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1. SURGICAL MANAGEMENT OF ORAL PATHOLOGICAL LESIONS Chapter 22

2. Basic surgical goals 1-Eradication of pathological condition 2-Functional rehabilitation of patient

3. SURGICAL MANAGEMENT OF THE CYSTS AND CYST LIKE LESIONS

4. CYST Cysts are pathological fluid filled cavities lined by epithelium

5. Cyst key feature Form sharply-define radiolucencies with smooth border Fluid may be aspirated and thin-walled cysts may be transilluminated. Grow slowly, displacing rather than resorbing teeth. Symptomless unless infected and are frequently chance radiographic findings Rarly large enough to cause pathological fracture. Form compressible and fluctuant swelling if extended into soft tissue. Appear bluish when close to the mucosal surface.

6. SURGICAL MANAGEMENT OF CYSTS 1 Enucleation 2 Marsupialization 3 Enucleation after marsupialization 4 Enucleation with Curratage

7. 1.Enucleation ( Partsh II ), Ostectomy Enucleation is a surgical process by which the total removal of a cystic lesion is achieved. Shelling out of the entire lesion without rupture

8. 1.Enucleation INDICATION Enucleation is treatment of choice for the removal of cysts of the jaw, should be used with any cyst of the jaw that can be safely remove without damaging the adjacent structure.

9. 1.Enucleation ADVANTAGES Complete lining is available for histological examination. Initial excisional biopsy (enucleation) treat the lesion. Little after care is necessary. The cavity usually heal without complication.

10. 1.Enucleation DISADVANTAGES Normal tissue may be jeopardized. Chances of damaging the apices of vital teeth projecting into the cyst. Vital structure could be damage: ( Max Antrum, I A canal ). Jaw could be fracture.

11. 1.ENUCLEATION i. At the time of tooth extraction. ii. Without tooth extraction.

12. 1.Enucleation i. At the time of tooth extraction.

13. 1.Enucleation ii. Without tooth extraction. . Aspiration . Mucoperiosteal flap . Osseous window . Removal of cyst . Specimen care

14. 1.Enucleation I. Aspiration Any radiolucency that required surgical removal should perform aspiration to give the diagnostic information regarding the nature of lesion. Straw coloured fluid Cyst Fresh blood vascular lesion Pus Infection Air Max antrum, traumatic bony Cavity

15. 1.Enucleation II . Mucoperiosteal flap . Should be full thickness . Aviod nurovascular bundle . Keep incision over sound bone for closer

16. 1.Enucleation III- Osseos window . It is a creation of access from bone to the lesion. . An already eroded bone can be enlarged by rounger or bur . If cortical bone is intact, a rotating bur can be used to make the osseos window . Size of the window depend on the size of the lesion

17. 1.Enucleation Iv-Removal of cyst A thin bladed curate suitable for claeving the cystic lining from the wall of the bony cavity. The concave surface always be towards the bone and convax surface toward the cyst. Care must be taken to avoid tearing of the cyst. Prevent the vital structure from damage .

18. 1.Enucleation Once the cyst remove, bony cavity inspect for removal of the remanant tissue. Obviously devitalization of teeth occurs, so endodontic treatment may be necessary in near future. Irrigate the the cavity with saline to remove the debrise. Water tight suture place. Radiogaraphic evidence of bone fill take 6 to 12 months

19. Enucleation done

20. 1.Enucleation V-Specimen care

21. 2. MARSUPIALIZATION ( Decompresion, Partsh I, Ostostomy ) It is a 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.

22. 2.MARSUPIALIZATION INDICATIONS Amount of tissue injury. Surgical access. Assistance in eruption of the teeth Extend of the surgery. Size of the lesion

23. 2.MARSUPIALIZATION ADVANTAGES Simple procedure to perform and prevent the vital structure from damage.

24. 2.MARSUPIALIZATION DISADVANTAGES Pathological tissue is left and not all pathological tissue available for histopathological examination. Patient remain inconvenient by cystic cavity which must be kept clean to prevent infection from food debris

25. Marsupialization

26. Marsupialization

27. Marsupialization

28. Marsupialization

29. Marsuplization indicated

30. 2.MARSUPIALIZATION TECHNIQUE . Diagnosis confirm by aspiration. . The initial incision is elliptical or circular, H incision create a large window (1cm or large) on cystic cavity. . If bone is thin, initial incision can be extended through bone into cystic cavity. . if bone is thick , osseos window is make by a bur.

31. 2.MARSUPIALIZATION The cyst is incised to remove window of lining, which submited for pathological examination. The content of cyst evacuated. Irrigate the cyst to remove any residual fragments of debris. If cystic lining is thick and access permit the cystic wall arround the window suture to the oral mucosa. Other wise pack with antibiotic gauze.

32. 2.MARSUPIALIZATION The pack is left 10-14 days to prevent the oral mucosa heal over the cyst. After 2 weeks the lining heal with to oral mucosa around th periphery of the window. Careful instructionto the patient regarding cleansing of the cavity are necessary

33. 3.ENCLEATION AFTER MARSUPIALIZATION The combine approach reduces morbidity and accelerate complete healing of the defect.

34. 3.ENCLEATION AFTER MARSUPIALIZATION INDICATIONS The cyst that does not totally oblitrate after marsupilzation, enucleation should be considerd. Patient feeling difficulty to clean the previous marsupialized cavity.

35. 3.ENCLEATION AFTER MARSUPIALIZATION ADVANTAGES In the marsupialization phase: . Simple procedure prevent vital structure. In the enucleation phase: . The entire lesion available for histological examination. .Development of thickened cystic lining makes enucleation easier.

36. 3.ENCLEATION AFTER MARSUPIALIZATION DISADANTAGES Total cyst not remove initially for pathological examination, subsequent enucleation may then detect any different pathological condition.

37. 3.ENCLEATION AFTER MARSUPIALIZATION TECHNIQUE The cyst first marsupialized allow the osseous healing. Once cyst decrease in size make easier to complete surgical removal, enucleation perform as definitive treatment. The appropriate time for enucleation when bone cover vital structure prevent to damage and fill the adequate bone to prevent jaw fracture.

38. 3.ENCLEATION AFTER MARSUPIALIZATION .The cyst has a common epithelial lining with the oral cavity after marsupialization. .The window is made initially into the cyst contain epithelial bridge between cystic cavity and oral cavity. .An elliptical incision completely encircling the window down to the sound bone. .Stripping the cyst from the window into the cystic cavity and cyst can be enucleated without difficulty

39. 4.ENUCLEATION WITH CURETAGE After enucleation a currate or bur is used to remove 1 to 2 mm of bone arround the entire periphery of the cystic wall.

40. 4.ENUCLEATION WITH CURETAGE INDICATIONS When removing the odontogenic keratocyst. Cyst that recurs after through removal.

41. 4.ENUCLEATION WITH CURETTAGE ADVANTAGES If enucleation leaves epithelial remnants, curettage may remove them, thereby decreasing the chances of recurrence.

42. 4.ENUCLEATION WITH CURETTAGE DISADVANTAGES Curattage is more destructive for adjacent bone, dental pulps and vital structure.

43. 4.ENUCLEATION WITH CURETTAGE TECHNIQUE After enucleation bony cavity inspected for proximity of adjacent structre. A sharp currate or bur with sterile irrigation used to remove 1-2 mm layer of bone. Care should be taken to prevent the adjacent structre.