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  1. 1. PRESENTED BY :DR.NIKIL JAIN P.G. 1ST YEAR CYST Of Oral & Maxillofacial Tissues
  2. 2. CONTENTS  Definition  Classification  Pathogenesis  Clinical examination  Odontogenic cyst  Inflammatory cyst  Conclusion  References
  3. 3. DEFINITION  Killey and kay(1966) – cyst constitutes an epithelium –lined sac filled with fluid or semifluid material.  Fit for odontogenic and fissural cyst but wat about SOLITARY BONE CYST OR STAFNE’S CYST????????????
  4. 4.  Killey and kay (1966) – revised definition”A cyst is an abnormal cavity in hard or soft tissue which is contains fluid, semifluid or gas and is often encapsulated and lined by epithelium.”
  5. 5.  Kramer’s(1974) – A cyst is pathologic cavity having fluid, semifluid, or gaseous contents that are not created by the accumulation of pus; frequently, but not always, is lined by epithelium.
  6. 6. CLASSIFICATION  Various classifications have been given:  Robinson (1945)  Thoma-Robinson-Bernier (1960)  Kruger (1964)  WHO (1971)  Shear (1983)
  7. 7.  According to shear’s -  Cyst of jaws  Cyst associated with maxillary antrum  Cyst of soft tissues of the mouth,face,neck and salivary glands
  8. 8. cyst of jaws Epithelial Non-epithelial Developmental Inflammatory Odontogenic Non-odontogenic
  9. 9.  Odontogenic cyst -  Odontogenic keratocyst  Dentigerous cyst  Eruption cyst  Gingival cyst of infants  Gingival cyst of adults  Developmental lateral periodontal cyst  Botryoid odontogenic cyst  Glandular odontogenic cyst  Calcifying odontogenic cyst
  10. 10.  Non-odontogenic cyst  Midpalatal raphe cyst of infants  Nasopalatine duct cyst  Nasolabial cyst
  11. 11.  Inflammatory origin  Radicular cyst, apical and lateral  Residual cyst  Paradental cyst and juvenile cyst  Inflammtory collateral cyst
  12. 12.  Non-epithelial lined cyst  Solitary bone cyst  Aneurysmal bone cyst  Traumatic bone cyst  Hemorrhagic bone cyst
  13. 13.  Cyst associated with maxillary antrum -  Mucocele  Retention cyst  Pseudocyst cyst  Post operative maxillary cyst
  14. 14.  Cysts of the soft tissue of the mouth ,face and neck –  Dermoid and epidermoid cyst  Branchial cyst  Thyroglossal duct cyst  Anterior median lingual cyst  Oral cyst with gastric or intestinal epithelium  Cystic hygroma  Nasopharyngeal cyst  Thymic cyst  Cyst of salivary glands  Hydatid cyst
  15. 15. PATHOGENESIS OF CYST FORMATION  Odontogenic cyst are derived from odontogenic epithelium of stomodeum Enamel organ Reduced enamel epithelum Remnants of dental lamina(cell rests of serrae) Remnants of hertwig’s root sheath(cell rests of malassez)
  16. 16. PATHOGENESIS Formation of cyst take place in generally three stages :  Initiation  Cyst formation  Enlargement or expansion of cyst cavity
  17. 17. INITIATION  Initiation of cyst formation mostly from odontogenic epithelium  Stimulus which initiates this process is unknown  Factors involved Proliferation of epithelial lining I. Fluid accumulation in cystic cavity II. Bone resorption
  18. 18. CYST FORMATION  Cavity lined by stratified squamous epithelium ???????????????  Shear (1963),Tencate (1972), Harris(1974) , Valderhauge(1974)
  19. 19.  If a cleft produced by accumulation of a purulent exudate in the form of a microabscess involved one of the proliferating strands of epithelium , then the epithelial cells would be expected to line the cleft.
  20. 20. Another mechanism- epithelial cells become oriented in relation to their source of nutrition and the adjacent connective tissue. In normal situation they cover a surface and finally desquamated If the proliferating epitheliun beneath the surface ,as in granuloma ,cells will migrate inwards and desquamate in the center of mass.
