Cyst

1. PRESENTED BY :DR.NIKIL JAIN
P.G. 1
ST
YEAR
CYST
Of
Oral &
Maxillofacial
Tissues

2. CONTENTS
Definition
Classification
Pathogenesis
Clinical examination
Odontogenic cyst
Inflammatory cyst
Conclusion
References

3. DEFINITION
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????????????

4. 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.”

5. 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.

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

7. According to shear’s -
Cyst of jaws
Cyst associated with maxillary antrum
Cyst of soft tissues of the mouth,face,neck
and salivary glands

8. cyst of jaws
Epithelial Non-
epithelial
Developmental Inflammatory
Odontogenic Non-odontogenic

9. Odontogenic cyst -
Odontogenic keratocyst
Dentigerouscyst
Eruption cyst
Gingival cyst of infants
Gingival cyst of adults
Developmental lateral periodontal cyst
Botryoidodontogenic cyst
Glandular odontogenic cyst
Calcifying odontogenic cyst

10. Non-odontogenic cyst
Midpalatal raphe cyst of infants
Nasopalatine duct cyst
Nasolabial cyst

11. Inflammatory origin
Radicularcyst, apical and lateral
Residual cyst
Paradentalcyst and juvenile cyst
Inflammtorycollateral cyst

12. Non-epithelial lined cyst
Solitary bone cyst
Aneurysmal bone cyst
Traumatic bone cyst
Hemorrhagic bone cyst

13. Cyst associated with maxillary antrum -
Mucocele
Retention cyst
Pseudocyst cyst
Post operative maxillary cyst

14. Cysts of the soft tissue of the mouth ,face and
neck –
Dermoidand epidermoidcyst
Branchialcyst
Thyroglossalduct cyst
Anterior median lingual cyst
Oral cyst with gastric or intestinal epithelium
Cystic hygroma
Nasopharyngeal cyst
Thymiccyst
Cyst of salivary glands
Hydatidcyst

15. PATHOGENESIS OF CYST FORMATION
Odontogenic cyst are derived from
odontogenic epithelium of stomodeum
Enamel organ
Reduced enamel epithelum
Remnants of dental lamina(cell rests of serrae)
Remnants of hertwig’s root sheath(cell rests of
malassez)

17. PATHOGENESIS
Formation of cyst take place in generally three
stages :
Initiation
Cyst formation
Enlargement or expansion of cyst cavity

18. INITIATION
Initiation of cyst formation mostly from
odontogenic epithelium
Stimulus which initiates this process is
unknown
Factors involved
Proliferation of epithelial lining
I.Fluid accumulation in cystic cavity
II.Bone resorption

19. CYST FORMATION
Cavity lined by stratified squamous
epithelium ???????????????
Shear (1963),Tencate (1972), Harris(1974) ,
Valderhauge(1974)

20. 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.

21. 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.

22. ENLARGEMENT
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

23. Harris (1974) classified theories of cyst
enlargment:
Mural growth
a)Peripheral cell division
b)Accumulation of cellular content
Hydrostatic enlargement
a)Secretion
b)Transduationand exudation
Bone resorbingfactor

24. CLINICAL EXAMINATION
Diagnostic features
Symptoms of cyst
Signs of cyst
Clinical stages of cysts
Secondary effects on jaw
Investigation

25. Diagnostic features :
Sign and symptoms of a cystic lesion depend
on
1.Dimension of lesion
2.Type of cyst
3.Location of cyst
4.Important structures adjacent to cyst
5.Presence of infection in the cyst

26. Symptoms of cyst:
1.Pain and swelling
2.Salty taste
3.Difficulty in mastication
4.Ill fitting denture
5.Displaced teeth
6.Space between the teeth

27. Signs of cyst:
1.Bone expansion
2.Fluctuant swelling under oral mucosa
3.Non vital tooth(if radicular cyst)
4.Missing tooth
5.Sinus formation with discharge
6.Large cyst distortion of adjacent structures
7.Hollow sound on percussion

28. Clinical stages of cyst :
1.Periostealstimulation : curved enlargement
of bone
2.Tennis ball consistency:canbe indented on
percussion
3.Egg shell crackling :micro cracks on cortical
plate
4.Fluctuation :complete resorption of bone
overlying the cyst
5.Sinus formation
6.Infection due to contamination from oral
cavity

