MANAGEMENT OF CYSTS

OF THE ORAL AND

MAXILLOFACIAL REGION
ABDUL KALAM AZAD
 INTRODUCTION

A cyst is a pathological cavity usually lined by epithelium with

fluid or semifluid contents, not created by the accumulation of
pus.

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 DIAGNOSIS

CRITERIA FOR DIAGNOSIS

◾ Based On Clinical Features

◾ Based On Anatomical Site Of Jaw

◾ Based On Histological Features

◾ Based On Aspirate Fluid

◾ Based On Radiographic Features

PRESENTING SIGNS AND SYMPTOMS

Intrabony cysts may remain symptomless for many years and only
come to light as an incidental finding on routine dental inspection
or radiographic investigation or can present in the following
variety of ways:

a) Association with teeth

- Radicular (dental) cysts - most common of all cysts and are
associated with a non-vital root of a tooth.
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-Ectopic teeth can often be associated with cysts either as the
primary cause as with the dentigerous cyst or when displaced by a
cyst, such as an odontogenic keratocyst.

b) Site:
- 75% of odontogenic keratocysts present at the mandibular angle
- 88% of glandular odontogenic cysts occur at the anterior
mandible
- Nasopalatine cyst arises from tissues within the incisive canal

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- inflammatory lateral periodontal cyst (a variant of a radicular
cyst), the true lateral periodontal cyst, the peripheral
odontogenic keratocyst and gingival cyst of adults are
present in the gingiva coronal to the apices and in-between
teeth in the premolar areas.

C) Swelling:
- Swelling is a common presenting complaint
- the swelling is normally clinically discrete and well
demarcated.

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- In case of extensive expansion of the cyst, the overlying
bone will be thin or absent and the surface will feel firm but
flexible
- if the overlying bone has been completely eroded it will
appear as a tense bluish swelling that feels ‘fluctuant’

d) Patterns of growth and anatomical site:

- Cysts expands quicker through cancellous and thin cortical
bone and so tend to present sooner in the anterior region than in
the posterior mandible.
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- cysts in the posterior mandible/maxilla spreads along
cancellous bone or into the maxillary air sinus respectively,
thus making clinically obvious swelling a late feature.
- Cysts that develop by fluid accumulation and consequent
hydrostatic pressure, e.g. inflamatory and dentigerous cysts,
develop spherically - expand through cortical bone relatively
early.
- odontogenic keratocysts grow by cellular Proliferation -
expanding within the cancellous bone- late expansion.

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e) Pain:
- Pain is uncommon and is usually indicative of acute
infection.

f) Lobulation:
- Where a radiolucency displays lobulation, it is strongly
suggestive of the keratocyst due to the ‘invasion’ of lining
epithelium through the cancellous bone space leaving behind
isthmi of bone.

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g) Associated signs and symptoms;
-Can affect the adjacent structures, teeth and neurovascular
structures.
-Erupted teeth are occasionally loosened or displaced, disrupt
the occlusion or alter the shape of the alveolus and the fit of a
prosthesis.
- Rarely cysts can resorb teeth (infection increasing the risk) or
cause a pathological fracture.

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 INVESTIGATIONS

- Simple cysts- OPG, periapical and occlusal views are

normally sufficient.
- Cysts extending into soft tissues (e.g. the lingual area or the
maxillary sinus and pterygoid regions)- advanced imaging
such as CT required.
- The rare soft-tissue cysts—branchial, thyroglossal and
dermoid—need specialist investigation - ultrasound, CT and
MRI scanning.
- the general radiological features of cysts can be summarized
as radiolucencies with a well defined, corticated margin.

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- The features of site, shape, relationship to teeth and whether
there is any lobulation will all contribute to the FINAL diagnosis

- All cyst specimens should be submitted for histological

examination

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 TREATMENT

RATIONALE FOR TREATMENT OF CYSTS OF ORAL CAVITY

§ Cysts tend to increase in size and produce facial

disfigurement.
§ Cysts tend to get infected.
§ Cysts weaken the jaw and may cause pathological fracture.
§ Some cysts can undergo changes. Eg: Ameloblastoma,
Mucoepidermoid carcinoma ( histological study to be done)
§ Cysts prevent eruption of teeth. (dentigerous cyst)
§ Involvement of neighboring structures.( maxillary sinus,
1 nose, adjacent tooth)
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 AIMS OF TREATMENT

§ 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.

