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Annali di Stomatologia | 2026; 17(3): 704-710

ISSN 1971-1441 | DOI: 10.59987/ads/2026.3.704-710

Articles

Management of benign osteolytic jaw lesions: a systematic review of marsupialization versus enucleation

Sofia Rastelli1, Gian Luca Pancrazi2, Giulia Santamaria2, Alfredo De Rosa2, Paolo Latorre2, Giulia Polli2, Raffaele Vinci2

1Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy

2Dipartimento di Scienze della Vita, della Salute e delle Professioni Sanitarie, Università Link Campus University Roma, Italy

*Corresponding author: Alfredo De Rosa - a.derosa@unilink.it

Article History

Received: May 14, 2026

Accepted; July 15, 2026

Published: July 30, 2026

Abstract

Background

Benign osteolytic lesions of the jaws include odontogenic cysts and selected benign odontogenic tumors. Enucleation and marsupialization/decompression are commonly used surgical approaches, but their relative morbidity and recurrence remain debated.

Objective

To describe lesion characteristics and compare author-reported outcomes after enucleation and marsupialization, with or without subsequent surgery or adjunctive treatment.

Methods

A PubMed search, supplemented by reference-list screening, Google Scholar, and manual searching, identified studies meeting predefined eligibility criteria. The review was prepared with reference to the PRISMA statement [7].

Results

Ninety-two articles describing 4,059 jaw lesions were included. Initial treatment was enucleation in 2,690 lesions, marsupialization in 1,336, and another procedure in 33. Adequate follow-up (≥6 months) was available for 2,401 lesions. Crude recurrence proportions were 87/538 (16.2%) after marsupialization and 285/1,840 (15.5%) after enucleation. Reported infections, immediate postoperative paresthesia, and fractures were less frequent after marsupialization; however, denominators varied substantially across outcomes.

Conclusions

The descriptive pooled data suggest similar crude recurrence proportions and fewer reported short-term complications after marsupialization. These findings do not establish equivalence because lesion histology, treatment protocols, follow-up, and study designs were heterogeneous, and no formal comparative meta-analysis or risk-of-bias assessment was reported. Marsupialization may be considered in selected lesions when primary enucleation is expected to carry substantial morbidity, often as the first stage of a planned two-stage approach.

Keywords: odontogenic cysts; odontogenic tumors; marsupialization; decompression; enucleation; bone regeneration.

Introduction

Benign osteolytic lesions of the jaws comprise a clinically heterogeneous group that includes radicular and dentigerous cysts, odontogenic keratocysts (historically termed keratocystic odontogenic tumors), ameloblastomas, and other benign odontogenic lesions. Their management depends on histology, lesion size, anatomical site, cortical integrity, proximity to teeth and neurovascular structures, patient age, and the anticipated risk of recurrence.

Marsupialization creates a surgical communication between the lesion and the oral cavity, reducing intracystic pressure and allowing progressive reduction of the lesion. It may be used as definitive treatment in selected cases or as a preliminary procedure before secondary enucleation. Published clinical series have documented lesion reduction and favorable long-term outcomes after marsupialization [1–3].

Enucleation consists of complete removal of the lesion and its lining or capsule. It provides a larger specimen for histopathological assessment and may achieve treatment in a single operation. Adjunctive procedures, such as peripheral ostectomy, cryotherapy, or Carnoy solution, are sometimes added for lesions with higher recurrence potential [4–5]. Clinical and histopathological assessment after enucleation has also been described [6]. These adjuncts were grouped with enucleation in the present review.

The objective of this systematic review was to describe the number, location, and histology of benign odontogenic osteolytic lesions and to compare author-reported recurrence, complications, and bone healing after marsupialization/decompression and enucleation. Because these lesions have different biological behavior, the pooled results are interpreted as descriptive rather than as evidence of therapeutic equivalence.