29. Secondary effects on jaw due to cyst :
1.Numbness
2.Pathological fracture of jaw
3.Secondary infection
4.Malignant transformation

30. Investigation includes :
1.Radiographic examination/C.T. scan
2.Contrast studies
3.Aspiration
4.Vitality test
5.Biopsy

31. Radiograph for cyst
1.IOPA for small periapicalcyst to see tooth
involvegd
2.Occlusalview to check lingual cortical
expansion
3.PNS view (occipitomental)to show relation to
maxillary antrumand nasal cavity
4.Lateral oblique (mandible)to check proximity to
lower border
5.PA view to check expansion of ramusof
mandible,surveyof symphysis,body and rami
of mandible
6.OPG (shows entire affected region.sizeand
site of the region can be assessed

32. 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

33. 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

34. Aspiration
Cystic contents are aspirated using a wide
bore needle(18 guage) and syringe(5 ml)
Different types of aspirates obtained
Provisional diagnosis may be based on types
of aspirate

35. Types of AspirateDiagnosis
Clear , pale , straw colouredfluid
with cholesterol crystals
Dentigerouscyst
Creamy white , thickaspirate Odontogenic cyst
Yellowish ,foul smelling fluid Infected cyst
Blood 1.Needle in blood vessel
2.Vascular lesion
Air 1.Maxillary antrum
2.Traumatic bone cyst

36. On biochemical evaluation of aspirated fluid
If total protein content >4gm/100 mlindicataed
radicular cyst or dentigerous cyst
If total protein content <4gm/100 ml indicated
odontogenic keratocyst

37. 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.

38. 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.

39. 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

40. Etiology
Developmental in origin
Considered to arise by the accumulation of
fluid between reduced enamel epithelium
and the crown of an uneruptedtooth or an
impacted tooth
The eruptive forces in the tooth cause
changes in the vascular hydrodynamics
which results in seprationof reduced enamel
epithelium from crown.
There is fluid accumulation between these
two.

41. Basis of observations at operation and
histologicexamination distinguish two types :
1.Standard dentigerouscyst
2.Extrafollicularvariety

42. Clinical features
Second most common cyst
Commonly seen in 1
st
and 3
rd
decade of
life
Males more affected than females
Capable to becoming aggressive lesion

43. 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

44. Radiographic Features
Unilocular,well defined radiolucencywith
sclerotic margins around the crown of an
uneruptedtooth
Three radiographic types
circumferential
lateral
paradental

46. Cyst Contents
Yellowish straw coloured fluid rich in
cholestrol crystals
If cyst infected ,purulent material can be
obtained on aspiration

47. Histopathological features
Lined by stratified squamous epithelium
Lumen may contain fibrillar keratin
Presence of bilaminated eosinophilic
amorphous hyaline like Rushton bodies
Cholestrol crystals

48. Treatment
Marsuplization
Enucleation of cyst together with removal of
unerupted teeth
This permits decompression of a resulting
decrease in the size of bone defects.

49. ODONTOGENIC KERATOCYST
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

50. Pathogenesis –
Developmental anomaly
Arises from odontogenic epithelium
Dental lamina
Basal cells from overlying mucosa
Enamel organ-by degenration of stellate
reticulum

51. Clinical features
Most common in 2
nd
and 3
rd
decade of life
Males more commonly affectd
Mandible more affected than maxilla
Most common site is mandibular angle region
Greatest recurrence rate –as high as 60%
Asymtomatic usually until secondarily infected

52. Radiographic features –
Unilocularor multilocularradiolucency
In early stages ,unilocularradiolucencywith
well defined sclerotic margin
It can arise in any part of jaw and is
independent of the teeth,itcan mimic any of
the cyst radiographicallye.g. dentigerous
cyst,primordialcyst,radicularcyst
As OKC expands it causes severe bone
destruction producing a multilocular
radiolucencyand soap bubble appearance
radiographically

53. Cyst contents
Contains dirty white material
Cystic fluid has a large amount of exfoliated
keratin squamous
Smear can be stained and examined for
keratinized cells
When 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

54. Histological features
Epithelium lining is usually parakeratinized
Epithelial lining is of uniform thickness ,5-8
layers of cells
Basal 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

55. Causes of high recuurence rate
Aggressive pecularity was first reported by
pindborg and Hansen (1963)
Tendency to multiplicity
Presence 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

56. Treatment
Bramley (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

57. Unilocularlesions with scalloped or
loculatedperiphery 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 hydroxyapatitecrystals,
autogenousbone graft, corticocanellous
chips

58. Larger multilocularlesion with or
without cortical perforation,mayrequire
resection of the involved bone followed
by primary or secondary reconstruction
with reconstruction plates or stainless
stellmesh or bone graft like iliac crest
graft,costochondralgraft or allogenous
bone graft.

