Distraction Sugosteogenesis: Its Biologic Bases and Therapeutic Principles

Histologic features of bone regenerated by means of negative pressure in the context of odontogenic keratocyst

PURPOSE

The objective of the present research is to describe the histologic features of the bone regenerated by means of negative pressure (sugosteogenesis) in a group of patients diagnosed with odontogenic keratocyst (OKC) who underwent active decompression and distraction sugosteogenesis (ADDS) at our institution.

MATERIALS AND METHODS

The authors designed a retrospective case series study. The population included patients with a histologic diagnosis of odontogenic keratocyst in whom active decompression and distraction sugosteogenesis followed by enucleation was performed. All patients were seen and followed from July 2019 to January 2021. The investigation was approved by the Institutional Review Board, and it observed the Declaration of Helsinki on medical protocol. Variables of this study included age, gender, anatomic location (mandible or maxilla), and histologic characteristics of the bone regenerated by means of negative pressure. Histologic features were defined as being consistent or inconsistent with viable mature bone.

RESULTS

Bone biopsies of 6 patients were considered. In total, 83.33% of patients were males and 16.66% females. One hundred percent of the bone samples subjected to negative pressure showed features of viable mature bone.

CONCLUSIONS

In this study, the histological features of the bone subjected to negative pressure demonstrated the normal characteristics of the mature, normal bone.

Odontogenic Keratocyst: A Clinical Entity With Favorable Response to Active Decompression and Distraction Sugosteogenesis

Objective

The purpose of this study was to determine the usefulness of active decompression and distraction sugosteogenesis (ADDS) for the management of non-syndromic odontogenic keratocysts (OKC).

Materials and Methods

A retrospective case series study was designed and implemented. The study observed the Declaration of Helsinki on medical protocol and ethics and it was approved by the university's Institutional Review Board (IRB). The medical files of all patients who underwent ADDS for OKCs of the jaws at the Department of Oral and Maxillofacial Surgery of a tertiary university-affiliated medical center were reviewed. Data were collected on patient's age, gender, presenting signs and symptoms, lesion location, locularity, pre-ADDS, size of the lesion, post-ADDS, pain, days with bloody discharge and/or proteinaceous fluid inside the system's external unit, days to achieve hermetic seal, size of the lesion 2 weeks after ADDS, percentage of reduction, patient's complaints/complications, and follow-up period. Pre- and post-ADDS panoramic radiographs were reviewed for reduction parameters.

Results

Six patients, 5 males and 1 female, with an average age of 45.16 years (range 16-74 years) were studied. ADDS was performed during 4 weeks in all patients. During the therapy, the extraoral unit collected blood during 2.83 days in average. In average, after the third day, the cystic cavity started to drain a proteinaceous fluid for about 9.33 days (range 6-15 days). The average pre-ADDS Standard Lesional Area Index (SLAI) was 18.17 cm2 (range 4.40 cm2-34.58 m2) and, after 2 weeks of ADDS, the average SLAI was 5.47 cm2 (range 0.49 cm2-15.39 cm2). The average percentage of reduction, after 2 weeks, was 73.93% (range 55.49%-97.51%), which yielded an overall good reaction of OKCs to ADDS. No significant reduction of the lesions was observed from week 2 to week 4, when ADDS ceased. All lesions were enucleated after 3 months. After an average of 14 months of follow-up (12 to 17 months), no signs of recurrence have been observed.

Transverse Tibial Bone Transport Enhances Distraction Osteogenesis and Vascularization in the Treatment of Diabetic Foot

Objective

To investigate the effect of transverse tibial bone transport on the treatment of Wagner Stage 4 diabetic foot.

Methods

From January 2017 to October 2019, a total of 19 patients with Wagner Stage 4 diabetic foot ulcers were recruited. All patients were treated with transverse tibial bone transport. A detailed follow‐up was carried out at 1 week, 1 month, 3 months, 6 months, and 1 year after surgery. The wound healing rate and the limb salvage rate at 1 year after the surgery were evaluated. Preoperative and 3‐month postoperative digital subtraction angiography (DSA) were obtained. The level of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF) and platelet‐derived growth factor (PDGF) before surgery and on 1st, 4th, 11th, 18th, 28^th, and 35th days after surgery were measured. Operation time, intraoperative blood loss, postoperative complications, visual analog scale (VAS) pain score, skin temperature, Semmes‐weinstein monofilament (SWM), and ankle brachial index (ABI) were also assessed.

