Cysts of oral cavity

Etiopathogenesis, Investigation,
Diagnosis and Management

Dr. Mukhallat Qazi

IInd yr PG
OMFS
 Contents
• Introduction • Radicular cyst
• Definition • Dentigerous cyst
• Classification • Odontogenic Keratocyst
• Etiopathogenesis • COC
• Clinical presentation of a • Gingival cyst
Cyst • Eruption Cyst
• Investigations • Lateral periodontal cyst
• General features • Nasopalatine cyst
• Treatment- • Nasolabial cyst
– Partsch I • ABC
– Partsch II
• Ant Median Lingual cyst
• Dermoid and Epidermoid
 Introduction
• “CYST”- “Kystis ” (Greek)
– sac, bladder, pouch, or bag
– “Kyso” “I hold”

• Professor Mervyn Shear

(1931-2017)
 Definition
• An abnormal cavity in hard or soft tissues
which contains fluid, semifluid or gas and is
often encapsulated and lined by epithelium
Killey and Kay (1966)
• A pathologic cavity having fluid, semifluid, or
gaseous contents that are not created by the
accumulation of pus; frequently, but not
always, is lined by epithelium
Kramer (1974)
 Classification
SHEAR

• Cysts of the jaws

• Cysts associated with the maxillary antrum
• Cysts of the soft tissues of the mouth, face,
neck and salivary glands
 Classification
Odontogenic
Cysts of the jaws

Developmental origin
Non-odontogenic

Radicular cyst, apical

Epithelial lined
and lateral

Residual cyst
Inflammatory origin
Paradental cyst and
juvenile paradental cyst
Solitary bone cyst
Inflammatory collateral
Not epithelial lined
cyst
Aneurysmal bone cyst
 Cysts of the jaws
A. EPITHELIAL-LINED CYSTS

• Developmental
Origin
(a) Odontogenic b) Non-odontogenic
i. Gingival cyst of infants
ii. Odontogenic keratocyst
i. Midpalatal raphé cyst of infants
iii. Dentigerous cyst
ii. Nasopalatine duct cyst
iv. Eruption cyst
iii. Nasolabial cyst
v. Gingival cyst of adults
vi. Developmental lateral periodontal
cyst
vii. Botryoid odontogenic cyst
viii. Glandular odontogenic cyst
ix. Calcifying odontogenic cyst
 Mucocele

Retention cyst
Cysts associated with
the maxillary antrum
Pseudocyst

Postoperative
maxillary cyst
 Dermoid and epidermoid cysts

Lymphoepithelial (branchial) cyst

Thyroglossal duct cyst

Cysts of
Anterior median lingual cyst (intralingual cyst of foregut
the soft origin)

tissues of Oral cysts with gastric or intestinal epithelium (oral

alimentary tract cyst)

the mouth, Cystic hygroma

face and Nasopharyngeal cyst

neck Thymic cyst

Cysts of the salivary glands: mucous extravasation cyst;

mucous retention cyst; ranula; polycystic (dysgenetic) disease
of the parotid
Parasitic cysts: hydatid cyst; Cysticercus cellulosae; trichinosis
Robinson’s classification (1945)

A. From odontogenic tissues

1. Periodontal cyst
2. Dentigerous cyst
3. Primordial cyst
B. From Non dental tissues
1. Median cyst
2. Incisive canal cyst
3. Globulo-maxillary cyst
 Lucas classification (1964)

Odontogenic Periodontal
Dentigerous
Primordial

Fissural Nasopalatine
Globulo maxillary
Naso labial
Median cysts

Bone cysts Solitary bone cyst

Aneurysmal bone cyst
Stafne’s bone cavity
 Classification WHO- 1992
• Epithelial cysts of the jaws
• Developmental
• Inflammatory
• Nonepithelial cysts of the jaws (Pseudocysts)
• Aneurysmal bone cyst
• Solitary bone cyst (simple, traumatic, hemorrhagic, idiopathic bone cavity)
• Other cysts in the Head & Neck region
• Soft tissue cysts
• Pseudocysts
• Miscellaneous
 Classification WHO- 1992
• Epithelial cysts of the jaws
– Developmental
• Gingival cyst of infant ( Epstein pearls)
• Gingival cyst of Adult
• Eruption cyst
• Odontogenic Keratocyst
• Dentigerous cyst
• Lateral periodontal cyst/ Botryoid odontogenic cyst
• Glandular odontogenic cyst (Sialo-odontogenic cyst)
• Calcifying odontogenic cyst (Gorlin’s cyst)
• Nasolabial cyst (Nasoalveolar cyst)
• Nasopalatine duct cyst (Incisive canal cyst)
 Classification WHO- 1992

