CYSTS OF THE JAW Part 1

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  1.  pathological cavity  often fluid filled lined by epithelium  in many instances, exact pathogenesis of these lesions is still uncertain Cysts 2.  A Cyst is…
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  • 1.  pathological cavity  often fluid filled lined by epithelium  in many instances, exact pathogenesis of these lesions is still uncertain Cysts
  • 2.  A Cyst is a pathologic cavity having fluid, semi fluid or gaseous content and which is not created by accumulation of pus.  Most cysts, but not all, are lined by epithelium. (KRAMER 1974)
  • 3.  TRUE CYSTS :  Cysts which are lined by epithelium, E.g. Dentigerous Cyst, Radicular Cyst, etc.  PSEUDO CYSTS :  Cysts which are not lined by epithelium, E.g. Solitary Bone Cyst, Aneurismal Bone Cyst,Trumatic bone cyst etc.
  • 4. •Radicular /dental root apex type •Lateral type •Residual type •Primordial cyst •Dentigerous cyst From odontogenic tissues •Median cyst •Incisive canal cyst •Globulomaxillary cyst From non dental tissues
  • 5. DEVOLOPMENTAL ODONTOGENIC CYST •PRIMORDIAL CYST •GINGIVAL CYST •ERRUPTION CYST •DENTIGEROUS CYST •LATERAL PERIODONTAL CYST DEVOLOPMENTAL NON-ODONTOGENIC CYST •NASOPALATINE CYST •GLOBULOMAXILLARY CYST OTHER CYSTS OF THE JAW •ABC •TRAUMATIC BONE CYST OTHER CYST OF ORAL REGION NOT ELSEWHERE CLASSIFIED •DERMOID CYST •EPIDERMOID CYST •GINGGIVAL CYST OF NEW BORN •PALATAL CYST OF NEW BORN
  • 6.  1 Developmental Origin  (a) Odontogenic i. Gingival cyst of infants ii. Odontogenic keratocyst iii. Dentigerous cyst iv. Eruption cyst v. Gingival cyst of adults vi. Developmental lateral periodontal cyst vii. Botryoid odontogenic cyst viii. Glandular odontogenic cyst ix. Calcifying odontogenic cyst  b) Non-odontogenic i. Midpalatal raphé cyst of infants ii. Nasopalatine duct cyst iii. Nasolabial cyst A. EPITHELIAL-LINED CYSTS
  • 7.  2 INFLAMMATORY ORIGIN i. Radicular cyst, apical and lateral ii. Residual cyst iii. Paradental cyst and juvenile paradental cyst iv. Inflammatory collateral cyst  B. NON-EPITHELIAL-LINED CYSTS 1. Solitary bone cyst 2. Aneurysmal bone cyst
  • 8. 1. Dermoid and epidermoid cysts 2. Lymphoepithelial (branchial) cyst 3. Thyroglossal duct cyst 4. Anterior median lingual cyst (intralingual cyst of foregut origin) 5. Oral cysts with gastric or intestinal epithelium (oral alimentary tract cyst) 6. Cystic hygroma 7. Nasopharyngeal cyst 8. Thymic cyst 9. Cysts of the salivary glands: mucous extravasation cyst; mucous retention cyst; ranula; polycystic (dysgenetic) disease of the parotid 10. Parasitic cysts: hydatid cyst; Cysticercus cellulosae; trichinosis
  • 9.  TWO STAGES 1. Cyst initiation 2. Cyst enlargement or expansion a. Initiation b. Formation c. Enlargement
  • 10. • Initiation results in the proliferation of the devoloping odontogenic epithelial cells and the formation of small cavity.  a. Cell Rests of Malassez :  Remanants of Hertwigs epithelial root sheath in the PDL after the root formation is completed.  b. Reduced Enamel Epithelium :  Residual epithelial cells surrounds the crown of the tooth after enamel formation is complete.  c. Cell Rests of Serres (Dental Lamina) :  Islands of epithelial cells that originate from the oral epithelium and remain in the tissue after inducing tooth development.
