CYST Of Oral & Maxillofacial Tissues

Definition Classification Pathogenesis Clinical examination Odontogenic cyst Inflammatory cyst Conclusion References

Killey and kay(1966) – cyst constitutes an epithelium –lined sac filled with fluid or semifluid material.

Fit for odontogenic and fissural cyst but wat about SOLITARY BONE CYST OR STAFNE’S CYST????????????

Killey and kay (1966) – revised definition”A cyst is an abnormal cavity in hard or soft tissue which is contains fluid, semifluid or gas and is often encapsulated and lined by epithelium.”

Kramer’s(1974) – A cyst is pathologic cavity having fluid, semifluid, or gaseous contents that are not created by the accumulation of pus; frequently, but not always, is lined by epithelium.

Various classifications have been given: Robinson (1945) Thoma-Robinson-Bernier (1960) Kruger (1964) WHO (1971) Shear (1983)

According to shear’s -

Cyst of jaws Cyst associated with maxillary antrum Cyst of soft tissues of the

mouth,face,neck and salivary glands

cyst of jaws Epithelial Non-

epithelial

Developmental Inflammatory

Odontogenic Non-odontogenic

Odontogenic cyst - Odontogenic keratocyst Dentigerous cyst Eruption cyst Gingival cyst of infants Gingival cyst of adults Developmental lateral periodontal cyst Botryoid odontogenic cyst Glandular odontogenic cyst Calcifying odontogenic cyst

Non-odontogenic cyst

Midpalatal raphe cyst of infants Nasopalatine duct cyst Nasolabial cyst

Inflammatory origin

Radicular cyst, apical and lateral Residual cyst Paradental cyst and juvenile cyst Inflammtory collateral cyst

Non-epithelial lined cyst Solitary bone cyst Aneurysmal bone cyst

Traumatic bone cyst Hemorrhagic bone cyst

Cyst associated with maxillary antrum -

Mucocele Retention cyst Pseudocyst cyst Post operative maxillary cyst

Cysts of the soft tissue of the mouth ,face and neck –

Dermoid and epidermoid cyst Branchial cyst Thyroglossal duct cyst Anterior median lingual cyst Oral cyst with gastric or intestinal

epithelium Cystic hygroma Nasopharyngeal cyst Thymic cyst Cyst of salivary glands Hydatid cyst

Odontogenic cyst are derived from odontogenic epithelium of stomodeum

Enamel organReduced enamel epithelumRemnants of dental lamina(cell rests of

serrae)Remnants of hertwig’s root sheath(cell rests

of malassez)

Formation of cyst take place in generally three stages :

Initiation Cyst formation Enlargement or expansion of cyst

cavity

Initiation of cyst formation mostly from odontogenic epithelium

Stimulus which initiates this process is unknown

Factors involved Proliferation of epithelial liningI. Fluid accumulation in cystic cavityII. Bone resorption

Cavity lined by stratified squamous epithelium ???????????????

Shear (1963),Tencate (1972), Harris(1974) , Valderhauge(1974)

If a cleft produced by accumulation of a purulent exudate in the form of a microabscess involved one of the proliferating strands of epithelium , then the epithelial cells would be expected to line the cleft.

Another mechanism- epithelial cells become oriented in relation to their source of nutrition and the adjacent connective tissue.

In normal situation they cover a surface and finally desquamated

If the proliferating epitheliun beneath the surface ,as in granuloma ,cells will migrate inwards and desquamate in the center of mass.

