By Mohammad Hussein Zaki

Lecturer Oral & Maxillofacial Surgery Faculty of Dentistry – Minia University

Surgical Management of cystic lesions

Odontogenic It is derived from a tooth-related apparatus

Tooth formation:

• Dental lamina.

• Enamel organ.

• Dental papilla.

• Hertwig’s root sheath.

• Redued enamel epithelium

• Epithelial rests of Malassez.

Definition: Pathological cavities, lined with epithelium,

and contain fluid or semi-fluid material.

Pathologic cavity or sac within the hard or soft

tissues that may contain fluid, semifluid or gas

and not always lined by epithelium (It may be

lined by epithelium, fibrous tissue or

occasionally even by neoplastic tissue.

Cyst will be surrounded by a definite

connective tissue wall.

The cystic fluid either is:

secreted by the cells lining the cavity.

derived from the surrounding tissue fluid.

Cyst initiation.

Proliferation of the epithelial lining and the

formation of a small cavity.

Enlargement of this cystic cavity.

Cyst initiation.

Stimulus is unknown.

Precipitating factors:

• Infection.

• Individual predisposition.

Cyst initiation.

Mechanism:

• Proliferation of the epithelial lining.

• Fluid accumulation within the cyst cavity.

• Bone resorption.

Cyst initiation.

Mechanism:

Enlargement of this cystic cavity.

Mechanism:

Enlargement of this cystic cavity.

Mechanism:

• Increase in the volume of the contents.

• Increase in the surface area of the sac(epithelial

proliferation).

• Resorption of the surrounding bone.

Enlargement of this cystic cavity.

Mechanism:

• Displacement of the surrounding soft tissues.

• The periosteum is stimulated to form a layer of new

bone. (Subperiosteal deposition)

Presenting symptoms and signs.

Intrabony cysts may remain symptomless for

many years.

Discovered as an incidental finding on routine

dental inspection or radiographic investigation.

Association with teeth.

Radicular (dental) cysts.

Ectopic teeth.

Site.

Many cysts show a predilection for specific

areas.

Swelling.

Intraoral and extraoral.

Discrete and well demarcated.

The surface will feel firm but flexible or

fluctuant.

Pain.

uncommon.

Indicative of acute infection.

Lobulation.

Pattern of cyst growth with ‘invasion’ of lining

epithelium through the cancellous bone space

leaving behind isthmi of bone.

Associated signs/symptoms.

Teeth.

Neurovascular bundles.

Mandibular inferior border.

Special investigations.

Radiology.

• Simple plain films.

• Advanced imaging.

Special investigations.

Histological examination.

• Aspiration Biopsy.

• Excisional Biopsy.

• Incisional Biopsy.

Loss of vitality of teeth.

Infection.

Neuropraxia in infected cysts.

Pathological fracture.

Neoplastic changes.

Postoperative wound dehiscence.

Postoperative infection.

Recurrence in some cysts.

Clinical Picture.

Radiographic Picture.

Basic Surgical Goals.

Eradication of Pathologic Condition.

Functional rehabilitation of patient.

Related teeth.

Enucleation.

Complete removal of the cystic sac and

healing of the wound by primary intention.

Done through the layer of fibrous connective

tissue between the epithelial lining and the

bony wall of the cystic cavity.

Enucleation.

Indications:

• Any cyst of the jaw that can be safely removed

without unduly sacrificing adjacent teeth and other

anatomic structures.

• Recurrent cysts.

Enucleation.

Advantages:

• Entire removal of pathological tissues.

• Pathologic examination of the entire cyst can be

undertaken.

• Primary closure of the wound

• Healing is rapid.

• Postoperative care is reduced.

Enucleation..

Disadvantages:

• After primary closure, it is not possible to directly

observe the healing of the cavity.

• In young persons, the unerupted teeth in relation to

the cyst will be removed.

Enucleation..

Disadvantages:

• Removal of large cysts will weaken the mandible,

making it prone to jaw fracture.

• Damage to adjacent vital structures.

• Pulpal necrosis.

Enucleation..

Technique:

Enucleation with primary closure.

• Access to the lesion.

Enucleation..

Technique:

Enucleation with primary closure.

• Removal of bone and

exposure of part of the cyst.

Enucleation..

Technique:

Enucleation with primary closure.

• Removal of bone and

exposure of part of the cyst.

Enucleation..

Technique:

Enucleation with primary closure.

• Enucleation of the cystic sac.

Enucleation..

Technique:

Enucleation with primary closure.

• Care of the wound

and suturing.

Enucleation..

Technique:

Enucleation and packing.

Enucleation..

Technique:

Enucleation and packing.

• Indicated in large infected cyst.

• Enucleation is performed and then the cavity is packed.

• The wound heals with granulation tissue until

epithelialization is complete.

• Used when there is a dehiscence after primary closure.

Marsupiaiization.

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.

Marsupiaiization.

The sole therapy for a cyst.

Followed by later enucleation.

Marsupiaiization.

Indications:

• Young child, with developing tooth germs.