• Epithelial cysts of the jaws

– Inflammatory
– Radicular cyst (Periapical / Periradicular)
 Apical
 Lateral
 Residual
– Paradental cyst (Mandibular infected buccal
bifurcation cyst, inflammatory collateral cyst)
 KRUGER’S CLASSIFICATION (1964)

A) Congenital cyst
Thyroglossal
Bronchogenic
Dermoid
B) Developmental cyst
I. Non-dental origin
a) Fissural type II. Dental origin
a) Periodontal
Naso-alveolar
• Periapical
Median • Lateral
Incisive canal cyst • Residual
(Naso-palatine) b) Primordial
Globulomaxillary c) Dentigerous
b) Retention type
Mucocoele
Ranula
 THOMA, ROBINSON, BERNIER
CLASSIFICATION (1960)
I. Odontogenic ectodermal II. Non odontogenic ectodermal
epithelial cyst.
epithelial cyst
A. Follicular cyst A. Intraosseous cyst
(a) primordial cyst (a) Median
(b) dentigerous cyst (b) Intermaxillary
(i) lateral (c) Nasoalveolar
(ii) Central B. Nasoplatine cyst
B. Periodontal cyst (a) Incisive canal cyst
(a) Apical (b) Cyst of papilla palatina
(b) Lateral
C. Residual cyst
(a) follicular
(b) periodontal
D. Multiple cyst
E. Multilocular cyst
F. Polycytoma cyst
G. Cholesteatoma
Etiopathogenesis
 Cyst initiation
Type of odontogenic epithelium Cyst

Odontogenic
keratocyst/keratocystic
Epithelial rests (glands of Serres)
odontogenic tumour (KCOT/KOT)
Lateral periodontal and gingival
Reduced enamel epithelium
Dentigerous (follicular)
(enamel organ)
Eruption

Epithelial rests of Malassez (root

sheath of Hertwig) Radicular
 Cyst enlargement
THEORY

Harris (1974) Postulated the theories

Mural growth
a) Peripheral cell division
b) Accumulated contents

Hydrostatic Enlargement
a) Secretion (Transudation & exudation)
c) Increased osmolarity

Bone resorption
 General features
Jaw cysts Soft tissue cysts
• Slowly enlarging
• Usually a hard, painless, smooth, • Slowly enlarging
rounded swelling
• Usually painless
• Normally buccal plate expansion
• “Eggshell crackling” on palpation • Fluctuant on palpation
of large cysts
• Occasional pathologic fracture
• Displacement of adjacent teeth
may occur
• Prominence generally on the labial
side
• Well circumscribed radiolucency,
unilocular or multilocular with
sclerotic border
 Clinical presentation of a Cyst
• Serendipitous discovery of most cysts on radiographs, before
expansion is evident
• Absence of a tooth from its place in the arch  dentigerous
cyst
• Carious, discolored, fractured or heavily filled tooth related to
the swelling  radicular cyst
• Percussion of the teeth overlying a cyst gives dull sound
solitary bone cyst
• Solitary bone cyst  mandible
• Stafne bone cavity  inferior to inferior dental canal
 Clinical presentation
• Paresthesia and anesthesia is rare Infected cysts may
cause neuropraxia
• Expansion of the lingual aspect alone odontogenic
cyst in the ramus or third molar region
• Expansion of both cortical plates  not a cyst
• Fluctuation is elicited when the cystic lining lies
immediately beneath the mucosa.
 Investigations
• Vitality of the teeth-
– Non vital teeth: Radicular cyst
• Radiographic examination-
– IOPAs for small lesions
– Occlusal films
– Extraoral radiographs:
• Lateral Oblique, OPG
– CT scans
Use of radio opaque medium