Basic mechanism for cyst enlargement is similar but additional factors involved which differ from type to type

Steps involved: Attraction of fluid into cyst cavity Retention of fluid in the cavity Production of a raised internal

hydrostatic pressure Resorption of surrounding bone with an

increase in size of bone cavity

Harris (1974) classified theories of cyst enlargment:

Mural growtha) Peripheral cell division b)Accumulation of cellular content Hydrostatic enlargementa) Secretionb)Transduation and exudation Bone resorbing factor

Diagnostic features Symptoms of cyst Signs of cyst Clinical stages of cysts Secondary effects on jaw Investigation

Diagnostic features :Sign and symptoms of a cystic lesion

depend on 1. Dimension of lesion2. Type of cyst3. Location of cyst4. Important structures adjacent to cyst5. Presence of infection in the cyst

Symptoms of cyst :1. Pain and swelling2. Salty taste3. Difficulty in mastication 4. Ill fitting denture5. Displaced teeth6. Space between the teeth

Signs of cyst :1. Bone expansion2. Fluctuant swelling under oral mucosa 3. Non vital tooth(if radicular cyst)4. Missing tooth 5. Sinus formation with discharge6. Large cyst distortion of adjacent

structures7. Hollow sound on percussion

Clinical stages of cyst :1. Periosteal stimulation : curved

enlargement of bone2. Tennis ball consistency:can be indented

on percussion3. Egg shell crackling :micro cracks on

cortical plate4. Fluctuation :complete resorption of

bone overlying the cyst5. Sinus formation6. Infection due to contamination from

oral cavity

Secondary effects on jaw due to cyst :

1. Numbness 2. Pathological fracture of jaw 3. Secondary infection4. Malignant transformation

Investigation includes :

1. Radiographic examination/C.T. scan2. Contrast studies3. Aspiration 4. Vitality test 5. Biopsy

Radiograph for cyst1. IOPA for small periapical cyst to see tooth

involvegd2. Occlusal view to check lingual cortical

expansion 3. PNS view (occipitomental)to show relation

to maxillary antrum and nasal cavity4. Lateral oblique (mandible)to check

proximity to lower border5. PA view to check expansion of ramus of

mandible,survey of symphysis ,body and rami of mandible

6. OPG (shows entire affected region.size and site of the region can be assessed

Radiographic interpretations Radiographs help to define

site ,size,extent and marginal outline of lesion

Characteristic appearance of a cyst is a round or oval radiolucency surrounded by sharp radioopaque line of condensed bone

(this line missing in an infected cyst or a very large cyst that is growing rapidly.

Large cyst in mandible may displace inferior nerve canal, clearly seen in radiograph

Contrast studies To find out exact size and relation of the

cyst whose extent is doubtful. Water soluble contrast solution can be

injected to cyst after removing cystic fluid Avoid painful excess pressure in cystic

cavity After filling with radiopaque

dye ,essential radiographs are taken Contrast medium removed by aspiration

carefully to avoid negative pressure in cystic cavity

Aspiration

Cystic contents are aspirated using a wide bore needle(18 guage) and syringe(5 ml)

Different types of aspirates obtainedProvisional diagnosis may be based on

types of aspirate

Types of Aspirate

Diagnosis

Clear , pale , straw coloured fluid with cholesterol crystals

Dentigerous cyst

Creamy white , thick aspirate

Odontogenic cyst

Yellowish ,foul smelling fluid

Infected cyst

Blood 1.Needle in blood vessel

2.Vascular lesion

Air 1.Maxillary antrum2.Traumatic bone

cyst

On biochemical evaluation of aspirated fluid

If total protein content >4gm/100 ml indicataed radicular cyst or dentigerous cyst

If total protein content <4gm/100 ml indicated odontogenic keratocyst

Vitality test :

Vitality test is done for tooth involved in the cyst and those adjacent to it.

If tooth non-vital, it is most likely to be a radicular cyst.

Biopsy

When type of cyst is not confirmed by aspiration , a biopsy may be done to categorise the cyst prior to treatment plan.

Gold standard to determining the cyst and to differentiate from neoplasm.

Dentigerous Cyst Term given by Paget in 1963

Cyst which enclose the crown of an unerupted tooth by expansion of its follicle, and attached to its neck – shears 1983

Etiology Developmental in origin Considered to arise by the

accumulation of fluid between reduced enamel epithelium and the crown of an unerupted tooth or an impacted tooth

The eruptive forces in the tooth cause changes in the vascular hydrodynamics which results in sepration of reduced enamel epithelium from crown.

