cysts of the jaws for the fourth year.ppsx

a brief description covering the topic of cysts of the jaw

1. Cysts Of The Oral And
Maxillofacial Region
Dr. Omer Abdoun
BDS, MD, ABHS
Oral & Maxillofacial Surgery

2. •Definition
•Types of Cysts
•Parts of a Cyst
•Classification Of Jaw Cysts
•Clinical, Radiological, Histological Features And
Differential Diagnosis Of Important Jaw Cysts.
OVERVIEW

3. •A Cyst is a pathological cavity having fluid,
semifluid or gaseous contents and which is
not created by the accumulation of pus.
Most cysts, but not all, are lined by
epithelium. (KRAMER 1974).
DEFINATION OF CYST

4. •TRUE CYSTS: which is lined by epithelium
e.g dentigerous cyst, radicular cyst etc.
•PSEUDO CYSTS: not lined by epithelium, e.g.
Solitary bone cyst, Aneurismal bone cyst etc
TYPES OF CYSTS

5. Cyst has following parts:
•WALL (made of connective
tissue)
•EPITHELIAL LINING
•LUMEN OF CYST
PARTS OF A CYST

6. CLASSIFICATION

7. 7
1 INFLAMMATORY ORIGIN
i.Radicular cyst, apical and
lateral
ii.Residual cyst
iii.Paradental cyst and juvenile
paradental cyst
iv.Inflammatory collateral cyst
I. CYSTS OF THE JAWS
A. EPITHELIAL-LINED CYSTS

8. 2 Developmental Origin
(a) Odontogenic
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
I. CYSTS OF THE JAWS
A. EPITHELIAL-LINED CYSTS
b) Non-odontogenic
i.Midpalatal raphé cyst of infants
ii.Nasopalatine duct cyst
iii.Nasolabial cyst

9. B. NON-EPITHELIAL-LINED CYSTS
1.Solitary bone cyst
2.Aneurysmal bone cyst
I. CYSTS OF THE JAWS

10. 1.Mucocele
2.Retention cyst
3.Pseudocyst
4.Postoperative maxillary cyst
II. CYSTS ASSOCIATED WITH THE MAXILLARY ANTRUM

11. 1.Dermoid and epidermoid cysts
2.Lymphoepithelial (branchial) cyst
3.Thyroglossal duct cyst
4.Anterior median lingual cyst (intralingual cyst of foregut origin)
5.Oral cysts with gastric or intestinal epithelium (oral alimentary tract
cyst)
6.Cystic hygroma
7.Nasopharyngeal cyst
8.Thymic cyst
9.Cysts of the salivary glands: mucous extravasation cyst; mucous
retention cyst; ranula; polycystic (dysgenetic) disease of the parotid
10.Parasitic cysts: hydatid cyst; Cysticercus cellulosae; trichinosis
III. CYSTS OF THE SOFT TISSUES OF THE
MOUTH, FACE AND NECK

12. TWO STAGES
1.Cyst initiation
2.Cyst enlargement or
expansion
PATHOGENESIS

13. •Initiation results in the proliferation of the epithelial cells
and the formation of small cavity.
a. Cell Rests of Malassez :
Remanants of Hertwigs epithelial root sheath in the PDL
after the root formation is completed.
b. Reduced Enamel Epithelium :
Residual epithelial cells surrounds the crown of the tooth
after enamel formation is complete.
c. Cell Rests of Serres (Dental Lamina) :
Islands of epithelial cells that originate from the oral
epithelium and remain in the tissue after inducing tooth
development.
CYST INITIATION

14. THEORY
Harris (1974) Postulated the theories
1)Mural growth
a) Peripheral cell division
b) Accumulated contents
2)Hydrostatic
a) Secretion
b) Transuduation & exudation
c) Dialysis
CYST ENLARGEMENT

15. 1.Increase in the volume of its contents.
2.Increase in the surface area of the sac or epithelial
proliferation.
3.Resorption of surrounding bones.
MECHANISM REGARDING
ENLARGEMENT

16. •Increased internal pressure – transmitted to the adjacent bone –
bone undergoes resorption – bony cavity enlarged.
•Due to the above changes, the surface area of cyst lining is
increased by cell multiplication.
•Epithelial cells divide – cyst enlarges within bony cavity by the
release of bone resorbing factors from the capsule.
•Stimulate osteoclast function – eg: prostaglandins like PGE
2 &
PGI
2.
BONE RESORPTION

