1.8} Cysts Clinical comments and highlights The presence of um in the marrow of the maxilla and mandible is one of the many dissimilarities between the jaws and other bones. The source of the epithelium is beth odonto- genic and nonodontogenic. Cysis occurring in the upper and lower jaws are classified according to the origin of epithelial cells lining the cyst membrane. The purpose of this classification ap- peas to be (1) to identify the cyst as being related in its origin to teeth (i., edontegenic or non- ‘odontogenic and related to the development along the line of closure of embryonic processes) and (2) to signal the possible need for either root canal therapy or tooth extraction in addition to enu- cleation of the cyst. Bhaskar classifies eyste as follows: Ogoniogenic Nonodontogenic 1 Primordial Arise from the file ot 1 Median palatine ) Arse fom epithelium found in 2 Dentigerous | enamel onpan referred to 2 Median alveolar | the line of fasion of facia 3. Multilocular st 3 Globulomaxillary { process: collectively called 4 Radicular Anse from the ress 4 Nasoalveolar J fisual ts 5 Residual reneed 5 Nasopalatine Arise from remaant of Nonepithelial (pseudocysts) ce 1 Traumatic 2 Idiopathic bone vty 3 Aneurvsmal bone To differentiate odontogenic cysts from other radiolucent lesions, including cysts of non- ‘edontogente origin: 1 Obtain a careful history: trauma, pain, toothache, smelling, drainage, numbness 2 Examine the mouth carefully: expansion, crepitus, inflammation, drainage, tooth discol- ‘oration, hypermobility, vitality, asymmetry of the area when compared with the opposite side. 3 Examine roentgenogeams carefully: nature of the marginal contour, radiopaque or radio- lucent border, regular or irregular outline of the periphery, size of the lesion, lesions present in other bones, tooth displacement. 4 Obtain blood chemistry studies, In general it can be stated that the preferred therapy for cysts is enucleation. Marsupialization fs resorted to in those instances in which the cyst is 50 large that enucleation runs the risk of Govitsliaion of a number of teeth er pathologic fracture of the surrounding bone, The principles Gescribod in the following pages are applicable to the majority of cases encountered and apply to cysts not illustrated 175DENTIGEROUS CYST Clinical comments and highlights The clinical diagnosis of dentigerous cyst is made in the presence of a radiolucency with an. associated developing tooth. These cysts are found most frequently in the mandibular third molar region. 1 Test the vitality of the adjacent tooth or teeth 2. Design a fap to adoquately expose the operative site 3. Carofully enucleate the cyst, avoiding damage to the inferior alveolar neurovascular bundle 4 Attempt primary closure. Drains can be placed if the blood clot subsequently breaks down Surgical technique A® Typically the cyst is found in the mandibular third molar and contains a developing tooth. Examine ite relation to the adjoining tooth, mandibular canal, and medial and lateral cortical plates and its extension into the ramus. B Incise the oral mucosa between the medial and lateral temporal crests on the anterior border of the ramus. Carry the incision forward around the gingival sulcus as far as necessary to ex- pose the operative site. C+ Reflect che buccal gingiva by first detaching it from the cervical portion of the teeth with a no. 77 elevator. Follow with a periosteal elevator in the subperiosteal plane. D+ Remove the bone overlying the cyst to the extent necessary 10 enucleate the cyst. A no, 703 bbur, mallet and chisel, and Kerrison rongeurs may be used. E + Establish the plane between the eyst and crypt by depressing the cyst membrane away from the bone. Incision of the cyst wall with partial evacuation of its contents helps to collapse the cyst and facilitates its removal through an opening smaller than the greatest cyst diameter. Clamp an Allis forceps to the cyst wall and enucleate it from the mandible, F + Finish the bony margins with a pear-shaped acrylic bur under saline irrigation. Remove any remaining loose bone fragments and reposition the flap. Maintain the wound edges with 3-0 Black silk 176RADICULAR CYST: PARTSCH PROCEDURE Clinical comments and highlights Enucleation of the cystic membrane has the advantage of a definitive procedure. A disadvan- tage is that it is not universally applicable. When a cystic lesion extends to the peripical region of several adjoining teeth, enucleation will quite likely result in their devitalization. Marsupializa- tion therefore is a sensible and appropriate substitute, carried out until root apices are ag tained within a protective bony socket and the size of the cyst has significantly diminished. 4 Marsupialization is applicable when enucleation will result in devit mn of teeth, 2 Construct a window through which the cyst can be irrigated and observed. 