Management of oral cyst

1. Cysts Of The Oral And
Maxillofacial Region
Dr. Saleh Bakry
Assistant Professor of Oral and
Maxillofacial Surgery

2. • A Cyst is a pathological cavity having fluid,
semifluid or gaseous contents and which is
not created by the accumulation of pus and
lined by epithelium
DEFINATION OF TRUE
CYST

3. Pathological cavity not lined by epithelium and
may contain fluid or may be empty.
DEFINATION OF
PSEUDOCYST

4. Cyst has following parts:
• WALL (made of
connective tissue)
• EPITHELIAL LINING
• LUMEN OF CYST
PARTS OF A CYST

5. ODONTOGENIC:
1. Cells of the basal layer of
the oral epithelium.
2. The dental lamina.
3. The epithelial rests of
Serres (which represent
remnants of the dental
lamina).
4. The enamel organ.
5. The reduced enamel
epithelium.
6. The epithelial rests of
Malassez.
NON-ODONTOGENIC:
1. Entrapped epithelium
between embryonic
processes (fissural cysts).
2. Epithelium from remnants
of the cervical sinus (i.e.
epithelium of brnchial
cleft origin).
3. Secretory glandular
epithelium.
4. Remnants of the
epithelium of the naso-
palatine duct.
ORIGIN

6. CLASSIFICATION

7. I. ODONTOGENIC CYSTS
A. Inflammatory Apical, lateral, Residual.
B. Developmental:
1. Follicular:
• Dentigerous cyst.
• Primordial cyst.
I. CYSTS OF THE JAWS

8. 2. Extra-Follicular:
• Lateral developmental periodontal cyst.
• Gingival cysts:
 Gingival cyst of the newborn.
 Gingival cyst of the adult.
• Keratinizing and Calcifying Odontogenic Cyst
(Gorlin Cyst, Cystic keratinizing tumor).

9. II. NON-ODONTOGENIC CYST
A. Fissural cysts
• Nasoalveolar (nasolabial cyst).
• Median maxillary cysts.
Median alveolar cyst.
Median palatine cyst.
• Median mandibular cyst.

10. • Nasopalatine duct cyst.
 Incisive canal cyst.
 Cyst of palatine papilla.
• Globulomaxillary cyst.
B. Congenital cysts (Banchial cleft types)
• Branchial cleft cyst.
• Thyroglossal tract cyst.
• Dermoid and Epidermoid cysts.
• Heterotopic oral gastro-intestinal cyst.

11. III. Pseudocysts
• Traumatic bone cyst (haemorrhagic bone cyst; solitary
bone cyst).
• Aneurysmal bone cyst.
• Static bone cyst (developmental salivary gland
inclusion cyst; latent bone cyst; Stafne's idiopathic
bone cavity).
IV. Cysts of Salivary Glands
• Mucocele.
• Ranula.

12. 1. Gingival cyst
2. Nasoalveolar cyst
3. Cyst of palatine papilla
4. Branchial cleft cyst.
5. Thyroglossal tract cyst.
6. Dermoid and Epidermoid cysts.
7. Heterotopic oral gastro-intestinal cyst.
8. Mucocele.
9. Ranula.
SOFT TISSUE CYSTS

13. DIAGNOSIS OF
CYSTIC LESIONS

14. 1. Painless swelling.
2. Absence of a tooth or teeth.
3. Loosening or irregularity of teeth.
4. Tilting of teeth
5. Discolored tooth
I. HISTORY

15. 1. TEETH POSITION:
• Absence of tooth  unerupted 
dentigerous cyst.
• Not formed  primordial cyst.
• Extracted  residual cyst.
• Cysts  displace tooth, while neoplasm 
cause root resorption.
II. CLINICAL EXAMINATION

16. 2. TEETH VITALITY:
• Presence of discolored pulpless tooth 
inflammatory cyst.
• Vital tooth  fissural, developmental,
primordial cyst or psuedocyst.
• Site:
• Globulomax. Cyst  between upper lateral
and canine roots.
• Naso-palatine cyst  behind upper central
incisors (related to incisive canal).