Materials and Methods

Reporting framework and information sources

The review was prepared with reference to the PRISMA 2009 statement [7]. PubMed was searched and the electronic search was supplemented by reference-list screening, Google Scholar, and manual searching.

Eligibility criteria

The eligibility framework was defined using PICOS:

  • □ Population: predominantly adult cohorts with ameloblastoma, odontogenic cysts, or benign odontogenic tumors; studies including more than 15% children were excluded.
  • □ Intervention: marsupialization or decompression, with or without a subsequent surgical procedure.
  • □ Comparator: enucleation, with or without adjunctive therapy.
  • □ Outcomes: morbidity, bone regeneration, and recurrence.
  • □ Study designs: retrospective observational studies and case series; studies reporting fewer than 10 cases were excluded.

Exclusion criteria were animal or in vitro studies; publication before 2000; studies with more than 15% children, syndromic patients, non-odontogenic lesions, non-osteolytic lesions, secondary/revision lesions, malignant lesions, or procedures other than enucleation and marsupialization; and studies reporting fewer than 10 cases.

Search strategy

The author-reported search concept was: (marsupialization OR decompression OR enucleation OR cystectomy OR fenestration OR “pouch procedure” OR “Partsch operation” OR curettage) AND (ameloblastoma OR “odontogenic tumor” OR “odontogenic cyst”). The search yielded 1,373 records, and five additional records were identified from other sources. The screening process is shown in Figure 1.

Reference handling: All references present in the source submission were retained and renumbered sequentially. Where no study-level extraction table was available, the original citation groupings were preserved without inferring additional study-level data.

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Figure 1. Study-selection flow diagram based on the counts reported in the source manuscript.

Study selection and data extraction

Records were screened by title and abstract, followed by full-text assessment. For each included study, the extracted variables were number of lesions, histology, anatomical site (maxilla or mandible), average size, treatment, short-term complications (infection, fracture, and immediate postoperative paresthesia), long-term complications (recurrence and persistent paresthesia), bone regeneration, and follow-up.

For classification purposes, lesions initially treated by marsupialization and subsequently enucleated were assigned to the marsupialization group. Enucleation combined with cryotherapy, peripheral ostectomy, or Carnoy solution was assigned to the enucleation group. This classification reflects the initial treatment strategy but may dilute the effects of subsequent procedures.

Results

Study selection and lesion characteristics

The search identified 1,373 database records and five additional records. After preliminary exclusions, 1,037 records remained for title and abstract screening. Of these, 317 full-text articles were assessed and 92 were included. The full-text exclusion count was reconciled to 225 (317 assessed minus 92 included).

The 92 studies described 4,059 jaw lesions: 2,564 odontogenic keratocysts, 509 dentigerous cysts, 438 ameloblastomas, 365 radicular or residual cysts, 23 myxoid odontogenic tumors, and 160 other lesions. Location was reported for 4,012 lesions: 928 in the maxilla and 3,084 in the mandible; location was not specified for 47 lesions. The source manuscript associated the localization and biological-characterization section with references [8–12].

Initial treatment was enucleation in 2,690 lesions, marsupialization in 1,336, and another procedure in 33. Fifty-three studies provided at least 6 months of follow-up, covering 2,401 lesions: 1,840 treated by enucleation, 538 by marsupialization, and 23 by another procedure.

Recurrence

Among lesions with adequate follow-up, 374 recurrences were reported: 285 after enucleation, 87 after marsupialization, and two after other procedures. The crude recurrence proportions were 15.5% after enucleation and 16.2% after marsupialization (Table 1).

Table 1. Recurrence according to initial treatment.
Initial treatment Lesions with adequate follow-up Recurrences Recurrence (%)
Marsupialization 538 87 16.2
Enucleation 1,840 285 15.5

Short-term complications

Infection data were available for 981 procedures. Infection was reported after 84 of 859 enucleations (9.8%) and two of 122 marsupializations (1.6%) (Table 2)

Table 2. Postoperative infection according to initial treatment.
Initial treatment Procedures with available data Infections Infection (%)
Marsupialization 122 2 1.6
Enucleation 859 84 9.8

Immediate postoperative paresthesia data were available for 1,060 procedures. Paresthesia was reported after 126 of 946 enucleations (13.3%) and after three of 114 marsupializations (2.6%) (Table 3).