17. 52.30%
18.10%
11.60%
8.00%
5.60%
4.20% SHEAR 2006
Radicular cyst
Dentigerous cyst
Odontogenic keratocyst
Residual cyst
Paradental cyst
Unclassified odontogenic
cysts
FREQUENCY OF EPITHELIAL
CYSTS OF JAWS

18. RADICULAR CYST

19. •Also called APICAL PERIODONTAL CYST
•Radicular cysts are the most common inflammatory cysts
and arise from the epithelial residues in the periodontal
ligament as a result of periapical periodontitis following
death and necrosis of the pulp.
•Quite often a radicular cyst remains behind in the jaws after
removal of the offending tooth and this is referred to as a
residual cyst.
RADICULAR CYST

20. 1.PHASE OF INITIATION:
•Accepted generally that rests of Malassez included within a
developing periapical granuloma proliferates to form the lining
of radicular cyst.
•How these cells are stimulated is not clear.
•Some product of non vital pulp can be responsible which
simultaneously evokes an inflammatory response in CT.
•Immune factors also held responsible as plenty of plasma cells
are seen in a periapical granuloma.
PATHOGENESIS

21. 2. PHASE OF CYST FORMATION:
•Can occur in two possible ways.
•One theory states that epithelium proliferates and covers
the bare connective tissue surface of the abscess cavity.
•Another theory – cyst cavity forms within proliferating
epithelium as the cells in center move away from their
nutrient source.
PATHOGENESIS

22. •Primarily symptom less.
•Discovered accidentally during routine dental X ray exam.
•Slowly enlarging hard bony swelling initially. Later, if cysts
breaks through cortical plates, lesion becomes fluctuant.
•Diagnostic criteria – associated teeth are non vital
•Rare in deciduous teeth.
SIGNS & SYMPTOMS

23. •Classically presents as
round / ovoid lucency with
sclerotic borders and
associated with pulpally
affected tooth / teeth.
•If infection supervenes, the
margins become indistinct,
making it impossible to
distinguish it from a
peripaical granuloma.
RADIOLOGICAL FEATURES
Radiograph of a radicular cyst. The lesion is a well
defined radiolucency associated with the apex of a non-
vital root filled tooth.

24. HISTOLOGICAL FEATURES
Quiescent epithelium lining a mature, long-standing
radicular cyst (H & E).
Mucous cells in the surface layer of the stratified
squamous epithelial lining of a radicular cyst (H & E).

25. HISTOLOGICAL FEATURES
Hyaline bodies in the epithelial lining of a radicular
cyst (H & E).
Mural nodule of cholesterol-containing granulation
tissue fungating into the cavity of a radicular cyst
(H & E).

26. Radiographic appearance of a large residual
cyst left behind after extraction of 1
st

mandibular molar.
•The histopathological features of the
residual cyst are similar to those
described above for conventional
radicular cysts. However, because
the cause of the cyst has been
removed, residual cysts may
progressively become less inflamed
so that eventually the cyst wall is
composed of uninflamed
•The epithelial lining may be thin and
regular and indistinguishable from a
developmental cyst such as a
dentigerous cyst or lateral
periodontal cyst. collagenous fibrous
tissue.
RESIDUAL CYSTS

27. Following lesions must be distinguished from other periapical
radiolucencies–
1.Periapical granuloma
2.Peripaical cemento – osseous dysplasia (early lesions)
DIFFERENTIAL DIAGNOSIS:

28. PARADENTAL CYSTS

29. •A cyst of inflammatory origin-
occurring on lateral aspect of root of
partially erupted mandibular 3
rd

molar with an associated history of
pericoronitis
• Age : 20-40 years
• Tooth is vital
• Facial swelling
• Facial sinus in some cases
PARADENTAL CYSTS

30. •Affected tooth is tilted Well
demarcated RadioLucency Distal
to partially erupted tooth
•Lamina Dura is intact
•New bone may be laid down
RADIOGRAPHIC FEATURES
a
b
(a,b) Two cases of bilateral paradental cysts associated with erupting
mandibular third molar teeth. The cysts are distal and buccal to the
involved teeth. Note that the periodontal ligament space is not widened
and that the distal part of the cyst is separate from the distinct distal
follicular space.

