We have recently published an article about the "decompression" that is a particular method of marsupialization. Marsupialization implies the creation of an accessory pouch that is unacceptable for the patient. The surgical decompression , with a minimal intervention, by creating an epithelized path-way between the cyst lumen and the oral cavity allows the dimensional reduction up to the 95% of the original volume of the lesion. In some cases with obtained the completely resolution of the lesion with no necessity of enuclation. This mininvasive approach is changing significantly our surgical approach.

I think every case of such lesions should be managed according to it's nature, we can not consider a universal guide for all cystic lesions. I had a case of cystic lesion in the mandible long time ago treated successfully by enucleation, bone grafting and plating, so you can imagine the wide range of treatment from simple marsubialization to enucleation and grafting or even more advanced options,

Regards.

In order to accelerate bone regeneration, to prevent soft tissue collapse into the defect and to improve bone strength, in last years numerous authors have proposed for the treatment of jaw cystic lesions the combined use of additional graft biomaterials as filling. However, currently available data do not indicate the superiority of additional bone grafts, and the enucleation of jaw cysts with safe closure of the wound still represents the standard procedure to the present day. For a literature review: Ettla T, Gosaua M, Saderb R, Reicherta TE. Jaw cysts - Filling or no filling after enucleation? A review. J Craniomaxillofac Surg. 2012; 40 :485-493

This is a very interesting topic...

Despite Partsch described the marsupialization more than 100 year ago, this technique has not been widely indagated. However in the last year, with the introduction of "minimal invasiveness", marsupialization has attracted the attention of some researcher.

I see some cases treated with this technique:

- three cases of Keratocystic odontogenic tumor

- one case of dentigerous cyst associated to a deeply impacted lower wisdom tooth

In all cases was obtained complete healing.

Moreover in literature appeared some cases of ameloblastoma treated with this technique.

Regarding the enucleation associated to filling material there is little knowledge.

The major advantage of this technique is to avoid a major surgery, however patient's compliance is fundamental.

I would go for enucleation whenever possible since it is more comfortable for the patient. However when enucleation of a mandibular cyst is impossible or hard to perform, i.e. when it extends high up the ramus towards the condyle, I would choose enucleation

thanks for raising this intersting issue. Despite the fact that marsipulisation is incomplete treatment for cystic lesions, I think it is has a role in overall mangement of various lesions. No marsipulisation should considered before obtaining definitive tissue diagnosis. I have seen this treament is very effective in many cases of dentigerous cysts and also in selected cases of Keratocystic odontogenic tumor.For the laterhe ihave limited the marsipulisation to very large and bilateral cases to get a smaller lesion for radical exicision. the intersting os befobservation that many cysts may shrink significantly and even disappear after biopsy. but this require the surgeon to be patient enough to observe some patients before rushing to enucleate the whole lesion.

The properly so called cysts of the jaws are endosseous lesions, mainly containing fluid material, that appear radiologically as well-defined lucent areas within the bone, tipically with a sclerotic rim, although severe inflammation may result in a less evident sclerotic border. A true cyst is delimited by a fibro-connective wall, coated inside by a multistratified epithelium. Most of the cysts in the jaws arise from odontogenic sources, although also non odontogenic - nasopalatine duct cyst, globule-maxillary cyst, median palatal or mandibular cyst, being however, the last three controversial as independent nosological entities - or pseudocystic lesions - Stafne cyst, aneurismal bone cyst, hemorrhagic bone cyst - can be observed.

Being very variegated the context of the simil-cystic radiolucencies of the jaws, the finding of a seemingly cystic lesion in the maxillary/mandibular bone requires thorough evaluation by clinical history, careful physical examination (the state of the mucous membranes in the affected area, the presence of necrotic teeth in relation to the lesion, any deformation of the jaw, the presence of egg-shell crackling of the cortical bone on palpation), and radiographic assessment (OPT, TC) before considering surgical treatment options to follow.

