1) Cysts are pathological cavities that can form in hard or soft tissues and may contain fluid, semisolid, or gaseous material. 2) Cysts are generally classified as intraosseous or soft tissue cysts, and epithelial or non-epithelial cysts. 3) Common intraosseous cysts include odontogenic cysts like dentigerous and radicular cysts arising from dental tissues, and non-odontogenic cysts such as nasopalatine duct cysts arising from other epithelial tissues.

1. CYSTS OF ORAL AND
MAXILLOFACIAL REGION
Dr Ranjith Kalliath

2.  Cyst is a pathological cavity within
the hard and soft tissue and that may
contain fluid, semisolid or gaseous
material; which may or may not lined
by epithelium, fibrous tissue or
occasionally even by neoplastic
tissue.

3.  1)Intraosseous cyst
2)Soft tissue cysts
 A) Epithelial cyst
a. Odontogenic cyst
Developmental
Inflammatory
b. Non odontogenic
B) Nonepithelial cyst
C) Cyst of maxillary antrum

4.  1)Odontogenic
a) Developmental
Primordial cyst (Keratocyst)
Dentigerous cyst (follicular)
Periodontal cyst
Calcifying odontogenic cyst
 b) Inflammatory
Radicular cyst
Residual cyst

5. 2. Non odontogenic
a) Fissural cyst
Median mandibular cyst
Median palatal cyst
Globulomaxillary cyst
b) Incisive canal or nasopalatine duct
cyst

6.  II. Nonepithelial cyst
Solitary bone cyst
Aneurysmal bone cyst
Stafne bone cyst
 Cyst of maxillary antrum
Surgical ciliated cyst of maxilla
Benign mucosal cyst of the maxillary
antrum

7.  SOFT TISSUE CYST
A) Odontogenic
i) Gingival cyst
a) Adult
b) Newborn
B) Nonodontogenic
i) Anterior median lingual cyst
ii) Nasolabial cyst
C)Salivary gland cyst
Retention cyst
a) Mucocele
b) Ranula

8. D) Developmental congenital cysts
i) Dermoid & Epidermoid cyst
ii) Lymphoepithelial cyst
iii)Thyroglossal duct cyst
iv) Cystic hygroma
E) Parasitic cyst
i) Hydatid cyst
ii) Cysticercosis
F) Heterotropic cyst
Oral cyst with gastric or intestinal epithelium.

9. Primordial cyst (Keratocyst)
 Robinson first popularised the term
primordial cyst.
 Arise from
 1) Primordial odontogenic epithelium
ie, from dental lamina or its
remnants.
 2) Odontogenic basal cell herniation
/ enamel organ, prior to the
formation of calcified structure, thus
this cyst is found in place of tooth.

10.  Term keratocyst coined by Philipson
because of histologic appearance.
 Both parakeratinized and
orthokeratinized.
 Incidence:
 occurs in 2nd ,3rd & 4th decade.
 more commonly in male.

11.  Site: More in mandible than maxilla.
In mandible, 1/2 involve the angle of
mandible extending into ascending
ramus.

12. Clinical features
 Small cyst detected by accidental
radiograph.
 Extension along the marrow cavity
then only expansion of the bone
occurs.
 Enlargement of cyst causes
displacement of teeth and teeth
overlying the cyst produces dull or
hollow sound .

13.  Missing tooth from the normal series
teeth will have vital pulp.
 Buccal expansion of bone is common,
lingual and palatal expansion are
rare.
 Large cyst can deflect the
neurovascular bundle.

14.  In acute infection, pus accumulate
within sac and neuropraxia of nerve
result with the onset of labial
parasthesia or anesthesia.
 Associated with NEVOID BASAL CELL
CARCINOMA SYNDROME OR GORLIN
GOLTZ SYNDROME.
 (Plantopalmar keratosis, bifid rib,
basalcell carcinoma, skeletal
abnormality)

15. Radiologic features
 Can be unilocular or multilocular.
 Borders are either smooth or scalloped -
unilocular.
 Multilocular cyst is one large cyst and small
daughter cyst giving the polycystic
appearance and later it gets fuses with
primary cyst to give multilocular
appearance. Then expansion of buccal and
lingual cortical plate and resorption as well
as perforation of the mandible occurs.

17. Pathogenesis
 Developmental anomaly of
odontogenic epithelium.
Main source being
 -Dental lamina or its remnants.
 -Basal cells from the overlying oral
mucosa.
 -enamel organ - by degeneration of
stellate reticulum.

18.  Cyst contents
Dirty white viscoid suspension of
keratin. Total protein below 4
gm/100ml.
 PATHOLOGY
Lined by thin walled stratified
squamous epithelium. Keratin is of
orthokeratin,
 Parakeratin (higher recurrence).

19. TREATMENT
 Marsupialization is incorrect because
of higher incidence & tendency to
recur.
 a. Small single cyst with regular
spherical outline,should be
enucleated from an intra-oral
approach.

20.  b. Large or less accessible cyst with regular
spherical outline should be enucleated from
an extra oral approach
 Unilocular lesions with scalloped or lobulated
periphery and small multilocular lesions
should be treated by marginal excision, ie,
resection of the containing block of bone
while maintaining the continuity of the
posterior and inferior borders as in the
ascending ramus, angle and body of
mandible.