31. •The cysts are lined by a
hyperplastic, non-keratinised,
stratified squamous epithelium
which may be spongiotic and of
varying thickness.
•An intense inflammatory cell
infiltrate was present associated
with the hyperplastic epithelium
and in the adjacent
•fibrous capsule is the seat of an
intense chronic or mixed
inflammatory cell infiltrate. fibrous
capsule
HISTOLOGICAL FEATURES
Paradental cyst adjacent to the root of an impacted
mandibular third molar. The cyst is lined by non-keratinised
stratified squamous epithelium of variable thickness and
showing areas of proliferation (H & E).

32. DENTIGEROUS
CYST

33. • The dentigerous cyst is defined as a cyst that originates
by the separation of the follicle from around the
crown
of an unerupted tooth
•The dentigerous cyst encloses the crown of an
unerupted tooth and is attached to the tooth at the
cementoenamel junction
•The pathogenesis of this cyst is uncertain, but
apparently it develops by accumulation of fluid
between the reduced enamel epithelium and the
tooth crown.

34. Click icon to add picture
Gross specimen of a dentigerous cyst.
Cyst encloses the crown of the tooth and is attached to
its neck
DENTIGEROUS CYST

35. AGE : 1st to 3rd decades.
GENDER : more frequently in males than in females.
SITE :
• 2/3
rd
of follicular cyst associated with unerupted mandibular
teeth, primarily III molar.
• Maxillary canine
• Mandibular premolar
• Maxillary 3
rd
Molar
• Supernumerary tooth also can be involved
CLINICAL FEATURES

36. •Most cysts grow to a large size before being discovered
accidentally while observing a dental x ray to detect
the cause of an unerupted tooth.
•Large lesions can cause cortical expansion, leading to
facial asymmetry, teeth displacement, root resorption,
even pain, if infected.
SIGNS & SYMPTOMS

37. •Manifests as unilocular, well defined, ‘lucency with
sclerotic margins, associated with crown of impacted /
unerupted tooth.
•A large DC may show persistence of boney trabeculae,
giving the appearance of multilocularity.
RADIOLOGICAL FEATURES

38. • CENTRAL TYPE:

• LATERAL TYPE :

• CIRCUMFERENTIAL
TYPE :
RADIOLOGICAL FEATURES

39. Click icon to add picture
A central type of dentigerous cyst. Note resorption of
the root of the first mandibular molar
RADIOGRAPHIC FEATURES

40. Click icon to add picture
Radiograph of two dentigerous cysts in the same
patient. The cyst on the right is a lateral type; that on
the left is a circumferential type
RADIOGRAPHIC FEATURES

41. CT scan of a maxillary dentigerous cyst extending
to, and impinging on, the floor of the nose.
RADIOGRAPHIC FEATURES

42. DIFFERENTIAL DIAGNOSIS
Although it presents a unique feature, yet some lesions
must be considered in its differential diagnosis :
1.Unicystic ameloblastoma
2.Adenomatoid odontogenic tumor.

43. COMPLICATIONS
1.Recurrence due to incomplete surgical removal.
2.Development of ameloblastoma either from lining epithelium
or from odontogenic islands in the connective tissue wall.
3.Development of squamous cell carcinoma from same two
sources.
4.Development of mucoepidermoid carcinoma from mucus
secreting cells in the lining.

44. ODONTOGENIC
KERATOCYST

45. •The odontogenic keratocyst is a distinctive form of developmental
odontogenic cyst that deserves special consideration because of its
specific histopathologic features and clinical behavior.
•There is general agreement that the odontogenic keratocyst arises
from cell rests of the dental lamina.(Serres)
•This cyst shows a different growt h mechanism and biologic behavior
from themore common dentigerous cyst and radicular cyst.
•Several investigators suggest that odontogenic keratocysts be
regarded as benign cystic neoplasms rather than cysts

46. AGE : occur over a wide age range and cases have been
recorded as early as the first decade and as late as
the ninth.
In most series there has been a pronounced peak
frequency in the second and third decades.
GENDER : more frequently in males than in females.
SITE : The mandible is involved far more frequently than
the maxilla
50% cases occur in angle region and extend to
ascending ramus and forwards to body of
mandible.
CLINICAL FEATURES

