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Rakhimov Zokir Kayimovich, Khamitova Firuza Artikovna, Kambarova Shakhnoza Alihuseynovna, Pulatova Shahzoda Karimovna, Safarova Mashhura Sulaymonovna, Bukhara State Medical Institute Department of Surgical Dentistry Head of maxillofacial surgery department E-mail: [email protected]
EXPERIENCE IN THE TREATMENT OF PATIENTS WITH ODONTOGENIC JAW CYSTS
Abstract: In the practice of the dental surgeon, odontogenic cysts make up 78-96% of the total number of cysts and 7-12% of the total number of diseases of the jaws. These figures indicate the relevance of the problem of treating this pathology. The priority tasks of surgical treatment of patients with odontogenic cystamias are the restoration of bone structure and the preservation of the function of the teeth. The main method of surgical treatment remains cystectomy with resection of the root apex. The disadvantages of cystectomy include the reduction of the function of the teeth in the area of the cyst, reinfection and residual bone cavities, which reduce the strength of the bone. Disruption of the integrity of the bone in the surgical area is often associated with prolonged healing, the outcome of which is incomplete or incomplete restoration of bone tissue.
Keywords: odontogenic jaw cysts, cystotomy, cystectomy and two-step operation, platelet-rich plasma, osteo-inductive properties.
The upper and lower jaw is often found in the practice of the dental surgeon. To date, effective methods of surgical treatment have been developed, including the use of various osteoplastic materials for filling bone cavities. This applies mainly to small sized cystic formations, when shown precys-toectomy, platelet-rich plasma,
Improving the treatment of odontogenic jaw cysts continues to be a pressing problem in surgical dentistry. This is due to the wide prevalence of the disease, the possibility of such complications as cyst suppuration, the development of osteomyelitis, deformity of the jaws, loss of teeth, the occurrence of a pathological fracture and even the so-called central jaw cancer from the epithelium of the cyst wall, as well as frequent relapses after surgical treatment.
Currently, there is no consensus in the literature about the optimal shape of the incision of the mucous membrane of the alveolar margin of the jaw during operations for odontogenic cysts. One of the important tasks of the surgical treatment of peritoneal cysts of the jaws is the preservation of teeth located in the area of the cyst and adjacent to it, the restoration of their full function [1; 2; 4]. The presence of an infected root protruding into the cyst cavity dictates the need to resect the tip of the tooth root simultaneously with the removal of the cyst sheath. Sometimes during the resection of the apex of the tooth root there is a question about retrograde filling of the canal. Currently, there is no consensus in the literature about
which filling material should be preferred. At the same time, the frequency of complications associated with poor-quality retrograde root canal filling remains high enough.
In assessing the size of the bone defect formed after the removal of odontogenic cysts, the working classification of abdominal defects of small, medium, large size and extensive [2; 4] was used. The main operative interventions in the treatment of extensive jaw cysts are cystotomy, cystectomy and two-step surgery. Indications for cystotomy are large cysts of the upper jaw, sprouting into the maxillary sinus with the destruction of the bone bottom of the cavity of the bottom and the palatal plate, extensive cysts of the lower jaw with significant thinning of the bony walls of the jaw, the patient's old age or the presence of severe concomitant diseases. Indications for cystectomy are cysts of small size within 1-2 intact teeth, an extensive mandible cyst, in which there are no teeth in its zone and a sufficient thickness (up to 1 cm) of the jaw is preserved, a large cyst on the upper jaw, with preserved bony wall bottom of the nasal cavity and maxillary sinus. The choice of cystotomy or cystectomy in the treatment of extensive jaw cysts is discussed by many authors. Some are supporters of cystotomy, considering that cystectomy is a traumatic operation with the possibility of damage to adjacent intact teeth, damage to the neurovascular bundle, pathological mandible fracture, probability of opening the maxillary sinus and nasal cavity, the possibility of autolysis of a blood clot in the bone cavity [6].
Others advocate cystectomy, arguing that cystotomy is a nonradical intervention in which cavities are formed, defects that require long postoperative care associated with the periodic change of iodoform tampons, sometimes wearing obturators for 1-1.5 years. All this contributes to the deterioration of the cleansing of the oral cavity with the oral fluid and creates conditions for the reproduction of microorganisms. The above, as well as the deformation of the external contours of the face have a negative impact on the quality of life of patients in the early and late postoperative period.
