-
Prepared by
P.Nandakumar
VTECH
CYSTIC SWELLING OF THE JAWS
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
-
CYST - DEFINITION
Pathologic cavity or sac within the hard or soft tissues that may
contain fluid, semifluid or gas. It may be lined by epithelium,
fibrous tissue or occasionally even by neoplastic tissue.Initially,
cysts do not contain pus, when cystic contents secondarily
infected, pus develops.
Cyst Formation
Cyst initiation - Proliferation of epithelial lining &
formation of small cavityEnlargement / Expansion of cystic cavity
then occurs.
-
CLASSIFICATION
Cysts of the jaws, oral and facial soft tissues
Intraosseous Cysts Soft Tissue Cysts
Epithelial cystsNon-epithelial cysts Cysts of maxillary
antrum
Odontogenic cystNon-odontogenic cyst (Fissural cyst)
DevelopmentalInflammatory
-
INTRAOSSEOUS CYSTS
Epithelial cystsOdontogenic epithelial
originDevelopmentalPrimordial cyst (keratocyst)Dentigerous
(follicular) cystLateral periodontal cyst lateral botryoid
odontogenic cystCalcifying odontogenic (Gorlin)
cystInflammatoryRadicular cyst (apical/lateral periodontal)Residual
cystNon-odontogenic epithelial originFissuralMedian
mandibularMedian palatalGlobulomaxillaryIncisive canal
(nasopalatine duct or median anterior maxillary) cyst
- Non-epithelial cystsSolitary bone cyst (traumatic)Aneurysmal
bone cystStafnes bone cavityCysts of the maxillary antrumSurgical
ciliated cyst of maxillaBenign mucosal cyst of the maxillary
antrum
-
SOFT TISSUE CYSTS
OdontogenicGingival cystsAdultNewbornNonodontogenicAnterior median
lingual cystNasolabial cyst (or nasoalveolar cyst)Retention
cystsSalivary gland cystsMucoceleRanula
- Developmental/congenital cystsDermoid and epidermoid
cystsLymphoepithelial cyst (cervical / intraoral)Thyroglossal duct
cystCystic hygromaParasitic cystsHydatid
cystsCysticerocisHeterotropic cystsOral cysts with gastric or
intestinal epithelium
-
INTRAOSSEOUS CYSTS
(A) ODONTOGENIC EPITHELIAL ORIGIN
1) PRIMORDIAL CYST (KERATOCYST)
The term keratocyst coined by Philipsen (1956) and was based on
histologic appearances of the cystic lining.Two variants are
identified: (a) orthokeratinized and (b) parakeratinized
odontogenic keratocysts
- IncidenceSlight predilection for males.Predominantly seen in
second, third and fourth decades.SiteAngle of mandible.Majority of
cysts seen posterior to first bicuspids.Clinical featuresPatient is
free of symptoms until cysts reached large size because the cyst
initially extends in medullary cavity and expansion of bone occurs
late.Displacement of teeth.
- Teeth overlying cyst produce dull / hollow sound on
percussion.Buccal expansion of bone.Teeth adjoining cyst will have
vital pulps.Large mandibular cysts, deflect neurovascular bundle
into abnormal position.In acute infection, pus within the sac
causes neuropraxia which results in labial paresthesia.When pus is
drained, sensation returns to normal.
- Radiological featuresKeratocyst can be uniocular or
multiocular.Buccal and lingual expansion is seen.Resorption of
lower cortical plate of mandible.Perforation of bone.Cyst
contentsContain a dirty white, viscoid suspension of keratin which
an appearance of pus but without an offensive smell.
- TreatmentSmall single cysts with regular spherical outline
Enucleation from intraoral approach.Larger cysts with regular
spherical outline Enucleation from extraoral approach.Uniocular
lesions with scalloped outline Marginal excision.
- Larger multiocular lesions with or without cortical perforation
Resection of involved bone followed by primary or secondary
reconstruction with stainless steel, vitallium, titanium and bone
grafting with iliac crest graft, costochondral graft or allogenous
bone graft.Carnoys solution for conservative approach to large
keratocysts and used to cauterize bony defect.
