Cysts of the Jaws.

Dr. Kiran I. Desai

H.O.D & PROFESSOR ORAL MAXILLOFACIAL SURGERY K.M.SHAH DENTAL COLLEGE & HOSPITAL.

DEFINITION:

It is an abnormal cavity in hard or soft tissues which contains fluid, semi fluid, blood or gas & is often encapsulated and lined by epithelium By Killey Kay Seward.

A cyst is a pathological cavity having fluid, semifluid or gaseous contents which is not created by accumulation of pus. It is freqently but not always lined by epithelium. By Shear.

CLASSIFICATION
CYST OF THE JAWS

ODONTOGENIC EPITHELIAL ORIGIN.

NON ODONTOGENIC EPITHELIAL ORIGIN

BONE CYST

KERATINIZING

NON KERATINIZING

NASOPALATINE CYST

SOLITARY BONE CYST

PRIMODIAL CYST

RADICULAR CYST PERIAPICAL, LATERAL,RESIDUAL

NASOALVEOLAR CYST

ANEURYSMAL BONE CYST

ODONTOGENIC KERATOCYST

DENTIGEROUS CYST

MEDIAN PALATAL CYST

ERUPTION CYST

Classification-2 Non odontogenic and fissural cyst. Globulomaxillary cyst Nasopalatine cyst Median mandibular cyst Anterior ingual cyst Dermoid & epidermoid cysts Palatine cyst of newborn Cyst of neck oral floor & salivary glands. Thyroglossal cyst Branchial cleft cyst Oral cyst with gastric & Mucocele & ranula. Pseudocyst of jaws Aneurysmal bone cyst Static bone cyst Traumatic bone cyst( haemorrhagic, solitary) Stafnes bone cyst.

CLINICAL FEATURES- signs

Small cyst rarely demostrates any signs. Large cyst may cause expansion of cortical plates or perforation of the cortical plate depending upon the rapidity of growth. Thinning of cortical plate gives a egg shell crackling on palpation. Fluctuation cn be elicited in cases where overlying bone is destroyed. Discharge can be present with a sinus opening if cyst becomes infected. Percussion of tooth produces a dull or hollow sound in contrast to normal high pitched sound. Loosening & displacement of adjacent teeth Large mandibular cyst may displace or due to pressure over the neurovascular bundle causing anaesthesia or parathesia. Vitality of tooth involved may be affected in cases of radicular cyst. In edentulous patients, a previously comfortable , well fitting denture may become dislodged and may result into development of a denture granuloma

Clinical features- symptoms

Small cyst are symptomless. First symptom a patient experiences are pain & swelling. Lump in the sulcus Missing tooth in cases of dentigerous cyst. Pathologic fracture of jaw due to large cyst. If cyst becomes secondarily infected a sinus tract with discharge may be present and patient complains of foul smelling and nasty taste in mouth. In edentulous patients discomfort and ill fitting denture. Discolouration or loosening of tooth.

Radiographic examination:

Classically, the radiographic appearance of an odontogenic cyst is that of a well defined round or oval area of radiolucency, circumscribed by a sharp radioopaque margins. But variation is always present depending on the type of cyst , also depends on the location & degree of bone destruction & expansion Most common views used : periapical & occlusal view. In case of large cyst extraoral views provides a extra supplement to the conventional intraoral radiographs Lateral oblique & posteroanterior views for mandibular lesions. Waters views for maxilla Panoramic view for both A radiopaque contrast medium can be injected via a wide bore needle preceded by removal of any cystic fluid content but it is important to have a second needle entering the cyst cavity to prevent adverse changes in pressure within the cyst.---TOLLERS double lumen needle is also used to prevent a negative pressure during aspiration and painful positive pressure during injecting.( avoid great force while injecting esp in maxilla due to thin or soft tissue partition between cyst and sinus .

Aspiration

Aspiration of a suspected cyst is valuable diagnostic aid Aspiration is achieved by the help of a wide bore needle inserted into the cystic lesion with patient under local anaesthesia

Aneurysmal bone cyst : blood on aspiartion with pressure. Central haemangioma : blood on aspiartion with less pressure. Dentigerous cyst : Yellowish fluid with cholesterol crystals. Radicular cyst : straw colored fluid. Protein content: 5-11 gm/100ml Keratocyst : dirty white or pale yellow inspissated odourless material. protein content : less than 4 gm/100ml. Infected cyst : pus & normal cystic fluid. Chronic cyst : thick semi solid yellow or brown mass which cannot be aspirated. Solitary bone cyst : golden yellow fluid which clot on standing.

Operative procedures:

Why treatment is needed?

Cysts increases in size & eventually becomes infected. Large cyst can cause weakening of bone resulting in pathological fracture. Affects important adjoining structure like teeth, neurovascular bundle, sinus, nasal cavity . Carcinomatous changes can be seen on long standing cases in some. Large cyst results in facial deformity. Infected cyst may lead to sinus tract formation either intraoral or extraoral.

Treatment classification:
1)

Decompresson or marsupialization.(partsch I technique)

A) with incomplete removal of lining. decompression by opening into mouth. decompression by opening into maxillary sinus or nose. B) with complete removal of lining. decompression by opening into mouth. decompression by opening into maxillary sinus or nose.

Treatment classification: continued

Enucleation with wound closure.(partsch-II technique)

1)With primary closure without bine grafting. 2) With packing. 3) With bone grafting. 4) Secondary closure after primary marsupilization.

