Cysts Of The Oral Cavity

Cysts Of The Oral Cavity

Classification True cysts Pseudocysts (false cysts) Cyst-like lesions

1-True cyst: It is a pathological cavity containing fluid or semifluid, lined by epithelium e.g. Dentigerous cyst

2-Pseudo cysts: Is a cavity not lined by epithelium, may contain fluid or may be empty e.g. Solitary bone cyst

3-Cyst like lesions: 1- Normal anatomical patterns 2- Inflammatory conditions 3- Pseudocysts 4- Hormonal (Endocrinal) disturbances 5- Dysplastic 6- Metabolic disturbances 7- Benign tumors 8- Malignant tumors

Parts of a Cyst Wall (made of CT) Epithelial lining Cysts lumen

How does a cyst expand Cyst develops and continues by cytokine stimulation of ep rests and is added to by central cellular breakdown products 7

Epithelial Origin Odontogenic or Non-odontogenic Odontogenic ep.:
Cells of the basal layer Dental lamina Ep. Rests of “Serres” Ep. Rests of Malassez Reduced Enamel ep. Epithelial Origin

Epithelial Origin Odontogenic or Non-odontogenic Non Odontogenic ep.:
Ep. Entrapped btw fissures Secretory glandular ep Nasopalatine duct remnants Epithelial Origin

Depending on the origin of Epithelium
Odontogenic cysts (odont. Ep) A- Inflammatory B- Developmental Non-odontogenic cysts (Non-odont. Ep.) A- Fissural cysts B- Cysts of facial skin & neck Pseudocysts. Retention phenomenon cysts

Odontogenic Cysts A-Inflammatory Apical periodontal cyst
Lateral periodontal cyst Residual periodontal cyst

Odontogenic Cysts (cont.)
B-Developmental 1-Follicular Dentigerous cyst Primordial cyst (Odontogenic keratocyst)

2-Extra-Follicular Lateral developmental periodontal cyst Gingival cysts Gingival cyst of the newborn. Gingival cyst of the adult Keratinizing and calcifying odontogenic cyst (Gorlin Cyst, Cystic keratinizing tumor) Cystic degeneration of odontogenic tumors (cystic ameloblastoma, cystic odontome).

Nonodontogenic Cysts A-Fissural cysts (arising from fissures)
Nasoalveolar (nasolabial, Klestadt's cyst) (soft tissue cyst related to the maxilla) Median maxillary cysts Median alveolar cyst Median palatine cyst Median mandibular cyst Nasopalatine duct cyst Incisive canal cyst Cyst of palatine papilla Globulomaxillary cyst.

Nasolabialcyst incisive canal cyst
midpalatal cyst

Non-odontogenic Cysts (Cont.)
B- Cysts of facial skin & neck Branchial cleft cyst (benign lympho-epithelial cyst of the neck) Thyroglossal tract cyst Dermoid and Epidermoid cysts

Pseudocysts Cysts of Non Epith Origin
Aneurysmal bone cyst Traumatic (Solitary) bone cyst Latent (Static ) bone cyst

Retention Phenomenon Mucocele Ranula

Basic surgical goals Remove the entire lesion
Main goal of OMFS in treatment: Remove the entire lesion Leaving no remnants of cystic epithelium that could proliferate → recurrence Treatment methods vary, depending on the nature of the lesion It is very important to identify the lesion histologically (different Biopsy techniques), as treatment modality greatly depends on the histopathologic nature of the lesion

Diagnosis I. History Pain loose teeth Occlusion
II. Clinical examination Signs&symptoms Site Vitality Inspection/percussion/palpation III. Radiographic examination IV. Biopsy

I. History Pain Loose teeth Occlusion Swellings
Delayed eruption of teeth

II. Clinical examination
A- Signs: Small cysts are OFTEN asymptomatic Discovered accidentally, by routine radiographs Majority, are characterized by Swelling

II. Clinical examination (Cont.)
1-Palpation: depending on the degree of bone resorption, may reveal: Bony hard swelling Thin bone → Springy feeling (e.g. compressing a table-tennis ball between your fingers) Even thinner bone → characteristic “Egg-shell crackling”

NB: As the cyst enlarges, expansion of the alveolar bone occurs frequently on the labial (buccal) aspect of the lower jaw, except OKC (odontogenic keratocyst) it can affect the lingual aspect of the jaw as well. While in maxillary cysts, expansion could be on the expense of either the labio-buccal or labio-palatal plates

None of these palpation findings are pathognomonic or diagnostic of a cyst They only represent the amount of remaining bone in that area, not necessarily a cyst, but a cyst or any other pathological lesion Bone resorption continues until the buccal bone has been resorbed leading to the characteristic Fluctuation