47. Relative distribution of
odontogenic keratocysts in the jaws.
SITE DISTRIBUTION

48. •Pain, swelling or discharge.
•Occasionally, paraesthesia of the lower lip or teeth.
•Some are unaware of the lesions until they develop
pathological fractures.
•In many instances, patients are remarkably free of
symptoms until the cysts have reached a large size, involving
the maxillary sinus and the entire ascending ramus,
including the condylar and coronoid processes.
•Antero posterior expansion through the medullary spaces
CLINICAL FEATURES

49. characterized by
•Multiple nevoid basal cell
epitheliomas
•Odontogenic Keratocyst of the
jaws
•Bifid ribs– sixth rib
•Plantar & palmar pits
•Occular hypertelorism
•Frontal bossing
•Ectopic calcifications
GORLIN-GOLTZ SYNDROME

52. •OKC demonstrate a well-defined radiolucent area with
smooth and often corticated margins.
•Large lesions, particularly in the posterior body and
ascending ramus of the mandible, may appear multilocular
•An unerupted tooth is involved in the lesion in 25% to 40%
of cases; in such instances, the radiographic features
suggest the diagnosis of dentigerous cyst
RADIOGRAPHIC FEATURES

53. Radiograph of a small odontogenic keratocyst.
RADIOGRAPHIC FEATURES

54. Radiograph of an odontogenic keratocyst with scalloped
margins.
RADIOGRAPHIC FEATURES

55. Click icon to add picture
Radiograph of a multilocular odontogenic keratocyst.

56. Radiograph of an odontogenic keratocyst that has
enveloped an unerupted tooth to produce a
‘dentigerous’ appearance.
RADIOGRAPHIC FEATURES

57. •The epithelial lining is composed of a uniform layer of stratified
squamous epithelium,usually six to eight cells in thickness.
•The epithelium and connective tissue interface is usually flat, and
rete ridge formation is inconspicuous.
•The basal cell layer has columnar / cuboidal cells with reversely
polarized nuclei, imparting a “picket fence” or “tombstone”
appearance.
•The luminal surface shows flattened parakeratotic epithelial cells,
which exhibit a wavy or corrugated appearance.
•Small satellite cysts, cords, or islands of odontogenic epithelium
may be seen within the fibrous wall .
HISTOLOGIC FEATURES

58. Epithelial lining is 6 to 8 cells thick, with a hyperchromatic and
palisaded basal cell layer. Note the corrugated parakeratotic
surface.
OKC

59. Satellite microcysts in the wall of an odontogenic keratocyst that
appear to be arising directly from an active dental lamina.
SATELLITE MICROCYSTS

60. •COMPLICATIONS IN OKC :
1.Malignant transformation of cyst lining rare, but has been
reported.
2.Recurrence – high rate of recurrence.
•REASONS FOR RECURRENCE :
1.Thin, fragile lining is very difficult to remove completely.
2.New cysts develop from satellite cysts left behind.
3.Some cysts may be left behind in cases of Gorlin – Gotz
syndrome.
4.New cysts can also develop from basal cells of overlying oral
epithelium, especially in ramus – 3rd molar region.

61. ERUPTION CYST

62. •Typical c/f of an eruption cyst. Note a
bluish colored, dome shaped swelling
over the unerupted molar.
•The dentigerous cyst develops around
the crown of an unerupted tooth lying
in the bone,
•The eruption cyst occurs when a
tooth is impeded in its eruption
within the soft tissues overlying the
bone.
ERUPTION CYST
Eruption cysts involving the maxillary permanent
incisors.

63. PATHOGENESIS
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64. CLINICAL FEATURES
AGE : found in children of different ages, and occasionally
in adults if there is delayed eruption
SITE : most commonly associated with the first permanent
molars and the maxillary incisors

65. RADIOLOGICAL FEATURES
• The cyst may throw a soft-tissue shadow, but there is
usually no bone involvement except that the dilated and
open crypt may be seen on the radiograph.

