An evaluation of bone healing in cavities in the jaws implanted with a collagen matrix

Comparison Between the Bone Lid Technique and the Traditional Technique in Surgical Treatment of the Posterior Mandibular Lesions: A Randomized Controlled Trial

Introduction

Cystic lesions of the jaws and the impacted teeth are two of the most common cases that require surgical intervention in oral and maxillofacial surgery; however, surgeons also frequently use a traditional technique that involves the removal of the buccal bone plate. This study was conducted to compare the clinical and radiologic outcomes of the bone lid technique and the traditional technique.

Methods

This randomized controlled trial included 20 patients who were randomly divided into two groups (n = 10 each): the T group, in which the lesions were accessed using the traditional technique with classical rotating instruments, and the BL group, in which the lesions were accessed with the bone lid technique performed using a piezoelectric device, with repositioning of the buccal bone plate. Operative time, pain, edema, inferior alveolar nerve injury, and bone defect healing were measured during clinical and radiological follow-ups at 24 h, 72 h, one week, one month, and six months after the surgery.

Results

Normal soft tissue and bone healing were observed in all cases except one case in the BL group. The T group had a shorter mean operative time than the BL group. In terms of pain, edema, and inferior alveolar nerve injury, the groups did not differ statistically significantly. The percentage of bone defect healing was significantly greater in the BL group than in the T group after six months of follow-up.

Conclusion

The bone lid technique performed using a piezoelectric device was effective and safe for managing lesions in the posterior mandibular region and was not associated with increased postoperative complications. The disadvantages of this technique include a longer operative time and the need for fixation tools in some cases. In contrast, this technique outperforms the traditional technique in terms of reducing bone loss and improving the healing of bone defects.

Influence of biodegradable polymer membrane on new bone formation and biodegradation of biphasic bone substitutes: an animal mandibular defect model study

Purpose

The purpose of this study was to evaluate the influence of biodegradable polycaprolactone membrane on new bone formation and the biodegradation of biphasic alloplastic bone substitutes using animal models.

Materials and methods

In this study, bony defect was formed at the canine mandible of 8 mm in diameter, and the defects were filled with Osteon II. The experimental groups were covered with Osteoguide as barrier membrane, and the control groups were closed without membrane coverage. The proportion of new bone and residual bone graft material was measured histologically and histomorphometrically at postoperative 4 and 8 weeks.

Results

At 4 weeks, the new bone proportion was similar between the groups. The proportion of remaining graft volume was 27.58 ± 6.26 and 20.01 ± 4.68% on control and experimental groups, respectively (P < 0.05). There was no significant difference between the two groups in new bone formation and the amount of residual bone graft material at 8 weeks.

Conclusion

The biopolymer membrane contributes to early biodegradation of biphasic bone substitutes in the jaw defect but it does not affect the bone formation capacity of the bone graft.

Bone Lid Technique Using a Piezoelectric Device for the Treatment of a Mandibular Bony Lesion

Different techniques for the enucleation of jaw cyst lesion in the oral and maxillofacial regions have been proposed, including the bone lid technique. The purpose of this case report is to describe the case of a cystic lesion, approached with the bone lid technique performed using a piezoelectric device, with an 8-month clinical and radiographic follow-up. A 14-year-old male patient was treated for a suspicious lesion detected on a panoramic radiograph. The concerned area was surgically accessed, and a radiographically predetermined bony window was drawn, and the beveled bony lid was removed. The underlying lesion was enucleated and sent for pathology as a routine procedure, and the removed bony lid was repositioned in situ and secured with a collagen tape. Healing was uneventful with limited swelling and reduced pain. A complete radiographic bone healing at the previously diseased site was confirmed with an 8-month cone beam computed tomography (CBCT) scan with no buccal bone resorption nor ridge collapse. The bone lid technique with a piezoelectric device was noninvasive and atraumatic in this case. Further studies are needed and could lead to the adaptation of this approach as a possible standard of care.

Mesenchymal stem cells in post-surgical cavities of large maxillary bone lesions

BACKGROUND

Recent studies have highlighted that MSCs are capable of regenerating large bone defects when used in combination with bone substitutes and increasing allo-graft osteointegration. We investigated the hypothesis that autologous MSCs may lead to increased bone regeneration and reduced healing time in post-surgical cavities of large maxillary bone lesions.