• Elderly, debilitated patient.

• Proximity to vital structures.

• Assistance in eruption of teeth.

Marsupiaiization.

Indications:

• Very large cysts, where enucleation, could result in

a pathological fracture.

• Difficult access to all portions of the cyst.

• Vital adjacent teeth.

Marsupiaiization.

Advantages:

• Simple procedure.

• Spare vital structures from damage.

• Allows eruption of teeth.

• Prevents oronasal, oroantral fistulae.

• Prevents pathological fractures.

Marsupiaiization.

Advantages:

• Reduces operating time.

• Reduces blood loss.

• Helps shrinkage of cystic lining.

• Allows for endosteal bone formation to take place.

• Alveolar ridge is preserved.

Marsupiaiization.

Disadvantages:

• Pathologic tissue is left in situ.

• Histologic examination of the entire cystic lining is

not done.

• Prolonged healing time.

• Harbors food stuffs.

Marsupiaiization.

Disadvantages:

• Periodic irrigation of cavity.

• Inconvenience to the patient.

• Prolonged follow up visits.

• Periodic changing of pack.

• Regular adjustments of plug.

• Secondary surgery may be needed.

Marsupiaiization.

Technique:

Partsch I

Partsch II

Marsupialization by opening into nose or antrum.

Marsupiaiization.

Technique:

Partsch I.

• A circular, oval

or elliptic incision.

Marsupiaiization.

Technique:

Partsch I.

• Removal of bone.

Marsupiaiization.

Technique:

Partsch I.

• Removal of cystic

lining specimen.

Marsupiaiization.

Technique:

Partsch I.

• Suturing.

Marsupiaiization.

Technique:

Partsch I.

• Suturing.

Marsupiaiization.

Technique:

Partsch I.

• Packing.

Marsupiaiization.

Technique:

Partsch I.

• Packing.

⁃ Gauze impregnated with an antibiotic ointment.

⁃ Secured by sutures.

⁃ Left inside for 7 to 14 days.

Marsupiaiization.

Technique:

Partsch I.

• Use of plug.

Marsupiaiization.

Technique:

Partsch I.

• Use of plug.

⁃ Stable & retentive.

⁃ Initially, a plug should be made of a resilient material.

⁃ Later, a well fitting acrylic plug.

Marsupiaiization.

Technique:

Partsch I.

• Maintenance of cystic cavity.

⁃ Cleansing and irrigation of the cavity by regular

flushing with an oral antiseptic rinse.

Marsupiaiization.

Technique:

Partsch II.

• Two stage technique.

⁃ First marsupilization.

⁃ At a later stage, when the cavity becomes smaller, the

procedure of enucleation is performed.

Marsupiaiization.

Technique:

Partsch II.

• Indications.

⁃ Bone has covered the adjacent vital structures.

⁃ Adequate bone fill has strengthened the jaw to prevent

fracture during enucleation.

Marsupiaiization.

Technique:

Partsch II.

• Indications.

⁃ Patient finds it difficult to clean the cavity.

⁃ Detection of any occult pathologic condition.

Marsupiaiization.

Technique:

Marsupialization by Opening into Nose or Antrum.

Marsupiaiization.

Technique:

Marsupialization by Opening into Nose or Antrum.

• Indicated in cysts that have encroached on the

antrum or nasal cavity.

Marsupiaiization.

Technique:

Marsupialization by Opening into Nose or Antrum.

Odontogenic Epithelial Origin.

Primordial Cyst/ Keratocyst.

Arises from primordial odontogenic epithelium.

5 to 10 % of odontogenic cysts of the jaws.

Predominates in the 2nd , 3rd and 4th decades.

Males > Females.

Mandible > Maxilla.

• Angle.

Odontogenic Epithelial Origin.

Primordial Cyst

Odontogenic Epithelial Origin.

Primordial Cyst

Free of symptoms until the cysts have reached a

large size at times involving the entire ascending

ramus.

Odontogenic Epithelial Origin.

Primordial Cyst

Displacement of the teeth.

Vital teeth.

Buccal bony expansion.

Deflection of the neurovascular bundle into an

abnormal position.

Odontogenic Epithelial Origin.

Primordial Cyst.

Aspiration: thick, granular, yellowish material.

Odontogenic Epithelial Origin.

Primordial Cyst.

Pathology:

Odontogenic Epithelial Origin.

Primordial Cyst.

Pathology:

Odontogenic Epithelial Origin.

Primordial Cyst.

Treatment:

• Single cysts with regular outline Enucleation.

• Small multilocular lesions Marginal Resection.

• Large multilocular lesions Segmental Resection.

Odontogenic Epithelial Origin.

Primordial Cyst.

Recurrence :

• High recurrence rate.

Odontogenic Epithelial Origin.

Dentigerous (Follicular) Cyst.

Results from the enlargement of the follicular space of

the whole or part of the crown of an impacted or

unerupted tooth.

Odontogenic Epithelial Origin.

Dentigerous (Follicular) Cyst.