59. ERUPTION CYST
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

60. Clinical features
Smooth , round soft tissue swelling over an
erupting tooth
Pink or bluish in colour
Not commonly seen as they undergo
spontaneous rupture or disappears from
masticatory trauma as the tooth enters the
oral cavity

61. Radiographic features–
Cyst in soft tissues, no significant radiographic
features are soon

62. Treatment –
Marsupialisation

63. GINGIVAL CYST OF INFANTS
Soft tissue cysts on the alveolar crest of the
gum pads of a newborn
Arise from remnants of dental lamina

64.  Clinical features
Appears as pearly white nodules 2-3 mm in
diameter on the alveolar ridge
May 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 pearls
Similar lesions on lingual , buccal aspect of
alveolar ridge are called Bohn’s nodules

65. Pathology
Thin lining of stratified squamous cell
epithelium which may reveal
parakeratinization
Contain desquamated keratin

66. Treatment
No treatment as they rupture spontaneously on
eruption of underlying teeth

67. GINGIVAL CYST OF ADULTS
Soft tissue odontogenic developmental cyst
Location in gingival tissue
Etiology :
Remnants of dental lamina or cell rests of
serres
From enamel organ or epithelial islands of the
surface epithelium
As traumatic implantation cyst

68. Clinical features
No sex predilection
Occurs in 5
th
or 6
th
decade of life
Mandible is more frequently involved
Rarely seen in anterior part of jaw
Asymptomatic, painless, slow growing, Soft
and fluctuant
Seen in attached gingiva or the inter den tal
papilla on labial aspect, smooth surface
Adjacent teeth are normal

69. Hitopathology
Lined by stratified squamous cell epithelium
and contains fluid
Treatment
Surgical excision
No tendency to recurrence

70. LATERAL PERODONTALCYST
First reported by standish and shafer in 1958
Cysts occur in the lateral peridontal position
Inflammatory etiology

71. Clinical features
Occurs in 4
th
to 7
th
decade of life
Males are affected more than females
Most frequent locations mandibular premolar
area,followed by anterior region of maxilla
Asymptomatic
Associated teeth vital
3
rd
molar most common and any infection can
cause spreading infection of submandibular
space

72. Radiographic features
Well defined radiolucency round or ovoid with
sclerotic margin
Lamina dura of the tooth destroyed
Smaller than 1cm in size and present between
the cervical margin and apex of the tooth
In case of 3
rd
molar seen to be present in the
bifurcation, buccal or lingual surface of roots

73. Pathogenesis
Reduced enamel epithelium
Remnants of dental lamina
Cell rests of malassez
Cystic contents
Serous caseous contents

74. Pathology
Lined by well formed , non keratinized stratified
squamous epithelial lining
Localized epithelium proliferation may be seen
Connective tissue wall may show inflammatory
cell infiltrate
Treatment plan
Enucleation

75. BOTRYOIDODONTOGENIC CYST
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

76. Clinical features
Occurs in 5
th
-7
th
decade of life
Most frequent location mandible in cuspid-
premolar region
Swelling may be present
Pain
Parasthesia
Discharge (rarely)

77. Radiographic features
Unilocular radiolucency
Treatment
Enucleation

78. CEOC
First described by Gorlin in 1964
Shows features of cyst and tumour
Clinical features
Relatively rare cyst
Most often seen in second decade,no sex
predilection but more common in children
and young individuals
Mostly seen in anterior part of the jaw

79. Initially Symptomless
Swelling
Pain (rare)
Peripheral or intraosseous lesion may be seen
Later stages hard bony expansion
Some cyst arise close to periosteum and
produce a saucer shaped depression in bone
Pathogenesis
Remnants of dental lamina
Stellate Reticulum, Reduced enamel
epithelium