There is fluid accumulation between these two.

Basis of observations at operation and histologic examination distinguish two types :

1. Standard dentigerous cyst2. Extrafollicular variety

Asymptomatic unless they develop into very large cyst or get infected

Expansion of bone Facial asymmetry Displacement and root resorption of

adjacent teeth Pain may occur if secondary infection

supervenes

Radiographic Features

Unilocular ,well defined radiolucency with sclerotic margins around the crown of an unerupted tooth

Three radiographic types circumferential lateral paradental

Cyst Contents

Yellowish straw coloured fluid rich in cholestrol crystals

If cyst infected ,purulent material can be obtained on aspiration

Histopathological features Lined by stratified squamous

epithelium Lumen may contain fibrillar keratin Presence of bilaminated eosinophilic

amorphous hyaline like Rushton bodies Cholestrol crystals

Treatment Marsuplization Enucleation of cyst together with

removal of unerupted teeth This permits decompression of a

resulting decrease in the size of bone defects.

Odontogenic keratocyst term first coined by philipsen in 1956

These cyst are quite aggressive and usually extensive at the time of diagnosis

Very high recurrence rate

Pathogenesis –Developmental anomaly Arises from odontogenic epitheliumDental laminaBasal cells from overlying mucosaEnamel organ-by degenration of stellate

reticulum

Clinical featuresMost common in 2nd and 3rd decade of lifeMales more commonly affectdMandible more affected than maxillaMost common site is mandibular angle

regionGreatest recurrence rate –as high as 60%Asymtomatic usually until secondarily

infected

Radiographic features –Unilocular or multilocular radiolucencyIn early stages ,unilocular radiolucency

with well defined sclerotic marginIt can arise in any part of jaw and is

independent of the teeth,it can mimic any of the cyst radiographically e.g. dentigerous cyst,primordial cyst,radicular cyst

As OKC expands it causes severe bone destruction producing a multilocular radiolucency and soap bubble appearance radiographically

Cyst contentsContains dirty white materialCystic fluid has a large amount of

exfoliated keratin squamousSmear can be stained and examined for

keratinized cellsWhen keratin content is high ,the fluid

may appear thick and can be mistaken for pus but is odourless

Electrophoresis shows total protein content of fluid to be 4g/dl

Histological featuresEpithelium lining is usually

parakeratinizedEpithelial lining is of uniform

thickness ,5-8 layers of cellsBasal layer cell tall columnar and nuclei

are polarized giving tomb stone appearance

Connective tissue layer shows satellite cells or daughter cyst which have a high rate of invasiveness

Causes of high recuurence rateAggressive pecularity was first reported

by pindborg and Hansen (1963)Tendency to multiplicityPresence of satellite cyst Cystic lining is very fragile and thin ,

making it difficult to remove in one piece

Epithelial lining og keratocysts have an intrinsic growth factor

Cyst can arise from basal cell of mucosa

TreatmentBramley (1971/1974) had very rationally

outlined the surgical management of these cyst as followes

Small single cyst with regular spherical outline,enucleated from intra oral approach

Large or less accessible cyst with regular spherical outline ,enucleated from extraoral approach. Care should taken to ensure that all fragments of extremly thin lining are removed

Unilocular lesions with scalloped or loculated periphery and small multilocular lesions , treated by marginal resection ,while maintaining the continuity of posterior and inferior border.

If cystic lining is found to be adherent to overlying mucosa or muscle then it should be excised along with marginal excision

Defect is closed primarily and can be left to heal by secondary intention

Can be filled with hydroxyapatite crystals, autogenous bone graft, corticocanellous chips

Larger multilocular lesion with or without cortical perforation,may require resection of the involved bone followed by primary or secondary reconstruction with reconstruction plates or stainless stell mesh or bone graft like iliac crest graft,costochondral graft or allogenous bone graft.

