definition of the cyst classification of cyst inflammatory radicular cyst keratocyst dentigerous cyst enucleation marsupialization

1. CYSTS OF OROFACIAL
REGION
Dr. Haydar Munir Salih Alnamer
Maxillofacial specialist
BDS, Ph.D (Board certified)

3. • Cysts are the most common cause of chronic swellings of the jaws.
They are more common in the jaws than in any other bone
because of the many rests of odontogenic epithelium remaining in
the tissues
• Cyst is define as pathologic cavity within the hard or soft
tissues, lined by epithelium and contain fluid, semifluid or
gas (not created by accumulation of pus) and surrounded
by connective tissue wall or capsule.

4. THE MAIN MECHANISMS OF CYST FORMATION
INVOLVED IN VARYING DEGREES:
1.Proliferation of the epithelial lining and
connective tissue capsule
2. Accumulation of fluid within the cyst
3. the resorption of the surrounding bone

6. CLINICAL FEATURES OF JAW CYST
• Most jaw cysts behave similarly and usually grow slowly
and expansively.
• They differ mainly in their relationship to a tooth, and
the radiographic features are usually a good guide as to
their nature.
• Even when it is not possible to decide the nature of a
cyst, this affects treatment only with less common types.
(keratocysts and unicystic ameloblastomas)
• Diagnosis ultimately depends on histopathology

7. KEY FEATURES OF JAW CYSTS
•Form sharply-defined radiolucencies with smooth
borders
•Fluid may be aspirated and thin-walled cysts may
be transilluminated
•Grow slowly, displacing rather than resorbing
teeth
•Symptomless unless infected and are frequently
chance radiographic findings

10. KEY FEATURES OF JAW CYSTS
•Rarely large enough to cause pathological fracture
•Form compressible and fluctuant swellings if
extending into soft tissues
•Appear bluish when close to the mucosal surface
•Large cysts usually deflect the neurovascular
bundle, paresthesia and anesthesia is rare

12. CLASSIFICATION OF CYST
1. intra- osseous cyst
2. Soft tissue cyst

13. INTRAOSSEOUS CYST
I. Epithelial Cysts:
Odontogenic epithelial origin
Developmental
Primordial cyst (keratocyst)
Dentigerous (follicular) cyst
Calcifying odontogenic (Gorlin) cyst
Eruption cyst
Lateral periodontal cyst
Inflammatory
Radicular cyst (apical/lateral periodontal)
Residual cyst

15. INTRAOSSEOUS CYST
I. Epithelial Cysts:
Non-odontogenic epithelial origin (Fissural cyst):
Median mandibular
Median palatal
Globulomaxillary
Incisive canal (nasopalatine duct or median anterior
maxillary) cyst

16. INTRAOSSEOUS CYST
II. Non-epithelial cysts: (PSUDOCYST)
Solitary bone cyst (traumatic)
Aneurysmal bone cyst
Stafne’s bone cavity
III. Cyst of the maxillary antrum:
Surgical ciliated cyst of maxilla
Benign mucosal cyst of the maxillary antrum

17. SOFT TISSUE CYST
Odontogenic Gingival cysts:
Adult
Newborn
Non-odontogenic (fissural)
Anterior median lingual cyst
Nasolabial cyst
Retention cysts: Salivary gland cysts
Mucocele
Ranula

18. SOFT TISSUE CYST
Developmental/congenital cysts:
Dermoid and epidermoid cysts
Branchial cyst (cervical/intraoral)
Thyroglossal duct cyst
Cystic hygroma

19. INFLAMMATORY RADICULAR CYST
• The most common of all cysts of odontogenic origin.
(65%- 70%)
• The involved tooth is non-vital.
• The incidence is highest in the anterior maxillary and the
posterior mandibular teeth.
• A round or ovoid shaped radiolucency
• A straw colored or brownish fluid and cholesterol
crystals.
• Treatment: enucleation

22. LATERAL RADICULAR CYST

23. RESIDUAL RADICULAR CYST

24. RADICULAR CYST ASPIRATION

25. KERATOCYST
• It is about 5 to 10% of odontogenic cysts of the jaws
• tend to grow in an anteroposterior direction within the
medullary cavity and clinically observable expansion of
the bone occurs late
• The teeth adjoining the cyst are vital
• can be unilocular or multilocular
• contain cheesy like material

