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Seminar on cyst
- 1. SEMINAR ON CYSTS OF ORAL AND MAXILLOFACIAL REGION CHIEF GUEST PROFESSOR Dr. ISMAT ARA HAIDER HEAD OF DEPARTMENT, OMS DHAKA DENTAL COLLEGE AND HOSPITAL PRESENTED BY • Dr. NUSRAT FAHMIDA TRISHA
- 2. • DEFINITION AND PARTS • CAUSES • CLASSIFICATION • PATHOPHYSIOLOGY • FREQUENCY • DIAGRAMATIC DESCRIPTION OF DIFFERENT CYSTIC LESIONS OF OROFACIAL REGION • PRINCIPLE OF MANAGEMENT • OPERATIVE PROCEDURES • COMPLICATIONS • FOLLOW-UP PROTOCOL OVERVIEW
- 3. CYST Definition : A cyst is a pathological cavity or sac within the hard or soft tissues that may contain fluid, semifluid or gas & may always lined by epithelium.
- 4. Parts of cyst: • There are three main parts of cyst: • Wall that is made of connective tissue • Epithelial lining • Lumen of the cyst.
- 5. Causes of cyst: Common causes of cyst includes • Tumors • Genetic conditions • Infections • A fault in an organ of a developing embryo. • A defect in the cells. • Chronic inflammatory conditions. • Blockages of ducts in the body that causes a fluid build up. • Impact injury that breaks a vessel.
- 6. TYPES: • True cyst: These are the cysts that are lined by epithelium e.g Dentigerous cyst, Radicular cyst. • Pseudo cyst : These are the cysts that are not lined by epithelium. E.g Solitary bone cyst,Aneurismal bone cyst.
- 7. CYSTS OF THE JAWS,ORAL AND FACIAL SOFT TISSUES INTRAOSSEOUS CYSTS EPITHELIAL ODONTOGENIC CYSTS DEVELOPMENTAL INFLAMMATORY NONODONTOGENIC CYSTS(ISSURAL) NONEPITHELIAL CYSTS OF MAXILLARY ANTRUM SOFT TISSUE CYSTS
- 8. Intraosseous cyst: A. Epithelial cyst: • Odontogenic: 1.Developmental a . Primordial cyst b. Dentigerous cyst c. Lateral periodontal cyst d. Calcifying Odontogenic (Gorlin ) cyst 2. Inflammatory a. Radicular cyst b. Residual cyst • Non Odontogenic : 1. Fissural: a. Median mandibular cyst b. Median palatal cyst c. Globulomaxillary. 2. Incisive canal (nasopalatine duct or median anterior maxillary ) cyst B. Non epithelial cyst (Pseudo cyst ): 1. Solitary bone cyst 2. Aneurismal bone cyst • Cysts of the maxillary antrum: 1. Surgical ciliated cyst of maxilla 2. Benign mucosal cyst of the maxillary antrum
- 9. SOFT TISSUE CYSTS • Soft tissue cyst: 1. Odontogenic: • Gingival cyst a. Adult b. Newborn 2. Non Odontogenic • Anterior medien lingual cyst • Nasolabial cyst 3. Retention cyst: • Salivary gland cysts: a. Mucocele b. Renula 4. Developmental/congenital cyst: a. Dermoid and epidermoid cyst b. Lymphoepithelial cyst c. Thyroglossal duct cyst d. Cystic hygroma 5. Parasitic cyst: a. Hydatid cyst b. Cysticerosis 6. Heterotrophic cyst Oral cyst with gastric or intestinal epithelium.
- 10. Pathophysiology of cyst • Phases of cyst development :
- 11. Cyst initiation • Inflammatory cysts : Infection • Other cysts : 1. Dental lamina 2. Enamel organ 3. Reduced enamel epithelium 4. Cell rests of Malassez
- 12. Cyst formation • Proliferation of Epithelial Lining and fibrous Capsule • Insufficient diffusion of oxygen and nutrients • Death of central cells or disquamation of the central cells. • Formation of a small cystic cavity
- 13. Cyst enlargement • Attraction of fluid into tthe cyst cavity • Retention of the fluid within the cavity • Production of raised internal hydrostatic pressure • Resorption of the surrounding bone with an increase in the size of the cavity
- 14. 15% 55% 20% 10% Frequency of Cystic Lesions Tx in MOT of DDCH Dentigerous Cyst Radicular Cyst Mucocele Other Cystic Lesion FROM AUGUST ’16 TO JANUARY ‘17
- 16. PRIMORDIAL CYST INCIDENCE SITE CLINICAL FEATURES RADIOLOGY PATHOL0GY TREATMENT • OCCUR MAINLY IN 2ND,3RD OR 4TH DECADE • SLIGHTLY MALE PRDILECTION MORE COMMON IN ANGLE OF MANDIBLE,EXTEN DING INTO RAMUS OR BODY OF MANDIBLE • ASSYMPTOMATIC UNTIL LARGE SIZE • USUALLY BUCCAL EXPANSION • SINGLE MISSING TOOTH DISPLACEMENT OF TOOTH,DULL OR HOLLOW PERCUSSION SOUND OF OVERLYING TEETH ADJOINING TEETH ARE VITAL • LARGE CYST INVARIABLY DIFLECT THE NEUROVASVULAR BUNDLE INTO ABNORMAL POSITION • LABIAL PARASTHESIA OR ANAESTHESIA IF INFECTED • UNILOCULAR • SOMETIMES SCALLOPED OUTLINE GIVINGA MULTILOCUL AR APPEARANC E • BORDERS ARE HYPEROSTOT IC • ADJACENT TEETH DISPLACED OF DIVEREGED • LIND BY KERATINIZD STRATIFIED SQUAMOUS EPITHELIUM • THIN CAPSULE • FRE OF INFLAMMATO RY CELL • ENUCLEATION • RESECTION OF INVOLVED BONE FOLLOWED BY RECONSTRUC TON