MARSUPIALIZATION(PARTSCH I)

A large cyst in a mandible for which the necessary surgical intervention would weaken the jaw that a fracture may result , in such cases first marsupialization is performed and when sufficient bone has reformed- secondary enucleation is carried out. A cyst which involves the apices of one or more vital teeth such that the blood supply to the pulp passes through the capsule of the lining, so enucleating a lining may result in necrosis of the pulp so to conserve the vitality of the teeth , marsupialization is performed. In a case of dentigerous cyst in a young person , which prevents the tooth involved & others from erupting, marsupilization is usually performed followed by secondary enucleation after eruption of the involved teeth.

Advantages

For this great surgical skill is not required and method is conservative with respect to adjacent important structures. There is no risk of creating an oro-antral or oro-nasal fistula. No risk of damaging adjacent microvascular bundle. Unerupted tooth in case of dentigerous cyst can be brought into occlusion. No risk of pathological fracture. All surgery confined to the accessible buccal wall of the cyst. Finally very little raw tissue exposed at the end of the operation and hence initial healing is rapid and discomfort is minimal. Least surgical intervention. Very good for old patients.

Disadvantages:

Pathological tissue is left in situ. If cavity is large it will take a long time to fill in and frequently the patients finds this embrassing. If the diameter of opening or aperture is small , the opening may eventually close completely, continuity of cyst membrane will then be re established and the cyst will refill and continue to expand. Patient has to wear acrylic bung or plug. Requires frequent irrigation. Chances of secondary infection.

Contra indications

Small cyst. Non ododntogenic cyst.

ENUCLEATION (PARTSCH II)

Indications: 1) Any small size cyst where there is no chances of fracture. 2) Keratocyst where there is very thin lining & more chances of recurrence where complete removal of the lining by enucleation is particularly important is the treatment of choice. 3) Fissural cyst.

Advantages

This is the most satisfactory method of treatment of a cyst as : Patient is spared from the inconvience of a larger cavity in the mouth which requires frequent irrigation with syringe over a long period. As a soon as incision heal , pt is no longer troubled. Method avoid tedious post operative measures such as packing & irrigation of the wound and fitting of cystic bung. Removal of complete cystic pathological lining, so no chance of recurrance Cystic cavity is covered by mucoperiosteal flap and space filled with blood clot which eventually organise to form normal bone and eventually obliteration of defect by normal bone. Provide pathologist complete specimen to facilitate correct diagnosis. No malignant transformation of the cystic lining.

DISADVANTAGES

Chances of pathological fracture in case of large cyst. Stripping out of the cyst sac will result in necrosis of the pulp of the teeth concerned & devitalized teeth. A dentigerous cyst in a young person which is preventing the tooth concerned & perhaps others from erupting. Great surgical skill required to enucleate cystic lining without fracturing the mandible & without injurying neurovascular bundle or without perforation of nasal or antral mucosa or palatal perforation. Chances of creating oro-antral or oro-nasal fistula. More chances to damage neurovascular bundles. When cystic lining is firmly adherent to muco-periosteum of nose or maxillary sinus or palate it is difficult to seperate.

DISADVANTAGES

Chances of puncture or tear of cystic lining. Following primary closure, it is impossible to observe the healing of the cyst by direct vision and therefore it is necessary to have follow up post operative radiograph of the area at regular interval to observe the progress of bone regeneration.

INDICATION

Any small size cyst where there is no chance of fracture. Keratocyst where there is very thin lining and more chances of recurrence where complete removal of the lining by enucleation is treatment of choice. Fissural cyst

CONTRAINDICATIONS

In large cyst in the mandible where there is chances of fracture, in such cases it is advisable at first to marsupialize through a limited opening, when sufficient bone is reformed secondary enucleation of the tissue lining of cavity carried out followed by primary closure to hasten healing. A cyst which involves the apices of one or more healthy teeth, in such a case stripping out of cyst sac will result in necrosis of the pulp of the teeth concerned. If it is desirable to conserve the pulp of such teeth and avoid extraction and RCT cyst should be treated by marsupialization. Dentigerous cyst in young patient which is preventing the tooth concerned from eruption marsupialization is usually followed by satisfactory eruption of involved teeth, orthodontic treatment may be subsequently needed to

TECHNIQUE ENUCLEATION OF CYST WITH PRIMARY CLOSURE OR PARTSCH II (1910)

This is a surgical procedure, leaves the surgical opening into cyst cavity covered by a muco-periosteal flap and space filled with blood clot, which eventually organises to form normal bone. The method is often called PartschII technique (Partsch 1910). Before operating upon a cyst involving the roots of teeth it is important to decide:

Provisionally which teeth are to be conserved and which are useless and should be extracted. It is also prudent to consider if lining will be difficult to enucleate. The lining can be expected to be adherent if:

The cyst has already been decompressed by the extraction of a tooth, the development of the sinus or the drainage incision in its wall. In these circumstances bone would be growing in towards the fibrous capsule. The cyst has eroded the cortex and the lining is in contact with the periosteum, particularly the thin mucoperiosteum of maxillary sinus or nose.

TECHNIQUE ENUCLEATION OF CYST WITH PRIMARY CLOSURE OR PARTSCH II (1910)

The lining is attached to the periodontal membrane of adjacent teeth. The lining may be friable:

If the cyst has been grossly infected If the lining is very thin as for exception in Keratocyst.