Paresthesia and/or Anesthesia of the lower lip are not common findings but could exist in: Cases of very large cysts pressurizing the inferior alveolar nerve Infected cysts: sudden ↑ in pressure from pus accumulation, may exert pressure symptoms → paresthesia of inferior alveolar nerve

Globulomaxillary cyst (between upper lateral and canine)
2- Site COMMON EXAMPLES Globulomaxillary cyst (between upper lateral and canine)

Site (common examples)
Nasopalatine cyst (between upper central incisors,can have a heart shape)

Palatine papilla cyst

Gingival Cyst

Nasolabial cyst

Primordial cyst (lower8)

Dentigerous cyst (lower and upper 8,3,4)

Dentigerous cyst

(confined to maxilla except median mandibular cyst)
Fissural cysts (confined to maxilla except median mandibular cyst)

Is virtually confined to the mandible
Solitary bone cyst Is virtually confined to the mandible

Odontogenic Kerato Cyst (often seen in the lower 8 area and extending to the ramus)

Static (Latent) bone cyst (below the mandibular canal)

Teeth vitality 3- Teeth vitality
Certain types of cysts can involve vital teeth, such as: Odontogenic keratocyst Developmental cyst solitary bone cyst lateral peridontal cyst Others involve non-vital teeth, such as: Inflammatory peridontal cyst

4-Loosening or absence of teeth
Cysts : Rarely cause loosening of adjacent teeth until the cyst is very large. Absence of one or more teeth may imply the presence of a developing Dentigerous cyst or OKC of the primordial type

Percussion 5-Percussion on teeth overlying a solitary bone cyst will produce a dull or hollow sound in comparison to the high pitched sound of the teeth on the opposite side of the jaw. If a sinus is evident then it should be dried and examined since pressure may cause the discharge of a “glairy” cholesterol- containing fluid, or it may be a yellow purulent discharge

B- Symptoms: Cysts may be asymptomatic, pt could be unaware of the lesion until informed by his dentist While in other cases the pt complains of a swelling and/or an intra-oral discharge that is considered salty, sweet or just an unpleasant taste

Infected cysts may cause the pt to present with a large abscess, while less sever infections may cause dull throbbing pain (due to enlargment) While in complete or partially edentulous pts., cysts may be the cause of either discomfort under or difficulty in wearing dentures Adjacent teeth may be either moved or tilted as the lesion expands

III. Radiographic Examination
A- Intra oral films: Periapical Occlusal Lateral or topographical occlusal views. B- Extra oral films: Panoramic RD lateral oblique Postro anterior view Lateral sinus view Occipito-mental Water’s (sinus) view CT

Radiographic appearance of cysts is characteristic, exhibiting a distinct, dense periphery of reactive bone (Condensing Osteitis) with a radiolucent core Radicular cyst 46

Most cysts are unilocular in nature, however multilocularity is often seen in some keratocysts and cystic ameloblastomas unilocular multilocular

III. Radiographic Examination (Cont.)
However, RD variations exist, depending not only on the cyst type, but are related: Location Duration Degree of expansion Presence/absence of infection

In cyst diagnosis by RD, films can be taken, but the type of film, depends on the size of the lesion: Intra-oral: smaller sized lesions ( min. of 2 films at right angles to one another) Extra-oral: in larger lesions

Visualize soft tissue cysts and sinus tracts
Other radiological diagnostic techniques: (Radio opaque contrast media) Visualize soft tissue cysts and sinus tracts Differentiate a maxillary cyst from the antrum Add a picture

IV. Biopsy Excisional (small lesions) Incisional (larger lesions)
Aspiration (FNA) Drill Punch Frozen section Oral cytology

IV. Biopsy Aspiration Valuable diagnostic aid
Simple/min. pt. discomfort A wide bore needle is introduced into the suspected cystic cavity under LA, then aspiration of intra-lesional fluid contents is done

IV. Biopsy Aspiration (CONT.)
Aspiration results: Yellow-straw colored fluid ( containing cholesterol crystals) Cyst

Aspiration results: -ve Air Solid mass Latent bone cyst Gauge blockage
Antrum ( maxillary sinus) Traumatic bone cyst

Aspiration results: Pus Blood Sticky viscous fluid Abscess
Infected cyst Blood Vascular lesion Aneurysmal bone cyst Sticky viscous fluid Mucocele/ranula