As well known, in order to formulate a preliminary diagnosis, which is compatible with the clinical and radiological findings, it is necessary to consider:

- patient age

- location (maxilla; anterior / posterior mandible)

- shape, dimension and appearance (unilocular? corticated outline? expanding in the antero-posterior or in the bucco-lingual dimension? )

- in relation with an unerupted tooth? in relation with necrotic tooth/teeth?

- cortical plate disruption? root resorption? tooth displacement?

Nevertheless in some cases the preliminary differential diagnosis may challenge the clinician.

For example, a follicular (dentigerous) cyst presents tipically as a well-demarcated radiolucent lesion in relation with the cervical area of an unerupted tooth (commonly the third molar). Nevertheless, also keratocystic odontogenic tumor may present in the same location (posterior mandible), as unilocular radiolucency, in continuity with the follicular tissue of an impacted tooth. Moreover, the possibility of ameloblastic transformation of a dentigerous cyst has been reported.

In accordance with the considerations made above, it is clear that, whenever possible, the surgical enucleation probably remains the treatment of choice, as supported by a more comprehensive scientific evidence.

Marsupialization is however to be preferred in some cases:

- in deciduous or mixed dentition, when are involved the gems of permanent teeth

- in the presence of a follicular cyst, when the aim is the recovery of the involved tooth

- in the very elderly or debilitated patients, in which ademolitive intervention is not indicated

- when, for the considerable size of the cystic lesion, there is a real risk of mandibular fracture

- to achieve decompression and reduction in size of the cyst, as a step preliminary to a subsequent cystectomy

Although evidence base still favors definitive surgery whenever possible, there is some recent reports that even large keratocystic odontogenic tumors respond to marsupialization (Pogrel, Jordan J Oral Maxillofac surg 2004; 62.651-655), actually with complete resolution, with the “neoplastic” epithelium being replaced through metaplasia by epithelium wholly similar to that of the oral mucosa.

These findings of course open new perspectives towards less invasive and more conservative approaches, especially – as already pointed out by Dr Barbato, Dr Nesse and Dr Gaballah, in selected cases of very large lesions with presunctive diagnosis of dentigerous cysts or keratocystic odontogenic tumor in order to avoid major surgery (very large and bilateral cases). I’m learning with interest that also ameloblastoma can benefit from a decompression, in order to reduce its volume before surgical removal, as reported by Dr Lizio in his very interesting publication. So, at the state of knowledge, I think that the conservative management of odontogenic lesions appears very promising as definitive treatment or as a therapy preceding and supporting a subsequent surgical enucleation.

Thanks for asking this interesting question!

Mandibular cysts, which are small (less than 4cm in maximum diameter), with a well defined cystic sac are easier to enucleate. However, some cysts have a poorly defined, cystic sac and especially for multicystic lesions and large ones, may require excision followed by reconstruction. Marsupialialization may be uncomfortable for the patient and may also predispose to infection, for some types of cysts. It may take time and may be associated with multiple morbidities, before complete cure. Sclerotherapy is a newer option, especially for non-keratinized, single cysts. The treatment of choice must consider the histology of the cysts, wether it be a single cyst or multi-cystic, the cost, the patient's comfort, aesthetics and functional outcomes.

The technique that should be employed is very much dependent on the pathology of the lesion. There should not be a 'universal approach' to the management of the lesions of the jaws.

I agree with isabella openion but after marsupialization the removed part should be biopsied if the biopsy result is cystic lesion it should be removed totally according to the lesion otherwise marsupialization until lesion be away from vital and important structures the enucleated totally.thanks

The Partsch II method, which was intended exclusively for the treatment of small cysts, has become, except in rare cases , method of choice for the treatment of jaw cysts which is dependent on the size and localization of the lesion, the bone integrity of the cystic wall and its proximity to vital structures.