- 18. DENTIGEROUS CYST INCIDENCE SITE CLINICAL FEATURES RADIOLOGY PATHOL0GY ASPIRATI ON TREATMENT • 1ST , 2ND / 3RD DECADE • EQUAL OR MALE PREDILEC TION • MANDIBLE>MAX ILLA • LATE ERUPTING TETH ARE MOSTLY AFFECTED • LOWR 3RD MOLAR> UPPER CUSPID>UPPER 3RD MOLAR>LOWR BICUSPID • PAINLESS SLOW GROWING • INITIALLY SMOOTH,HARD SWELLING,WHEN IT ATTAN A LARGE SIZE,THE COVRING BONE BECOME THIN, EGG SHELL CRACKLING SOUND ON PALPATION • TEETH ABSENT FROM ARCH • PAIN PRESENT IF SECONDARY INFECTION OCCURS • FACIAL ASSYMETRY INCASE OF LARG SIZE • WELL DEFINED UNILOCULAR RADIOLUCENT AREA ASSOCIATED WITH CROWN OF UNERUPTD OR IMPACTED TEETH • MULTILOCULAR EFFECT CAN BE SEEN • WELL DEFINED SCLEROTC MARGIN • UNERUPTED TEETH CAN BE OUT OF DIRECTION OF ERUPTION 2-3 LAYERS OF NON KERATINIZED FLAT OR CUBOIDAL CELL STRAW COLOR FLUID CILDREN- MARSUPIALIZAT ION ADULT- ENUCLEATION
- 19. DENTGROUS CYST
- 20. LATERAL PERIODONTAL CYST INCIDENCE SITE CLINICAL FEATURES RADIOLOGY PATHOL0GY ASPIRATION TREATMENT FOUND IN ADULTS(20- 60YRS) NO SEX PREDILECTION MANDIBULAR CUSPID OR BCUSPID OR 3RD MOLAR AREA ARE FREQUENT SITE FOLLOWED BY ANTERIOR MAXILLA • FOUND IN ROUTINE Rx • BUCCALY OR LINGUALLY GINGIVAL SWELLING PRESENT • LINGUAL TYPE OF CYST INVOLVING LOWR 3RD MOLAR IS MORE COMMON AND CAUSE SUBMANDIB ULAR SPACE INFECTION • WELL DIFINED ROUND OR OVOID RADIOLUCEN T AREA OF LESS THAN 1cm WITH SCLEROTIC MARGIN • LAMINA DURA IS DESTROYED • LINED BY WELL FORMD NON- KERATINZED STRATIFIED SQUAMOUS EPITHELIUM • INFIAMMATO RY CELL PRESENT IN CT SEROUS, CASEOUS CONTENT ENUCLEATION
- 22. CALCIFYING ODONTOGENIC CYST INCIDENCE SITE CLINICAL FEATURES RADIOLOGY PATHOL0GY TREATMENT -MORE COMMON IN CHILDREN AND YOUND ADULT -NO SEX PREDILECTION COMMON IN BOTH JAW BUT MOST COMMON IN ANT MANDIBLE • ASYMPTOMATIC • MOST FRQUENT SYMPTOM IS SWELLING • LATER- HARD BONY EXPANSION • SAUCER SHAPED DEPRESSION,IF CYST IS CLOSED TO PERIOSTEUM • OCCASIONALLY DISPLACEMENT OF TOOTH • WELL DEMARCATED OR IRREGULAR PERIPHERY • BOTH UNILOCULAR/MULTIL OCULAR • COTICAL PERFORATION PRESENT • IRREGULAR RADIOPAQUE SPECKS MAY BE SEEN • MAY BE ASSOCIATED WITH COMPLEX ODONTOMA OR UNERUPTED TOOTH LINED BY STRATIFIED SQUAMOUS EPITHELIUM AND HAS COLUMNER OR CUBOIDAL BASAL LAYR OF CELLS -ENUCLEATION -WIDE EXCISION,IF ASSOCIATED WTH ANOTHER ODONTOGENI C TUMOR
- 25. RADICULAR CYST INCIDENC E SITE CLINICAL FEATURES RADIOLOGY PATHOL0GY ASPIRATION TREATMENT -3RD &4TH DECADE -MALE PRDILECT ION • ANT. MAXILLA> MANDIBL E • IN MANDIBL E,MOST COMMON LY POSTERIO R TOOTH • SYMPTOMLESS • SLOW GROWING • INITIALLY BONY HARD, AS IT ENLARGES COVERING BECOMES THIN AND FLUCTUATION POSITIVE • BUCCAL AND PALATAL EXPANSION OR ONLY PALATAL INCASE OF MAXILLA.LABIAL EXPANSON IN CASE OF MANDIBLE • MUCOSA IS NORMAL AT FIRSTAS IT ENLARGES PROFOUND DARK BLUISH TINGE PRESENT • IF INFECTED,INTRAORAL SINUS TRACT WITH DISCHARGING PUS PRESENT • INVOLVED TOOTH MAY BE NON VITAL OR DISCOLORED • ROUND,PE AR OR OVOID SHAPED RADIOLUC ENCY OUTLINE BY NARROW RADIOPAQ UE MARGIN • LINED BY NON- KERATINIZE D STRATIFIED SQUAMOU S EPITHELIU M • INFLAMMA TORY CELL PRESENT • UN- INFCTED: STRAW COLOR • LONG STANDING INFECTION: DIRTY WHITE OR CASEOUS MATERIAL OR PUS • ENUCLEATI ON OR MRSUPILIZ ATION • EXTRACTIO N OR RESTORATI ON IN CASE OF NON VITAL TOOTH • EXCISION IN CASE OF EXTERNAL SINUS TRACT
- 27. RESIDUAL CYST INCIDENCE SITE CLINICAL FEATURES ASPIRATION TREATMENT • MIDDLE AGE OR ELDERLY PATIENT • NO SEX PREDILECTION • COMMON IN MAXILLA,MAINL Y EDENTULOUS SITE • ASSYMPTOMATI C • PATHOLOGICAL FRACTURE OR SIGNS OF ENCROACHMNT IN CASE OF LARGE CYST • STRAW FLUID • SAME AS RADICULAR
- 30. DVELOPMENTAL FISSURAL CYSTS: • DEVELOPMENTAL FISSURAL CYSTS THEY ARE CLASSIFIED INTO 3 TYPES- • 1.MEDIAN MANDIBULAR CYST • 2.MEDIAN PALATAL CYST • 3.GLOBULOMAXILLARY CYST #THIS TYPE OF CYST ARE NONODONTOGENIC, THAT ARISE OWNING TO EPITHELIAL INCLUSIONS OR ENTRAPMENTS IN THE LINES OF CLOSURE OF THE DEVELOPING FACIAL PROCESS DURING THE EMBRYONIC PERIOD OF LIFE.