-
2) DENTIGEROUS (FOLLICULAR) CYST)
Resulted from enlargement of the follicular space of whole or part
of crown of an impacted or unerupted tooth and is attached to neck
of tooth.IncidenceSlight predilection for males.Seen in first,
second, third decades.SiteCommon in mandible.
- Clinical featuresFacial asymmetry.Ill-fitting dentures.Adjacent
teeth fail to erupt or may be tilted.Lateral expansion causes
smooth, hard, painless, prominence, later as cyst expands, bone
become thinned and indented with pressure on palpation.Egg-shell
crackling sound.
- Radiological featuresUniocular radiolucency.Cysts have
well-defined sclerotic margin unless when they are infected the
margins are poorly defined.With pressure of enlarging cyst,
unerupted tooth may be pushed into abnormal positions.Causes root
resorption of adjacent teeth.
- E.g.Lower third molar pushed into inferior border or into the
ascending ramus.Upper incisors, canines pushed into maxillary sinus
or floor of nose.Dental follicle expand around unerupted or
impacted tooth in 3 variations;circumferential,lateral, andcentral
or coronal.
- PathogenesisDevelop by accumulation of fluid between reduced
enamel epithelium or within enamel organ itself of unerupted or
impacted teeth.Also due to degeneration of stellate reticulum at
early stage of development.Cyst contentsContain clear yellow fluid
in which cholesterol crystals may be present or purulent material
if infection occurs.
- TreatmentMarsupialization (Partsch surgery) Indicated in
children if the cyst is very large in size and involved tooth to be
maintained.Enucleation Cyst enucleated together with involved tooth
in adults, as the possibility of the tooth erupting is low.
-
3) DEVELOPMENTAL LATERAL PERIODONTAL CYSTS
Found lateral to roots of vital teeth.IncidenceCommonly found in
adults.No age or sex predilection.SiteCommon in mandible.Often
related to mandibular cuspid, bicuspid, and third molar roots.
- Clinical featuresAssociated teeth is vital.At times gingival
swelling occur on buccal or lingual aspect.Lingual type of cyst
involving mandibular third molar are more common and if infected
can cause sever spreading infection of submandibular
space.Radiological featuresLoss of lamina dura.Well-defined round
or ovoid radiolucency with sclerotic margin.Cyst present between
cervical margin and apex of root.
- PathogenesisOrigin is from reduced enamel epithelium, remnants
of dental lamina or cell rests of malassez.Cystic contentsHas
serous caseous conent.TreatmentEnucleation.
-
4) CALCIFYING EPITHELIAL ODONTOGENIC CYST
Also known as Gorlin cyst.IncidenceNo sex predilection.More common
in children and young adults.SiteCommon in anterior part of
mandible.
- Clinical featuresSwelling of jaw.Hard bony expansion of
lesion.Lingual and palatal expansion.Cysts arise close to
periosteum produce saucer-shaped depression in the
bone.Displacement of teeth.
- Radiological featuresUniocular or multiocular.Cortical
perforation.Calcifications as irregular radiopaque specks seen
within bone cavity.Resorption of roots of adjacent teeth.Cyst
associated with complex odontome or unerupted tooth.
- PathogenesisArises from remnants of dental lamina, stellate
reticulum or reduced enamel epithelium.TreatmentEnucleation.If
associated with complex odontoma, a conservative removal is
adequate.
-
5) RADICULAR CYST
It is an inflammatory cyst results due to infection extending from
pulp into surrounding periapical tissues.IncidenceMost common
odontogenic cyst.Commonly affects males.Peak incidence is in the
third and fourth decades.SiteCommon in anterior maxilla.
- Clinical featuresTeeth with non-vital pulps.Slowly enlarging
swellings.Pain present in the presence of suppuration.Bony hard
swelling with the covering bone become thin and exhibits
springiness on fluctuation.Intra oral sinus tract with discharging
pus or brownish fluid when cyst is infected.Tooth sensitive to
percussion, hypermobile or displaced.Pathologic fracture.Temporary
parasthesia of regional nerve if cyst is infected.
- Radiological featuresRound, pear or ovoid shaped radiolucency,
generally outlined by narrow radio-opaque margin that extends from
lamina dura of involved tooth.Root resorption is rare.