21.  If there is difficulty to access, extra
oral exposure is necessary.
 If the cystic lining is found to be
adherent and is contiguity with
overlying oral mucosa, it should be
excised along with marginal excision.
 The defect is closed primarily and can
be left to heal by secondary intention
or can be filled with hydroxyapatite
cystals

22.  Large multilocular lesions with or
without cortical perforation.
May require resection of the involved
bone followed by primary and
secondary reconstruction with a
choice of reconstruction plates.

23. DENTIGEROUS CYST /
FOLLICULAR CYST
 Due to enlargement of follicular space
of the whole or part of the crown of
an impacted or unerupted tooth and
is attached to the neck of the tooth.
 - Paget coined the term.
 - Incidence :most commonly seen but
less than the apical types.

25.  Common in 1st ,2nd and 3rd
decades.
 More commonly seen in males.
 Mandible > maxilla.
 Mandibular 3rd molar > upper
cuspids > maxillary 3rd molar.

26. Clinical features
 Affect adult dentition or supernumerary
teeth.
 Teeth will be missing. Adjacent teeth may
fail to erupt or tilted by the cyst.
 Cyst cause expansion of bone and thinning
of bone.
 Fragile outer shell of bone become
fragmented and a sound is produced called
egg shell crackling.

27. Radiographic features
 - Unilocular radiolucency associated with
crown of impacted teeth with well defined
sclerotic border unless infected the margins
are poorly defined.
 - Pressure of cyst causes the unerupted
teeth to push away from direction of
eruption.
 eg:- lower third molar may be pushed to
the inferior border or into the ascending
ramus. It has a greater tendency to cause
root resorption. Multiple cyst seen in
cleidocranial dysplasia.

28. Pathogenesis
 Develop due to the accumulation of
fluid between reduced enamel
epithelium of unerupted or impacted
teeth.
 A width of 3-4 mm is considered as a
cyst,can also occur as a result of
degeneration of stellate reticulum.
 Cystic contents : clear yellow fluid,
cholesterol crystal or purulent if
infected.

29. Pathology :
 Mural thickening which exhibit
ameloblastic change.
 cyst lining is reduced enamel
epithelium 2-3 layer thickness.
 Epithelium contains hyaline bodies.
 Cholesterol clefts in connective tissue.

31. Treatment
Based on the size of cyst, two approaches
1.Extra oral approach
2.Intra oral approach
 Marsupialization (Partsch surgery) in
children when cyst is large in size.
Enucleation
 In adult cyst enucleated with
involving tooth.
 Complication: Pre ameloblastic
lesions.

32. DEVELOPMENTAL LATERAL
PERIODONTAL CYST
 Found lateral to the roots of vital
tooth.
 Etiology – inflammatory.
 Incidence - in adults.
 Site - mandible, cuspids, bicuspids
and molars.

33. Clinical features –
 associated vital teeth, buccal & lingual
gingival swelling. The lingual type of
mandibular 3rd molar can cause
submandibular space infection.
 Radiographic features
 Reveals a well defined round or ovoid
radiolucency with a sclerotic margin.
 Lamina dura of involved teeth destroyed.
 Present between cervical margin & apex of
the root.

34.  Pathogenesis
from reduced enamel epithelium
,remnants of dental lamina, cell rests
of malassez .
 Treatment – Enucleation.

35. BOTRYOID ODONTOGENIC CYST
 Variant of the lateral periodontal
cyst .Resemble bunch of grape hence
the term botryoid.

36. CALCIFYING EPITHELIAL ODONTOGENIC CYST
(CEOC) GORLIN CYST
 Less common.
 No sex predilection, more in children
and young adult.
 Clinical features :
 swelling is the most frequent
complaint .Peripheral and intra-
osseous lesions which produces bone
swellings.
 When it arise close to periosteum it
produces a saucer shaped depression.

37. Radiologic features
 Unilocular or multilocular
radiolucency.
 Periphery may be well demarcated or
irregular calcification seen as radio
opaque flecks (driven snow
appearance).
 Resorption of roots of adjacent teeth.

38. Pathogenesis
 Cyst associated with complex
odontome or unerupted teeth.
 Remnants of dental lamina.
 Stellate reticulum.
 Reduced enamel epithelium.

39. Pathology –
 -stratified squamous epithelium 6-8 cell
thick(ameloblast like cells). In some areas
the lining is thin in patches the epithelial
proliferation, the cells become swollen &
eosinophilic due to a form of
Keratinization.
 These are ghost cells. They undergo
calcification. They are enlarged ballooned
ovoid and having a faint outline of nucleus.
 - Melanin deposition in the epithelial lining.

40. Treatment
 Enucleation.
 If associated with ameloblastic
fibroma wider excision is required.

41. INFLAMMATORY (PERIODONTAL)
 Radicular Cysts
 When arise apically it is termed periapical
(periodontal) radicular cyst.
 When side of root of a pulpless tooth -
lateral (periodontal) radicular cyst.
Developmental lateral periodontal cyst
associated with a vital tooth.
 Periodontal cyst : lateral
 -apical
 -residual

42.  Incidence - Most common of all cysts.
Males are more common.
Peak incidence in 3rd & 4th
decades.
 Sites - Maxillary anterior (since they
are more prone to caries and
trauma).
 Mandibular posterior teeth

43. Clinical features
 slowly enlarges.
 pain when suppuration occurs.
 As the cyst increases in size the covering
bone become thin and exhibits springiness
due to fluctuation.
 If lateral incisor, palatal expansion seen.
 Mandible - lingual expansion rare. Mucosa
overlying the cyst is normal colour initially,
then presence of dialated blood vessel and
finally it will take on a profound dark bluish
tinge in case of large cysts.