METHODS

This study involved 10 patients (TEST GROUP) (6 males and 4 females). All patients had expansive mandibular lesions larger than 3 cm. From the surgical point of view, the 10 patients were treated with MSCs (withdrawal of the iliac crest bone marrow BMMSs) directly into the post-surgical cavity, without the addition of filler.

RESULTS

and radiological data, in the postoperative, were compared to those of patients who did not receive any grafting of MSCs. The 7 patients with mandibular lesions showed a rapid and very good healing with an 85-90% ossification of the major defect at 12 months.

CONCLUSIONS

Through the use of stem cells a greater ossification of the residual cavity (85-90%) was observed at 12 months after surgical enucleation in contenitive defects.

Evaluation of Spontaneous Bone Regeneration after Enucleation of Large Cysts of the Jaws using Radiographic Computed Software

Introduction

Spontaneous regeneration of bone is commonly seen in the small surgical defects caused by enucleation of cysts. However, in case of large surgical defects caused by the enucleation, spontaneous regeneration of bone is a rare phenomenon and it depends on factors, such as age of the patient, intact periosteum, and proper stabilization.

Materials and methods

The study included 16 patients, who reported to the department of oral and maxillofacial surgery with the complaint of pain and swelling in the jaws diagnosed as cyst. The sample included equal numbers of male and female subjects aged between 15 and 40 years. Panoramic radiographs were taken pre- and postoperatively on day 2 of the enucleation.

The dimensions of the cyst were evaluated on the radiograph according to the proforma.

Subsequent radiographs were taken at regular intervals of 1.5, 3, and 6 months using standard parameters and were analyzed using MCID™ analysis software of imaging research.

Results

Mean reduction was seen in up to 39 and 60% in the cystic cavity size and increase in the mean density up to 59 and 90.2% at 3 and 6 months intervals respectively.

Conclusion

Spontaneous bone regeneration was seen even after primary closure of the large cystic defect without the need for placement of foreign substances or grafts and it also eliminated the complications resulting from placement of foreign substance. Further studies are required in a larger sample with longer follow-up durations to confirm the outcome of the present work for the benefit of patients.

Clinical significance

The present study depicted that spontaneous bone regeneration can occur with accepted results after simple enucleation of jaw cyst without the aid of any graft material. Hence, simple enucleation may be considered as a first line of treatment modality for cystic lesion of the jaws. This simplifies the surgical procedure, decreases the economic and biologic costs, and reduces the risk of postoperative complications. Follow-up is necessary along with patient's compliance for the success of treatment.

How to cite this article

Wagdargi SS, Rai KK, Arunkumar KV, Katkol B, Arakeri G. Evaluation of Spontaneous Bone Regeneration after Enucleation of Large Cysts of the Jaws using Radiographic Computed Software. J Contemp Dent Pract 2016;17(6):489-495.

Interventions for the treatment of keratocystic odontogenic tumours

BACKGROUND

The keratocystic odontogenic tumours (KCOTs) account for between about 2% and 11% of all jaw cysts and can occur at any age. They are more common in males than females with a male:female ratio of approximately 2:1. Although they are benign, KCOTs are locally very aggressive and have a tendency to recur after treatment. Reported recurrence rates range from 3% to 60%. The traditional method for the treatment of most KCOTs is surgical enucleation. However, due to the lining of the cyst being delicate and the fact that they frequently recur, this method alone is not sufficient. Adjunctive surgical treatment has been proposed in addition to the surgical enucleation, such as removal of the peripheral bone (ostectomy) or resection of the cyst with surrounding bone (en-bloc) resection. Other adjunctive treatments proposed are: cryotherapy (freezing) with liquid nitrogen and the use of the fixative Carnoy's solution placed in the cyst cavity after enucleation; both of which attempt to address residual tissue to prevent recurrence.

OBJECTIVES

To assess the available evidence comparing the effectiveness of interventions for the treatment of KCOTs.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 17 March 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2015, Issue 2), MEDLINE via Ovid (1946 to 17 March 2015) and EMBASE via Ovid (1980 to 17 March 2015). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials comparing one modality of intervention with another with or without adjunctive treatment for the treatment of KCOTs. Adults, over the age of 18 with a validated diagnosis of solitary KCOTs arising in the jaw bones of the maxilla or mandible. Patients with known Gorlin syndrome were to be excluded.

