Prepared by

P.Nandakumar

VTECH

CYSTIC SWELLING OF THE JAWS

DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY

CYST - DEFINITION

Pathologic cavity or sac within the hard or soft tissues that may contain fluid, semifluid or gas. It may be lined by epithelium, fibrous tissue or occasionally even by neoplastic tissue.Initially, cysts do not contain pus, when cystic contents secondarily infected, pus develops.

Cyst Formation

Cyst initiation - Proliferation of epithelial lining & formation of small cavityEnlargement / Expansion of cystic cavity then occurs.

CLASSIFICATION

Cysts of the jaws, oral and facial soft tissues

Intraosseous Cysts Soft Tissue Cysts

Epithelial cystsNon-epithelial cysts Cysts of maxillary antrum

Odontogenic cystNon-odontogenic cyst (Fissural cyst)

DevelopmentalInflammatory

INTRAOSSEOUS CYSTS

Epithelial cystsOdontogenic epithelial originDevelopmentalPrimordial cyst (keratocyst)Dentigerous (follicular) cystLateral periodontal cyst lateral botryoid odontogenic cystCalcifying odontogenic (Gorlin) cystInflammatoryRadicular cyst (apical/lateral periodontal)Residual cystNon-odontogenic epithelial originFissuralMedian mandibularMedian palatalGlobulomaxillaryIncisive canal (nasopalatine duct or median anterior maxillary) cyst

Non-epithelial cystsSolitary bone cyst (traumatic)Aneurysmal bone cystStafnes bone cavityCysts of the maxillary antrumSurgical ciliated cyst of maxillaBenign mucosal cyst of the maxillary antrum

SOFT TISSUE CYSTS

OdontogenicGingival cystsAdultNewbornNonodontogenicAnterior median lingual cystNasolabial cyst (or nasoalveolar cyst)Retention cystsSalivary gland cystsMucoceleRanula

Developmental/congenital cystsDermoid and epidermoid cystsLymphoepithelial cyst (cervical / intraoral)Thyroglossal duct cystCystic hygromaParasitic cystsHydatid cystsCysticerocisHeterotropic cystsOral cysts with gastric or intestinal epithelium

INTRAOSSEOUS CYSTS
(A) ODONTOGENIC EPITHELIAL ORIGIN
1) PRIMORDIAL CYST (KERATOCYST)

The term keratocyst coined by Philipsen (1956) and was based on histologic appearances of the cystic lining.Two variants are identified: (a) orthokeratinized and (b) parakeratinized odontogenic keratocysts

IncidenceSlight predilection for males.Predominantly seen in second, third and fourth decades.SiteAngle of mandible.Majority of cysts seen posterior to first bicuspids.Clinical featuresPatient is free of symptoms until cysts reached large size because the cyst initially extends in medullary cavity and expansion of bone occurs late.Displacement of teeth.

Teeth overlying cyst produce dull / hollow sound on percussion.Buccal expansion of bone.Teeth adjoining cyst will have vital pulps.Large mandibular cysts, deflect neurovascular bundle into abnormal position.In acute infection, pus within the sac causes neuropraxia which results in labial paresthesia.When pus is drained, sensation returns to normal.

Radiological featuresKeratocyst can be uniocular or multiocular.Buccal and lingual expansion is seen.Resorption of lower cortical plate of mandible.Perforation of bone.Cyst contentsContain a dirty white, viscoid suspension of keratin which an appearance of pus but without an offensive smell.

TreatmentSmall single cysts with regular spherical outline Enucleation from intraoral approach.Larger cysts with regular spherical outline Enucleation from extraoral approach.Uniocular lesions with scalloped outline Marginal excision.

Larger multiocular lesions with or without cortical perforation Resection of involved bone followed by primary or secondary reconstruction with stainless steel, vitallium, titanium and bone grafting with iliac crest graft, costochondral graft or allogenous bone graft.Carnoys solution for conservative approach to large keratocysts and used to cauterize bony defect.