It is a dilatation of the normal folicular space above the crown of the erupting tooth caused by accumulation of tissue fluid or blood

Smilar to dentigerous cyst which developes during the eruption of tooth when tooth is within the soft tissues surrounding the bone.

Also known as eruption hematoma

Clinical features

Smooth , round soft tissue swelling over an erupting tooth

Pink or bluish in colourNot commonly seen as they undergo

spontaneous rupture or disappears from masticatory trauma as the tooth enters the oral cavity

Radiographic features – Cyst in soft tissues, no significant

radiographic features are soon

Treatment – Marsupialisation

Soft tissue cysts on the alveolar crest of the gum pads of a newborn

Arise from remnants of dental lamina

Clinical features Appears as pearly white nodules 2-3 mm

in diameter on the alveolar ridgeMay be solitary or multiple Cyst appears white in colour due to

presence of keratin within the cyst Similar lesions on mid palatine raphe are

called epstein’s pearlsSimilar lesions on lingual , buccal aspect

of alveolar ridge are called Bohn’s nodules

Pathology Thin lining of stratified squamous cell

epithelium which may reveal parakeratinization

Contain desquamated keratin

Treatment No treatment as they rupture

spontaneously on eruption of underlying teeth

Soft tissue odontogenic developmental cyst

Location in gingival tissueEtiology :Remnants of dental lamina or cell rests of

serresFrom enamel organ or epithelial islands of

the surface epitheliumAs traumatic implantation cyst

Clinical featuresNo sex predilectionOccurs in 5th or 6th decade of lifeMandible is more frequently involvedRarely seen in anterior part of jawAsymptomatic, painless, slow growing,

Soft and fluctuantSeen in attached gingiva or the inter den

tal papilla on labial aspect, smooth surface

Adjacent teeth are normal

HitopathologyLined by stratified squamous cell

epithelium and contains fluid Treatment Surgical excision No tendency to recurrence

First reported by standish and shafer in 1958

Cysts occur in the lateral peridontal position

Inflammatory etiology

Clinical featuresOccurs in 4th to 7th decade of lifeMales are affected more than femalesMost frequent locations mandibular premolar

area,followed by anterior region of maxillaAsymptomatic Associated teeth vital3rd molar most common and any infection can

cause spreading infection of submandibular space

Radiographic featuresWell defined radiolucency round or ovoid with

sclerotic margin Lamina dura of the tooth destroyedSmaller than 1cm in size and present

between the cervical margin and apex of the tooth

In case of 3rd molar seen to be present in the bifurcation, buccal or lingual surface of roots

Pathogenesis Reduced enamel epitheliumRemnants of dental laminaCell rests of malassez

Cystic contentsSerous caseous contents

Pathology Lined by well formed , non keratinized

stratified squamous epithelial lining Localized epithelium proliferation may be

seenConnective tissue wall may show

inflammatory cell infiltrate

Treatment plan Enucleation

Weathers and Waldron 1973 Arises from odontogenic epithelial rests Variant of lateral periodontal cyst Gross appearance of large lesion

resembling a bunch of grapes ,hence the term botryoid

Clinical featuresOccurs in 5th -7th decade of lifeMost frequent location mandible in

cuspid-premolar regionSwelling may be presentPain ParasthesiaDischarge (rarely)

Radiographic features Unilocular radiolucency

Treatment Enucleation

First described by Gorlin in 1964 Shows features of cyst and tumourClinical featuresRelatively rare cystMost often seen in second decade,no sex

predilection but more common in children and young individuals

Mostly seen in anterior part of the jaw

Initially Symptomless Swelling Pain (rare)Peripheral or intraosseous lesion may be seenLater stages hard bony expansionSome cyst arise close to periosteum and

produce a saucer shaped depression in bone

Pathogenesis Remnants of dental laminaStellate Reticulum, Reduced enamel

epithelium

Radiographic featuresWell defined lesions with sclerotic or

diffuse borderSmall radiopaque flecks are seen in the

cystic cavity which is characterstic of this cyst

Some lesions are unilocular and some exhibit multilocular radiolucency

Cortical perforation May be associated with unerupted toothResorption of the roots of adjacent teeth