Useful to demonstrate the

relationship of naso labial
cyst to the surface of the
maxilla and to the nasal
cavity
 • Aspiration-
PATHOLOGY ASPIRATE OTHER FINDINGS
Dentigerous Clear ,pale straw Cholesterol crystals
cyst colour fluid Total protein >4g/dl
Resembles serum
OKC Dirty, creamy white Para keratinized squames
suspension Total protein <4g/dl, mostly
albumin
Periodontal Clear, Pale yellow Cholesterol crystals
cyst straw colour fluid Total protein 5-11g/dl
Infected Cyst Pus, brownish fluid PMNLs, Cholesterol clefts
Mucocele, Mucus
Ranula
Gingival cyst Clear fluid
Solitary bone Serous fluid, blood,
cyst empty cavity
Dermoid cyst Thick sebaceous
material
• Biopsy-
– For large cysts where diagnosis is unclear
• Assessment-
– Size
– Extent of bone loss, risk of pathological fracture
– Adjacent structures
– Vital/non-vital teeth: periodontal status and
decision to treat and keep?
– Need for rehabilitation/reconstruction of defect
– Syndrome identification in multicystic lesions
 Frequency of Epithelial Cysts of Jaws

4.20% SHEAR 2006 Radicular cyst

5.60%

Dentigerous cyst
8%
Odontogenic keratocyst

11.60%
52.30% Residual cyst

Paradental cyst
18.10%

Unclassified odontogenic
cysts
Radicular cyst
C/F: Signs and symptoms
– Most common type – Painful condition at
– Peak in 3rd 4th and 5th initial stage of
decades inflammation but
eventually becomes
– 60% in maxilla asymptomatic
(Maxillary anterior
region) – Associated teeth non-
vital
– Slow growing, fluctuant
if cortical plates
breached
Radiographic Features:
Well circumscribed round/ovoid radiolucency at the
apex of the tooth involved, a sclerotic border is
seen
Loss of lamina dura
DDx-
PA granuloma
PA cemento osseous dysplasia

Treatment:
• Involved tooth may be removed, Periapical
tissue carefully curetted
• RCT with apicocectomy and enucleation
 Dentigerous/Follicular cyst
A cyst that produces an enlargement of the
follicular space around the crown of a developing
or unerupted tooth
C/F:
2nd most common type of odontogenic cyst
Most prevalent among children and adults
Affects late erupting teeth
 Mandibular 3rd molars
 Maxillary cuspids
 Maxillary 3rd molars
 Mandibular cuspids
Signs and symptoms-
– Painless unless infection sets in
– May result to some degree of deformity or facial
asymmetry
– As result of pressure the tooth involved may migrate to a
considerable distance
– The cyst becomes very large before discovery
– Tooth is missing from the normal series of dentition
– Multiple dentigerous cysts-
• Cleidocranial dysplasia
• Maroteaux Lamy syndrome
Radiographic findings:
Well defined radiolucency associated with the
crown of an impacted or unerupted tooth
Generally unilocular, with corticated margin
Displacement of associated unerupted tooth
• CENTRAL TYPE:

• LATERAL TYPE :

• CIRCUMFERENTIAL
TYPE :
Radiograph of two dentigerous cysts in the same
patient. The cyst on the right is a lateral type; that on
the left is a circumferential type
• CT scan of a maxillary dentigerous cyst extending
to, and impinging on, the floor of the nose.
 DIFFERENTIAL DIAGNOSIS

1. Unicystic ameloblastoma
2. Adenomatoid odontogenic tumor.
Treatment:
-Removal of associated tooth with enucleation
-If cystic lesion is very large, marsupialization may be
done to allow decompression and subsequent
shrinkage.
-Marsupialization in children if the tooth is to be saved

GROSS SPECIMEN OF A
DENTIGEROUS CYST.
Cyst encloses the crown of the
tooth and is attached to its neck
 Odontogenic Keratocyst

• OKC- Philipson in 1956

• Histologic features- Browne in 1970-
71
• Mostly lined by parakeratinized
epithelium, although orthokeratinized
variants exist
• Arise from remnants of dental lamina
 Keratocystic Odontogenic
Odontogenic Tumor
Keratocyst
Why redesignated as a tumor-
• Clinical behavior- high recurrence rate post
simple enucleation
• Histologic appearance
• Presence of tumor markers within the cyst
– PCNA, Ki67, BCE 2 sequence of the enzyme
dihydrolipoyl acetyltransferase, MMP 2 and 9,
p53.