- Pathogenesis
Occurs in three phases;
Phase of initiation
Chronic low grade invasion from pulp
Periapical granuloma
(Activation and proliferation)
Epithelial rests in periodontal ligament
(forms)
Strands, arcades or rings.
Phase of cyst formationCystic cavity forms, lined by stratified
squamous epithelium.Phase of enlargementOnce initiation of cyst
occurred, continuation of enlargement occur due toAccumulation of
fluidRetention of fluidRaised intracystic pressure
- Cystic contentsUninfected cyst fluid Straw coloured, or
brownish and has cholesterol clefts.Long standing infection a dirty
white caseous material present.TreatmentEnucleation with primary
closure is treatment of choice.Non-vital teeth associated with cyst
can be extracted or retained by endodontic procedures or
apicocetomy.Large cyst encroach upon maxillary antrum or inferior
alveolar nerve or nose treated by marsupalization.
-
6) RESIDULAL CYST
It is one that overlooked after the causative tooth or root is
extracted.EtiologyIncompletely removed periapical granuloma, or
cyst that potentially enlarges.IncidenceNo sex predilection.Common
in middle-aged and elderly patients.SiteCommon in maxilla and
edentulous site.Clinical featuresMostly asymptomatic.Pathologic
fractures.TreatmentEnucleation with primary closure.
-
(B) NON-ODONTOGENIC EPITHELIAL ORIGIN
1) MEDIAN MANDIBULAR CYST
IncidenceNo sex predilection.SiteFound symmetrically in the midline
of mandible.Clinical featuresCyst is small in size and
approximately 1-3 cm in size.Associated teeth are vital.Labial
swelling is palpable.Teeth may be divergent.
- Radiological featuresCyst is small, well-defined, circular or
ovoid in shape.Lamina dura is intact.TreatmentEnucleation
-
2) MEDIAN PALATAL CYST
IncidenceNo sex predilection.Mainly seen in adults.SiteSeen in
maxillary alveolus or in hard palate.Clinical featuresExpansion of
bone.Palpable ovoid swelling in mid-palatal region.Radiological
featuresOvoid or irregular radiolucency in mid-palatal
region.TreatmentEnucleation with primary closure.
-
3) GLOBULOMAXILLARY CYST
Also termed as lateral fissural cyst.IncidenceSeen in adults and in
either sex.SiteBetween maxillary lateral incisor and
canine.Clinical featuresLateral incisor and canine tilted coronally
with root divergence.Both teeth vital.
- Radiological featuresPear shaped radiolucency seen between
maxillary lateral incisor and canine with apex pointing toward
alveolar crest.Lamina dura intact.Root divergence
present.TreatmentEnucleation with primary closure.
-
4) NASOPALATINE DUCT CYST
IncidenceSeen in adulthood.Slight predilection for male.SiteCommon
in lower portion of maxilla between apices of central incisor.
- Clinical featuresAsymptomatic.Do not enlarge beyond 1.5 to 2
cm.Recurrent swelling in the anterior region of midline of palate
or on the labial aspect between central incisors.Displacement of
teeth.Patient complains swelling, pain discharge.Discharge is salty
taste and originate from sinus tract at or near incisive
papilla.Burning sensations or numbness.
- Radiological featuresWell-defined cystic outline between or
above roots of maxillary central incisors.Round or ovoid or
heart-shaped radiolucency seen between maxillary central
incisors.Lamina dura intact.Roots are divergent.Cystic
contentMucoid material or pus present if the cyst is
infected.TreatmentEnucleation.
-
(C) NON-ODONTOGENIC NON-EPITHELIAL BONE CYSTS
1) SOLITARY BONE CYST
IncidenceOccur in children and adolescents.Males are affected
more.SiteCommon in subapical region above the inferior dental canal
in the canine and molar region.Clinical featuresAssociated teeth
vital unless involved.Cortex is thinned.Expansion involves lingual
aspect below mylohyoid ridge.Radiological featuresUniocular
cavity.TreatmentGentle curettage.
-
2) ANEURYSMAL BONE CYST
IncidenceNo sex predilection.Seen mainly in children, adolescents
or young adults.SiteCommon in posterior region of mandible.Clinical
featuresFirm swelling, rapid enlargement.Displacement of teeth,
though they are vital.Egg-shell crackling.Not pulsatile.