44.  sinus tract formation which discharge pus if
infected.
 involved tooth will be non - vital,
discoloured, fractured or with heavy
restoration or a failed root canal.
 sensitive to percussion ,hypermobile or
displaced.
 nerve paraesthesia may occur.
pathologic fractures with large cyst.

45. Radiologic feature
 round, pear or ovoid shaped radiolucency
generally outlined by a narrow radio
opaque margin the extends from the lamina
dura of the involved teeth.
 - In large cyst peripheral white lines is
absent.
 Lateral radicular cyst may be seen in
association with an accessory root canal or
lateral perforation during root canal
therapy.

47. Treatment
 Non-vital teeth that are associated
with the cyst can either be extracted
(depending on condition of sufficient
bone support and restorative
possibilities) or they can be retained
by endodontic treatment and
apicoectomy.
 External sinus tracts should always be
excised to prevent epithelial ingrowth

48. RESIDUAL CYST
Causes
 a) An incompletely removed
periapical granuloma or cyst that
potentially enlarges.
 b) An impacted tooth associated with
a lateral dentigerous cyst is removed
but the cystic lesion is unrecognised
and left in situ, this residual cyst
persists and enlarge.

49.  A cystic lesion develop on either a
deciduous teeth or retained tooth
which either exfoliates or is extracted
without knowledge of the underlying
pathologic process.
 Treatment: Similar to radicular cyst
 Care should be taken to maintain and
preserve the contour of the
edentulous ridge

50. INTRAOSSEOUS CYST OF NON-ODONTOGENIC
EPITHELIAL ORIGIN
 Developmental fissural cyst
 a) Median mandibular cyst
 b) Median palatal cyst
 c) Globullomaxillary cyst
 d) Nasopalatine duct cyst

51. Globullomaxillary cyst
 It arises at the site of fusion of globular
process of medial process and the maxillary
process. Seen between maxillary lateral
incisor & canine.
 Radiologic features –
 Pear shaped radiolucency between
maxillary lateral incisor & cuspid with apex
pointing towards the alveolar crest.
 Careful surgical enucleation followed by
primary suture

53. NASOPALATINE DUCT CYST
 Nasopalatine canal connects the nasal
& oral cavity seen between the
central incisor.
 Salty sensation from the sinus tract.
 Radiologic features
 Heart shaped radiolucency because
of the presence of nasal spine

54. NON ODONTOGENIC
NONEPITHELIAL BONE CYSTS
 Solitary bone cyst
 Traumatic or hemorrhagic bone cyst.
 Etiology :
 Trauma and hemorrhage with failure of organization.
 Abnormal calcium metabolism.
 Chronic low-grade infection.
 Necrosis of fatty marrow secondary to ischemia.
 Clinical features :
 located above the mandibular canal and has a typical
scalloped appearance as it often extends between the
root of the teeth

55. ANEURYSMAL BONE CYST
 Etiology :
History of trauma.
venous occlusion.
More in mandible.
 Clinical features –
firm swelling, teeth may show
displacement ,egg - shell cracking
sound.

56.  Radiologic features
Unilocular radiolucency with internal
ridges of new bone with septal
formation giving honey - comb or soap
- bubble appearance.
 Stafne's idiopathic bone cyst
located below the mandibular canal.

57. RETENTION (Salivary gland)
cyst
 a) Mucocele
 b) Ranula
Mucocele
 True retention cyst
 Mucous extravasation cyst

58. Mucocele
 It is a true retention cyst which is
lined by epithelium and the other is
the mucous extravasation cysts,
which occurs because of the pooling
of mucus. It has no epithelial lining is
surrounded by compressed
connective tissue.

59. Etiology
 obstruction of a salivary duct
 trauma to a salivary duct which is
either pinched or severed.
 Trauma to secretory acini.
 Congenital atresia of submandibular
duct orifices.
 Cystic type of papillary cystadenoma

60.  Incidence
 Commonly seen in minor salivary
glands.
 Site : Majority of mucoceles are seen
to affect the lower lip with the
exception of the anterior half of the
hard palate which is devoid of
salivary gland

61. Clinical features
 They appear as a painless, superficial
well circumscribed swelling on
mucosa.
 Size : 1-2 mm
 Colour is variable, it may be
translucent or bluish.
 The mucocele may rupture
spontaneously with the liberation of a
viscous fluid.

62.  Treatment
 Enucleation of mucocele is frequently
followed by recurrences. They are
best treated by surgical excision
together with associated minor
salivary gland tissue and surrounding
connective tissue. The mucosal
margin are then undermined and
sutured in apposition.

63. RANULA
 Ranula is a mucocele that is present
on the floor of the mouth, beneath
the tongue, owing to its resembles to
a frog's belly it has been termed
'ranula'.
 Two types;
 superficial
 plunging type

64. Etiology
 Extravasation of mucous due to trauma to
the excretory ducts of the sublingual
salivary gland.
 Plunging type,this extravasated mucous
passes through the mylohyoid muscle and
collects in the submandibular region.
 Dialated submandibular ducts could be a
causative factor because of atresia of
submandibular duct orifices.

65.  Clinical features:
 A dome shaped bluish swelling of a
superficial ranula may be seen
located laterally in the floor of the
mouth beneath the tongue.
 The tongue may be raised or
displaced as it enlargers the swelling
may cross midline.

