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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 13  |  Issue : 3  |  Page : 430-436  

Dredging: A conservative surgical approach for treatment of large cystic lesions of the jaws


Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Asarwa, Ahmedabad, Gujarat, India

Date of Submission28-Oct-2021
Date of Acceptance28-Jun-2022
Date of Web Publication10-Dec-2022

Correspondence Address:
Dr. Jigar Dhuvad
Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Asarwa, Ahmedabad - 380 016, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njms.njms_486_21

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   Abstract 


Background: Treatment modalities of odontogenic cystic lesions of the jaws range from conservative to radical. “Dredging” may be considered the “middle path” between conservative and radical treatment options. It comprises three entities—decompression, followed by repeated scraping of the lesion, and finally, peripheral ostectomy providing margin clearance but without significant morbidity.
Aim: To evaluate the outcome of “dredging” in the management of large cystic lesions of the jaws, without major resections and maintaining normal functions.
Methodology: This prospective study was conducted on 30 patients. Inclusion criteria were odontogenic cystic lesions at least 2 cm in size either in the proximity of vital structures or in children with developing tooth germs or so large that upon enucleation, can result in pathological fracture. All underwent decompression followed by dredging performed at every 2 to 3 months intervals.
Results: Drastic decrease in size of the lesion as measured on Cone Beam Computed Tomography (CBCT) and new bone formation was evident in all patients. The total Reduction Rate (RR) of the cystic lesions was 88.79% in 9.2 months. RR was highest in Calcifying epithelial odontogenic cyst (CEOC) followed by Unicystic Ameloblastoma (UA), Odontogenic Keratocysts (OKC), Dentigerous cyst (DC), and Radicular Cyst (RC) in CBCT. The mean speed of shrinkage was fastest in CEOC, followed by OKC, UA, RC, and DC after dredging. Shrinkage was higher in patients below 20 years of age (P 0.012) and patients with large cystic lesions (P 0.00447).
Conclusion: The results suggest that dredging with regular, long-term follow-up can be a successful treatment method for large cystic lesions in young adults. This method includes the benefits of both conservative and radical treatment methods but lacks the disadvantages of either.

Keywords: Decompression, dredging, odontogenic cystic lesions, odontogenic keratocyst, unicystic ameloblastoma


How to cite this article:
Patel H, Bhatt U, Anchlia S, Dhuvad J, Mansuri Z, Rajpoot D. Dredging: A conservative surgical approach for treatment of large cystic lesions of the jaws. Natl J Maxillofac Surg 2022;13:430-6

How to cite this URL:
Patel H, Bhatt U, Anchlia S, Dhuvad J, Mansuri Z, Rajpoot D. Dredging: A conservative surgical approach for treatment of large cystic lesions of the jaws. Natl J Maxillofac Surg [serial online] 2022 [cited 2023 Jan 26];13:430-6. Available from: https://www.njms.in/text.asp?2022/13/3/430/363079




   Introduction Top


Treatment modalities of cystic lesions of the jaws range from conservative to radical. Radical treatment options for large cystic lesions such as segmental/marginal resection reduce the rate of recurrence but produce greater morbidity and deformity of the jaws. On the other hand, conservative options like marsupialization lead to the preservation of vital structures, but remnants of the epithelial lining may lead to recurrence requiring further surgical treatment. While there is no consensus on optimal treatment, complications and morbidity need to be avoided, particularly with large cysts.[1]

“Dredging” may be considered the “middle path” between conservative and radical treatment options. It comprises three entities—decompression, followed by repeated scraping of the lesion, and finally, peripheral ostectomy providing margin clearance but without significant morbidity. The aim is to reduce intracystic pressure via continuous drainage, so allowing newer growth centripetally from the bony walls. Repetitive removal of cystic lining and scar tissues from the bone cavity accelerates new bone formation followed by peripheral osteotomy or resection of much smaller portions of bone as definitive treatment, thereby significantly reducing final morbidity. The primary reason for doing dredging is not to prevent recurrence but principally to prevent large bony defects due to resection of such large lesions either primarily or due to pathological fracture after enucleation. Dredging as a treatment modality is exclusively reserved for such large lesions only, irrespective of their recurrence potential.[2]

This study was performed to clinically and radiographically assess the quantitative effectiveness of dredging in terms of reduction in cyst area and volume. It also studied volume reduction correlation with the age and gender of patients, the initial size of the cyst, duration of treatment, and the histology of the cyst.


