RANA PRIMENA PARCIJALNE AKRILATNE OPTURATOR PROTEZE U POSTOPERATIVNOM TRETMANU KOŠTANIH DEFEKATA NAKON MARSUPIJALIZACIJE VELIKIH VILIČNIH CISTI EARLY USE OF PARTIAL ACRYLIC DENTURE OBTURATOR IN THE POSTOPERATIVE TREATMENT OF BONE DEFECTS AFTER MARSUPIALISATION OF LARGE JAW CYSTS

1 UNIVERZITET U NIŠU, MEDICINSKI FAKULTET, ODSEK STOMATOLOGIJA, NIŠ, SRBIJA 2 UNIVERZITET U NIŠU, MEDICINSKI FAKULTET, KLINIKA ZA STOMATOLOGIJU, ODELJENJE ORALNA HIRURGIJA, NIŠ, SRBIJA 3 UNIVERZITET U NIŠU, MEDICINSKI FAKULTET, KLINIKA ZA STOMATOLOGIJU, ODELJENJE ZA ORALNU MEDICINU I PARODONTOLOGIJU, NIŠ, SRBIJA 4 UNIVERZITET U NIŠU, MEDICINSKI FAKULTET, KLINIKA ZA STOMATOLOGIJU, ODELJENJE ZA PROTETIKU, NIŠ, SRBIJA 5 UNIVERZITET U NIŠU, MEDICINSKI FAKULTET, KLINIKA ZA STOMATOLOGIJU, ODELJENJE ZA DEČJU I PREVENTIVNU STOMATOLOGIJU, NIŠ, SRBIJA


Introduction
Surgical therapy of large jaw cysts often involves partially removing the sac of cysts and cysts decompression or marsupialisation (cystostomy). The operation was described by Partsch in 1892. The intervention is implemented when the size of the bone defect does not guarantee the stability of the blood clot, threatens neighbouring structures, and threatens to fracture of the lower jaw in older patients who are at risk for operation under general anesthesia, and especially in children when it comes to aggressive cystic lesions 1 .
The cut goes along the edge of the future bone defect, removing the surface of the cystic sac and emptying (aspirating) the contents of the cyst. Width flap is inserted into the resulting bone defect or circumferentially excised and sutured to the edge of the bone defect. The cavity is filled with iodoform gauze that is changed in seven days with the previous washing and disinfecting the wound. Later, after a few weeks, making partial acrylic dentures obturator (PADO) is recommended. The simplest prosthesis can be made without teeth, although aesthetically and functionally far better are the ones that include teeth alveoli and the surrounding tissue 2 .
Decrease of cystic wall inflammation, volume reduction and secondary decompression initiate the surrounding of osteoblast activity. Over time, there is a peripheral formation of new bone and gradual reduction in volume of the bone defect. The process of creating a new bone takes a few months or even more than a year depending on the size and shape of the defect. Epiloguе of marsupialisation is metaplasia of cystic epithelia into layered epithelium of the oral cavity or the afterglow of the whole or parts of cystic sac 3 . Subsequent enucleation is associated with aggressive clinical lesions such as odontogenic keratocysts 4 . A decision is made based on histopathological findings.
Iodine gauze in the bone defect within a period of several weeks can cause considerable inconvenience to the patient, one of which is usually pain during its replacement, a strong odour and bad breath. In addition, each substitute iodoform gauze after surgery causes removal of the surface layers of a blood clot and bleeding, which slows epithelialization of the defect.
The aim is to show the successful implementation of early partial acrylic dentures obturator (PADO) in the upper and lower jaw in two patients after marsupialisation large jaw cysts.   U narednom periodu kod oba pacijenta nisu uočene nikakve smetnje i nepravilnosti, u smislu pojave komplikacija ili cističnih recidiva.
The second patient, D. R. was also female, 86 years of age, with unilateral edentulous and cystic lesions that stretched from the first premolar to trigonum retromolar lower jaw on the right side ( Figure 5). In this case, cysts marsupialisation was performed as well (figure 6.), iodine gas was placed , on the seventh day the alginate print was taken and on the tenth day PADO was set ( Figures 7  and 8), which was treated in the same manner as in the previous case. Epithelization occurred on the 23rd day. Complete defect filling with the newly created bone tissue occurred 8 months after surgery. In this case, PADO was adjusted so that it is worn as a definitive prosthesis.
In the forthcoming period, both patients showed no disturbances and irregularities in terms of complications or recurrence of cyst.