  21. 21. ENLARGEMENT  Basic mechanism for cyst enlargement is similar but additional factors involved which differ from type to type  Steps involved:  Attraction of fluid into cyst cavity  Retention of fluid in the cavity  Production of a raised internal hydrostatic pressure  Resorption of surrounding bone with an increase in size of bone cavity
  22. 22.  Harris (1974) classified theories of cyst enlargment:  Mural growth a) Peripheral cell division b) Accumulation of cellular content  Hydrostatic enlargement a) Secretion b) Transduation and exudation  Bone resorbing factor
  23. 23. CLINICAL EXAMINATION  Diagnostic features  Symptoms of cyst  Signs of cyst  Clinical stages of cysts  Secondary effects on jaw  Investigation
  24. 24.  Diagnostic features : Sign and symptoms of a cystic lesion depend on 1. Dimension of lesion 2. Type of cyst 3. Location of cyst 4. Important structures adjacent to cyst 5. Presence of infection in the cyst
  25. 25.  Symptoms of cyst : 1. Pain and swelling 2. Salty taste 3. Difficulty in mastication 4. Ill fitting denture 5. Displaced teeth 6. Space between the teeth
  26. 26.  Signs of cyst : 1. Bone expansion 2. Fluctuant swelling under oral mucosa 3. Non vital tooth(if radicular cyst) 4. Missing tooth 5. Sinus formation with discharge 6. Large cyst distortion of adjacent structures 7. Hollow sound on percussion
  27. 27.  Clinical stages of cyst : 1. Periosteal stimulation : curved enlargement of bone 2. Tennis ball consistency:can be indented on percussion 3. Egg shell crackling :micro cracks on cortical plate 4. Fluctuation :complete resorption of bone overlying the cyst 5. Sinus formation 6. Infection due to contamination from oral cavity
  28. 28.  Secondary effects on jaw due to cyst : 1. Numbness 2. Pathological fracture of jaw 3. Secondary infection 4. Malignant transformation
  29. 29.  Investigation includes : 1. Radiographic examination/C.T. scan 2. Contrast studies 3. Aspiration 4. Vitality test 5. Biopsy
  30. 30.  Radiograph for cyst 1. IOPA for small periapical cyst to see tooth involvegd 2. Occlusal view to check lingual cortical expansion 3. PNS view (occipitomental)to show relation to maxillary antrum and nasal cavity 4. Lateral oblique (mandible)to check proximity to lower border 5. PA view to check expansion of ramus of mandible,survey of symphysis ,body and rami of mandible 6. OPG (shows entire affected region.size and site of the region can be assessed
  31. 31.  Radiographic interpretations  Radiographs help to define site ,size,extent and marginal outline of lesion  Characteristic appearance of a cyst is a round or oval radiolucency surrounded by sharp radioopaque line of condensed bone (this line missing in an infected cyst or a very large cyst that is growing rapidly.  Large cyst in mandible may displace inferior nerve canal, clearly seen in radiograph
  32. 32.  Contrast studies  To find out exact size and relation of the cyst whose extent is doubtful.  Water soluble contrast solution can be injected to cyst after removing cystic fluid  Avoid painful excess pressure in cystic cavity  After filling with radiopaque dye ,essential radiographs are taken  Contrast medium removed by aspiration carefully to avoid negative pressure in cystic cavity
  33. 33.  Aspiration Cystic contents are aspirated using a wide bore needle(18 guage) and syringe(5 ml) Different types of aspirates obtained Provisional diagnosis may be based on types of aspirate
  34. 34. Types of Aspirate Diagnosis Clear , pale , straw coloured fluid with cholesterol crystals Dentigerous cyst Creamy white , thick aspirate Odontogenic cyst Yellowish ,foul smelling fluid Infected cyst Blood 1. Needle in blood vessel 2. Vascular lesion Air 1. Maxillary antrum 2. Traumatic bone cyst
  35. 35. On biochemical evaluation of aspirated fluid If total protein content >4gm/100 ml indicataed radicular cyst or dentigerous cyst If total protein content <4gm/100 ml indicated odontogenic keratocyst
  36. 36.  Vitality test : Vitality test is done for tooth involved in the cyst and those adjacent to it. If tooth non-vital, it is most likely to be a radicular cyst.
  37. 37.  Biopsy When type of cyst is not confirmed by aspiration , a biopsy may be done to categorise the cyst prior to treatment plan. Gold standard to determining the cyst and to differentiate from neoplasm.