   Materials and Method Top


This prospective study was conducted on 30 patients having cystic lesions in the maxilla and mandible in the Dept. of Oral and Maxillofacial Surgery from 2018 to 2020. The Institutional Ethical Committee gave clearance for this study. The study has been approved by the Institutional Ethical Committee vide letter no IEC GDCH/OS.3/2019 dated 10/04/2019.

Patients with large lesions, either cysts or cystic tumors, at least in the size of 2 cm either in proximity to vital structures or lesions in children with developing tooth germs or lesions where enucleation would cause such thinning of the lower border so as to increase chances of pathologic fracture were included in this study. Patients with solid lesions, where a thorough examination of the entire lining of the lesion was required, for example, biopsy shows dysplastic changes and lack of patient compliance, and unavailability for follow-up were excluded from this study.

The treatment protocol comprised of decompression of cystic lesions by opening a window labially and crestally by removing the tooth or buccally and suturing an endotracheal tube with the walls of the opening to maintain patency of the opening. Daily irrigation was done through the tube for a week till epithelization around the tube was complete. The impression compound kept the tube temporarily closed. Thereafter, the tube was replaced by an acrylic plate, made with a bung protruding inside the cavity, thereby retaining its patency.

This was followed by dredging of the cystic cavity after Orthopantomogram (OPG) every 2 to 3 months in patients, wherein the scar tissue formed was scraped along with the pathological lining.

Dredging was carried out multiple times until bone fill was seen radiographically on OPG, which was confirmed then by Cone Beam Computed Tomography (CBCT). Thereafter, the final enucleation/peripheral ostectomy/marginal resection was performed.

Evaluation of the effect of dredging

(1) OPGs, taken at 2- to 3-month intervals in the same OPG machine, were used to measure the cystic size. A software program Carestream3D measured the area and counted the number of pixels, with a resolution of 100 pixels per inch. To account for magnification on the OPG, the distance between the condylar heads was equalized and therefore, the mandible size was recalculated.

The reduction rate (RR)% of the area of the lesion was calculated:



A - area of the lesion before dredging.

B - area of the lesion after dredging.

(2) The reduction in volume of the lesion was measured on the pre- and post-dredging CBCT.

Lesion volume (mm3) = MSI × MAP × MML

MSI - maximum superioinferior length

MAP - maximum anteroposterior length

MML - maximum mediolateral length

The RR % after dredging was measured using the same formula as in OPG.



A - volume of the lesion before dredging.

B - volume of the lesion after dredging.

[[Figure 1] about here].
Figure 1: The reduction rate (RR) % of the area and volume of the lesion was calculated using OPG and CBCT. (a), (b), and (c)- lesion before dredging, (d and e), and (f) – lesion after dredging

Click here to view


(3) The speed of volume shrinkage of the lesion per month was calculated on CBCT:



A - volume of the lesion before dredging.

B - volume of the lesion after dredging.

D - duration of dredging in months.

Data were analyzed with the Microsoft Excel SPSS 13.0 and Chi-square, Student t-test, and Pearson correlation tests. Results were significant at P < 0.05.

Observations and results

The study group consisted of 30 patients with a total of 36 cystic lesions. In that, 21 (70%) were males and 9 (30%) were females (3:1), and the average age was 24.4 years (range 6–54 years). The prevalence was maximum between 11 and 20 years [16 patients (53.33%)]. Symptoms duration was between 1 month to 1 year. Swelling, pain, and infection were the clinical presentations in 24 patients (80%).

