Cysts of the jaws / dental implant courses

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 Definition
 Classification
 Pathogenesis
 Signs and symptoms (general)

•Clinical
•Radiology
•Aspiration
•Biopsy

Indian Dental academy
• www.indiandentalacademy.com
• Leader continuing dental education
• Offer both online and offline dental courses

 Goals of treatment
 Factors considered

• Marsupialisation (Partsch-1 procedure)
• Enucleation (Partsch-2 procedure)

 Killey and Kay (1966)
“Abnormal cavity in hard or soft tissues which
contains fluid, semifluid or gas and is often
encapsulated and lined by epithelium”
 Kramer (1974)
A cyst is a pathological cavity having
fluid,semifluid or gaseous contents and which is not
created by accumulation of pus and frequently but
not always lined by epithelium

 Epithelial cysts of the jaws
▪ Developmental
▪ Inflammatory
 Nonepithelial cysts of the jaws (Pseudocysts)
▪ Aneurysmal bone cyst
▪ Solitary bone cyst (simple, traumatic, hemorrhagic, idiopathic
bone cavity)
 Other cysts in the Head & Neck region
▪ Soft tissue cysts
▪ Pseudocysts
▪ Miscellaneous

 Epithelial cysts of the jawsEpithelial cysts of the jaws
 DevelopmentalDevelopmental
▪ Gingival cyst of infant ( Epstein pearls)
▪ Gingival cyst of Adult
▪ Eruption cyst
▪ Odontogenic Keratocyst
▪ Dentigerous cyst
▪ Lateral periodontal cyst/ Botryoid odontogenic cyst
▪ Glandular odontogenic cyst (Sialo-odontogenic cyst)
▪ Calcifying odontogenic cyst (Gorlin’s cyst)
▪ Nasolabial cyst (Nasoalveolar cyst)
▪ Nasopalatine duct cyst (Incisive canal cyst)

 Epithelial cysts of the jaws
▪ Inflammatory
 Radicular cyst (Periapical / Periradicular)
 Apical
 Lateral
 Residual
 Paradental cyst (Mandibular infected buccal
bifurcation cyst, inflammatory
collateral cyst)

 Other cysts in the Head & Neck region
▪ Soft tissue cysts
 Epidermoid cyst
 Thymic cyst
 Bronchogenic cyst
 Thyroglossal cyst
 Gastric Heterotrophic cyst
 Salivary duct cyst
 Ciliated cyst of the maxillary antrum
 Lymphoepithelial: oral cervical
▪ Pseudocysts
 Mucus retention cyst
 Mucocele of the sinus
 Cystic hygroma
▪ Miscellaneous
 Dermoid cyst
 Polcystic disease of parotid
 HIV associated lymphoepithelial lesion

 In general there are 2 phases in a cyst pathogenesis:
▪ Initiation or cyst formation
▪ Enlargement or expansion of cystic cavity

 Proliferation of epithelial lining
 Intra cystic fluid accumulation
 Resorption of bone as fluid accumulates
and epithelial lining proliferates

 Increased hydrostatic
pressure
 Increased osmotic
pressure
 Increase in surface area
of lining “mural” factor
 Displacement of
surrounding soft
tissues or resorption

In few cysts like OKC, keratin formation is more than
hydrostatic and osmotic factors. In such cases,
instead of uniform expansion, there are finger like
projections into the surrounding bone. This factor
might determine the recurrence and aggressiveness of
a cyst.

 Physical signs depend on the size of a cyst. If
the cyst is small with no alveolar expansion,
there is absence of signs. As the cyst becomes
larger expansion of alveolar bone occurs.
 Periosteum is stimulated to form new bone
producing a curved enlargement.