2) DENTIGEROUS (FOLLICULAR) CYST)

Resulted from enlargement of the follicular space of whole or part of crown of an impacted or unerupted tooth and is attached to neck of tooth.IncidenceSlight predilection for males.Seen in first, second, third decades.SiteCommon in mandible.

Clinical featuresFacial asymmetry.Ill-fitting dentures.Adjacent teeth fail to erupt or may be tilted.Lateral expansion causes smooth, hard, painless, prominence, later as cyst expands, bone become thinned and indented with pressure on palpation.Egg-shell crackling sound.

Radiological featuresUniocular radiolucency.Cysts have well-defined sclerotic margin unless when they are infected the margins are poorly defined.With pressure of enlarging cyst, unerupted tooth may be pushed into abnormal positions.Causes root resorption of adjacent teeth.

E.g.Lower third molar pushed into inferior border or into the ascending ramus.Upper incisors, canines pushed into maxillary sinus or floor of nose.Dental follicle expand around unerupted or impacted tooth in 3 variations;circumferential,lateral, andcentral or coronal.

PathogenesisDevelop by accumulation of fluid between reduced enamel epithelium or within enamel organ itself of unerupted or impacted teeth.Also due to degeneration of stellate reticulum at early stage of development.Cyst contentsContain clear yellow fluid in which cholesterol crystals may be present or purulent material if infection occurs.

TreatmentMarsupialization (Partsch surgery) Indicated in children if the cyst is very large in size and involved tooth to be maintained.Enucleation Cyst enucleated together with involved tooth in adults, as the possibility of the tooth erupting is low.

3) DEVELOPMENTAL LATERAL PERIODONTAL CYSTS

Found lateral to roots of vital teeth.IncidenceCommonly found in adults.No age or sex predilection.SiteCommon in mandible.Often related to mandibular cuspid, bicuspid, and third molar roots.

Clinical featuresAssociated teeth is vital.At times gingival swelling occur on buccal or lingual aspect.Lingual type of cyst involving mandibular third molar are more common and if infected can cause sever spreading infection of submandibular space.Radiological featuresLoss of lamina dura.Well-defined round or ovoid radiolucency with sclerotic margin.Cyst present between cervical margin and apex of root.

PathogenesisOrigin is from reduced enamel epithelium, remnants of dental lamina or cell rests of malassez.Cystic contentsHas serous caseous conent.TreatmentEnucleation.

4) CALCIFYING EPITHELIAL ODONTOGENIC CYST

Also known as Gorlin cyst.IncidenceNo sex predilection.More common in children and young adults.SiteCommon in anterior part of mandible.

Clinical featuresSwelling of jaw.Hard bony expansion of lesion.Lingual and palatal expansion.Cysts arise close to periosteum produce saucer-shaped depression in the bone.Displacement of teeth.

Radiological featuresUniocular or multiocular.Cortical perforation.Calcifications as irregular radiopaque specks seen within bone cavity.Resorption of roots of adjacent teeth.Cyst associated with complex odontome or unerupted tooth.

PathogenesisArises from remnants of dental lamina, stellate reticulum or reduced enamel epithelium.TreatmentEnucleation.If associated with complex odontoma, a conservative removal is adequate.

5) RADICULAR CYST

It is an inflammatory cyst results due to infection extending from pulp into surrounding periapical tissues.IncidenceMost common odontogenic cyst.Commonly affects males.Peak incidence is in the third and fourth decades.SiteCommon in anterior maxilla.

Clinical featuresTeeth with non-vital pulps.Slowly enlarging swellings.Pain present in the presence of suppuration.Bony hard swelling with the covering bone become thin and exhibits springiness on fluctuation.Intra oral sinus tract with discharging pus or brownish fluid when cyst is infected.Tooth sensitive to percussion, hypermobile or displaced.Pathologic fracture.Temporary parasthesia of regional nerve if cyst is infected.

Radiological featuresRound, pear or ovoid shaped radiolucency, generally outlined by narrow radio-opaque margin that extends from lamina dura of involved tooth.Root resorption is rare.