80. Radiographic features
Well defined lesions with sclerotic or diffuse
border
Small 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 tooth
Resorption of the roots of adjacent teeth

81. Histological features
Basal layer is composed of cuboidal or
columnar cells with polarised nuclei
Most peculiar feature is presence of ghost
cells. these are eosinophilic ,pale,swollen
epithelial cells that have lost their nuclei
Treatment
Enucleation

82. GLANDULAR ODONTOGENIC CYST
Padayachee and Van wyk 1987
Same characteristic with lateral peridontal
cyst or botryoid cyst
Unilocular or multiloculat radiolucency
Cortical plare expansion

83. Treatment
Enucleation
Marsupialisation if lesion approach vital
structure

84. RADICULARCYST
Also known as apical periodontal cyst
Associated with roots of non-vital teeth
Most common odontogenic cyst .in all cases
the pulp iis necrosed
Etiology-
Dental caries
Fractured tooth
Thermal /chemical injury to pulp
Iatrogenic pulp injury

85. Initiation and progression
Dental caries
Chronic pulpitis
Pulp necrosis
Periapicalgranuloma

87. Clinical features
Most common
Males affected more than females
Occurs in 3
rd
-4
th
decade of life
Incidence highest in anterior maxilla
Asymptomatic
Tooth must be non-vital
Pain if associated with suppuration
Temporary parasthesia

88. Radiological features
Round or pear shaped or oval shaped
radiolucency outlined by a narrow radio-
opaque margins
Treatment
Enucleation with primary closure

89. RESIDUAL CUST
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

90. 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

91. Treatment
Enucleation with primary closure

92. INFLAMMATORY PARADENTALCYST
First reported by Main 1970
Associated with a lateral accessory root
canal of a non vital tooth
In 3
rd
decade of life
Male mostly affected
Mandibular 3
rd
molar mostly

93. Radiological features
Often 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

94. NON-ODONTOGENIC CYST
Nasopalatine duct cyst
Derived from embryonic epithelial residues in
nasopalatine canal
Or from epithelium included in lines of fusion of
embryonic facial process
May be occur within the nasopalatine canal or
in soft tissues of the palate
At the opening of the canal –cyst of palatine
papiilla

95. Clinical features
Mostly 3
rd
to 6
th
decades of life
Higher ratio of man affected
Common symptom swelling
Also occurs in midline on labial aspect
May produce bulging of nose
Pain and discharge which is salty in taste
Displacement of teeth

96. Radiological features
Round or oval shape radiolucency some time
Heart shape radiolucency in between the
central incisors
Treatment
Surgical enucleation

97. Nasolabial cyst –
Occurs outside the bone in nasolabial folds
below the alae nasi
Arises 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

98. Wide age spread from 12-75 years
Women affected more
Swelling
Pain and difficulty in nasal breathing
Slow growing
Swelling of lip, fill out the nasolabial and lift the
alae nasai
Fluctuant

99. Radiological features-
Radiolucency of alveolar process above the
apices of incisors teeth
Treatment
Enucleation

100. NON-EPITHELIAL CYST
Solitary bone cyst
Aneurysmal bone cyst

101. ANURYSMALBONE CYST
Jaffe and Litchtenstein 1942
Often seen in lonf bones and spine
Aetiology
Trauma
Possible relationship with giant cell lesion
Variations in hemodynamics of area
Sudden venous occlusion

102. Clinical features
Very rare
Children and young adults mostly affected
Mandible affected more than maxilla
Firm swelling
Displacement of teeth
Egg shell crackling
Lesion not pulsatile

103. Treatment
Complete curretage
Local excision with bone grafting

104. SOLITARY BONE CYST
Termed as haemorrhagic bone cyst

105. 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


106. Clinical features
Occurs in children and adolescent
Male predliction
Mandible affected more
Symptomless
Expansion of lingual cortex

108. MANAGEMENT OF CYST OF THE JAWS
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.

109. 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

110. Operative Procedures
Basically two types
Enucleation
Marsupialization

111. Enucleation
Enucleation and packing
Enucleation and primary closure
Enucleation and primary closure with
reconstruction
Enucleation wth chemical cauterisation
Marsupialisation
Partsch I
Partsch II
Marsupialization by opening into nose or antrum

