Med Oral Patol Oral Cir Bucal. 2019 Jan 1;24 (1):e47-52.

The effectiveness of decompression as initial treatment for jaw cysts

Journal section: Oral Surgery doi:10.4317/medoral.22526

Publication Types: Research http://dx.doi.org/doi:10.4317/medoral.22526

The effectiveness of decompression as initial treatment for jaw cysts:

A 10-year retrospective study

Saša Marin 1, Barbara Kirnbauer 2, Petra Rugani 2, Alexandra Mellacher 2, Michael Payer 3, Norbert Jakse 4

1
Doctor of Dental Medicine, Oral surgery specialist, Department of Oral Surgery, Faculty of Medicine, University of Banja Luka
2
Doctor of Dental Medicine, Division of Oral Surgery and Orthodontics, Department of Dental Medicine and Oral Health, Medi-
cal University of Graz
3
Associate Professor, Division of Oral Surgery and Orthodontics, Department of Dental Medicine and Oral Health, Medical
University of Graz
4
Full Professor and Head, Division of Oral Surgery and Orthodontics, Department of Dental Medicine and Oral Health, Medical
University of Graz

Correspondence:
Division of Oral Surgery and Orthodontics
Department of Dental Medicine and Oral Health
Medical University of Graz
Billrothgasse 4, A-8010 Graz, Austria
Marin S, Kirnbauer B, Rugani P, Mellacher A, Payer M, Jakse N. The
sasa.marin@med.unibl.org
effectiveness of decompression as initial treatment for jaw cysts: A 10-
year retrospective study. Med Oral Patol Oral Cir Bucal. 2019 Jan 1;24
(1):e47-52.
http://www.medicinaoral.com/medoralfree01/v24i1/medoralv24i1p47.pdf
Received: 16/04/2018
Accepted: 12/11/2018
Article Number: 22526 http://www.medicinaoral.com/
© Medicina Oral S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946
eMail: medicina@medicinaoral.com
Indexed in:
Science Citation Index Expanded
Journal Citation Reports
Index Medicus, MEDLINE, PubMed
Scopus, Embase and Emcare
Indice Médico Español

Abstract
Background: Decompression is an approved alternative to cystectomy in the treatment of jaw cysts. This study
aimed to evaluate its effectiveness as an initial procedure, as well as factors with potential to influence outcome.
Material and Methods: the frequency of decompression was analysed, whether completed in one session or fol-
lowed by enucleation at the Division of Oral Surgery and Orthodontics, Department of Dental Medicine and Oral
Health, Medical University of Graz, from 2005 to 2015. Further analysis focussed on factors potentially influenc-
ing outcome: cyst location, histopathology, means of preserving the cyst opening, cyst size, patient age.
Results: In all, 53 patients with 55 jaw cysts (mean age of 35.1) were treated by initial decompression in the
ten-year period. In the majority of cases, histopathological analysis revealed a follicular cyst (43.6%), followed
by odontogenic keratocysts (23.7%), radicular cysts (21.8%), residual cysts (7.3%) and nasopalatine cysts (3.6%)
Treatment was completed with a single decompression in 45.5% of the cases. Among those, 72.0% were follicular
cysts and 8.0% odontogenic keratocysts. Subsequent enucleation was needed in 54.5% of all cases, with a major-
ity in the keratocystic group (36.7%). Histological findings, means of keeping the cyst open, and patient age were
found to influence the effectiveness of decompression.
Conclusions: Decompression could be performed as a procedure completed in one session or combined with
subsequent enucleation, mainly dependent on histopathological findings. Subsequent enucleation of odontogenic
keratocysts is highly recommended.

Key words: Jaw cysts, decompression, enucleation, histopathology, obturator.

