Brief Clinical Studies The Journal of Craniofacial Surgery
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Surgical Management of Large
Odontogenic Cysts of
the Mandible
Paola Bonavolontà, MD, PhD,
Giovanni Dell’Aversana Orabona, MD, PhD,
Marco Friscia, MD, Lorenzo Sani, MD,
Vincenzo Abbate, MD, Giorgio Iaconetta, MD, PhD,y
and Luigi Califano, MD, PhD
Introduction: Odontogenic cysts are defined as those cysts that
arise from odontogenic epithelium and occur in the tooth-bearing
regions of the jaws. Cystectomy, marsupialization, or decompres-
sion of odontogenic cyst are the most common treatments proposed
for this pathology. The aim of this study is to retrospectively
evaluate the result of decompression based on the volumetric
reduction of the cystic cavity and new bone formation by cone
beam computerized tomography (CBCT).
Methods: The 16 patients affected by a large odontogenic man-
dibular cyst were enrolled in the study. All the patients underwent a
surgical decompression of the cyst followed by the enucleation after
a follow-up ranging from 6 to 9 months according to the volume’s
reduction and new bone formation. All the patients were evaluated
with a CBCT before and after the surgical decompression to
measure and analyze the percentage of reduction of the cystic
volume before proceeding with the enucleation.
Results: The decompression of the cyst showed a reduction of the
cystic volume ranging from 38.2% to 54.4% proportionally to the
treatment duration. The highest percentage of volume reduction
From the Department Neurosciences, Reproductive and Odontostomato-
logical Sciences, Federico II University of Naples, Naples; and
yDepartment of Neurosurgery, University of Salerno, Salerno, Italy.
Received April 2, 2019.
Accepted for publication May 9, 2019.
Address correspondence and reprint requests to Giovanni Dell’Aversana
Orabona, MD, PhD, Via Pansini 5, Naples, Italy;
E-mail: dellaversana@unina.it
The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web site (www.jcraniofa-
cialsurgery.com).
Copyright # 2019 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000005725
e658 # 2019 Mutaz B. Habal, MD
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 30, Number 7, October 2019
observed was 54.4% in 1 patient followed-up for 9 months, before
the surgical enucleation.
Conclusion: In our experience, the decompression seems to be the
most suitable technique for the primary treatment of large odonto-
genic cyst of the jaws followed by the enucleation after 6 to 9
months. The CBCT is an objective method to evaluate the cystic
volume reduction after the decompression and helps the surgeon
with the surgical planning.
Key Words: Cone-beam computed tomography, decompression,
dentigenous cyst, mandibular cyst
O dontogenic cysts are pathological bone lacunae that originate
from the proliferation and/or degeneration of epithelial com-
ponents that remain from the odontogenesis process.1 –3
Mandibular cysts represent approximately 24% of all these
cysts, and they have the higher incidence in the posterior area of
this bone, most frequently involving the region of the third lower
molar.4– 7 Occasionally they can become extremely large, resulting
in a considerable cortical bone expansion leading to facial deform-
ities and asymmetries.8,9
Many Authors do believe that at the base of growth and
expansion of cysts, there is an increase in osmotic pressure within
the cystic lumen, where the increasing hydrostatic pressure applied
to peripheral bone enhances osteoclastic reabsorption and contrib-
utes to its expansion.10
Treatment, generally, is based in a surgical cystectomy. Healing
will occur with the organization of the blood clot in the residual
bone cavity. This technique is indicated for lesions surrounded by a
stable amount of bone, however, can be followed by complications
especially in large mandibular cysts.
In this case, we propose to perform the decompression of the cyst
followed by enucleation after 6 to 9 months in order to avoid
major complications.>
The aim of this study was to retrospectively evaluate the result of
decompression based on the volumetric reduction of the cyst cavity
and new bone formation with cone beam computerized tomography
(CBCT).11
METHODS
A retrospective study was carried out between May 2014 and
February 2016 at the Department of Maxillofacial Surgery of the
University of Naples Federico II. Among 47 patients affected by
odontogenic cyst, we selected 16 patients (11 men and 5 women),
ranging in age between 16 and 77 years, and the average age was
45.1 years.