§ To preserve important adjacent structures such as nerves and healthy tissues.

§ To achieve rapid healing of the operation site.

§ To restore the part to a near normal form and to restore normal function.
§ To conserve the erupted healthy teeth, partially erupted teeth or certain teeth
which may serve a functional role in the arch.
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Cysts of the jaws are treated in one of the following four basic
methods:

1. Marsupialization (Partsch 1 Operation or Cystotomy)

2. Enucleation and primary closure of cysts of small size (

Partsch II operation or cystectomy)

3. A staged combination of the two procedures.

4. Enucleation and its modifications.

1. MARSUPIALIZATION
• Marsupialization, decompression OR the Partsch I operation -
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.
Indications for marsupialization:
1. AGE: in a young child with developing tooth germs or in elderly,
debilitated patients.
2. PROXIMITY TO VITAL STRUCTURES:cysts in Proximity to
maxillary sinus, neurovascular structures or which can damage
vital tooth.
3. Assistance in eruption of teeth : if unerupted tooth associated with
a cyst can be guided into occlusion
4. Size of cyst : In very large cysts, a risk of jaw fracture during
enucleation is possible.
Technique of Marsupialization:
1) Anaesthesia : General anesthesia,
conscious sedation or local anesthesia
2) Aspiration : cystic contents are
aspirated.
3)Incision : a) Circular, oval or
elliptic incision 1 cm or larger leaving
a margin of 1 cm from the gingival
margins of teeth or alveolar crest in
edentulous patient.
: b) Inverted U
shaped incision with broad base to the
buccal sulcus. Mucoperioteum is
reflected in this case.
4) Removal of bone:
- When the bone is thin, the
incision can extend through
the mucoperiosteum, bone
and cystic lining into the
cystic cavity.
- When the bone is thick, Using
a round bur, the surgeon de-
roofs the cystic lesion by
removing the cortical bone
overlying the lesion and being
careful not to remove the
cystic lining 19
-A round dental curette or the broad end of a Woodson
elevator is used to carefully dissect the cystic lining from
the bony edges.
-The most superior portion of the cystic lesion is grasped
with Adson or DeBakey forceps and excised AND sent
for histopathologic examination.
- Irrigation of cystic cavity to remove any residual
fragments of debris.

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-At this point the free margins
of the cystic lining are sutured
to the free gingival margins,
using a fine noncutting (round)
needle with 4-0
Vicryl suture.

- The remainder of the mucosal

incision is closed primarily,
ensuring the cystic access
remains open.
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 CONTINUE…

- 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.
- Maintenance of cystic cavity
Instruct the patient to clean and irrigate the cavity regularly with oral antiseptic
rinse with a disposable syringe.
Advantages :
• It is a simple procedure to perform.
• Marsupialization also spare vital structures from damage
should immediate enucleation be attempted.
• Reduces operating time.
• Prevents pathologic fractures
• Prevents oro-nasal, oro-antral fistula.
• Reduces blood loss
• Alveolar ridge is preserved.
Disadvantages :
• Pathologic tissue is left in situ, without thorough histologic
examination.
• Prolonged healing time
• Risk of invagination and new cyst formation.
• 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

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POSTOPERATIVE COMPLICATIONS OF
MARSUPIALIZATION

- stenosis of the pouch, thereby reestablishing the cystic cavity.

- infection,
- An inability to maintain adequate wound hygiene,
- dislodgement, or blockage of the catheters if any, used

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2. ENUCLEATION
• Enucleation or PARTSCH II is the process by which the total
removal of a cystic lesion is achieved.

• Enucleation – done with care, in an attempt to remove the

cyst in one piece without fragmentation, 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.
Indications :
• Enucleation is the treatment of choice for any cyst of the
jaws that can be safely removed without unduly sacrificing
adjacent structures.

Advantages :
• pathologic examination of the entire cyst can be undertaken
• the initial excisional biopsy (i.e., enucleation) has also
appropriately treated the lesion.
• The patient does not have to care for a marsupial cavity with
constant irrigations.
• Primary healing of the wound.
 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.

