Cysts of the oral and maxillofacial region Presented by Dr.Ali AL-Hiyali BDS,MSc OMFS AL-Mustansyria university /college of dentistry

Tutorial outcome By the end of this tutorial , you should Nominate the cysts of oral and maxillofacial region Know the clinical and radio graphical features of each type Appreciate the uniqueness of keratocysts How presentation will benefit audience: Adult learners are more interested in a subject if they know how or why it is important to them. Presenter’s level of expertise in the subject: Briefly state your credentials in this area, or explain why participants should listen to you.

What is ? Benign , pathologic cavity Lined by epithelium (mostly) Filled with Fluid (often) ,semifluid or gas substances (Kramer’s , 1974) Surrounded by connective tissue wall Common pathological lesions of the jaws Mostly are asymptomatic unless infected or enlarged A: Connective tissue wall B: Epithelium Lesson descriptions should be brief.

Effect on adjacent structures: Example objectives At the end of this lesson, you will be able to: Save files to the team Web server. Move files to different locations on the team Web server. Share files on the team Web server. Adapted from: White and Pharoah: Oral Radiology-principles and interpretation, page 380

Classification of the jaws cysts : Jaw cysts I.Odontogenic cysts II. Non odontogenic cysts A. Developmental Non-odontogenic cysts B.Pseudocysts Non-odontogenic cysts C. Soft tissue cysts

Periapical cyst Residual cyst Periodontal cyst Eruption cyst Dentigerous Gingival cyst keratocyst (KC)???? I. Odontogenic cysts

Odontogenic cysts Epithelial lining is form the remnants of tooth formation Types are presented in the adjacent diagram Keyes: G: gingival, E:eruption , L:lateral, R:residual , P: periapical(radicular), D: dentigerous and OKC: odontogenic keratrocyst ???

I. Odontogenic cysts Periapical cyst Periodontal cyst Residual cyst Is the commonest jaw cyst Arise from the remnant of epithelial cells of Malassez Stimulated by chronic infection Mainly occurred at the apex of the dead or endodonticaly treated teeth Periodontal cyst Same as periapical , but occurs on the lateral aspect of the teeth Residual cyst Occurs in edentulous area , presented before tooth extraction

Radicular cyst Periodontal cyst Residual cysts

I. Odontogenic cysts Dentigerous cyst The cyst lining is attached to the non erupted teeth at the cemento enamel junction Raised from the reduced enamel epithelium Second most commonly occurred cyst Have same Radiographical features of Unicystic ameloblastoma !!

I. Odontogenic cysts Eruption cysts Formed over erupting teeth Purple –blueish in colour Lining could be originating from Enamel organ : if no deciduous predecessors associated Epithelial rest of Malassez : if deciduous predecessors is found

I. Odontogenic cysts Keratocysts (KC) Reclassified as keratocystic odontogenic tumour (KCOT)(Barens et al 2005) Lined by epithelium Can be classified into : Orthkeratinised Parakeratinised Believed to be raised from : Enamel organ or Dental lamina

I. Odontogenic cysts Keratocysts (KC) Radiographically seen as : single or multiple radiolucent area Has the feature of having daughter or satellite cysts These daughter cysts could escape from the lumen of KC

I.Odontogenic cysts Keratocysts (KC) Due to this feature the Keratocysts : Has high recurrence rate (5-60%) Recently recognized as odontogenic tumor(KCOT) Mainly occurs in the ascending ramus of the mandible Expand in anterio-posterior direction in the medullary bone

I. Odontogenic cysts Keratocysts (KC) Gorlin-Goltz syndrome: autosomal dominant inherited disorder Multiple odontogenic KC cysts Basal cell carcinoma Frontal bone boozing Saddle nose Palmar/plantar pits Calcification of falx cerebri

Growth theories of odontogenic cysts(by Harris,1974) Osmotic growth (except the KC) Liquefaction of cells +ve osmotic pressure Bone resorption Mural growth (only KC ) Direct growth of lining epithelium

II. Non-Odontogenic cysts A. Developmental B. Pseudocysts C. Soft tissue cysts

A. Developmental cysts Very rare Also known as fissural cysts Located at fusion site of facial and mouth processes Associated with vital teeth Has mucoid fluid when aspirated

A. Developmental cysts Nasopalatine cyst Also known as incisive canal cyst Heart shaped cyst Incisive canal >7mm Salty taste

Median cyst A. Developmental cysts At midline of maxilla or mandible Very rare

A. Developmental cysts Globulomaxillary cyst Located between maxillary laterals incisors and canines Separate their roots Vital teeth The embryonic fusion theory has no evidence support

B. Non-epithelial lined cysts (Pseudocysts) Stafne bone cysts Not true cyst, found below ID canal Inclusion of salivary tissue in body of mandible Aneurysmal bone cyst No epithelial lining , slow growing Vascular bone , soap bubble appearance Solitary bone cyst Scalloped outline passing between teeth roots Found above the ID canal

C. Soft tissue cysts Dermoid cyst Branchial cyst Nasolabial cyst Found in the skin Arise due to trauma Tx: surgical excision Nasolabial cyst Located over the nasolabial fold under the ala of the nose Not in the bone surgical excision Branchial cyst Incomplete of obliteration of branchial cleft Lateral side of the neck anterior to the SCM Mainly seen in children Surgical excision under GA Thyroglossal cyst Arise from thyroglossal duct Midline of the neck Move on swallowing C. Soft tissue cysts

References Principles of oral and maxillofacial surgery , Chapter 13, treatments of cysts of the Jaws . Contemporary oral and maxillofacial surgery. Fifth edition .Chapter 22: surgical Management of oral pathologic lesions.

