Fate of Mandibular canals displaced by enlarged

cystic lesion: does the inferior alveolar

neurovascular bundle relocate to its original
position?

British Journal of Oral & Maxillofacial Surgery,2018

Han et al
Citation:5
Impact Factor:2.018

Presented By- Dr. Gauri Sharma

Approved By- Dr. Rajanikanth K
INTRODUCTION
Kramer in 1974 defined cyst as,

“a pathological cavity having fluid, semi fluid or gaseous contents and

which is not created by accumulation of pus”
INTRODUCTION

• Cystic fluid has a higher osmotic pressure than the surrounding environment

• Results in the inflow of tissue fluids into the cystic cavity

• Causes the size of the cyst to increase, thereby displacing or destroying the
neighbouring hard tissue.

• Cysts in the mandible displace the adjacent teeth and the mandibular canal, or
encroach on the cortical lining of the canal
 AIM
• The aim of the study was to evaluate the pattern of displacement of the
mandibular canal by cysts and the repositioning of the mandibular canal
after enucleation.
METHODOLOGY:STUDY DESIGN

• Retrospective cohort study

• Conduted between 2006 and 2015 at 2 differenent centeres

• Postoperative biopsies were taken and all cysts were diagnosed

histopathologically

• All patients who had their cysts enucleated were followed up for five years
to rule out recurrence
METHODOLOGY: INCLUSION &
EXCLUSION CRITERIA
INCLUSION CRITERA EXCLUSION CRITERIA

Patients with mandibular cysts who had them Patients under the age of 18 were excluded to
enucleated between 2006 and 2015 at two rule out the influence of mandibular growth.
university hospitals were included

patients were included in the study if they had

had postoperative panoramic radiographs taken
after at least 12 months
METHODOLOGY: STUDY GROUPS
• Cysts that encroached on mandibular canal
Group A which were enucleated without a bone graft

• Cysts that did not encroach on the mandibular

Group B canal, and were enucleated without a bone graft

• Cysts that encroached on the mandibular canal,

Group C and were enucleated with a bone graft

 METHODOLOGY
• Each subject had computed tomography (CT) preoperatively.

• The images were used to assess

site and size of cysts
position of the mandibular canals relative to the cysts.
Cystic encroachment and displacement of the mandibular canals

• Panoramic radiographs were used to assess changes in mandibular canal

height
 METHODOLOGY:ASSESSMENT OF
RADIOGRAPH
• Height of the mandibular canal (C): height
from the lower cortex of the mandibular
canal to the mandibular lower border

• L1:length from cusp tip to the root apex of

tooth adjacent to the cyst

• L2:length from root apex of the adjacent

tooth to the mandibular lower border

• L3:length from distal cementoenamel

junction of the tooth adjacent to the cyst to
the mandibular lower border
 RESULTS
• 70 patients (and 72 sites) who had their cysts enucleated were included in the study

• Group A:37 patients

• Group B:14 patients
• Group C:21 patients

• Their mean (range) age was 45 (18–75) years

• The cystic lesions were diagnosed histopathologically as:

 dentigerous cysts (48/72)
periapical cysts (11/72)
odontogenic keratocysts (11/72)
residual cysts (2/72).
RESULTS
• An organic bovine bone matrix (Bio-Oss) was grafted in 18 subjects

• Autogenous iliac particulated marrow and cancellous bone was grafted in

3 subjects

• Five patients with bone grafts developed postoperative infections (5/21)

• Five patients who did not have bone grafts developed postoperative
infections (5/51).
RESULTS
RESULTS:
• The height of the mandibular canal differed significantly before and after
operation in Group A (p < 0.001), but not in Groups B and C

• Sex, age, and pathological diagnosis had no significant influence on the

postoperative changes in the height of the mandibular canal
 DISCUSSION
• As mandibular cysts continuously enlarge in limited spaces, they easily intrude
into adjacent anatomical structures

• Usually they develop above the mandibular canal, and so the authors had
assumed that they usually displace the canal inferiorly
 DISCUSSION
• In the case of cysts that encroach on the mandibular canal and are treated
without a bone graft (Group A), the mean height of the mandibular canal
increased superiorly by a mean of 2.36 (1.65) mm and this was significant
after the cyst had been enucleated

• This means that the displaced inferior alveolar neurovascular bundle tended
to relocate to a supposedly normal position

• Cases in which the mandibular canal was encroached on and treated with a
bone graft (Group C), the mandibular canals did not relocate postoperatively.
STRENGHTS
• There were no differences in height in L1, L2, and L3 between
panoramic images taken before and after operation, which means
that a digital panoramic view does not induce vertical distortion in the
height, and analysis of panoramic images is valuable
LIMITATIONS
• CT has more power to evaluate the positional changes of anatomical
structures

• However, CT also has some limitations in that it is difficult to obtain

images with the same orientations before and after operations

• Postoperative CT cannot easily be used as part of a routine check

 CONCLUSION
• Mandibular canals were displaced inferiorly by mandibular cysts as they grew and
eventually encroached on the canal, to expose the inferior alveolar neurovascular
bundle

• After the cystic compression ceased, the displaced neurovascular bundle tended
to relocate towards a supposedly normal positiion

• In contrast, the displaced mandibular canal did not relocate when the cortex of
the canal remained sound, or when bone was grafted just above the exposed
inferior alveolar neurovascular bundle
THANK YOU