  38. 38. Dentigerous Cyst  Term given by Paget in 1963  Cyst which enclose the crown of an unerupted tooth by expansion of its follicle, and attached to its neck – shears 1983
  39. 39. Etiology  Developmental in origin  Considered to arise by the accumulation of fluid between reduced enamel epithelium and the crown of an unerupted tooth or an impacted tooth  The eruptive forces in the tooth cause changes in the vascular hydrodynamics which results in sepration of reduced enamel epithelium from crown.  There is fluid accumulation between these two.
  40. 40.  Basis of observations at operation and histologic examination distinguish two types : 1. Standard dentigerous cyst 2. Extrafollicular variety
  41. 41. Clinical features Second most common cyst Commonly seen in 1st and 3rd decade of life Males more affected than females Capable to becoming aggressive lesion
  42. 42.  Asymptomatic unless they develop into very large cyst or get infected  Expansion of bone  Facial asymmetry  Displacement and root resorption of adjacent teeth  Pain may occur if secondary infection supervenes
  43. 43. Radiographic Features  Unilocular ,well defined radiolucency with sclerotic margins around the crown of an unerupted tooth  Three radiographic types circumferential lateral paradental
  44. 44. Cyst Contents  Yellowish straw coloured fluid rich in cholestrol crystals  If cyst infected ,purulent material can be obtained on aspiration
  45. 45.  Histopathological features  Lined by stratified squamous epithelium  Lumen may contain fibrillar keratin  Presence of bilaminated eosinophilic amorphous hyaline like Rushton bodies  Cholestrol crystals
  46. 46.  Treatment  Marsuplization  Enucleation of cyst together with removal of unerupted teeth  This permits decompression of a resulting decrease in the size of bone defects.
  47. 47. ODONTOGENIC KERATOCYST  Odontogenic keratocyst term first coined by philipsen in 1956  These cyst are quite aggressive and usually extensive at the time of diagnosis  Very high recurrence rate
  48. 48.  Pathogenesis – Developmental anomaly Arises from odontogenic epithelium Dental lamina Basal cells from overlying mucosa Enamel organ-by degenration of stellate reticulum
  49. 49.  Clinical features Most common in 2nd and 3rd decade of life Males more commonly affectd Mandible more affected than maxilla Most common site is mandibular angle region Greatest recurrence rate –as high as 60% Asymtomatic usually until secondarily infected
  50. 50.  Radiographic features – Unilocular or multilocular radiolucency In early stages ,unilocular radiolucency with well defined sclerotic margin It can arise in any part of jaw and is independent of the teeth,it can mimic any of the cyst radiographically e.g. dentigerous cyst,primordial cyst,radicular cyst As OKC expands it causes severe bone destruction producing a multilocular radiolucency and soap bubble appearance radiographically
  51. 51.  Cyst contents Contains dirty white material Cystic fluid has a large amount of exfoliated keratin squamous Smear can be stained and examined for keratinized cells When keratin content is high ,the fluid may appear thick and can be mistaken for pus but is odourless Electrophoresis shows total protein content of fluid to be 4g/dl
  52. 52.  Histological features Epithelium lining is usually parakeratinized Epithelial lining is of uniform thickness ,5-8 layers of cells Basal layer cell tall columnar and nuclei are polarized giving tomb stone appearance Connective tissue layer shows satellite cells or daughter cyst which have a high rate of invasiveness
  53. 53.  Causes of high recuurence rate Aggressive pecularity was first reported by pindborg and Hansen (1963) Tendency to multiplicity Presence of satellite cyst Cystic lining is very fragile and thin , making it difficult to remove in one piece Epithelial lining og keratocysts have an intrinsic growth factor Cyst can arise from basal cell of mucosa
  54. 54.  Treatment Bramley (1971/1974) had very rationally outlined the surgical management of these cyst as followes Small single cyst with regular spherical outline,enucleated from intra oral approach Large or less accessible cyst with regular spherical outline ,enucleated from extraoral approach. Care should taken to ensure that all fragments of extremly thin lining are removed
  55. 55. Unilocular lesions with scalloped or loculated periphery and small multilocular lesions , treated by marginal resection ,while maintaining the continuity of posterior and inferior border. If cystic lining is found to be adherent to overlying mucosa or muscle then it should be excised along with marginal excision Defect is closed primarily and can be left to heal by secondary intention Can be filled with hydroxyapatite crystals, autogenous bone graft, corticocanellous chips
  56. 56. Larger multilocular lesion with or without cortical perforation,may require resection of the involved bone followed by primary or secondary reconstruction with reconstruction plates or stainless stell mesh or bone graft like iliac crest graft,costochondral graft or allogenous bone graft.