Mandible was involved in 27 lesions, maxilla in three lesions, and both the jaws in six patients. The main radiographic findings are shown in [Table 1].
Table 1: Measurement of reduction rate according to pathology in OPG and CBCT

Click here to view


The cystic cavity was filled with straw-colored fluid in 11 and curd-like material in 12 patients and blood-mixed fluid in three patients. Pus was found in four patients. Upon biopsy, the lesion was Odontogenic Keratocysts (OKC) in 18 (60%), Unicystic Ameloblastoma (UA) in five (16.6%), Radicular Cyst (RC) in four (13.3%), Dentigerous cyst (DC) in two (6.6%), and Calcifying epithelial odontogenic cyst (CEOC) in one patient (3.3%). Six patients had the Gorlin goltz syndrome. The total dredging time ranged from 8 to 12 months (average 9.2 months) and the number of times dredging was done ranged from one to three (average 2.1).

The mean RR of the lesion in OPG and CBCT and the mean speed of shrinkage per month according to both, pathology and age groups, are shown in [Table 2] and [Table 3], respectively. The total RR was 88.79% in 9.2 months. RR was highest in CEOC followed by UA, OKC, DC, and RC in CT/CBCT (P 0.00447). The mean speed of shrinkage was fastest in CEOC, followed by OKC, UA, RC, and DC after dredging. Shrinkage was higher in patients below 20 years of age (P 0.012) and patients with large cystic lesions (P 0.00447).
Table 2: Measurement of reduction rate according to age in OPG and CBCT

Click here to view
Table 3: Teeth involvement in cystic lesions

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Patients were followed up for 6 to 24 months (average of 9.3 months) with no evidence of recurrence on follow-up. Complications included tube dislodgement into the cystic cavity (n = 2), which was retrieved from the cystic cavity and reinserted, and another complication was temporary lower lip hypoesthesia (n = 2).

[[Figure 2] and [Figure 3] about here].
Figure 2: (a) Pre-op intraoral photograph, (b) Opening of cystic lesion, (c) Placement of decompression tube, (d) 1st dredging, (e) 2nd dredging, (f) Closure after peripheral ostectomy, (g) 9 months follow-up, and (h) and (i) Histopathologic examination of OKC before and after dredging

Click here to view
Figure 3: (a) Pre-op OPG showing unilocular radiolucency extending from distal to 37 with unerupted 38 to ramus region. (b) 3 months follow-up OPG 1st dredging. (c) 6 months follow-up 2nd dredging good healing of bone. (d) 9 months follow-up shows normal bony contour with cortical outline without evidence of recurrence

Click here to view



   Discussion Top


Conventional treatment strategies, such as curettage and resection of the jaws, have been widely used to treat large cystic lesions.[3] However, they may lead to injury to adjacent tissues, teeth, nerves, pathologic fractures, and a higher incidence of recurrence.[4] Moreover, bony reconstruction is required after resection, which adds to surgical morbidity, medical costs, and decreased masticatory function. On the other hand, conservative treatment takes a long time for bone formation and more chances of recurrences.

One of the conservative modalities is “Dredging,” which comprises three entities—Decompression as the first step, which involves creating an opening in the cyst to relieve pressure. The second step is dredging or bone scraping several times. On OPG, when bone fill causes large lesions to decrease to a size easily amenable to removal without damage to adjacent structures, confirmation is done by CBCT. Then, peripheral ostectomy or marginal resection is performed in the third step to ensure complete eradication of the pathology, without causing any significant morbidity to the patient.

In the present study, the age distribution was similar to other studies, the highest incidence being 11 to 30 years, with a rare case of a patient of 60 years.[5],[6] In the younger age group, the jaws undergo greater growth and development of the dentition, leading to the ubiquitous presence of epithelial rests after odontogenesis; all thereby may lead to the formation of a cyst.

In this study, the higher frequency of males (3:1) could be due to them being more likely to neglect or sustain trauma to their teeth or vice versa. These observations are also reported by Meningaud et al.,[7] and Prockt,[8] on the other hand, reported the opposite.