Provisional diagnosis of a cyst is confirmed if:
Aspirate is a light-straw colored fluid containing cholesterol crystals Demonstrated by running some of the aspirated fluid onto a dry swab, the crystals will give a shimmering effect when viewed under strong light On microscopic examination, cholesterol crystals have an envelope without a stamp appearance Add a picture here

Inability to retract plunger → Tumor mass and not a cyst
Solitary bone cyst → characteristic golden yellow aspirate which clots on standing, the supernatant fluid over the clot will show the presence of bilirubin

If the aspiration is from an OKC, aspirate is usually a pale yellow cheesy-like material which appears to be like pus but in reality, is a liquefied mass of desquamated keratin Differentiated by the absence of an offensive odor (pus) and the history of presence/absence of infection

If the cyst is secondarily infected then pus and normal cystic fluid are present, which could be difficult to aspirate. On aspiration it could be difficult to detect any cholesterol crystals Microscopic examination of the aspirated fluid with paper electrophoresis is of diagnostic value A smear of the cystic fluid can also be prepared and stained to demonstrate typical keratinized cells

Apical inflammatory periodontal cyst
1- Also called (radicular cyst) 2- Associated with non vital tooth 3-can begin as apical granuloma

Lateral inflammatory periodontal cyst
Due to infection reaching the periodontal ligament through an accessory root canal

Residual cyst Present in edentulous area after tooth extraction (with previous apical or lateral inflammatory periodontal ligament)

Follicular cysts A-Primordial cyst
1- It is formed before any calcified tooth structure is formed 2- associated with missing tooth 3- can cause enlargement, displaced teeth, can be asymptomatic 4- site:retromolar area with ascending ramus. 5-radiographically: well demarcated radiolucent area ( unilocular, multilocular or multiple) 6- can turn to ameloblastoma Add a picture here

B- Dentigerous cyst 1- formed around the crown of unerupted tooth
2- could turn to ameloblastoma 3- roots of adjacent teeth may be resorbed and tilted 4- common sites: lower 8, lower 5 and upper 3 Add a picture here

C- Eruption cyst It is a form of dentigerous cyst developing around the crown of deciduous or permanent teeth in children NB Complete enucleation is the treatment of choice for follicular cysts because of their potential neoplastic changes Add a picture here

Gingival cysts A- Dental lamina cyst of the Newborn
Epstein’s pearls : mid palatal Bohn’s nodules : at the crest of the alveolar ridge B- Gingival cyst of the Adult over 40 years of age Negative at the radiograph

Odontogenic Keratocyst
Has high rate of recurrence due to daughter or satellite cysts. Could be : primordial cyst, lateral periodontal cyst,extrafollicular dentigerous cyst and apical periodontal cyst. Signs and symptoms: pain, swelling, expansion of bone, drainage to the surface and paraesthesia. Radiographically: Unilocular or multilocular radiolucency with smooth or scalloped surrouding sclerotic bone. Sometimes it causes resorption of roots of adj teeth Add a radiographic picture Add picture

Calcifying Odontogenic Cyst
Radiographically: salt and pepper appearance

Branchial Cleft Cyst

Thyroglossal Tract Cyst

Pseudocysts A-Traumatic bone cyst
Lies above the inferior alveolar canal

B- Aneurysmal bone cyst
Causing blood soaked sponges RD: honeycomb or soap bublle appearance

C-Static (latent) bone cyst
Lies below the inferior alveolar canal

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Aims Of Treatment 1- To remove the pathologic epithelium that
forms the lining (Enucleation), or to enable the patients body to re-arrange the position of the abnormal tissue so that it is eliminated within the jaw. 2- To do so with the minimum of trauma to the patient while obtaining a successful outcome. 3- To preserve adjacent important structures eg: nerves and healthy teeth. 4- To achieve rapid healing to the surgical site. 5- To restore normal or near to normal function.

Treatment Of Cysts Cysts of the jaws are treated in one of four basic methods: 1) Enucleation. 2) Marsupialization. 3) A staged combination of the previous 2 procedures. Marsupilization followed by enucleation( Decompression) 4) Enucleation with curettage.

1- Enucleation. It is the process by which the total removal
of a cystic lesion is achieved ( shelling out) without rupture of it’s lining if possible. Enucleation of cysts should be done with great care in order to remove the cyst in one piece without fragmentation. This reduces greatly the incidence of recurrence.

2) Small to moderate sized cysts that do
Indications: 1) Accessible cysts. 2) Small to moderate sized cysts that do not endanger vital structures. 3) Cysts that do not involve soft tissues.

Advantages: 1) The main advantage is that the hole cystic tissue can undergo pathological examination. 2) Removal of the entire pathologic tissue. 3) Healing is more rapid than marsupilization. 4) Decreases the need for post operative care and irrigation.