Table 3. Immediate postoperative paresthesia according to initial treatment.
c Procedures with available data Paresthesia events Paresthesia (%)
Marsupialization 114 3 2.6
Enucleation 946 126 13.3

Iatrogenic fracture was reported in 23 of 801 enucleations (2.9%) and in none of 114 marsupializations with available data (Table 4).

Table 4. Iatrogenic fracture according to initial treatment.
Initial treatment Procedures with available data Fractures Fracture (%)
Marsupialization 114 0 0.0
Enucleation 801 23 2.9

Long-term paresthesia

Persistent paresthesia was reported in seven of 650 enucleations (1.1%) and in none of 84 marsupializations with available data (Table 5).

Table 5. Long-term paresthesia according to initial treatment.
Initial treatment Procedures with available data Persistent events Persistent paresthesia (%)
Marsupialization 84 0 0.0
Enucleation 650 7 1.1

Bone regeneration and lesion reduction

Five studies, reported as including 143 patients, were identified in the source manuscript as evaluating bone regeneration after enucleation [13–17]. Follow-up intervals and outcome definitions were heterogeneous. The manuscript described three studies as assessing reduction in residual cavity size and two as assessing changes in radiographic density. The two studies with 24-month follow-up were reported to show near-complete radiographic filling of the residual cavity, although the timing and measurement methods were not uniform.

Twenty-four studies, covering 627 patients, were reported to evaluate reduction in lesion size during marsupialization. Follow-up ranged from 4 to 24 months, with an author-reported average of approximately 9 months. Eleven studies evaluating 298 patients at approximately 8–10 months reported an average reduction of 49.5%. The original submission associated this evidence set with references [22–38]. Because studies used either linear dimensions or volume and applied different follow-up schedules, these pooled values should be regarded as descriptive.

Discussion

This review aggregated 92 studies and 4,059 benign osteolytic jaw lesions. Enucleation was the most frequent initial procedure. Among lesions with at least 6 months of follow-up, the crude recurrence proportions were similar: 15.5% after enucleation and 16.2% after marsupialization. These proportions are unadjusted and should not be interpreted as proof of equivalence.

The recurrence estimate for enucleation varied across studies. The source manuscript attributed examples of low and high recurrence to references [18–19] and compared the pooled estimate with the review cited as reference [20]. Because the supplied file did not include a study-level extraction table linking each numerical result to its bibliographic record, these individual attributions should be checked against the authors’ original extraction dataset. Variation is nevertheless expected because recurrence depends strongly on histology, treatment adjuncts, completeness of removal, and follow-up duration.

Reported short-term complications were less frequent after marsupialization. However, outcome denominators were available for only subsets of the total cohort, and complication ascertainment was not standardized. Some patients classified in the marsupialization group later underwent enucleation. Nowair and Eid described postoperative paresthesia after secondary enucleation rather than during the marsupialization phase [21], illustrating the difficulty of assigning complications in staged treatment pathways.

The author-reported bone-healing data support progressive radiographic filling after enucleation and substantial lesion reduction during marsupialization [13–17,22–38]. Histological changes during marsupialization, including reduced epithelial proliferation in odontogenic keratocysts, were also represented in the original reference set. Nevertheless, linear and volumetric measurements, radiographic density indices, and follow-up intervals were not comparable across studies.

Marsupialization may reduce the extent of a later operation and may be particularly useful for large lesions, lesions near the inferior alveolar nerve, lesions associated with thin cortical bone, or patients in whom primary enucleation carries a high risk of fracture or neurological injury. Its disadvantages include prolonged treatment, dependence on patient adherence and cavity hygiene, repeated follow-up, and frequent need for secondary surgery. Enucleation offers definitive tissue removal and a complete specimen but may carry greater morbidity in anatomically complex or extensive lesions.