66. Non-odontogenic
developmental cyst of soft
tissue
 a) Dermoid and epidermoid cyst
 b) lymphoepithelial cyst
 1) Branchial cleft cyst
 2) Thyroglossal duct cyst
 3) Cystic hygroma

67. Dermoid Cyst
 Dermoid cysts are developmental
cysts in young adults that are
uncommon in the oral and
maxillofacial area (accounting for only
2% of all dermoid cysts).
 In this region the cysts are mostly
found in the sub-mental triangle
external to the mylohyoid muscle or
in the floor of the mouth oral to the
mylohyoid muscle.

69.  On occasion, a larger cyst will present
both oral and external to the
mylohyoid muscle. Some will occur in
the midline of the tongue or in the
submandibular triangle.
 The cyst presents as a painless
compressible mass, which is movable
unless prohibited by its size. Most are
small, but some have exceeded 12
cm.

70.  They will frequently distend the mucosa so
thoroughly that some of the yellow fluid
contents may be seen.
 When they present in the floor of the
mouth, they displace the tongue upward,
which may interfere with speech. In the
submental triangle, they will create a
double-chin appearance

71.  Dermoid cysts in these locations arise from
epithelial entrapment when the branchial
arches of each side fuse in the midline.
 Because the branchial arches form both
oral and extraoral structures, epithelium
may become entrapped in either location,
resulting in mainly midline dermoid cysts in
either type of structure.
 Because there are other facial areas in
which embryonic processes fuse, one would
expect dermoid cysts to occur in these
locations as well

72.  Orbital dermoid cysts arise in the
naso-optic groove and are commonly
associated with hemifacial
microsomia.
 A dermoid cyst that occurs in the
floor of the mouth will most closely
resemble a ranula.

73.  A dermoid cyst that occurs in the submental triangle
also will most closely resemble a ranula (that is, a
plunging ranula).
 Additional considerations in this location include a
submental space abscess, a thyroglos-sal tract cyst,
cystic hygroma, and lymph node enlargements such
as those found in cat-scratch disease, tuberculosis-
related lymphadenitis (scrofula), and HIV-related
lymphadenopathy.
 A dermoid cyst that occurs in the tongue may
resemble a granular cell tumor, a schwannoma, a
salivary gland tumor, or a rhabdomyoma

74.  Aspiration of the mass reveals its cystic
nature by a return of straw-colored fluid or
a semisolid mixture of keratin and other
cell products.
 Large lesions may be better assessed and
surgically planned by obtaining a CT scan
or an MRI scan.
 A dermoid cyst's CT scan appearance
should suggest a thick wall and a fluid
center.

75.  As suggested by its name, these cysts
contain elements present within the dermis.
 The lining is a kera-tinizing, stratified
squamous epithelium, with keratin present
in the lumen.
 The wall contains skin appendages,
sebaceous glands, hair follicles, and/or
sweat glands. Thus sebum may also be
present within the lumen. The approach to
excision is dictated by cyst location

76.  Large lesions require a wider access, and some
lesions may require both a transoral and a
transcutaneous approach.
 With either approach, removal is difficult because of
the cyst's adherence to surrounding tissues and
occasionally because of its size.
 These cysts tend to become fibrosed to surrounding
tissue, requiring sharp more than blunt dissection.
 Dermoid cyst in the midline of the anterior tongue.
This presentation would usually be associated with an
intact mucosa. Here the ulceration is due to an earlier
biopsy

77. HlSTOPATHOLOGY
 Treatment and prognosis
 Ocular dermoid cysts are sometimes a component of
hemifacial microsornia. Here a dermoid cyst in the
inferior outer quadrant of the left orbit arose from
epithelial remnants of the naso-optic groove.
 Dermoid cyst with stratified squamous epithelial
lining, keratin in the lumen, and sebaceous glands
and hair follicles in the wall.
 A sharp pericapsular excision of a dermoid cyst is
usually required because of its fibrosis to surrounding
tissues

78. Epidermoid Cyst/Sebaceous
Cyst
 Epidermoid and so-called sebaceous cysts
may arise in any part of the facial skin or
neck, but they are most common in the
midcheek and preauricular area.
 They arise more commonly in individuals
with irregular complexions indicative of
active or past acne
 About 80% are painless, solitary masses,
and the other 20% are painful because of
secondary infection

80.  Most are freely movable within the
skin, but some are fixed because of
fibrosis from repeated infections
 Sebaceous cysts arise from hair
follicle epithelium, which includes
sebaceous cells, and/or have the
potential to form sebum on their own

81.  They are believed to be caused by a
plugging phenomenon that results in
the subsequent build-up of sebum
and proliferation of the epithelium.
 Epidermoid cysts are thought to arise
from epithelium in the upper portion
of the pilosebaceous unit and,
therefore, do not produce sebum

82.  Most cases are suspected from the
history of acne and of past cysts with
infections, but less apparent
epidermoid cysts will present in a
manner similar to a lymph node
enlargement.

83.  In various locations, they may be
confused with entities more specific
to that location. In the preauricular
area an epidermoid cyst may
resemble a parotid tumor, in the
midlateral neck a bronchial cyst, in
the midline of the neck a thy-
roglossol tract cyst, and in the
submental triangle a dermoid cyst

84.  Epidermoid/sebaceous cysts are
usually treated when the pain and
swelling related to secondary in-
fection leads the patient to seek
care.While antibiotics to eradicate
staphylococcal organisms and moist
heat will alleviate symptoms over
time, re-infection is common.