- 31. INCIDENCE SITE CLINICAL FEATURES RADIOLOGY PATHOLOGY TREATMENT NO AGE , SEX PRDILECTION FOUND SYMMETRICALLY IN THE MIDLINE OF MANDIBLE • SMALL IN SIZE,APRX 1- 3cm IN SIZE • ASSOCIATED WITH VITAL TOOTH • LABIAL SWLLING MAY BE PALPABLE • THE TEETH MAY BE DIVERGENT • SMALL GENERALY WELL DEFINED CIRCULAR OR OVOID IIN SHAPE • LAMINA DURA OF THE INVOLVED TEETH IS INTACT • CYST IS LINE BY STRATIFIED SQUAMOUS EPTHELIUM • THE FIBROUS CONNECTIVE TISSUE WALL MAY REVEAL AN INFLAMMATOR Y INFILTRATE. • THE CYST SHOULD BE CAEFULLY ENUCLEATD WITHOUT THE INVOLVEMENT OR DAMAGE TO THE APICES OF THE INCISORS. MEDIAN MANDIBULAR CYST
- 33. MEDIAN PALATAL CYST INCIDENCE SITE CLINICAL FEATURES RADIOLOGY PATHOLOGY TREATMENT NO SEX PREDILECTION,SEE N MAINLY N ADULTS • MAXILLARY ALVEOLUS • HARD PALATE B/W THE INCISIVE FOSSA AND POSTERIOR BORDER OF HARD PALATE • NO SIGNS AND SYMPTOMS EXISTS UNLSS THE CYST BECOME LARGE WITH THE EXPANSION OF BONE • A PALPABLE OVOID SWELLING PRESENT IN THE MID PALATINE REGION OR MID ALVEOLAR REGION • A MAXILLARY OCCUSAL VIEW WILL HELP TO IDENTIFY THE OVOID OR IRREGULAR RADIOLUCENCY IN THE MID PALATAL REGION, OFTEN IT IS DIFFICULT TO DISTINGUISH THE CYST FROM AN EXTENSIVE INCISIVE CANAL CYST • CYST IS LINED WITH STRATIFIED SQUAMOUS EPITHELIUM, PSEUDOSTRATIF IED CILLIATED COLUMNER OR CUBOIDAL EPITHELIUM. • CHRONIC INFLAMMATORY INFILTRATION MAY BE SEEN IN THE SUB- EPITHELIAL CONNECTIVE TISSUE • CAREFUL ENUCLEATION IS THE LINE OF TX WITH PRIMARY CLOSURE
- 35. GLOBULOMAXILLARY CYST INCIDENCE SITE CLINICAL FEATURES RADIOLOGY PATHOLOGY TREATMENT NO SEX PREDILICTI ON SEEN IN ADULTS • COMMONLY SEEN B/W MAXILLARY LATERAL INCISOR AND CUSPID TEETH • THE LATERAL AND MAXILLARY CUSPID TEETH WILL BE FOUND TO BE TILTED CORONALLY WITH ROOT DIVERGENCE. • VITALITY TEST WILL BE NORMAL FOR BOTH TEETH • IF THE CYST IS SMALL IT IS SPHERICAL IN SHAPE ,AS IT ENLARGES A TYPICAL PEAR SHAPED RADIOLUCENCY IS SEEN B/W THE MAXILLARY LATERAL INCISOR AND CUSPID WITH THE APEX POINTING TOWARD THE ALVEOLAR CREST. • THE LAMINA DURA OF BOTH TEETH IS PRESERVED • THE ROOTS REVEAL DIVERGENCE • THE EPITHELIAL LINING IS OF PSEUDOSTRATIFED COLUMNER CILIATED EPITHELIUM, OFTEN DERIVD FROM THE NASAL MUCOSA • THE WALL WHICH IS THICK,MAY HAVE CONC. OF PLASMA CELLS LYMPHOCYTES • CAREFULL ENUCLEATION WITHOUT DAMAGE TO THE ADJOINING ROOTS OF THE TEETH ,FOLLWED BY PRIMARY CLOSURE.
