Dr. Bhavik Miyani, Resident Doctor in Department of Oral & Maxillofacial Surgery, NPDCH, Visnagar.

1. #9TH JOURNAL CLUB
PRESENTATION
Presented by,
Dr. Bhavik Miyani,
2nd Year PG,
Department of OMFS.
Guided by,
Dr. Anil Managutti,
Dr. Shailesh Menat,
Dr. Rushit Patel,
Dr. Jigar Patel
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Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 492e497
Z. Yaman, B. T. Suer: Clinical comparison of ultrasonic surgery and conventional
surgical techniques for enucleating jaw cysts. Int. J. Oral Maxillofac. Surg. 2013;
42: 1462–1468. # 2013 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.
CLINICAL COMPARISON OF ULTRASONIC
SURGERY AND CONVENTIONAL SURGICAL
TECHNIQUES FOR ENUCLEATING JAW CYSTS

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Abstract
• The conventional treatment of odontogenic cysts usually involves enucleation of the cyst using rotary
and manual instruments; such procedures can cause trauma to the cystic epithelium or soft tissues in
the region, such as sinus membrane perforation or nerve damage.
• The use of ultrasonic surgery may reduce the risk of damage to soft tissues.
• The objective of this study was to evaluate the performance of ultrasonic surgery in removing
odontogenic cysts.
• Eighty-two cysts were removed from 68 patients over a period of 45 months.
• Ultrasonic surgery was used for 34 patients and conventional surgical procedures were used for 34
control patients.
• Two surgeons rated the cutting efficiency, visibility of the surgical field, ease of operation, and ease of
cyst epithelium removal on a 100-mm visual analogue scale.
• The operation time was also recorded. No major intraoperative or postoperative complications were
observed, and there was no cyst recurrence.
• Ultrasonic surgery for enucleating jaw cysts was found to increase the operation time, but also
markedly increased the visibility of the operation field. In cases where cyst enucleation is performed in
difficult areas that require delicate manipulation, there is less risk of damage to vital structures such as
neurovascular tissues with ultrasonic surgery.
Keywords: ultrasonic surgery; jaw cyst; enucleation;

4. INTRODUCTION
• Epithelium by removal of the overlying bone lamina (if present), complete enu-
cleation of the cyst epithelium, and management of the involved dentition and bony
cavity, followed by primary wound closure.
• 2 Rotary instruments such as burrs, and manual instruments such as rongeurs and
curettes, are standard instruments that are used to expose, separate, and remove
the cystic epithelium from the surrounding tissues.
• Rotary instruments must be used with caution in close proximity to anatomical
structures such as the maxillary sinus and mandibular canal, to avoid serious
complications.
• Additionally, rotary instruments may damage the cystic membrane, jeopardizing
total removal of the lesion.
• Residual cystic membrane fragments tend to produce recurrent cysts, hence the
necessity to completely excise the cyst epithelial lining during the operation.
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5. • Ultrasonic surgery has recently emerged as a potentially safer alternative approach to using
the mechanical instruments and motor-driven devices tradition-ally used in bone-related
procedures in oral and maxillofacial surgery.
• Ultrasonic surgery uses an innovative device developed by Vercellotti for performing oral
bone surgery. Piezoelectric ultrasonic oscillations of a modulated 25–30 kHz frequency
characterize the ultrasonic surgical device.
• Micro-oscillations created in the piezoelectric hand-piece cause bone-cutting inserts to
vibrate linearly between 60 and 210 mm. This microoscillational frequency allows selective
cutting of only mineralized structures.
• The key novelty of clinically applied ultrasonic surgery devices is their precise and selective
cut-ting properties. Ultrasonic surgery cuts mineralized tissues such as bone with micron
accuracy, yet does not cut soft tissues such as blood vessels and nerves.
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6. • Atraumatic handling of the soft tissues is a prerequisite for the total
removal of a cystic lesion and is technically comparable to handling the
sinus membrane during sinus bone grafting.
• The most common complication of sinus bone grafting is sinus
membrane perforation, which often negatively affects the result.
• Several authors have reported that ultrasonic surgery can minimize sinus
perforation rates during sinus bone grafting.
• This advantage would be useful for surgical jaw cyst enucleation, where
soft tissue preservation is necessary.
• Since ultrasonic surgery was originally developed for atraumatic bone
surgery, its use in jaw cyst enucleation has rarely been reported in the
literature.
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7. MATERIAL AND METHODS
• The study group consisted of 68 consecutive patients treated between February
2007 and October 2010.
• Inclusion criteria were: (1) the need for jawbone cyst removal, and (2)
agreement to participate in the study and postoperative follow-up schedule.
• The exclusion criterion was any sign of malignancy. All patients were in good
health except for nine who had mild (controlled) systemic diseases. Patients
were informed about the surgery, postoperative recovery, and possible
complications.
• This study was carried out in accordance with the Declaration of Helsinki on
medical protocol and ethics, and all participants signed an informed consent
agreement (parents signed in the case of minors). Each patient was randomly
allocated to either the ultrasonic surgery group or a conventional technique
group; this latter group were operated on using manual and rotary
instruments.
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• The same surgical team performed all jaw cyst enucleation surgeries.
• The ultrasonic surgery group consisted of 34 patients with 43 odontogenic cysts,
and the conventional surgery group consisted of 34 patients with 39 odontogenic
cysts.
• Parameters assessed Four parameters were assessed and evaluated for each
patient: cutting efficiency of the ultrasonic surgery or rotary instrument, surgical field
visibility, ease of operation, and ease of cyst epithelium removal.
• To appraise these parameters, a visual analogue scale (VAS) was used. Each VAS
scoring form had four identical 100-mm continuous lines extending between two end-
points that corresponded to the four parameters evaluated.