Large cystic lesions cause may predispose the mandible for pathological fractures. However this is very rare. my policy is to get a tissue diagnosis first. For large cysts, I take a biopsy under local anaesthesia and place a tube for decompression at the same time. If the biopsy proves to be something other than Kerato cystic Odontogenic Tumour (KOT), I tend to ennucleate at the next visit.

Decompression works the same way as marsupialization. Though in marsupialization it is recommended to suture the oral mucosa to the cystic mucosa this not necessery.In all my cases I never sutured the mucosa but the epithelium will migrate and epithelialization takes place. In the past I used to resect large KOT's of mandible and reconstructed with Fibula free flaps, recently I have become more conservative and decompression has become my treatment of choice. This will involve placement of a tube and irrigation with chlorhexide solution daily to keep the cavity clean. It takes about 6 months to 1 year for the bone to fill but it works. this way one can avoid resection and major surgery. The mental (lip) sensations also spared.

For smaller KOT's I do ennucleation and aggressive removal of bone around the cyst with a large bur.This removes satallite cysts.

Problem with marsupialization /decompression is recurrent infections.However this is uncommon.

If I know the cyst is something other than KOT I tend to ennucleate if at all possible as this couses less discomfort for the patient.

Large cysts of maxilla is a different ball of game. Again the challange is management of KOT's. They tend to involve the maxillary antrum. If you do not handle them early they can invade the skull base and orbits and resection becomes a nightmare. My policy is to ennucleate the cyst and open to the antrum. The theory is as it is connected through the antrum to the nasal cavity this works like marsupialization.However, longterm results not available.

We are just preparing a paper on quite a number of keratocystic odontogenic tumors of a size which would require the resection/damage of "vital neighboured tissues" (=teeth, mandibular nerve & vessels, jaw bone and surrounding tissues) if a complete removal would be done... Since >>10y we treat KOT by "cystostomy" (making the cyst to a stoma (a recessus) of the mouth cavity, by fenestrating the cyst; like marsupialisation but without suturing). This allows to get at least some tissues for histology, a quite good survey of the contents and the tissues clinically, thus a quite acceptable guess of the nature of the "cyst".

[We had too many issues with tubes somewhen no longer patent, so we left decompression long ago. Maybe the infections seen by Kumara Ekanayake are related to such problems? I can't remember any infection in our cases.]

Without exact data at hand: there are very good experiences, the surgery is limited, the tissues are maintained. Some cases were enucleated in a second surgery (after a reduction in the size, if neighboured structures were no longer endangered, taking into account an additonal removal of bone to remove the satellite cysts). After complete healing (according to radiography bone fill of the former cavity) there are some recurrences. The cases were retreated with the same method.

In my opinion there is no indication for an (unnecessary) aggressive surgical treatment in these cases.

We don't have any experiences with ameloblastomas and decompression/cystostomy; thanks for the hint... seems that we have to rethink nature and growth pattern of these tissues...

Hi

It is still a debate about the treatment of cysts of the jaws. First of all the type of cyst has to be ruled out by clinical examination, radiographic appearance & by taking a biopsy especially the odontogenic keratocyst which has got a high rate of recurrence. As a rule, the odontogenic keratocyst requires a thorough enucleation with margin clearance of the soft as well as the hard tissues to prevent recurrence. Secondly, the age of the patient & the presence of permanent tooth bud play an important role in the treatment of cysts. In the presence of huge dentigerous cyst in a young individual, the treatment of choice will be to marsupialize rather than enucleation to preserve and allow the permanent tooth to erupt. In the case of OKC in a mixed dentition with developing tooth bud, the protocol to be followed is to marsupialize the cyst so as to shrink in a period of time to preserve the adjacent vital structures& enucleation should be addressed to prevent relapse. The same protocol holds well in case of a large dentigerous cyst occurring in a mixed dentition period. The so said protocol can also be followed for the adults if there is more destruction of bone involving the lower border thus avoiding pathological fracture & need for fixation of reconstruction plates with or without bone graft. An aggressive enucleation should be done for large OKC's without involving the lower border. In the maxilla, marsupialization followed by enucleation holds good for OKC involving the lateral wall of the nose & the maxillary sinus even though it is rare to occur & decompression will be the treatment of choice for dentigerous cysts.