- 37. NASOPALATINE DUCT CYST INCIDENCE SITE CLINICAL FEATURES RADIOLOGY PATHOLOGY TREATMENT • IT HAS A SLIGHT PREDILEC TION FOR THE MALE SEX • SEEN IN ADULTHO OD IN THE 4TH,5TH AND 6TH DECADE • THE CYST MAY ARISE AT ANY POINT ALONG TH INCISIVE CANAL BUT IT IS SEEN MORE COMMONLY IN THE LOWR PORTION OF MAXILLA,B/W THE APICES OF THE CENTRAL INCISOR • ANOTHER VARIANT IS THE CYST OF PALATINE PAPILLA , WHICH IS LOCATED WITHIN SOFT TISSUE IN THE REGION OF INCISIVE PAPILLA, AT THE OPENING OF THE CANAL • ASSYMPTOMATIC AS THEY DON’T ATTAIN A VERY LARGE SIZE BEYOND 1.5- 2cm • NOTABLE COMMON SYMPTOM IS A RECURRENT SWELLING IN THE ANT. REGION OF THE MIDLINE OF THE PALATE, OR ON THE LABIAL ASPECT B/W THE CENTRAL INCISORS,AT THE TIMES THE CYST MAY EXTEND LABIOPALATALLY • FLUCTUATION POSITIVE • DISPLACEMENT OF TOOTH • THE PT COMPLAINS OF PAIN, SWELLING AND DISCHARGE WHICH DESCRIBED AS SALTY TASTE • BURNING SENSATION/NUMBNESS • WLL DEFINED CYSTIC OUTLINE PRESENTB/W OR ABOVE THE ROOTS OF MAXILLARY CENTRAL INCISORS • IT CAN BE ROUND,OVOID OR HEART SHAPED • THE ROOTS OF CENTRAL INCISOR MAY SHOW DIVERGENCE AND INTACT LAMINA DURA AROUND THE TOOTH APICES • THE TYPE OF EPITHELIUM FOUND MAY VARY AT DIFFERENT LEVELS. IT MAY BE STRATIFIED SQUAMOUS AT A LOWER LEVEL, MORE SUPERIORLY IT MAY BE PSEUDOSTRATIFIED COLUMNER OR CUBOIDAL AS WELL AS CILIATED. • MUCOUS GLAND, GOBLET CELL AND CILIA IS HIGHLY INDICATED • ASPIRATION: VISCOUS FLUID CONTENT MAY BE MUCOID MATERIAL/EVEN PUS, IF THE CYST HAS BEEN INFECTED • CAREFULL SURGICAL ENUCLEATI ON
- 40. THEY ARE USUALLY KNOWN AS CYST LIKE CONDITION WHICH INCLUDES- • SOLITARY BONE CYST • STAFNE’S IDOPATHIC BONE CAVTY • ANEURYSMAL BONE CYST
- 41. SOLITARY BONE CYST ETIOLOGY INCIDENCE SITE CLNICAL FEATURES RADIOLOGY PATHOLOGY TREATME NT • TRAUMA AND HEMORRHAGE • SPONTANEOU S ATROPHY IN A CENTRAL BENIGN GIANT CELL LESION • ABNORMAL CALCIUM METABOLSM • CHRONIC LOW GRADE INFECTION • NECROSIS OF FATTY MARROW SECONDARY TO ISHCHEMIA • ABERATION IN THE DEVELOPMEN T AND GROWTH • SEEN IN FIRST 2 DECADES OF LIFE(SIMP LE BONE CYST) • OLDER AGE GROUP(S OLITARY BONE CYST) SUBAPICAL REGION,ABOV E THE INFERIOR DENTAL CANAL IN THE CUSPID AND MOLAR REGION • SYMPTOMLESS • ASSOCIATED TEETH ARE VITAL • UNERRUPTD TEETH ARE USUALLY MOLARS MAY B PREVENTD FROM ERUPTION • UNILOCULAR CAVITY,LATER IT PRODUCES A SCALLOPED OUTLINE TO THE UPPER BORDER AROUND THE ROOTS • THE ROOTS MAY BE DISPLACED, LAMINA DURA IS INTACT, RESORPTION IS NOT SEEN • NO VISIBLE LINING, IN SOME CASES A THIN MEMBRANE GRANULATION TISSUE OR BLOOD CLOTS MAY BE EVIDENT • LOOSE VUSCULAR FIBROUS TISSUE MEMBRANE WITH HAEMOSIDRIN PIGMENT SEEN WITH MULTINUCLEATED CELL • ASPIRATION:- >A DEEP YELLOW COLORED FLUID PRESENT CONTAINS PLASMA PROTEIN >FOR SMALL CYST-HEAVILY BLOOD STAIND FLUID OR FRESH BLOOD OBTAINED GENTLE CURETTAG E
- 43. ANEURYSMAL BONE CYST ETIOLOGY INCIDENCE SITE CLNICAL FEATURES RADIOLOGY PATHOLOGY TREATMENT • H/O TRAUMA • POSSIBLE RELATIONS HIP WITH GIANT CELL LESION • VARIATION OF THE HEMODYN AMIC OF THE AREA • SUDDEN VENOUS OCCLUTIO N • NO SEX PREDILECT ION • SEEN MANLY IN CHILDREN, ADOLESCE NTS OR YOUNG ADULTS POSTERIOR MANDIBULAR REGION • FIRM SWELLING PRESNT • A H/O RAPID ENLARGE MENT • TEETH SHOW DSPLACEM ENT THOUGH THEY EMAIN VITAL • EGG SHELL CRACKLIN G • UNLOCULA R,OVAL OR SPHERICAL SHAPE RADIOLUC ENCY • SOMETIM ES MULTILOC ULAR OR HONEYCO MB OR SOAP BUBBLE APPEARAN CE ASPIRATION: DARK VENOUS BLOOD VARIOUS TX MODALITIES CAN BE DONE.
- 45. CYST OF MAXILLARY ANTRUM • SURGICAL CILIATED CYST OF THE MAXILLA • BENIGN MUCOSAL CYST OF THE MAXILLARY ANTRUM
- 48. SOFT TISSUE CYSTS • Soft tissue cyst: 1. Odontogenic: • Gingival cyst a. Adult b. Newborn 2. Non Odontogenic • Anterior medien lingual cyst • Nasolabial cyst 3. Retention cyst: • Salivary gland cysts: a. Mucocele b. Renula 4. Developmental/congenital cyst: a. Dermoid and epidermoid cyst b. Lymphoepithelial cyst c. Thyroglossal duct cyst d. Cystic hygroma 5. Parasitic cyst: a. Hydatid cyst b. Cysticerosis 6. Heterotrophic cyst Oral cyst with gastric or intestinal epithelium.
