Management of Cysts

Odontogenic Cysts Management

1. Management of cysts Dr. Hadi Munib Oral and Maxillofacial Surgery Resident

2. outline Definition of cysts and key features of it Diagnosis of cysts Classification of cysts Surgical Management of Jaw Cysts Common Clinical Cysts References

3. Definition of cysts A Pathological cavity having fluid or semi-fluid contents. Epithelial Lining More common in the jaws than any other bone

4. Key features of cysts Asymptomatic unless they become  secondarily infected . Expand slowly and rarely cause fractures Displacing and loosening rather than resorbing of teeth and roots. Sharp Well-Defined Radiolucency surrounded by smooth borders

5. Signs and Symptoms Range from: None Swelling Intra-Oral Discharge Pain Denture Difficulties Looseness of teeth Eggshell cracking. Paresthesia Pathological Fractures

6. Diagnosis of cysts History and Examination [Inspection, Palpation, Percussion and Auscultation] Aspiration Vitality tests of teeth Imaging Biopsy Albumin level in serum ( <4 g/ dL or > 4 g/ dL )

7. Diagnosis of Cysts

8. Types of cysts Odontogenic >90% of all cysts. Developmental: Odontogenic keratocyst Dentigerous (follicular) cyst Eruption cyst Lateral periodontal cyst Gingival cyst of adult Glandular cyst Inflammatory Radicular Paradental Non-Odontogenic -Epithelial lined: Nasopalatine duct cyst Nasolabial cyst Median palatine cyst Median mandibular cyst Globulomaxillary cyst - Nonepithelial lined: Solitary bone cyst Aneurysmal bone cyst Stafne’s bone defect

9. Surgical Management Marsupialization Enucleation Enucleation and Curettage Enucleation with Peripheral Ostectomy Enucleation with Carnoy’s Solution Enucleation with Bone Grafting Marsupialization followed by Enucleation Resection

10. Marsupialization Decompression – Creating a surgical window in the wall of the cyst Indications: Poor Medical Health. Size of the cysts. Assistance in eruption. Difficult access. Advantages: Simple, safe and can be done by any practitioner Disadvantages: High dependence on compliance and leaving pathological tissues. Technique

11. Enucleation Total Removal of cystic lesion. Indications: the treatment of choice for removal of cysts of the jaws that can be safely removed without unduly sacrificing adjacent structures. Advantages: Total removal of cystic lesion, not dependent on compliance Disadvantages: Requires a professional and risky Technique

12. Enucleation and curettage After enucleation a curette or bur is used to remove 1 to 2 mm of bone around the entire periphery of the cystic cavity. Indications: Odontogenic Keratocyst and Recurrent cysts Advantage: Decrease likelihood of recurrence Disadvantage: Destructive

13. Enucleation with peripheral oStectomy Enucleation Bone removal 3 – 5 mm High Recurrence Rate Cysts

14. Enucleation and carnoy’s solution Enucleation Carnoy’s Solution contains 100% ethanol, chloroform and glacial acetic acid in a 6:3:1 ratio with added ferric chloride. Penetrates into bone up to depth of 1.54 mm after 3-5 minutes of application Odontogenic Keratocyst

15. Enucleation and bone grafting Enucleation Not recommended If autogenous bone used this will increase morbidity If synthetic bone used this will delay healing

16. Marsupialization followed by enucleation After initial healing of Marsupialization, enucleation is done. Indications: if the cyst does not totally obliterate after marsupialization and if the patient is finding difficulty in cleaning Advantages: Simple procedure that spares adjacent vital structures for Marsupialization and total removal of cystic cavity for Enucleation Disadvantages.

17. resection

18. Common Clinical Cysts

19. Types of cysts Odontogenic >90% of all cysts. Developmental: Dentigerous (follicular) cyst Odontogenic Keratocyst Eruption cyst Lateral periodontal cyst Gingival cyst of adult Glandular cyst Inflammatory Radicular Paradental Non-Odontogenic -Epithelial lined: Nasopalatine duct cyst Nasolabial cyst Median palatine cyst Median mandibular cyst Globulomaxillary cyst - Nonepithelial lined: Solitary bone cyst Aneurysmal bone cyst Stafne’s bone defect

20. Radicular Cysts Most common inflammatory cyst Three types: apical, residual and lateral Associated with non-vital tooth Apical radiolucency indistinguishable from a periapical granuloma May be symptomless Treatment?

21. Dentigerous Cysts Developmental Associated with an unerupted tooth. [Most common teeth] Three types: Central, Lateral and Circumferential types Differential Diagnosis. Gardner’s Syndrome Treatment?

22. Odontogenic Keratocyst More aggressive with higher rate of recurrence. Nevoid basal cell carcinoma syndrome association Recurrence Rate is up to 62% Posterior Mandible Anterior-Posterior Growth Unilocular vs. Multilocular Treatment

23. Glandular Odontogenic cysts Aggressive Anterior portion of the jaws Recurrence 30% Differential Diagnosis Treatment.

24. Lateral Periodontal Cyst Vital tooth Asymptomatic Lower Premolars Botryoid

25. Nasopalatine duct cysts Most common non-Odontogenic cyst Palatal to upper centrals > 7 mm Heart shaped Radiolucency Treatment

26. Globulomaxillary cysts Umbrella term Cystic lesions appearing between the upper lateral incisor and canine tooth. Embryonic Fusion Apical cysts. Treatment is by enucleation.

27. Median mandibular cyst Cystic lesions in the midline of the jaw. Odontogenic in origin

28. Nasolabial cysts Soft tissue cyst with unknown etiology. Fourth and Fifth decades Male: Female 1:4. Swelling at the nasal fold. Local resorption of the maxilla. It can be lined by squamous or respiratory epithelium Treatment is by excision. Ultrasound

29. Aneurysmal bone cyst Aggressive Radiographically Well-Circumscribed soap bubble–type lesion. Histologically has Giant Cell Component. It responds well to moderately aggressive curettage, although hemorrhage can be a problem. Recurrences are rare.

30. Solitary Bone cyst Traumatic Asymptomatic Posterior Mandible Biopsy is curative

31. Stafne’s bone defect Salivary Gland Depression Mandible Contains ectopic salivary tissue in continuity with the submandibular salivary gland. Bilateral anomaly Sialography ? Beneath ID canal

32. References Oral Pathology 4 th Edition Chapter 6: Cysts of the jaws Peterson’s Principles Of Oral And Maxillofacial Surgery Chapter 30: Cysts Contemporary Oral And Maxillofacial Surgery Chapter 23: Surgical Management of Oral Pathologic lesions

33. Thank you