Odontogenic Cyst: Graft or Not?

I do not believe there is a contraindication for grafting if you felt confident that you have clinically removed all the infected tissue and placed the patient on antibiotics. My opinion is based on clinical experience and not on lit. review.

Grafting depends on the type of odentogenic cysts. If the cyst is an agressive variety like odentogenic keratocyst grafting should not be done immediately as its recurrance rate is high

With the infection still prevalent, waiting to graft has proven to be best, most of the time. After primary healing and the infection gone, about 4 weeks would be long enough to wait before grafting. The healing hormones will still enhance healing at 4 weeks, and should aid in the healing of the grafted area. I have had some success grafting in infected areas, if I put the patient on aggressive antibiotics for a week prior to surgery and flush the area with saline/tetracycline (250 mg in 25 cc of saline) to remove/kill some of the infection. Leave the saline/tetracycline in the area for at least a minute and then flush copiously with saline. The tetracycline does retard bone formation a little, but not with the same aggressiveness of infection in the area. As a side note, I like the Bio Guide membranes, but am not crazy about the Bio Oss material. It works, but takes forever to change into normal bone. If you wait 6 months, you may be happily supprised at just how much bone has filled in on its own. Best of luck

My position is simple, if I am able to remove all infected tissue I do graft. I allways place the patient under strong antibiotherapy previous to the the surgery. As a rule we allways mix tetracycline with our grafting material 125mgx1g of bone. and its true it delays the start of the transformation but it helps it go faster after some time due to its local acidity. primary closure is a must when grafting. We sometimes use capset as a binder and membrane or we go with a pericardial membrane that resists very well if its exposed. best of luck

In my experience in dealing with bone destruction due to granulomtaous tissue or a cyst; I feel after the initial removal of the pathology, a thorough curretage, and washing with both tetracycline and citric acid, followed by a saline rinse. If primary closure can be achieved, it is best,if not a PTFE membrane and sutures for 2-3 weeks, during which a sloughing off of any pathological cells will hopefully occur, and new mucosa will grow under the PTFE to bridge the gap of the soft tissue. The area is then re entered, the immature osteoid and sloughed off cells is curreted out of the bony void and a graft mixture of Cerasorb, Osteogen and Demineralized Freeze Dried Bone mixed with some tetracyline powder, into PRP. An attempt to make a fibrin membrane can be used from the spinning of the blood, and since there is now primary closure after the 2-3 week waiting. The particulate graft is a good matrix, and will generally help get a fuller graft and protect the perimeter buccal and lingual walls.The waiting period prevents pathological tissue from invading an immediate graft mixture which may not allow proper healing. Gerlad Rudick dds Montreal

All of above challenges relate to space-maintaining concept. It depends on the future treatment plannning. How old is the patient? Is it going to replace the second premolar area with an implant? Had the crestal bone area been involved when extracting the tooth? Was the anatomy of the deferct well-contained? You should prevent ridge collapsing by using Ti-reinforced membranes or material+resorbable membrane, if implant therapy is the next step and the anatomy of the defect is not space-maintainable. Neda Moslmei

Dear collegues, Please check the Journal of Periodontology 2007, July issue. My article describes for the first time succesful bone grafting after removing a lateral periodontal cyst. You have the pdf on my website:nartperiodoncia.com

in my experience i procede in this way: Three days before the surgery, a cephalosporine and the same for four o five days after. one day before 20 mg. piroxicam andthe same for four or five days after. During the intervention i use calcium-carbonate as oseous-substitute mixed with iniectable powder of a cephalosporine plus betametasone iniectable powder. after five minutes i put i one piece implant bejond the original alveolus for a better stability and then avery strong surgical needl. in this way the patient, after this surgery,needs generally only one or two tablets of paracetamol (500 mg. per time) ,he has a very reduced swalling, practically no pain. This in my 40 years in medical and dental practice.

What was the histology of the cyst? Did you base the diagnosis of "odontogenic" on solely clinical exam ?

Antibiotics 3 days prior to surgery is not a modern practice. Effective antibiotic tx should be within 1 hr of the surgical case. IMHO grafting is generally not needed as the bony defect will heal quite well.

There were a few cases that taught me an important lesson. A buried tooth was lying just beneath an area to be implanted (anterior maxilla). I removed the buried tooth through a labial window and in spite of grafting (with TCP), the ridge "collapsed" after 6 months. What was originally a 6mm ridge became a 3mm ridge. Implant surgery was more challenging and aesthetics were compromised. Then came the cyst in the upper central. The bone near the cervical region was perfect. 6mm ridge all the way down to the cyst almost 10mm apical. I enucleated the cyst, then proceeded to sink the implant. Primary stability was excellent. Only thing was that the apex was hanging in the window. I grafted the defect. 4 months later, the implant integrated nicely and I managed to restore much more aesthetically than with delayed placement. The moral of the story is that if the removal of the cyst or buried tooth needs a window that is close to the sulcus and if you have enough labial bone to achieve good primary stability with the implant, sink it immediately and graft the window to cover the exposed apex of the implant. The results are a lot more aesthetic.