- 49. MUCOCELE ETIOLOGY INCIDENCE SITE CLINICAL FEATURES PATHOLOGY TREATMENT • OBSTRUCTION OF A SALIVARY DUCT • TRAUMA TO A SALIVARY DUCT WHICH IS EITHER PINCHED OR SEVERE • TRAUMA TO THE SECRETORY ACINI • CONGENITAL ATRESIA OF SUBMANDIBULAR DUCT ORIFICES • CYSTIC TYPE OF PAPILLARY CYSTADENOMA NO AGE AND SEX PREDILECTION • MOST COMMONLY SEEN IN LOWER LIP • SMALL IN SIZE,APRX 1- 2mm,BUT DO NOT EXCEED 1-2cm • FLUCTUATION TEST: POSITVE • COLOR: VARIABLE,MAY BE TRANSLUCENT OR BLUISH • MAY RUPTURE SPONTANEOUSLY WITH THELIBERATION OF A VISCOUS FLUID • MUCOUS EXTRAVASATION CYSTS DO NOT HAVE ANY EPITHELIAL LINNG • RETENTION CYSTS WILL BE PARTLY OR COMPLETELY LINED BY EPITHELIUM. • EXCISIONAL BIOPSY
- 50. RANULA ETIOLOGY SITE CLINICAL FEATURES TREATMENT • EXTRAVASATION OF MUCOUS DUE TO TRAUMA TO THE EXCRETRY DUCTS OF THE SUBLINGUAL SALIVARY GLAND • IN THE PLUNGING TYPE THIS EXTRAVASATED MUCOUS PASSES THROUGH THE MYLOHYOID MUSCLE AND COLLECTS IN THE SUBMANDIBULAR REGION • DILATED SUBMANDIBULAR DUCTS COULD BE A CAUSATIVE FACTOR,BCS OF ATRESIA OF SUBMANDIBULAR DUCT ORIFICES FLOOR OF THE MOUTH BENEATH THE TONGUE • SHAPE: DOME SHAPED UNILATERAL • SIZE: 2/3cm IN DIAMETER • COLOR: BLUISH IN COLOR • SOFT FLUCTUANT • TYPICALLY PANLESS,BUT MAY INTERFERE WITH SPEECH OR MASTICATION • TONGUE MAY BE RAISED OR DISPLACED AS IT ENLARGES • MAY CROSS THE MIDLINE • AT TIMS,IF THE SWELLING IS PUNCTURED OR TRAUMATISD A MUCOUS SECRETION IS EVIDENT • SURGICAL EXCISION • MARSUPIALIZATION, RESUTS IN RECURRENCE.
- 51. MUCOCELE & RANULA FIG: MUCOCELE FIG: RANULA
- 54. DIAGNOSTIC TOOLS • HISTORY • CLINICAL EXAMINATION • RADIOGRAPHIC EXAMINATION: 1. PERIAPICAL RX 2. OCCLUSAL VIEW OF TH MAXILLA AND MANDIBLE 3. EXTRA-ORAL RADIOGRAPH: OBLIQUE LATERAL VIEW, OPG, PA MANDIBLE VIEW. • CT SCAN • RADIOPAQUE DYES • ASPIRATION • BIOPSY
- 55. DIAGNOSTIC KEY-POINTS( CLINICALLY) • ABSENCE OF TOOTH FROM ITS PLACE IN THE ARCH, ASSOCIATED WITH IMPACTED THIRD MOLARS ,CANINES AND PREMOLARS – DENTIGEROUS CYST • PRESENCE OF A CARIOUS DISCOLORED, FRACTURED OR HEAVILY FILLED TOOTH – APICAL PERIODONTAL CYST • DURING EXTRACTION OF A TOOTH IF CYSTIC FLUID ESCAPE FROM THE SOCKET- RADICULAR CYST • PAINFUL SWELLING WITH/WITHOUT DISCHARGING SINUS, NEUROPREXIA – INFECTED CYST • DULL OR HOLLOW PERCUSSION SOUND- SOLITARY BONE CYST • EXPANSION OF THE LINGUAL ASPECT ALONE IN RAMUS OR 3RD MOLAR REGION – ODONTOGENIC CYST • EXPANSION OF BOTH CORTICAL PLATES- INDICATES LESION OTHER THAN A CYST
- 56. RADIOGRAPHIC EXAMINATION: RADIOGRAPH INDICATION PERIAPICAL RX SMALL CYSTIC LESION OCCLUSAL VIEW OF MAXILLA PALATAL BONE DESTRUCTION OCCLUSAL VIEW OF MANDIBLE EXPANSION OF THE CORTICAL PLATES EXTRA-ORAL RADIOGRAPH FULL EXTENSION OF CYSTIC LESION OBLIQUE LATERAL VIEW, OPG, PA MANDIBLE VIEW. REVEAL BOTH LATERAL AND MEDIAL EXPANSION OF THE RAMUS DX INDICATION CT SCAN ASSESMENT OF LARGE CYSTIC LSION AND MULTICYSTIC LESION RADIOPAQUE DYE WHEN THE SIZE AND RELATION OF THE CYST IS IN DOUBT ASPIRATION HELPS IN ASSESMENT OF DIFFERENT TYPE OF CYST BIOPSY TO DETECT ANY METAPLASTIC CHANGE, NATURE OF THE CYST
- 57. VITALITY OF TEETH NAME OF THE CYST VITALITY OF TOOTH TEETH ADJOINING PRIMOIDAL CYST,FISSURAL CYST,SOLITARY BONE CYST,LATERAL PERIODONTAL CYST AND OTHER NON-ODONTOGENIC CYST OFFENDING TOOTH VITAL APICAL PERIODONTAL CYST OFFENDING TOOTH NON-VITAL INFECTED CYST TEMPORARY ABSENCE OF A VITAL RESPONSE IN ADJACENT TEETH
- 60. BIOPSY • PREFERRED METHOD: 1. INCISIONAL BIOPSY- LARGE CYSTIC LESION 2. EXCISIONAL BIOPSY- SMALL CYSTIC LESION, eg; MUCOCELE 3. FNAC