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Technique:
• Any radiolucent lesion should be
aspirated before surgical
exploration as it gives diagnostic
information regarding the nature
of the lesion.

• enucleation via the extraction

socket can be easily
accomplished using curettes when
the cyst is small.
1. ENUCLEATION WITH PRIMARY CLOSURE

A. ANESTHESIA: LA or GA
B. INCISION & FLAP DESIGN:
- A firm incision should be made through periosteum to bone.
- The location of the lesion dictates where the flap incisions are
to be made.
- mucoperiosteal flaps should be full thickness and incised
through mucosa, submucosa, and periosteum

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- There are four principal flap designs for enucleation
i) Semilunar flap
ii) Two sided ( triangular ) flap
iii) Three sided ( trapezoidal ) flap
iv) OCHSENBEIN LUBKE FLAP

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i)Semilunar flap
- Curved incision from the vestibular
fold having a bow shaped course with
the lowest point at least 0.5 mm from
the gingival margin.
- less risk of recession of the gingival
tissues.

Disadvantages:
● restricted access to apical tissues.
● difficult to ensure the incision line ends
up resting on bone
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● wound dehiscence
ii) Two sided flap
- A relieving incision is made
in the oral mucosa of the
buccal sulcus, and the
incision is extended around
the gingival margin of the
tooth to be treated
- An advantage is the ease of
repositioning of the flap after
surgery.
- Disadvantage is restricted
accessibility.
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iii) three sided flap
- Made by giving a second
vertical incicsion to the
horizontal incision.
- provides excellent access
for most surgical
endodontic procedures.
- No tension on tissues.
Disadvantages:
- Recession of gingiva

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iv) ochsenbein lubke flap
- Combination of semilunar and
vertical incisions
- Flap is scalloped to follow the
gingival architecture
- Advantages are most adequate
visibility, sparing of marginal
gingiva, good esthetic results and
ease of reapproximation of flap
and suturing.

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C. FLAP REFLECTION
- Full-thickness flap or mucoperiosteal flap is raised with
sharp elevator in firm contact with bone to minimize
hemorrhage and to prevent tearing of the tissue.

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D) LATERAL CORTICOTOMY
- Frequently, the cortical bone overlying the apex has been resorbed
, exposing a soft tissue lesion.
- If the opening is small, it is enlarged using a medium size (no.5 or
6) round bur to create a window in the buccal bone to expose
part of the lesion

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- The lateral corticotomy should be made over an area of
sound bone that will not be involved in closure of the
incision line.
- The corticotomy should be of sufficient size to allow for
adequate access to the lesion and to preserve surrounding
tissue

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E) REMOVAL OF CYST
-double-ended curette is used with the sharp edge placed against
the bone.
- The concave surface of the instrument should always be kept in
contact with the osseous surfaces of the bone cavity
- This will allow for enucleation of the lesion and minimize the
occurrence f tear of the pathologic entity
- When careful enucleation is not performed, remnants of the
pathology may result in persistence of the lesion
- Once the lesion has been successfully enucleated, it is removed
intact from its cavity
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F) CURETTAGE OR PERIPHERAL OSTECTOMY and
CLOSURE
• a sharp curette may be used to ensure that the cavity is
thoroughly curetted and that no gross pathology remains.
• A peripheral ostectomy - with a large, round diamond bur
with copious cool irrigation to remove 1 to 2 mm of
surrounding bone until the cavity is clear of all visible
pathology.
• Once the cavity is devoid of residual pathologic tissue, it is
irrigated and the flap is replaced and a watertight closure is
recommended with interrupted horizontal mattress sutures

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G) POSTOPERATIVE PANORAMIC RADIOGRAPH
Postoperative and follow-up radiographs are obtained to assess:
- the extent of the procedure,
- to assure that the lesion has been successfully removed,
- to determine if there have been any pathologic or surgical
fractures of the affected area, and
- to evaluate any reconstructive procedures that may have
been performed

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2. ENUCLEATION WITH CHEMICAL CAUTERIZATION
• Chemical cauterization is done in the treatment of OKC.

• After enucleation AND peripheral ostectomy, a chemical cauterizing

agent Carnoy’s Solution is applied along the walls of the cystic
cavity.

• It is left for about 5-7 minutes and then irrigated thoroughly with
saline.

