Maxilary cystectomy in patient treated with new oral anticoagulants: a case report

OBJECTIVES The aim of this case report is to present the management of a patient on direct oral anticoagulant therapy (DOAC) and undergoing enucleation of an upper jaw cystic lesion. The most recent literature regarding the treatment of patients on anticoagulant therapy is also reviewed, with more emphasis on the management of intra-operative bleeding. MATERIALS AND METHODS A 90 -year -old patient on apixaban therapy underwent outpatient surgery for enucleation of radiolucent lesion of the upper jaw. Intra-oral clinical examination revealed the presence of a palatal swelling starting from the central incisor of the left upper hemiarch and extending to the ipsilateral second premolar, asymptomatic and of elastic consistency, approximately 4 cm in size. Orthopantomography of the dental arches showed a unilocular radiolucent lesion with well-defined margins of about 3 cm major axis, originating at element 2.4 and extending up to the level of elements 2.1, 2.2, 2.3. Surgery to enucleate the lesion under local anesthesia was then planned and performed and, in accordance with the guidelines issued by the European Society of Cardiology (ESC) in 2021, without suspending ongoing apixaban-based anticoagulation therapy. The following surgical steps were performed: local anesthesia, staging of a triangular mucoperiosteal flap with mesial discharge to element 2.1, extended intrasulcularly to element 2.7, soft tis sue debridement, dislocation and avulsion of elements 2.1, 2.3, 2.4, 2.5, 2.6 and 2.7, which was followed by enucleation of the cystic lesion and subsequent revision of the residual bone cavity. No clinically relevant intraor post -operative hemorrhage occurred. RESULTS The outcome of histopathological examination confirmed the clinical diagnosis of odontogenic root cyst. Post -operative clinical and radiographic follow-up showed progressive healing of hard and soft tissues in the absence of infectious and hemorrhagic complications. CONCLUSIONS The treatment of choice for odontogenic cysts of the maxillae is surgical enucleation of the lesion, sometimes associated with avulsion of the involved dental elements. In dental procedures with hemorrhagic risk, in agreement with recent literature, it appears unnecessary to suspend current therapy with direct oral anticoagulants. CLINICAL SIGNIFICANCE In the context of oral surgery, failure to discontinue direct anticoagulant therapy results in an increased risk of intra-operative bleeding, which, in most cases, can be managed through local hemostatic maneuvers.