- 61. ASSESMENTS DONE BEFORE BIOPSY : • ESTIMATION OF THE SIZE OF THE CYSTIC LESION • EXTENT OF BONE LOSS • SHOULD THERE BE RISK OF PATHOLOGICAL FRACTURE • RELATIONSHIP OF THE CYST TO ADJACENT STRUCTURES • VITAL TEETH SHOULD BE PRESERVED • NON-VITAL TEETH SHOULD BE TREATED EITHER BY ROOT CANAL FILLING & APICOECTOMY Or EXTRACTION • IF BONE LOSS IS GOING TO B EXTENSIVE AS IN SURGICAL EXCISION, THEN CONSENT & PREPARATION FOR REHABILITATION METHODS SHOULD BE PLANNED • ACUTELY INFECTED CYSTS SHOULD BE TREATED WITH ANTIBACTERIAL DRUGS OR EVEN DRAINAGE PRIOR TO SURGERY SHOULD BE CONSIDERED • IN CASE OF MULTICYSTIC LESIONS,EFFORTS SHOULD BE MADE TO IDENTIFY A POSSIBLE SYNDROME • POSTOPERATIVE MONITORING OF TEETH BY VITALITY TESTS SHOULD BE DONE
- 63. OPERATIVE PROCDURES • CYSTS OF THE JAWS MAY BE TREATED BY ONE OF THE FOLLOWING METHODS: 1. MARSUPIALIZATION ( DECOMPRSSION) - PARTSCH I - PARTSCH II - MARSUPIALIZATIOB BY OPNING INTO NOSE OR ANTRUM 2. ENUCLEATION -ENCLEATION AND PACKING -ENUCLEATION AND PRIMARY CLOSURE -ENUCLATION OR PRIMARY CLOSURE WITH RECONSTRUCTION/BONE GRAFTING
- 64. PARTSCH I OPERATION ALSO KNOWN AS CYSTOTOMY OR DECOMPRSSION • PRINCIPLE: THIS PROCEDURE RFERS TO CREATING A SURGICAL WINDOW IN THE WALL OF THE CYST, AND EVALUATION OF THE CONTENT, AND MAINTAINING CONTINUITY BETWEEN THE CYST ABD THE ORAL CAVITY,MAXILLARY SINUS OR NASAL CAVITY. >THIS PROCESS DECREASE INTRA-CYSTIC PRESSURE PROMOTES SHRINKAGE OF THE CYST AND BONE FILL THE REMAINING CYSTING LINING LEFT IN SITU CAN BE USED AS A SOLE THERAPY OR AS A PRELIMINARY STEP IN MX, WITH ENUCLEATION DEFERRED UNTIL LATER.
- 65. INDICATION AGE OF THE PATIENT AMOUNT OF TISSUE INJURY AND PROXIMITY TO VITAL STRUCTURE SURGICAL ACCESS ASSISTANCE IN ERUPTION IF TEETH EXTENT OF SURGERY SIZE OF CYST VITALITY OF TEETH
- 66. ADVANTAGES • SIMPLE PROCEDURE TO PERFORM • SPARES VITAL STRCTURES • ALLOWS ERUPTION OF TEETH • PREVENTS ORONASAL, OROANTRAL FISTULA • PRVENTS PATHOLOGICAL FRACTURE • REDUCES OPERATING TIME • REDUCES BLOOD LOSS • HELP SHRINKAGE OF CYSTIC LINING • ALLOWS FOR ENDOSTEAL BONE FORMATION TO TAKE PLACE • ALVOLAR RIDGE IS PRESERVED
- 67. DISADVANTAGES • PATHOLOGICAL TISSUES LEFT IN SITU • HISTOLOGICAL EXAMINATION OF THE ENTIRE CYSTIC LINING IS NOT DONE • PROLONGD HEALING TIME • INCONVENIENCE TO THE PATIENT • PROLONGED FOLLOW UP VISITS • PERIODIC IRRIGATION OF THE CAVITY • REGULAR ADJUSTMENT OF PLUG • PERIODIC CHANGING OF PACK • SECONDARY SURGERY MAY BE NEEDED • FORMATION OF SLIT LIKE POCKETS THAT MAY HABOR FOOD STUFFS • RISK OF INVAGINATION AND NEW CYST FORMATION
- 68. SURGICAL TECHNQUE • 1.ANAESTHESIA • 2.ASPIRATION • 3.INCISION: CIRCULAR, OVAL OR ELIPTICAL. INVERTED U SHAPD INCISION WITH BROAD BASE TO THE BUCCAL SULCUS. MUCOPERIOSTEUM IS REFLECTED IN THIS CASE. • 4.REMOVAL OF BONE • 5.REMOVAL OF CYSTIC LINING SPECIMEN • 6.VISUAL EXAMINATION OF RSIDUAL CYST • 7.IRRIGATION OF THE CYSTIC CAVITY • 8. SUTURING: CYSTIC LINING SUTURED WITH THE EDGE OF ORAL MUCOSA. IN U SHAPED FLAP, THE MUCOPERIOSTEUM FLAP CAN BE TURNED INTO CYSTIC CAVITY COVERING THE MARGN. THE REMAINING IS SUTURED TO ORAL MUCOSA.
- 69. • 9. PACKING: PREVENTS FOOD CONTAMINATION AND COVERS WOUND MARGINS. DONE WITH RIBBON GAUGE SIAKED WITH WHITE VARNISH. COMPOSITION: BENZOIN-10mg IODFORM-10 mg STORAX-7.5g BALSAM OF TOLU- 5g SOLVENT ETHER -100ml >PACK IS GENERALLY SUTURED AND LEFT INSIDE FOR 7-14 DAYS 10. MAINTENANCE OF THE CYSTIC CAVITY:INSTRUCT THE PT TO CLEAN AND IRRIGATE THE CAVITY REGULARLY WITH ANTISEPTIC RINSE WITH A DISPOSABLE SYRINGE.
- 70. 11. USE OF PLUG: -PREVENTS CONTAMINATION &PRESERVES PATENCY OF CYSTIC ORIFICE -PLUG SHOULD BE STABLE, RETENTIVE AND SAFE DESIGN. -SHOULD BE MADE OF RESILIENT MATERIAL LIKE ACRYLIC TO AVOID IRRITATION. 12. HEALING: CAVITY MAY OR MAY NOT BE OBLITERED TOTALLY. DEPRESSION REMAIN IN THE ALVEOLAR PROCESS.
