Taking it on the Chin

After a brief hiatus,  the LANAP- case presentation series has resumed. This iteration will focus on specific procedures made possible by the use of the Periolase. They will include, but are not limited to “non-periodontitis” procedures.

Today’s discussion revolves around a mandibular cyst that was referred for biopsy/ removal. This 64 y.o. fellow, medical history non-contributory, had developed this lesion over the course of the last year. It was painless and had the Dentist not told him about it he wouldnt have known. In terms of why this happened, your guess is as good as mine.

Enclosed we will see the clinical course of this progression. Radiographs will come later but are not what makes this case interesting. To wit, there has been excellent healing of the site internally, but to see the films before complete fill has been achieved will not shed much light on the situation.

What interested me about this situation was twofold… Firstly, the idea that I would be able to separate out the epithelial lining without disturbing the underlying connective tissue as well as the possibility from an operator’s point, to be able to perform the procedure sans suturing. This is no small thing as a flap of this nature would require significant closure over the site to prevent collapsing of the soft tissue into the defect. Moreover, no grafting of the site was performed, which would normally necessitate some sort of “scaffolding” to support the healing.

The procedure was performed with a standard full thickness trapezoidal-flap, and then laser enucleation was completed. Upon achieving clotting in the site, the flap was replaced but only laser energy was used to ” tack ” it back to its original position. This allowed for a virtually painless recovery period, one which would have been decidedly uncomfortable had there been suturing involved.

Finally, we see 2 month healing and what is particularly interesting to note is that there was no in-folding of the tissue into the site despite the lack of a sub-structure , be it a graft or a membrane. This was a pleasant surprise to the patient. For the record, the patient was apprised that a secondary procedure might be necessary, and he was ok with it from the outset.

Review of the pathology reveals that it was a cyst and that there is no further treatment necessary at this time.

As more films become available I will distribute them periodically. For now however, we now know that we can add these types of procedures to our arsenal in our ever evolving attempts to improve patient care. Comments, thoughts and pithy-isms are always welcome and as always, keep on healing.

pre-op view of anterior mandible. n.b. “bluish”
appearance of cyst

ibid. this view helps us appreciate the actual size of the lesion
relative to the jaw.

with flap elevated

after laser ablation

after laser hemostasis

with flap replaced and ” Sewing machine- like tacking”
back into place. No suturing involved. Excellent hemostasis

one week post-op. slight creeping of fibrin around the margins.
Pt reports no post-op discomfort although still some slight
inflammation.

2 month healing with excellent tissue remodeling.
n.b. the normal architecture of the mandible.
preventing the collapse of the tissue is paramount to
uneventful healing. In cases like this where no
scaffold is utilized, this take on even more significance.

Neal

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