26. MULTILOCULAR KERATOCYST

27. UNILOCULAR KERATOCYST

28. CONTENT OF KERATOCYST

29. RECURRENCE OF KERATOCYST
•The recurrence rate may vary from 5-60% with
most occurring in the first 5 years.
•Some of the possible reasons reported for
recurrence are as follows:
1. Presence of satellite cysts,
2. Cystic lining is very thin and fragile,
3. portions of which may be left behind

30. ENUCLEATION

31. PERIPHERAL OSTECTOMY

32. CARNOYS' SOLUTION

33. EN-BLOCK RESECTION

34. GORLIN-GOLTZ SYNDROME

35. DENTIGEROUS CYST
• Results because of the enlargement of the 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.
• More common than the keratocyst but less common
than the inflammatory types
• dentigerous cysts have a higher tendency to cause root
resorption of adjacent teeth
• Treatment: marsupialization in children and enucleation
in adult

36. DENTIGEROUS CYST

37. DENTIGEROUS CYST

38. Gingival cyst of infants
• (Bohn nodules) up to 80% of newborn infants have small
nodules or cysts in the gingivae Most resolve spontaneously
• Cysts (Epstein's pearls) may also arise from nonodontogenic
epithelium along the midpalatine raphe. also resolve
spontaneously in a matter of months.
Gingival cysts of adults
• Gingival cysts are exceedingly rare. They usually form after
the age of approximately 40. Clinically, they form dome-
shaped swellings less than 1 cm in diameter and sometimes
erode the underlying bone. They are unlikely to recur after
enucleation

39. BOHEN NODULES Epstein pearls

40. GINGIVAL CYST OF THE ADULT

41. FISSURAL CYSTS
•Fissural cysts are non-odontogenic cysts that
arise owning to epithelial inclusions or
entrapments in the lines of fusion of the
developing facial processes during the
embryonic stage.

42. FISSURAL CYSTS

43. MEDIAN PALATINE CYST

44. NASOPALATINE CYST

45. NASOPALATINE CYST

46. GLOBULOMAXILLARY CYST

47. GLOBULOMAXILLARY CYST

48. SOLITARY BONE CYST
& ANEURYSMAL BONE CYST
•Solitary bone cyst and aneurysmal bone cysts are
without epithelial lining (pseudocysts). These also
are cystic only in their radiographic appearances
•It is not confined to the jaws as similar lesions are
seen elsewhere in the skeleton
•Mainly due to trauma
•It is seen mainly in children, adolescents or young
adults

49. SOLITARY BONE CYST

50. ANEURYSMAL BONE CYST

51. STAFNE BONE CAVITY
•Stafne's bone cavity is not a cyst, it is included
because of their clinical similarity to cysts of the
jaw bones
•due to failure of the normal deposition of bone
during development of the jaws
•Below the inferior alveolar canal, mainly unilateral
•No treatment

52. STAFNE BONE CAVITY

53. MUCOCELE & RANULA
• Two types of distinct entities described are, the true
retention cyst which is lined by epithelium and the other
is the mucous extravasation cyst which occurs because
of the pooling of mucus, it does not have any epithelial
lining and is surrounded by connective tissue cells
• Majority of mucocele are seen to affect the lower lip
• Ranula is variant of a mucocele that is present on the
floor of the mouth, beneath the tongue.
• Treatment: They are best treated by surgical excision
together with the associated salivary gland

56. RANULA

59. PLUNGING RANULA

61. DERMOID AND EPIDERMOID CYSTS
• The dermoid cyst is a form of cystic teratoma, which is lined
by epithelium and in addition reveals the presence of skin
appendages, e.g. hair, sebaceous glands or teeth. The
epidermoid cyst is also lined by epithelium but does not
contain any skin appendages.
• Dermoid are seen in the midline in the floor of the mouth
above or below the geniohyoid muscle
• Those above the geniohyoid muscle, elevate the tongue,
causing difficulty with mastication and speech. Those
present inferior to the geniohyoid muscle, cause a
submental swelling that has been described as a double
chin

62. DERMOID AND EPIDERMOID CYSTS

63. DERMOID AND EPIDERMOID CYSTS

64. DERMOID AND EPIDERMOID CYSTS

65. THYROGLOSSAL DUCT CYST
• It can occur anywhere in the midline along the course of
the embryonic thyroglossal duct,
(which extends from the foramen caecum of the tongue
into the deep fascia near the thyroid isthmus)
• Pathognomonic is the movement of the cyst during
swallowing and protrusion of the tongue
• Complete radical surgical excision of the cyst along with
its tract is essential to prevent recurrence.