Pathogenesis

Occurs in three phases;

Phase of initiation

Chronic low grade invasion from pulp

Periapical granuloma

(Activation and proliferation)

Epithelial rests in periodontal ligament

(forms)

Strands, arcades or rings.

Phase of cyst formationCystic cavity forms, lined by stratified squamous epithelium.Phase of enlargementOnce initiation of cyst occurred, continuation of enlargement occur due toAccumulation of fluidRetention of fluidRaised intracystic pressure

Cystic contentsUninfected cyst fluid Straw coloured, or brownish and has cholesterol clefts.Long standing infection a dirty white caseous material present.TreatmentEnucleation with primary closure is treatment of choice.Non-vital teeth associated with cyst can be extracted or retained by endodontic procedures or apicocetomy.Large cyst encroach upon maxillary antrum or inferior alveolar nerve or nose treated by marsupalization.

6) RESIDULAL CYST

It is one that overlooked after the causative tooth or root is extracted.EtiologyIncompletely removed periapical granuloma, or cyst that potentially enlarges.IncidenceNo sex predilection.Common in middle-aged and elderly patients.SiteCommon in maxilla and edentulous site.Clinical featuresMostly asymptomatic.Pathologic fractures.TreatmentEnucleation with primary closure.

(B) NON-ODONTOGENIC EPITHELIAL ORIGIN
1) MEDIAN MANDIBULAR CYST

IncidenceNo sex predilection.SiteFound symmetrically in the midline of mandible.Clinical featuresCyst is small in size and approximately 1-3 cm in size.Associated teeth are vital.Labial swelling is palpable.Teeth may be divergent.

Radiological featuresCyst is small, well-defined, circular or ovoid in shape.Lamina dura is intact.TreatmentEnucleation

2) MEDIAN PALATAL CYST

IncidenceNo sex predilection.Mainly seen in adults.SiteSeen in maxillary alveolus or in hard palate.Clinical featuresExpansion of bone.Palpable ovoid swelling in mid-palatal region.Radiological featuresOvoid or irregular radiolucency in mid-palatal region.TreatmentEnucleation with primary closure.

3) GLOBULOMAXILLARY CYST

Also termed as lateral fissural cyst.IncidenceSeen in adults and in either sex.SiteBetween maxillary lateral incisor and canine.Clinical featuresLateral incisor and canine tilted coronally with root divergence.Both teeth vital.

Radiological featuresPear shaped radiolucency seen between maxillary lateral incisor and canine with apex pointing toward alveolar crest.Lamina dura intact.Root divergence present.TreatmentEnucleation with primary closure.

4) NASOPALATINE DUCT CYST

IncidenceSeen in adulthood.Slight predilection for male.SiteCommon in lower portion of maxilla between apices of central incisor.

Clinical featuresAsymptomatic.Do not enlarge beyond 1.5 to 2 cm.Recurrent swelling in the anterior region of midline of palate or on the labial aspect between central incisors.Displacement of teeth.Patient complains swelling, pain discharge.Discharge is salty taste and originate from sinus tract at or near incisive papilla.Burning sensations or numbness.

Radiological featuresWell-defined cystic outline between or above roots of maxillary central incisors.Round or ovoid or heart-shaped radiolucency seen between maxillary central incisors.Lamina dura intact.Roots are divergent.Cystic contentMucoid material or pus present if the cyst is infected.TreatmentEnucleation.

(C) NON-ODONTOGENIC NON-EPITHELIAL BONE CYSTS
1) SOLITARY BONE CYST

IncidenceOccur in children and adolescents.Males are affected more.SiteCommon in subapical region above the inferior dental canal in the canine and molar region.Clinical featuresAssociated teeth vital unless involved.Cortex is thinned.Expansion involves lingual aspect below mylohyoid ridge.Radiological featuresUniocular cavity.TreatmentGentle curettage.

2) ANEURYSMAL BONE CYST

IncidenceNo sex predilection.Seen mainly in children, adolescents or young adults.SiteCommon in posterior region of mandible.Clinical featuresFirm swelling, rapid enlargement.Displacement of teeth, though they are vital.Egg-shell crackling.Not pulsatile.