Disadvantages: If any of the conditions outlined in the indications for marsupialization exist, then enucleation is a disadvantage. Therefore each cyst must be evaluated individually, and the pros & cons of each modality of treatment should be weighed.

Advantage Disadvantage Contraindication Remove all pathological tissue Little patient compliance It just takes about 10 days to see any healing activity. oral hygiene is not so important. You can just leave the patient and do follow-up Difficult You need a specialist to do especially if the cyst was too big or the cyst in the maxilla near the orbit or pterygomandibular area. You need to have experties. High morbidity to surrounding tissue you might endanger the maxillary sinus, the nasal lining of the nose, the ID canal you might also thinning the posterior or the lower border of the mandible, making it susceptible to fracture In most cases we use this method. We just do marsupilization in certain cases Large cyst encroaching vital structure Existing pathological fracture pt come with already fractured bone because of the large cyst. In this case it’s contraindicated to do enucleation. We will do marsupilization with splinting of the fractured bone. We can consider doing enucleation after we gain some bone

Technique Armamentarium: 1) Syringe and local anesthetic.
2) Bard Parker handle and blades 15,12. 3) Mucoperiosteal elevator. 4) Retractors. 5) Curettes (different sizes). 6) rongeurs. 7) Hand piece and surgical burs.

8) Root canal instrumentation.
9) Allis forceps. 10) Suction tips. 11) Adequate illumination. 12) Antiseptic solution for irrigation. 13) Bone file. 14) Dental forceps. 15) Needle holder and suture materials with needle.

When extracting teeth with periapical
radiolucencies small in size, then enucleation could be performed via the tooth’s socket. But caution is to be taken when working adjacent to vital structures.

With larger cysts a mucoperiosteal flap
must be done and some bone removal (buccal plate) to expose the cyst lining. Once access is obtained to the cyst then enucleation should begin. A thin bladed curette is the most suitable instrument for separating the connective tissue cyst wall from the bone.

We should use the largest curette that
can be accommodated into the bony cavity and we should apply it by facing its concave side towards the bone while the convex side is facing the cyst wall to strip it from the bone.

Care must be taken to avoid tearing to the
cyst and allowing its contents to escape because the margins are defined easier if the cyst wall is intact. Furthermore, the cyst separates more readily when the intra-cystic pressure is maintained, unless the opening of the bony cavity is smaller than the cyst, then aspiration of the fluid content before its removal is recommended.

In large cysts or cysts proximal to
neurovascular structures, the vessels or nerves are usually pushed to one side of the cavity so extreme caution must be applied, and handled as atraumatically as possible. Once the cyst is removed then the bony cavity should be inspected well for any tissue remnants.

Irrigation and drying the cavity with gauze
aids in visual inspection, and if any tissue is spotted it should be removed. Then the bony margins are filled (bone file) prior to primary closure. Any roots included in or around a cyst should be curetted aggressively and if its apex has been exposed then it should be Endodontically treated and most probably apicectomy should also be performed.

That is to prevent any odontogenic
infection of the cystic cavity due to the generation of the dental pulp. After enucleation a watertight primary closure is performed, the bony cavity will be filled with a blood clot which or organizes with time. Areas that have been expanded by cystic growth will eventually remodel and return to normal.

Radiographic post operative follow-up is
necessary and the complete bone healing can take 6-12 months depending on the cavities size. If the primary closure breaks down usually in large cysts, dehiscence occurs then the bony cavity needs to be packed open and left to heal by secondary intention.

The wound is then packed with sterile
gauze lightly impregnated with an antibiotic ointment after irrigation with sterile saline. This procedure is repeated every 2-3 days, gradually reducing the size of the pack to allow for granulation tissue healing.

When it has reached a small size then we
can irrigate without packing to allow for the final closure by the oral epithelium that closes the top of the opening and then osseous healing will progress.

2. Marsupialization. Marsupialization, decompression, de-roofing and the Partsch operation all refer to creating a surgical window in the cyst wall. The only portion of the cyst that is removed is of the window, while the remaining cyst lining is left in situ.

This will allow for decrease of intra-cystic pressure which in-turn will allow for shrinkage of the cyst and the regain of lost bone. It can be used as either a sole therapy or could be followed by enucleation at a later stage.

Indications: The following factors should be considered. 1- Amount of tissue injury: If enucleation of a cyst would cause oro-nasal or oro-antral fistulae, injury to major neurovascular structures or devitalization of healthy teeth then marsupialization is considered.

