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British Journal of Oral and Maxillofacial Surgery xxx (2019) xxx–xxx

Percutaneous cryoablation of benign bony tumours of the

mandible
L. May a,∗ , J. Blatter a , P. Bize b , G. Tsoumakidou c , A. Denys c , M. Broome a
a Department of Oral and Maxillofacial Surgery, CHUV, Lausanne, Switzerland
b Department of Diagnostic and Interventional Radiology, Clinique de Genolier, Genolier, Switzerland
c Department of Diagnostic and Interventional Radiology, CHUV, Lausanne, Switzerland

Accepted 31 October 2019

Abstract

Treatment of bony tumours of the oral and maxillofacial area usually involve resection. However, access to certain areas may be difficult
because of the size or site of the tumour. A poor view of the lesion during operation is another limiting factor, which can lead to incomplete
resection in difficult cases. Percutaneous cryoablation is a common procedure for treating benign and malignant bony lesions outside the
oral and maxillofacial area, but has to our knowledge never been used as a stand-alone treatment as we describe here. In 2016, three patients
with benign bony tumours of the mandible (one a keratocyst, one an angiofibroma, and one a giant cell granuloma) were treated with one
session of percutaneous cryoablation. Outcomes were monitored with computed tomography or magnetic resonance imaging at one year.
No patient had a procedure-related complication, and there were no other complications. Radiological controls showed complete recovery.
Percutaneous cryoablation seems to be an interesting and valuable alternative to resection for bony lesions with its limited access and high
operative morbidity.
© 2019 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: bone tumours; cryoablation; tumours of the oral and maxillo-facial area

Introduction lesions. Adjuvant treatments are rarely used for these benign
tumours.
The maxillofacial region can be affected by a wide range Since the first report of tissue destruction by freezing by
of benign but locally recurrent and aggressive bony lesions Arnott in 1851,1 Emmings et al2 and Marcove and Miller3
such as ameloblastomas, myxomas, odontogenic keratocysts, studied the technique in canine mandibles and in primary and
central giant granulomas, and other fibro-osseous lesions, and metastatic bone tumours, respectively. Sippel and Emmings
there are many ways to treat them. reported the first use of cryotherapy in the management of pri-
Recommendations range from aggressive surgical options mary maxillofacial tumours of bone in 1969 for the treatment
such as “en bloc” resection, to simple enucleation or less of a recurrent ossifying fibroma of the mandible.4
invasive procedures such as marsupialisation of large cystic Since then, several studies have reported successful
combination treatments of ameloblastomas,5–7 myxomas,8,9
keratocystic odontogenic tumours,10–12 and central giant cell
lesions5,9 consisting of enucleation or curettage followed by
∗ Corresponding author at: Department of Oral and Maxillofacial Surgery, cryotherapy. One must, however, differentiate cryotherapy as
CHUV, 46 rue du Bugnon, 1011 Lausanne, Switzerland.
E-mail address: laurence.may@chuv.ch (L. May).

https://doi.org/10.1016/j.bjoms.2019.10.316
0266-4356/© 2019 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: L. May, J. Blatter, P. Bize et al.. Percutaneous cryoablation of benign bony tumours of the mandible. Br
J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.10.316
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Fig. 1. Recurrence of an odontogenic keratocyst of the ascending ramus. Fig. 2. Treatment of the odontogenic keratocyst of the ascending ramus
with percutaneous introduction of a cryoprobe under direct computed tomo-
graphic guidance.
described above from the cryoablation that we describe in our
cases.
Cryotherapy is the injection, or application of soaked
tissues, of frozen liquid (such as nitrogen), whereas cryoab-
lation is the application of probes that are cooled down to
a desired temperature in the centre of the lesion. Cryoab-
lation as we describe it has been used in the treatment of
peripheral bony lesions, but to our knowledge no one has
described its outcome when used alone for bony lesions in
the maxillofacial area.