Histological featuresBasal layer is composed of cuboidal or

columnar cells with polarised nucleiMost peculiar feature is presence of

ghost cells. these are eosinophilic ,pale,swollen epithelial cells that have lost their nuclei

Treatment Enucleation

Padayachee and Van wyk 1987 Same characteristic with lateral

peridontal cyst or botryoid cyst Unilocular or multiloculat radiolucency Cortical plare expansion

TreatmentEnucleation Marsupialisation if lesion approach vital

structure

Also known as apical periodontal cyst Associated with roots of non-vital teeth Most common odontogenic cyst .in all

cases the pulp iis necrosedEtiology-Dental cariesFractured toothThermal /chemical injury to pulpIatrogenic pulp injury

Initiation and progression Dental caries

Chronic pulpitis

Pulp necrosis Periapical granuloma

Clinical featuresMost commonMales affected more than femalesOccurs in 3rd -4th decade of lifeIncidence highest in anterior maxillaAsymptomaticTooth must be non-vitalPain if associated with suppurationTemporary parasthesia

Radiological featuresRound or pear shaped or oval shaped

radiolucency outlined by a narrow radio-opaque margins

Treatment Enucleation with primary closure

Residual cyst ,that is overlooked after causative tooth or root is extracted

An incomplete removed pariapical granuloma An impacted tooth associated with a lateral

dentigerous cyst but cystic lesion unrecognized and left in situ,residual cyst persist and will enlarge

Cystic lesion developes on either a decidous or retained tooth which either exfoliatesor is extracted without knowledge of underlying pathology

Mainly in middle aged and elderly patient

No sex predilection Incidence greater in maxilla than

mandible Asymptomatic Occasionally sign of pathologic fracture

or signs of encroachment

Treatment

Enucleation with primary closure

First reported by Main 1970 Associated with a lateral accessory root

canal of a non vital tooth In 3rd decade of life Male mostly affected Mandibular 3rd molar mostly

Radiological featuresOften superimposed on the buccal root face as

well demarcated radiolucencies,often with corticated margin.

Periodontal ligament space not widened and lamina dura is intact around the tooth

Treatment Enucleation

Nasopalatine duct cystDerived from embryonic epithelial residues

in nasopalatine canalOr from epithelium included in lines of

fusion of embryonic facial processMay be occur within the nasopalatine

canal or in soft tissues of the palateAt the opening of the canal – cyst of

palatine papiilla

Clinical features Mostly 3rd to 6th decades of lifeHigher ratio of man affectedCommon symptom swelling Also occurs in midline on labial aspectMay produce bulging of nosePain and discharge which is salty in tasteDisplacement of teeth

Radiological featuresRound or oval shape radiolucency some

time Heart shape radiolucency in between the central incisors

Treatment Surgical enucleation

Nasolabial cyst –Occurs outside the bone in nasolabial

folds below the alae nasiArises from epithelium enclaved at the

site of fusion of the globular, lateral nasal and maxillary process

It could develop from remnants of embryonic nasolacrimal rod or duct

Wide age spread from 12-75 yearsWomen affected moreSwelling Pain and difficulty in nasal breathingSlow growingSwelling of lip, fill out the nasolabial and

lift the alae nasaiFluctuant

Radiological features-Radiolucency of alveolar process above

the apices of incisors teeth Treatment Enucleation

Solitary bone cyst Aneurysmal bone cyst

Jaffe and Litchtenstein 1942 Often seen in lonf bones and spine

Aetiology Trauma Possible relationship with giant cell lesionVariations in hemodynamics of areaSudden venous occlusion