Dear Ramesh Candamourty,

I think that it is ok if you present us your opinion as your opinion. But, please, don't do that in a way that everybody has the impression that you have found the final truth and now give us a lecture in such an apoditic way.

Who says that it is a rule that... or

the protocol to be followed is...

or ... should be done?

You don't give any references, while your text is written as it would be supported by multiple publications of the highest evidence level, that means meta-analyses of a high number of prospective, blinded, randomized clinical trials with high power, and the results are definite and unambiguous, with statistics not only highly significant, but also clinically relevant.

This critical remark does not mean that you are not right with your opinions, but the choice of your words is wrong in a world where people have different opinions - and for very good reasons. The history of medicine (and not only that; every field we humans are somehow involved in) is full of misinterpretations, faults, wrong recommendations. Thus we should be careful with what we say or write...

Nevertheless, welcome in the discussion, and thank you for sharing with us *your opinion*. ;-)

Best regards

Yango

Dear Yango. thanks for your answer. I agree with you with regard the need

to support our idea with evidence. the evidence based medicine is nicest way to support our work and believe. thanks again

Dear Yango,

I can provide you with the literature proof, facts and references & infact we have performed couple of large OKC with decompression and the same later by enucleation with no relapse. In all OKC's, w use carnoy'solution as well during enucleation. But since the research gate had asked the answer for the question, I did reply based on my experience & u dont have the right to criticize anybody. I accept with the evidence based dentistry & will soon provde u with the answers.

Dear Ramesh

I highly appreciate your and other's opinions and mostly the nice way of accepting the other's ideas as long as they are supported by evidence. this is the way by which we share knowledge and enrich our scientific database

Regards to all .

Dear Ramesh,

I am sorry that I obviously offended you. That was not my intention; in contrast, I tried to give some hints for a better communication. That was obviously not successful, I did it wrong. I will try in future to find a different way...

To explain my reaction:

I use some strategies and methods (mainly in dental trauma) which are quite different to the commonly accepted "conventional" approach - which is even laid down in Guidelines. My results, however, tell a different story. Do you know the feeling when you are convinced you are right, but the whole world has just a contradictory opinion, but does not discuss, instead presents you apodictive statements? And does not even consider looking at your analysis in which you prove that the whole world is wrong because there are some little statistical catastrophies in the original articles on which all the conventional treatment is based? You get very sensible, and each time you have the impression that someone tries to establish a "rule", that someone tells you to "follow this protocol" or that "should be done" screws you up.

Now, the actual situation: I give some information on a certain treatment, and just the next post, yours, gives (in parts) a completely different opinion, but not written as a personal opinion, instead written in a manner which does not allow any other opinion: this leaves the impression that you criticize heavily our approach. You could read it as: "oh, you unknowing people over there, listen, I tell you the right thing, it is beyond any debate, so don't ever try to criticize it, it is as I say, and there is nothing which could be added or changed".

I now think that was not your intention, but how could I know? If you would have written : "in our department we follow these protocols..." everything would have been ok. But your post sounded as if you would not allow any other opinion...

I therefore just tried to give some hints how I think we should communicate: not rejecting other opinions by using words and expressions which don't leave any other opinion except that single one...

To summarize: there were two combined issues with your post, each alone having the potential to upset me. Maybe that is the reason I was too rigorous in my post, but I definitely didn't want to make you angry...

Hope you understand me?

Again, sorry.

Waiting for your references.

Kind regards

Yango

Dear Ramesh,

I do not think it is necessary to use Carnoy's solution. This solution is very caustic and can lead to damage to ID nerve.

