School of Dental Medicine, University of Zagreb, Croatian Dental Society - Croatian Medical Association
Abstract
U svibnju ove godine u ambulantu Kliničkoga zavoda za oralnu kirurgiju dolazi mlada bolesnica, u dobi od 28 godina. Upućena je od oralnoga kirurga zbog velike ciste u donjoj čeljusti. Donosi ortopan koji pokazuje veliko multilokularno prosvjetljenje u donjoj čeljusti s desne strane koje se proteže od područja drugoga pretkutnjaka do semilunarne incizure na uzlaznome kraku. Ponavljamo ortopantomogram ali se prosvjetljenje bitno ne razlikuje od onoga na ortopanu koji je donijela bolesnica.
Zbog napuhnutoga donjega ruba čeljusti i multilokularnoga prosvjetljenja nismo sigurni o kakvoj se patološkoj promjeni radi. Da bismo se lakše odlučili kakav operativni zahvat učiniti, šaljemo bolesnicu na CT donje čeljusti, ali nas nalaz i dalje drži u neizvjesnosti premda smo za nijansu uvjereniji da se radi o cisti a ne o cističnome tumoru. Prije konačne odluke kako operirati, u lokalnoj anesteziji uzimamo dio tkiva iz koštane šupljine, a biopsija potvrđuje pretpostavku da se radi o keratocisti. Budući da se radi o izrazito velikoj cisti i prijetećoj opasnosti od prijeloma donje čeljusti ako bismo potpuno odstranili bukalni kortikalis, odlučujemo se za dvofaznu tehniku. Plan je da se u prvoj fazi učini dekompresija ciste otvaranjem kalote na najprominentnijem dijelu ciste s bukalne strane i izradi obturator. Navedenim načinom omogućuje se regeneracija stanjene kosti. Obturator se nosi stalno i ne reducira ga se. Bolesnica odlazi redovito stomatologu, bar dva puta u tjednu, koji ispire šupljinu u kosti s 3% vodikovim peroksidom i fiziološkom otopinom. Kada klinički i rtg nalaz pokaže da se je cista počela smanjivati a defekti u kosti zacjeljivati, odlučit ćemo se za drugu fazu liječenja u kojoj bi se potpuno odstranila cista a zaostali defekt u kosti primarno zatvorio. Rtg snimke 6 tjedna i 3 mjeseca nakon zahvata pokazuju dobar oporavak kosti i znatno smanjenu cističnu šupljinu. Nastavak liječenja planira se za otprilike mjesec dana. Dobiveni rezultat pokazuje opravdanost ovakva pristupa u liječenju velikih cista.A young female patient, aged 28 years, was admitted to the Out patient Department of the Clinical Department of Oral Surgery in May of this year. She was referred to us by an oral surgeon because of a large cyst in the mandible. The patient brought with her an orthopantograph which showed a large multilocular translucency in the mandible on the right side, which extended from the area of the second premolar up to the incisura semilunaris on the ramus of mandible. We performed another orthopantograph on which the translucency did not differ essentially from that on the orthopantograph which the patient had brought. Because of the swelling of the lower edge of the jaw and multilocular translucency we were unsure as to the nature of the pathological lesion. To help us decide on which operative procedure to use we sent the patient for a CT of the mandible. However the finding failed to dispel our uncertainty, in spite of the fact that we felt almost convinced that it was a cyst and not a cystic tumour. However, before finally deciding on which operation to perform we took a piece of tissue, under local anaesthesia, from the osseous cavity for biopsy which confirmed our suspicion that it was a keratocyst. As it was an exceptionally large cyst and because of the danger of mandibular fracture in the case of complete removal of the buccal corticalis, we decided to use the biphase technique. The plan was to carry out decompression of the cyst in the first phase by opening the calotte on the most prominent part of the cyst from the buccal side and construct an obturator. This method enables regeneration of the thinned bone. The obturator is worn continuously and is not reduced. The patient has a check-up by the dentist at least twice a week, who rinses the cavity in the bone with 3% hydrogen peroxide and physiological solution. As soon as the clinical and radiographic findings show that the cyst has decreased and that the bony defect has healed we plan to carry out the second phase of treatment, in which the cyst will be completely removed and the remaining bone defect primarily closed. The X-rays performed 6 weeks and 3 months after the operation show good recovery of the bone and significantly decreased cystic cavity. Continuation of treatment is planned in approximately one month. The results obtained show the justification of such an approach in the treatment of large cysts