3 If desirable, when root apices are protected, remove the remaining cystic membrane. Surgical technique A= Diegrammatic representation of « radicular cyst extending from the mandibular left central incisor to the region of the second premolar. Enuclestion of the eystie membrane will likely cevitalize several teeth Circularly incise about 1.5 cm of the unattached and attached gingivae. Carefully avoid dam age to the mental nerve. C+ Remove the gingiva and underlying soft tissue until the entire labial plate of bone comes into view. Generally, because it is thin, it will appear bluish D+ With a no. 702 carbide bur, make multiple holes at the periphery of the soft tissue. Connect them and remove that segment of bone. E + Excise the exposed anterior portion of the cyst wall. Suture the cystic sac membrane to the alveolar mucosa F = Make an acrylic button with a long enough extension to remain in the cystic cavity during, the healing process. While the acrylic plug is being made, place a gauze packing in the wound.GLOBULOMANILLARY CYST Clinical comments and highlights The globulomaxillary cyst is diagnosed when it is found between the maxillary lateral incisor and canine, Both teeth are usually vital unless their vitality has been destroyed by caries or cyst pressure. Their roots appear to diverge, cradling the radiolucent mass betveen them. 1 Test the vitality of adjacent teeth Design the mucoperiosteal flap to adequately expose the mass. Remove overlying bone. Carefully enucleate the mass. Reposition the flap. 2 3 1 5 Surgical technique A + Inspect the area of involvement Determine the superolateral extent of the cyst and the vie tality of the teeth. B + Design the flap to extend 5 to 10 mun beyond all cystic margins. Reflect the mucoperiosteum superiorly, exposing the cuter covering cortical bone. C+ Remove the overlying bone with « bus, chisel, and rongeur. D = Incise the mass and evacuate its contents (partially at least), This results in partial collapse of the cyst. Identify the plane of cleavage slong which the cyst will separate from the sur- sounding bone, Place a curette of periosteal elevator in this plane and carcfully peel away the cyst wall from the bone, Smooth the margins of the opening with « large pear-shaped acrylic bur or bone file E + Replace the soft tissues and suture with 3.0 black silk 180NASOPALATINE CYST (INCISIVE CANAL CYST) Clinical comments and highlights ‘The diagnosis is clinically established in the presence of a heart-shaped midline maxillary radiolucency. The adjacent teeth are vital unless previously devitalized by caries, dental restora~ tions, or cyst pressure, 1 Test the vitality of adjacent teeth, 2 Approach the cyst paletally 3 Carefully enucleate the entire cyst wall, with particular attention to its junction with the incisive papilla. Surgical technique A + The roeatgenogtam demonstrates the midline heart-shaped radiolucency extending laterally. Test the vitality of the teeth related to the cyst B + Typical appearance of the palatal mucosa, swollen and displaced in the midline, associated with a large cyst of long standing C+ Incice the palatal mucoperiostoum from the premolar of one side to that of the other. De- tach the cervial portion fist with a no. 77 elevator and follows with a periosteal elevator. D+ Enlarge the opening through which the cyst is ta be removed with 2 no. 703 bur under saline irigation E © Enucleate the cystic mass from its crypt with a curette. Carefully separate it from the neuro- vascilar bundle ad its attachment to the incisive papilla F + Reposition the flap and place transpapillary sutures to maintain it in position, A clear acrylic splint or cross-palatal sutures help to Keep the tissues against the palate 182PLATE 13-4NASOLABIAL CYST Clinical comments and highlights Diagnosis of nasolabial cyst is made clinically on the basis of location and feel. The eyst 4s found high in the vestibular fold of the maxilla between the lateral incisor and canine. It distorts the nostril and lip and may extend inte the nasal cavity. The mass is slightiy compress- sole, painless unless secondarily infected, and covered by normal oral mucosa. It develops from epithelial remnants enclaved at the junction of che mmxillary process with the medial and lateral, nasal processes. 1 Examine asymmetry of the lip, nese, and vestibule. 2 Incise the oral mucosa just to the eyst wall. 3 Establish a plane for dissection. 4 Clove the inciston in layers Surgical technique A + Clinical examination reveals a prominence of the lip on the involved side. The nostril is displaced anterosuperierly. The floor of the nose may show a bulge, reflecting encroachment. Intraorally the bulge is visible depressing the height of the vestibule. The mass feels firm but reilecs its fluid content on pressure B = Incise the mucosa everlying the mass, extending the incision 3 mm beyond the cyst margins anteroposteriorly. Incise only through the mucosa to the cyst wall C = Establish the plane of dicsection at the junction of the cyst wall, Dissect along the superior, medial, lateral, anterior, and posterior margins, D = Fix the mass with an Allis clamp and continue dissection about its periphery. E « If necoccary, use 2 curette to detach the mass from surrounding tissue F + Close the wound with 2.0 silk.