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Med Oral Patol Oral Cir Bucal. 2019 Jan 1;24 (1):e47-52. The effectiveness of decompression as initial treatment for jaw cysts

Introduction cine and Oral Health, Medical University of Graz, from

Cystic lesions occur more frequently in the upper and 2005 to 2015.
lower jaws than in other bones of the human body, The inclusion criteria for the study were cyst in the up-
mainly due to the presence of cells that are remnants of per or lower jaw treated with decompression and com-
the embryonal neuroectoderm. One further explanation plete medical records.
is that the embryonic teeth are located in the jaw bones. The exclusion criteria were cyst in the upper or lower
Triggers are either inflammatory stimuli or develop- jaw treated initially with enucleation or resection, soft
mental disorders (1). Because they are usually slow tissue cysts, and incomplete medical records.
growing and asymptomatic, cysts may grow very large, The following data were collected and analysed: fre-
displacing and even damaging surrounding structures, quency of decompression and decompression followed
with subsequent infection, root resorption, nerve inju- by enucleation, patient’s age and gender, location and
ries or bone fractures (2,3). size of the cyst, histopathological findings, means of
Treatments range from single decompression, marsupi- preserving the cyst opening.
alization, enucleation and bone resection to a combina- Histopathology reports were obtained from the Institute
tion of these approaches (4,5). While there is no con- of Pathology of the Medical University of Graz.
sensus on optimal treatment, complications and further After surgical decompression, the cyst was kept open
morbidity are to be avoided, particularly with large with iodoform gauze for the first few postoperative
cysts. days. Thereafter, besides continued gauze packing, ob-
Decompression as initial procedure is a common con- turators, brackets with chains, and drains were used.
servative approach requiring preparation and preserva- Patients were advised to follow all postsurgical instruc-
tion of a cyst opening. The aim is to decrease intracystic tions scrupulously, rinsing the cyst opening twice a day
pressure by constant drainage, so allowing new centrip- with 0.9% NaCl solution using a syringe, and clean-
etal bone growth from the bony cyst walls (6). The cyst ing dental devices mechanically with a toothbrush or
opening can be preserved with simple iodoform gauze swabs. For the first 2 days, postoperative care included
packing, a custom-made obturator, bracket and chain on cryotherapy with cold packs and for pain management,
involved impacted teeth, and drains (7,8). dexibuprofen 200 mg for children and 400 mg for adults
The main advantages of decompression are that it spares (Seractil® 200 or 400mg, Gebro Pharma, Austria) 3
tissue, minimizes the likelihood of damage to adjacent times a day. Routine follow-up included clinical and ra-
structures, and avoids the cost of hospitalization (9,10). diological studies at least every three months. Addition-
Complications have been reported more frequently al appointments were arranged depending on individual
when enucleation was performed as a single procedure needs and compliance. Digital panoramic x-rays were
for extensive jaw cysts. According to the literature, the taken with the Orthophos XG plus DS (Sirona Dental
prevalence of permanent sensory disturbance ranges Systems GmbH, Bensheim, Germany) with 60–70kVp
from 2.0-18.0%, of transient hypoesthesia from 8.0- and 14-17 mA.
35.0%, and of incomplete ossification from 12.0-40.0% Those patients with insufficient cyst shrinkage after
(11-15). decompression later underwent enucleation (Figs. 1,2).
Disadvantages of decompression include the duration of -Statistical analysis
treatment, discomfort, and reliance on patient compli- Data were presented with descriptive statistics. The
ance. Further, remnants of the epithelial lining can lead statistical analyses were performed with SPSS soft-
to cyst recurrence requiring further surgical treatment ware (IBM SPSS statistics 24.0, IBM Corporation, New
(16,17). York, United States) at a 5% significance level. The chi-
Some authors have suggested subsequent enucleation square test and Student’s t-test were applied to quantita-
for aggressive cysts with a high relapse rate, and when tive and continuous variables.
the outcome of decompression is unsatisfactory (18,19).
This retrospective study aimed to evaluate the effec- Results
tiveness of decompression for treatment of jaw cysts There were 53 patients (55 cysts) in the ten-year study
with consideration of possible outcome-influencing fac- period with a mean age of 35.1 years; 39 were male
tors including patient age, cyst location and size, histo- (73.6%) and 14 female (26.4%) (Table 1). Cysts were
pathology, and means of preserving the cyst opening. more common in the mandible (38 cysts) than in the
maxilla (17 cysts). Mandibular cysts were most often
Material and Methods found in the posterior region (molar-retromolar (34.2%)
After approval of the study by the local ethics commit- followed by retromolar (23.7%)), while maxillary cysts
tee, data were collected and analysed from patients who were most common in the frontal region (35.2%) (Table
had undergone decompression at the Division of Oral 2). Follicular cysts were most frequent (43.6%), fol-
Surgery and Orthodontics, Department of Dental Medi- lowed by odontogenic keratocysts (23.7%), radicular

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Med Oral Patol Oral Cir Bucal. 2019 Jan 1;24 (1):e47-52. The effectiveness of decompression as initial treatment for jaw cysts

Fig. 1. (A) the cyst opening 7 days after decompression; (B) customized obturator; (C) applied customized
obturator.