Results

The wound healing rate and the limb salvage rate were both 94.74% in the patients at 1 year after the surgery. DSA showed the thickening of the calf and foot arteries, clear visualization, and a rich vascular network. The levels of VEGF, bFGF, and PDGF on the 11th, 18th, 28^th, and 35th days after surgery were significantly higher than those before surgery (p < 0.05). The EGF level on the 18th, 28th, and 35th days after surgery was significantly higher than that before surgery (p < 0.05). Superficial wound complications occurred in one patient during the hospitalization. There was no movement area infection, skin flap necrosis, tibial fracture, loosening of the external fixator, or rupture in study.

Conclusion

Transverse tibial bone transport can improve the blood circulation of the affected limbs, promote the healing of diabetic foot wounds, and reduce the amputation rate of the affected limbs. Transverse tibial bone transport can promote the healing of Wagner Stage 4 diabetic foot.

Potential role of active decompression and distraction sugosteogenesis for the management of ameloblastomas: Report of two cases and review of the literature

Ameloblastomas are aggressive odontogenic entities well-known for their high tendency to recur. Clinical presentation includes lesions discovered on routine examination or radiographs, pathologies causing facial swelling, pain, cortical expansion, tooth mobility, root resorption, and paresthesia. Radiographic findings comprise large unilocular or multilocular radiolucencies with well-defined borders associated to an impacted tooth. Ameloblastomas are classified as unicystic, multicystic/solid, and peripheral. Treatment options include marsupialization, decompression, enucleation, or curettage with or without adjuvant measures such as Carnoy's solution, marginal resection, and segmental resection. Recently, active decompression with distraction sugosteogenesis (ADDS) was introduced for the conservative management of odontogenic cystic conditions. The purpose of this paper is to present 2 cases of a conventional ameloblastoma treated by means of ADDS. The purpose of this novel approach is to significantly reduce the amount of time required to decompress cystic-like lesions. In these cases, ADDS proved to be a viable treatment because it demonstrated a reduction in size of the initial lesion by new osseous formation within 2 weeks of placement of the device. The cases presented in this paper demonstrate that ADDS could be a valuable treatment modality for this type of ameloblastoma, although further research is necessary to validate this philosophy.

Does active decompression of odontogenic keratocyst change the histologic diagnosis?

AIM

The purpose of this study was to compare the histopathologic findings of pre- and post-active decompression of odontogenic keratocyst and to establish if such findings were consistent.

MATERIALS AND METHODS

A retrospective case series from a group of patients diagnosed with odontogenic keratocyst who underwent active decompression and distraction sugosteogenesis followed by final enucleation was designed and implemented. The dependent variable was changed in histologic diagnosis, as evaluated by an oral and maxillofacial pathologist. Other variables included age, gender, anatomic location of the lesion, and time elapsed from initial biopsy to final enucleation.

RESULTS

Six patients diagnosed with odontogenic keratocyst who underwent active decompression followed by enucleation and curettage were studied. The mean age was 45.6 years (range, 16 to 74) 83.33% were males, 16.66 females. Lesions were located in the mandible in 83.33% of cases and in the maxilla in 16.66% of cases. Post-active decompression histologic examination at the time of definitive enucleation was consistent with the initial diagnosis in 83.33% of cases.

CONCLUSIONS

The histopathological diagnosis at the time of definitive treatment by enucleation and curettage is consistent with the pre-active decompression diagnosis.

Potential role of active decompression with distraction sugosteogenesis for the management of odontogenic cystic lesions: a retrospective review of 10 cases

PURPOSE

The aim of this paper is to describe active decompression and distraction sugosteogenesis as an alternative for the management of odontogenic cystic lesions. The technique, demographics, success rate, and complications will be presented.

PATIENTS AND METHODS

A retrospective case series study design was implemented. This included patients found in our database from 2015 to 2018 with a diagnosis of any odontogenic cyst, in whom active decompression with distraction sugosteogenesis was implemented. The patient's medical history, demographics, radiographic characteristics of the cyst, technique/device employed, complications, and rate of success were recorded.

