Dr. Tomislav Krhen

Dentigerous cyst enucleation, tooth extraction and bone augmentation with cerabone® plus – A 6-month follow-up

INITIAL SITUATION

This case report describes the enucleation procedure of the most common type of odontogenic developmental cyst. This patient, however, had the recurrence of the same cystic lesion in posterior mandible two years after initial surgical intervention. The patient (female, 20 years old in good general health and normal healthy dentition) was referred by an orthodontist during her orthodontic treatment. She had two impacted molars (tooth 47 and 48) and the initial treatment plan by her orthodontist was to extract the second molar to make enough space for wisdom tooth to normally erupt in its place. With second molar extraction, the neighbouring cyst had also been removed. X-ray control after two years showed recurrence of the cyst, considerably larger than before, as it now had much larger space to grow into (Fig. 2 – 5). The result was no further eruption of the wisdom tooth (Fig. 1). Fortunately, the cyst was not inflammatory in origin, patient had no swelling or symptoms other than wisdom tooth displacement.  

TREATMENT PLANNING

Decision for the treatment plan was a routine wisdom tooth extraction surgery with the enucleation of the accompanying cystic lesion, with somewhat bigger flap design for better surgical field of view. The main concern was the trauma to the Inferior Alveolar Nerve (IAN). Luckily for the patient, the cyst showed no aggressive behaviour, only displacing local anatomical structures, leaving IAN mostly protected with its thin cortical bone layer.

The other concern was soft tissue invagination into the large bone defect that inevitably would be left in the place of wisdom tooth and its cyst, making bone regeneration in that region uncertain. The problem might arise from the necessity to close the flap over the defect, as this large area is not supported by a solid surface underneath, making primary soft tissue closure almost impossible. The decision for including the new cerabone® plus biomaterial was guided by the following ratio; we’ll use the already tried and proven, premium quality xenograft infused with the regenerative capacity of the hyaluronic acid to enhance the soft tissue healing capacity, ensuring the firm surface of bone underneath for stable soft tissue closure.

SURGICAL PROCEDURE

The procedure took place under local anesthesia. First, a triangular full thickness flap design (according to Ward) for easy access was applied (Fig. 6). An initial osteotomy with a round burr was performed around the tooth in the second step, which exposed the cyst (Fig. 7 and 8). In order not to burst it, a blunt side of a Hemingway bone curette was used around the cyst, grinding and pushing against the bone wall (Fig. 9). Then, a hole was drilled on the distal side of the tooth to help with Cryer elevator, while pushing the cyst from underneath with the curette (Fig. 10 and 11). Afterwards, the impacted tooth was extracted with the cyst still attached apically, which confirms that it is of dentigerous / odontogenic origin from that same tooth (Fig. 12). The bone defect that remained from tooth- and cyst removal was then cleaned and irrigated with peroxide and saline solution (Fig. 13 and 14). cerabone® plus was prepared with sterile saline solution according to the hydration protocol (Fig. 15 – 21). The stickiness of the augmentation material allowed the prepared graft to be directly transferred with the spatula to the bone defect in one single step (Fig. 22). A plugger instrument was used to condense the grafting material deep into the defect (Fig. 23 and 24). Finally, the flap was closed using polyester 4/0 sutures with only single interrupted suture technique, as there was no flap tension due to flap design (Fig. 25). The sutures were removed seven days after application.

FINAL RESULT

As planned, the primary soft tissue healing was successful, enabling the optimal conditions for uninterrupted bone regeneration to happen. Post-surgical healing was uneventful, with fast soft tissue closure, and clinical situation was stable (Fig. 26). At six months, a control CBCT scan was performed that showed good bone healing and no visible pathology anymore (Fig. 27 and 28). The patient expressed a high level of satisfaction with procedure outcome and materials used for faster regeneration.

CONCLUSION

The ease of handling (aka “sticky bone”) and its healing capabilities set this bone grafting material apart from others, mostly because of its practicality. Healing after six months showed nice bone integration, soft tissue closure and most importantly, no postoperative cystic recurrence. The patient had no postoperative complications or any nerve paresthesia.

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