DATA COLLECTION AND ANALYSIS

Review authors screened trials for inclusion. Full papers were obtained for relevant and potentially relevant trials. If data had been extracted, it would have been synthesised using the fixed-effect model, if substantial clinical diversity were identified between studies we planned to use the random-effects model with studies grouped by action provided there were four or more studies included in the meta-analysis, and we would have explored the heterogeneity between the included studies.

MAIN RESULTS

No randomised controlled trials that met the inclusion criteria were identified.

AUTHORS' CONCLUSIONS

There are no published randomised controlled trials relevant to this review question, therefore no conclusions could be reached about the effectiveness or otherwise of the interventions considered in this review. There is a need for well designed and conducted randomised controlled trials to evaluate treatments for KCOTs.

Jaw cysts - filling or no filling after enucleation? A review

INTRODUCTION

Jaw cysts are common lesions in the oral and maxillofacial region. Enucleation of the lesions and primary closure of the defects, the so-called "cystectomy", has evolved as the treatment of choice. In order to reduce infections and to accelerate bone regeneration, different types of bone grafts are increasingly investigated for defect filling.

MATERIAL AND METHODS

The present review reflects the most recent studies using autogenous, allogenic, xenogenic and alloplastic bone grafts and compares the results to current investigations about conservative cyst enucleation without using any filling materials. Relevant studies with significant patient sample sizes were electronically searched in PubMed and Medline.

RESULTS

Simple cyst enucleation and blood clot healing show low complication rates and sufficient bone regeneration even in large defects. Prospective randomized trials comparing the additional use of filling materials to the "cystectomy" are rare. Currently available data do not indicate the superiority of additional bone grafts.

CONCLUSION

Enucleation of jaw cysts and primary closure without bone substitutes remains "state of the art" in most cases.

Interventions for the treatment of keratocystic odontogenic tumours (KCOT, odontogenic keratocysts (OKC))

BACKGROUND

The keratocystic odontogenic tumours (KCOTs) account for between about 2% and 11% of all jaw cysts and can occur at any age. They are more common in males than females with a male:female ratio of approximately 2:1. Although they are benign, KCOTs are locally very aggressive and have a tendency to recur after treatment, reported recurrence rates range from 3% to 60%. The traditional method for the treatment of most KCOTs is surgical enucleation. However, due to the lining of the cyst being delicate and the fact that they frequently recur, this method alone is not sufficient. Adjunctive surgical treatment has been proposed in addition to the surgical enucleation, such as removal of the peripheral bone (ostectomy) or resection of the cyst with surrounding bone (en-bloc) resection. Other adjunctive treatments proposed are: cryotherapy (freezing) with liquid nitrogen and the use of the fixative Carnoy's solution placed in the cyst cavity after enucleation; both of which attempt to address residual tissue to prevent recurrence.

OBJECTIVES

To assess the available evidence comparing the effectiveness of surgical interventions and adjuncts for the treatment of KCOTs.

SEARCH STRATEGY

Databases searched were: the Cochrane Oral Health Group's Trials Register (to 28th July 2010), CENTRAL (The Cochrane Library 2010, Issue 3), MEDLINE (from 1950 to 28th July 2010), and EMBASE (from 1980 to 28th July 2010). The reference lists of all trials identified were cross checked for additional trials. There were no language restrictions and several articles were translated.

SELECTION CRITERIA

Randomised controlled trials comparing one modality of surgical intervention with another with or without adjunctive treatment for the treatment of KCOTs. Adults, over the age of 18 with a validated diagnosis of solitary KCOTs arising in the jaw bones of the maxilla or mandible. Patients with known Gorlin syndrome were to be excluded.

DATA COLLECTION AND ANALYSIS

Review authors screened trials for inclusion. Full papers were obtained for relevant and potentially relevant trials. If data had been extracted, it would have been synthesised using the fixed-effect model, if substantial clinical diversity were identified between studies we planned to use the random-effects model with studies grouped by action provided there were four or more studies included in the meta-analysis, and we would have explored the heterogeneity between the included studies.

MAIN RESULTS

No randomised controlled trials that met the inclusion criteria were identified.

AUTHORS' CONCLUSIONS

There are no published randomised controlled trials relevant to this review question, therefore no conclusions could be reached about the effectiveness or otherwise of the interventions considered in this review. There is a need for well designed and conducted randomised controlled trials to evaluate treatments for KCOTs.