Clinical features
• Age- 2nd and 3rd decades
• Male> female
• Mandible> Maxilla
– 50% angle involvement
KCOT
Clinical presentation
• Pain, swelling, or discharge
• Paraesthesia of the lower
lip or teeth
• Variable in size and number
• Bone expansion in 60%
cases
 Radiographic features
• Well-defined radiolucent area with smooth and often corticated
margins
• Unilocular >> multilocular
• Larger lesions show scalloped margin
• Sclerotic border
• Displacement of teeth
GORLIN-GOLTZ syndrome, characterized by

• Multiple nevoid basal cell epitheliomas

• Odontogenic Keratocyst of the jaws
• Bifid ribs– sixth rib
• Plantar & palmar pits
• Occular hypertelorism
• Frontal bossing
• Ectopic calcifications
DIFFERENTIAL DIAGNOSIS
TREATMENT

• Unilocular ‘lucencies – Aggressive or

– Dentigerous cyst, Eruption conservative?
cyst, COC, AOT, Unicystic • Age
ameloblastoma etc.
• Site
• Multilocular ‘lucencies • Size
– Conventional • Occurrence
ameloblastoma, CEOT,
Central giant cell
granuloma, Aneurysmal
bone cyst etc.
• Decompression followed by enucleation
• Enucleation with peripheral ostectomy
• Chemical cautery- Carnoy’s solution
• En bloc resection
• Follow up examinations
• Most recurrence- within 5 years of treatment
Vital staining
 KCOT Recurrence
The reasons for this recurrence rate are believed to be :
• Tendency to MULTIPLICITY, including the occurrence of satellite
cysts which may be retained during an enucleation procedure.
• They have a thin FRIABLE LINING, which is fragile, and portions are
easily left behind.
• A SCALLOPED MARGIN poses difficulty for in toto removal of the
cyst.
• Some of these lesions may originate from the oral mucosa and
DAUGHTER CYSTS are seen between the oral mucosa and the cyst
itself.
• An INTRINSIC GROWTH POTENTIAL with tumor like property
• Off shoots from BASAL LAYER of oral epithelium
 Enucleation alone

Recurrence rate Enucleation and curettage

Enucleation and Carnoy's solution

Enucleation plus liquid nitrogen cryotherapy

Marsupialization alone

Decompression followed by residual

cystectomy
Resection

– Essam Ahmed Al-Moraissi et al

Journal of Cranio-Maxillofacial Surgery
Volume 45, Issue 1, January 2017, Pages 131–144
 CALCIFYING ODONTOGENIC CYST

• Also called as Odontogenic ghost cell cyst or Gorlin cyst.

• In the latest WHO publication -renamed calcifying cystic
odontogenic tumour (CCOT).
• COC is a unicystic process and develops from the reduced
dental epithelium or remnants of dental lamina.
• The cyst lining has the potential to induce formation of
dentinoid or even odontoma in adjacent CT wall.
• Intraosseous as well as extraosseous variants
 Classification Of The Odontogenic Ghost Cell
Lesions
‘Simple’ cysts
Group 1 : Calcifying odontogenic cyst (COC)

Cysts associated with odontogenic hamartomas or

Group 2 : benignn eoplasms: calcifying cystic odontogenic
tumours (CCOT).
Solid benign odontogenic neoplasms with similar cell
morphology to that in the COC, and with dentinoid
Group 3 : formation
Dentinogenic ghost cell tumor
Malignant odontogenic neoplasms with features
Group 4 : similar to those of the dentinogenic ghost cell tumour
Ghost cell odontogenic carcinoma
• C/F-
– Equally common in maxilla
and mandible
– Site- canine premolar
region
– Both intraosseous as well
as extraosseous forms
• Signs and symptoms-
– Swelling, seldom with pain
– Intraosseous lesions- bony
expansion and facial
asymmetry
– Displacement of teeth
 RADIOLOGICAL FEATURES
Radiographic features
• Usually unilocular lucency

• Irregular calcified masses of

varying sizes may be seen
within the lucency.