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• For each patient, the operator (an oral surgeon with 17 years of experience)
and the assessor (an oral surgeon with 7 years of experience) independently
completed two identical VAS scoring forms immediately after the surgery.
• A clinical assistant measured VAS scores using a millimetre ruler.
• The operation time was also monitored from the start of the mucosal incision
to the end of suturing, using a chronometer.
• Before any surgical procedure, a detailed patient medical history was
obtained.
• Panoramic and peri-apical radiographs were taken preoperatively to assess
cyst dimensions.
• Preliminary jaw cyst diagnoses were made according to the patient’s history,
clinical examination, and radiographic findings.

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• A confirmatory computerized tomography evaluation was also performed for
25 patients. Four-teen patients had multiple lesions, which were all
enucleated.
• Final diagnoses were established by histopathological examination of
surgical specimens.
• Most patients were treated under local anaesthesia, although 16 patients
(24%) required general anaesthesia.
• An aspiration test was performed at the beginning of operations to rule out
vascular and solid lesions.

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• Two patients underwent decompression by a lateral orbital approach; 1
patient showed an improvement in visual acuity.
• In 2 other patients, a spontaneous recovery was observed.
• Four of the 8 patients underwent open reduction and fixation of the
maxillofacial fractures.
• Of the remaining 4, 1 patient had a non displaced ZMC fracture that was
treated without surgical intervention and 3 patients refused any surgical
intervention (Table 3).

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• CONVENTIONAL SURGERY TECHNIQUE
• Conventional jaw cyst enucleation was performed as described by Ellis.
• After reflecting a mucoperiosteal flap, rotary instruments such as carbide or
diamond burrs attached to a straight hand-piece were used to remove the bone
lamina overlying the cyst epithelium.
• Manual instruments such as curettes, periosteal elevators, and sinus lift
elevators, or rongeurs were used to separate the cyst epithelium from
surrounding bone.
• Great care was exercised in removing entire lesions.