  57. 57. ERUPTION CYST  It is a dilatation of the normal folicular space above the crown of the erupting tooth caused by accumulation of tissue fluid or blood Smilar to dentigerous cyst which developes during the eruption of tooth when tooth is within the soft tissues surrounding the bone.  Also known as eruption hematoma
  58. 58.  Clinical features Smooth , round soft tissue swelling over an erupting tooth Pink or bluish in colour Not commonly seen as they undergo spontaneous rupture or disappears from masticatory trauma as the tooth enters the oral cavity
  59. 59.  Radiographic features – Cyst in soft tissues, no significant radiographic features are soon
  60. 60.  Treatment – Marsupialisation
  61. 61. GINGIVAL CYST OF INFANTS  Soft tissue cysts on the alveolar crest of the gum pads of a newborn  Arise from remnants of dental lamina
  62. 62.  Clinical features Appears as pearly white nodules 2-3 mm in diameter on the alveolar ridge May be solitary or multiple Cyst appears white in colour due to presence of keratin within the cyst Similar lesions on mid palatine raphe are called epstein’s pearls Similar lesions on lingual , buccal aspect of alveolar ridge are called Bohn’s nodules
  63. 63.  Pathology Thin lining of stratified squamous cell epithelium which may reveal parakeratinization Contain desquamated keratin
  64. 64.  Treatment No treatment as they rupture spontaneously on eruption of underlying teeth
  65. 65. GINGIVAL CYST OF ADULTS  Soft tissue odontogenic developmental cyst  Location in gingival tissue Etiology : Remnants of dental lamina or cell rests of serres From enamel organ or epithelial islands of the surface epithelium As traumatic implantation cyst
  66. 66.  Clinical features No sex predilection Occurs in 5th or 6th decade of life Mandible is more frequently involved Rarely seen in anterior part of jaw Asymptomatic, painless, slow growing, Soft and fluctuant Seen in attached gingiva or the inter den tal papilla on labial aspect, smooth surface Adjacent teeth are normal
  67. 67.  Hitopathology Lined by stratified squamous cell epithelium and contains fluid  Treatment Surgical excision No tendency to recurrence
  68. 68. LATERAL PERODONTAL CYST  First reported by standish and shafer in 1958  Cysts occur in the lateral peridontal position  Inflammatory etiology
  69. 69.  Clinical features Occurs in 4th to 7th decade of life Males are affected more than females Most frequent locations mandibular premolar area,followed by anterior region of maxilla Asymptomatic Associated teeth vital 3rd molar most common and any infection can cause spreading infection of submandibular space
  70. 70.  Radiographic features Well defined radiolucency round or ovoid with sclerotic margin Lamina dura of the tooth destroyed Smaller than 1cm in size and present between the cervical margin and apex of the tooth In case of 3rd molar seen to be present in the bifurcation, buccal or lingual surface of roots
  71. 71.  Pathogenesis Reduced enamel epithelium Remnants of dental lamina Cell rests of malassez  Cystic contents Serous caseous contents
  72. 72.  Pathology Lined by well formed , non keratinized stratified squamous epithelial lining Localized epithelium proliferation may be seen Connective tissue wall may show inflammatory cell infiltrate  Treatment plan Enucleation
  73. 73. BOTRYOID ODONTOGENIC CYST Weathers and Waldron 1973  Arises from odontogenic epithelial rests  Variant of lateral periodontal cyst  Gross appearance of large lesion resembling a bunch of grapes ,hence the term botryoid
  74. 74.  Clinical features Occurs in 5th -7th decade of life Most frequent location mandible in cuspid-premolar region Swelling may be present Pain Parasthesia Discharge (rarely)
  75. 75.  Radiographic features Unilocular radiolucency  Treatment Enucleation
  76. 76. CEOC  First described by Gorlin in 1964  Shows features of cyst and tumour Clinical features Relatively rare cyst Most often seen in second decade,no sex predilection but more common in children and young individuals Mostly seen in anterior part of the jaw
  77. 77. Initially Symptomless Swelling Pain (rare) Peripheral or intraosseous lesion may be seen Later stages hard bony expansion Some cyst arise close to periosteum and produce a saucer shaped depression in bone Pathogenesis Remnants of dental lamina Stellate Reticulum, Reduced enamel epithelium
  78. 78.  Radiographic features Well defined lesions with sclerotic or diffuse border Small radiopaque flecks are seen in the cystic cavity which is characterstic of this cyst Some lesions are unilocular and some exhibit multilocular radiolucency Cortical perforation May be associated with unerupted tooth Resorption of the roots of adjacent teeth
  79. 79.  Histological features Basal layer is composed of cuboidal or columnar cells with polarised nuclei Most peculiar feature is presence of ghost cells. these are eosinophilic ,pale,swollen epithelial cells that have lost their nuclei  Treatment Enucleation
