Interdisciplinary approach to treatment of maxillary radicular cysts: Minimization of surgical invasiveness and medication load

The use of autologous plasma has been explored in periodontology and maxillofacial surgery. Since it has a high concentration of biologically active factors and can be used in different forms (liquid, membrane, clot), it can be used in surgeries, including on bone tissue. Based on data on the effect of autologous plasma on inflammatory response, stimulation of osteogenesis and tissue regeneration according to the biological pathway, studies today continue to make supporting findings for the use of autologous plasma. In addition, the use of ultrasonic devices in dentistry is widespread and ultrasonication can be used during surgery on bone tissue. embedImagecenter("Imagecenter_1_1911",1911, "large");

Material and methods

Sixteen patients aged 24–55 who had been diagnosed with maxillary odontogenic radicular cysts were selected for the study and had undergone etiotropic treatment. The patients were divided into four groups depending on the treatment provided and the criteria given in Tables 1–3. All patients in the main and Control 1 groups underwent complete clinical and radiographic examination. Data on patients in the Control 2 and 3 groups was collected from a database of city policlinics in Kiev. All of the patients were divided according to preoperative preparation and surgical method during cystectomy. In the main and Control 1 groups, preoperative endodontic treatment of the involved teeth was performed and temporary splinting was done using orthodontic buttons attached with a light-curing composite (Spectrum TPH, DENTSPLY) and fixed with an elastic ligature without tension. In patients in the main group, venous blood was drawn preoperatively and autologous plasma was prepared using BTI technology. The prepared material was stored in sterile glass vials until needed.

Table 1: Patient division into groups according to type of preoperative preparation.

Group	Age (years)	Sex (F/M)	Place of operation	Preoperative preparation
				Endodontic treatment	Anti-inflammatory, anti-oedematous therapy
Main (3 patients)	24-55	2 F, 1 M	DSPMC, Kyiv Regional Clinical Hospital	Endodontic root canal treatment with Pro Taper AH Plus	3 days before: Nimesulid powder 100 mg (o.d.) Loratadinum 0.01 mg (o.d.)
Control 1 (5 patients)	24-55	3 F, 2 M	DSPMC, Kyiv Regional Clinical Hospital	Endodontic root canal treatment with Foredent (SpofaDental) Endomethasone N (Septodont) phosphate cement	3 days before: Nimesulid powder 100 mg (o.d.) Loratadinum 0.01 mg (o.d.)
Control 2 (4 patients)	24-55	2 F, 2 M	Other city policlinics	Endodontic root canal treatment with Foredent Endomethasone phosphate cement	None
Control 3 (4 patients)	24-55	2 F, 2 M	Other city policlinics	Endodontic root canal treatment with Foredent Endomethasone phosphate cement	None

 

For surgical access, under local anaesthetic, an intrasulcus incision was performed, as well as a horizontal incision, in the area of the interdental papilla base according to the Minimally Invasive Surgical Technique and the Modified Papilla Preservation Technique,[2] and vertical incisions were made in the area of the adjacent healthy teeth. The mucoperiosteal flap was formed and raised, and a bone window over the cyst was made using a surgical drilling bur. The curettage of the cyst cavity and the roots of the involved teeth was performed using a combination of manual and ultrasonic methods (Cavitron Select SPS, DENTSPLY) until complete cavity degranulation.

Table 2: Patient division into groups according to type of surgical method. 

GROUP	Surgical stage
	Incision, shape of mucoperiosteal flap	Treatment of cystic cavity Curettage (method)		Cystectomy with apicectomy and retrograde filling of root canals	Filling of cystic cavity
Main	Trapezoidal with preservation of interdental papilla and gingival contour	Standard	Standard + ultrasonication	Resection + filling with ProRoot MTA	PRGF-Endoret (clot, membrane)
Control 1	Trapezoidal, semilunar	Standard	Standard + ultrasonication	Resection + filling with ProRoot MTA	Bio-Oss
Control 2	Trapezoidal, semilunar	Standard	None	Resection + filling with Phosphadent (VladMiVa)	Other bone fillers
Control 3	Trapezoidal, semilunar	Standard	None	Resection + retrograde root filling	None

 

Table 3: Patient division into groups according to suturing technique and post-operative management.

Group	Suturing method and material                Post-operative management
	Standard (interrupted sutures)	Proposed method	Antibiotics	Anti- inflammatory and analgestic therapy	Time of suture removal
Main	None	Polyamide 5.0	None	Nimesulid powder 100 mg (b.i.d. for 5 days) Loratadinum 0.01 mg (o.d. for 5 days)	Day 14
Control 1	None	Polyamide 5.0	Azithromycin 500 mg (1 tablet per day for3 days)	Nimesulid powder 100 mg (b.i.d. for 5 days) Loratadinum 0.01 mg (o.d. for 5 days)	Day 14
Control 2	Polyamide 3.0–4.0 Polyester 3.0–4.0	None	Ceftriaxone 500 mg (1 tablet b.i.d. for 7 days)	Nimesulid powder 100 mg (b.i.d. for 5 days) Loratadinum 0.01 mg (o.d. for 5 days)	Day 7-10
Control3	Polyamide 3.0–4.0 Polyester 3.0–4.0	None	Ceftriaxone 500 mg (1 tablet b.i.d. for 7 days)	Nimesulid powder 100 mg (b.i.d. for 5 days) Loratadinum 0.01 mg (o.d. for 5 days)	Day 7-10