  • 11.  THEORY  Harris (1974) Postulated the theories  1) Mural growth  a) Peripheral cell division  b) Accumulated contents 2) Hydrostatic  a) Secretion  b) Transuduation & exudation  c) Dialysis 3) Bone resorbing factor
  • 12.  Mural growth  1) Peripheral cell division  2) Accumulated contents • 1)CELL DEVISION -Presence of low grade infection -- stimulate cells – cell rests of Malassez – to proliferate and form arcades of epithelium. • cons of theory –The theory has been criticized on basis that such regression will lead to an irregularly thickened inner surface because of resistance of surrounding bone. • 2)ACCUMULATION OF MURAL SQAUMES • Kramer suggested that keratocyst enlarges by increased accumulation of mural squames
  • 13. 1. Increase in the volume of its contents. 2. Increase in the surface area of the sac or epithelial proliferation. 3. Resorption of surrounding bones.
  • 14.  FACTORS 1. Secretions: ◦ Mucus secreting cyst – Lining secretes mucus – accumulation of mucus – increase in volume 2. Transudation & exudation: Inflammatory cyst or Presence of infection. a. Inflammatory cells release cofactors b. Lymphocytes release lymphokine c. Osteoclast activating factor (OAF) & d. Monocytes release interleukin- I which stimulates the fibroblasts to release prostaglandiins. This epilthelial cell breakdown products form a HYPEROSMOLAR CYST FLUID 3. Increased osmolarity: a. Raises internal hydrostatic pressure. b. Attracts fluid into the cavity. c. Retention of fluid within the cavity
  • 15. • Toller suggested the role of osmolarity by the cyst fluid in enlargement of cyst. The Mean Osmolarity was 296 mosmol compared with Serum Osmolarity of 282 mosmol. • The increase in the osmotic pressure is related to proteins present in the cyst fluid such as large molecules of albumin, globulin, fibrinogen. • Desquamated epithelial cells of cyst lining undergo autolysis & produce a larger number of molecules of lower molecular weight, raising the osmolarity of the fluid.
  • 16. • DIALYSIS :  It results from the higher osmolarity of cyst fluid than serum. • Fluid is attracted into the cyst cavity by products of epithelial cell autolysis. • Water from the tissue fluid (surrounding tissue) is attracted into the cyst to raise the internal pressure. • This hydrostatic pressure is transmitted to the adjacent bone.
  • 17. • Semi permeable membrane –  governs access into the cyst prevents the escape of certain substances from the contents. • Attracted fluid are unable to diffuse out of the cavity. • The products of epithelial autolysis could effect both osmotic attraction and retention within the cavity.
  • 18. • Increased internal pressure – transmitted to the adjacent bone – bone undergoes resorption – bony cavity enlarged. Due to the above changes, the surface area of cyst lining is increased by cell multiplication. • Epithelial cells divide – cyst enlarges within bony cavity by the release of bone resorbing factors from the capsule. Stimulate osteoclast function – eg: prostaglandins like PGE2 & PGI2.
