CYSTS OF THE JAW Part 1

Cysts of JAWS

Prepared byDr. Abhishek PT

PG RESIDENT Dept OMFS

pathological cavity

often fluid filled lined by epithelium

in many instances, exact pathogenesis of these lesions is still uncertain

Cysts

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)

Definition

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.

Types Of Cysts

From odontogenic tissues

•Radicular /dental root apex type•Lateral type•Residual type•Primordial cyst•Dentigerous cyst

From non dental tissues

•Median cyst•Incisive canal cyst•Globulomaxillary cyst

CLASSIFICATION BY ROBINSON(1945)

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

CLASSIFICATION BY WHO(1995)

OTHER CYST OF ORAL REGION NOT ELSEWHERE

CLASSIFIED

•DERMOID CYST•EPIDERMOID CYST•GINGGIVAL CYST OF NEW BORN•PALATAL CYST OF NEW BORN

CLASSIFICATION BY SHEAR

1 Developmental Origin (a) Odontogenic

i. Gingival cyst of infantsii. Odontogenic keratocystiii. Dentigerous cystiv. Eruption cystv. Gingival cyst of adultsvi. Developmental lateral periodontal

cystvii. Botryoid odontogenic cystviii. Glandular odontogenic cystix. Calcifying odontogenic cyst

b) Non-odontogenic

i. Midpalatal raphé cyst of infantsii. Nasopalatine duct cystiii. Nasolabial cyst

I. Cysts of the jaws

A. EPITHELIAL-LINED CYSTS

2 INFLAMMATORY ORIGINi. Radicular cyst, apical and lateralii. Residual cystiii. Paradental cyst and juvenile paradental cystiv. Inflammatory collateral cyst

B. NON-EPITHELIAL-LINED CYSTS1. Solitary bone cyst2. Aneurysmal bone cyst

I. Cysts of the jaws

1. Dermoid and epidermoid cysts2. Lymphoepithelial (branchial) cyst3. Thyroglossal duct cyst4. Anterior median lingual cyst (intralingual cyst of foregut origin)5. Oral cysts with gastric or intestinal epithelium (oral alimentary tract cyst)6. Cystic hygroma7. Nasopharyngeal cyst8. Thymic cyst9. Cysts of the salivary glands: mucous extravasation cyst; mucous retention cyst;

ranula; polycystic (dysgenetic) disease of the parotid10. Parasitic cysts: hydatid cyst; Cysticercus cellulosae; trichinosis

III. Cysts of the soft tissues of the mouth, face and neck

TWO STAGES

1. Cyst initiation2. Cyst enlargement or

expansion

PATHOGENESIS

a. Initiation b. Formationc. Enlargement

• 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.

CYST INITIATION

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

CYST ENLARGEMENT

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

EPITHELIAL PROLIFERATION

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.

Mechanism regarding enlargement

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 cofactorsb. Lymphocytes release lymphokinec. 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

Increase in the volume

• 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.

Raised internal hydrostatic pressure

• 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.

Attraction of fluid into the cavity

• 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.

Retention of fluid within the cavity

• 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.

BONE RESORPTION

(SHEAR 2006)

Frequency Of Epithelial Cysts Of Oral Region

52.30%

18.10%

11.60%

8%

5.60%

4.20%SHEAR 2006 Radicular cyst

Dentigerous cyst

Odontogenic keratocyst

Residual cyst

Paradental cyst

Unclassified odontogenic cysts

Criteria For Diagnosis Based On Clinical Features Based On Anatomical Site Of Jaw Based On Histological Features Based On Aspirate Fluid Based On Radiographic Features

Based On Clinical Features 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

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

DIAGNOSTIC FEATURES

SYMPTOMS 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

PRIMARY1) Bone expansion2) Enlargement3) Consistency4)Window formation5)fluctuation6)sinus formation with dischaarge6 )large cyst distortion of adjacent structures7)Effect on teeth

SIGNS OF CYST

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

CLINICAL EXAMINATION

1 Numbness2 Pathological fracture of jaw3 Secondary infection4 Malignant transformation

Effects of the jaws (secondary)

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.

Radiographs

PA VIEW : Shows expansion of the ramus of mandible

ASPIRATION

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 -----

Various Aspirates

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 ----

BLOOD ON ASPIRATION penetration to blood vessels Vascular lesions ABCAIR ON ASPIRTIONMaxillary sinus Traumatic bone cystNEGATIVE ASPIRATION :SOLID TUMOR

ASPIRATION

Contrast study for the cyst in maxillary sinus

Ultrasonic Diagnosis

Other diagnostic features

TREATMENT

Cysts of the jaws are treated in one of the following methods

(1) Marsupialization(2) Enucleation

1. Marsupialization (decompression)

• 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.

Indication

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.

Marsupiaiization

Advantages :

1)It is a simple procedure to perform. 2)Marsupiaiization also spare vitalstructures from damage3)Allows erruption of cyst4)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

Technique of Marsupiaiization

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

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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.

Continue…

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.

3. WALDRON’S METHOD (PARTSCH II)

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.

ADVANTAGES 1)Protection of anatomic structures 2)Cystic cavity becomes lined with respiratory

maxillary sinus or nasal cavity 3)Primary closure of oral wound4)Reducing intra cystic pressureDISADVANTAGES Development of an oroantral or oronasal fistula,If there is a breakdown of the wound.

Marsupilialization by opening into nose or antrum

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

Surgical technique

- 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

Enucleation 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

Enucleation

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.•

Enucleation

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

Reflection of flap is done with periosteal elevator /howarth beginning from under the periosteum of anterior buccal incision

Enucleation

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

Enucleation

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.

ENUCLEATION OF CYST

Surgical removal the of the cyst

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

Modifictions

Enucleation with Curettage

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

Only when there is large odontogenic keratocyst with massive bone destruction,segmental resection is unavoidable.

Also when there is neoplastic transformation of the cyst

Segmental resection

-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 layerwiseCare is taken to salvage the marginal mandibular nerve

m

Pterygomassetric sling is devided Periosteum is incised down Flap raised superiorly Window created by guttering with bone burs or with chiesel and mallet

Fracture Post operrative

wound dehiscence Loss of vitality of

teeth Dysplastic

neoplastic r malignant changes

Complications of cystic lesion

http://en.wikipedia.org/wiki/Cysts_of_the_jawshttp://www.gorlingroup.org/jupgrade/index.php/about-gorlin-syndrome/11-jaw-cystshttp://www.slideshare.net/makkahguys/jaw-bone-chttp://www.slideshare.net/JanmiPascual/cysts-of-oral-region-5?related=1ysthttps://www.bestdentistguide.com/oral-cysts

References: Books