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Kramer (1974)
A cyst is a pathological cavity having
fluid,semifluid or gaseous contents and which is not
created by accumulation of pus and frequently but
not always lined by epithelium.
INTRODUCTION
Definition
Classification
Pathogenesis
Clinical
Radiology
Aspiration
Biopsy
TREATMENT (GENERAL)
Reasons to treat
Principals of management
Goals of treatment
Factors considered
CYSTS OF HEAD & NECK REGION
Eruption cyst
Odontogenic Keratocyst
Dentigerous cyst
Displacement of
Increased osmotic surrounding soft tissues
pressure ..Lytic products or resorption
of the epithelial and
inflammatory cells
DEVELOPMENT OF CYST
THEORIES OF CYST EXPANSION
( HARRIS 1974)
Mural growth.
1. peripheral cell division
2. accumulation of cellular contents
Hydrostatic pressure theory.
Denture instabity
SIGNS
Physical signs depend on the size of a
cyst. If the cyst is small with no alveolar
expansion, there is absence of signs. As
the cyst becomes larger expansion of
alveolar bone occurs.
Periosteum
is stimulated to form new
bone producing a curved enlargement.
Initially
lateral bone expansion turns to thinning of
cortex and can be depressed like a tennis ball or
egg shell crackling to palpation
Radiography Aspiration
Electrophoresis
keratocyst protein less than 4 gm/100ml
other dental cysts protein content more
than 5 gm/100 ml
Vitality test
biopsy
RADIOGRAPH
A well defined round or oval area of
radiolucency circumscribed by sharp
radioopaque margin of condensed bone.
Radiographic variation depends on
.type of cyst
.location of cyst
.degree of bone destruction and expansion
.infection
RADIOGRAPHY
Intraoral
standard IOPA
occlusal
Extraoral
Blood..hemangioma
Preservation of teeth
Nature of lesion
Degree of destruction
Presence of infection
Marsupialisation
Enucleation
MARSUPIALIZATION
( DECOMPRESSION PARSCH 1 )
Incomplete removel of lining..
to open it in mouth
to open it in maxillary sinus
Secondary closure after primary
decompresssion
MARSUPIALISATION FOLLOWED BY
ENUCLEATION:
With decortication
Use of cryosurgery.
ENUCLEATION WITH PACKED OPEN
1. With extraction
2. Without extraction (RCT conservative)
3. Combined with caldwel luc operation
4. Combined with fixation of pathologic fracture
COMBINED WITH FIXATION IN PATHOLOGIC
FRACTURE
INCISION DESIGN
SEMILUNAR INCISION
MARSUPIALIZATION
Reflecting mucoperiosteum and removing
adequate bone followed by cutting of adequate
window in cystic lining .
The contents are evacuated to releive tension.
Less time
Complete removel
of cystic lining with
reflection of
mucoperiosteal flap and
closure of wound by
primary approximation.
ENUCLEATION AND PRIMARY CLOSURE (E & P)
Periapical cyst
Simplicity
no pathologic tissue left behind
Bung necessory
Combined disadvantages of both enucleation
and marsupiazation
Restoration of alveolar ridge difficult
Wound closure
Maintains bony
contour
Increase strength of
bone
Shorter follow up
period
ENUCLEATION WITH CURETTAGE
This means after enucleation a curette or bur is used to
remove 1 to 2mm of bone around entire periphery of cystic
cavity
Chemical cauterization Phenol/alcohol
- Carnoys solution
(ferric chloride, absolute alcohol,
glacial acetic acid, chloroform)
Thermal cauterization
Cryocautarization.
INDICATION (E&C)
Advantage
Ifenucleation leaves epithelial remnants curettage
will remove them, thereby decreasing likelihood of
recurrence
Disadvantage
May damage adjacent bone and tissues
TECHNIQUE (E&C)
After enucleation the
bony cavity is inspected
for proximity to adjacent
structures. A sharp
curette or bone bur with
a sterile irrigation can be
used to remove 1-2mm
layer of bone around
complete periphery of
cystic cavity. Then
cleanse the cavity and
closed.