Spontaneous bone healing of the large bone defects in the mandible

Spontaneous healing of large bone defects in the mandibles of 33 patients was studied. Standard postoperative clinical and radiographic examinations were performed immediately after surgery and after 2, 6 and 12 months. They were analysed using a novel relative bone densitometry method and indexes of relative bone healing were established. Spontaneous bone regeneration occurred in all patients clinically, and the computer analysis of radiographs showed that the mean final bone density in the bone defects was 88% of the bone density of the surrounding healthy bone. In the cases of smaller defects (the greatest diameter on panoramic radiographs was 20-30 mm) the final bone density was 97%, while the larger defects finally healed with 84% of the bone density of the surrounding bone. Increased patient age had a negative influence on healing and the shape of the bone defects was more important for healing than their volume. Spontaneous bone healing occurred even in large bone defects in the mandible, therefore this simple treatment with low economic and biological costs should be the treatment of choice, taking into account the patient's age, surgical principles and time of rehabilitation.

Polylactide/polyglycolide copolymer in bone defect healing in humans

This pilot study aims to evaluate the healing of a large defects in the human jawbone filled with a Poly-Lactide-co-Glycolide (PLG) polymer (Fisiograft) by means of clinical, radiological and histological methods and to compare the results with those of platelet-rich plasma (PRP) clot or autologous bone (AB) fillings. Bone cysts, where previous non-surgical treatments failed to promote healing, underwent surgery. Nineteen consenting male patients were randomly split into three groups, packed with PRP, AB or PLG. A core biopsy was performed 4 and 6 months after surgery. All treated defects showed clinical, radiological and histological progresses over time. AB provided the best clinical and histological performance and PLG had overlapping outcomes; PRP filling was statistically different. Six months after surgery, bone activities were enhanced in sites treated with PLG and fairly good with PRP. Additionally, PLG showed some new lamellar formations. In conclusion, outcomes were best with AB graft, but suitable results were achieved using PLG to promote healing of severe bone defects. PLG shows only a delayed regenerative capability but does not require a secondary donor site.

Healing of bone defects by an osteopromotion technique using solvent-dehydrated cortical bone plate: a clinical and radiological study

Osseous defects of the jaws following trauma, cysts, infection or congenital deformity may show poor osteogenesis and the affected area may never be completely filled with bone. It is widely accepted in guided tissue regeneration that physically halting soft connective tissue proliferation into bone allows bone regeneration. This concept is called the "osteopromotion principle." The purpose of the present study was to evaluate the effect of solvent-dehydrated cortical bone plates as a barrier to allow bone regeneration by assessing the osteopromotion principle. 30 patients (18 male, 12 female) with cystic lesions of the jaws were assigned to two different groups. The patients in Group A were treated by enucleation. In Group B, were treated by removal of the lesion and placing a solvent-dehydrated cortical bone plate on top of the cyst cavity to avoid ingrowth of connective tissue. Both groups were evaluated radiographically using spiral-computed tomography (CT) before surgery and 12 months postoperatively. In group B, all cystic cavities showed complete bone healing in 12 months. At the same period, invasion of the soft connective tissue were observed in the patients treated only by enuclation. This study demonstrates that solvent-dehydrated cortical bone plates can be used as a barrier in treatment of cyst cavities and they hinder ingrowth of connective tissues and promote successful bone healing.

Long-term results of the application of solvent-dehydrated bone xenograft and duramater xenograft for the healing of oroantral osseous defects: a pilot experimental study

The aim of this study was to investigate the long-term effects of the use of human cadaveric solvent-dehydrated bone graft and duramater as a barrier membrane for the treatment of oroantral communication. Standard oroantral osseous defects were created in five minipigs. Subjects received cancellous bone graft in the form of block or microchips, duramater or a combination of bone and membrane. Uneventful healing was achieved in all of the subjects, clinically including the control site which did not receive any material. The operated bone segments were evaluated both by radiological and histological examinations after 6 months. Radiological evaluation was carried out using bone density analysis software and histological evaluation made by light microscopy. Radiological and histological results revealed that bone grafting of oroantral osseous defects improved the bone quality. However, application of duramater did not change this activity, both alone or combined with bone grafts. Within the limits of this experimental study, although solvent-dehydrated bone grafts were found superior and could be applied for the healing of osseous oroantral defects, resorbable membranes did not contribute to this process.