85.  It is therefore best to excise such
cysts and to treat the excisional
wound with staphylococcal antibiotic
coverage for a 10-day period.
 The removal of an
epidermoid/sebaceous cyst is usually
more difficult than expected because
of its fibrosis to surrounding tissues

86.  A small elliptical portion of overlying skin
should be excised to include the drainage
point or hair follicle of origin ,The cyst's
adherence to surrounding tissues often
requires meticulous, sharp dissection
 An electrocautery to control small bleeding
points is recommended, as an avascular
pericapsular plane found in many other
cysts is usually not present

87.  If the cyst ruptures during removal, its
complete excision will be more difficult and
less probable.
 If this occurs, injecting the cyst with a
volume of soft tissue liner or alginate will
reinflate it, facilitating its removal.
 The resultant wound should be thoroughly
irrigated and closed in layers, and a
pressure dressing applied.

88.  Antibiotic therapy should continue for 10
days and is recommended to include
coverage of the anticipated staphylococcal
organisms.
 Dicloxicillin (Dynapen.Wyeth-Ayerst), 500
mg by mouth four times daily; cephalexin
(Keflex, Dista), 500 mg by mouth four
times daily; and ciprofloxacin (Cipro,
Bayer), 500 to 750 mg orally twice daily,
are reasonable antibiotic choices for this
indication.

89.  Epidermoid/sebaceous cysts are lined
by keratinizing stratified squamous
epithelium. Sebaceous cells may be
present in the wall and inflammatory
cells and fibrosis may be apparent.
Keratin and/or sebum may fill the
lumen .

90.  PROGNOSIS - True sebaceous cysts
are more recurrent than simple
epidermoid cysts and other cysts
because of their greater difficulty to
remove.
 In addition, new cysts often arise in
the same patient because of a pre-
disposition related to skin anatomy.

91. Epidermal inclusion cysts
 Epidermal inclusion cysts are histologically
defined as cysts of the skin lined only by
stratified squamous epithelium.
 They are caused either by traumatic
implantation of epithelium into the dermis
or by embryonic inclusion.
 From either genesis, the cyst will present at
any age as a smooth, freely movable, pain-
less mass in the subcutaneous-dermal level
of the skin.
 The skin surface will be intact, with no
apparent drainage poin

93.  Epidermal inclusion cysts are
diagnosed and treated by simple
pericapsular excision without the
need to excise overlying epithelium.
 The only major surgical consideration
is the placement of the incision: ei-
ther a natural skin crease or a resting
skin tension line produces a minimally
noticeable scar

94.  Epidermal inclusion cysts are lined by
keratinizing stratified squamous
epithelium.
 The wall is fibrous, and as the name
suggests, there is a resemblance to
the epidermis because no skin
appendages are present.
 Keratin typically fills the lumen

95.  Epidermal inclusion cysts only rarely
recur because of their uncomplicated
complete removal, unlike sebaceous
cysts, which often recur from the
residual lining of an incompletely
removed cyst, or from new cysts
arising in predisposed individuals

96. Branchial Cyst
 The branchial cyst will usually arise rapidly
(I to 3 weeks) as a mass in the neck just
anterior and deep to the
sternocleidomastoid muscle at the level of
the carotid bifurcation.
 Less commonly, some cysts will develop
higher along the sternocleidomastoid
border, appearing in the preauricular-
parotid area, or lower along the
sternocleidomastoid border, appearing in
the supraclavicular area.

98.  Most arise in preteens, teenagers, and
young adults and are preceded by an upper
respiratory tract infection.
 Branchial cysts often attain a very large
size (exceeding 8 cm) and do not move
with head motion or upon swallowing .
 They will feel firm and, although not fixed,
they also are not readily movable.

99.  Many will be painful or at least tender
to palpation since their stimulus is
related to inflammation, Rare cysts
will be overtly infected and may
present with a draining cutaneous
fistula

100.  Branchial cysts are believed to be related to
residual or buried epithelium from the
branchial clefts;
 hence the name sometimes used is
branchial cleft cyst.
 The fact that they occur at the three levels
of the branchial clefts and that at any level
they have a residual tract leading to the
pharynx supports this concept.

101.  Those that arise at the carotid bifurcation
level are thought to be related to the
second branchial cleft, which is the biggest
and deepest cleft.
 An alternative theory of origin is that
epithelium of salivary origin becomes
embryonically entrapped within cervical
lymph nodes and later undergoes cystic
degeneration.
 The histopathologic finding of lym-phoid
aggregates in these cysts would seem to
support this theory.

102.  This theory alone does not adequately
explain the association with pharyngeal
infection or the pharyngeal sinus tract
associated with this cyst
 Lesions similar to the branchial cyst, called
lymphoepithelial cysts, occur in the floor of
the mouth and in the parotid gland.
 They are identical in their histopathology
and probably arise from entrapped epithe-
lium in these locations as well

103.  Those in the floor of the mouth tend to be
less than I cm and readily ex-cisable.
 Those in the parotid gland may be 2 to 5
cm and require superficial parotidectomies
 A large, firm mass in the neck in this
location always suggests the possibility of
metostot/c squomous cell carcinoma

104.  A CT scan reveals the thick, hyperdense
wall and fluid-filled, hypodense lumen of a
branchial cyst.
 Its location, deep to the
sternodeidomastoid muscle and superficial
to the carotid sheath, is also seen on the
scan
 Branchial cyst (lymphoepithelial cyst) with
stratified squamous epithelial lining and
lymphoid tissue in the wall. A germinal
center is present.