The inclusion criteria were: cystic diameter greater than or equal
to 2.5 cm; thickness of the cystic wall less than or equal to 2 cm, and
a positive biopsy examination for odontogenic cyst.
The exclusion criteria were: subjects with concomitant malig-
nant disease; patients treated by bisphosphonates, subjects with
keratin cyst, and ameloblastoma or patients treated with
primary cystectomy.
In all the patients a CBCT was performed before the decom-
pression procedure. After the surgical decompression, all the
patients performed a regular follow-up monthly and for clinical
control of the tube position and oral hygiene. An orthopantomo-
graphy for the evaluation of the cystic diameter was performed
every 3 months. Before proceed with the enucleation all the
patients performed a new CBCT scan to prove the reduction of
cystic volume. The volume evaluation was measured with
OSIRIX DICOM viewer. A pre-selection of cystic cavity on
The Journal of Craniofacial Surgery  Volume 30, Number 7, October 2019
FIGURE 1. (A) Preoperative CBCT scan with 3d reconstruction showing a large
mandibular cyst with a volume of 51067 cm3. The unerupted lower third molar
is evident in the angular region; (B) Postoperative axial CBCT scan with 3D
reconstruction of the same patient treated with decompression. The cystic
volume passed from 51067 cm3 to 3.0389 cm3 after 7 months of follow up. It is
also well represented the mobilization of the third molar included in the cystic
cavity. CBCT, cone beam computerized tomography.
CBCT images for subsequent segmentation of mandibular struc-
ture was performed. This pre-selection consisted in manually
creating a region of interest (ROI) comprising all mandibular
tissues, performed slice by slice. The 3-dimensional ROIs were
defined for each scan and OSIRIX simulation using automatic 3-
dimensional fitting and regularization realized the reference
volumes of cystic cavity and a 3D rendering (Fig. 1A,B). Once
the cortical-basal bone measured at least 3 mm, all the patients
were operated for the enucleation of the cyst and histopatholo-
gical examination was performed.
In all the patients the first surgical step was the decompression of
the cyst by using a nasogastric tube, manually cut in segments of
about 1 cm in length. The enucleation was performed when the
cavity volume was clinically reduced on CBCT after 6 to 9 months
follow-up (Fig. 2).
During this period all the patients performed a regular follow-up
to confirm the tube position and patency.
Surgical Procedure
The decompression procedure was performed under local
anesthesia, opening a small osteomucous breach.
FIGURE 2. Decompression device obtained from a nasogastric tube. Note the
radiopaque marker line.
# 2019 Mutaz B. Habal, MD
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
After performing the breach, an incisional biopsy was performed
for the histopathological diagnosis of the lesion. The diameter of the
inlet hole was smaller than the diameter of the drainage, in order to
have a good primary stability of the device at the end of the
procedure. The device was inserted and stabilized by silk sutures,
soaking the mucosal margins.
RESULTS
Among the 16 patients treated by cystic decompression of the
jaws, the reduction rate was analyzed according to the distri-
bution in the following group: age, gender, lesion, location,
and size.
The cystic lesions were localized between the body and the
mandibular branch in the 68.7%, and in the symphyseal region in
the 31.3%.
The duration of decompression ranged from 6 up to 9 months
with an average of 7.6 months.
The CBCT performed before and after the decompression,
showed a reduction of the cystic volume from 38.2% to a maximum
of 54.4%. We observed that the reduction of the cystic volume was
proportional to the duration of the decompression time with a
reduction of the cystic volume up to a maximum of 54.4% in
the patient treated for 9 months. There was an increase in basal
cortical bone thickness up to 300% ensuring a resistance that
allowed us to safely remove the cyst (see Supplemental Digital
Content, Table 1, http://links.lww.com/SCS/A796).