Management of oral and maxillofacial cystic lesions : diagnosis and treatment Presented by Dr.Ali AL-Hiyali BDS,MSc OMFS AL-Mustansyria university /college of dentistry

Tutorial outcome Understand the ladder of management process for cystic lesions Know the possible differential diagnosis of radiolucent lesion Appreciate the importance of Aspiration Evaluate the role of histological investigation to confirm the diagnosis Have an idea about the common surgical procedures used in the treatment of oral cystic lesion

Histological investigation Clinical examination Diagnosis Radiographs Diagnosis :

Step 3 Step 2 Step 1 Intraoral Inspection Clinical examination extra oral History

Diagnosis : Clinical examination History : Frequently asymptomatic Pain : if infected Swelling of the face : large cysts Difficulties in wearing dentures Mental nerve anaesthesia or paraesthesia Pathological fracture

Diagnosis : Intra oral and extra oral examination Tenderness Alveolar swelling or enlargement Bluish colour in the mucosa Check teeth vitality Teeth displacement ,mobility and loss

Diagnosis: Palpation by finger:

Diagnosis Radiographs and imaging Periapical films : only show small cysts OPG (OPT): shows the large cystic lesions Round , radiolucent area bounded by radio- opaque line CBCT(Cone beam computed tomography) Occipeto - mental view Shows large cysts Gives the right details in 3D manner

CBCT

Differential diagnosis of radiolucent lesion All cystic lesion has the appearance of radiolucent area However , not each radiolucency is cystic lesion The differential diagnosis of oral radiolucent lesion are: Odontogenic Cystic lesion Non-odontogenic cystic lesion Bone diseases (osteomyelitis ) Benign odontogenic tumour malignant bone tumour

Diagnosis III. Histological investigation Most accurate method to confirm the diagnosis Achieved by having a sample via Incisional biopsy Excisional biopsy Aspiration Every case must be sent for biopsy

Aspiration Biopsy All cysts should be aspirated Gauge 18 needle,5ml syringe Extract the cystic content The uninfected cyst should not be aspirated more than 24 h, to avoid infection The most important diagnostic measure Read it carefully from the chapter

Assessment : After having all of Clinical , radiographical and histological examination ready and before commencing the treatment , you should assess: Size of the cysts and amount of bone resorption Proximity to any vital structures (nerves, antrum, teeth,..) Removal of non-vital teeth or any tooth involved in KCOT

Treatment procedures: Enucleation Marsupialization Staged combination of both Enucleation with curettage

Enucleation indication Treatment of choice for most cystic lesions Note: its contraindicated in dentigerous cyst Pros Remove the entire lesion Whole specimen can be pathologically investigated No need for constant irrigation for the residual cavity Heals rapidly Cons Could jeopardize normal tissue Devitalize some teeth Require tooth removal

Enucleation procedure

Enucleation : surgical procedure Flap Should provide good access Made over sound and hard bone Bone removal With irrigation Make window to achieve access to the cyst lining Lining removal By Mitchel trimmer Separate the lining for the bone

Enucleation : surgical procedure Lining removal By Mitchel trimmer Separate the lining for the bone Keep the integrity of the lining (no tearing) Closure Watertight primary closure with sutures Healed by primary intention No need for antibiotics unless the cyst is large

Enucleation : surgical procedure Packing!!when ? This used for large lesions or possible clot breakdown Achieve healing by secondary intention ½ inch ribbon gauze soaked with antibiotic ointment whitehead’s varnish (WHV) or Bismuth Idofrom Paraffin Paste (BIPP) Changed every 2-3 days Or pack it with bone graft Follow up KCOT for 5 years All cases must be under supervision postoperatively

Marsupialization(Decompression) Make an opening into the cyst lining This procedure is : simple Less traumatic (no bone removal is required) Perfect for ill patient Undamaging for vital structures However, it has slow healing

Indication Preserve the tooth Dentigerous or eruption cysts Proximity of vital structures (nerve, blood vessels) to the cystic lesion Very large cyst (pathological fracture) Ill pateints Pros Simple Preserve vital structures cons Leave part of pathological lesion in situ Part of specimen be histologically examined (false biopsy results ) Patient’s inconvenience

Marsupialization: surgical procedure

Marsupialization: surgical procedure No need for antibiotic prophylaxis unless for ill patients Buccal flap reflection Buccal bone removal to expose the lining Cut the lining with scissors and drain out the content Pack with WHV or BIPP In large cases , obturator may be required Suture the lining to the mucosa Follow up

Enucleation after Marsupialization: Some cases require combination of both procedure like Very large cystic lesion Or KCOT presented at the ascending ramus Marsupialization first Wait for cyst to shrink Enucleate

Enucleation and curettage Enucleate Burs used to remove 1-2mm of the bone surrounding the cyst This procedure is used to achieve complete removal of remnants of the lining : KCOT Any recurred cyst

Summary To manage a cystic lesion : Take thorough history Inspect ,palpate, Aspirate Refer for OPG or CBCT and biopsy Assess the general condition (size, site , patient’s general health) Choose the perfect surgical procedure Follow up please !!!

References Principles of oral and maxillofacial surgery , Chapter 13, treatments of cysts of the Jaws . Contemporary oral and maxillofacial surgery. Fifth edition .Chapter 22: surgical Management of oral pathologic lesions.