  • 19.  (SHEAR 2006) 52.30% 18.10% 11.60% 8% 5.60% 4.20% SHEAR 2006 Radicularcyst Dentigerouscyst Odontogenickeratocyst Residual cyst Paradental cyst Unclassified odontogenic cysts
  • 20.  Based On Clinical Features  Based On Anatomical Site Of Jaw  Based On Histological Features  Based On Aspirate Fluid  Based On Radiographic Features
  • 21.  Small cysts are usually asymptomatic  Large cysts exhibits large swelling and pain  Irregularity of teeth-missing tooth, impacted tooth, supernumerary tooth, displacement of tooth, non vital tooth, carious tooth, etc  Presence of fluctuation in the swelling upon palpation  Condition of the bone plate-bulging and thinning over the outer cortical bone plate
  • 22.  Signs and symptoms depends ..  Dimension of a lesion  The type of cyst  Location of cyst in jaw  Important structures present adjacent to the cyst  Presence of infection of the cyst
  • 23. Pain and swelling in involved region Salty / unpleasant taste in mouth Anaesthesia /paraesthesia If pathological fractures – symptom change in occlusion/difficulty in mastication. Ill fitting dentures Displacement of teeth /Discoloration Missing teeth in normal series
  • 24.  PRIMARY 1) Bone expansion 2) Enlargement 3) Consistency 4)Window formation 5)fluctuation 6)sinus formation with dischaarge 6 )large cyst distortion of adjacent structures 7)Effect on teeth
  • 25. 1. PERIOSTEL STIMULATION: CURVED ENLARGEMENT OF BONE 2. TENNIS BALL CONSISTENCY: CAN BE IDENTIFIED BY PRESSURE 3. EGG SHELL CRACKLING : MICROCRACKS ON CORTICAL PLATE 4. FLUCTUATION :COMPLETE RESORPTION OF BONE OVERLYING CYST 5. SINUS FORMATION : DRAINAGE OF CYST CONTENT 6. INFECTION DUE TO CONTAMINATION FROM ORAL CAVITY
  • 26. 1 Numbness 2 Pathological fracture of jaw 3 Secondary infection 4 Malignant transformation
  • 27.  IOPA  Occlusal view  PNS cyst in maxillary region to show proximity and relation to maxillary sinus and or nasal cavity  OPG affected region of the jaws size and shape then site can be assessed.  LATERAL OBLIQUE :Cyst encroaching lower border of mandible.
  • 28.  PA VIEW : Shows expansion of the ramus of mandible
  • 29. PATHOLOGY ASPIRATE Other Findings of Aspirates Dentigerous Cyst Clear, pale straw colour fluid Cholesterol crystals. Total protein in excess 4 g / 100ml. Resembles serum Odontogenic Keratocyst Dirty, creamy white viscoid suspension Para keratinized squames. Total protein less than 4 g /100ml. Mostly albumin Periodontal Cyst Clear, pale yellow straw colour fluid Cholesterol crystals. Total protein 5 — 11g / 100ml Infected Cyst Pus, brownish fluid Polymorphonuclear leukocytes, ,Cholesterol clefts Mucocele, Ranula Mucus ----- Gingival Cysts Clear fluid -----
  • 30. PATHOLOGY ASPIRATE Other Findings of Aspirates Solitary Bone Cyst Serous fluid, blood or empty cavity Necrotic blood clot Stafne’s Bone Cyst Empty cavity – yield air --- Dermoid Cyst Thick sebaceous material --- Fissural Cyst Mucoid fluid ----
  • 31. BLOOD ON ASPIRATION  penetration to blood vessels  Vascular lesions  ABC AIR ON ASPIRTION Maxillary sinus Traumatic bone cyst NEGATIVE ASPIRATION :SOLID TUMOR
  • 32.  Contrast study for the cyst in maxillary sinus  Ultrasonic Diagnosis
  • 33.  Cysts of the jaws are treated in one of the following methods (1) Marsupialization (2) Enucleation
  • 34. • Marsupialization or decompression, and the Partsch operation all refer to creating a surgical window in the wall of the cyst, evacuating the contents of the cyst. • The only portion of the cyst that is removed is the piece removed to produce the window. The remaining cystic lining is left in situ. • This process decreases intracystic pressure and promotes shrinkage of the cyst and bone fill. Marsupialtzatron can be used as the sole therapy for a cyst or as a preliminary step in management, with enucleation deferred until later.