66. GINGIVAL CYST OF ADULTS

67. PATHOGENESIS
• A number of suggestions have been made about the
pathogenesis of the gingival cyst in adults.
• It was originally proposed that they may arise from
odontogenicepithelial cell rests; or by traumatic
implantation of surface epithelium; or by cystic
degeneration of deep projectionsof surface
epithelium

68. ORIGIN
•Cystic transformation of dental lamina, traumatic
implantation of surface epith.
•Dome shaped soft, fluctuant swelling which is <1cm in
diameter
•Lesion is slow growing and painless
•Adjacent teeth usually vital

69. 79

70. Signs and symptoms:
•Slowly enlarging, well
circumscribed painless swelling.
•Invariably occurs on facial aspect of
free / attached gingiva.
•Surface of lesion is smooth and of
normal color.
•Fluctuant lesion, adjacent teeth are
vital
CLINICAL FEATURES
AGE :5
th
– 6
th
decade of life
SITE :mand. canine and Pre Molar
area; attached gingiva or I/D papilla

71. There is a faint radiographic shadow indicative of superficial bone
erosion.
RADIOLOGICAL FEATURES

72. LATERAL PERIODONTAL
CYST

73. •Uncommon
•The designation ‘lateral periodontal cyst’ is confined to those
cysts that occur in the lateral periodontal position and in which
an inflammatory etiology and a diagnosis of collateral OKC have
been excluded on clinical and histological grounds
(Shear and Pindborg, 1975).
LATERAL PERIODONTAL CYST

74. •Age : 20 – 60 years, peak in 6th decade.
•Sex : Male predilection.
•Site : Lateral PDL regions of mandibular premolars,
followed by anterior maxilla
CLINICAL FEATURES

75. •Usually asymptomatic as it occurs on the lateral aspect of
root of tooth.
•Occasionally pain and swelling may occur.
•Associated teeth are vital, unless otherwise affected.
•Cysts rarely < 1cm in size, except for BOTRYOID VARIETY
which is larger and also a multilocular lesion.
SIGNS & SYMPTOMS

76. •Round to ovoid ‘lucency with
sclerotic margins.
•Cyst can be present anywhere
between cervical margin to
root apex.
•Radiographically, it can be
confused with collateral OKC.
RADIOLOGICAL FEATURES
Radiograph of a lateral periodontal cyst lying between the
mandibular premolar teeth. The margins are well corticated,
indicative of slow enlargement.

77. RADIOLOGICAL FEATURES
Lateral periodontal cyst. Radiolucent lesion
between the roots of a vital mandibular canine and
first premolar.
Lateral periodontal cyst. A larger lesion causing
root divergence.

79. CALCIFYING
ODONTOGENIC CYST

80. •Also called as Odontogenic ghost cell cyst or Gorlin cyst.
•It has many features of odontogenic tumor, therefore it is
placed in the category of tumors in the latest WHO
classification of odontogenic cysts and tumors and was
renamed calcifying cystic odontogenic tumour (CCOT).
CALCIFYING ODONTOGENIC
CYST

81. •Age : Wide range, peak in 2
nd
decade.
•Sex : Equal.
•Site : Anterior segment of both jaws
CLINICAL FEATURES

82. •COC is a unicystic process and develops from the
reduced dental epithelium or remnants of dental
lamina.
•The cyst lining has the potential to induce
formation of dentinoid or even odontoma in
adjacent CT wall.
PATHOGENESIS

83. •Swelling is the commonest complaint, seldom
associated with pain.
•Intraosseous lesions can cause hard bony expansion
and resulting facial asymmetry.
•Displacement of teeth can also occur.
SIGNS & SYMPTOMS

84. •Intraosseous lesions produce
well defined lucency which
is usually unilocular.
•Irregular calcified masses of
varying sizes may be seen
within the lucency.
•Displacement of root/roots
with or without root
resorption and expansion of
cortical plates also seen
RADIOLOGICAL FEATURES
Radiograph of a calcifying odontogenic cyst of the maxilla.
There is a well-demarcated margin and calcifications
suggestive of tooth material.

85. Radiograph of a calcifying odontogenic cyst with well-demarcated
margins extending from the right to the left premolar regions of the
mandible. Numerous calcifications are present, some suggestive of small
denticles.
RADIOLOGICAL FEATURES

86. NASOPALATINE DUCT
(INCISIVE CANAL) CYST

87. •Also classified as “FISSURAL CYSTS”.
•Believed to be derived from epithelial remnants included
during closure of embryonic facial processes.
•Usually occurs within the nasopalatine canal or in soft tissue
of palate at the opening of canal.
NASOPALATINE DUCT
(INCISIVE CANAL) CYST

88. •Age : 4
th
, 5
th
& 6
th
decades.
•Sex : More in females
•Frequency: Commonest non odontogenic
developmental cyst
CLINICAL FEATURES

89. •Commonest symptom is swelling,
usually in anterior region of mid
palate.
•Swelling can also occur in midline
on labial aspect of alveolar ridge.
•If pressure on NP nerves – pain
•Exclude possibility of periapical
cyst by testing vitality of incisors.
SIGNS & SYMPTOMS

90. NASOPALATINE DUCT
(INCISIVE CANAL) CYST
Small nasopalatine cyst presenting as a soft ovoid
swelling in the midline of the maxilla, posterior to
the central incisor teeth.
Large nasopalatine duct cyst extending laterally and
posteriorly to involve much of the hard palate.