17. • Cyst of palatine papilla  related to palatine papilla.
• Naso-labial cyst  between ala of the nose and lip.
• Primordial  lower third molar area.
• OKC molar-ramus region.
• Dentigerous  upper/lower third molar – upper
canine.
• Dermoid & epidermpid cysts  below the tongue in
midline.

18. 3. BONE EXPANSION:
• Small cyst no bone expansion.
• Large cyst  buccal plate expansion,
indentation upon pressure (ping-pong ball),
egg shell cracking, and then fluctuation.

19. • Un-infected cyst  well defined radiolucent area
surrounded by sharp radioopaque margin.
• 2ry infected  radiolucency with an irregular
margin.
• Special appearance:
 Nasopalatine cyst  heart shaped
appearance (due to superimposition of
anterior nasal spine on its R.L. area).
 Globulomaxillary cyst  inverted pear
shaped (as it diverts roots of 2 and 3).
III. RADIOGRAPHIC EVALUATION

20.  Traumatic bone cyst  scalloped appearance
(roots determine shape of cyst).
 Aneurysmal bone cyst  soap bubble
appearance (pumping action of the blood).
 Primordial cyst  multilocular R.L.

21. Intra-Oral Radiography:
• Periapical films.
• Standard occlusal view.
• Lateral or topographical
occlusal view.
Extra-Oral Radiography
• Lateral oblique views.
• Postero-anterior projection.
• Occipito-mental view.
• Panoramic view.
• Advanced radiographic
techniques:
• CT scanning
• Cone beam ct scanning.
• Injection of radio-opaque
material
TECHNIQUES

22. This technique is used to visualize soft tissue cysts and sinus
tracts and to differentiate a maxillary cyst from the maxillary
sinus.
This technique is contraindicated in patients with severe renal
disease and hepatic disorders.
IV. OTHER RADIOLOGICAL DIAGNOSTIC
TECHNIQUES (INJECTION OF RADIOPAQUE
CONTRAST MEDIA)

23. Def.: it is the removal of tissue from a living individual
for microscopic diagnostic examination. It is the most
definitive confirmatory process for diagnosis.
Value of biopsy:
Proper and correct diagnosis.
Determine degree of malignancy.
Determine prognosis.
V. BIOPSY

24. • The most valuable investigation for cyst and fluctuant
lesions.
• Simple & cause minimal inconvenience of the patient.
• The aspiration can be submitted to Microscopic
examination, chemical analysis or microbiological
examination.
THE RESULT OF ASPIRATION:
• –ve  solid mass or latent bone cyst.
• Air  maxillary sinus / nose / traumatic bone cyst.
• Pus (foul odor)  abscess / infected cyst.
• Yellowish white fluid with no foul odor  keratocyst.
VI. ASPIRATION BIOPSY

25. • Straw color fluid with cholesterol crystals  cystic
fuid.
• Blood (differentiated by sedimentation if left
upright for a while)  vascular lesion / aneurismal
bone cyst.
• Sticky clear viscous fluid (saliva)  mucocele /
ranula.

26. 1. Increasing in size leading to  bone destruction.
2. Disfigurement.
3. Involvement of adjacent teeth leading to
looseness, displacement or resorption.
4. Infection.
5. Weakening of the mandible with possibility of
pathological fracture.
6. Encroaching vital structures.
7. Malignant transformation.
REASONS OF CYST
TREATMENT

27. 1. Removal of the pathological lining.
2. Conservation of erupted, partially erupted and un-
erupted teeth.
3. Preservation of adjacent vital structures
4. Restoration of the affected area to its original
form.
5. Achieve rapid healing of the surgical site.
OBJECTIVES OF CYST
TREATMENT