105.  The lining of a branchial cyst is usually a
stratified squamous epithelium, although
sometimes it is pseu-dostratified and
columnar and occasionally ciliated.
 The lining can be ulcerated.The fibrous wall
contains prominent lymphoid tissue, which
often has well-developed germinal centers.
 In most cases, the lymphoid tissue is in
close proximity to the epithelium.These
histologic features are diagnostic

106.  Branchial cysts are excised and their
residual tract ligated.
 The cyst is approached with a horizontal
neck incision in the closest natural skin
crease over the prominence of the mass
 The cyst is found deep in the cervical fascia
and is deep to the platysma muscle.
Positioned anterior to and lying upon the
carotid sheath, the cyst is readily separable
from its surrounding tissues.

107.  If the cyst is perforated and deflates,
making its removal more difficult, the
cavity may be injected with a soft tissue
liner or alginate to re-inflate it.The return of
contour assists the technique of blunt
pericapsular dissection required for removal
 However, unlike the easily torn lining of the
thyroglossal tract cyst, the branchial cyst
has a very thick wall that is not easily torn,
and therefore this maneuver is rarely
needed

108.  With the carotid sheath and the
sternodeidomastoid muscle retracted
posteriorly, a tract may be found to course
from the cyst through the carotid
bifurcation to the lateral pharyngeal wall.
 This tract is ligated as deep as possible
before the cyst and a portion of its tract are
delivered.
 The resultant wound is usually drained
because of the dead space it represents.

109.  The patient is also treated with a 10-day course of
antibiotics to eradicate any pharyngitis and to reduce
the population of the pharyngeal flora.
 Aqueous penicillin G, 1.2 million U intravenously every
6 hours, is usually used until discharge,
 followed by oral phenoxymethyl penicillin , 500 mg
four times daily for 5 to 7 more days.
 In the penicillin-allergic patient, erythromydn, I g
intravenously every 6 hours until discharge, is
suggested followed by erythromydn ethyl
succinate,400 mg three times daily for 5 to 7 more
days.

110.  Branchial cysts are permanently
eradicated by surgical excision
 Rarely, a recurrence may develop at
another level, which probably
represents a new cyst.A rare
carcinoma within or associated with
the cyst has been reported.

111. Thyroglossal Tract Cyst
 The thyroglossal tract cyst is the
most common cyst found in the neck.
 It will often be preceded by an upper
respiratory tract infection and has a
rapid ascendancy of 2 to 4 weeks.
 Most (60%) occur in the midline over
the thyrohyoid membrane.

113.  About 15% occur slightly off the
midline and may, therefore, prevent
the clinician from considering a
thyroglossal tract cyst
 About 2% will arise within the tongue
itself deep to the foramen cecum.
 The remainder (23%) will occur in the
midline below the level of the
thyrohyoid membrane

114. Differential diagnosis
 Most cysts will be doughy,.round masses
with a smooth, rounded surface.
 Because they are often stimulated by an
upper respiratory tract infection, many are
tender to palpation, some are painful, and
others may be overtly infected with a
cutaneous fistula draining pus.
 They will classically move with the hyoid
bone when the patient swallows because
the tract that remains connected to the cyst
also goes through the body of the hyoid
bone

115.  About 60% of thyroglossal tract cysts
occur in adolescents or in adults in
their 20s.
 About 10% occur in children, and
only 30% occur in adults older than
30 years.
 The incidence proportionately
decreases after the age of 30 years.

116.  Thyroglossal tract cysts arise from
stimulated residual epithelial cells from the
descent of embryonic oral epithelial cells
that formed the thyroid gland.
 The source of this dormant epithelium that
becomes activated in later years is the cells
that invaginated from the fetal tongue
area.
 The anterior two thirds of the tongue arises
from the first branchial arch, and the
posterior one third arises from the third
branchial arch.

117.  The second branchial arch between the two involutes.
Before it involutes, the thyroid anlage in the area
destined to become the foramen cecum invaginates
downward at about the fourth week of fetal life.
 The tract courses through the developing hyoid bone
until the tenth week of fetal life and finally comes to
rest at the inferior edge of the developing thyroid
cartilage.
 Involution of the tract as well as the second branchial
arch representation in the oral cavity occurs at this
time. Residual epithelium and even elements of
thyroid gland tissue remain after involution.

118.  The uncomplicated thyroglossal tract
cyst will be strongly suggested by its
rapid development, its mid-line or
near-midline presentation, and its
movement on swallowing

119.  Other midline or paramidline solitary
mass lesions include a lipoma, a
seboceous cyst, a dermoid cyst, or
lesions related to a lymphodenopothy
(which may be related to nonspecific
infections), cat-scratch disease, a
lymphoma

120.  A branchial cyst would not be a
serious consideration because
although it may occur at several
levels in the neck, it is always in the
area of the anterior border of the
sternodeido-mastoid muscle or the
preauricular area and not in the
midline

121. HlSTOPATHOLOGY
 Thyroglossal tract cysts are usually lined
with pseudostratified columnar epithelium
that may be cili-ated.
 They are sometimes lined with stratified
squamous epithelium, especially when the
cyst is located more superiorly.
 The wall frequently contains thyroid follicles
.Malignancy rarely develops, but
adenocarcinomas have been reported

122.  Treatment is performed by a surgical
excision called the 5/strunk procedure.
 The cyst is approached with a horizontal
neck incision in the nearest available skin
fold over the mass.
 The cyst will protrude from between the
two sternohyoid muscles, which are
reflected laterally to increase exposure.