91. •Seen as lucency usually in incisive
canal – DIFFICULT TO DISTINGUISH
FROM A NATURALLY LARGE INCISIVE
CANAL.
•Lucency with AP dimension upto 10
mm considered as enlarged incisive
canal, but if lucency < 14 mm, then
NP duct cyst.
•The lucency appears well defined
with sclerotic borders, in midline of
palate between roots of incisors.
RADIOLOGICAL FEATURES

92. Radiograph of a nasopalatine duct cyst showing a pear-shaped
radiolucency in the anterior maxilla. The lamina dura on the left is intact
although the apex appears to be in the cyst.
RADIOLOGICAL FEATURES

93. Shows a large round radiolucency. The roots of the
maxillary incisor teeth are displaced laterally.
RADIOLOGICAL FEATURES

94. •Radicular cyst, if it is associated with a pulpally
involved tooth.
•Large incisive canal.
DIFFERENTIAL DIAGNOSIS

95. NASOLABIAL CYST

96. •The nasolabial cyst occurs outside the bone in the
nasolabial folds below the alae nasi.
•It is traditionally regarded as a jaw cyst although
strictly speaking it should be classified as a soft
tissue cyst.
NASOLABIAL CYST

97. • Age : Peak incidence in 4
th
& 5
th
decades.
• Sex : More in females.
• Frequency: Rare in occurrence.
CLINICAL FEATURES

98. •Commonest complaint – slowly
growing swelling and
occasionally, pain and difficulty
in nasal breathing.
•Extra orally – filling out of
nasolabial fold and may lift ala
nasi.
•Intra orally – bulge in labial
sulcus.
•Fluctuant lesion.
SIGNS & SYMPTOMS
Nasolabial cyst producing a swelling of the right
upper lip, forming a bulge in the labial sulcus.

99. •Difficult to interpret on
radiograph.
•May be seen as localized
increased lucency of alveolar
process above apices of incisors.
•Lucency results from pressure
resorption on labial surface of
maxilla.
RADIOLOGICAL FEATURES
Standard occlusal radiograph of a patient with a nasolabial
cyst. There is a posterior convexity of the left half of the
radiopaque line that forms the bony border of the nasal
aperture.

100. SOLITARY BONE CYST

101. •Also called as Hemorrhagic bone cyst, or Traumatic
bone cyst.
•Commonly seen in mandible, rare in maxilla.
•Identical to solitary bone cyst of humerus in
children and adolescents.
SOLITARY BONE CYST

102. •Age : Young individuals
•Sex : Equal
•Site : Body and symphysismenti of mandible.
CLINICAL FEATURES

103. •None of the theories are certain about exact cause.
•First theory – cyst may follow trauma to bone which causes
intra medullary hemorrhage which fails to organize. This
clot subsequently liquefies - CYST.
•Recent theory osteogenic cells fail to differentiate locally
and thus instead of bone, the undifferentiated cells form
synovial tissue.
PATHOGENESIS

104. •Asymptomatic.
•Rarely, swelling and pain may be seen.
•Half of all patients give a history of trauma to the
area.
SIGNS & SYMPTOMS

105. •Appears as a lucency with
irregular but well defined
edges and slight
cortication.
•On occlusal view the
‘lucency is seen to extend
along cancellous bone.
RADIOLOGICAL FEATURES
Radiograph of a solitary bone cyst involving an
extensive area in the right body of the mandible. This
example has a well-defined margin with cortication.
Interradicular scalloping is a prominent feature.