Radiological featuresUniocular radiolucency.Ballooning of cortex.Honeycomb or soap-bubble appearance.Outer cortical plate destroyed.Displacement of teeth.Root resorption.Cystic contentDark venous blood.TreatmentCurettage.Local excision with bone grafting.

3) STAFNES BONE CAVITY

IncidenceCommon in children.SiteCommon in mandible.Clinical featuresSymptomless.Non-progressive lesions.Radiological features1 3 cm in size and appear as round or oval defect below inferior alveolar canal.TreatmentRegular radiological follow-up.

CYSTS OF THE MAXILLARY ANTRUM
1) SURGICAL CILIATED CYST OF MAXILLA

SiteClose proximity to maxillary sinus, but no communication between them.Clinical featuresDull, localized pain in maxilla.Cystic lesion not associated with any tooth.Radiological featuresWell-defined radiolucent expansion of maxilla with radiopaque margin.Cyst appear to encroach upon the sinus.TreatmentEnucleation

2) BENIGN MUCOSAL CYST OF THE MAXILLARY ANTRUM

IncidenceHigher incidence in third decade.SiteIn floor of sinus.Clinical featuresDull pain over antral region.Numbness in maxillary region.Nasal obstruction, yellowish discharge from nose.

Radiological featuresSpherical, ovoid radiopacities within maxillary antrum.TreatmentCaldwell-Luc approach in symptomatic patients.Drainage via cannulation through intranasal antrostomy in asymptomatic patients.

SOFT TISSUE CYSTS
1) NASOLABIAL CYST

IncidenceCommonly seen in females.SiteAbove buccal sulcus under ala of nose.Clinical featuresSwelling is seen involving lip that lifts up nasolabial fold and obliterates labial sulcus.Cysts are fluctuant and painless unless infected secondarily.TreatmentSurgical removal by intraoral approach.

RETENTION CYSTS
2) MUCOCELE

IncidenceMinor salivary gland.No predilection for age or sex.SiteCommon in lower lip.Also occurs in cheeks, ventral surface of tongue, floor of mouth, retromolar area.

Clinical featuresPainless cyst.Well-circumscribed swellings on mucosa.Do not exceed 1-2 cm in size.Fluctuation is positive.It may be translucent or bluish.TreatmentSurgical excision with associated minor salivary gland tissue and surrounding connective tissue.

3) RANULA

SitePresent on the floor of mouth, beneath tongue.Two types have been identified (i) superficial ranula, and (ii) plunging ranula.Clinical featuresDome-shaped bluish swelling of superficial ranula seen located laterally in the floor of mouth beneath tongue.Tongue may be displaced as it enlarges.TreatmentSurgically remove sublingual gland.

OPERATIVE PROCEDURES

MARSUPALIZATION (DECOMPRESSION)Partsch IPartsch IIMarsupalization by opening into nose on antrumENUCLEATIONEnucleation and packingEnucleation and primary closureEnucleation and primary closure with reconstruction/bone grafting

MARSUPALIZATION (DECOMPRESSION)

PrincipleCreating a surgical window in the wall of the cyst and evacuation of the cystic contents.Decreases intra-cystic pressure and promotes shrinkage of the cyst and bone fill.The only portion that is removed is the piece removed to produce the window.IndicationsAge in young child, enucleation damage tooth buds.Proximity to vital structures.Eruption of teeth.Size of cyst.Vitality of teeth.

AdvantagesSimple procedures to perform.Spares vital structures.Allows eruption of teeth.Prevents oronasal, oroantral fistulae.Prevents pathological fractures.Reduced operating time, blood loss.Alveolar ridge preserved.Allows for endosteal bone formation.

DisadvantagesPathologic tissue is left in situ.Prolonged healing time.Inconvenience to patient.Periodic irrigation of cavity.Regular adjustments of plug.Periodic changing of pack.Formation of slit-like pockets that harbor foodstuffs.Risk of invagination and new cyst formation.