In the present study, cystic lesions were more frequent in the posterior mandible (66.66%). The mandible was the most commonly affected site even in the study by Meninguad et al.,[7] but Ochsenius et al.[9] and Varinauskas et al.[10] reported the maxilla as more commonly affected.

In this study, OKC accounted for 60% of all cysts, followed by UA 16.66%, RC 13.33%, DC 6.66%, and CEOC 3.33%. Although the literature indicates that RC is the most frequent cysts in the jaws,[11] they are generally smaller and are initially treated with enucleation itself. Only large radicular cysts are treated with decompression and dredging when enucleation could damage surrounding structures, or in the case of geriatric and high-risk patients. This explains the relatively lesser number of RC in the present study.

OKCs have a tendency to grow in cancellous bone considerably before significant expansion is seen buccally or lingually, thereby delaying diagnosis. Donoff[12] showed collagenase activity in keratocyst epithelium relating to the ability of keratocysts to grow expansively within the bone. This probably explains OKC being the most common lesion in this study. Six patients had the Gorlin Goltz syndrome with multiple OKCs of the jaws.

On follow-up dredging, major histologic changes in the epithelium were seen in 17 cases. Hyperplastic, stratified, non keratinizing squamous epithelium with a thick connective tissue wall was observed most commonly. In some cases, 100% transformation of the epithelium did not take place. This is probably because transformation is a time-related process.[13]

The number of times the cavity has been entered and curetted after the first time of decompression is termed as the number of dredging. In certain cases, even one-time dredging was adequate to give bone enough to perform definitive surgery on the lesion.

As reported by Marker et al.,[12] in this study too, histologic changes in the epithelium in OKC (56.6%) were found. Most of the parakeratotic and orthokeratotic OKCs had converted into hyperplastic, stratified, non keratinizing squamous epithelium after dredging. These did not appear microscopically as OKC at all.

Most of the cysts involved mandibular third molars (14 out of 21; 66.7%). About 22 lesions (73.33%) invaded or displaced adjoining structures, such as the maxillary antrum, nasal floor, and inferior alveolar canal.

Although no studies report decreased nerve injury or devitalization of teeth, or adjoining structures following dredging in this study, lesions after dredging moved away from the inferior alveolar canal, maxillary antrum, and adjacent teeth, and bone fill was seen where there was a cystic lesion earlier in a mean duration of 7.7 months in all the 21 patients which were in close proximity to vital structures. Additionally, due to the decrease in size, the entire lesion was easier to visualize and less bone was required to be removed to ensure complete eradication of the lesions. Similar findings were observed by Schlieve et al.[14]

Tan et al.,[15] compared tooth loss after three types of treatment of mandibular OKC (enucleation, segmental mandibulectomy, and marsupialization) and post-treatment masticatory performance with and without a removable partial prosthesis and found that preservation of posterior teeth was important to maintain masticatory function. In the present study, 91 teeth were saved out of a total of 228 (39.91%) teeth involved in cystic lesions. The importance of the number of teeth that could be salvaged can not be underrated as for the patient, it is something that is directly and significantly related to esthetics and the function being maintained making the post-surgical rehabilitation simpler.

Although OPG helps in diagnosing cystic lesions, it is not of use in measuring their volume.[16] CBCT is more useful for evaluating the topography of cystic lesions, volume integrity of the margins, site and size and proximity to, and displacement of adjacent structures.[17]

Literature has stated that even radiological bone formation happens in 2 to 3 months. We have witnessed it over time too during the course of this study. Also, the whole point of doing this soon was to increase the bone turn-over rate to fill in the bone defect sooner than that by marsupialization. This is the basic concept of dredging, as quoted by the study of Dredging—a conservative surgical approach for the treatment of large cystic lesions of the jaws.

To calculate the size of the cystic lesions, Nakamura[2] and Enislidis[18] scanned the 2D area of the cysts using OPG, after calculating the magnification. The percentage of reduction in the area of the lesion was calculated using a formula that compared the area of the lesion before and after marsupialization. In the present study, measurements were done using both OPG and CBCT.