106. TREATMENT

107. REASONS
•Cysts tend to increase in size.
•Cysts tend to get infected.
•Cysts weaken the jaw. ( pathological fracture)
•Some cysts undergo changes. Eg: Ameloblastoma,
Mucoepidermoid carcinoma
•Cysts prevent eruption of teeth. (dentigerous cyst)
•Involvement of neighboring structures.( maxillary sinus,
nose, adjacent tooth)
PRINCIPLES OF TREATMENT

108. 1.To remove the lining totally or to remove a part of
lining to enable the body to rearrange the position
of abnormal tissue so that it is eliminated from
within the jaws.
2.To preserve adjacent structures such as nerves and
healthy tissues.
3.To achieve rapid healing of the operation site.
4.To restore the part to a near normal form and to
restore normal function.
1.AIMS OF TREATMENT

109. 1. Marsupialization (Partch 1 Operation) (Cystotomy)
Combined Decompression & enucleation
Marsupialization through nose or antrum
2)Enucleation (Partch 2 Operation) (Cystectomy))
a) Enucleation & packing
b) Enucleation & primary closure
c) Enucleation & primary closure with reconstruction /
bone grafting
TREATMENT

110. •RADIOLOGY
a.Periapical x-rays
b.Occlusal view x-rays
c.Lateral oblique view x-rays
d.Panoramic x-rays
e.P.A view x-rays
f.Sinus view x-rays
•C.T.SCAN
•RADIOPAQUE DYES
•ASPIRATION
•BIOPSY
DIAGNOSIS

111. VARIOUS ASPIRATES
PATHOLOGY ASPIRATE Other Findings of Aspirates
Dentigerous Cyst Clear, pale straw colour
fluid
Cholesterol crystals.
Total protein in excess
4 g / 100ml. Resembles serum
Odontogenic KeratocystDirty, creamy white
viscoid suspension
Para keratinized squames.
Total protein less than
4 g /100ml. Mostly albumin
Periodontal Cyst Clear, pale yellow straw
colour fluid
Cholesterol crystals.
Total protein 5 — 11g / 100ml
Infected Cyst Pus, brownish fluidPolymorphonuclear
leukocytes, ,Cholesterol clefts
Mucocele, Ranula Mucus -----
Gingival Cysts Clear fluid -----

112. VARIOUS ASPIRATES
PATHOLOGY ASPIRATE Other Findings of
Aspirates
Solitary Bone Cyst Serous fluid, blood or
empty cavity
Necrotic blood clot
Stafne’s Bone Cyst Empty cavity – yield air ---
Dermoid Cyst Thick sebaceous material ---
Fissural Cyst Mucoid fluid ----

113. Cysts of the jaws are treated in one of the following four basic methods:
(1)Enucleation,
(2)Marsupialization,
(3)A staged combination of the two procedures, and
(4)Enucleation with curettage.
TREATMENT

114. •Enucleation is the process by which the total removal of a
cystic lesion is achieved.
•Enucleation of cysts should be performed with care, in an
attempt to remove the cyst in one piece without frag-
mentation, which reduces the chances of recurrence by
increasing the likelihood of total removal.
•However, maintenance of the cystic architecture is not
always possible, and rupture of the cystic contents may
occur during manipulation.
1. ENUCLEATION

115. Indications :
•Enucleation is the treatment of choice
Advantages :
•pathologic examination of the entire cyst can be undertaken
•The patient does not have to care for a marsupial cavity with
constant irrigations.
Disadvantages
•Normal tissue may be jeopardized
•Fracture of the jaw
•Devitalization of associated teeth
•Impacted teeth that the clinician may wish to save could be
removed.
ENUCLEATION

116. TECHNIQUE :
•Aspiration Biopsy of Radiolucent Lesions
•Mucoperiosteal Flaps
•Osseous Window
•Removal of Specimen
ENUCLEATION

117. Aspiration Biopsy of Radiolucent Lesions :
Mucoperiosteal Flaps :
•the flap design should provide 4 to 5 mm of sound
bone around the anticipated surgical margins
•mucoperiosteal flaps for biopsies in or on the jaws
she be full thickness and incised through mucosa,
submucosa, and periosteum
ENUCLEATION

118. Osseous Window :
•once the flap has been elevated, a rotating bur
should be used to remove an osseous window
•The size of the window depends on the size of the
lesion and the proximity of the window to normal
anatomic structures such as roots and
neurovascular bundles.
ENUCLEATION

119. ENUCLEATION OF CYST

120. ENUCLEATION OF CYST

121. •Marsupialization, decompression, and the Partsch operation all 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. Marsupialtzatron can be used as the sole therapy
for a cyst or as a preliminary step in management, with enucleation
deferred until later.
2. MARSUPIAIIZATION