Clinical featuresVery rareChildren and young adults mostly affectedMandible affected more than maxillaFirm swelling Displacement of teethEgg shell cracklingLesion not pulsatile

Treatment Complete curretage Local excision with bone grafting

Termed as haemorrhagic bone cyst

Aetiology Trauma and haemorrhage with failure of

organization Spontaneous atrophy of the tissue in a

central benign giant cell lesion Abnormal calcium metabolism Chronic low grade infection

Clinical featuresOccurs in children and adolescentMale predlictionMandible affected moreSymptomlessExpansion of lingual cortex

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.

Rationale behind treating a cyst To avoid displacement and loosening of

teeth To avoid pathological fractures of the

jaw due to expanding lesion To avoid displacement of the inferior

alveolar canal and destruction of other vital structure around the cyst

To aim at removing the entire lining, preserving the adjacent structures

Operative Procedures

Basically two types Enucleation Marsupialization

EnucleationEnucleation and packingEnucleation and primary closureEnucleation and primary closure with

reconstructionEnucleation wth chemical cauterisation MarsupialisationPartsch IPartsch IIMarsupialization by opening into nose or

antrum

Marsupialisation or Partsch I operation also known as cystotomy or

decompression Partsch 1892 described a type of

compression procedurePrinciple :Marsupialization or decompression refers

to creating a surgical window in the wall of cyst, and evacuate cystic contents

Indication

Age - Young child with developing tooth buds

When development of the displaced teeth has not progressed,and enucleation would damage the tooth buds.

Proximity to vital structures – when proximity of cyst to vital structures, could create an oronasal ,oro antral fistula , injure neurovascular structures or damage vital teeth

Eruption of teeth – marsupialization permit the eruption of unerupted teeth

Size of cyst – very large cyst where enucleation

could result in a pathological fracture

Vitality of teeth- when apices of the many adjacent teeth are involved with in the large cyst

Advantages Simple procedure to performSpares vital structuresAllows eruption of teeth Prevents oro nasal oroantral fistulaPrevents pathological fractureReduces operating timeReduces blood lossHelps shrinkage of cystic liningAllows for endosteal bone formation to

take place

DisadvantagesPathologic tissue is left in situHistologic examination of entire lining is

not doneProlonged healing timeInconvenience to the patientProlonged follow up visits Periodic irrigation of cavityRegular adjustment of plugPeriodic changing of packSecondary surgery may be needed

Anaesthesia Aspiration Incisions – circular oval eliptical inverted ‘u’ Removal of bone Removal of cystic lining specimen Irrigation of cystic cavity

Suturing Packing – white head’s varnish tincture of benzoin bismuth iodine paraffin

paste(BIPP) Maintenance Use of plug Healing

Waldron’s method(1941) Two stage technique Combination of two standard technique First marsupialization Second enucleation,when the cavity

becomes smaller

IndicationsWhen bone has covered the adjacent vital

structuresAdequate bone fill has strengthened the

jaw to prevent fracture during enucleation

Pt. finds difficult to clean cavityFor detection of any occult pathologic

condition

Advantages

Development of a thickened cystic lining which makes enucleation easier

Spares adjacent vital structuresCombined approach reduces morbidityAccelerated healing processAllows histopathological examination of

residual tissue

Disadvantages

Patient has to undergo secondary surgery and possible complications

Cyst that have destroyed a large portion of of the maxilla and have ancroached on the antrum or nasal cavity

Technique 1. Anaesthesia2. Incision – gingival curvilinear incision

taken along the involving teeth3. Two releasing incision are made at

45°angle and extending in to buccal sulcus

Mucoperiosteal flap is raised Removal of bone(usually in large

cysts ,an opening already exist)This stage a window is made by

removing a portion of cystic lining like partsch I technique

Second unroofing is performed by removing antral lining presents between the cavities

This allows the cyst cavity to become lined with normal ciliated and mucous secreting epithelium regenrating from the respiratory mucosa other than a squamous epithelium

Additionally intranasal antrostomy may be performed .