• Displacement of root/roots
with or without root
resorption and expansion of
cortical plates also seen
 DIFFERENTIAL DIAGNOSIS

• Based on radiographic appearance, following lesions

must be included in the provisional diagnosis –
• Ameloblastoma
• CEOT
• AOT
• Ameloblastic fibro odontoma
Treatment
Enucleation
 GINGIVAL CYST OF ADULT
• Gingival cyst of adult is an uncommon cyst of
gingival soft tissue occurring in either the free or
attached gingiva
• Lesion is slow growing and painless
• Adjacent teeth usually vital
C/F-
– 5th to 6th decade
– Flesh colored swelling
– Bluish hue due to cystic fluid
– Canine and premolar region mandible
Signs and symptoms-
• Slowly enlarging, well circumscribed painless
swelling.
• Fluctuant lesion, adjacent teeth are vital
Radiological features Treatment

• Excisional biopsy

Radiograph of a gingival cyst in an adult.

There is a faint radiographic shadow
(marked with arrows) indicative of
superficial bone erosion.
 Gingival cyst of infants
• Bohn’s nodules or Epstein’s pearls.
• Rare after three months of age.
• Seen on the alveolar ridge or along the mid
palatine raphe.
• Usually 2 to 3 mm in diameter.
• Treatment : Not indicated.
 Eruption cyst
• The eruption cyst occurs when a tooth is
impeded in its eruption within the soft tissues
overlying the bone.
C/F-
Age: Children, rarely in adults in delayed
eruption
Site: First permanent molars and maxillary
incisors, Max>mand
Signs and symptoms:
Asympomatic
Dome shaped raised swelling
Soft to touch
Translucent and fluctuant
Treatment-
• Partial excision of soft tissue followed by
compression of cyst (large size)
• Incision and exposure of underlying crown
• Spontaneous regression may not require
treatment
 Lateral Periodontal Cyst
The designation ‘lateral periodontal cyst’ is
confined to those cysts that occur in the lateral
periodontal position and in which an
inflammatory etiology and a diagnosis of
collateral OKC have been excluded on clinical and
histological grounds
(Shear and Pindborg, 1975)
C/F-
• Age: 20-60 yrs, peak at 6th decade
• Sex: M>F
• Site: Lateral PDL regions of mandibular
premolars, anterior maxilla
Signs and symptoms-
• Usually asymptomatic
• Occasional pain and swelling
• Vital teeth
• <1 cm in size (except botyroid variety)
 Radiological features

• Round to ovoid ‘lucency with

sclerotic margins.
• Cyst can be present anywhere
between cervical margin to
root apex.
• Radiographically, it can be
confused with collateral OKC.

Radiograph of a lateral periodontal cyst lying between the

mandibular premolar teeth. The margins are well corticated,
indicative of slow enlargement.
Treatment-
Enucleation
NON ODONTOGENIC CYSTS
 Nasopalatine Duct
(Incisive Canal) Cyst
• Also classified as “FISSURAL CYSTS”

• Believed to be derived from epithelial remnants included

during closure of embryonic facial processes.

• Usually occurs within the nasopalatine canal or in soft tissue

of palate at the opening of canal.
C/F-
• Age: 4th 5th and 6th decades
• Sex: F>M
• Commonest non-odontogenic developmental cyst
• Swelling
– anterior region of mid palate
– midline labial aspect of alveolar ridge
• Pain if there is pressure on NP nerves
• Vital adjacent teeth
• The lucency
appears well defined
with sclerotic
borders, in midline
of palate between
roots of incisors.
 • Radicular cyst if teeth
are pulpally involved
• Large incisive canal

Treatment-
Enucleation
 NASOLABIAL CYST
• The nasolabial cyst occurs outside the bone in the
nasolabial folds below the alae nasi.
C/F-
Age : 4th & 5th decades.
Sex : F>M
Frequency: Rare
 RADIOLOGICAL FEATURES

• Localized increased
lucency of alveolar
process above apices of
incisors.
• Lucency results from
pressure resorption on
labial surface of maxilla.
Treatment-
Enucleation
 BONE CYSTS
• SOLITARY BONE CYST