  • 35. 1. Amount of tissue injury : Proximity of a cyst to vital structures can mean unnecessary sacrifice of tissue if enucleation is used. 2. Surgical access : If access to all portions of the cyst is difficult, portions of the cystic wall may be left behind, which could result in recurrence. 3. Assistance in eruption of teeth : If an unerupted tooth that is needed in the dental arch is involved with the cyst (i.e., a dentigerous cyst), marsupialization may allow its continued eruption into the oral cavity 4. Extent of surgery : Marsupialization is a reasonable alternative to enucleation, because it is simple and may be less stressful for the patient 5. Size of cyst : In very large cysts, a risk of jaw fracture during enucleation is possible. It may be better to marsupialize the cyst and defer enucleation until after considerable bone fill has occurred.
  • 36.  Advantages : 1)It is a simple procedure to perform. 2)Marsupiaiization also spare vitalstructures from damage 3)Allows erruption of cyst 4)Prevents pathological fractures  Disadvantages : 1) Pathologic tissue is left in situ, without thorough histologic examination. 2) Patient is inconvenienced in several respects 3) The cystic cavity must be kept clean to prevent infection, because the cavity frequently traps food debris. 4) In most instances this means that the patient must irrigate the cavity several times every day with a syringe
  • 37.  1) Anaesthesia  2) Aspiration  3) Incision  Circular, oval or elliptic. Inverted U shaped incision with broad base to the buccal sulcus. Mucoperioteum is reflected in this case.  4) Removal of bone  5) Removal of cystic lining specimen  6) Visual examination of residual cystic lining  7) Irrigation of cystic cavity  8) Suturing  Cystic lining sutured with the edge of oral mucosa.  In U shaped incision the mucoperiosteal flap can be turned into cystic cavity covering the margin. The remaining is sutured to oral mucosa. PARTSCH 1
  • 38.  9) Packing-- Prevents food contamination & covers wound margins.  Done with ribbon gauze soaked with WHITEHEAD VARNISH.  COMPOSTION:  Benzoin – 10g  Iodoform – 10g  Storax - 7.5g  Balsam of Tolu – 5g  Solvent ether to 100ml  Pack removed after 2 weeks.  10) Maintenance of cystic cavity  Instruct the patient to clean and irrigate the cavity regularly with oral antiseptic rinse with a disposable syringe.
  • 39.  11) Use of plug  Prevents contamination. Preserves patency of cyst orifice.  Plug should be stable, retentive and safe design.  Should be made of resilient material ( avoid irritation) like acrylic.  12) Healing  Cavity may or may not obliterate totally. Depression remains in the alveolar process.
  • 40.  INDICATIONS • When bone has covered the adjacent vital structures. • Adequate bone fill. Prevents fracture during enucleation. • When patients find it difficult to cleanse the cavity. • To detect any occult pathological condition.  ADVANTAGES • Spares adjacent vital structures • Accelerates healing process • Development of thick cystic lining – enucleation easier • Allows histopathological examination of residual tissue. • Combined approach reduces morbidity  DISADVANTAGES • Patient has under go second surgery and any possible complicatton associated with surgery.
  • 41. ADVANTAGES 1)Protection of anatomic structures 2)Cystic cavity becomes lined with respiratory maxillary sinus or nasal cavity 3)Primary closure of oral wound 4)Reducing intra cystic pressure DISADVANTAGES Development of an oroantral or oronasal fistula, If there is a breakdown of the wound.