 Initially lateral bone expansion turns to thinning of
cortex and can be depressed like a tennis ball or egg
shell crackling to palpation
 Later fragmented outer shell disappear and the cyst
lining is beneath oral mucosa
 Fluctuation can be elicited
 Greater distension of cystic wall leads to eventual discharge
of fluid into mouth, which is frequently followed by
secondary infection and abscess

 Small cysts are usually asymptomatic and only if infected, discharge
from the cyst into the mouth and produce a nasty taste.
Ex: Fissural cyst – salty taste when a sinus is present.
 Edentulous patient – Complains of displacement of denture; denture
ulcer
 Non vital tooth associated with periapical cyst – Discoloration or lose
tooth / teeth.
 If there is a tooth missing- pathology can be suspected.
Ex: Dentigerous cyst.

 RadiographyRadiography
o Radiography – various
intraoral and extraoral
views
 AspirationAspiration
o It is a valuable diagnostic
aid
o A wide bore needle
should be inserted into
the suspected cystic
lesion under L.A and
cavity then aspirated

Needle aspiration Cholesterol Crystal
Contrast media
CT Scan

 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.

 Age and physical state of the patient
 Young patient – prompt healing
 Children – because of rapid cyst – growth
 Prompt treatment and accessibility to be
considered
 Poor accessibility – max tuberosity, lingual
aspect of mandible, ramus of mandible

 Enucleation of cyst and primary closure
 Enucleation and open packing
 With removal of teeth
 With tooth conservation
 Combined with Caldwell Luc operation
 Combined with fixation of pathologic fracture
 Marsupialisation and healing by secondary intention
 Combination: marsupialisation followed by
enucleation after cavity shrinks

Enucleation is the shelling out of an entire
cystic cavity without rupture.
A layer of fibrous connective tissue exists
between wall and bone which forms a
cleavage plane for stripping a cyst from
its bony cavity

Treatment of choice for removal of any
cyst that can be done without undue
sacrifice of adjacent structures

 Advantage
 The main advantage is that pathologic
examination of entire cyst can be undertaken
 Secondly this can lead to treating of lesion
 Disadvantage
 Normal tissue may be involved in surgical
procedure

 Pathologic or iatrogenic fracture
 Cyst involving apex of healthy tooth – pulpal
necrosis
 Dentigerous cyst – young patient – prevents
tooth from erupting

 If cyst evoked cortex, and lining in contact with
periosteum
 Lining attached to PDL membrane of adjacent teeth
 Lining is friable if grossly infected and very thin

Administer L.A to site involved. Mucoperiosteal flap is
raised to gain access into cystic cavity. Incision is done in
such a way that future suture lines rests on normal bone so
that flap heals well which also facilitates for good
retraction.

 After elevation of flap, area of bony expansion is identified. At the
thinned out bony wall a window is made to gain entry into cyst. If the
cyst wall is of equal thickness a series of holes are made in oval fashion
and all the holes are joined by a fissure bur or chisel/ gouge and mallet.

Depending on need theDepending on need the
window can be enlargedwindow can be enlarged
with rongeur forceps. Thuswith rongeur forceps. Thus
cystic cavity is widelycystic cavity is widely
exposedexposed
A plane of cleavage is utilized between cysticA plane of cleavage is utilized between cystic
lining and bony wall to dissect out cystic sac inlining and bony wall to dissect out cystic sac in
one piece along with contents out of bony wallone piece along with contents out of bony wall
and subjected to histopathologic examinationand subjected to histopathologic examination

If any tooth or root is involved, necessary treatment
either extraction or apicoectomy with apical seal can
be done

 Cavity is cleaned and bony margins smoothened. Once
hemostasis achieved flap is repositioned.
 Wound margins closed with interrupted sutures. Cavity is now
filled with blood clot. In due course of time blood clot gets
organized and helps in regeneration of bone
 Sutures are removed on 6th or 7th postoperative day. Analgesics
and antibiotics will take care of post operative infection and pain