I have no doubt that decompression works and I am treating a patient at present who presented with an infected large cyst in the mandiblar angle area. It did not respond to antibiotics and spontaneous discharge of pus is taking place. He was referred by the general dental practitioner with an OPG and I still have no tissue diagnosis as trismus preventing me doing a biopsy. Interesting matter is that there is significant amount of bone formation taking place evident in the latest Orthopantomogram.

Therefore I beleive that it is the decompression and irritating nature of pus and infective material causing this change.

I will hopefully open up the cyst and take a sample for biopsy.

I also have noticed decompression working for ameloblastomas as well. Remember this is all anecdotal and my experience only.

Dear Kumara Ekanayake,

Carnoy's solution is used only in case of OKC as it fixes & cauterizes the remnants left behind after enucleation to prevent recurrence & the nerve can always be protected by covering with a gauze soaked in Vaseline. Decompression or marsupiliazation works well with OKC for a long period of time with the cystic cavity filled with betadine soaked gauze or white head varnish & should be changed with regular intervals till the infection subsides & the cavity regresses. Later enucleation has to be addressed especially for OKC for its tendency to recurr. The same hold good for large ameloblastoma's.

Yes. provided patient's compliance is good...:-)

Hello all.. A most interesting conversation.. A point to be considered is the variations in the pathogeneis of these cystic lesions. if caused by an inflammatory process decompression, and control of any infection and its cause should yield very good results. If caused by a cyst like the OKC(now tumor)which has a tendency to recur mostly due to proliferative nature of the lining and its ability to produce satellite cysts, decompression and subsequent enucleation may not prevent recurrence. It would be interesting if clinical colleagues could share their experience in terms of the duration of follow up approximately. for the various procedures followed in each type of cyst and outcome.

Yes, Mandana,

you are right, and we are just working on this. I'm not directly involved in the evaluation, and don't know the exact data, thus here I can just report some observations about OKC.

Following decompression, sometimes we do a second surgery, to remove the satellite cysts. Sometimes the healing is that good (filling up the bony deficit), and neighboured teeth or other structures would be endangered/in need of removal, so we don't do second surgery in every case. We keep our patients in regular control. Thus, if recurrences occur, the lesions are still small, thus surgery is easier.

Yes, there are recurrences, but I don't know whether the risk is higher compared to a radical approach. We have to wait for the evaluation. The adavantage, however, is clear: I can't remember any patient in whom (partial) resections of the jaw or loss of teeth were necessary. Thus, even if the recurrences would be clearly higher than in radical surgery, we would have to discuss the advantages/disadvantages of the different strategies. I know what I would decide, and most of the patients as well.

What is still unclear to me: What's about the satellite "cysts"? Do they follow the central lesion when it is shrinking in size? And why? Or do they stay at the position they had when decompression is done?

Thank you Yango for the reply. I guess we are all waiting and watching for results that can establish the less aggressive modes of treatment as the standard protocol, especially since so many of the patients are young and losing large parts of the mandible really affects the rest of their life .

AS for the satellite cysts I am not aware of any studies on their fate after the decompression. it is an intersting question.Theoretically speaking the satelite cysts would stay may be in a less active form( much like epithelial cell rests) and may become active if the connective tissue stroma or other stimuli cause the progression to a cyst again which would cause a recurrence.

And then is the issue of OKC being a tumor- how can decompression actually work.. tumors by definition should continue to proliferate even if benign. So a situation that leaves the causative cells or lining inside should not lead to resolution of the problem . One more reason for staying with cyst.

Good idea, Mandana, I think into the same direction.

