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

2. 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.

3. 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.

4. 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

5. 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

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

7. 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 ???

8. 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

9. Radicular cyst
Periodontal cyst
Residual cysts

10. 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 !!

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

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

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

21. 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

22. 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

23. 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

25. 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.

26. 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

27. 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

28. Histological investigation
Clinical examination
Diagnosis
Radiographs
Diagnosis :

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

30. 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

31. 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

32. Diagnosis:
Palpation by finger:

33. 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

34. CBCT

35. 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

36. 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

37. 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

38. 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

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

40. 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

41. Enucleation procedure

42. 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

43. 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

44. 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

45. 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

46. 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

47. Marsupialization: surgical procedure

48. 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

49. 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

50. 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

51. 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 !!!

52. 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.