CHAIRSIDE INVESTIGATIONS OF CYSTS-1.pptx

Presentation on how to investigate a cystic jaw swelling

1. CHAIRSIDE INVESTIGATIONS OF CYSTS. DR BABARINSA I.A (BDS LAGOS)

2. OUTLINE INTRODUCTION. CLASSIFICATION OF CYSTS OF THE MOUTH AND JAWS. PRINCIPLES OF TREATMENT OF CYSTS. EXAMINATION AND CHAIR SIDE INVESTIGATIONS. SUMMARY.

3. INTRODUCTION A cyst is a pathological cavity having fluid, semi-fluid or gaseous contents and which is not created by the accumulation of pus. It is usually, but not always, lined by epithelium. (Kramer 1974). There are three basic structures in a cyst:: A lumen . An epithelial lining. An outer wall/capsule.

4. INTRODUCTION Cysts of the jaws are more common than in any other bone, and the majority are lined wholly or in part by epithelium. Although the pathogenesis of many of these cysts is poorly understood, they are divided into two main groups depending on the origin of the lining epithelium.

5. CLASSIFICATION OF CYSTS Shear’s modification of WHO classification 2007: (International Reference Centre for Histopathological Definition and Classification of Odontogenic Tumors, jaw cysts and Allied lesions ). I. Cysts of the jaws. II. Cysts associated with the maxillary antrum. III . Cysts of the soft tissues of the mouth, face, neck and salivary glands.

6. Cysts of the jaws A. Epithelial lined. B. Non-epithelial lined. Epithelial-lined cysts 1.Developmental origin. 2. Inflammatory origin. Developmental Cysts ( a) Odontogenic (arising from odontogenic tissues). ( b) Non-odontogenic (arising from ectoderm involved in the development of the facial tissues).

7. Developmental Odontogenic epithelial lined jaw cysts: i . Gingival cyst of infants. ii. Odontogenic Keratocyst . iii . Dentigerous cyst. iv. Eruption cyst. v . Gingival cyst of adults. vi. Developmental lateral periodontal cyst. vii . Botryoid odontogenic cyst. viii. Glandular odontogenic cyst. ix. Calcifying odontogenic cyst.

8. INFLAMMATORY ODONTOGENIC CYST Radicular cyst, apical and lateral, residual cyst. Paradental cyst. Non-odontogenic cysts ( Fissural cysts) Nasopalatine duct cyst. Nasolabial cyst. Globulomaxillary cyst. Median palatal cyst. Median mandibular cyst.

9. Non-epithelial-lined cyst{ pseudocysts } 1. Solitary bone cyst. 2. Aneurysmal bone cyst. 3. Stafne bone cyst.

10. CYSTS ASSOCIATED WITH THE MAXILLARY ANTRUM Mucocele ; mucous retention cyst or mucous extravasation cyst . Surgical ciliated cyst of the maxillary antrum. CYSTS OF THE SOFT TISSUES OF THE MOUTH, FACE AND NECK Dermoid and Epidermoid cysts. Lymphoepithelial (branchial) cyst. Thyroglossal duct cyst. Anterior median lingual cyst ( Intralingual cyst of foregut origin ). Oral cysts with gastric or intestinal epithelium (oral alimentary tract cyst ). Cystic hygroma . Nasopharyngeal cyst. Cysts of the salivary glands: mucous extravasation cyst; mucous retention cyst; ranula ; polycystic ( dysgenetic ) disease of the parotid. Parasitic cysts: hydatid cyst; Cysticercus cellulosae ; trichinosis.

11. HISTOGENETIC CLASSIFICATION OF ODONTOGENIC CYSTS Dental lamina rests (Rests of Serres ) Lateral periodontal cyst. Odontogenic keratocyst . Gingival cyst of adults. Dental lamina cysts of newborn. Glandular odontogenic cyst (Sialo-odontogenic cyst ). Reduced enamel epithelium Dentigerous cyst. Eruption cyst. Paradental cyst. Hertwig's epithelial root sheath (Rests of Malassez ) Periapical cyst.

12. PRINCIPLES OF TREATMENT History taking. Clinical Examination. Radiographic Examination. Aspiration of cyst.

13. History The first step towards diagnosing cysts is via a thorough history and physical examination. Some cyst have age, gender and site predilection. Some can occur following trauma ( e.g mucocele ) while some may give a history of previous extractions and impacted teeth (which could point towards Primordial or Dentigerous cyst). Larger cysts may cause swelling of the jaw or face which in the edentulous may be associated with difficulty in wearing dentures. In the mandible, pressure on the inferior dental nerve almost never gives rise to mental anesthesia or paresthesia.

14. Clinical Examination Missing teeth must be charted and the standing teeth carefully examined for caries, periodontal disease, mobility and impaction . Missing teeth is associated with dentigerous /primordial cyst while loosening of the tooth relates to the late stage of the cyst. The vitality of all teeth near lesion must be tested with an electric pulp tester and the results compared with similar teeth on the unaffected side . Radicular (Periapical) Cyst is associated with Non-vital tooth.