Biocompatibility of anionic collagen matrix as scaffold for bone healing

The basic approach to the treatment of bone defects involves the use of scaffolds to favor tissue growth. Although several bioscaffolds have been proposed for this purpose, the search for new and enhanced materials continues in an attempt to address the drawbacks of the present ones. Modifying current materials can be a fast and cheap way to develop new ones. Among them, type I collagen allows its structure to be modified using relatively simple techniques. By means of an alkaline treatment, anionic collagen with enhanced piezoelectric properties can be obtained through hydrolysis of carboxyamides groups of asparagine and glutamine residues from collagen in carboxylic. The process applied to a raw source of collagen, bovine pericardium, provided a sponge-like structure, with heterogeneous pore size, and, moreover, the complete removal of interstitial cells. For the evaluation of the biocompatibility of such matrices, they were implanted in surgically created bone defects in rat tibias. Empty defects served as controls. This experimental model allowed a preliminary evaluation of the osteoconductiveness of the matrices. The histological results presented a low inflammatory response and bone formation within a short period of time, similar to that of controls. The low cost of production associated to the biocompatibility and osteoconductivity performance make the anionic collagen matrices promising alternatives for bone defects treatment.

Comparative study of three different membranes for guided bone regeneration of rat cranial defects

The purpose of the study was to compare the efficacy of a non-resorbable polytetrafluoroethylene (e-PTFE) membrane (Gore-Tex) versus a resorbable polyglactin membrane (Vicryl) and a newly designed collagenic membrane for enhancing bone regeneration on rat skull defects. The study was conducted on 30 adult Wistar rats. On each animal, two symmetrical, 6 mm wide, full-thickness, skull defects were created in the parietal regions. The right defect was chosen as the experimental site and the left one was left empty as a control. Each experimental site was covered by an inner and outer membrane. The 30 rats were divided into three groups: In group 1 (n=10), a non-resorbable polytetrafluoroethylene (e-PTFE) membrane was used. In group 2 (n= 10), a resorbable polyglactin 910 membrane was used. In group 3 (n= 10), a collagen membrane processed from avian eggshell was used. In each group, the animals were euthanized at 60 days. The harvested specimens were processed for contact radiography and standard histological examination. The results were assessed by a Fisher's exact test. In group 1, partial bone healing was observed in seven out of 10 animals and complete in three out of 10 animals (P<0.001). In group 2, no or minimal bone healing was observed in seven out of 10 animals and partial bone healing was observed in three out of 10 animals. In group 3, no or minimal bone healing was observed in nine out of 10 cases and partial bone healing in only one animal. In conclusion, only the non-resorbable e-PTFE membrane group exhibited a favourable result in this study. This study suggests that the structure of the membrane is at least as important as its composition.

Spontaneous bone regeneration after enucleation of large mandibular cysts: a radiographic computed analysis of 27 consecutive cases

PURPOSE

This study evaluated the spontaneous bone healing after enucleation of large mandibular cysts subjectively and with a computed analysis of postoperative panoramic radiographs.

PATIENTS AND METHODS

Twenty-nine patients had large mandibular cysts treated by surgical enucleation. Postoperative clinical and radiographic examinations were performed at 6, 12, and 24 months in 27 patients. Bone regeneration and reduction of the residual cavities and bone density were evaluated with a computed analysis of preoperative and postoperative panoramic radiographs. A subjective and clinical radiographic evaluation of the healing process also was performed.

RESULTS

Uneventful healing and spontaneous filling of the residual cavities was obtained in all cases. The computed analysis of the postoperative radiographs showed mean values of reduction in size of the residual cavity of 12.34% after 6 months, 43.46% after 12 months, and 81.30% after 24 months. The increase in bone density was 37% after 6 months, 48.27% after 12 months, and 91.01% after 24 months.

CONCLUSION

Spontaneous bone regeneration can occur in large mandibular cysts without the aid of any filling materials. This simplifies the surgical procedure, decreases the economic and biologic costs, and reduces the risk of postoperative complications.

Tissue reaction to three subcutaneously implanted local hemostatic agents

Soft tissue response to three subcutaneously implanted local hemostatic agents; oxidised regenerated cellulose (Surgicel), gelatin sponge (Spongostan) and collagen sponge (Hemostagen) were evaluated histopathologically 7, 14, 21, 30 and 45 days following their implantation in rats. The results showed that all materials were well tolerated by soft tissues. These materials neither seemed to impair nor contribute to wound healing.