decompression showed a reduction in anti-apoptotic
gene BCL-2 Marker that is found in high concentration in
the epithelial lining of KCOTs while the loss of Bcl-2 from
marsupialized cysts was observed.21 Another reason for the
reduction in the size of OKC is by inhibiting interleukin-1alpha
expression and epithelial cell proliferation.22 Mitotic activity of
the epithelial cells also decreases after marsupialization.
b
Figure 2: (a) Before treatment and (b) 3 months after
marsupialization. Note to the new bone deposition between
inferior dental canal and cyst with ground glass appearance.
Final hypothesis emphasis on the fact that decreases intracystic
negative pressure following marsupialization may enhance
bone formation around jaw cysts.23
b
a
Figure 3: (a) Huge mural ameloblastoma that reduced the airway space and displaced it laterally and (b) Marsupialization by
serum set alleviate the emergent situation.
160
Marsupialization for treatment of jaw cysts … Rahpeyma et al
Journal of International Oral Health 2016; 8(2):158-162
permanent tooth entrapped in the cyst lumen or ectopically
displaced by the cyst, then expecting the tooth to erupt
after marsupialization is not realistic. Patient age, as well as
impacted premolar angulation to the adjacent teeth axes,
the cusp depth, space/tooth size, eruption period and cyst
size, as measured on initial images are predictors in the
success of eruption.27
• Patient/parents cooperation has paramount importance
in this procedure because of prolonged treatment of
marsupialization. The most important factor in this
technique is the patient understanding of the treatment
planning and spending time for effective irrigation. This
technique is not recommended in mentally retarded
patients with multiple jaw cysts because this group has not
high collaboration in daily self-irrigation even with the help.
• Multifocal nature of OKC should be considered. A separate
window for each cyst is mandatory.
• Large radiographically multilocular mandibular cyst
extending to the ramus may not respond well to
marsupialization.
Figure 4: Post marsupialization changes in odontogenic
keratocyst. Microscopic feature: Hyperplastic, stratified, nonkeratinizing squamous epithelium (original magnification
×400, hematoxylin and eosin stain).
Posterior part of such cysts is far from access by irrigation
solution and creating a window, posterior to the mandibular
anterior border of the ramus is not possible.
• Decompression followed by enucleation with primary
closure should be considered when the surgeon decides to
choose the best device for marsupialization. Creating a large
window is not recommended because of inability to primary
close the window after programed enucleation of the cyst.
Dehiscence of the wound if the mucosa is sutured under
tension or the need for soft tissue flaps (if the window is very
large), are limitations of these devices (Figure 5). Creating
marsupialization window in the palate is not recommended
because primary closure after cyst enucleation is impossible.
• Treatment of mural ameloblastoma and calcifying
epithelial odontogenic cysts by marsupialization followed
by enucleation is not accepted universally and is very
dependent on the case.
• Marsupialization is done under local anesthesia, so very
young children are not good candidates for this procedure.
• Breakage of the acrylic device and detachment of infusion
set (inward/outward) is possible that needs to immediate
replacement. Adjustment and reduction of acrylic extension
that has penetrated into the cystic lumen is mandatory in
programed intervals.
Figure 5: The need for buccinator myomucosal flap to close
created window.
The fact that majority of the cysts in this series was OKC
come from nature of the cyst that enlarges, without expansion.
These cysts are often discovered when they reach large sizes.24
Fibrosis in the cyst capsula and thickened cyst wall are the
other advantages of marsupialization that leads to enblock
enucleation of the cyst.25
Marsupialization in treatment of jaw cysts has some
limitations that are listed below:
• Histopathologic examination of the whole cyst epithelium is
not possible.26 Some cysts may undergo ameloblastomatous
or carcinomatous (mucoepidermoid or squamous
cell carcinoma) changes. That need to more radical
surgeries. Obtaining and sending the biopsy specimen for
histopathologic examination is necessary.
• Masrsupialization of a cyst lesion to allow tooth eruption,
necessarily will not lead to the resolution of the cyst
and tooth eruption into the oral cavity. If the involved
Conclusion
Marsupialization is a good adjuvant technique for the
management of large cystic lesions involving the jaws.
Attention to the limitations of this technique is mandatory.
Inability to examine the whole cyst microscopically, the
questionable eruption of the permanent tooth involved with
the cyst, dependency on the patient cooperation, difficulty of
irrigation fluid circulation in multilocular jaw cysts and finally
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Marsupialization for treatment of jaw cysts … Rahpeyma et al
Journal of International Oral Health 2016; 8(2):158-162
problem of soft tissue closure after final cyst enucleation(if
the created window has large dimensions), all are in the list.
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