Limitations

The principal limitations are: use of a single bibliographic database; inconsistent reporting of language restrictions; no reported duplicate independent screening or extraction; no formal risk-of-bias assessment; inclusion of heterogeneous cysts and tumors with different recurrence profiles; grouping of staged marsupialization plus enucleation under the initial procedure; grouping of enucleation with different adjunctive treatments; variable and incomplete follow-up; outcome-specific missing denominators; descriptive pooling without comparative meta-analysis; and absence of a study-level extraction table linking each pooled datum to the included studies. These limitations substantially reduce the certainty of the comparative conclusions.

Conclusions

The author-reported pooled data showed similar crude recurrence proportions after marsupialization and enucleation, while infections, immediate postoperative paresthesia, and fractures were reported less frequently after marsupialization. The evidence does not demonstrate equivalence because the underlying studies and lesions were highly heterogeneous and no risk-adjusted comparative synthesis was performed. Marsupialization should therefore be considered selectively, particularly when primary enucleation is expected to cause substantial morbidity, and may function as the first stage of a planned two-stage treatment. Future studies should use histology-specific cohorts, standardized definitions of complications and bone healing, uniform follow-up intervals, and prospective comparative designs.

References

  • 1. Hasegawa T, Ri S, Kitamura M, et al. Marsupialization of cystic lesions in the jaws: a clinical evaluation of 58 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;88(6):651–656.
  • 2. Nakamura N, Mitsuyasu T, Mitsuyasu Y, et al. Marsupialization for odontogenic keratocysts: long-term follow-up analysis of the effects and changes in growth characteristics. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94(5):543–553. doi:10.1067/moe.2002.128022.
  • 3. de Castro JF, Vargas PA, Lopes MA. Marsupialization revisited: long-term follow-up of 87 cases. Int J Oral Maxillofac Surg. 2005;34(4):396–400.
  • 4. Tong AC, Ng IO, Au FY, et al. Recurrence of odontogenic keratocysts: a comparative study of histopathological and clinical features. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;104(6):788–794.
  • 5. Pogrel MA, Jordan RC. Marsupialization as a definitive treatment for the odontogenic keratocyst. J Oral Maxillofac Surg. 2004;62(6):651–655. doi:10.1016/j.joms.2003.08.029.
  • 6. Ide F, Obara K, Mishima K, et al. Enucleation of odontogenic cysts: a clinical and histopathological study. Oral Dis. 2003;9(6):298–301.
  • 7. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700. doi:10.1136/bmj.b2700.
  • 8. Burioni R, Silvestrini L, D’Orto B, Tetè G, Nagni M, Polizzi E, et al. Could dental material reuse play a significant role in preservation of raw materials, water, energy, and costs? Microbiological analysis of new versus reused healing abutments: an in vitro study. Bioengineering (Basel). 2024;11(6):574.
  • 9. Serratì S, Panzardi I, Margheri F, Chillà A, Torre E, Fibbi G, et al. Urokinase and its receptor in follicular and inflammatory cysts of the jaws. Oral Dis. 2010;16(8):753–759. doi:10.1111/j.1601-0825.2010.01679.x.