  80. 80. GLANDULAR ODONTOGENIC CYST  Padayachee and Van wyk 1987  Same characteristic with lateral peridontal cyst or botryoid cyst  Unilocular or multiloculat radiolucency  Cortical plare expansion
  81. 81.  Treatment Enucleation Marsupialisation if lesion approach vital structure
  82. 82. RADICULAR CYST  Also known as apical periodontal cyst  Associated with roots of non-vital teeth  Most common odontogenic cyst .in all cases the pulp iis necrosed Etiology- Dental caries Fractured tooth Thermal /chemical injury to pulp Iatrogenic pulp injury
  83. 83.  Initiation and progression Dental caries Chronic pulpitis Pulp necrosis Periapical granuloma
  84. 84.  Clinical features Most common Males affected more than females Occurs in 3rd -4th decade of life Incidence highest in anterior maxilla Asymptomatic Tooth must be non-vital Pain if associated with suppuration Temporary parasthesia
  85. 85.  Radiological features Round or pear shaped or oval shaped radiolucency outlined by a narrow radio-opaque margins  Treatment Enucleation with primary closure
  86. 86. RESIDUAL CUST  Residual cyst ,that is overlooked after causative tooth or root is extracted  An incomplete removed pariapical granuloma  An impacted tooth associated with a lateral dentigerous cyst but cystic lesion unrecognized and left in situ,residual cyst persist and will enlarge  Cystic lesion developes on either a decidous or retained tooth which either exfoliatesor is extracted without knowledge of underlying pathology
  87. 87.  Mainly in middle aged and elderly patient  No sex predilection  Incidence greater in maxilla than mandible  Asymptomatic  Occasionally sign of pathologic fracture or signs of encroachment
  88. 88. Treatment Enucleation with primary closure
  89. 89. INFLAMMATORY PARADENTAL CYST  First reported by Main 1970  Associated with a lateral accessory root canal of a non vital tooth  In 3rd decade of life  Male mostly affected  Mandibular 3rd molar mostly
  90. 90.  Radiological features Often superimposed on the buccal root face as well demarcated radiolucencies,often with corticated margin. Periodontal ligament space not widened and lamina dura is intact around the tooth  Treatment Enucleation
  91. 91. NON-ODONTOGENIC CYST  Nasopalatine duct cyst Derived from embryonic epithelial residues in nasopalatine canal Or from epithelium included in lines of fusion of embryonic facial process May be occur within the nasopalatine canal or in soft tissues of the palate At the opening of the canal – cyst of palatine papiilla
  92. 92.  Clinical features Mostly 3rd to 6th decades of life Higher ratio of man affected Common symptom swelling Also occurs in midline on labial aspect May produce bulging of nose Pain and discharge which is salty in taste Displacement of teeth
  93. 93.  Radiological features Round or oval shape radiolucency some time Heart shape radiolucency in between the central incisors  Treatment Surgical enucleation
  94. 94.  Nasolabial cyst – Occurs outside the bone in nasolabial folds below the alae nasi Arises from epithelium enclaved at the site of fusion of the globular, lateral nasal and maxillary process It could develop from remnants of embryonic nasolacrimal rod or duct
  95. 95. Wide age spread from 12-75 years Women affected more Swelling Pain and difficulty in nasal breathing Slow growing Swelling of lip, fill out the nasolabial and lift the alae nasai Fluctuant
  96. 96. Radiological features- Radiolucency of alveolar process above the apices of incisors teeth Treatment  Enucleation
  97. 97. NON-EPITHELIAL CYST  Solitary bone cyst  Aneurysmal bone cyst
  98. 98. ANURYSMAL BONE CYST  Jaffe and Litchtenstein 1942  Often seen in lonf bones and spine  Aetiology Trauma Possible relationship with giant cell lesion Variations in hemodynamics of area Sudden venous occlusion
  99. 99.  Clinical features Very rare Children and young adults mostly affected Mandible affected more than maxilla Firm swelling Displacement of teeth Egg shell crackling Lesion not pulsatile
  100. 100.  Treatment Complete curretage Local excision with bone grafting
  101. 101. SOLITARY BONE CYST  Termed as haemorrhagic bone cyst
  102. 102.  Aetiology Trauma and haemorrhage with failure of organization  Spontaneous atrophy of the tissue in a central benign giant cell lesion  Abnormal calcium metabolism  Chronic low grade infection 
  103. 103.  Clinical features Occurs in children and adolescent Male predliction Mandible affected more Symptomless Expansion of lingual cortex
  104. 104. MANAGEMENT OF CYST OF THE JAWS  Removal of lining or enable the body to rearrange position of abnormal tissue to eliminate from within, and prevention of recurrence.  Minimum trauma to patient and maximum conservation of tissue mainly of dental components.  Preserve adjacent important structures  Achieve rapid healing; to minimize number of visits  Restore the part to near normal and normal function  Prevention of pathologic fracture  Facial esthetics.