Also called-simple bone cyst,traumatic bone

cyst,haemorragic bone cyst
Occurs mainly in children and adolescents
b/w Canine and 3rd molar regions of the
mandible
Majority are asymptomatic
 SOLITARY BONE CYST
• Radiographically –irregular radiolucency with
scalloping

• Surgical exploration shows rough bony walled cavity

• No soft tissue lining

• TREATMENT: Exploration of area and induce bleeding

after evacuating the contents
 Aneurysmal Bone Cyst
• Uncommon cyst, found mostly in long bones
and spine.
C/F -
– Age : First 3 decades.
– Sex : Mainly females.
– Site : molar regions of mandible & maxilla.

Signs & symptoms:

– Hard, rapidly growing swelling which can cause
malocclusion.
– If lesion perforates cortical plates, can cause “egg shell
crackling”.
Radiographic features
DIFFERENTIAL DIAGNOSIS

• Conventional ameloblastoma
• CEOT
• Central giant cell granuloma

Treatment-
Curettage
Local excision with bone grafting
Curettage with cryotherapy
Percutaneous intralesional calcitonin injection wit methylprednisolone
Arterial embolisation and en bloc resection
 Anterior Median lingual cyst
• AImost always present since birth.
• Site: Anterior two thirds of the tongue.
• Clinical features: At birth, a fluctuant swelling
may be seen involving the anterior two-thirds
of the dorsal surface of the tongue.
• Treatment: Incision and drainage is followed
by recurrence. The cyst should be enucleated.
 Dermoid and epidermoid cysts
• Age- Young adolescents
• Site- Midline in the floor of the mouth, above or below the
geniohyoid m.
• C/F:
– Tongue elevation, difficulty in mastication and speech
– Submental swelling (double chin)
– Dough like on palpation
• Treatment: Complete radical surgical excision of the cyst
along with its tract is essential to prevent recurrence.
Owing to its proximity to the hyoid bone, a central part of the hyoid
bone, approximately 1 to 2 cm may require to be removed during
surgery.
MANAGEMENT
 General principles of treatment
1. Progressive increase in size
2. Likely to get infected
3. Constitute an area of weakness
4. May result in pathological fracture
5. To confirm the benign nature
6. Encroachment on neighbouring structures
 Aims of treatment
• Removal of lining or enable the body to rearrange position of
abnormal tissue to eliminate from within, and prevention of
recurrence.
• Minimum trauma to patient and maximum conservation of tissue
mainly of dental components.
• Preserve adjacent important structures
• Achieve rapid healing; to minimize number of visits
• Restore the part to near normal and normal function
• Prevention of pathologic fracture
• Facial esthetics.
 TREATMENT
1. Marsupialization (Partsch 1 Operation) (Cystotomy)
2. Enucleation (Partsch 2 Operation) (Cystectomy)
– Enucleation
– Enucleation with curettage
– Enucleation after marsupialization
– Eucleation and resection
 Marsupialization
• Creating a surgical window in the wall of the cyst, evacuating
the contents of the cyst, and maintaining continuity between
the cyst and the oral cavity, maxillary sinus, or nasal cavity.

• 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
• promotes shrinkage of the cyst
• Promotes bone fill.
 Indication

Amount of tissue injury

Surgical access
Assistance in eruption of teeth
Extent of surgery
Size of cyst
 Marsupiailization
Advantages :
• It is a simple procedure to
perform. Marsupiaiization
also spare vital
• structures from damage
should immediate
enucleation be attempted.
Disadvantages :
• Pathologic tissue is left in
situ, without thorough
histologic examination.
• Patient is inconvenienced in
several respects
• The cystic cavity must be
kept clean to prevent
infection, because the cavity
frequently traps food debris.
• In most instances this means
that the patient must irrigate
the cavity several times
every day with a syringe
 Technique of Marsupiaiization
1) Anaesthesia
2) Aspiration
3) Incision
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.
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.
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.
 Enucleation

• Enucleation is the
process by which the
total removal of a cystic
lesion is achieved.