  • 10. Suyama Y, Kubota Y, Yamashiro T, Ninomiya T, Koji T, Shirasuna K. Expression of keratinocyte growth factor and its receptor in odontogenic keratocysts. J Oral Pathol Med. 2009;38(5):476–480. doi:10.1111/j.1600-0714.2009.00760.x.
  • 11. Suyama Y, Kubota Y, Ninomiya T, Shirasuna K. Immunohistochemical analysis of interleukin-1 alpha, its type I receptor and antagonist in keratocystic odontogenic tumors. J Oral Pathol Med. 2008;37(9):560–564. doi:10.1111/j.1600-0714.2008.00667.x.
  • 12. Zhang X, Wang J, Ding X, Xing S, Zhang W, Wang L, et al. Altered expression of podoplanin in keratocystic odontogenic tumours following decompression. Oncol Lett. 2014;7(3):627–630. doi:10.3892/ol.2013.1764.
  • 13. Chacko V, Kuriakose S, KS. Conservative management of a case of plexiform ameloblastoma. Dent Update. 2011;38(5):336–338. doi:10.12968/denu.2011.38.5.336.
  • 14. Chiapasco M, Rossi A, Motta JJ, Crescentini M. Spontaneous bone regeneration after enucleation of large mandibular cysts: a radiographic computed analysis of 27 consecutive cases. J Oral Maxillofac Surg. 2000;58(9):942–948; discussion 949. doi:10.1053/joms.2000.8732.
  • 15. Capparè P, Nagni M, D’Orto B, Ferri S, Speroni S, Gherlone EF. Full-arch implant-prosthetic rehabilitation in patients affected by hypertension: a randomized clinical trial at 7 years follow-up. Appl Sci (Basel). 2023;13(3):1712.
  • 16. Zhao Y, Han QB, Liu B. Intracystic negative pressure may promote bone formation around jaw cysts. Shanghai Kou Qiang Yi Xue. 2011;20(2):217–218.
  • 17. Ihan Hren N, Miljavec M. Spontaneous bone healing of large bone defects in the mandible. Int J Oral Maxillofac Surg. 2008;37(12):1111–1116. doi:10.1016/j.ijom.2008.07.008.
  • 18. D’Orto B, Tetè G, Nagni M, Visconti RF, Polizzi E, Gherlone EF. Full-arch implant-prosthetic rehabilitation in patients with cardiovascular diseases: a 7-year follow-up prospective single-cohort study. J Clin Med. 2024;13(4):924. doi:10.3390/jcm13040924.
  • 19. Schussel JL, Stramandinoli RT, Dissenha JL, Avila LF, Sassi LM. Retrospective study of 25 cases of keratocystic odontogenic tumor: epidemiology and treatment. J Contemp Dent Pract. 2011;12(2):100–103. doi:10.5005/jp-journals-10024-1016.
  • 20. Barlattani A Jr, Franco R, Martelli M, Gianfreda F, Ferro R, Basili M, et al. Guided bone regeneration in patients taking bisphosphonates: two case series. Oral Implantol (Rome). 2019;12:194–204.
  • 21. Nowair IM, Eid MK. A modified surgical approach for the treatment of mandibular unicystic ameloblastoma in young patients. J Craniomaxillofac Surg. 2020;48(2):148–155. doi:10.1016/j.jcms.2019.12.013.
  • 22. Rosa A, Franco R, Miranda M, Casella S, D’Amico C, Fiorillo L, et al. The role of anxiety in patients with hereditary angioedema during oral treatment: a narrative review. Front Oral Health. 2023;4:1257703. doi:10.3389/froh.2023.1257703.
  • 23. Nagni M, D’Orto B, De Cunto R, Cattoni F, Vinci R. Implant-prosthetic rehabilitation with immediately loaded post-extractive implants: retrospective clinical cohort study at 18-month follow-up. Appl Sci (Basel). 2025;15(1).
  • 24. Rosa A, Ranieri N, Miranda M, Mehta V, Fiorillo L, Cervino G. Mini crestal sinus lift with bone grafting and simultaneous insertion of implants in severe maxillary conditions as an alternative to lateral sinus lift: multicase study report of different techniques. J Craniofac Surg. 2024;35(1):203–207. doi:10.1097/SCS.0000000000009834.