28. TREATMENT

29. Cysts of the jaws are treated in one of the following four basic methods:
(1) Enucleation,
(2) Marsupialization,
(3) A staged combination of the two procedures, and
(4) Enucleation with curettage.
TREATMENT

30. • Enucleation is the process by which the total removal of a cystic lesion
is achieved (shelling out) without rupture of its lining if possible.
• Enucleation of cysts should be performed with care, in an attempt to
remove the cyst in one piece without frag-mentation, which reduces
the chances of recurrence by increasing the likelihood of total removal.
• However, maintenance of the cystic architecture is not always possible,
and rupture of the cystic contents may occur during manipulation.
1. ENUCLEATION

31. INDICATIONS :
• Accessible cyst.
• Small to moderate size cysts.
• Cysts which do not encroach vital structures.
• Cysts that do not involve the soft tissues.
CONTRAINDICATIONS:
• Large cyst surgical access would weaken the jaw that a fracture might
occur.
• Dentigerous cyst in a young person involving erupting teeth or tooth.
• When endangering the vitality of the teeth near the cyst.
• Cysts with friable thin membrane. E.g. keratocyst.
• Eruption cyst.
ENUCLEATION

32. ADVANTAGES:
• Removal of the entire pathological tissue.
• Healing is more rapid than marsupialization.
• Decreases the need for postoperative care and irrigation.
DISADVANTAGES:
• Possibility of damaging surrounding vital structures & teeth.
• Complete removal of the cyst lining may not be possible
when it extends to involve soft tissue.
• Risk of fracture mand or oro-antral & oro-nasal
communication.
ENUCLEATION

33. OPERATIVE PROCEDURES:
1. Enucleation through the socket.
2. Enucleation with primary closure.
3. Enucleation with space obliteration and primary
closure.
A. ENUCLEATION THROUGH THE SOCKET:
1. When extracting teeth with periapical radiolucencies
 small in size.
2. Enucleation could be performed via the tooth’s socket.
ENUCLEATION

34. B. ENUCLEATION WITH PRIMARY CLOSURE:
1. L.A. or G.A.
2. Determine teeth management RCT or extraction.
3. Reflect a mucoperiosteal flap of sufficient width.
4. Gaining access to the cyst lining by bone removal & enlarge
the bony opening.
5. Evacuate the cyst collapse cyst lining facilitate cyst
removal.
6. Use bone curette, mucoperiosteal elevator to completely
remove the cyst lining from the walls of the bony cavity
while grasping it with Allis forceps.
ENUCLEATION

35. 7. Debridement and thorough observation.
8. Closure and sutures (left for 7-10 days)
9. External pressure pack for buccal approach or
palatal acrylic stent if palatal approach.
10. Routine immediate postoperative care:
• Pressure pack.
• Cold application for the 1st 24 hrs.
• Warm saline mouth bath the next 24 hrs.
ENUCLEATION

36. C. ENUCLEATION WITH SPACE OBLITERATION AND PRIMARY
CLOSURE:
1. Same steps from 1 to 7.
2. For space obliteration:
• Hemostatic resorbable sponges.
• Autogenous cancellous bone grafting.
• Allogenic bone grafting.
• DFDB.
3. Then continue steps 8 - 10.
ENUCLEATION

37. ENUCLEATION OF CYST

38. ENUCLEATION OF CYST

39. • Marsupialization, decompression, and the Partsch operation
all refer to creating a surgical window in the wall of the cyst,
evacuating the contents of the cyst, and maintaining
continuity between the cyst and the oral cavity, maxillary
sinus, or nasal cavity.
• The only portion of the cyst that is removed is the piece
removed to produce the window. The remaining cystic
lining is left in situ.
2. MARSUPIAIIZATION

40. 1. Release of the intracystic fluid.
2. Release of the intracystic pressure.
3. The functional stresses will be allowed to stimulate new
bone formation beneath the cyst membrane.
4. Causes  gradual obliteration of the cyst cavity &
exteriorization of the cyst lining
5. At the end, the cystic cavity is completely replaced with
bone and the lining diminishes until it disappears.
MECHANISM