Fig. 2. (A) panoramic radiograph of odontogenic keratocyst before decompression; (B) panoramic radiograph 1 year after decompression and
before subsequent enucleation; (C) panoramic radiograph 1 year after subsequent enucleation; (D) panoramic radiograph obtained 2 years after
subsequent enucleation; (E) panoramic radiograph 5 years after subsequent enucleation.

Table 1. Descriptive patient data.

Sex Cysts Patients Mean age SD p
n (%) n (%)
Male 40 (72.7) 39 (73.6) 38.9 19.7 p = 0.013
Female 15 (27.3) 14 (26.4) 24.9 18.4
Total 55 (100.0) 53 (100.0) 35.1 20.2

Table 2. Distribution of the cysts and surgical procedures by jaw location.

Location Maxilla Mandible Total Decompression Decompression
n (%) n (%) n (%) n (%) and enucleation
n (%)
Frontal 6 (35.2) 4 (10.5) 10 (18.2) 9 (36) 1 (3.3)
Frontal-premolar 4 (23.5) 2 (5.3) 6 (10.9) 2 (8) 4 (13.4)
Frontal-premolar-molar 2 (11.8) 0 (0.0) 2 (3.6) 1 (4) 2 (6.7)
Premolar 2 (11,8) 1 (2.6) 3 (5.5) 2 (8) 0 (0.0)
Premolar-molar 1 (5.9) 2 (5.3) 3 (5.5) 2 (8) 1 (3.3)
Premolar-molar-retromolar 1 (5.9) 0 (0.0) 1 (1.8) 0 (0) 1 (3.3)
Molar 1 (5.9) 7 (18.4) 8 (14.5) 3 (12) 5 (16.7)
Molar-retromolar 0 (0.0) 13 (34.2) 13 (23.6) 3 (12) 10 (33.3)
Retromolar 0 (0.0) 9 (23.7) 9 (16.4) 3 (12) 6 (20.0)
Total 17 (100.0) 38 (100.0) 55 (100.0) 25 (100) 30 (100.0)

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Med Oral Patol Oral Cir Bucal. 2019 Jan 1;24 (1):e47-52. The effectiveness of decompression as initial treatment for jaw cysts

cysts (21.8%), residual cysts (7.3%) and nasopalatine Discussion

cyst (3.6%). Most commonly, an obturator was used to This retrospective study focused on the evaluation of
keep the cyst open (54.5%), followed by bracket with the effectiveness of decompression for jaw cyst treat-
chain (25.5%), iodoform gauze packing (14.5%), and ment over a ten-year period and the influence of differ-
drain (5.5%) (Table 3). ent factors thereon. The main limitations of this study

Table 3. Relation between different factors and types of the surgical procedures.
Factors/ Decompression Decompression Total p
subcategory n (%) and enucleation n (%)
n (%)
All 25 (45.5) 30 (54.5) 55(100.0)
Histopathology
Follicular cyst 18 (72.0) 6 (20.0) 24 (43.6) p = 0.003
Odontogenic keratocyst 2 (8.0) 11 (36.7) 13 (23.7)
Nasopalatine cyst 1 (4.0) 1 (3.3) 2 (3.6)
Radicular 3 (12.0) 9 (30,0) 12 (21,8)
Residual cyst 1 (4.0) 3 (10,0) 4 (7,3)
Means
Bracket and chain 11 (44.0) 3 (10.0) 14 (25.5) p = 0.020
Obturator 11 (44.0) 19 (63.3) 30 (54.5)
Drain 0 (0) 3 (10.0) 3 (5.5)
Iodoform gauze packing 3 (12.0) 5 (16.7) 8 (14.5)
Cyst diameter (mm)
0-40 18 (72.0) 17 (56.6) 35 (63.6) p = 0.399
40-80 5 (20,0) 11 (36.7) 16 (29.1)
80-120 2 (8.0) 2 (6.7) 4 (7.3)
Patient age (years)
0-30 14 (56.0) 8 (26.7) 22 (40.0) p = 0.025
30-60 8 (32.0) 18 (60.0) 26 (47.3)
>60 3 (12.0) 4 (13.3) 7 (12.7)