And as it was mentioned here even ameloblastoma seem to decrease in size if decompressed... I was not aware of that, but if that is true, we have to reconsider some classifications - and/or our understanding of these tissues, as I mentioned in my post of April. It is a pity, there are so many interesting issues, and so few time. I just stumbled into this discussion, found it very interesting, but it is far from being my primary interest which is trauma and related issues... Nevertheless I will stay on board, and will update as soon as I get reliable data from my colleagues dealing with this more intensively... and I feel more and more attracted by this topic... We'll see...

The following is a good article on this topic :www.cda-adc.ca/jcda • March 2008, Vol. 74, No. 2

Thanks , that will be an interesting article to read...

Dear Mandana,

I tried decompression on a few ameloblastomas. It worked OK in some. But no long term follow up. One had no response at all and ended up with resection and reconstruction with a free flap. They were not unicystic ameloblastomas which respond to decompression according to literature.

Dear Kumara theanks for sharing your experience. Considering the cases were of the solid ameloblastoma type .. we will only know the result by long term follow up.

Dear Dr Mandana,

I am Dr Pavan M Patil, a student of yours during my undergraduation from KLE Belgaum. I am now a Maxillofacial Surgeon, having graduated from Belgaum. I have two cases of biopsy proven OKC's which have been treated by decompression alone, leading to complete resolution. I had treated them in August 2007, which makes it a follow up of close to six years now. No evidence of recurrence yet. I have a follow up radiograph taken every year since the last six years. Another large radicular cyst (4.5x 3.5 cm) is presently undergoing active stage of decompression with similar results.

Dear Pavan, Very glad to know you are an oral surgeon now.. Thanks for sharing your experience ... such long term follow up with records will go a long way in changing and improving treatment modalities.

I would like to know from my fellow surgeons the various decompression methods they use for treating large cysts.Thanks in advance.

A same time of proceedure named Dredging protocol is successfully utilized in our department for unicystic benign lesion even for some solid type of ameloblastoma. First stage is Deflation, then Enucleation then Dredging for subsequent 2 to 3 times to get the histopathology report negative for that tumour.

Dear Islam can you give me a reference that explaine this procedure

In our department, we prefer decompression than marsupialization, but only for a non solid tumor. To be sure we do aspiration of the content of the lesion and then we place a drain for decompression

The most important aspect of the question would be to analyze what lesion is presenting itself as a unicystic lesion in the first place.

Odontogenic cysts, KCOT (formerly OKC) or Unicystic Ameloblastoma ... In each of these conditions the long term outcome might be different. KCOT being mostly presenting as a multicystic/scalloped lesion still sometimes can present with large unicystic appearance (though not very common) when the lesion's locules have collapsed / condensed ... and what might be present is a mild scalloping that might be not be conclusive.

Unicystic ameloblastoma is a more definitive clinical diagnostic problem because most of the lesions are 'mistaken' for other odontogenic cysts and treated as such. Post surgical biopsy results would later clinch the diagnosis to be Unicystic ameloblastoma! Now again, the subtype of unicystic ameloblastoma is more important to analyze its 'invasive' behavior further complicating our issues.

Odontogenic cysts respond well to this treatment modality but this is a problematic and long method of treatment requiring patient as well as clinician's active involvement ...

Marsupialization as a definitive treatment strategy for KCOT (formerly OKC) has been discussed in length by Pogrel in 2004 who was very much an advocate of the same and he retracted his statement in a recent publication again that it may not be the solution for all situations. PMID: 15170272

He later published a 'partial retraction' of the above in PMID: 17236955

Now the more controversial topic of unicystic Ameloblastoma - if the diagnosis is clinched before surgery, then a more appropriate treatment modality based on the sub type if available would be best! The intramural variety behaving like the solid / mutlicystic variety of ameloblastoma. This lesion would not be ideal to be treated with marsupialization. Moreover, the occurrence of this ameloblastoma in younger children further complicates the issues since in children, at the first instance of the lesion. it is recommended to go with a more conservative approach preferably with preservation of the periosteum (if possible) - which has been shown by Marx to be conducive to almost total regeneration of the resected bone! (in children). If the patient is co operative, marsupialization followed by enucleation as you have mentioned has been a proposed method relying on the marsupialization to 'shrink' the lesion and then definitive enucleation to complete the procedure. The problem with this technique is that

1. We do not have a final definitive diagnosis of the lesion as the lesion's wall/lining is still left in situ (or only part of the roof is available which is only as good as a incisional biopsy specimen and again may not be very clear)

2. The enucleated sample from second stage which is removed would be found to have undergone changes in the epithelial lining causing diagnostic issues again for the histopathologist.

