CASO CLÍNICO

 

Mandibular pathologic fracture associated with radicular cyst. Report of three clinical cases

Fractura patológica de la mandíbula asociada a quiste radicular. Reporte de 3 casos clínicos

 

 

J. Bouguila¹, L. Córdova Jara², I. Zairi¹, A. Adouani¹

¹ Servicio de Cirugía Plástica y Máxilo Facial, Hospital Charles Nicolle, Tunis, Tunez
² Equipo de Cirugía Oral y Máxilo Facial. Hospital San José, Santiago de Chile.
Facultad de Odontología Universidad de Chile. Santiago de Chile. Chile

Correspondence

 

 

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ABSTRACT

Introduction. Radicular cyst is the most common cyst of the oral cavity. It may range in size from a small periapical lesion to one that can obliterate the antral space or cause mandibular fracture.
Case reports. We report three cases of radicular cyst complicated by mandibular fracture that occurred after maxillofacial trauma. The diagnosis was strongly suggested by panoramic radiography and confirmed by pathology examination of the operative specimen. Treatment consisted in cyst enucleation followed by immobilization of fragments by osteosynthesis or maxillomandibular fixation. The clinical and radiologic outcome was favorable.
Discussion. The particularities and treatment are discussed.
Conclusion. Treatment success is dependent on adequate therapy, theprinciples of which are removing the lesion and providing stable fixation.

Key words: Radicular cyst; Pathologic fracture; Mandible.

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RESUMEN

Introducción. El quiste radicular es el quiste más común de los maxilares. Su tamaño puede variar desde una lesión que abarca el proceso alveolar hasta uno extenso que oblitera el espacio antral maxilar o causa una fractura patológica mandibular.
Reporte de casos. Se reportan tres casos con fractura patológica mandibular asociados a quiste radicular ocurridos después de trauma facial. El diagnóstico fue sugerido por un estudio clínico, radiografía panorámica y confirmado por el estudio histopatológico de la pieza operatoria. El tratamiento consistió en enucleación quística seguido por inmovilización de fragmentos con osteosíntesis o bloqueo intermaxilar. El resultado clínico y radiológico a corto plazo fue favorable.
Discusión. Se discuten aspectos propios de la patología y su terapia.
Conclusión. El éxito del tratamiento depende de una adecuada terapia en que sus principios más importantes son la remoción de la lesión mediante enucleación y una fijación estable.

Palabras clave: Quiste radicular; Fractura patológica; Mandíbula.

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Introduction

Mandibular fracture is one of the most common traumatic injuries in the maxillofacial territory¹ and radicular cyst is one of the most common odontogenic jaw lesions. Both lesions occur sporadically.

A study was made of the data in the archives of the Plastic and Maxillofacial Surgery Department of Charles Nicolle Hospital (Tunis, Tunisia) from a 10- year period (1995 to 2004) that satisfied the criterion of: mandibular pathologic fracture associated with the presence of local radicular cyst. Out of a total of 1100 facial fractures, 3 (0.27%) fractures met these conditions.

The three clinical cases are reported and their treatment is discussed.

 

Clinical case

Case 1

An 18-year-old man was seen for facial trauma due to violence. He presented pain and a swollen chin area. The radiographic image revealed a symphyseal fracture that intersected a periapical radiolucent lesion (Fig. 1).

The patient was treated by cyst enucleation and immobilization of the fragments by maxillomandibular fixation (Figs. 2 and 3). He later underwent root canal. Histopathologic study verified the diagnosis of radicular cyst. Panoramic radiography performed one month after surgery demonstrated the favorable evolution of both lesions.

Case 2

A 40-year-old man was hospitalized for fracture of the left mandibular angle and right mandibular body associated with a large radiolucent lesion (Fig. 4). The radiolucent lesion was enucleated with the associated dental roots using an intraoral approach. The fragments were stabilized by maxillomandibular fixation using Ivy loops (Fig. 5). The histology confirmed its nature as a radicular cyst.

Case 3

A 44-year-old man was admitted for facial trauma. The radiographic study revealed a large radiolucent lesion and a fracture of the angle with displacement (Fig. 6).

Enucleation of the lesion, extraction of the causal dental roots, and reduction-osteosynthesis of the fracture were performed with intraosseous wires and a miniplate with monocortical screws (Fig. 7).

Histologic study of the enucleated material revealed an inflammatory radicular cyst. Bone consolidation was confirmed radiographically two months later.

 

Discussion

A bone fracture is a complete or partial discontinuity in a bone caused by direct or indirect forces.² Pathologic fracture is defined as a fracture caused by the presence of previous bone pathology, in this case, of the mandible. Its incidence is less than 2% of all facial fractures. ¹ The pathogenesis of pathologic fracture is not absolutely clear, but some authors postulate minimum or inadequate trauma that causes fracture on a pre-existent bone lesion. However, it is difficult to quantify the minimum trauma necessary by scientific means.² Most pathologic fractures reported in the literature are associated with osteoradionecrosis or oral malignant lesions.^1,2

Pathologic fracture caused by radicular cyst is rare. In the last 50 years,^2,4 few reports have been published on the topic. Most have been reports of individual cases. The first was described by Mardsen³ in 1964; Schegg⁴ reported another in 1974. Ezsias and Sugar² reported two cases that were treated by open reduction using reconstruction plates to give continuity to the mandible. Gerhards¹ published three cases of fractures caused by underlying odontogenic cysts (two radicular cysts and a follicular cyst), which were treated by open reduction, miniplates, and monocortical screws.

It is particularly interesting that lesions that have a high incidence (63-78 % of all jaw cysts)^5,6 cause fractures so sporadically. Most of the fractures occur during mastication or when the patient suffers an accident.¹ In our cases, the fractures were secondary to violent injury.

Mandibular pathologic fracture associated with radicular cyst must be treated by eliminating the cause, or primary condition, and immobilizing the fragments by osteosynthesis, plates, and maxillomandibular fixation.^1,2

The recommended treatments for radicular cystic lesions include enucleation, curettage, marsupialization, and, occasionally, segmental mandibular resection.^1,2,6,7 Marsupialization (Sakkas & Pogrel)⁸ reduces the frequency of mandibular pathologic fracture or bone discontinuity. Nevertheless, the disadvantage of this technique is the long time required for success, which limits its use to patients capable of undergoing the procedure.^6,8 Enucleation therapy has been proposed in other studies.⁶ The cystic cavity generally is filled with iodine-soaked gauze, which creates favorable conditions for epithelization. It has been seen that there is no recurrence with enucleation, which may indicate that resection is not necessary, as long as access is adequate and the lesion can be completely enucleated. The causal tooth must be treated and the therapy given will depend on the degree of damage, the location, relation with the fracture seam, etc. Histopathologic examination of the material removed is obligatory, this being the most specific method for establishing the diagnosis of radicular cyst.^2,6 The time for bone healing may be longer,² but in the cases reported here, an acceptable result was obtained in the usual times. Regular radiologic clinical monitoring is necessary to achieve complete bone regeneration. Therapeutic success depends on proper therapy, the most important principles of which are removal of the lesion by enucleation, treatment of the causal tooth, and supplying stable fixation.

 

 

Correspondence:
Dr. L. Córdova Jara
Facultad de Odontología. Universidad de Chile
Calle Olivos 943, Independencia, Santiago de Chile.
Email: luiscordovajara@vtr.net

Recibido: 29.02.08
Aceptado: 16.06.08

 

 

References

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