A single decompression completed treatment in 45.5% were that it was retrospective and that medical data
of cases, mostly in the frontal region of the jaws and in were not always complete.
patients under 30 years (56.0%). Among these patients, The study included 53 patients with a mean age of 35.1
follicular cysts were most frequent (72.2%) and the years and 55 cystic lesions treated initially with decom-
most commonly used devices were brackets with chains pression. In accordance with the literature, the most fre-
(44.0%) (Table 3). quent cystic lesions occurred in anterior maxilla in male
Subsequent enucleation was needed in 54.5% of the patients (20-22), though there were more cysts overall in
cases, mostly in the posterior region. Patients were the mandible than the maxilla. The reason for the higher
usually 30-60 years old (60%) and odontogenic kera- frequency of the cysts in lower jaw could be the use of
tocysts (36.7%) were most common. An obturator was enucleation as the initial treatment for cystic lesions in
often used after decompression followed by enucleation maxilla, while this study focused on jaw cysts initially
(63.3%) (Table 3). treated with decompression.
The effectiveness of decompression was found to corre- Similarly, histopathologically, follicular cysts and
late with histopathology, the means of keeping the cyst odontogenic keratocysts were most frequent (43.6%
open, and patients’ age (p=0.003, p=0.020 and p=0,025). and 23.7%, respectively). The literature indicates that
More detailed information is presented in Table 3. radicular cysts are the most frequent cysts in the jaws
The cyst’s diameter was not found to have an influence (23). Radicular cysts are smaller and are initially treated
on the effectiveness of the procedure (p=0.399) (Table with enucleation. Only large radicular cysts are treated
3). with decompression when enucleation could damage

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Med Oral Patol Oral Cir Bucal. 2019 Jan 1;24 (1):e47-52. The effectiveness of decompression as initial treatment for jaw cysts

surrounding structures, or in the case of geriatric and successful in patients under 30 years of age than in older
high-risk patients. The frequencies of residual cysts patients, which could be explained by the higher occur-
and nasopalatine cysts of 7.3% and 3.6%, respectively, rence of follicular cysts in younger patients. Follicular
are in line with the literature averages of 4.2-13.7% and cysts are not as aggressive as odontogenic keratocysts,
2.2-4.0% (20,22). Histopathological findings showed which is why the process is likely to succeed when de-
that the cyst type influences the surgical approach compression is the chosen treatment.
(p=0.003), with decompression followed by enucleation
applied mostly for odontogenic keratocysts. As a single Conclusions
procedure, decompression was most frequently used for Decompression is mainly performed to avoid morbidity.
follicular cysts (72%), but only for 8% of odontogenic It can be performed as a single complete procedure or
keratocysts. Some authors have advocated decompres- combined with subsequent enucleation, mainly depend-
sion for odontogenic keratocysts (24), although sur- ing on histopathological findings. Enucleation after de-
geons often prefer decompression followed by enucle- compression is highly recommended for odontogenic
ation for these aggressive cysts that are highly prone to keratocysts.
recurrence (18).
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Ethics statement
The study was approved by the Ethics Committee of the Medical
University Graz, 27-523 ex 14/15.

Acknowledgements
We thank D.I. Irene Mischak for statistical analysis and Eugenia
Lamont from the Section for Surgical Research, Medical University
of Graz, for critical revision of the article.

Conflict of interest
There is no conflict of interest in this study and it did not receive any
specific grant from funding agencies in the public, commercial, or
not-for-profit sectors.

Saša Marin and Barbara Kirnbauer have contributed equally to this

work.

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