Cavity packed with a ribbon gauze soaked withtincture of benzoin or antibiotic ointment

Principle - surgical removal of entire cystic lining

Shelling out of the entire cystic lining without rupture

After enucleation of the cyst the underlying space filled with blood clot,which eventually organizes to form normal bone

IndicationsTreatment of OKCRecurrence of cystic lesions of any

cyst type

Advantages-Primary closure of woundsRapid healingPostoperative care is reducedThorough examination of entire cystic

lining can be done

Disadvantages – In young persons , the unerupted teeth

in dentigerous cyst will be removed with the lesion

Removal of large cystic lesion in mandible ,making it prone to fracture

When a cyst involves the apices of one or more teeth in such a way that the blood supply to the pulp passes through the capsule of lesion,enucleation of cyst could be result in pulpal necrosis

Enucleation with primary closure-AnaesthesiaIncision- envelope flap trapezoidalElevation of Mucoperiosteal flapBone removalExposure of cystic liningTry to remove entire cyst lining in a single

pieceIrrigation of cavity and hemostasis ensuredsuturing

Enucleation with open packing large cyst which was previously

infected ,closure may not be possiblethe wound is packed with gauze

impregnated with bismuth idoform parafin paste (BIPP) or whitehead’s varnish.

Whitehead’s varnish contains Benzoin 10 gm, Storax 7.5 gm, Balsam of tolu 5gm, iodoform 10 gm, solvent ether upto 100ml

Enucleation with bone curettageAfter enucleation if there is a doubt that a

part of lining has been left behind, it can be curetted out

A bone curett is used to scrap the bone and remove any remaining lining

Enucleation with peripheral osteotomyInstead of using a curett a large round

burr may be used to remove around 1-2mm of bone around the entire peripheral cavity

Enucleation with chemical cauterisation Stoelinga has advocated the use of

carnoy’s solution Mainly indicated in OKC.

Carnoy’s solution contains Glacial acetic acid, Choloroform, Absolute alcohol, Ferric chloride

Enucleation with bone graftingBone grafting with autogenous

cancellous bone grafts can be done in case of large bony defects

Bone graft obliterates the cavity and stimulates osteogenesis

There is , however , a risk of infection of the bone graft which may lead to failure

Segmental resection

Indicated when there is a large odontogenic keratocyst with massive bone destruction

Indicated when there is suspected neoplastic transformation of the cyst

Procedure Anaesthesia Incision – a submandibular incision ,

which may at times be required to extend into postramal region,is taken 1.5 – 2 cm below thr inferior border of mandible

Incision extends ,through skin and subcutaneous tissue,blunt and sharp dissection carried out layerwise through tissue planes e.g. superficial cervical fascia ,platysma ,and deep cervical fascia.

Care is taken to marginal mandibular nerve and facial artey and vein are clamped and ligated

Small bleeders cauterized with diathermyPterygomassetric sling divided ,periosteum

incised down to bone and flap is raised superiorly to expose the bone

Depending upon the extent of lesion involvement to surrounding tissues ,enucleation or marginal resection done.

Risk of bone fracture (pathological)If fracture occurs during surgery,after

removal of cyst bone plating should be done to strength the mandible

Inferior dental nerve involvementIf cyst is in very close proximity with to

neurovascular bundle,possibility of damage must be explained to pt.in advance

Management of teeth related to cyst

Diagnosis is always very important to decide the treatment plan of the cyst

Care always should be done to prevent nearer structure or tooth or tooth bud.

A text book of cyst and management by shears

Text book of minor oral surgical procedure by jeffery L.hoe

Text book of oral surgery part II-by laskin Text book of oral minor surgery by killey n keys Text book of oral pathology by shafers Text book of oral maxillofacial surgery by

neelima malik