Odontogenic Epithelial Origin.

Dentigerous (Follicular) Cyst.

More common than permordial cyst.

First, second, third decades.

Both sexes are affected equally.

Mandible > Maxilla.

• Lower third molars > upper cuspids > upper third molars >

lower bicuspid teeth.

Odontogenic Epithelial Origin.

Dentigerous (Follicular) Cyst.

Odontogenic Epithelial Origin.

Dentigerous (Follicular) Cyst.

Odontogenic Epithelial Origin.

Dentigerous (Follicular) Cyst.

Aspiration clear yellowish fluid.

Odontogenic Epithelial Origin.

Dentigerous (Follicular) Cyst.

Pathology.

Odontogenic Epithelial Origin.

Dentigerous (Follicular) Cyst.

Pathology.

• The cystic lining is of non keratinized reduced enamel

epithelium, consists of 2 to 3 cell layers of flat or

cuboidal cells and is attached to the tooth at CEJ.

• The fibrous connective tissue wall is loosely arranged

& contains considerable glycosaminoglycan ground

substance.

Odontogenic Epithelial Origin.

Dentigerous (Follicular) Cyst.

Treatment

• Children with very large cyst Marsupialization.

• Adults with small lesion Enucleation.

• Adults with large lesion Marsupialization/Enucleation.

Odontogenic Epithelial Origin.

Dentigerous (Follicular) Cyst.

Behavior and Prognosis.

Odontogenic Epithelial Origin.

Developmental Lateral Periodontal Cysts.

Lateral to the roots of vital teeth.

Mandible > Maxilla.

Aspiration serous caseous content.

Odontogenic Epithelial Origin.

Developmental Lateral Periodontal Cysts.

Odontogenic Epithelial Origin.

Developmental Lateral Periodontal Cysts.

Treatment:

• Enucleation.

• Attempt to avoid extraction of neighboring teeth.

Odontogenic Epithelial Origin.

Botryoid Odontogenic Cyst

Odontogenic Epithelial Origin.

Radicular cyst.

Cyst occurring at the apex or lateral to root of

the tooth.

Most frequently results from infection via

pulp chamber & root canal through

carious involvement of tooth.

Odontogenic Epithelial Origin.

Radicular cyst.

Odontogenic Epithelial Origin.

Radicular cyst.

Odontogenic Epithelial Origin.

Radicular cyst.

Odontogenic Epithelial Origin.

Radicular cyst.

Aspiration:

Odontogenic Epithelial Origin.

Radicular cyst.

Treatment:

• Extraction & curretage of apical zone.

• Root canal treatment followed by enucleation then

apicoectomy.

Odontogenic Epithelial Origin.

Radicular cyst.

Pathology:

• Stratified squamous epithelium, the lining may be thin

or thick upto 5 mm in size. An inflammatory infiltrate of

polymorphonuclear leucocytes will be seen in the

lining..

Odontogenic Epithelial Origin.

Radicular cyst.

Pathology:

Odontogenic Epithelial Origin.

Radicular cyst.

Pathology:

• The fibrous capsule is composed of collagen and

loose connective tissue. Acute and chronic

inflammatory cell infiltrate may be found in the fibrous

capsule.

Nonodontogenic Epithelial Origin.

Globulomaxillary cyst .

Inverted pear shape cyst Separates the roots

of the maxillary lateral incisor and canine.

Vital teeth.

Nonodontogenic Epithelial Origin.

Globulomaxillary cyst .

Nonodontogenic Epithelial Origin.

Globulomaxillary cyst .

Pathology.

Treatmnet.

Nonodontogenic Epithelial Origin.

Median mandibular cyst .

Nonodontogenic Epithelial Origin.

Nasopalatine duct cyst.

(incisive canal cyst)

Circular-shaped located in the region of the

maxillary central incisors.

The projection of the anterior nasal spine gives this

cyst the characteristic heart-shaped appearance.

Teeth is vital.

Nonodontogenic Epithelial Origin.

Nasopalatine duct cyst.

(incisive canal cyst)

Nonodontogenic Epithelial Origin.

Median palatal cyst.

Nonepithelial Origin.

Traumatic bone cyst.

Nonepithelial Origin.

Aneurysmal bone cyst.

Aneurysmal bone cyst.

Odontogenic Epithelial Origin.

Eruption cyst.

Soft cystic swelling, usually blue or purple in

color, is seen in children on the alveolus

overlying an erupting tooth.

Odontogenic Epithelial Origin.

Eruption cyst.

Nonodontogenic Epithelial Origin.

Dermoid and Epidermoid Cysts.

They may occur on the hard or soft palate, on

the dorsum at the tongue, of more commonly

in the floor of the mouth.

Aspiration: Yellow cheesy material

Nonodontogenic Epithelial Origin.

Dermoid and Epidermoid Cysts.

Nonodontogenic Epithelial Origin.

Dermoid and Epidermoid Cysts.

Nonodontogenic Epithelial Origin.

Dermoid and Epidermoid Cysts.