  105. 105.  Rationale behind treating a cyst  To avoid displacement and loosening of teeth  To avoid pathological fractures of the jaw due to expanding lesion  To avoid displacement of the inferior alveolar canal and destruction of other vital structure around the cyst  To aim at removing the entire lining, preserving the adjacent structures
  106. 106.  Operative Procedures Basically two types  Enucleation  Marsupialization
  107. 107. Enucleation Enucleation and packing Enucleation and primary closure Enucleation and primary closure with reconstruction Enucleation wth chemical cauterisation Marsupialisation Partsch I Partsch II Marsupialization by opening into nose or antrum
  108. 108.  Marsupialisation or Partsch I operation also known as cystotomy or decompression  Partsch 1892 described a type of compression procedure Principle : Marsupialization or decompression refers to creating a surgical window in the wall of cyst, and evacuate cystic contents
  109. 109.  Indication Age - Young child with developing tooth buds When development of the displaced teeth has not progressed,and enucleation would damage the tooth buds. Proximity to vital structures – when proximity of cyst to vital structures, could create an oronasal ,oro antral fistula , injure neurovascular structures or damage vital teeth
  110. 110. Eruption of teeth – marsupialization permit the eruption of unerupted teeth Size of cyst – very large cyst where enucleation could result in a pathological fracture Vitality of teeth- when apices of the many adjacent teeth are involved with in the large cyst
  111. 111.  Advantages Simple procedure to perform Spares vital structures Allows eruption of teeth Prevents oro nasal oroantral fistula Prevents pathological fracture Reduces operating time Reduces blood loss Helps shrinkage of cystic lining Allows for endosteal bone formation to take place
  112. 112.  Disadvantages Pathologic tissue is left in situ Histologic examination of entire lining is not done Prolonged healing time Inconvenience to the patient Prolonged follow up visits Periodic irrigation of cavity Regular adjustment of plug Periodic changing of pack Secondary surgery may be needed
  113. 113. SURGICAL TECHNIQUE  Anaesthesia  Aspiration  Incisions – circular oval eliptical inverted ‘u’  Removal of bone  Removal of cystic lining specimen  Irrigation of cystic cavity
  114. 114.  Suturing  Packing – white head’s varnish tincture of benzoin bismuth iodine paraffin paste(BIPP)  Maintenance  Use of plug  Healing
  115. 115. MODIFICATIONS OF MARSUPIALIZATION  Waldron’s method(1941)  Two stage technique  Combination of two standard technique  First marsupialization  Second enucleation,when the cavity becomes smaller
  116. 116.  Indications When bone has covered the adjacent vital structures Adequate bone fill has strengthened the jaw to prevent fracture during enucleation Pt. finds difficult to clean cavity For detection of any occult pathologic condition
  117. 117.  Advantages Development of a thickened cystic lining which makes enucleation easier Spares adjacent vital structures Combined approach reduces morbidity Accelerated healing process Allows histopathological examination of residual tissue
  118. 118.  Disadvantages Patient has to undergo secondary surgery and possible complications
  119. 119. MARSUPIALIZATION BY OPENING INTO NOSE OR ANTRUM Cyst that have destroyed a large portion of of the maxilla and have ancroached on the antrum or nasal cavity Technique 1. Anaesthesia 2. Incision – gingival curvilinear incision taken along the involving teeth 3. Two releasing incision are made at 45°angle and extending in to buccal sulcus
  120. 120. Mucoperiosteal flap is raised Removal of bone(usually in large cysts ,an opening already exist) This stage a window is made by removing a portion of cystic lining like partsch I technique Second unroofing is performed by removing antral lining presents between the cavities
  121. 121.  This allows the cyst cavity to become lined with normal ciliated and mucous secreting epithelium regenrating from the respiratory mucosa other than a squamous epithelium  Additionally intranasal antrostomy may be performed . Cavity packed with a ribbon gauze soaked withtincture of benzoin or antibiotic ointment