112. Marsupialisation or Partsch I operation
also known as cystotomy or decompression
Partsch 1892 described a type of
compression procedure
Principle :
Marsupialization or decompression refers to
creating a surgical window in the wall of cyst,
and evacuate cystic contents

113. 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

114. 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

115. Advantages
Simple procedure to perform
Spares vital structures
Allows eruption of teeth
Prevents oro nasal oroantral fistula
Prevents pathological fracture
Reduces operating time
Reduces blood loss
Helps shrinkage of cystic lining
Allows for endosteal bone formation to take
place

116. Disadvantages
Pathologic tissue is left in situ
Histologic examination of entire lining is not
done
Prolonged healing time
Inconvenience to the patient
Prolonged follow up visits
Periodic irrigation of cavity
Regular adjustment of plug
Periodic changing of pack
Secondary surgery may be needed

117. SURGICAL TECHNIQUE
Anaesthesia
Aspiration
Incisions –circular
oval
eliptical
inverted ‘u’
Removal of bone
Removal of cystic lining specimen
Irrigation of cystic cavity

118. Suturing
Packing–white head’s varnish
tincture of benzoin
bismuth iodine paraffin
paste(BIPP)
Maintenance
Use of plug
Healing

120. MODIFICATIONS OF MARSUPIALIZATION
Waldron’s method(1941)
Two stage technique
Combination of two standard technique
First marsupialization
Second enucleation,when the cavity
becomes smaller

121. Indications
When bone has covered the adjacent vital
structures
Adequate bone fill has strengthened the jaw to
prevent fractureduring enucleation
Pt. finds difficult to clean cavity
For detection of any occult pathologic condition

122. Advantages
Development of a thickened cystic lining which
makes enucleation easier
Spares adjacent vital structures
Combined approach reduces morbidity
Accelerated healing process
Allows histopathological examination of
residual tissue

123. Disadvantages
Patient has to undergo secondary surgery and
possible complications

124. MARSUPIALIZATIONBY OPENING INTO NOSE OR
ANTRUM
Cyst that have destroyed a large portion of of
the maxilla and have ancroachedon the
antrumor nasal cavity
Technique
1.Anaesthesia
2.Incision –gingival curvilinear incision taken
along the involving teeth
3.Two releasing incision are made at 45°angle
and extending in to buccal sulcus

125. 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

127. This allows the cyst cavity to become
lined with normal ciliated and mucous
secreting epithelium regenrating from
the respiratory mucosaother than a
squamous epithelium
Additionally intranasal antrostomy may
be performed .
Cavity packed with a ribbon gauze
soaked withtincture of benzoin or
antibiotic ointment

128. ENUCLEATION
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,whicheventually organizes to form
normal bone

129. Indications
Treatment of OKC
Recurrence of cystic lesions of any cyst
type
Advantages-
Primary closure of wounds
Rapid healing
Postoperative care is reduced
Thorough examination of entire cystic
lining can be done

130. 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

131. Enucleation with primary closure-
Anaesthesia
Incision-envelope flap
trapezoidal
Elevation of Mucoperiostealflap
Bone removal
Exposure of cystic lining
Try to remove entire cyst lining in a single
piece
Irrigation of cavity and hemostasisensured
suturing

134. Enucleation with open packing
large cyst which was previously infected
,closure may not be possible
the 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

135. Enucleation with bone curettage
After 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 osteotomy
Instead of using a curett a large round
burr may be used to remove around 1-
2mm of bone around the entire
peripheral cavity

136. 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

137. Enucleation with bone grafting
Bone 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

139. Segmental resection
Indicated when there is a large
odontogenic keratocyst with massive
bone destruction
Indicated when there is suspected
neoplastic transformation of the cyst

140. Procedure
Anaesthesia
Incision –a submandibularincision ,
which may at times be required to
extend into postramalregion,istaken
1.5 –2 cm below thrinferior border of
mandible
Incision extends ,through skin and
subcutaneous tissue,bluntand sharp
dissection carried out layerwisethrough
tissue planes e.g. superficial cervical
fascia ,platysma,and deep cervical
fascia.

141. Care is taken to marginal mandibular
nerve and facial artey and vein are
clamped and ligated
Small bleeders cauterized with diathermy
Pterygomassetric 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.

142. COMPLICATIONS OF CYSTIC LESION AND
MANAGEMENT
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 involvement
If 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

143. CONCLUSION
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.

144. REFERENCES
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