However, after cystectomy, the question arises about the restoration of bone formation with bone-plastic material, since with large bone defects and with suppuration of cysts of the blood clot organization often does not occur, it becomes infected and lysed. The experience of clinical observations showed low efficiency of some materials, especially with significant sizes of bone defects, since they are not always completely replaced by bone, but encapsulated by connective tissue, support chronic inflammation, increase bone resorption or partially rejected [1]. In this regard, the correct choice of osteoplastic materials for filling the bone defect in case of extensive jaw cysts plays a leading role for the favorable rehabilitation of patients.
According to the literature, one of the most effective means of increasing the regenerative capacity of tissues when applied topically, today is the patient's blood plasma, enriched with platelets. According to recent studies, platelets contain high concentrations of growth factors - tissue hormones that initiate regeneration processes:
- the main growth factor is (J FGF, which affects the growth of all cell types in a wound, stimulates the production of extracellular matrix components, accelerates the processes of angiogenesis, proliferation of capillary endothelial cells, and their migration into collagen;
- transforming growth factors - TGF-alpha, actively influencing angiogenesis and TGT -beta, stimulating che-motaxis of fibroblasts and their production of new collagen, elastin and fibronectin fibers;
Growth factors do not exist in the blood in a free form and act locally, being released during the organization of a blood clot (8).
In 1998, R. E. Marx et al. Developed a method for producing platelet-rich plasma (P.R.P.) by centrifuging the patient's blood and applied it in the clinic. P.R.P. effect. based on a high content of growth factors (approximately two orders of magnitude higher than in peripheral blood) and their powerful stimulating effect on the regeneration processes. In particular, in the conditions of the bone wound P.R.P. demonstrates pronounced osteoinductive properties, accelerating the formation and maturation of bone tissue, filling the defect, 1.5-2
times. Not less significantly the drug affects the healing of soft tissue wounds.
The aim of our study was to increase the efficiency of treatment of patients with odontogenic jaws by improving the quality of the examination and preparing the patient for surgery, clarifying the indications for choosing the optimal surgical method of treatment, improving the methods of individual stages of surgery, justifying the use of cystectomy in the surgical treatment of extensive jaw cysts filling the resulting bone defect platelet-rich plasma (PRP).
Material and methods
Despite the differences in the origin of cysts, the clinical manifestations are of the same type and have no symptoms for a long time: growth is slow, painless, functional impairment is not detected. Cosmetic changes occur only when a large tooth-sized cyst reaches, and in cases of keratocyst, which grows, as a rule, along the longitudinal jaw, they are absent, due to which the cyst is detected at a later date. Cysts are sometimes found accidentally when examining a patient for other diseases or if inflammation occurs in the cyst.
During the period 2013-2018, 80 patients with odontogenic cysts of the jaws were under our supervision, ofwhich 35 were classified as extensive. Of the total number of patients with extensive jaw cysts, 15 were women and 20 men aged from 18 to 64 years. Radicular cysts were found in 21 cases, follicular in 9 patients, residual in 5 patients. Extensive cysts on the upper jaw were found in 18 patients, on the lower one in 17.
Complaints of patients with non-suppurative extensive cysts at admission were reduced to the presence of jaw deformities or fistulas on the alveolar process, and 6 patients noted numbness of the lower lip on the lower j aw. With suppuration of cysts, the general condition worsened, patients complained of pain and swelling.
During external examination of patients, deformation of the face was rarely observed. More often, asymmetry of the face was observed in the presence of cysts in the anterior part of the upper and lower jaws. In one patient, during germination of the cyst in the nasal cavity with rhinoscopy, a gerbera roll was observed. In case of non-suppurating cysts, when examined from the side of the oral cavity, in 19 patients the smoothness or protrusion of the rounded shape of the anterior wall of the jaw in the area of the transitional fold was determined. Palpation of the deformities was painless, the vybuchani boundaries are clear. Dupuytren's symptom was observed in 18 patients. In 5 patients with cysts in the region of the large molars of the upper jaw, no visible deformation of the jaw was observed due to the growth of the cyst towards the maxillary sinus. In the case of follicular cysts, the intraoral examination revealed the absence of one or two permanent teeth, and in some cases the presence of milk teeth in adult
patients. If there is a defect in the jaw bone under the mucous membrane, a bone window was palpated, in the center of which the fluctuation was determined.