Discussion
Large bone cysts in the maxilla and mandible are treated by the open method, because the formation of unstable blood coagulum represents the locus minoris resistentiae for the occurrence of acute infection. The resulting bone defects are major morbidity. They are filled with the iodoform gauze whose task is to prevent secondary bleeding, provide antiseptic effect, prevention of food falling and foreign bodies in the wound, as well as the elimination of the negative impact of the saliva.
However, the iodine gas in a longer time period creates a number of inconveniences to the patient which are reflected in its excessively strong smell, swelling under the action of saliva and prominiranju from the defect which partly prevents and hinders mastication, as well as the build-up of food residue on the surface of the gauze which decomposes and smells. Each new gauze replacement is quite painful for the patient, because the gauze sticks to the periphery and the edges of the defect parafinskom pastom to delimično, ali nepotpuno onemogućava. Iz tih razloga, epitelizacija rane znatno je sporija i često traje duže od mesec dana.
Kao što je već istaknuto, obe naše pacijentkinje nastavile su da nose PAOP kao definitivne proteze. Prethodnim korekcijama, tokom koštanog i mekotkivnog zarastanja, PAOP su dovedene u idealnu poziciju prema okolnim tkivima. Uz odsustvo dekubita, bolova i drugih smetnji, kao i uz naviku (predlog: naviknutost) pacijenta na njihovo nošenje, nije bilo potrebe za izradom novih definitivnih proteza. I drugi autori navode da u The main goal of prosthetic treatment after major surgery in the upper and lower jaw is the rehabilitation of lost structures with advancing the restoration of function of chewing, swallowing and speaking, as well as the improvement in the patient`s appearance 5 . PADO makes a mechanical barrier between the operated and part of the oral cavity. Its smooth surface prevents sticking of the clot and secondary bleeding when doing the toilets and disinfection of the wounds. It prevents the accumulation of fluids and food, contamination of wounds, and causes rapid epithelialization and organization, and consequently wound healing associated with a defect in the bone 6 . Eventually, there is a faster bone healing, i.e., filling of the newly created bone defect.
Early PADO production has a very important role and improves the quality of life of treated patients 7,8 . At the same time, with respect to iodine gauze it shows the following advantages: 1) less trauma in tissue replacement, 2) absence of pain and bleeding, 3) faster wound epithelialization, 4) normal mastication, 5) a lack of odor iodophor 5) acceptable aesthetic, 6) easy to remove and install, 7) reduction of food residue and its decomposition, 8) ease of maintenance of oral hygiene and 9) absence of bad breath. Setting PADO immediately after surgery makes the patient unconscious of surgical deformities, which is very important regarding the psychological side 2 . Recovery time is shorter and allows the patient to return to the community as a functional member 2 .
During the healing process, frequent monitoring and processing of PADO is required. As the defect fills the newly created bone with soft tissue, the PADO surface that fills the cavity cystic defect reduces. In addition to an ideal fit and adjustments early, sometimes you can do other modifications in terms of adding teeth to improve aesthetics, mastication and speech 9 .
As it has already been pointed out, both our patients continued to wear PADO as definitive prosthesis. With corrections during the healing of bone and soft tissue, PADO is brought in the ideal position in relation to the surrounding tissues. With the absence of decubitus, pain and other disorders, as well as with the habit of the patient to their carrying, there was no need to create a new prosthesis. Other authors state that in certain situations PADO can serve as a definitive prosthesis 10 .
Regeneration of bone defects depends on their size. Defects of 3 teeth regenerate for up to 12 months and the damage to more than 3 teeth up to 20 months or more. Defects in the During the healing process, frequent monitoring and processing of Paope is required. As the defect fills the newly created bone with soft tissue, the Paope surface that fills the cavity cystic defect određenim situacijama PAOP mogu poslužiti kao definitivne proteze 10 .
upper jaw regenerate faster than in the lower, due to a better blood circulation and abundant cancellous, as proven in this case 11 . In addition, elongated defects quickly regenerate compared to round, where the clot retraction is pronounced. Bone regeneration lasted five months in the maxilla and eight months in the mandible, which was pretty fast due to their age and size of the defect.

Conclusion
Early PADO development proved to be very effective in terms of improving epithelialization of bone defects after marsupialisation of large jaw cysts. The comfort provided by the absence of the negative impacts sometimes allows its use as a definitive prosthesis, even after the defect is filled with the new bone tissue.