In all the patients analyzed, an incisional biopsy was performed
during the decompression procedure. A second biopsy was done
during the enucleation to confirm the histological diagnosis of
odontogenic cyst.
The complications observed were: in 3 cases the lost of the
drainage tube, in 2 patients the development of an infection due to
poor oral hygiene, and the device obstruction. No major compli-
cations like fracture were observed.
DISCUSSION
The most widely used and widely demonstrated treatment for the
removal of small-sized odontogenic cysts of the jaw is the
enucleation. The treatment of large odontogenic cyst is still
controversial.
Unfortunately, the complete removal may be difficult and
followed by several complications especially when the cyst is
proximal to vital structures such as the inferior alveolar neurovas-
cular bundle, or inferior border of the mandible. In these cases, the
marsupialization or decompression for jaws cystic lesion seems to
be an effective alternative treatment.
The marsupialization approach, described by Partsch in 1892, is
a technique involving the creation of a large window of the
cyst wall, converting the cyst into a pouch so the cyst is decom-
pressed, exposing the cyst lining to the oral environment. This
communication between the oral cavity and the cyst wall reduces
the internal pressure of the lesion, and promote the generation of
new bone tissue.12–19
A more recent option is the decompression of the cyst. This
technique is based on the relieves of the pressure within the cyst,
and can be performed by making a small opening in the cyst
and keeping it open with a drainage. In our series, we decided
to perform the decompression in all the patients affected by
large mandibular cyst (diameter 2.5 cm; thickness of the cystic
wall 2 cm).
Anatomical vital structures closed into the cavity, such as the
mandibular nerve or the extended dental roots, can be preserved
from possible surgical damage due to this treatment.
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Brief Clinical Studies The Journal of Craniofacial Surgery
FIGURE 3. (A) Preoperative CT scan showing the basal bone cortex thickness
before decompression (0.238 cm); (B) Postoperative CT scan of the same
patient after 7 months of decompression showing the improvement basal bone
cortex thickness (0.907 cm). CT, computerized tomography.
The device we used as drainage tube, with a diameter of 4.7 mm,
was a nasogastric tube sectioned manually by the surgeon during
the decompression.
This device has 2 important characteristics: it is easily
modeled and contains a radiopaque marker line, which makes
it identifiable for subsequent instrumental checks. The catheter
was manually cut and created in segments of about 1 cm in
length. The 2 ends were modeled through a heated and molded
bunsen in order to obtain 2 flared safety contours. The purpose
of the flares was to reduce the risk of the drainage lost or
dislocation in the cystic cavity.
Finally, the device created was subjected to sterilization by
plasma gas.
All patients were trained to irrigate the drainage tube with 0.12%
chlorhexidine, 2 or 3 times a day, to prevent possible obstructions
with food residues.
As far as we know, this is the first case described in literature in
which the decision to proceed with the enucleation is based on an
accurate evaluation of the cystic volume on the CBCT.
The main advantages of CBCT imaging used as preoperative
study are that it offers a real-size dataset with 3D reconstruction and
low radiation dose compared with the CT. To monitoring the cystic
chaining during the follow up we measured the cystic volume in
cm3 using a radiological program (Osirix DICOM viewer) which
allows the realization of very reliable measurement of the lesions’
volume and allows us to calculate the percentage of reduction
after treatment.
The surgical enucleation of the residual cyst was planned
by the surgeon based on the reduction of the volume cyst
and augmentation of the cystic wall thickness on the CBCT
after a 6 to 9 months follow-up. The enucleation was performed
when the cortical-basal bone had a thickness of at least 3 mm,
guaranteeing sufficient mechanical resistance to operate safely
(Fig. 3A,B).