  • 42.  Cyst affected large portion of maxilla: - Cyst approached from buccal aspect of alveolar region - Gingival curvilinear incision is given and two releasing incisions - Like in partsch I a window is made - Second unroofing performed by removing the antral lining
  • 43. - Thus providing communication between the cavitities. Thus providing continuity - And forms normal ciliated epithelum regenerated from mucosa other than squamous epithelium - Cavity packed with ribbon gauze socked in benzoine or antibiotic oinment - Water tight primary closure is done
  • 44.  Principle :Allows the cavity to be covered with mucoperiosteal flap and space fills with blood clot,  Which will eventually organize and filled with normal bone  Indications : • Enucleation is the treatment of choice  Advantages : • pathologic examination of the entire cyst can be undertaken • the initial excisional biopsy (i.e., enucleation) has also appropriately treated the lesion. • The patient does not have to care for a marsupial cavity with constant irrigations.  Less chances of recurrance  Healing time is faster  Disadvantages • Fracture of the jaw • Relatvely radical procedur • Devitalization of adjacent teeth • Pulpal necrosis • Unerrupted impacted teeth may be removed with the cyst. • Risk of oroantral/oronasalcommuniction • Removalof large cyst may weaken the mandible
  • 45.  TECHNIQUE : • Aspiration Biopsy of Radiolucent Lesions • Mucoperiosteal Flaps • Osseous Window • Removal of Specimen • Enucleation and packing : when there is previous infection or infected large cyst primary closure may become unsuccessful as it could lead to the breakdown of the wound / approximating wound edges. • Such cases enucleation is perfomed and cavity is packed as in marsupilialization. • Also used as secondary meassure when dehiscense is present. •
  • 46.  Aspiration Biopsy of Radiolucent Lesions : • Any radiolucent lesion should be aspirated before surgical exploration. • This provides the dentist with valuable diagnostic information regarding the nature of the lesion  Mucoperiosteal Flaps : • Several varieties of mucoperiosteal flaps are available; the choice depends chiefly on the size and location of the lesion. • Access may necessitate extension of the irmcoperiosteal flap. The location of the lesion dictates where the flap incisions are to be made. • The flap design should provide 4 to 5 mm of sound bone around the anticipated surgical margins • Mucoperiosteal flaps for biopsies in or on the jaws should be full thickness and incised through mucosa, submucosa, and periosteum
  • 47.  Reflection of flap is done with periosteal elevator /howarth beginning from under the periosteum of anterior buccal incision
  • 48.  Osseous Window : • Once the flap has been elevated, a rotating bur should be used to remove an osseous window • The size of the window depends on the size of the lesion and the proximity of the window to normal anatomic structures such as roots and neurovascular bundles.  In case of sinus tract may present or cyst may eroded through the cortex and lying with periosteal layer reflection may be difficult.  Underlying cystic lining can be separated with mosquito forceps
  • 49.  Technique : • A dental curette is used to peel the connective tissues wall of the specimen from surrounding bone. • The convex surface of the instrument should always be kept in contact with the osseous surfaces of the bone cavity • The bony cavity is inspected after irrigation with sterile saline • Any residual fragments of soft tissue within the cavity should be removed with curettes. • Once the cavity is devoid of residual pathologic tissue, it is irrigated and the flap is replaced and sutured in its proper location.
  • 50. ENUCLEATION OF CYST
  • 51. Enucleation with primary closure Enucleation with Open packing Enucleation with bone curettage Enucleation with peripheral osteotomy Enucleation with chemical cauterisation Enucleation with bone grafting Segmentl resection
  • 52.  Disadvantages : • Curettage is more destructive of adjacent bone and other tissues • The dental pulps may be stripped of their neurovascular supply when curettage is performed close to the root tips • Adjacent neurovascular bundles can be similarly damaged
  • 53.  Only when there is large odontogenic keratocyst with massive bone destruction,segmental resection is unavoidable.  Also when there is neoplastic transformation of the cyst
  • 54. -surgery is performed under general anaesthesia -A submandibular incision is placed 2.5-3 cm below inferior alveolar border -blunt and sharp dissection carried oout layerwise Care is taken to salvage the marginal mandibular nerve m
  • 55. Pterygomassetric sling is devided Periosteum is incised down Flap raised superiorly Window created by guttering with bone burs or with chiesel and mallet
  • 56.  Fracture  Post operrative wound dehiscence  Loss of vitality of teeth  Dysplastic neoplastic r malignant changes
  • 57. http://en.wikipedia.org/wiki/Cysts_of_the_jaws http://www.gorlingroup.org/jupgrade/index.php/about- gorlin-syndrome/11-jaw-cysts http://www.slideshare.net/makkahguys/jaw-bone- chttp://www.slideshare.net/JanmiPascual/cysts-of-oral- region-5?related=1yst References: Books
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