Maintains bony
contour
Increase strength
of bone
Shorter follow up
period

 Incision is made deep involving mucoperiosteum, bone and cystic
lining thereby cutting a window in the roof of cyst
 If the intervening bone is thick, it can be removed with chisel,
rongeurs and bur
 Fluid content is evacuated with suction
 The cystic lining is sutured with oral mucosa around opening

 Cystic cavity is packed with iodoform gauze/ acriflavin/ povidone
iodine/ L.A. jelly / Metrohex gel loosely
 Cavity is irrigated and pack is changed every 4th-5th day, every
time using a small pack than earlier
 Cystic epithelial lining is transformed into normal mucus
membrane. Slowly cavity fills up because of fluid pressure in
bone. Regeneration occurs beneath defect. If a tooth is
embedded in cavity, it stands a chance of eruption into oral
cavity or can be orthodontically treated.

 Large cyst where enucleation is not possible
 Large cyst that have weakened bone and there is fear of
pathologic fracture if enucleation is tried
 Dentigerous cysts – where eruption is needed
 Large cyst which might enter into paranasal sinuses /
maxillary sinuses / damage to neurovascular bundle if
enucleation tried
 Medically compromised patient

 Periodic post
operative follow up
for a longer period
 Pathologic cyst lining
is not totally
eliminated

• This means after enucleation a curettage or bur is used to
remove 1 to 2mm of bone around entire periphery of
cystic cavity
• Chemical cauterization – Phenol/alcohol
- Carnoy’s solution
(absolute alcohol, glacial acetic acid, chloroform)
• Thermal cauterization
• Cryocautarization.

In OKC because of high recurrence rate
In any recurrence cyst after thorough removal
 Advantage
 If enucleation leaves epithelial remnants curettage will
remove them, thereby decreasing likelihood of
recurrence
 Disadvantage
 May damage adjacent bone and tissues

After enucleation the bony cavity is inspected for proximity to
adjacent structures. A sharp curette or bone bur with a sterile
irrigation can be used to remove 1-2mm layer of bone around
complete periphery of cystic cavity. Then cleanse the cavity
and closed.

 Also called “Waldron’s operation”
 A 2 stage procedure.
 In the 1st stage marsupialisation is performed and cavity
allowed to shrink in size.
 In the 2nd stage cyst lining is totally eliminated

In repeated recurrence cases, radical surgery is
indicated and excision of block of bone. If large
section of jaw is resected, reconstruction
followed by immediate bone graft is done

It is defined as the one which encloses the
crown of an Unerupted, Supernumerary
tooth and is attached to the neck

 Frequency – 15-20%
 Age – 2nd and 3rd decades of life
 Sex – males > females; 1.6:1
 Race – whites > Blacks; 4:1

Site – Mandible > maxilla
Mandible – 3rd molar
Maxillary canine
Mandibular premolars
Maxillary 3rd molar
Supernumerary

 Usually seen on radiographs when taken because
of missing tooth, failure to erupt etc.
 Patients become aware of cysts because of
slowly enlarging swellings
 Resorption of roots of adjacent teeth
 Expansion of bone with facial asymmetry
 Displacement of teeth: pain

It originates after crown of tooth has been
completely formed due to accumulation of
fluid between reduced enamel epithelium and
tooth crown

 Cyst is seen as radiolucent area associated in some
fashion with an unerupted tooth crown
 Radiolucent area may appear to project laterally from
tooth crown, if cyst is large or there has been
displacement of teeth – lateral dentigerous cyst
 Circumferential dentigerous cyst – cyst surrounds the
entire crown of teeth without involving occlusal
surface
 Dentigerous cyst is usually a smooth unilocular lesion
but occasionally multilocular also seen

Radiological presentation of Dentigerous cyst

Ameloblastoma
Epidermoid carcinoma
Mucoepidermoid carcinoma

Enucleation together with involved
tooth
Marsupialisation which in case of
involved tooth might be brought to
normal position in arch