The complications occurred were in 3 case the lost of the device
and in 2 patients the development of an infection due to poor oral
hygiene and device’s obstruction. All the complications were
treated without sequelae. In 3 cases the tube was repositioned
during the follow-up examination, and in 2 patients, who developed
an infection, 5-day amoxicillin and clavulanic acid treatment
were administered.
CONCLUSION
In our opinion, the decompression followed by the enucleation
seems to be the most suitable technique for the primary treatment of
large odontogenic cysts. This technique allows the preservation of
the dental elements, reduces the risk of damaging important ana-
tomical structures and iatrogenic fracture. It is a simple and rapid
e660
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 30, Number 7, October 2019
technique that allows the surgeon to act in safety, ensuring optimal
result and lower incidence of major complications. Unfortunately,
the decompression treatment requires compliance of the patient due
to long time of treatment, clinical follow up, and the need of 2
surgical procedures.
In comparison, a primary enucleation of the cyst is a treatment
performed only in 1 surgery, with less discomfort for the patient and
lower frequency of the follow up, but for the large jaw cyst it is
associated to a higher incidence of major complications including
infections, iatrogenic fractures, lesion or loss of dental elements due
to the greater invasiveness of the surgery and the lower post-
operative mechanical resistance.
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dentigerous cyst crossing the midline. Natl J MaxillofacSurg
2013;4:100–103
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cystic lesion. Clinical Long-term study of 73 cases. Oral Surg Oral Med
Oral Pathol Oral Radiol End Lod 2011:164–169
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Bucal 2012;17:1000–1005
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tomography (CBCT) imaging of the oral and maxillofacial region: a
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13. Partsch C. Uber kiefercysten, Treatment of keratocysts: the case for
decompression and marsupialization. J Oral Maxillofac Surg
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14. Goyal S, Sharma S, Kotru M, et al. Role of FNAC in the diagnosis of
intraosseous jaw lesions. Med Oral Patol Oral Cir Bucal 2015;20:
284–291
15. Wushou A, Zhao Y, Shao Z. Marsupializationis the optimal treatment
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16. Kirtaniya BC, Sachdev V, Singla A, et al. Marsupialization: a
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# 2019 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 30, Number 7, October 2019
18. Anavi Y, Gal G, Miron H, et al. Decompression of odontogenic cystic
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Application of a Lateral Pedicled
Cranial Bone Flap for the
Treatment of Secondary
Zygomaticomaxillary Defects
Wenpeng He, MS,y Xi Gong, MD,z Yang He, MD,§
Lei Zheng, MD,§ Yi Zhang, MD,§ and Renfa Lai, MDy
Abstract: This study aimed to evaluate the effect of laterally-based
pedicled cranial bone flap (LBPCBF) for the repair of secondary
zygomaticomaxillary defects. Between December 2014 and
December 2016, 6 patients with unilateral zygomaticomaxillary
defects were selected; of these, 5 had trauma, and 1 was exposed to
titanium mesh in the infraorbital area due to radiotherapy following
total maxillectomy for right maxillary squamous cell carcinoma.
Preoperatively, 3 patients suffered from an intraoral vestibular
groove fistula, 2 suffered from an extraoral fistula, and 1 from
local exposure of titanium mesh. Surgical treatment was imple-
mented in all 6 patients, of which, the 5 trauma patients underwent
debridement, reduction, and fixation of periorbital fracture, fol-
lowed by repair of the defects in the infraorbital margin, anterior
wall of maxillary sinus, and zygomatic body with LBPCBF, and
then, reconstruction of the orbital floor with titanium mesh. The
other patient with exposed titanium mesh underwent repair of
defects in the infraorbital margin and anterior wall of the maxillary
sinus with LBPCBF after titanium mesh trimming. Postoperative
review at 6 months revealed disappearance of intraoral fistula,
From the Medical Center of Stomatology, The First Affiliated Hospital;
ySchool of Stomatology, Jinan University, Guangzhou; zSecond Dental
Center; and §Department of Oral and Maxillofacial Surgery, Peking
University School and Hospital of Stomatology & National Clinical
Research Center for Oral Diseases & National Engineering Laboratory
for Digital and Material Technology of Stomatology & Beijing Key
Laboratory of Digital Stomatology, Beijing, China.
