30 March 2021

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Marsupialization as treatment of jaw bones cysts

Authors: Daniela Sorrentino, Sem Decani, Demetrio Lamloum, Niccolò Lombardi, Andrea Nicali

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The purpose of this paper is to describe the marsupialization technique as part of the surgical treatment of maxillary bone cysts. This procedure is particularly useful for interrupting the expansive growth process of some types of cysts, resulting in a partial, but consistent, reduction in the size of the cysts which allows a more conservative management during the subsequent enucleation. Marsupialization preserves noble anatomical structures such as the inferior alveolar nerve and vital structures such as dental elements. Iatrogenic mandibular fracture, possible during more radical interventions is also reduced. Numerous studies have also shown that following exposure of the cystic lesion to the oral cavity, a histological change occurs in the epithelial lining of the cyst. This becomes thicker and assumes characteristics more similar to those of the normal oral mucosa, helping the enucleation the cyst during the second surgical access.

MATERIALS AND METHODS
Three marsupialization surgical procedures are described and are related to the treatment of a keratotic odontogenic tumor and of a follicular cyst. The surgical technique involves the transformation of the cystic lesion into an accessory cavity, in communication with the oral cavity. A shutter device was designed in order to avoid wound contamination during meals and to maintain the opening of the bone lesion into the oral cavity. Patients were instructed to perform cleansing by daily irrigations. A second surgical access, to complete cyst enucleation, was successful performed in two cases, while it was not necessary for one of the three subjects. Patients underwent were a follow-up period and until complete resolution of the pathological processes.

RESULTS AND CONCLUSIONS
In patients treated with marsupialization, a rapid decrease in the size of the osteolytic lesions was observed, which allowed an improvement in the initial patients’ symptoms. It was also possible to appreciate bone neo-deposition, which can be evaluated by radiographic controls, with a consequent increase in the volume of cortical bone reducing the risk of iatrogenic fracture. An increase in the distance between the cystic walls and the relevant anatomical structures such as the inferior alveolar nerve was also observed. This decreased the probability of iatrogenic damage during the complete removal of the cysts. Complete enucleation was performed by a second surgical procedure, 6 months later in one case and 1 year later in the second one. These second surgical accesses were less invasive and safer in terms of intra and post-operative complications. None of the patients to date have had recurrences.

Clinical relevance: Although other surgical techniques for the permanent removal of jawbone cysts are available, in case of extensive cystic lesions, the classical surgical approach could be more aggressive, and destructive and susceptible to early and late complications. The success rate of marsupialization, as a primary step in the treatment of very large cystic lesions, allows a more conservative and less invasive subsequent surgical approach.