41. 1. Eruption cyst in patients below 20 years of age.
2. Dentigerous cysts to allow tooth to erupt.
3. Large cysts encroaching on the soft tissue
4. Large cysts encroaching the maxillary sinus.
5. Large cysts encroaching the nose.
6. When enucleation cause weakening of the mandible
7. When enucleation cause injury to healthy tissues.
INDICATION

42. CONTRAINDICATIONS:
1. Fissural cysts.
2. Cysts with tumor potentials as KCOC & Keratocysts.
ADVANTAGES:
1. Simple.
2. Contour of the jaw is preserved.
3. Protects neighboring structures from surgical damage.
4. Avoids possibility of developing oro-antral or oro-nasal
fistulae.
MARSUPIAIIZATION

43. Disadvantages:
1. Possible recurrence.
2. Maximum post-operative care required.
3. Sometimes difficult to clean.
4. Healing is slow especially in elderly patients.
MARSUPIAIIZATION

44. 1) Anaesthesia
2) Aspiration
3) Incision
Circular, oval or elliptic. Inverted U shaped incision with broad base
to the buccal sulcus. Mucoperioteum is reflected in this case.
4) Removal of bone
5) Removal of cystic lining specimen
6) Visual examination of residual cystic lining
7) Irrigation of cystic cavity
8) Suturing
Cystic lining sutured with the edge of oral mucosa.
In U shaped incision the mucoperiosteal flap can be turned into cystic
cavity covering the margin. The remaining is sutured to oral mucosa.
TECHNIQUE OF
MARSUPIAIIZATION

45. 9) Packing-- Prevents food contamination & covers wound margins.
Done with ribbon gauze soaked with WHITEHEAD VARNISH.
COMPOSTION:
Benzoin – 10g
Iodoform – 10g
Storax - 7.5g
Balsam of Tolu – 5g
Solvent ether to 100ml
Pack removed after 2 weeks.
10) Maintenance of cystic cavity
Instruct the patient to clean and irrigate the cavity regularly with oral
antiseptic rinse with a disposable syringe.
CONTINUE…

46. 11) Use of plug
Prevents contamination. Preserves patency of cyst orifice.
Plug should be stable, retentive and safe design.
Should be made of resilient material ( avoid irritation) like acrylic.
12) Healing
Cavity may or may not obliterate totally. Depression remains in the
alveolar process.
CONTINUE…

48. 3. ENUCLEATION AFTER
MARSUPIALIZATION
INDICATIONS
• When bone has covered the adjacent vital structures.
• Adequate bone fill. Prevents fracture during enucleation.
• When patients find it difficult to cleanse the cavity.
• To detect any occult pathological condition.
ADVANTAGES
• Spares adjacent vital structures
• Accelerates healing process
• Development of thick cystic lining – enucleation easier
• Allows histopathological examination of residual tissue.
• Combined approach reduces morbidity

49. DISADVANTAGES
• Patient has under go second surgery and any possible
complication associated with surgery.
3. ENUCLEATION AFTER
MARSUPIALIZATION

50. 4. ENUCLEATION WITH
CURETTAGE
• Enucleation with curettage means that after enucleation a
curette or bur is used to remove 1 to 2 mm of bone around
the entire periphery of the cystic cavity
• Any remaining epithelial cells that may be present in the
periphery of the cystic wall or bony cavity must be removed.
• These cells could proliferate into a recurrence of the cyst.

51. Indications :
Remove any remaining epithelial cells that may be present to
prevent the recurrence of the cyst, as in:
• Treating an odontogenic keratocyst (parakeratotic) 
aggressive clinical behavior + high rate of recurrence (20-60%)
+ daughter or satellite cysts may be found at periphery of
main cystic lesion.
• If it recurs after this treatment  bone resection with 1cm
safety margin should be done.
ENUCLEATION WITH
CURETTAGE