Ameloblastoma
AOT
OkC

It is associated with erupting deciduous
permanent teeth in children. It is essentially
dilation of normal follicular space about crown
of erupting tooth caused by accumulation of
tissue fluid or blood. Clinically lesion appears as
a circumscribed, fluctuant, often translucent
swelling of alveolar ridge over site of erupting
teeth

The term OKC was introduced by Philipsen (1956)
based on histologic appearance of cystic lining.
Magitot (1872) – certain follicular cysts developing
prior to formation of any dental hard tissues.
Seward (1963) – redefined odontogenic cyst as those
arising from odontogenic epithelium which has not
taken a direct part in development of tooth

 It is a developmental anomaly arising from
odontogenic epithelium derived from dental
lamina or remnants
 Because of high recurrence rate and soft tissue
involvement the surgical management is like that
of a tumor.

 Age – 2nd and 3rd decade of life;
bimodal age distribution
 Sex – males > females; black > whites
 Site – Mandible > maxilla
 Varying distance into ascending ramus
and body
 Maxilla – can occur into sinus;
globulomaxillary area
 Patient complains of pain, swelling or
discomfort
 Occasionally parasthesia of lower lip
 Usually symptomless unless infected
 Displacement of adjacent teeth

 Appears small, avoid, or normal radioluscent areas
 Unilocular / multilocular; smooth periphery
 Well demarcated with sclerotic margin
 Rarely expansion of bone seen
 Spread along medullary spaces of bone than buccolingullay

 Envelopmental – cyst embracing an adjacent
unerupted tooth
 Replacement – cyst which forms in place of
normal tooth of series
 Extraneous – cyst seen in ascending ramus
away from teeth
 Collateral – cyst adjacent to roots of teeth

 Cyst is lined by regular keratinized stratified squamous ep about
5-8 cell layers thick and no rete pegs: usually parakeratotic and
orthokeratotic type can also be seen
 Corrugated appearance of parakeratotic layer
 Polished basal cells may be columnar / cuboidal
 Nuclei of columnar cell in parakeratotic lining tend to be oriented
away from basement membrane and are basophilic.This is a
distinguishing feature from other keratinized jaw cyst

 Small single lesions can be
completely enucleated
provided access is good
(Intra oral approach)
 Larger cyst – careful
enucleation and done by
extraoral approach; if an
intraoral approach may
lead to blind curettage

 Large multilocular lesions –
excision of immediate bone graft is
treatment of choice at first
operation
 Resection of involved bone and
reconstruction with stainless steel,
vitallium, titanium
 More conservative approach –
enucleation / excision and
cauterization of bone defect with
carnoy’s solution prevents
recurrence

 Recurrence
 Pindborg and Hansen (1963) reported a
recurrence of 62% in 16 cysts

 Tendency to multiplicity
 Satellite cyst
 Cystic lining is very thin and fragile, portions of which
may left behind
 Epithelial lining of OKC has intrinsic growth potential
 Cyst can arise from basal cells of oral mucosa

Developmental odontogenic cyst, first described by
Gorlin and associates in 1962.
Incidence: - Very few cases have been reported
- No sex predilection
- More common in children, young
adults.
Site: - Common site of occurrence is Ant. Part of
mandible.

• Mostly symptomless and discovered
• accidentally.
• Swelling is a frequent complain
• A peripheral or intraosseous lesion may
• be seen.
• Produce a hard bony expansion.

 Periphery may be well demarcated or irregular
 Cortical perforation may be seen
 Calcification as irregular radio-opaque specks
may be seen in cavity.

 Associated with nonvital teeth
 Age-3rd
to 4th
decade
 Males more than females
 Site-maxillary ant. Teeth more common
 Radiological features- Well circumscribed unilocular
radiolucency at apex/lateral aspect of root
 D/D-periapical granuloma
 Treatment- Enucleation with extraction/Endodontic
treatment
 Prognosis- Good

 Enucleation
 If cyst is associated with an odontogenic tumor
a wide excision is done

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