Received July 4, 2018.
Accepted for publication May 12, 2019.
Address correspondence and reprint requests to Yang He, MD, 22 Zhong-
guancun South Avenue, Haidian District, Beijing 100081, China;
E-mail: fridaydust1983@163.com
Authors WH and XG contributed equally to this work.
This study was supported by Beijing Natural Science Foundation
(17L20291) and Medical Scientific Research Foundation of Guangdong
Province, China (B2018136).
The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web site (www.jcraniofa-
cialsurgery.com).
Copyright # 2019 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000005776
# 2019 Mutaz B. Habal, MD
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
wound healing, and improvement of facial deformity in all 6
patients, of which 2 patients demonstrated postoperative ectropion.
The application of LBPCBF can simultaneously repair bone defects
in the infraorbital margin, anterior wall of maxillary sinus, and
zygomatic body, as well as, supplement the soft tissue, thereby
indicating a satisfactory treatment effect.
Key Words: Lateral pedicled cranial bone flap, reconstruction,
titanium mesh, treatment, zygomaticomaxillary defects
T rauma, tumor resection, and postoperative radiotherapy can
cause defects in the zygomatic and maxillary bones in the
infraorbital region of the face. These defects might lead to
secondary communications between the maxillary sinus and
extraoral or intraoral areas, as well as facial collapse deformity.
Such defects and deformities in the infraorbital region are
usually accompanied by bone and local soft tissue defects as
well as scar contracture. During treatment, simultaneous repair
of the bone defects in the infraorbital region and orbit, and
supplementation of the soft tissue is essential.1 Presently, a
vascularized flap is not commonly used, due to complications
at the donor site; also, a relatively small range of repair is
required for such defects.2
A soft tissue contracture deformity in this region can be repaired
by fascial padding with a temporalis myofascial flap and a laterally
pedicled pericranial periosteum flap, with a satisfactory treatment
effect.3 The conventional repair methods for infraorbital bone
defects include titanium mesh and skull external lamina grafts.
For defects caused by trauma, tumor removal, and radiotherapy,
both soft tissue and bone defects are observed, which need to be
repaired with one-stage surgical treatment. This can be achieved by
using a laterally pedicled pericranial flap together with an external
skull lamina.
While autogenous bone transplantation is the traditional
method for bone defects in the infraorbital maxilla and the
infraorbital rim, and the outer table of the skull is most commonly
used for transplantation, for patients with oral-maxillary sinus
fistula or oral cutaneous fistula, the risk of reconstruction is
relatively high due to the lack of soft tissue. A pericranial flap
with lateral pedicle not only realizes skull reconstruction, the
pedicle also makes up for soft tissue coverage on the bone surface.
Though it is not certain whether the pericranium that remains on
the surface of the skull can maintain part of the skull’s blood
supply, this approach is able to reduce patient risk, and this has
been confirmed by clinical application.
Since the cranial periosteum is connected with the lateral
temporalis myofascial flap, it is possible to prepare the laterally
pedicled pericranial flap with external skull lamina for the simul-
taneous repair of the bone defects and soft tissue contracture in the
infraorbital region. The cranial periosteum with a lateral pedicle has
sufficient tissue and blood supply to provide the external skull
lamina with a partial blood supply and adequate soft tissue cover-
age. This study retrospectively reviewed 6 patients undergoing
repair of secondary zygomaticomaxillary bone defects in the infra-
orbital region with this novel approach using a laterally-based
pedicled cranial bone flap (LBPCBF) and summarized the
clinical effects.
METHODS
Patients
Between December 2014 and December 2016, 6 patients with
unilateral zygomaticomaxillary defects who were admitted to the
e661