In this study, the time at which the final procedure was performed depended entirely on radiologic evaluation, when there was sufficient reduction for the final surgical procedure to be done without damaging adjacent structures. Park et al. opined the same. The radiographic appearance of new bone is ground glass or radial bone spicules in the periphery of cystic lesions or the original bone cavity.[17]

No previous literature has reported the RR after dredging so far, but there have been various studies on the effectiveness of decompression. Park et al.[19] reported a RR of 39.4% in an average of 6.9 months for DC, 36.7% in 13.4 months for UA, and 33.6% in 7.4 months for OKC after decompression. Enislidis et al.[18] reported an average reduction of the lesions by 81% in 446 days. Anavi et al.[20] reported a reduction of 79.3% in 9.2 ± 5.2 months. Lizio et al.[21] reported a 49.86% reduction in the mean of 5.7 months. The present study showed better results than all the reported literature on decompression as regard to total mean RR. It was 88.79% in CBCT in an average of 9.3 months by the process of dredging.

Out of the very few studies in the literature on dredging, Sasaki et al. performed enucleation by the “dredging method” for a large UA in the mandible, as reported by Kawamura in 1991.[2] After decompression and enucleation or enucleation alone, dredging was done five to six times within 2 to 3 months till no tumor cell nests were seen in the histopathology of the tissues removed in two consecutive dredgings. This procedure gave reduced recurrence and complication rate, no dysfunction or deformity, and accelerated new bone formation.

In this study, there was no statistically significant association between the shrinkage rate and the underlying histology of the lesion. Shrinkage was fastest in CEOC, followed by OKC, UA, RC, and DC after dredging. Anavi[20] wrote about the RRs of DC, OKC, RC, and glandular odontogenic cysts. Their results were comparable with this study, even though, they did not obtain a statistically significant difference between the pathological types.

Asutay[22] and Anavi[20] did not report statistically significant differences in the RR based on gender, similar to this study. But, in this study, a higher RR was seen in large lesions, in concordance with Gao et al.[23] and Park et al.[19] wherein the speed of decompression in large cystic lesions was analyzed.

Lizio et al.,[21] Gao et al.[23] and Kubota Y et al.[24] did not observe any correlation between age and RR. Park et al.,[19] Anavi et al.[20] and Song et al.[25] observed a correlation between age and the RR. Older patients had a slower rate of reduction of cystic lesions than younger ones. Anavi et al.[20] reported an average shrinkage time of 7.6 months in patients less than 18 years. This was significantly less than in adults. In this study too, the speed of shrinkage was affected by patient age (P 0.0012). Shrinkage was higher in patients below 20 years of age and patients with large cystic lesions. The dimensional shrinkage of the lesion was given importance in the study as it was a factor influencing the eventual defect size post final excision of the lesion. This forms the basic rationale and crux of adopting a conservative approach rather than radical surgical resection. Therefore, dredging may be recommended for all young patients with large cysts. The study itself states the indication in its follow-up and hence its recurrence rate but the purpose of the study was to find the middle path between conservative and radical, which has been successfully accomplished. There is no other study in the literature that talks about the advantages of dredging as remodeling for large cystic lesions of the jaws in such quantitative details.


   Conclusion Top


Even though this study has a relatively small sample size with short follow-up (9.3 months), thereby living the recurrence rate indeterminate, it is one of the very few studies in the literature that has quantitatively evaluated the outcome of “dredging” in the management of large lesions of the jaws. This is the concept, therefore we have already mentioned in conclusion that the recurrence rate cannot be determined by this amount of follow-up. But what can definitely be said are the benefits of Dredging over other traditional methods with respect to the time taken for bone turn over specifically in young adults. This procedure was advantageous in that without major resection and damage to vital structures, the lesion was removed and normal form and function of the jaws were maintained. The time is taken for bone turn-over after periodic dredging was significantly less as compared to the traditional marsupialization and decompression techniques, more so in younger adults. Therefore, this method includes the benefits of both conservative and radical treatment methods but lacks the disadvantages of either.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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