RESULTS

The sample consisted of 10 patients, with a mean age of 19.6 years (range 14-34). Sixty percent of all cases occurred in male patients and 40% in females. Forty percent of cases were consistent with odontogenic keratocysts with all cysts presenting in the mandible. No maxillary cases were documented. Seventy percent of such lesions were unilocular and 30% multilocular. Cortical fenestration/perforation was documented in 30% of cases and 1 pathologic fracture was seen. Active decompression was performed for an average of 37 days (range 30-50 days). With this system, radiographic resolution occurred in 1-3 months in 50% of cases, 6-12 months in 30% of cases, and 12 months in 20% of cases. Mean follow-up was 24.3 months. No recurrence was documented. Complications included fistula development (2 cases), flap dehiscence (1 case), and the size of the intraoral unit.

CONCLUSIONS

This investigation reviewed the authors' 5-year experience employing active decompression with distraction sugosteogenesis for the management of odontogenic cystic lesions and showed that this is a reliable alternative for the management of odontogenic cysts.

Decompression effects on bone healing in rat mandible osteomyelitis

Osteomyelitis (OM) of the jaw is usually caused by a chronic odontogenic infection. Decompression is the release the intraluminal pressure in the cystic cavity allowing gradual bone growth from the periphery. The aim of this study was to analyze the effectiveness of decompression in an OM jaw model. A 4-mm-diameter defect was made on mandibles of fourteen Sprague-Dawley rats and inoculated with S. aureus (20 μl of 1 × 10⁷ CFU/ml) injection. Two weeks later, four groups were made as non-treatment (C1), only curettage (C2), curettage and decompression (E1), and curettage and decompression with normal saline irrigation (E2). After four weeks, each group was analyzed. Most micro-CT parameters, including bone mineral density [0.87 (± 0.08) g/cm³] with bone volume [0.73 (± 0.08) mm³] was higher in E2 group than that of C1 group (p = 0.04, p = 0.05, respectively). E2 group in histology showed the highest number of osteocytes than those of control groups, 91.00 (± 9.90) (p = 0.002). OPN were expressed strongly in the E1 ("5": 76-100%) that those of other groups. Decompression drains induced advanced bone healing compared to that of curettage alone. Therefore, it could be recommended to use decompressive drain for enhancing the jaw OM management.

Decompressive effects of draining tube on suppurative and sclerosing osteomyelitis in the jaw

Background

Osteomyelitis (OM) in the jaw is an inflammatory disease of osseous tissue that begins in the medullary space and progressively expands to the cortical portion of the bone, the Haversian system, the periosteum and the overlying soft tissue. Despite advances in dental and medical care, OM persists and is of important concern in modern medicine. Active negative pressure is known to prevent post-operative hematoma; decrease the number of bacterial pathogens, accumulation of toxins, and necrotic tissue; and promote osteogenesis and angiogenesis with the use of a draining tube such as the Jackson-Pratt (JP) or Hemovac. The purpose of this study was to assess the effectiveness of decompression for the treatment of OM in the jaw.

Methods

This retrospective study included a total of 130 patients, 55 patients with sclerosing OM and 75 patients with suppurative OM were included. The radiographic bone densities expressed as a grayscale values (GSVs), were measured using an easy digitalized panoramic analysis (EDPA) method, processed on the conditional inference tree, generated by the R program® 3.2.3 with a probability of 96.8%. Rectangle annotation analysis of INFINITT PACS® (INFINITT Healthcare, Seoul, Korea) of 50 mm² was determined as the region of interest (ROI). Student’s t-test and ANOVA were used to determine significance (p < 0.05).

Results

Significant changes was observed between radiographic bone density in the sclerosing type with drain and without drain at the six-month and one-year follow-up (p < 0.05). Significant difference was demonstrated between the suppurative OM with drain and without drain groups at the one-year follow-up (p < 0.05).

Conclusion

The OM groups with drain exhibited more enhanced bone density compared to the groups without drain at the six-month and one-year follow-ups. The drain insertion for decompression is effective for the management of sclerosing and suppurative OM. It is recommended to implement it for the management of OM.