66. THYROGLOSSAL DUCT CYST

67. THYROGLOSSAL DUCT CYST

68. THYROGLOSSAL DUCT CYST

69. SISTRUNK PROCEDURE

70. CYSTIC HYGROMA
• it is a developmental abnormality, in which cavernous lymphatic
spaces communicate and form large thin walled cysts
• Typically they appear in the first few months of life
• swelling that is painless and compressible, the swelling may
increase in size over several months to a year, and they may
remain static or may even regress
• overlying skin may be bluish and transillumination will be
positive
• Hygroma may suddenly enlarge when there is an upper
respiratory infection. This may cause acute respiratory
obstruction and may require an emergency tracheostomy or
surgical extirpation

71. CYSTIC HYGROMA

73. CYSTIC HYGROMA

74. Cysts of the jaws, may be treated by one of the following basic
methods:
1. Marsupialization (decompression)
• Partsch I
• Partsch II (combined marsupialization and encleation)
• Marsupialization by opening into nose or antrum.
2. Enucleation:
• Enucleation and packing
• Enucleation and primary closure
• Enucleation and primary closure with reconstruction/bone
grafting.
GENERAL PRINCIPLES OF TREATMENT

75. MARSUPIALIZATION (PARTSCH I)

76. MARSUPIALIZATION

77. MARSUPIALIZATION

78. MARSUPIALIZATION
(POSTOPERATIVE PACKING )

79. ACRYLIC PLUG

80. INDICATIONS FOR MARSUPIALIZATION
1. Age:
2.Proximity to vital structures:.
3.Eruption of teeth:
4.Size of cyst:
5.Vitality of teeth:

81. ADVANTAGES OF MARSUPIALIZATION
1. Simple procedure to perform and reduces operating
time
2. Spares vital structures and prevents oronasal and
oroantral fistulae
3. Alveolar ridge is preserved and allows eruption of
teeth
4. Helps shrinkage of cystic lining and prevents
pathological fracture
5. Allows for endosteal bone formation to take place.

82. DISADVANTAGES OF MARSUPIALIZATION
1. Pathologic tissue is left in situ
2.Histologic examination of the entire cystic lining is not
done
3. Prolonged healing time and prolonged followup visits
4. Periodic changing of pack, periodic irrigation of cavity
5. Inconvenience to the patient
6. Secondary surgery needed
7. Formation of slit-like pockets that may harbor foodstuffs

83. MODIFICATIONS OF MARSUPIALIZATION 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 becomes smaller, the
procedure of enucleation is performed and
the entire tissue is examined
histopathologically

84. ENUCLEATION

85. ENUCLEATION

86. ENUCLEATION

87. ENUCLEATION

88. ENUCLEATION WITH PACKING

89. ENUCLEATION WITH
RECONSTRUCTION/ BONE GRAFT

90. ENUCLEATION WITH
RECONSTRUCTION/ BONE GRAFT

91. ENUCLEATION WITH
RECONSTRUCTION/ BONE GRAFT

92. ENUCLEATION
Indications:
1. Treatment of odontogenic keratocysts
2. Recurrence of cystic lesions

93. ENUCLEATION
Advantages:
1. Primary closure of the wound
2. Healing is rapid and postoperative care is
reduced
3. Thorough examination of the entire cystic lining
can be done.

94. ENUCLEATION
Disadvantages:
1. In young persons, the unerupted teeth in a
dentigerous cyst will be removed with the lesion
2. Removal of large cysts will weaken the mandible,
making it prone to jaw fracture
3. Damage to adjacent vital structures
4. Pulpal necrosis.

95. COMPLICATIONS OF CYSTIC LESIONS
1. Pathological fracture
2. Postoperative wound dehiscence
3. Loss of teeth vitality
4. Neuropraxia in infected cysts
5. Postoperative infection
6. Recurrence in some cysts
7. Dysplastic, neoplastic or even malignant changes

96. PATHOLOGICAL FRACTURE

97. SUGGESTED FOLLOW-UP:
• Long-term follow-up, at least up to 8 years for keratocysts
for early detection of dealing with any recurrence
• To check postoperative vitality of teeth
• Unerupted teeth that may require orthodontic assistance for
eruption
• Orthodontic assistance for alignment of displaced teeth
• Long-term follow-up of patients with Gorlin's syndrome.

98. “
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