Upon surgical management of two different types of pathological fractures caused by hidden cysts

Aim: Pathological fractures of the maxillary bones are quite rare; they occur when a weakening of the bone is generated by unrecognized bone diseases or surgical practices and so the fracture margin results in close proximity to the lesion. In this paper we describe the different surgical management of two maxillary bone’s fractures related to cysts, in order to promote a new surgical approach. Methods: Examining the CT scan of our rst patient, a 54-year-old woman with a history of accidental trauma, not only a zygomatic-maxillary complex (ZMC) fracture was found, but also an intrasinusal cystic lesion (22.5 x 28.8 mm) that had been expanded massively in the anterior and lateral walls. At rst, alterations in cutaneous sensitivity or damage to eyesight were excluded; subsequently oral antibiotic therapy was prescribed and after 4 days a surgical session in GA was planned. During surgery we recornized that the right buccal cortex of the maxilla was deformed by the lesion. After isolation of the right infraorbital nerve, the maxillary fracture was reduced, xing it with a microplate and titanium screws. Necrotic teeth 15 and 16 were extracted (the apexes were included in the lesion) and the cyst was easily enucleated using the bone gap created by the fracture’s margin. Then the anterior maxillary wall was replaced and, in order to overcome bone fragility, a large titanium plate was xed. The procedure ended with reduction and xation of other fractures and intraoral and cutaneous sutures. Further on, a 21-year old patient came to our observation with a traumatic mandibular fracture resulted from a scuf e. The physical examination excluded paresthesia, but showed altered occlusion and mandibular excursions. OPT and CT showed a left paramedian fracture of the mandible and another one near tooth 38; moreover, as occasional nding, a cyst was detected. After 6 days during surgicery under GA, a full thickness ap, from tooth 33 to 43, was raised and a traditional approach was chosen by opening a vestibular bone trap helped by piezoelectric instrument. Within the endosseous cavity only blood and minimal residuals of soft tissue were found. Finally the bone trap was repositioned, the fractures were reduced using miniplates and xing screws and the ap was repositioned and sutured. At the end of the surgery, an intermaxillary xation was applied and maintained for 15 days. Results: Histological examination of the rst case gave a diagnosis of odontogenic cyst. At 13 days after surgical session the facial symmetry and the physiological eye mobility were restored; the surgical wound was on way of consolidation. The histological examination of the fragments found within the bone de ciency that had caused the mandibular fracture con rmed a diagnosis of SBC. The last check (within 21 days) showed: good stability of the applied titanium plates, optimal healing of hard and soft tissues and physiological mandibular movements. Conclusions: Using the same surgical time to enucleate cyst and reduce a pathological fracture has the rationale to improve postoperative morbidity and prognosis. Therefore, if the more traditional approach has its undoubted value, the opportunity to access the cystic lesions by using the gap caused by the fracture line, the way we decided to approach our rst case, should be, in our opinion, taken into serious consideration in similar clinical and surgical situations.