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• ULTRASONIC SURGERY TECHNIQUE
• After reflecting a mucoperiosteal flap, an ultrasonic surgery device (Surgysonic; Esacrom
S.r.l, Bologna, Italy) was used to remove bone and separate the cyst epithelium from the
surrounding bone.
• Different types of tips (inserts) were used throughout the operations. All inserts were
visually inspected for any irregularities and were used several times after cleaning and
sterilizing in accordance with the manufacturer’s recommendations.
• Saw-shaped or diamond coated ball-shaped inserts were used to cut or reshape the bone.
Conical and spoon shaped inserts were used to separate the soft tissues (i.e. cyst
epithelium) from the surrounding bone.
• Manual instruments such as sinus lifting elevators were used as needed. The surgical
protocol for enucleating jaw cysts using the ultrasonic surgery approach is shown in Figs. 3
and 4.
• Primary closure was achieved in all patients. Six patients received mandibular ramus bone
grafts to reconstruct alveolar defects, and 57 patients received bovine-derived bone grafts.

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• Statistical analysis
• Statistical analyses were performed using SPSS software version 15.0 (SPSS,
Inc., Chicago, USA) and Medcalc version 9.2.0.1 (Medcalc, Belgium).
• Means and standard deviations were calculated for data variables. Bland–
Altman plots and Pearson’s correlation coefficient were applied to assess
agreement between the operator and assistant VAS evaluations.
• The Kolmogorov–Smirnov test was used to test for normality of the distribution
of the studied variables.
• These data were normally distributed. In order to evaluate and compare the VAS
scores, operation times, and demographic data between the ultrasonic surgery
and conventional instrument groups for the operator and the assessor, an
independent-samples t-test was carried out. A P-value of less than 0.05 was
considered statistically significant.

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• Results
• The present study was completed by 68 patients who satisfied the inclusion criteria.
The study sample comprised 25 females and 43 males; ages ranged between 9 and
64 years (mean 35.3 13.5 years).
• All surgeries were performed as planned and all patients recovered well after
surgery.
• For six patients (two in the ultrasonic surgery group and four in the conventional
surgery group), an incision line opening of less than 5 mm in length was observed,
and the dehiscence healed by secondary intention. For four patients (two in each
group), bovine derived bone grafts became infected and the infections responded to
antibiotic therapy without further problems.
• One intra-operative problem that was encountered with ultrasonic surgery was
insert breakage; two inserts were broken from their tips during operations.

16. o A diamond insert broke during surgery in one patient, and it took 15 min to find the
broken piece, which was deep in the maxillary sinus where the operation was
performed.
o The other broken insert was an angled saw-shaped insert that broke during the
harvesting of ramus block bone grafts. During the follow-up period, clinical exams
were performed and peri-apical or panoramic X-ray images were taken to detect
any recurrences.
o Fifty-two patients (76%) were compliant with the follow-up visits as scheduled. Non-
com-pliant patients (24%) were telephoned and requested to send a recent
panoramic X-ray taken by their local dentist. Postoperative follow-up periods ranged
from 18 to 57 months (mean 36.4 10.8 months) and there was no recurrence of
cysts.
o Histopathological examinations agreed with the preliminary diagnosis and revealed
that the lesions had odontogenic origin with classical cystic epithelial linings.
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17. • Operation times were extremely variable, ranging from 26 to 143 min (mean 51.0
27.9 min) in the ultrasonic surgery group, and from 23 to 72 min (mean 36.0 15.3
min) in the conventional surgery group.
• These variations were due to the extent and number of the lesions, and the time
required for secondary reconstructive procedures.
• Therefore, 16 patients who were operated on under general anaesthesia were
deemed complex cases, and their operation time values were evaluated separately.
• In the ultrasonic surgery group, the average operation time was 37.5 9.5 min for
simple cases and 88.4 28.1 min for complex cases. In the conventional surgery
group, the average operation time was 28.9 5.2 min for simple cases and 63.4
8.1 min for complex cases.
• Operation times were significantly longer in the ultrasonic surgery group compared
to the conventional surgery group for both the simple cases (P < 0.001) and the
complex cases (P = 0.03; Fig. 5).
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18. THANK YOU
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