So essentially we are left with no definitive clue as to the actual nature of the lesion in the first place! Even if the lesion regressed we have no idea what we were dealing with in the first place!

Another article in this regard would be by

"Andrade et al Trends in Pediatric Ameloblastoma and its Management: A 15 year Indian Experience Journal of Maxillofacial and Oral Surgery March 2013, Volume 12, Issue 1, pp 60-67 "

Marsupialiazation as a definitive treatment modality for a unicystic lesion which is not definitively diagnosed is going to give us lots of issues when we wish to analyse our results in retrospect or prospective way! And without that, we may never be able to have a definitive answer if marsupialization is indeed useful in more aggressive / neoplastic odontogenic tumors! But the reports by Pogrel seem to be suggesting that one must approach this method with caution when using it with neoplastic lesions like KCOT (and I believe we may add Unicystic Ameloblastoma to this).

Personally based on these perceptions as well as the problem of having a 'hygienic' cavity combined with a lot of patient co operation required and the need for regular meticulous follow up make this a not-so-ideal choice in a population like in India and in some countries like Africa where follow up is very difficult!

If marsupialization is being considered, I am wondering how many here actually practice another technique termed the "dredging method" first advocated by Kawamura for ameloblastoma in 1983(J. Oral Maxillofac. Surg. 1983;29:765.), 1988(Hokkaido J. Dent. Sci. 1988;9:104-106.) and again in 2001 (case report) in Asian J. Oral Maxillofac. Surg. 1991;3:81-88. This technique with its potential use in KCOT in addition to ameloblastoma has later is published in IJOMS!

The following is a publication in IJOMS in 2007 by Anwar Sadat et al (Bangladesh)

https://www.researchgate.net/publication/246826054_Treatment_of_ameloblastoma_and_keratocyst_by_dredging_method

Even though the method was first proposed in 1983 (I think) very little work has been done in this regard as far as I know. Does anyone else have any experience with this method ?

SUMMARY:-

Marsupialization though is initially appearing to be a very conservative and effective method, has inherent issues which can be problematic. As pointed out rightly by others, a long term follow up is also a mandatory aspect to be able to base our treatment on sound evidence based principles. But the very nature of the procedure precludes a proper diagnosis at times, which can adversely affect the credibility and strength of our reports! On a patient oriented basis, long term follow up and repeated visits/care might significantly add to the patient care costs as well as a risk of non compliance or loss of follow up. On these grounds, I am a little wary of using the technique of marsupialization in all unicystic lesions. I might consider enucleation + peripheral ostectomy (if odontogenic neoplasm) or enucleation alone if proven odontogenic cystic lesion or the dredging method (though in essence it is more troublesome and more repetitive in nature ... but a bit less radical for a lesion like ameloblastoma! The technique needs some more research ... I feel before being used regularly or before it is ignored and left in oblivion!)

It is easier to decide when dealing with bigger lesions since bigger lesions tend to be treated with more care because they usually indicate something 'big' whereas it is the lesions in the beginning stages discovered accidentally or the lesions which are not yet grown too big that tend to be a problem when it comes to diagnosis and are prone for mismanagement! These are the lesions that need more careful consideration as more aggressive lesions might masquerade as a more benign lesion!

Article Treatment of ameloblastoma and keratocyst by dredging method

Dear Akhilesh Ramasamy

Thanks for your valuable inputs on this topic which is very much needed for researchers and practitioners.