15. Clinical Examination On palpation, the consistency could also help in making a diagnosis of the cyst. This can range from Bony hard to depressible (ping-pong) to egg-shell cracking . It could be fluctuant sometimes (soft tissue cyst or late stage bone perforation).

16. Aspiration of cyst. Looking at the colour of the aspirate also helps in knowing the type of cyst.

17. ASPIRATION PROCEDURE Before recommending a cyst aspiration, make sure the patient does not have a bleeding abnormality and that they have normal vital signs (e.g. pulse, blood pressure, temperature). Then, based on radiographs, select the logical entry point for the aspiration needle where the bone is thinnest. Select the needle (20 gauge is common) and connect it to a 10 cc syringe. Using a standard 27 gauge needle and local dental anesthetic, anesthetize the mucosa or gingival area where you will insert the larger aspirating needle. Once the entry point tissue is numb, insert the 20 gauge needle through the tissue and overlying bone into the cyst. Once the needle is inside the cyst, withdraw fluid and then the needle. Apply pressure gauze until any bleeding at the entry point stops.

18. Do not drive the large gauge needle in and out multiple times in sensitive anatomic areas in order to avoid damage to structures, such as the Inferior Alveolar nerve in the mandible which could lead to post-op nerve damage. Occasionally one will find that the bone is too dense to allow needle penetration.  In these cases one must lay a flap and using a bone drill open a small hole through which the needle can be inserted inside the cyst.  Care must also be taken not to penetrate the cyst with the bone bur.

19. Aspiration of cyst. If blood is present and it clots on standing, it is indicative of either a Solitary bone cyst or a central hemangioma. On the other hand if blood is present and it does not clot on standing, Aneurysmal bone cyst is likely to be indicated. If pus is present, it is indicative of an infected cyst or an abscess .

20. Aspiration of a dirty white or greyish viscous fluid from the cyst suggests Odontogenic Keratocysts . Aspiration of a straw or golden yellow colored fluid from the cyst suggests Dentigerous cyst or U nicystic A meloblastoma . Aspiration of a Y ellow-brownish fluid with cholesterol crystals from the cyst suggests Radicular cyst .

21. Aspiration of Cheesy white fluid is suggestive of Dermoid Cyst. No fluid on aspiration could be either due to wrong technique or be indicative of a solid tumour . Air aspiration is suggestive of a traumatic bone cavity.

22. Content of the aspirate may also be smeared On white clothe/blotting paper, cholesterol crystals may appear shiny on exposure to sunlight ( shimmering effect ) in the case of Radicular cyst. H & E stain – inflammatory cells & blood cells. Papanicolau stain – Keratin.

23. Microscopic examination of aspirates could also show the presence of cholesterol, soluble protein by means of electrophoresis . Electrophoresis of cystic content (using Serum as control) shows Radicular and dentigerous cysts show reduction in the high molecular weight proteins & globulin. protein content is in excess of 4.0 gm per 100 ml. Non-infected Keratocysts have no distinct soluble protein band . Total protein content in the fluid is less than 5 gm per 100 ml and most of the protein content is  Albumin  which is a less soluble protein .

24. Quantitative electrophoresis test Keratocysts have soluble protein content < 4g/100mls while other cysts & cystic tumours >5g/100mls (infection/contamination of aspirate may distort these results.) Total protein content is about 5 -11 gm per 100 ml for periodontal cysts ( Albumin – 2.5 to 5g/dl, Globulin – 2 to 5 g/dl). Bilirubin estimation: Fluid from solitary bone cyst will clot on standing and fluid exuded from the clot has high Bilirubin concentration.

25. Incisional biopsies: They are i ndicated if Cystic lesion is in the angle or ramus of the mandible (where Keratocysts & ameloblastoma are common) and cannot be differentiated clinically. Excisional biopsies: Indicated for small lesions. Cystic content may also be cultured (if infected) for MCS . Ultrasonography : Can to some extent differentiate cysts from solid tumors useful only in soft tissue cysts and cysts with thin cortex or perforated cortex.

26. Radiology Investigations For Cysts Intraoral apical films like periapical radiograph suffice for small cysts. Larger ones need extra-oral (OPG) and occlusal views of the jaws to show their full extent. Computed Tomography(CT) scan. Radiographs are the m ost valuable tool in outlining the Extent and morphology of cyst, Relationship to teeth Relationship to vital anatomical structures Use of radio-opaque substances eg lipiodol , Hypaque Common radiographic appearance is a well circumscribed unilocular radioluscency with sclerosed border (except if infected).

27. TREATMENT Whether a cyst needs treatment depends on a number of factors including The type of cyst The location of the cyst If the cyst is causing pain or discomfort Whether the cyst is inflamed or infected

28. Vital teeth which have a satisfactory periodontal condition and are functional should be preserved by means of apicocectomy , root canal filling. Teeth should be extracted if they are non functional, poor periodontal condition, mobile and the patient already wear denture. Acutely infected cyst should be firstly treated by incision and drainage, antibiotics.

29. TREATMENT Enucleation Marsupialization

30. REFERENCES Neville, et. al: Oral and Maxillofacial Pathology 3rd Edition. Regezi , et. al: Oral Pathology: Clinical Pathologic Correlations, 4th Edition.