- Radiological featuresUniocular radiolucency.Ballooning of
cortex.Honeycomb or soap-bubble appearance.Outer cortical plate
destroyed.Displacement of teeth.Root resorption.Cystic contentDark
venous blood.TreatmentCurettage.Local excision with bone
grafting.
-
3) STAFNES BONE CAVITY
IncidenceCommon in children.SiteCommon in mandible.Clinical
featuresSymptomless.Non-progressive lesions.Radiological features1
3 cm in size and appear as round or oval defect below inferior
alveolar canal.TreatmentRegular radiological follow-up.
-
CYSTS OF THE MAXILLARY ANTRUM
1) SURGICAL CILIATED CYST OF MAXILLA
SiteClose proximity to maxillary sinus, but no communication
between them.Clinical featuresDull, localized pain in
maxilla.Cystic lesion not associated with any tooth.Radiological
featuresWell-defined radiolucent expansion of maxilla with
radiopaque margin.Cyst appear to encroach upon the
sinus.TreatmentEnucleation
-
2) BENIGN MUCOSAL CYST OF THE MAXILLARY ANTRUM
IncidenceHigher incidence in third decade.SiteIn floor of
sinus.Clinical featuresDull pain over antral region.Numbness in
maxillary region.Nasal obstruction, yellowish discharge from
nose.
- Radiological featuresSpherical, ovoid radiopacities within
maxillary antrum.TreatmentCaldwell-Luc approach in symptomatic
patients.Drainage via cannulation through intranasal antrostomy in
asymptomatic patients.
-
SOFT TISSUE CYSTS
1) NASOLABIAL CYST
IncidenceCommonly seen in females.SiteAbove buccal sulcus under ala
of nose.Clinical featuresSwelling is seen involving lip that lifts
up nasolabial fold and obliterates labial sulcus.Cysts are
fluctuant and painless unless infected
secondarily.TreatmentSurgical removal by intraoral approach.
-
RETENTION CYSTS
2) MUCOCELE
IncidenceMinor salivary gland.No predilection for age or
sex.SiteCommon in lower lip.Also occurs in cheeks, ventral surface
of tongue, floor of mouth, retromolar area.
- Clinical featuresPainless cyst.Well-circumscribed swellings on
mucosa.Do not exceed 1-2 cm in size.Fluctuation is positive.It may
be translucent or bluish.TreatmentSurgical excision with associated
minor salivary gland tissue and surrounding connective tissue.
-
3) RANULA
SitePresent on the floor of mouth, beneath tongue.Two types have
been identified (i) superficial ranula, and (ii) plunging
ranula.Clinical featuresDome-shaped bluish swelling of superficial
ranula seen located laterally in the floor of mouth beneath
tongue.Tongue may be displaced as it enlarges.TreatmentSurgically
remove sublingual gland.
-
OPERATIVE PROCEDURES
MARSUPALIZATION (DECOMPRESSION)Partsch IPartsch IIMarsupalization
by opening into nose on antrumENUCLEATIONEnucleation and
packingEnucleation and primary closureEnucleation and primary
closure with reconstruction/bone grafting
-
MARSUPALIZATION (DECOMPRESSION)
PrincipleCreating a surgical window in the wall of the cyst and
evacuation of the cystic contents.Decreases intra-cystic pressure
and promotes shrinkage of the cyst and bone fill.The only portion
that is removed is the piece removed to produce the
window.IndicationsAge in young child, enucleation damage tooth
buds.Proximity to vital structures.Eruption of teeth.Size of
cyst.Vitality of teeth.
- AdvantagesSimple procedures to perform.Spares vital
structures.Allows eruption of teeth.Prevents oronasal, oroantral
fistulae.Prevents pathological fractures.Reduced operating time,
blood loss.Alveolar ridge preserved.Allows for endosteal bone
formation.
- DisadvantagesPathologic tissue is left in situ.Prolonged
healing time.Inconvenience to patient.Periodic irrigation of
cavity.Regular adjustments of plug.Periodic changing of
pack.Formation of slit-like pockets that harbor foodstuffs.Risk of
invagination and new cyst formation.