- 71. ENUCLEATION AFTER MARSUPIALIZATION INDICATIONS: • WHEN BONE HAS COVERED TH ADJACENT VITAL STRUCTURES • ADEQUATE BONE FILL HAS STRENGTHENED THE JAW TO PREVENT FRACTURE DURING ENUCLEATION • PATIENT FINDS IT DIFFICULT TO CLEANSE THE CAVITY • TO DETECT ANY OCCULT PATHOLOGICAL CONDITION ADVANTAGES: • SPARES ADJACENT VITAL STRUCTURES • ACCELERATES HEALING PROCESS • DEVELOPMNT OF THICK CYSTIC LINING-ENUCLEATION EASIER • ALLOWS HISTOPATHOLOGCAL EXAMINATON OF RSIDUAL TISSUE • COMBINED APPROACH REDUCE MORBIDITY DISADVANTAGES: • PATIENT HAS TO UNDERGO SECOND SURGERY AND THE POSSIBLE COMPLICATIONS THAT ARE INVOLVED WITH SURGERY
- 73. MARSUPIALIZATION BY OPENING INTO NOSE OR ANTRUM CYSTS THAT HAVE DESTROYED A LARGE PORTION OF THE MAXILLA AND HAVE ENCROACHED ON THE ANTRUM OR NASAL CAVTY, THEN TH CYST IS APPROACHED FROM THE BUCCAL ASPECT OF THE ALVEOLAR REGION. ADVANTAGES: • PRIMARY CLOSURE OF THE ORAL WOUND • CYSTIC CAVITY IS OPENED INTO THE MAXILLARY SINUS IR NASAL CAVITY, THEREBY REDUCING INTRACYSTIC PRSSURE • CYSTIC CAVITY BECOMES LINED WITH RESPIRATORY MAXILLARY SINUS OR NASAL CAVITY • ADJACENT STRUCTURES ARE PROTECTED • RESTORATION OF THE NORMAL ANATOMY OF THE ANTRAL SPACE AND NOSE DISADVANTAGS: • DEVELOPMNT IF AN OROANTRAL OR ORONASAL FISTULA, IF THERE IS A BREAKDOWN OF THE WOUND
- 74. SURGICAL TECHNIQUE 1. INCISION: CURVILINEAR INCISION ALONG THE INVOLVED TEETH AND THEN RELEASING INCISION 2. OFFENDING TOOTH: IT IS EITHER ENDODONTICALLY TREATED OR EXTRACTED 3. MUCOPERIOSTEAL FLAP: RAISED WITH HOWARTH’S PERIOSTEAL ELEVATOR. 4. REMOVAL OF BONE 5. REMOVAL OF CYSTIC LINING 6. REMOVING THE ANTRAL LINNG B/W TWO CAVITIES 7. ADDITIONALLY, INTRANASAL ANTROSTOMY 8. PACKING 9. REPLACE THE FLAP
- 75. ENUCLEATION ENUCLEATION IS THE PROCESS BY WHICH THE TOTAL REMOVAL OF A CYSTIC LESION IF ACHIEVED. BY DEFINITION, IT MEANS SHELLING OUT OF THE ENTIR CYSTIC LESION WHITHOUT RUPTURE. ENUCLEATION ALLOWS FOR THE CYSTC CAVITY TO BE COVERED BY MUCOPERIOSTEAL FLAP AND THE SPACE FILLS WITH BLOOD CLOT, WHICH WILL EVENTUALLY ORGANIIZE AND FORM NORMAL BONE.
- 76. INDICATIONS: • TX OF ODONTOGENIC PRIMORDIAL CYST • TX OF OKC • RECURRENCE OF CYSTIC LESIONS OF ANY CYST TYPE ADVANTAGES: • PRIMARY CLOSURE OF WOUNDS • RAPD HEALING • POSTOPERATIVE CARE IS REDUCED • THOROUGH EXAMINATION OF ENTIRE CYSTIC LINNG CAN B DONE. DISADVANTAGS: • NORMAL TISSUE MAY BE JEOPARDIZED • FRACTURE OF THE JAW • DAMAGE TO ADJACENT VITAL STRUCTURE • IN YOUNG PT, UNERUPTED TEETH IN DENTIGEROUS CYST WILL BE REMOVED • PULPAL NECROSIS • DEVITALIZATION OF ASSOCIATED TEETH
- 77. TECHNIQUE • ASPIRATION BIOPSY OF THE RADIOLUCENT LESION • MUCOPERIOSTEAL FLAP • OSSEOUS WINDOW • REMOVAL OF SPECIMEN
- 78. MUCOPERIOSTEAL FLAP • SEVERAL VARIETIES OF MUCOPERIOSTEAL FLAPS ARE AVAILABLE, THE CHOICE DEPENDS CHIEFLY ON THE SIZE AND LOCATION OF THE LESION. • ACCESS MAY NECESSITATE EXTENTION OF THE FLAP. THE LOCATION OF THE LESION DICTATES WHERE THE FLAP INCISION ARE TO BE MADE. • THE FLAP DESIGN SHOULD PROVIDE 4 TO 5 MM OF SOUND BONE AROUND THE ANTICIPATED SURGICAL MARGINS. • MUCOPERIOSTEAL FLAP FR BIPSIES SHOULD BE OF FULL THCKNESS AND INCISD THROUGH MUCOSA, SUBMUCOSA AND PERIOSTEM.
- 79. TYPE OF FLAPS: • TRAPEZOIDAL FLAP • TRIANGULAR FLAP • ENVELOPE FLAP • SEMILUNAR FLAP • OTHERS..