122. 1.Amount of tissue injury : Proximity of a cyst to vital structures can mean
unnecessary sacrifice of tissue if enucleation is used.
2.Surgical access : If access to all portions of the cyst is difficult, portions of the
cystic wall may be left behind, which could result in recurrence.
3.Assistance in eruption of teeth : If an unerupted tooth that is needed in the
dental arch is involved with the cyst (i.e., a dentigerous cyst), marsupialization
may allow its continued eruption into the oral cavity
4.Extent of surgery : Marsupialization is a reasonable alternative to enucleation,
because it is simple and may be less stressful for the patient
5.Size of cyst : In very large cysts, a risk of jaw fracture during enucleation is
possible. It may be better to marsupialize the cyst and defer enucleation until
after considerable bone fill has occurred.

INDICATION

123. Advantages :
•It is a simple procedure to perform. Marsupiaiization also spare vital
structures from damage should immediate enucleation be attempted.
Disadvantages :
•Pathologic tissue is left in situ, without thorough histologic
examination.
•Patient is inconvenienced in several respects
•The cystic cavity must be kept clean to prevent infection, because the
cavity frequently traps food debris.
•In most instances this means that the patient must irrigate the cavity
several times every day with a syringe
MARSUPIAIIZATION

124. 1) Anaesthesia
2) Aspiration
3) Incision
Circular, oval or elliptic. Inverted U shaped incision with broad base to
the buccal sulcus. Mucoperioteum is reflected in this case.
4) Removal of bone
5) Removal of cystic lining specimen
6) Visual examination of residual cystic lining
7) Irrigation of cystic cavity
8) Suturing
Cystic lining sutured with the edge of oral mucosa.
In U shaped incision the mucoperiosteal flap can be turned into cystic cavity covering
the margin. The remaining is sutured to oral mucosa.
TECHNIQUE OF MARSUPIAIIZATION

125. 9) Packing-- Prevents food contamination & covers wound margins.
Done with ribbon gauze soaked with WHITEHEAD VARNISH.
COMPOSTION:
Benzoin – 10g
Iodoform – 10g
Storax - 7.5g
Balsam of Tolu – 5g
Solvent ether to 100ml
Pack removed after 2 weeks.
10) Maintenance of cystic cavity
Instruct the patient to clean and irrigate the cavity regularly with oral
antiseptic rinse with a disposable syringe.
CONTINUE…

126. 11) Use of plug
Prevents contamination. Preserves patency of cyst orifice.
Plug should be stable, retentive and safe design.
Should be made of resilient material ( avoid irritation) like acrylic.
12) Healing
Cavity may or may not obliterate totally. Depression remains in the
alveolar process.
CONTINUE…

128. 3. ENUCLEATION AFTER
MARSUPIALIZATION
INDICATIONS
• When bone has covered the adjacent vital structures.
• Adequate bone fill. Prevents fracture during enucleation.
• When patients find it difficult to cleanse the cavity.
• To detect any occult pathological condition.
ADVANTAGES
• Spares adjacent vital structures
• Accelerates healing process
• Development of thick cystic lining – enucleation easier
• Allows histopathological examination of residual tissue.
• Combined approach reduces morbidity
DISADVANTAGES
• Patient has under go second surgery and any possible complicatton
associated with surgery.

129. 4. 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
•Any remaining epithelial cells that may be present in the periphery of
the cystic wall or bony cavity must be removed.
•These cells could proliferate into a recurrence of the cyst.

130. Indications :
•In this case the more aggressive approach of enucleation with curettage
should be used.
•Daughter, or satellite, cysts found in the periphery of the main cystic
lesion may be incompletely removed
•The second instance in which enucleation with curettage is indicated is
with any cyst that recurs after what was deemed a thorough removal.
Advantages :
•If enucleation leaves epithelial remnants, curettage may remove them,
thereby decreasing the likelihood of recurrence.
ENUCLEATION WITH
CURETTAGE

131. 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
ENUCLEATION WITH
CURETTAGE

132. ENUCLEATION OF OKC
CONSERVATIVE TREATMENT

135. SURGICAL MANAGEMENT OF OKC
RADICAL TREATMENT

136. •Large cystic lesion involving left
ramus of Mandible and
extending up.
•There are areas of cortical
break.
Transverse View

137. SURGICAL PROCEDURE

142. Post operative after 1 month Healed incision area

143. Post operative Ortho Pantomogram