Patient develops swelling in left lower jaw area
The patient is a 27-year-old female from Chengam in Tamil Nadu, India. She began noticing the development of a swelling in her lower jaw around a year ago. This was on the left side. The swelling was not painful, but there was loosening of teeth in the affected region. This also began interfering with her eating and speech.
Alarmed at the turn of events, she visited a local dental surgeon who examined her. He also obtained imaging studies for the patient. Realizing that the problem was too complex and needed surgical intervention, he referred the patient to our hospital for further management.
Our hospital is a well-known center for jaw deformity surgery in India. All problems relating to jaw correction surgery are addressed at our hospital. Jaw lengthening surgery, jaw reduction surgery and jaw cyst surgery are specialty procedures performed at our hospital.
Initial consultation and treatment planning
Dr SM Balaji, jaw reconstruction surgeon, examined the patient and obtained a detailed history. He ordered for comprehensive imaging studies including a 3D CT scan. Imaging studies revealed that there was a cystic lesion extending from the left lower canine to the third molar. There was also perforation of the lingual cortex of the mandible.
Biopsy of the lesion confirmed the diagnosis of odontogenic keratocyst. He explained to the patient that total removal of affected portion of the mandible would be performed. Involved teeth in the region would also be extracted to prevent recurrence of the lesion.
Hemimandibulectomy would be followed by reconstruction of the bony defect with grafts harvested from the patient’s ribs. Rehabilitation of the patient would then be completed with placement of implants through dental implant surgery. This is the treatment protocol recommended by the American Association of Oral and Maxillofacial Surgeons.
It was explained that artificial crowns will be placed on the dental implants later. The artificial teeth would enable the patient to eat a normal diet. Normal speech would also be enabled by this treatment plan. The patient and her parents were in complete agreement with the treatment plan and consented to surgery. Removable dentures were not recommended to the patient. It was explained to them that meticulous dental care needed to be performed for good long term results.
Characteristics of an odontogenic keratocyst
An odontogenic keratocyst is a rare and benign but locally aggressive developmental cyst. It most often affects the posterior mandible and commonly presents in the third decade of life. Odontogenic keratocysts make up around 19% of jaw cysts. Radiographically, these lesions are unilocular when presented at the periapex and can be mistaken for radicular or lateral periodontal cysts.
Successful surgical excision of the odontogenic keratocyst
Under general anesthesia, a right inframammary incision was made and dissection was carried down to the ribs. Costochondral rib grafts were then harvested for reconstruction of the jaw. A Valsalva maneuver was performed to ensure that there was no perforation into the thoracic cavity. The incision was then closed in layers with sutures.
Attention was next turned to the odontogenic keratocyst. A crevicular incision was made in the mandible followed by elevation of a mucoperiosteal flap. The area of the cystic defect was identified followed by extraction of the teeth in the involved area. These included the canine, first premolar, second premolar and the three molars.
Hemimandibulectomy was then performed followed by application of diathermy to control bleeding. Antibiotic flushing was also done in the region of the bony defect. The mandible was reconstructed using a mandibular reconstruction plate. Rib grafts were also fixed using titanium screws. Wound was then closed with sutures following adequate hemostasis.
Follow up treatment after surgery
It was explained to the patient that dental implant would be fixed on the rib grafts after consolidation with the surrounding bone. This would be followed by fixation of crowns to the dental implants after adequate osseointegration has been demonstrated with the surrounding bones. The patient and her parents expressed understanding of the treatment plan.