- 80. TRIANGULAR FLAP
- 81. TRAPEZOIDAL FLAP
- 82. ENVELOPE FLAP
- 83. SEMILUNAR FLAP
- 84. Y-SHAPED AND X-SHAPED FLAP
- 85. ENUCLEATION WITH PRIMARY CLOSURE ENUCLEATION OF SMALL CYSTIC LESION FROM AN INTRAORAL APPROACH: 1. ANAESTHESIA 2. INCISION- TRAPEZOIDAL , ENVELOP FLAP 3. ELEVATION OF THE MUCOPERIOSTEAL FLAP 4. BONE REMOVAL 5. EXPOSURE OF CYSTIC LINING- TRY TO REMOVE ENTIRE CYST LINING IN A SINGLE PIECE 6. IRRIGATION OF THE CAVTY AND HEMOSTASIS ENSURED 7. SUTURING
- 87. ENUCLEATION OF LARGE, INACCESIBLE MANDIBULAR LESIONS FROM AN EXTRAORAL APPROACH:
- 88. PROCEDURE 1. ANAESTHESIA: GENERAL ANAESTHESIA 2. INCISION: • A SUBMANDIBULAR INCISION, WHICH MAY AT TIMS BE REQUIRED TO EXTEND INTO POST RAMAL REGION,IS TAKEN 1.5-2 CM BELOW THE INFERIOR BORDER OF MANDIBLE. • INCISION EXTENDS THROUGH SKIN AND SUBCUTANEOUS TISSUE , BLUNT AND SHARP DISSECTION CARRIED OUT LAYERWISED THROUGH TISSUE PLANES e.g; SUPERFICIAL CERVICAL FASCIA, PLATYSMA AND DEEP CERVICAL FASCIA. CARE IS TAKEN TO SALVAGE THE MARGINAL MANDIBULAR NERVE,FACIAL ARTERY AND VEIN ARE CLAMPED AND LIGATED. 3. SMALL BLEDERS CAUTRIZED WITH DIATHERMY. 4. TH PTERYGOMESSENTARY SLING IS DIVIDED, PERIOSTEUM IS NCISED DOWN TO BONE AND THE FLAP IS RAISED SUPERIORLY TO EXPOSE THE UNDERLYING BONE. 5. COMMONLY A BONY WINDOW ALREADY EXISTS, WHICH IS THEN ENLARGED.IF NOT, A SUITABLY SIZED WINDOW IS CREATED. 6. DEPENDING UPON THE EXTENT OF TH CYSTIC LESION AND INVOLVEMENT OF SURROUNDING TISSUES, THE SURGICAL PROCEDURE OF ENUCLEATION OR MARGINAL EXCISION IS PERFOMED
- 89. ENUCLEATION WITH RECONSTRUCTION/BONE GRAFTING • RECONSTRUCT PRIMARILY WITH A STAINLS TEEL R TITANIUM RECNSTRUCTIVE PLATES CAN BE DONE IN CASE F LARGE BONY DEFECTS. • BONE GRAFTING WITH AUTOGENOUS CANCELLOUS BONE( ILIAC CRST OR COSTOCHONDRAL GRAFT) GRAFTS. • WATER TIGHT CLOSURE BOTH EXTRA INTRA AND EXTRA ORALLY • INTERMAXILLARY LIGATION DURING THE HEALNG PHASE FOR 4 TO 6 WEEKS, FOR IMMOBILIZATION.
- 90. ENUCLEATION WITH BONE CURETTAGE • AFTER ENUCLEATION A CURETTE OR BUR IS USED TO REMOVE 1 TO 2 MM OF BONE AROUND THE ENTIRE PERIPHERY OF CYSTIC CAVITY • ANY REMAINING EPITHELIAL CELLS THAT MAY BE PRESENT IN THE PERIPHERY OF THE CYSTIC WALL OR BONY CAVITY MUST BE REMOVED. BECAUSE THESE CELLS COULD PROLIFERATE INTO A RECURRENCE OF CYST • ENUCLEATION WITH CHMICAL CAUTIRIZATION • STOELINGA HAS ADVOCATED THE USE OF CARNOY’S SOLUTION. CARNOY’S SOLUTION CONTAINS GLACIAL ACETIC ACID,CHLOROFORM, ABSOLUTE ALCOHOL, FERRIC CHLORIDE.
- 91. • INDICATION : MAINLY INDICATED IN OKC. ADVANTAGES: • IF ENUCLEATION LEAVES EPITHELIAL REMNANT, CURETTAGE MAY REMOVE THEM. DISADVANATGES: • MORE DESTRUCTIVE • DENTAL PULP MAY BE STRIPPED OFF THEIR NEUROVASCULAR SUPPLY DURING CURRETAGE
- 92. COMPLICATIONS OF CYSTC LESION • PATHOLOGICAL FRACTURE • INFECTION PRIOR TO SURGERY MAY BE ACUTE OR CHRONIC • POSTOPERATIVE WOUND DEHISCENCE • LOSS OF VITALITY OF TOOTH • NEUROPRAXIA IN INFECTED CYST • POSTOPERATIVE INFECTION • RECURRNCE IN SOME CYST • DYSPLASTIC, NEOPLASTIC OR EVEN MALIGNENT CHANGES
- 93. SUGGESTED FOLLOW UP • LONG TERM FOLLOW UP , AT LEAST UP TO 8 YEARS FOR PRIMORDIAL CYSTS FOR EARLY DETECTION OF DEALNG WITH ANY RECURRNCE. • TO CHECK POSTOPERATIVE VITALITY OF TEETH. • UNERUPTED TEETH THAT MAY REQUIRE ORTHODONTIC ASSISTANCE FOR ERUPTION. • ORTHODONTIC ASSISTANCE FOR ALIGNMENT OF DISPLACED TEETH • LONG TERM FOLLOW UP OF PATIENTS WITH GORLIN’S SYNDROME.
- 94. • References Textbook of oral and maxillofacial surgery by Neelima Anil Malik Peterson’s Principles of Oral and Maxillofacial surgery Cawson’s essentials of Oral pathology and Oral medicine Shafer’s Textbook of Oral pathology Slideshare