123.  The cyst will have a very thin lining that
can be easily ruptured during a dissection
around its periphery.
 Therefore.it is often useful first to aspirate
the fluid contents and then, while leaving
the needle in place, to inject an equal
volume of soft tissue liner material or
alginate .
 This maneuver, which is appropriate only
for soft tissue cysts, will prevent collapse of
the cystic shape and facilitate a
pericapsular dissection

124.  As'the cyst is separated from its
surrounding tissues, it will remain pedicled
on a stalk (the residual thyroglossal tract)
to the body of the hyoid bone.
 The body of the hyoid is resected and the
residual tract deep to it clamped and
ligated before the cyst, a portion of the
tract, and the body of the hyoid are
delivered.

125.  Removing the hyoid body will not
destabilize the hyoid.The remaining
suprahyoid and infrahyoid muscles attached
to the lesser and greater horns keep this
bone stable, as does the closure, in which
the reflected geniohyoid muscle attachment
from above is sutured to the thyrohyoid
muscle below.
 The remaining wound is drained and closed
in layers.

126.  Because thyroglossal tract cysts are often
initiated by a case of pharyngitis, a full course
of antibiotics, usually oral phenoxymethyl
penicillin , 500 mg four times daily for 10 days,
is recommended.
 Recent experiences with this classic Sistrunk
procedure have indicated that maintenance of
the body of the hyoid is possible without risk of
recurrence.

127.  Today, it is more common to tie off the tract
remnant at the surface of the hyoid bone
rather than to resect the body of the hyoid
bone
 Excised thyroglossal tract cysts rarely
recur.
 The specimen should be carefully inspected
for thickened areas as rare cases of a
malignancy occurring from the lining have
been reported

128. GENERAL PRINCIPLES OF
TREATMENT
Reason for treatment of benign cyst of
the oral cavity;
 Cyst tend to increase in size.
 Cyst tend to get infected.
 Cyst weaken the bone and can cause
pathologic fracture.
 Cyst prevent eruption of teeth.

129. Clinical features :
 Before expansion of the jaw is noticeable,
most cyst are discovered accidently on a
radiograph.
 In case of smooth rounded expansion of the
jaw bones, a cyst should be suspected until
proved other wise.
 A change in the fitting of dentures in the
presence of a swelling should give rise to
the suspicion of a cyst / tumour

130.  Absence of tooth from its place in the
arch suggests the presence of a
dentigerous cyst, particularly in the
young.
 Presence of a carious, discoloured,
fractured or heavily filled tooth
related to the swelling is suggestive
of an apical periodontal cyst.

131.  Tilting of the crown of the teeth
suggest that their roots have been
displaced by the expansion of a
cyst/tumour.
 fissural cyst are small in size.
 OKC are most seen in the lower 3rd
molar and extend into the ramus.

132.  Infected cyst may be painful, tender
swelling with discharging sinus.
 Egg shell cracking is the term used to
describe the fragile outer shell of bone that
has thinned out due to the expansion and
sensation and sound produced is like egg
shell cracking.
 Fluctuation is elicited when cyst living lies
beneath the mucosa.

133. Diagnosis
 1. Vitality of tooth
 2. Radiograph
 3. Radio opaque dyes
 4. Aspiration
 5. Biopsy

134. OPERATIVE PROCEDURE
 Basic method for treatment of cyst;
 1.Marsupialization (decompression) .
 Partsch I
 Partsch II (combined mrasupialisation
and enucleation).
 Marsupialisation by opening into nose
or antrum.

135. Enucleation
 Enucleation and packing.
 Enucleation and primary closure.
 Enucleation and primary closure with
reconstruction / bone grafting.

136. Marsupialization (Decompression)
 Principle:
 Marsupialization (partsch) refers to
creating surgical window in the wall of the
cyst and evacuation of the cystic contents.
This process decreases intra cystic pressure
and promotes shrinkage of cyst and bone
fill. The only portion that is removed is the
piece removed to produce the window.

137. Indication
 (a) Age :-
 In a young child, with developing
tooth germs or when development of
displaced tooth has not progressed,
enucleation would damage the tooth
buds. In the elderly debiliated
patient, marsupialization is less
stressfull and a reasonable
alternative.

138.  (b) Proximity to vital structure
 Cyst will create a oronasal or
oroantral fistula, injure neurovascular
structure or damage vital teeth.
 (c) Eruption of teeth
 In young patient with dentigerous
or OKC, marsupialization will permit
the eruption of the unerupted teeth

139.  (d) Size of cyst
 In very large cyst, enucleation
could result in a pathological fracture.
 (e) Vitality of teeth
 When pieces of many adjacent
erupted teeth are involved within a
large cyst. Enucleation could
prejudice the vitality of these teeth

140. Advantages
 Simple procedure.
 Spare vital structure.
 Allows eruption of teeth.
 Prevents oronasal / oroantral fistula.
 Reduce operating time.

141.  Reduce blood loss.
 Helps shrinkage of cystic lining.
 Allows endosteal bone formation to
take place.
 Alveolar ridge is preserved.

142. Disadvantages
 Pathologic tissue is left in situ.
 Histologic examination of entire cystic
lining is not done.
 Prolonged healing time.
 Inconvenience to the patient.
 Prolonged follow up visit.

143.  Regular irrigation of cavity.
 Periodic changing of pack.
 Secondary surgery may be needed.
 Formation of slit like process that
may harbor food stuffs.
 Risk of invagination and newcyst
formation.