-
SURGICAL TECHNIQUE
PARTSCH I
AnaesthesiaAdministration of general anaesthesia / conscious
sedation or simple local anaesthesia of the
area.AspirationIncisions types: Circular, oval, elliptic, inverted
U shaped.Removal of boneThin bone initial incision can be extended
through mucoperiosteum, bone and cystic lining into cystic
cavity.Thick bone bur holes re chilled in circular shape, and
removed with rongeurs.
-
Post Operative
Pre Operative
Marsupialization (Partsch I Operation)
- Removal of cystic lining.Visual examination of residual cystic
lining.Irrigation of cystic cavity.SuturingThe remaining cystic
lining is sutured with the edge of the oral mucosa of continuous or
interrupted sutures.PackingThe cavity is packed with ribbon gauze
which is impregnated with antibiotic ointment, tincture of benzoin
or bismuth iedoform paraffin paste.This pack prevent contamination
of cavity with food debris and provide coverage to the wound
margins.
- Maintenance of cystic cavityCleaning and irrigation of the
cavity by regular flushing with oral antiseptic rinse.Use of
plugPlug prevent the contamination of cystic cavity and preserve
the patency of cyst orifice.It should be made of resilient material
to avoid irritation to the raw margins.Healing
-
Intra Oral View
Radiographic View
Incision
Marsupialized Cavity
-
MODIFICATIONS OF MARSUPIALIZATION
PARTSCH II
Its a two stage technique, first marsupialization is performed and
when the cavity becomes smaller, enucleation is
performed.IndicationsPatient finds it difficult to clean the
cavity.Bone has covered adjacent vital structures.
- AdvantagesAccelerated healing process.Spares adjacent vital
structures.Development of a thickened cystic lining, which makes
enucleation easier.DisadvantagesPatient has to undergo secondary
surgery and possible complications may occur.
-
Marsupialization (Partsch II Operation)
Cyst capsule is shelled out, followed
by primary closure of wound
-
MARSUPIALIZATION BY OPENING INTO NOSE OR ANTRUM
AdvantagesPrimary closure of the oral wound.Adjacent structures are
protected.Cystic cavity is opened into maxillary sinus or nasal
cavity thereby reducing intracystic
pressures.DisadvantagesDevelopment of oroantral or oronasal fistula
if there is breakdown of the wound.
-
ENUCLEATION
PrincipleAllows for the cystic cavity to be covered by a
mucoperiosteal flap and space fills with blood clot which organize
and form normal bone.IndicationsTreatment of odontogenic
keratocyst.Recurrence of cystic lesions of any cyst type.
- AdvantagesPrimary closure of the wound.Healing is
rapid.Postoperative care is reduced.DisadvantagesAfter primary
closure, its not possible to directly observe the healing of the
cavity.Damage to adjacent vital structures.Pulpal
necrosis.Unerupted teeth in dentigerous cyst will be removed in
young patients.
-
SURGICAL TECHNIQUE
ENUCLEATION AND PACKING
This technique is advocated when it is believed that due to
previous infection or infected large cysts, primary closure would
be unsuccessful.Enucleation is performed and then cavity is packed
as in marsupialization.Wound heals with granulation tissue until
epitheliazation is complete.This method is also used as a secondary
measure when there is a dehiscence after primary closure.
-
ENUCLEATION WITH PRIMARY CLOSURE
Enucleation of small cystic lesion from an intraoral approach
Local anesthesia or general anesthesia
Incision placed around necks of involved teeth
Flap is reflected with periosteal elevator
Underlying cyst lining is gently eased away from cavity wall
with curved curettes
Care to be taken to prevent rupture of lining
Teeth that required to be removed are extracted
-
Cyst cavity inspected, any residual remnants removed separately
with mosquito artery forceps
Bleeding points arrested with pressure packs, bone wax, gel
foam, diathermy
Wound is flushed with normal saline and antiseptic solution
(provide iodine 2%)
Filling material is packed to obliterate the cavity prior to
closure
e.g. resorbable sponge, autogenous bone chips, hydroxylapatite
crystals
Flap is replaced
Interdental sutures placed.
-
Incision
Reflection
Exposure
Delivery