SURGICAL TECHNIQUE
PARTSCH I

AnaesthesiaAdministration of general anaesthesia / conscious sedation or simple local anaesthesia of the area.AspirationIncisions types: Circular, oval, elliptic, inverted U shaped.Removal of boneThin bone initial incision can be extended through mucoperiosteum, bone and cystic lining into cystic cavity.Thick bone bur holes re chilled in circular shape, and removed with rongeurs.

Post Operative

Pre Operative

Marsupialization (Partsch I Operation)

Removal of cystic lining.Visual examination of residual cystic lining.Irrigation of cystic cavity.SuturingThe remaining cystic lining is sutured with the edge of the oral mucosa of continuous or interrupted sutures.PackingThe cavity is packed with ribbon gauze which is impregnated with antibiotic ointment, tincture of benzoin or bismuth iedoform paraffin paste.This pack prevent contamination of cavity with food debris and provide coverage to the wound margins.

Maintenance of cystic cavityCleaning and irrigation of the cavity by regular flushing with oral antiseptic rinse.Use of plugPlug prevent the contamination of cystic cavity and preserve the patency of cyst orifice.It should be made of resilient material to avoid irritation to the raw margins.Healing

Intra Oral View

Radiographic View

Incision

Marsupialized Cavity

MODIFICATIONS OF MARSUPIALIZATION
PARTSCH II

Its a two stage technique, first marsupialization is performed and when the cavity becomes smaller, enucleation is performed.IndicationsPatient finds it difficult to clean the cavity.Bone has covered adjacent vital structures.

AdvantagesAccelerated healing process.Spares adjacent vital structures.Development of a thickened cystic lining, which makes enucleation easier.DisadvantagesPatient has to undergo secondary surgery and possible complications may occur.

Marsupialization (Partsch II Operation)

Cyst capsule is shelled out, followed

by primary closure of wound

MARSUPIALIZATION BY OPENING INTO NOSE OR ANTRUM

AdvantagesPrimary closure of the oral wound.Adjacent structures are protected.Cystic cavity is opened into maxillary sinus or nasal cavity thereby reducing intracystic pressures.DisadvantagesDevelopment of oroantral or oronasal fistula if there is breakdown of the wound.

ENUCLEATION

PrincipleAllows for the cystic cavity to be covered by a mucoperiosteal flap and space fills with blood clot which organize and form normal bone.IndicationsTreatment of odontogenic keratocyst.Recurrence of cystic lesions of any cyst type.

AdvantagesPrimary closure of the wound.Healing is rapid.Postoperative care is reduced.DisadvantagesAfter primary closure, its not possible to directly observe the healing of the cavity.Damage to adjacent vital structures.Pulpal necrosis.Unerupted teeth in dentigerous cyst will be removed in young patients.

SURGICAL TECHNIQUE
ENUCLEATION AND PACKING

This technique is advocated when it is believed that due to previous infection or infected large cysts, primary closure would be unsuccessful.Enucleation is performed and then cavity is packed as in marsupialization.Wound heals with granulation tissue until epitheliazation is complete.This method is also used as a secondary measure when there is a dehiscence after primary closure.

ENUCLEATION WITH PRIMARY CLOSURE

Enucleation of small cystic lesion from an intraoral approach

Local anesthesia or general anesthesia

Incision placed around necks of involved teeth

Flap is reflected with periosteal elevator

Underlying cyst lining is gently eased away from cavity wall with curved curettes

Care to be taken to prevent rupture of lining

Teeth that required to be removed are extracted

Cyst cavity inspected, any residual remnants removed separately with mosquito artery forceps

Bleeding points arrested with pressure packs, bone wax, gel foam, diathermy

Wound is flushed with normal saline and antiseptic solution (provide iodine 2%)

Filling material is packed to obliterate the cavity prior to closure

e.g. resorbable sponge, autogenous bone chips, hydroxylapatite crystals

Flap is replaced

Interdental sutures placed.

Incision

Reflection

Exposure

Delivery