RECURRENCE OF CYST
Frequency 15-20%
Age 2nd and 3rd
decades of life
Sex males > females;
1.6:1
Race whites > Blacks;
4:1
DISTRIBUTION OF DENTIGEROUS CYSTS AT
DIFFERENT DECADES.
As age progresses DC
occurrence shifted to
posterior mandible from
anterior maxilla.
TOOTHWISE DISTRIBUTION OF DC
DENTIGEROUS CYST
Central typeenvelop
crown symmetrically
Lateral typedilatation
of follicle on one side
Circumferential
typedue characteristic
manner of expansion of
follicle.
TYPES. CENTRAL TYPE
LATERAL DENTIGEROUS CYST
CIRCUMFERRENTIAL TYPE
CIRCUMFERRENTIAL LATERAL
PATHOGENESIS (DC)
dentigerous cysts may be of either
intrafollicular origin. accumulation of
fluid within the enamel organ itself.
patient age,
cyst site and size,
Ameloblastoma
Epidermoid carcinoma
Mucoepidermoid carcinoma
AMELOBLASTOMA FROM DENTIGEROUS
CYSTMISDIAGNOSIS
First, ameloblastoma, like an OKC, may involve
an unerupted tooth, particularly a third molar at
the angle of the mandible
Second, biopsies of ameloblastomas may be
taken of an expanded locule lined apparently
by a thin layer of epithelium.
Third, as Lucas (1954) has pointed out,
apparently isolated islets or follicles of
epithelium are sometimes found in the cyst
wall some distance from the epithelial lining
CASE 1
CASE 2
BONE RESORPTION DUE TO CYSTS
capsule and its leucocyte content.
the source of the interleukin could be the monocyte
macrophage infiltrate, the stromal fibroblasts and
the epithelial cyst linings,
IL-1 released by the cysts could lead to a number of
osteolytic cell reactions:
the stimulation of osteoclasts to resorb bone,
connective tissue cells to produce prostaglandins
osteoclast activation.
stimulates connective tissue cells to produce
collagenase
Releases a potent bone-resorbing factor that is
predominantly a mixture of prostaglandins (PG) E2
and E3
ERUPTION CYST It is associated with
erupting deciduous
permanent teeth in
children. It is essentially
dilation of normal
follicular space about
crown of erupting tooth
caused by accumulation
of tissue fluid or blood.
Clinically lesion appears
as a circumscribed,
fluctuant, often
translucent swelling of
alveolar ridge over site of
erupting teeth
HISTOLOGY
The superficial aspect is covered by
the keratinised, stratified,
squamous epithelium of the
overlying gingiva.
This is separated from the cyst by a
strip of dense connective tissue of
varying thickness which usually
shows a mild chronic inflammatory
cell infiltrate due to exposed to
masticatory trauma,
bifid ribs,
kyphoscoliosis,
cleft palate,
Medulloblastoma
Recurrence
Pindborg and Hansen (1963) reported a
recurrence of 62% in 16 cysts
REASON FOR RECURRENCE (OKC)
Tendency to multiplicity
Satellite cyst
Alternate possibilities:
1. Cyst in relation to deciduous tooth which exfoliates
or extracted without prior knowledge of cyst
2. Lateral dentigerous cyst
3. Incomplete removel of periapical cyst or granuloma
CLINICAL FEATURES
Edentulous jaws
Various mechanisms:
1. Attraction of fluid in cyst cavity
Enucleation
If cyst is associated with an odontogenic tumor
a wide excision is done
CASE 1
TREATMENT OF RADICULAR CYST WITH
APICOECTOMY
GINGIVAL CYST OF ADULTS AND LATERAL
PERIODONTAL CYSTS
SIMILARITIES
predilection for occurrence in the canine and
premolar area of the mandible
less frequently, in the maxilla.
Histologically similar.
Gregg and OBrien ..concluded that the
distinguishing clinical feature is the ability to
determine the involvement of the periodontal
ligament at surgical exploration; while
histologically is the presence in the lateral
periodontal cysts of plaquelike thickenings of
the epithelial linings.