• This solution is a chemical fixative which has the ability to penetrate

bone, kills epithelial remnants and dental lamina and maintains the
bony structure..
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Carnoy's solution:-

60 ml absolute alcohol + 30 ml chloroform + 10 ml acetic acid.

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3. ENUCLEATION AFTER MARSUPIALIZATION

• Initial healing is rapid after marsupialization but the size of the

cavity may not decrease appreciably past a certain point in
some cases.
• The objectives of marsupialization may be achieved at this
time, and a secondary enucleation may be undertaken without
injury to adjacent structures.
 COMPLICATIONS

COMPLICATIONS OF ENUCLEATION OF CYSTS

A) Intraoperative complications
• Injury to inferior alveolar nerve
• Injury to adjacent teeth
• Fracture of jaw
• Tearing of the lesion
B) Post operative complications
• Oro-antral communication
• Hematoma
• Infection
• Dead space formation
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 FOLLOW UP

-objective : to ensure that the wound heals (enucleation) and

that the packing changes to establish the epithelialized cavity
(marsupialization)
- Long-term follow-up : for any cyst where there is a
propensity for recurrence, such as the OKC where review
will extend beyond 6 months.
- Initially reviews should be conducted every 6 months, and
then yearly with radiographic monitoring.

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 PROTOCOLS FOR SPECIFIC CYST MANAGEMENT

1. RADICULAR OR RESIDUAL CYST

Treatment:
- Enucleation of the cyst combined with eradication of the
cause, i.e. the products of pulp necrosis.
- This may mean either
a) retaining the tooth with a combination of endodontic therapy
and surgery or
b) removal of the associated tooth at the time of the enucleation.

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2. DENTIGEROUS CYST:
- The two issues specific to management of dentigerous cysts are:
a) Other lesions such as keratocysts and ameloblastomas often have
ectopic teeth in dentigerous relationship, which may lead to
misdiagnosis.
b) it may be desirable to retain the ectopic tooth and allow it to
erupt into a functional position
Treatment:
i) Enucleation and extraction of involved tooth.
ii) Marsupialization is done in case of large cyst present in children
where tooth eruption is to be achieved.
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3. ODONTOGENIC KERATOCYST
-Has high potential for recurrence
Treatment:
- Treatment options focus on this potential for recurrence.
i) enucleation and treatment of the cavity with Carnoy’s
solution
ii) For large cysts, marsupialization to shrink the cyst down
and then deal with a much smaller residual cyst lining.

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4. ERUPTION CYST:
- They are uncommon and many burst spontaneously.
- If they don’t resolve quickly, the overlying tissue may need
to be removed to allow the tooth to erupt.

5. GINGIVAL CYST:
- Treatment is by local excision.

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6. GLOBULOMAXILLARY CYSTS:
- globulomaxillary cyst is an umbrella term used for cystic lesions
appearing between the upper lateral incisor and canine tooth.
- Treatment is Enucleation.
7. NASOPALATINE CYST OR INCISIVE CANAL CYSTS:
- symmetrical swelling behind the upper incisors in the midline
- Radiographs: midline round or oval radiolucent lesion which may
displace the roots of the central incisors laterally.
- Accurate vitality tests are essential to avoid misdiagnosis. It is
difficult to differentiate a small nasopalatine cyst from a large
incisive canal.
- -Treatment is enucleation.
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8. STAFFNE/ STATIC BONE CYST:
- A small, smooth outlined lesion is found beneath the second and third
molar teeth, below the inferior dental canal.
- accidental finding in radiograph, asymptomatic.
- No treatment required.
9. ANEURYSMAL BONE CYTS:
- It is more common in the mandible than maxilla.
- painful
- Painful in 50% of cases, or as an incidental finding on a radiograph.
- Radiographically it may be a uni or multilocular lesion with irregular
outline and occasional displacement of tooth roots
- Treatment is Curettage although the lesions can recur
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10. SOLITARY / HEMMORHAGIC/SIMPLE/TRAUMATIC
BONE CYST:
- a painless swelling or incidental finding on radiographs
affecting the mandible.
- Females are more commonly affected than males
- They rarely appear after adolescence as that these lesions
spontaneously resolve.
- In longstanding or large lesions, treatment is by curettage of
the cavity, which results in clot formation and complete bony
infill.
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THANKYOU

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