Diagnosis of odontogenic extensive cysts was performed by puncture biopsy, x-ray examination (orthopantomogram and x-ray of the jaws) and, if necessary, computed tomography. During puncture, cysts obtained opalescent clear fluid. When suppurating a cyst in punctate, pus appeared. The X-ray picture of cysts was characterized by the presence of a site of bone thinning of a rounded shape with clear boundaries. In the case of follicular cysts, the crown of the impacted tooth or the entire tooth is projected into the cystic cavity.
All patients underwent surgery-cystectomy with the filling of the residual bone cavity of platelet-rich plasma (P.R.P). In 19 patients, the operation was performed under local anesthesia (Sol. Ubistesiniforte 4%, Sol.Supercaini 6.0 ml), in 11 under general endotracheal anesthesia.
Cystectomy for all patients was performed by the classical method. Removal ofcysts in these cases was carried out according to the type of enucleation. The teeth, whose roots were in the cystic cavity and were of functional value, were preserved. They were previously depulped and endodontic treated. After complete removal of the cystic membrane, the resulting bone cavity was treated with antiseptics and filled with platelet-rich plasma (P.R.P). The wound was sutured tightly.
Results and discussion.
Dynamic observation ofpatients included, above all, a clinical examination, which was carried out according to the standard technique for 2-7, 14 days, 1,3,6 months later and a year after surgery. X-ray inspection included panoramic radiography ofthe jaws. On the first day, a pronounced infiltration of the wound edges was observed in 2 patients. Elimination of postoperative edema was observed for 6-7 days. Discrepancy ofstitches in the postoperative period was not observed in any case.
With re-examination after 1 month and the follow-up follow-up period, the patients had no complaints, the mucosa in the surgical area was pale pink, without puffiness. On the
6th month, a complete repair of the defect was observed radio-logically, however, homogeneity was not observed. Mature or-ganotypical bone tissue was traced along the periphery of the defect. In the central areas, the bone pattern did not show signs oforganotypicality: no formed gaversov channels, typical bone pattern, and bone mineralization were observed. In the control X-ray examination after one year, all patients showed complete recovery of the bone defect with an organotypic structure and mineralization. No decrease in the height ofthe bone tissue was observed in any case, which is very important for the further implantological rehabilitation of patients.
For illustration, we present clinical observation. Patient R., 20 years old, was admitted to the clinic on October 7, 2017. with complaints of swelling of the upper jaw, front and right. He considered himself a patient since May 2017, when he first came to the dental clinic, where a roentgenous maxillary cyst neoplasm was found on the roentgenogram on the right and right, about which the patient was sent to the maxillofacial department of the Bukhara regional multi-field medical center. Locally marked asymmetry of the face, due to swelling of the upper jaw to the right. Skin color has not been changed. On palpation, a tumor was determined, 3 x 4 cm in size, of dense consistency. Opening the mouth was free. There was a swelling in the alveolar process at the level of11-35 teeth. The mucous membrane is edematous, slightly hyperemic. On a panoramic X-ray image, an enlightenment of the lower jaw bone of an oval shape was visualized, with clear contours, 3.5 x 6 cm in size, emanating from the root of the 13 teeth of the upper jaw.
A diagnosis was made: extensive radicular cyst of the upper jaw, anterior and right (Fig 1). October 8, 2017 under local anesthesia, cystectomy was performed with resection of the apex of the 13th root (Fig 1). After cystectomy, the defect was filled with platelet-rich plasma (P.R.P) (Fig 3, 4) in combination with hydroxyapol. The wound was sutured tightly. The antibiotic Ceftroxan was administered intramuscularly for 5 days in accordance with the accepted daily dosages. The wound healed by first intention (Figure 5).
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Figure 1.
Figure 2.
Figure 3.
Figure 4.
Thus, despite the existing contraindications to cystectomy, it can be concluded that extensive odontogenic cysts of the jaws with more than 2-3 intact teeth involved and with thinning of the lower bone wall of less than 1 cm are not a definite indication for cystotomy. The use of correctly selected osteoplastic materials (in our casebased
Figure 5.
plasma platelet (PRP) in combination with hydroxyapol) helps to restore large bone defects with the formation of organotypical bone, corresponding to the anatomy of this area, in optimal time, which shortens the postoperative rehabilitation period of patients and promotes early functional body load.
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