144. Surgical technique
 Partsch - I
 Anesthesia : GA/LA
 Incisions : Types
 A circular ,oval or elliptical incision can
be taken, 1 cm or larger in size leaving a
margin of 0.5 - 1 cm from the gingival
margins of the teeth or alveolar crest in
edentulous patient.
 or

145.  Inverted U shaped incision can be taken
with a broad base towards the buccal
sulcus the mucoperiosteum is then
reflected
 Removal of bone
 When the bone is expanded and thinned
out, initial incision extended through the
mucoperiosteum, bone and cystic lining
into the cystic cavity. The cystic, lining and
cavity are submitted for histologic
examination.

146.  Thick bone : When overlying bone is thick,
bar holes are drilled in a circular shape,
which are then connected and the overlying
bone is removed carefully with a pair of
rongeurs or mosquito forceps.
 Removal of cystic lining specimen
 Cystic lining is then removed by stabbing
the scalpel through the lining against the
bone edge. Visual examination of residual
cystic lining is done.Then irrigation of cystic
cavity.

147.  Suturing : The cystic lining is sutured with the edge of
oral mucosa by continuous suture or interrupted
sutures
 Packing
 Cavity is filled with ribbon gauze which is
impregnated with an antibiotic ointment. The pack
helps to prevent contamination of the cavity with food
debris and also provides coverage of the wound
margin. The pack is left in the site for 7-14 days. By
the end of 2 weeks, the junction between the lining of
the cyst and oral mucosa around the periphery of the
window would have been healed.

148.  Maintenance of cystic cavity
 Careful instruction are given to the patient
regarding cleansing and irrigation of the
cavity by regular flushing with an oral
antiseptic rinse, with a disposable syringe.
 Use of plug
 A plug may be designed to prevent the
contamination of the cystic cavity and
preserve the patency of the cyst orifice.

149.  Healing
 The cavity may or may not obliterate
totally with time, some degree of a
permanent depression remains in the
alveolar process.

150. Modification of Marsupialisation
 Waldron's method or partsch II. This
is a two stage technique that
combines the two standard
procedures in which, first
marsupialization is performed and at
a later stage, when the cavity is
smaller, the procedures of
enucleation to be performed

151.  Indications
 Bone has covered the adjacent vital
structure. Adequate bone fill has
strengthened the jaw to prevent
fracture during enucleation. Patient
find it difficult to cleanse the cavity
for detection of any occult pathologic
condition.

152. Enucleation
 Principle : Enucleation allows for the cystic
cavity to be covered by a mucoperiosteal
flap and the space fills with blood clot which
will eventually organize and form normal
bone (total removal of cystic lesion).
 Indications :
 Treatment of OKC.
 Recurrence of cystic lesions of any cyst
type.

153.  Advantages
 Primary closure of the wound.
 Healing is rapid.
 Postoperative care is reduced.
 Thorough examination of the entire
cystic lining can be done

154.  Disadvantages
 After primary closure, it is not possible to
directly observe the healing of the cavity as
with marsupialisation. In young persons,
the unerupted teeth in a dentigerous cyst
will be removed with the lesion.
 Removal of large cyst will weaken the
mandible making it prone to jaw fracture.
 Damage to adjacent vital structure. Pulpal
necrosis.

155. Surgical technique
 Enucleation and packing
 Done in case when an infected large
cyst, a primary closure would be
unsuccessful and it could lead to a
breakdown of the wound or when there is
difficulty in approximately the wound
edges. In such cases enucleation is
performed and then cavity is packed as in
marsupialization. The wound heals to
granulation tissue until epithelization is
complet

156. Enucleation with primary
closure
 Surgical technique
1.Enucleation of small lesion from an intra
oral approach
 - Incision is carried around the necks of the
involved teeth and the adjoining teeth on
either side.
 -Depending on the location of the cyst,
incision is made buccally or palatally. --
Flap is reflected using a periosteal elevator.

157.  -In cases when sinus tract is present or
cyst has eroded through the cortex and is
lying in contiguity with the periosteal layer,
bone is removed to expose the underlying
cystic lesion.
 -In some cases, a window is already
existing this is expanded with the help of a
ronger.
 -In case where bone is intact, a broad
opening is made with the help of chisel or
mallet.

158.  -Then the underlying cystic lining is
separated and is raised away from the
cavity wall with the help of a curved
curette, the concave surface facing the
cystic lining -care taken to prevent the
rupture of the lining.
 -The cystic content is aspirated so that size
of the sac shrinks and visibility improves.
 -Teeth that required to be removed are
extracted in case of endodontically restored
teeth, apicectomy is done and their apices
are seated.

159.  Bleeding points are arrested with the
help of pressure packs, bone wall,
surgical or diatheomy, would is now
flushed with normal saline.
 -Cavity may be left to heal or packed
with filling material which obliterate
the cavity prior to closure: Eg-
resorbable spores, hydroxyapatite
crystals.

160. Enucleation of large inaccessible mandibular lesion
from an extra oral approach.
 2.OKC or dentigerous cyst that involving the
ascending ramus, body or angle of mandible is best
accessible from an extra oral approach.
Submandibular excision is made.
 Incision extend through the skin and subcutaneous
tissues.
 The periosteum is mused down to bone and the flap
is raised superiorly to expose the underlying bone.
 If a window is not present, a window is created and
expose the cystic lining and enucleation or marginal
excision is done. Tissue sent for histopathological
examination. Any remnants is then curreted.