Biopsy

Enucleation

• Enucleation means complete removal of a cyst. This can be done by currettage (using currette),or by blind sections of cystic lining (we put a blunt instrument and you sort of ‘peeling’ the bony lining).

• Appical cystoectomy

• For a cyst that has a recurrence potential, you need to do peripheral osteoctomy after removing the cyst. How? By removing the 3-4mm of bone surrounding the cavity with a big, sharp bur. Make sure that the bur are big enough to remove any remaining cyst or daughter cyst (if dealing with keratocyst).

• Opening a wide flap or window and remove all the cyst as one sac(with the lining intact). Then we close the window and leave it to be fill up with bone over time.

• In the case of dentigerous cyst, when you open the area you can see a bluish sac which is the cyst. Then you need to enlarge the bone around it. You bluntly remove the whole cyst with the causative impacted tooth. You can see that this is obviously a dentigerous cyst because the crown was completely covered with the dentigerous sac

MARSUPIALIZATION

Marsupialization, decompression, and the Partsch operation 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. This process decreases intracystic pressure and promotes shrinkage of the cyst and bone fill.Marsupialization can be used as the sole therapy for a cyst or as a preliminary step in management, with enucleation deferred until later.

Indications• Factors to determine weather to do masupialization or not as as

follow• 1.Amount of tissue Injury- Close Proximity of a vital structure

will indicate for marsupialization to avoid unwanted removal of adjacent vital tissue. Ex- If removal of cyst will result in formation of oroantral fistula then it's better to go for Marsupialization.

• 2.Surgical Access- If access to all portion of cyst is difficult and there is chance of leaving a piece of cyst wall.

• 3.Assistance in eruption- If cyst is associated with a unerupted tooth then marsupialization will help in eruption of tooth.

• 4.Extent of surgery- In a unhealthy and debilitated patient marsupialization is good alternative to extensive removal.

• 5.Sizeof cyst- A risk of Jaw fracture in a very large cyst, it may be better to go for Marsupialization.

Technique1.Prophylactic antibiotic is needed if patients health condition warrents. 2.Anesthetize the area. 3.Cyst is Aspirated. 4.Aspiration conforms the diagnosis then proceed for marsupialization. 5.Initial incision is circular or eleptical and create a large window in the cyst cavity. 6.If bone have been thinned or exposed then incision goes through bone into cavity. 7.If bone is thick then a surgical window is created by removing bone with help of bur. 8.Piece of tissue is submitted to the lab for further tests. 9.Content of the cyst are evacuated. 10.Cyst cavity is irrigated with normal saline to remove and residual fragment. 11.If access permits then perimeter of the cyst wall can be sutured with the oral mucosa. 12.Or you can pack the cavity with a strip of gauze impregnated with tincture of benzoin or antibiotic ointment and leave it for 15 days it will prevent the oral mucosa to heal over window. 13.Give careful instructions to the patients about cleansing of the cavity.

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. This is done to remove any remaining epithelial cells that may be present in the periphery of the cystic wall or bony cavity. These cells could proliferate into a recurrence of the cyst.

Inidcation

• odontogenic keratocyst. In this case the more aggressive approach of enucleation with curettage should be used because odontogenic keratocysts exhibit aggressive clinical behavior and a considerably high rate of recurrence. Daughter, or satellite, cysts found in the periphery of the main cystic lesion may be incompletely removed, which contributes to the increased rate of recurrence.‘

• any cyst that recurs after what was deemed a thorough removal. The reasons for curettage in this case are the same as those outlined previously

Advantages• If enucleation leaves epithelial remnants, curettage may

remove them, thereby decreasing the likelihood of recurrence.

Disadvantages• Curettage is more destructive of adjacent bone and

other tissues. The dental pulps may be stripped of their neurovascular supply when curettage is performed close to the root tips. Adjacent neurovascular bundles can be similarly damaged. Curettage must always be performed with great care to avoid these hazards.