  122. 122. ENUCLEATION  Principle - surgical removal of entire cystic lining  Shelling out of the entire cystic lining without rupture  After enucleation of the cyst the underlying space filled with blood clot,which eventually organizes to form normal bone
  123. 123.  Indications Treatment of OKC Recurrence of cystic lesions of any cyst type Advantages- Primary closure of wounds Rapid healing Postoperative care is reduced Thorough examination of entire cystic lining can be done
  124. 124.  Disadvantages – In young persons , the unerupted teeth in dentigerous cyst will be removed with the lesion Removal of large cystic lesion in mandible ,making it prone to fracture When a cyst involves the apices of one or more teeth in such a way that the blood supply to the pulp passes through the capsule of lesion,enucleation of cyst could be result in pulpal necrosis
  125. 125.  Enucleation with primary closure- Anaesthesia Incision- envelope flap trapezoidal Elevation of Mucoperiosteal flap Bone removal Exposure of cystic lining Try to remove entire cyst lining in a single piece Irrigation of cavity and hemostasis ensured suturing
  126. 126. Enucleation with open packing large cyst which was previously infected ,closure may not be possible the wound is packed with gauze impregnated with bismuth idoform parafin paste (BIPP) or whitehead’s varnish. Whitehead’s varnish contains Benzoin 10 gm, Storax 7.5 gm, Balsam of tolu 5gm, iodoform 10 gm, solvent ether upto 100ml
  127. 127. Enucleation with bone curettage After enucleation if there is a doubt that a part of lining has been left behind, it can be curetted out A bone curett is used to scrap the bone and remove any remaining lining Enucleation with peripheral osteotomy Instead of using a curett a large round burr may be used to remove around 1- 2mm of bone around the entire peripheral cavity
  128. 128.  Enucleation with chemical cauterisation  Stoelinga has advocated the use of carnoy’s solution Mainly indicated in OKC. Carnoy’s solution contains Glacial acetic acid, Choloroform, Absolute alcohol, Ferric chloride
  129. 129. Enucleation with bone grafting Bone grafting with autogenous cancellous bone grafts can be done in case of large bony defects Bone graft obliterates the cavity and stimulates osteogenesis There is , however , a risk of infection of the bone graft which may lead to failure
  130. 130. Segmental resection Indicated when there is a large odontogenic keratocyst with massive bone destruction Indicated when there is suspected neoplastic transformation of the cyst
  131. 131. Procedure Anaesthesia Incision – a submandibular incision , which may at times be required to extend into postramal region,is taken 1.5 – 2 cm below thr inferior border of mandible Incision extends ,through skin and subcutaneous tissue,blunt and sharp dissection carried out layerwise through tissue planes e.g. superficial cervical fascia ,platysma ,and deep cervical
  132. 132. Care is taken to marginal mandibular nerve and facial artey and vein are clamped and ligated Small bleeders cauterized with diathermy Pterygomassetric sling divided ,periosteum incised down to bone and flap is raised superiorly to expose the bone Depending upon the extent of lesion involvement to surrounding tissues ,enucleation or marginal resection done.
  133. 133. COMPLICATIONS OF CYSTIC LESION AND MANAGEMENT  Risk of bone fracture (pathological) If fracture occurs during surgery,after removal of cyst bone plating should be done to strength the mandible  Inferior dental nerve involvement If cyst is in very close proximity with to neurovascular bundle,possibility of damage must be explained to advance Management of teeth related to cyst
  134. 134. CONCLUSION Diagnosis is always very important to decide the treatment plan of the cyst Care always should be done to prevent nearer structure or tooth or tooth bud.
  135. 135. REFERENCES  A text book of cyst and management by shears  Text book of minor oral surgical procedure by jeffery L.hoe  Text book of oral surgery part II-by laskin  Text book of oral minor surgery by killey n keys  Text book of oral pathology by shafers  Text book of oral maxillofacial surgery by neelima malik