Surgical Techniques for Jaw Cysts

A jaw cyst is a pathological lesion that forms as a cavity filled with fluid or semi-solid material and lined by an epithelial wall. Because jaw cysts can weaken jawbone structure, displace teeth, or trigger pathological fractures, they often require surgical management. Minimally invasive approaches in jaw cyst surgery aim to reduce tissue injury, accelerate healing, and minimize postoperative complications.

One method considered minimally invasive is careful enucleation, performed using selective and aseptic techniques. A case study conducted by an FKG UGM student, Refitia Inayah Putri, under the supervision of drg. Pingky Krisna Arindra, Sp.BMM., Subsp.Ped.OM(K) and drg. Poerwati Soetji Rahajoe, Sp.BM(K)., Ph.D., entitled “Enukleasi pada kista residual: kasus insidental pada pasien usia muda”, demonstrated that enucleation—although not theoretically the most “minimal” approach—can be carried out carefully and produce favorable outcomes without complications. 

Definition and Indications for Enucleation

• A residual cyst is an inflammatory odontogenic cyst commonly found after tooth extraction and often originating from a radicular cyst.
• Enucleation is the complete removal of the entire cyst sac along with its epithelial lining, with the aim of preventing recurrence by avoiding residual epithelial remnants. 
• The primary indication for enucleation is a cyst of manageable size that allows complete removal without endangering vital structures (nerves, teeth, thin bone) surrounding the lesion.

Operative Technique (Step-by-Step)

In the reported case:

1. Imaging and advanced diagnosis
   • The patient underwent panoramic radiography and cone beam CT (CBCT) to determine cyst size, boundaries, and its relationship to critical structures. 
   • The lesion measured approximately 26 × 16 mm. 
2. Surgical preparation
   • Full sterilization and aseptic techniques were applied. 
   • Local anesthesia was administered, such as a mandibular block combined with mental nerve infiltration. 
3. Incision and flap design
   • A mucoperiosteal flap (e.g., triangular flap) was created to provide adequate exposure for manipulation. 
   • Flap elevation was performed carefully to avoid damage to surrounding soft tissues. 
4. Bone removal and access to the cyst
   • Gradual removal of cortical bone using burs or bone instruments (e.g., round burs or rongeurs) with continuous irrigation to prevent overheating. 
   • Adequate access was ensured so that the entire cyst wall could be reached. 
5. Cyst enucleation
   • The cyst sac was removed intact, gently separating the epithelial lining from bone to avoid rupture. 
   • In the reported case, three separate cyst sacs were identified and removed. 
   • Care was taken to ensure no epithelial remnants remained within the bone cavity. 
6. Irrigation and preparation for closure
   • The bone cavity was cleansed and irrigated with sterile saline. 
   • The cavity margins were smoothed to prevent soft tissue irritation. 
   • In the presence of large dead space, the use of drains, packing, or suturing to reduce the space was considered to facilitate primary healing. 
7. Flap closure
   • The flap was repositioned anatomically and sutured using proper suturing techniques. 
8. Postoperative therapy
   • Prophylactic antibiotics and analgesics were prescribed to prevent infection and control pain. 
   • Postoperative follow-up showed minimal swelling on day 1, reduced swelling and pain by day 7, and radiographic evidence of new bone formation at approximately day 30. 
   • Long-term evaluation is essential to ensure proper bone remodeling and absence of recurrence. 

Minimally Invasive Aspects and Trauma Reduction

Although enucleation is inherently a surgical procedure, its impact can be minimized by:

• Limiting flap size to only what is necessary.
• Using micro-instruments (fine burs, delicate curettes) for precise manipulation.
• Preserving as much cortical bone integrity as possible to maintain jaw strength.
• Avoiding disturbance of vital structures such as the inferior alveolar nerve or healthy tooth roots.
• Minimizing removal of normal soft tissues surrounding the cyst.
• Limiting the use of bone grafts, when possible, to avoid additional surgical trauma—in the reported case, no bone graft was used, and bone regeneration progressed well.

Advantages and Limitations

Advantages:

• Reduced surgical trauma and potentially faster healing time.
• Lower risk of complications (infection, paresthesia, bleeding) with careful technique.
• In the reported case, complication-free outcomes and new bone formation were observed within 30 days. 

Limitations / Risks:

• Risk of residual epithelial tissue if removal is incomplete, potentially leading to recurrence.
• Enucleation may pose high risk for very large cysts or lesions adjacent to critical structures (nerves, sinuses, tooth roots).
• Bone remodeling may require a prolonged period (12–24 months in some reports). 
• Long-term follow-up is necessary to monitor recurrence or residual defects.

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Minimally invasive surgical management of jaw cysts can be achieved through carefully planned and executed enucleation, taking into account lesion size and surrounding anatomical structures. In the reported case, enucleation without bone grafting resulted in favorable bone regeneration without complications. To maintain a minimally invasive approach, selective flap design, use of micro-instruments, and minimal removal of non-pathological tissues are strongly recommended. Long-term monitoring remains essential to ensure sustained surgical success and bone healing.

References
Refitia Inayah Putri, drg. Pingky Krisna Arindra, Sp.BMMSubsp.Ped.OM(K), drg. Poerwati Soetji Rahajoe, Sp.BM(K)., Ph.D., Enukleasi pada kista residual: kasus insidental pada pasien usia muda, https://jurnal.ugm.ac.id/mkgk/article/download/104869/41677

Author: Rizky B. Hendrawan | Photo: Freepik