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Cyst decompression - Courtesy ROOTS
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From: Randy Hedrick
To: ROOTS
Sent: Thursday, February 23, 2006 4:01 PM
Subject: [roots] Cyst Decompression

Decompression procedures

The topic of decompression procedures came up earlier this week and I dug out a case used on my ABE boards.  It has a
12yr recall from last November.  I did the endo as a GP the year before I went to my endo residency.  When I came
back after my residency he came to me in my first month or two in practice and I was quite surprised to see such a
large lesion.  I have included the write up for the Endo boards since it has all the details about the decompression
procedure.  It is very skimpy on the write up for the original endo because that is not what I was presenting for
evaluation.  Some details I can add about the original endo is that I had a very hard time getting it to quit
draining so I could obturate.  Back then I did not use any intracanal medication which may have lead to cyst
formation and continued serous drainage into the canal.  The most common application for a decompression procedure is
to shrink the size of the lesion to allow for the bony cortices to reform and then do a traditional apical surgery.
I believe this case is unique in that only a decompression procedure was done and complete healing occurred.  No
other therapy or antibiotics were given.  I would not expect to have complete healing in many other cases especially
if the endo is questionable.  At the presentation in 1993 you would have to say the endo was failing, but in the end
it healed completely so in fact the endo was successful!  - Randy Hedrick

Now that is excellent documentation. Excellent description. Thanks for digging that out randy. What would you change if anything if doing the procedure again today in 2006? Would you retreat? Would you irrigate the defect differently? - Gary Gary, I probably would have been more insistent on doing the surgery after some bony healing from the decompression if it had not been a simple single canal, my endo, my BU and my crown. If I didn't know about the quality of the endo I would have been very doubtful that only a decompression procedure would be successful. The crown margins weren't perfect but the esthetics were pretty good considering this was done with PFM technology from the early 90's. It didn't need to be replaced so I still wouldn't do a retreatment. He didn't want to do the surgery and was willing to take the responsibility if it didn't heal so I was willing to go along with it to see if it really would heal. He also was cooperative in that he was willing to come in for multiple follow-up appointments. Chlorhexidine probably would have been a consideration as an irrigant, it is well tolerated by the host tissues I believe. Saline irrigation after the chlorhexidine. I guess another approach would be to do the surgery immediately with a bone graft, calcium sulfate or a membrane procedure to prevent scar formation. That would allow for a biopsy specimen to be obtained. Still it's hard to want to change much with success like this. It's one of those cases that make you smile when you think about it! :-)) - Randy Hedrick Dear Randy, Sometimes you just have to believe." Thanks for sharing. Great teaching case since it was so well documented--not to mention that it demonstrates the desired result. I took the liberty of reverting the 11-09-05 image back to a jpeg and grayscale. Then I increased the contrast to try to match the contrast in your other images. Attached is the result. At first glance many would express concern that there was a radiolucent area and interpret it to reveal non- healing. However, as you know, this an example of excellent bone healing in a case where the cortical plates were resorbed to some extent. You will note the sclerotic border demonstrating the extent of the original cystic expansion, the relative radiolucency within that border (perhaps indicating less facial-palatal depth of bone as is sometimes seen in non-pathologic lingual depressions in the mandibular molar areas), and lastly a characteristic radial trabecular pattern to the healed bone in the area. As my good friend and Chairman of our Endodontic Department, Jim Dryden, would say, "Dad gum, there's nothing like a 12 year follow-up to prove a point". On a historical note, we were taught a surgical procedure for treatment of large lesions of the jaw called marsupializtion. In this procedure a flap was elevated over the facial aspect of the cyst with a portion of the cyst being removed. Instead of curetting the remaining cyst, the mucosal flap was then sutured to the cyst remaining in the crypt. The patient was then given instructions on irrigating the area after eating and follow- ups were scheduled until the lesion was deemed "small enough for enucleation." A variant of this procedure was learned while attending a meeting in Colorado in the early '70's. God, can I really be that old? An elderly gentleman from the Denver area projected slides and reviewed some long-term follow-ups of cases he had completed over the years. Unusual in his technique was that he completely removed a large section of mucosa overlying the facial aspect of large lesions along with the facial aspect of the cyst. Then he packed the crypt with what, as I can recollect, was a long gauze strip as was used in packing "dry sockets". He saw the patients weekly to change the gauze. Each week it took less gauze until the area healed over as was seen with your case. Sounds barbaric and gross but seeing was believing. By the way, the mucosa looked like nothing had ever happened. Well, that's enough story-telling for this morning. I hear my grandson stirring. That means there's a diaper to change and oatmeal and blueberries to prepare. Ain't vacation at the kid's place great? Again, Randy, congratulations on a job well done. - Grant
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