Active decompression and distraction sugosteogenesis for the treatment of calcifying odontogenic cyst

The calcifying odontogenic cyst is as a benign, rare developmental odontogenic cyst with a wide range of histologic characteristics. It may present along with other odontogenic pathologies such as odontoma, ameloblastoma, adenomatoid odontogenic tumor, ameloblastic fibroma, and ameloblastic fibro-odontoma. Clinically, it can be an either intra- or extraosseous painless swelling that can produce cortical expansion. It affects mostly the anterior area of the mandible. Radiographically, it appears as a well-circumscribed unilocular radiolucency containing flecks of indistinct radiopacities. In about one third of cases, an impacted tooth is associated. In this paper, we employ a patient with an enormous calcifying odontogenic cyst to review both the pathology and active decompression and distraction sugosteogenesis, a novel technique employed to treat odontogenic entities. This dual approach usually results in an accelerated bone healing (sugosteogenesis), partial removal of the cystic epithelium, thickening of the wall, and migration of chronic inflammatory cells which triggered epithelial modulation, ultimately causing a realignment in the biologic behavior of the lesion.

Analysis of Marsupialization of Mandibular Cysts in Improving the Healing of Related Bone Defects

PURPOSE

Marsupialization, designed to reduce the mandibular cyst volume, has continued to debated regarding its influence on the healing of the related bone cavity. The aim of the present study was to evaluate the 3-dimensional radiographic variation over time in mandibular odontogenic cystic lesions after marsupialization and assess the correlations between these variations and variables that can affect the procedure.

MATERIALS AND METHODS

We planned a retrospective cohort study. The predictor variables were the treatment duration, preoperative volume, patient age, histologic type, and number of preoperative residual bony walls. The outcomes variables were the postoperative volume reduction and the daily reduction rate calculated using computed tomography (CT) from before to after marsupialization using software designed for volumetric reconstruction and measurement of cyst-related bone defects. The descriptive and bivariate statistics were computerized, and the significance level was set at P = .05.

RESULTS

The sample included 15 patients (12 men and 3 women; mean age, 51.6; range, 27 to 85 years) affected by keratocysts (n = 6), dentigerous cysts (n = 6), and radicular cysts (n = 3) who had undergone marsupialization. The median duration of marsupialization was 406 days (25th to 75th percentile, 276 to 519). The mean ± standard deviation (SD) pre- and postdecompression volumes were 6,908.27 ± 2,669.058 and 2,468.13 ± 1,343.517 mm³, respectively (P < 0.001), and the mean ± SD percentage of reduction was 63.90 ± 13.12%. The volume decrease in the bone defects correlated positively with the treatment duration (P = .009) and preoperative volume (P < .001). However, no correlation was found with the other variables (P > .05) nor between the daily reduction rate and other variables (P > .05).

CONCLUSIONS

Marsupialization appears useful in improving the healing of cyst-related bone defects in mandibles, especially larger defects. Further studies with a wider sample size would add more knowledge to this topic.

The Changing Landscape in Treatment of Cystic Lesions of the Jaws

Objective:

Cystic lesions of the jaw are common pathologies of chronic swelling of the jaw in oral and maxillofacial regions. Different treatment modalities have been described in the literature. However, the existence and proper treatment of these cysts remains a contentious topic. The aims of this review were to discuss the complexity of various surgical treatment and as factors with potential to influence outcome treatment. Finally, a practical and a rational clinical guideline for the management of such lesions have been suggested.

Materials and Methods:

A literature search without language limitation was performed in 2018 using MEDLINE, PubMed, Scopus, and Embase. Keywords for the search included the following terms: jaws cyst, cystic lesions, odontogenic cysts, cystic tumors, pseudocysts, treatments, therapy, wound healing, bone regeneration, and teeth involved cysts. Prospective or retrospective clinical studies with a sample size of n ≥ 5 were evaluated and included in this review. The exclusion criteria were studies with unclear reporting of the treatment applied or outcome, nonhuman studies, case reports, letters, preface, comments, and cystic lesions associated to syndrome. After the full reading, 30 articles were included in the quantitative synthesis for the review. No meta-analysis could be performed due to the heterogeneity of the studies included. Clinical radiographic images were presented to illustrate the principles of some surgical treatments.

Conclusion:

Conservative surgery with primary closure defect (less than 4 cm) remains an initial approach, which reduces the morbidity of aggressive surgeries and obtains the complete bone healing before 24 months of postoperative. Marsupialization is considered as the most common option for the treatment of large cystic lesions when cases are carefully selected. Evocyst is an attractive new technique of obtaining complete bone defect healing within <3 months.