OCCURRENCE OF
GINGIVAL CYST LAT. PERIODONTAL
lateral periodontal cyst
PATHOGENESIS develops from reduced
enamel epithelium before
eruption of the tooth
the gingival cyst of adults
from junctional epithelium
(reduced enamel
epithelium) after eruption of
the tooth .
Origin from postfunctional
epithelium, such as reduced
enamel epithelium, would
help to explain the
unaggressive nature of the
gingival cyst of adults and the
lateral periodontal cyst
compared with the OKC
LATERAL PERIODONTAL GINGIVAL CYST
CYST OF ADULT
PATHOGENESIS OF LATERAL PERIODONTAL
CYST
CLINICAL PRESENTATION
GINGIVAL CYST OF ADULTS LATERAL PERIODONTAL CYSTS
RADIOGRAPHICAL
LATERAL PERIODONTAL CYST
GINGIVAL CYST
faint radiographic a round or oval well
shadow indicative of circumscribed
superficial bone radiolucent area, usually
erosion with a sclerotic margin.
The cysts lay somewhere
between the apex and
the cervical margin of
the tooth
Treatmentsurgical
Treatment..surgical enucleation
excision
NASOPALATINE CYST
The epithelial-lined cysts of non-odontogenic origin
had been thought to be derived from embryonic
epithelial residues in the nasopalatine canal and,
from epithelium included in lines of fusion of
embryonic facial processes.
It may occur within the nasopalatine canal .
nasopalatine duct cyst is preferred to the
synonymous incisive canal cyst
in the soft tissues of the palate, at the opening of
the canal, where it is called the cyst of the
palatine papilla
LOCATION
OCCURRENCE
PATHOGENESIS
In humans, vestigial remnants of this primitive
organ of smell may be found in the incisive canals
in the form of epithelial-lined ducts, epithelial
cords, epithelial rests or combinations of these.
Epithelial rests may show central degeneration.
The vomernasal organs of Jacobson are
sometimes mentioned as a possible source of
cysts in the incisive canal but this is most unlikely.
They are bilateral structures that lie at the base of
the nasal septum just above the nasal extremity of
the incisive canals.
CLINICAL PRESENTATION
most common symptom is
swelling, usually in the
anterior region of the midline
of palate
Swelling also occurs in the
midline on the labial aspect
of the alveolar ridge
pain through pressure on the
nasopalatine nerves
Discharge may be mucoid,
may be purulent foul taste
RADIOGRAPHIC FEATURES
a pear-shaped
radiolucency in the
anterior maxilla. The
lamina dura is intact
although the apex
appears to be in the cyst.
roots of the maxillary
incisor teeth are
displaced laterally.
Treatment: surgical
enucleation
DIFFERENTIATION FROM INCISIVE FOSSA
Roper-Hall concluded that any radiograph of the
fossa that showed a shadow less than 6mm wide
may be considered to be within normal limits,
provided the patients have no other symptoms.
Shear stated that a radiographic shadow with
anteroposterior dimensions of as much as 10mm
in the incisive fossa region may be within normal
limits. In the absence of any other symptoms
signs, such patients should be observed and re-
radiographed at intervals before proceeding to
surgery.
NASOLABIAL CYST
Thorough curretage
Excision and bone grafting
History of trauma
Symptomless
Empty
Golden yellow coloured fluid
Serosanguinous fluid
Presence of hemosiderin
TREATMENT
23 cm in diameter.
PATHOGENESIS OF PLUNGING RANULA
A deficiency or hiatus between the anterior and
posterior parts of the mylohyoid muscle
herniated projections of the sublingual gland
through these perforations
permit mucus extravasation into the
submandibular space and the tissues of the
neck.
mucus may extend deep into the cervical
tissues and occasionally into the thorax
TREATMENT
surgical removal of the sublingual gland
through the mouth without any cervical
approach is the initial form of treatment.
This removes the secreting source, thereby
preventing recurrences, and also avoids the
problem of a difficult neck dissection.
plunging ranulas have been treated with the