  • 25. D’Orto B, Baldi C, Bonafede V, Pacifici A, Ianniceli I, Nagni M. Analgesic drugs in dentistry: a narrative review. Ann Stomatol (Roma). 2023;14(1).
  • 26. Barlattani A Jr, Martelli M, Ottria L, Fiorillo L, Cicciù M, Gargari M, et al. Temporomandibular joint and lateral pterygoid muscle: functional considerations. J Craniofac Surg. 2025. doi:10.1097/SCS.0000000000011598.
  • 27. Nakamura N, Mitsuyasu T, Mitsuyasu Y, Taketomi T, Higuchi Y, Ohishi M. Marsupialization for odontogenic keratocysts: long-term follow-up analysis of the effects and changes in growth characteristics. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94(5):543–553. doi:10.1067/moe.2002.128022.
  • 28. Lee H, Lee SJ, Seo BM. Investigation of postoperative complications of intrabony cystic lesions in the oral and maxillofacial region. J Oral Maxillofac Surg. 2019;77(9):1823–1831. doi:10.1016/j.joms.2019.03.022.
  • 29. Nagni M, D’Orto B, Franceschi L, Zizza A, Cotticelli C, Ferrini F. Five-year follow-up study on full-arch implant-prosthetic rehabilitations: evaluation of immediate-load procedures with digital protocols. Eur J Musculoskelet Dis. 2024;13(3).
  • 30. Pogrel MA, Jordan RC. Marsupialization as a definitive treatment for the odontogenic keratocyst. J Oral Maxillofac Surg. 2004;62(6):651–655; discussion 655–656. doi:10.1016/j.joms.2003.08.029.
  • 31. Minervini G, Franco R, Di Blasio M, Martelli M, Gargari M, Bollero P, et al. Prevalence of bruxism in patients affected by epilepsy: a systematic review and meta-analysis. Acta Odontol Scand. 2025;84:155–164. doi:10.2340/aos.v84.42959.
  • 32. Ninomiya T, Kubota Y, Koji T, Shirasuna K. Marsupialization inhibits interleukin-1 alpha expression and epithelial cell proliferation in odontogenic keratocysts. J Oral Pathol Med. 2002;31(9):526–533. doi:10.1034/j.1600-0714.2002.00029.x.
  • 33. Carlesi T, Martelli M, Gargari M, Musumeci F, D’Ercole S, Malagnino VA, et al. Comparative evaluation of four root-end filling materials sealing ability in an in vitro study. J Biol Regul Homeost Agents. 2022;36(2 Suppl 1):189–199. doi:10.23812/j.biol.regul.homeost.agents.202236.2S1.24.
  • 34. D’Orto B, Chiavenna C, Leone R, Longoni M, Nagni M, Capparè P. Marginal bone loss compared in internal and external implant connections: retrospective clinical study at 6-years follow-up. Biomedicines. 2023;11(4):1128. doi:10.3390/biomedicines11041128.
  • 35. Kumar MS, Kumar MH, Vishalakshi K, Sabitha H. Radiographic assessment of bone formation using rhBMP-2 at maxillary periapical surgical defects: a case series. J Clin Diagn Res. 2016;10(4):ZR01–ZR04. doi:10.7860/JCDR/2016/11775.7522.
  • 36. Al-Moraissi EA, Pogrel MA, Ellis E 3rd. Does the excision of overlying oral mucosa reduce the recurrence rate in the treatment of the keratocystic odontogenic tumor? A systematic review and meta-analysis. J Oral Maxillofac Surg. 2016;74(10):1974–1982. doi:10.1016/j.joms.2016.03.043.
  • 37. Oddi C, Collina G, Ceresoli L, Ferri S, Grassi A, Nagni M. Use of the Magnet Mallet in a case of extraction and post-extraction implant-site preparation, in combination with regenerative therapy, in a hypertensive patient: a case report and literature review. Ann Stomatol (Roma). 2023;14(1).
  • 38. Uddin N, Zubair M, Abdul-Ghafar J, Khan ZU, Ahmad Z. Orthokeratinized odontogenic cyst: clinicopathological and radiological features of a series of 10 cases. Diagn Pathol. 2019;14(1):28. doi:10.1186/s13000-019-0801-9.