2- Surgical access: If the portions of the cyst are inaccessible and parts of the cyst wall might be left behind which will eventually lead to its recurrence then marsupialization could be considered as an initial treatment. 3- Extent of surgery: In unhealthy or debilitated patients where extensive surgery is contraindicated.

4- Assistance in eruption of teeth:
If a tooth/teeth are involved in the cyst or prevented from eruption by the cyst and the tooth is needed, then this technique will in most cases will allow us to keep teeth and later enucleate. 5- Size of cyst: In cases where the size of the cyst is very large and there is a risk of jaw fracture. marsupialization is preformed to allow for bone refilling before enucleation.

Advantages: Its main advantage is that it is a simple procedure to perform, and it also spares vital structures from damage. Disadvantages: 1) The presence of pathologic tissue in the jaws without examination.

2) The inconvenience for the patient in
regards that the cystic cavity has to be repeatedly irrigated to prevent food stagnation and infection. This might continue for several months depending on the size of the cyst cavity and the rate of bone filling.

Technique Any modality of treatment should be
performed after the confirmation of the diagnosis. After anesthetization usually a circular or elliptical incision is made to create a large window into the cystic cavity (1cm or more).

If the bone has been expanded and
thinned than the incision could involve the bone and the cystic wall which in turn will be submitted for pathologic examination. The contents of the cyst are then evacuated, then irrigation of the cyst lumen is done and inspection of the remaining tissue is carried out (why?).

Because there could be thickening or
ulceration in other parts of the cyst wall and in this case you should either take incisional biopsy from the suspicious area or resort to complete enucleation. If the cyst lining is thick enough then it could be sutured to the oral mucosa, but if not then it is packed with strip gauze impregnated with tincture of benzoin or an antibiotic ointment.

The pack is left in place for 10-14 days to
prevent the oral mucosa from healing over the cyst window. After that strict instructions are given to the patient regarding the cleansing of the cavity. If the cavity is kept clean there shouldn’t be a problem.

When marsupializing a large cyst in the
maxilla then the surgeon has 2 choices, either to open into the maxillary sinus, nasal cavity, or to open into the oral cavity. When opening into the sinus or nasal cavity then the oral opening is reflected and then completely closed.

3. Marsupialization followed by enucleation.
This technique is implemented more than marsupialization itself. The initial healing is rapid after marsupialization and the size of the cavity decreases, but after a certain period of time the improvement decreases or nearly stops. But by this time the objectives of marsupialization will have been achieved and enucleation maybe performed without harm to vital structures or teeth.

Indications: The indications here are the same as those for marsupialization. While another indication for this procedure is the inability for the patient to keep it clean. Or the surgeon may desire to examine the entire lesion histologically.

Advantages: The same as enucleation and marsupialization, plus another advantage is that the secondary enucleation is an easier procedure due to the thickening of the cyst lining and its decrease in size. Disadvantages: Is that there is pathological tissue left untill the second stage of treatment.

Technique After marsupialization osseous window is allowed
to progress and is followed-up by radiographic examination untill the surgeon sees evidence of adequate bone formation or tooth/teeth eruption then the second stage of treatment is decided.

The most important thing is that the initial
incision in a cyst that has been marsupialized differs than a cyst that is undergoing primary enucleation (why?). Because the cyst lining at this stage has a common epithelial lining with the oral cavity due to marsupialization. So this epithelium must be removed with the cyst lining.

To accomplish this an elliptical incision
completely encircling the window must be done and it should be deep done to touch sound bone. This allows the striping of the cyst lining from the window and the cyst can be enucleated without difficulty.

Primary closure is to be achieved even by
mobilizing soft tissue flaps to obtain a complete watertight closure. If not possible then we pack the cyst cavity as we did before with strip gauze impregnated with an antibiotic ointment, and it must be changed repeatedly while decreasing it in size and the cavity is irrigated with sterile saline untill complete obliteration of the cavity

4. Enucleation with curettage
In this procedure enucleation is carried out as before and then a bur or curette are used to remove 1-2 mm of bone around the entire periphery of the cystic cavity.

Indications: Its main indication is to remove any remaining epithelial cells that may be present so as to prevent the recurrence of the cyst. There are 2 main instances that will do so. 1) If you are treating an odontogenic keratocyst the reason is that odontogenic keratocysts exhibit aggressive clinical behavior with a high rate of recurrence (20% - 60%)

Daughter or satellite cysts may be found at
the periphery of the main cystic lesion. If it recurs after this treatment then bone resection with 1 cm safety margin should be done. 2) After the recurrence of any other cyst that was previously treated with thorough enucleation only.

Dentigerous cyst

Clinical case Dentigerous Cyst

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Cysts Of The Oral Cavity

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