Case reports

Between March and November 2016 three patients were

treated at the University Hospital, Lausanne, for benign
osseous tumours of the ascending ramus and condyle.
Cryoablation was done under conscious sedation and local
Fig. 3. Reossification of the odontogenic keratocyst of the ascending ramus
anaesthesia by interventional radiologists, and patients were one year after treatment.
followed up clinically and radiologically.
lesions through a lateral approach (Fig. 2), and followed by
Case 1 two freezing cycles (six minutes each) separated by two active
thawing cycles (four minutes each). There was no pain and
The first patient was a 42-year-old woman who presented no procedure-related complication (Fig. 3).
with a recurrent 9 mm odontogenic keratocyst of the right
ascending ramus. The lesion consisted of two coalescent Case 2
cystic lesions of 1 cm each. Initially, this lesion was 31 mm
in diameter and was first diagnosed and biopsied six years The second patient was a 19-year-old boy with a 9 mm oste-
before. It was treated with marsupialisation because of its olytic bone tumour associated with a pathological fracture of
size, followed by enucleation after six months. The first recur- the left mandibular condyle that was diagnosed on a max-
rence occurred after two years, and was excised. A second illofacial computed tomographic (CT) scan after a fist punch
recurrence presented at follow-up after five years, this time (Fig. 4). The lesion was biopsied under CT guidance and con-
in a surgically challenging area associated with high morbid- firmed to be a giant cell tumour. Treatment options comprised
ity (Fig. 1). Less invasive treatment with cryoablation was cryoablation, condylectomy, repeated intralesional corticoid
therefore chosen. injections, and nasal calcitonin injections, and the decision
Under conscious sedation after local anaesthesia, two Ice to proceed with cryoablation was taken to avoid articular
Seed cryoprobes (Galil Medical) were inserted into the cystic disorders after condylectomy or repeat procedures.

Please cite this article in press as: L. May, J. Blatter, P. Bize et al.. Percutaneous cryoablation of benign bony tumours of the mandible. Br
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Fig. 4. Giant cell tumour with a pathological fracture of the left mandibular Fig. 5. Reossification of the giant cell tumour with a pathological fracture
condyle. of the left mandibular condyle one year after cryotherapy.

Discussion

The procedure was done under local anaesthesia. A 14G Cryoablation is an accepted treatment for palliative or cura-
Bonopty® (ApriomedAB) access needle was advanced under tive destruction of a tumour.13 It uses the freezing temperature
CT guidance to the bony orifice left from the biopsy. Through to induce a specific tissue response.14 Minor freezing causes
the Bonopty, a 17G Ice Seed cryoprobe was inserted into inflammation, whereas severe freezing results in the destruc-
the centre of the tumour. This was followed by two freez- tion of tissue. The death of cells and tissue is caused
ing cycles of eight minutes, separated by two thawing cycles by intracellular and extracellular formation of ice crystals,
of four minutes. The function of the facial nerve was mon- osmotic and electrolyte disturbances, denaturation of lipid-
itored during ablation. In the hours after the procedure the protein complexes, and vascular stasis.
patient developed a slight facial nerve palsy, which com- Compared with chemical agents such as Carnoy’s
pletely regressed within a few hours. solution15 (fixative composed of 60% ethanol, 30% chloro-
form, and 10% glacial acetic acid with added ferric chloride),
cryosurgery has the advantage of causing cellular necrosis
in the bone while maintaining the inorganic osseous frame-
Case 3 work integrity. Regeneration occurs by sequential necrosis,
osteogenesis, and remodeling, whereas Carnoy’s solution
The third patient was a 18 year old boy who presented with a denatures the inorganic matrix and destroys its osteogenic
right condylar angiofibroma, and was treated under conscious and osteoconductive properties. Unlike the random distri-
sedation and local anaesthesia. Using a lateral approach, two bution of Carnoy’s solution in the tumour, diffusion of ice
Bonopty® bone access needles were positioned in parallel around the cryoprobes has a predictive size and shape that
1 cm apart in the lesion, and two Ice Seed cryoprobes were allows precise planning of treatment. CT scans and MRI may
inserted coaxially into the tumour. This was followed by two be used to monitor the diffusion of ice, which provides the
freezing-thawing cycles identical to case 2. advantage of a 3-dimensional image.
The main theoretical complication is the increased risk of
fractures as a result of the bony necrosis, as freezing weakens
the bone until it reossifies during the following months.16,17
Results A second complication might be neurosensory changes if the
cryoprobe is applied too close to a nerve.17 These may also
None of the three patients had any persistent or late postop- occur while using other treatments of the same lesions, such
erative complications. The clinical examinations showed no as marsupialisation, curettage, enucleation (with or without
signs of recurrence, and radiological images (CT) at one year the use of chemical agents such as Carnoy’s solution), and
showed reossification of all three lesions (Figs. 3 and 5). “en bloc” resection. All these other options are also far more
The only complication noted was in case 2 who developed invasive than cryoablation with increased risks of bleeding,
a slight facial nerve palsy after the procedure that completely infection, injury to adjacent anatomical structures, and scar-
regressed after a few hours. ring. Larger series are essential to compare cryoablation with

Please cite this article in press as: L. May, J. Blatter, P. Bize et al.. Percutaneous cryoablation of benign bony tumours of the mandible. Br
J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.10.316
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in the online version, at doi:https://doi.org/10.1016/j.bjoms.
2019.10.316.

Please cite this article in press as: L. May, J. Blatter, P. Bize et al.. Percutaneous cryoablation of benign bony tumours of the mandible. Br
J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.10.316