 

In the main and Control 1 groups, apicectomy of the involved teeth was performed. Before retrograde root canal filling (ProRoot MTA, DENTSPLY), the resectioned root canal cavities were prepared by ultrasonication (Cavitron Select SPS). In the main group, after antiseptic irrigation of the cyst cavity (Decasan, Yuria-Pharm), an intrafocus, grid-like osteotomy was performed using a small round bur (2mm) and staggered small perforations were made, achieving removal of 50% of the cortical bone layer surrounding the cyst. The prepared cavity was completely filled with PRGF autologous plasma in the form of a gel-like clot (mixed with blood clots collected during surgery) and a PRGF membrane, which completely covered the vestibular aspect of the defect. In the Control 1 group,the cyst cavity was filled using a xenogeneic bone substitute material (Bio-Oss, Geistlich) mixed with blood.

The flap was then adapted and repositioned coronally with the marginal flap edge advanced 0.2–0.5mm coronally to cement-enamel junction (CEJ). The suturing technique used in both groups was the same. The wound was sutured using a modified internal mattress suture.[1,3,4] The proximal ends of the sutures were knotted on to the orthodontic buttons, the suture in the interdental space was attached to two buttons on the adjacent teeth, which provided additional coronal flap repositioning and complete closure of the previously opened periodontium, as well as long-term blood clot stability. Interrupted sutures were used in the area of the vertical incisions until complete wound closure. The elastic ligature was attached to the orthodontic buttons without tension, providing additional immobilization of the teeth.

The surgical site was then covered with a cellulose dressing (Reso-Pac, Hager & Werken). The pressure bandage was prescribed for patients for a period of three nights. The post-operative medications prescribed are shown in Table 3 for each group. In the main and Control 1 groups, 0.12% chlorhexidine was prescribed (rising three times per day) for three weeks post-operatively for oral hygiene. The treatment of the Control 2 and 3 groups was provided in other clinics, and the data collection and details regarding the treatment process were obtained from the archives of the respective city clinics. The anamnesis and postoperative description of the soft-tissue condition were done at the Dental Training Centre (DSPMC) at P.L. Shupyk National Medical Academy of Postgraduate Education in Kiev.

Results

Our preliminary results during observation showed that the healing process in the main group was not accompanied by pain, owing to wound stability due to the suturing technique used. Only 33% of patients in the main group experienced pain on Day 1 and 2 post-operatively, compared with 50–60% of patients in all three control groups who experienced pain for 1–7 days. Also post-operative facial oedema was observed in all patients, but its duration was the shortest in all three patients in the main group, lasting 1–2 days, with a significant decrease on the third day. In patients in all three control groups, general antibiotic therapy was prescribed; in spite of this, in 25–50% of patients, a slight temperature increase was observed (from 37.0 °C to 37.5 °C) 1–2 days post-operatively. In the main group, general antibiotic therapy was not prescribed and the temperature increase was absent in all patients. Patients in all three control groups reported slight discomfort during eating 1–7 days post-operatively, but this was completely absent in patients in the main group.

During examination of post-operative ossification, the preliminary observation three weeks postoperatively was a decrease in the cystic cavity bone defect due to peripheral defect ossification corresponding to physiological mechanisms. Post-operative recession occurred in 40% of patients in the Control 1 group and in 87.5% of patients in the Control 2 and 3 groups after one month. The rate was 20% and 87.5%, respectively, after two months and 20% and 75%, respectively, after three months. In patients in the main group, marginal contour stability was observed and absence of recession after three months post-operatively.

Conclusion

The preliminary results showed that using PRGF autologous plasma prepared using BTI technology with its various consistencies (clot, membrane) for filling cystic bone cavities after their ultrasonication during cystectomy can be a useful method to minimize surgery time with quick antiseptic debridement and preparation and to avoid the usual antibiotic therapy if cysts are smaller than 3 cm. In addition, the suturing technique used provides complete wound closure in the interdental space and long-term coronal flap repositioning, minimizing the risk of postoperative recession and other complications. The preliminary data indicates a positive therapeutic effect of PRGF autologous plasma on the maturation and revascularization of the soft periodontal tissue and support of physiological bone tissue regeneration. Further studies are, however, required. Furthermore, this approach minimizes the medication load and maximally decreases patients’ discomfort during healing, which is the very aim of modern dental treatment approaches, being minimally invasive and supporting physiological response.

Table 4: Details of post-operative clinical manifestations.

Group	Post-operative manifestation
	Pain (%)	Facial oedema (%)	Temperature increase (%)	Discomfort during eating (days)	Tooth mobility (days)	Gingival recession
						Month 1	Month 2	Month 3
Main	33% on Day 1-2	100% on Day 1-3 and decrease of symptoms on Day 4-7	None	Day 1-3	None	None	None	None
Control 1	60% on Day 1-5	100% on Day 5-7	40% on Day 1-3	Day 1-3	None	40%	20%	20%
Control 2	50% on Day 1-7	100% on Day 5-7	50% on Day 1-3	Day 5-7	25% on Day 1-3	87,5%	87,52%	75%
Control 3	50% on Day 1-5	100% on Day 5-7	25% on Day 1-3	Day 5-7	25% on Day 1-3	87,5%	87,5%	75%

 

Editorial note: This article was published in cone beam – international magazine of cone beam dentistry No. 02/2015.