• “Shelling- out of the

entire cystic lesion
without rupture.”
Advantages : Disadvantages
• Pathologic examination • Normal tissue may be
of the entire cyst jeopardized
• Appropriate treatment • Fracture of the jaw
• Patient dependant • Devitalization of
factor reduced associated teeth
• Impacted teeth cannot
be saved
 Enucleation

TECHNIQUE :

Aspiration Biopsy of Radiolucent Lesions

Mucoperiosteal Flaps
Osseous Window
Removal of Specimen
 Enucleation
Aspiration Biopsy of Radiolucent Lesions
Mucoperiosteal Flaps :
Choice of flap –depends on the size and location of the lesion.
 Adequate access
 Location of the lesion
 Sound bone around anticipated surgical margins
Osseous Window :
Size of window
• Size of lesion
• Proximity to vital structures
Removal of specimen:
• Detachment of lining from the bony cavity using curette or broad end of periosteal
elevator
• Hold the Cyst using non toothed forceps so as not to rupture the lining and
remove the cyst in toto
• In case the cyst has to be punctured for removal, it should be done ony after the
entire cyst is free from the bone
 Enucleation

Removal of maxillary cyst with labial access, with flap design

Reflection of flap and exposure of surgical field.

Removal of bone at the labial aspect respective to the lesion.

Osseous window created to expose part of the lesion.

Removal of cyst from bony cavity, using hemostat and curette.

Surgical field after removal of lesion.

Operation site after placement of sutures.

ENUCLEATION OF CYST
ENUCLEATION OF CYST
 Enucleation after Marsupialization

INDICATIONS
When bone has covered the adjacent vital structures.
When patients find it difficult to cleanse the cavity.
To detect any occult pathological condition.
ADVANTAGES DISADVANTAGES
• Spares adjacent vital • Patient has to undergo
structures second surgery and any
• Accelerates healing process possible complication
• Development of thick cystic associated with surgery.
lining – enucleation easier
• Allows histopathological
examination of residual
tissue.
• Combined approach
reduces morbidity
 Enucleation with Curettage
Indications :
OKC-Daughter, or satellite, cysts found/expected in the periphery of the
main cystic lesion
Recurrence after thorough removal

Advantages : Disadvantages :

• If enucleation leaves epithelial • Curettage is more destructive

remnants, curettage may
remove them, thereby
decreasing the likelihood of
recurrence.
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
 Enucleation and primary closure with reconstruction / bone
grafting

• Reconstruction with
stainless steel or titanium
reconstructive plates

• Autogenous bone grafts:

Iliac crest, costochondral
• Synthetic bone
hydroxyapatite crystals
• Plasma rich fibrin matrix
 Resection
• Marginal resection
– surgical removal of a lesion intact, with a rim of uninvolved bone,
maintaining the continuity of the bone
• Segmental resection
– surgical removal of a segment of the mandible or maxilla without
maintaining the continuity of the bone
Extreme techniques, that result in considerable morbidity
Reconstructive measures are necessary to restore jaw function
and aesthetics
• Blanas et al. (2000)- lowest recurrence rate (0%) but the
highest morbidity rate
 Other treatment modalities
• Cryotherapy

(A) A smaller lesion treated with liquid nitrogen by the technique of filling the
cavity with KY jelly and placing a liquid nitrogen probe in it and freezing the
whole cavity. (B) The cryoprobe has been removed, showing the frozen KY
jelly and surrounding bony walls of the cyst cavity. These frozen areas are
allowed to thaw naturally and slowly and then the freeze is repeated. This
technique can be used only for small lesions less than about 1.5 cm.
• Piezosurgery
• Laser assisted management
 REFERENCES
• Cysts of the Oral and Maxillofacial Regions; Mervyn Shear
• Textbook of Oral & Maxillofacial pathology; Neville,
Damm,Allen,Bouquet:2nd edition
• Textbook on differential diagnosis of oral & maxillofacial
lesions; Norman K. Wood, Paul W. Goaz: 5th edition
• Textbook of Oral pathology; Shafer’s: 5th edition
• Contemporary Oral and Maxillofacial Surgery 6th edition;
Hupp, Ellis & Tucker
• Clinics OMS 2013
• Text book of oral maxillofacial surgery, Neelima anil malik
Thank you!