You are welcome. Just a small correction. I write my name as - Akilesh Ramasamy (that extra 'h' ) lol :) No offence meant ... just a matter of preference.

I agree with the points described by Akilesh Ramasamy. In my experience marsupialization has excellent indication for the treatment of unilocular cysts, preferentially. Regarding the treatment of lesions with "tumor behavior" I recommend more extensive procedures, such as resection.

Dredging method is a conservative surgical procedure in which after deflation and or encleation repeated dredging is applied to accelerate new bone formation by removing scar tissue..

a study has been published by Sadat SMA and Ahmed M, dredging method for unicystic ameloblastoma with excellent results

similar protocol might help for large cysts of the jaw ...

Jyotsna Galinde Prof. MGM Dental College, Navi Mumbai., India.

Marsuplisation is not the treatment of choice.

First, Cystic lesion is large , Biopsy is mandatory. If it is simple cyst may be lingual cortical plate is intact. One can do enucleation. If there is chance of pathological fracture or one want to save tooth underlying marsupalisation is treatment of choice.But lesion is invasive type , one should do excision and initially can put reconstruction plate if lower boerder of mandible is weak. Later reconstruction with bone graft.

I agree with the authors that masupialization is nowadays an useful treatment for large odontogenic cysts. Our protocol includes the cyst opening and the placement of a tutor which mantain the window opening. Lastly, we use a silicon tutor, custom-made, which offers confort to the patient and allows a long permanence of the device, at least 4-5 months. This prevents a premature closure of the window opening.

We send you a video with the device, and its characteristics. And a clinical case after 6 months of treatment.

The X-Ray image after six months of treatment

This is the device

ODONTOGENIC  KERATOCYST AND UNICYSITIC AMELOBLASTOMA  MAY BE THE UNICSITC MAY BE SMALL AND LARGE LESIONS OF THE JAW,  ABOUT THE SURGICAL TREATMENT OF KCOT (OKC)  AMELOBLASTOMA THERE IS CONTROVERSY AMONG THE ORAL MAXILLOFACIAL SURGEONS. TO AVOID THE MORBIDITY ONE SHOULD MAKE AN ATTEMPT TO ENUCLEATE / DECOMPRESS THE LESION. DREDGING AND APPLICATION OF THE CORNOY'S CAN BE USED TO AVOID THE RECURRENCE PROVIDED THERE SHOULD NOT BE LINGUAL CORTICAL PLATE DESTRUCTION OR PATHOLOGICAL FRACTURE.

I AM ATTACHING PREOPERATIVE AND POST OPERATIVE OPG OF  A CASE OF LARGE UNICYSTIC AMELOBLASTOMA  TREATED BY ME IN WHICH THERE IS RECURRENCE BUT THE MORBITY OF MANDIBLE IS MINIMISED

Marsupialization is always the better procedure for the treatment of large cystic lesions whenever it is closer to any vital structures and in cases having thin lower border which restrict us to do complete removal. The recurrence rate is very low and when the patient is  in growth age, the tooth bud erupts and come in occlusion.

You (and your patient) will always want to consider marsupialization and decompression. I have a decent casuistic with both large and small cystic lesions and they have responded well to decompression. Check out the attached case.

Check out these short reports. They might help...

Marsupialization, in my opinion, is simply opening & exposing the Cystic cavity to the air & the secretions within the oral cavity, that may act as sclerosants. However, Marsupialization has 2 effects: 1-The cystic fluids are free to move out or are drain freely & 2- The air & the saliva exposure on the cystic sac has a sclerosing effect on the cystic sac lining. These 2 effects causes the cyst to obliterate over time. The only problem, is that depending on the size & nature of the cystic sac & cystic fluids, it may take time, for complete obliteration.

For small lesions it is still used.

But for very large lesions and if you are working in remote centers then it can be an option.