Surgical Management of Odontogenic Cysts

Question 1

Surgical Management of Odontogenic Cysts
 It is important for the dentist to know the difference between a patient he or she can

Answer 1

handle and the ones that needs to referred to an Oral and Maxillofacial Surgeon.

Question 2

What is a Cyst ?

Answer 2

“A benign pathologic cavity within bone or in soft tissues, generally formed by a
connective tissue wall.”

Question 3

The cystic cavity, within the oral regions, is almost always lined by

Answer 3

epithelium.

Question 4

The cyst’s lumen usually contains (3)

Answer 4

fluids, keratin or cellular debris

Question 5

Odontogenic cyst can be defined as a cyst in which

Answer 5

lining of lumen is derived from
epithelium produced during tooth development.
Variety of odontogenic cysts.
Uniquely derived from tissues of developing teeth

Question 6

lassification of Odontogenic Cysts
(2)

Answer 6

 Histogenic Classification (Based on where the cyst is derived from)
 Inflammatory vs Developmental

Question 7

1. Cyst derived from rest cell of Malassez
   (2)

Answer 7

Periapical cyst
Residual cyst

Question 8

2. Cyst derived from reduced enamel epithelium
   (2)

Answer 8

Dentigerous cyst
Eruption cyst

Question 9

3. Cyst derived from dental lamina (Rest of Serrae)
   (4)

Answer 9

Odontogenic keratocyst
Dental lamina cyst of new born
Lateral periodontal
Glandular cyst

Question 10

4. Unclassified
   (1)

Answer 10

Paradental cyst

Question 11

Inflammatory Cysts
(2)

Answer 11

 Radicular Cyst
 Paradental Cyst

Question 12

Developmental Cysts
(4)

Answer 12

 Dentigerous Cyst
 Odontogenic keratocyst
 Developmental lateral
periodontal Cyst
 Glandular odontogenic
Cyst

Question 13

Odontogenic Cysts - Diagnosis
(4)

Answer 13

 Complete history
 Thorough clinical examination
 Plain radiographs
 CT Scan/ MRI

Question 14

 Complete history

Answer 14

 Pain, loose teeth, occlusion, swellings, delayed tooth eruption.
Dysesthesia and Paresthesia (Not so common),

Question 15

 Thorough clinical examination

Answer 15

 Inspection, palpation.

Question 16

 Plain radiographs

Answer 16

 Panorex, Occlusal, Periapical radiographs

Question 17

 CT Scan/ MRI

Answer 17

For larger lesions

Question 18

Aspiration

Answer 18

To rule out vascular lesions, cystic Lesions, solid tumors and inflammatory
conditions.
Establish a differential diagnosis.

Question 19

Odontogenic Cysts - Diagnosis
 Obtain tissue sample
 Incisional biopsy –
 Excisional biopsy –

Answer 19

Larger lesions prior to definitive therapy
Smaller cysts

Question 20

Odontogenic Cysts – Common Surgical Treatment options
(5)

Answer 20

 Curettage
 Enucleation
 Marsupialization
 Marsupialization followed by cystectomy
 Enucleation followed by Peripheral ostectom

Question 21

Curettage
(2)

Answer 21

 Curettage describes a surgical scraping of the cyst from the bony walls of the maxilla
or mandible with a special instrument called a curette that has a scoop, at its tip.
 For this procedure, it is important to create a bony window to expose the cyst in the
maxilla or mandible.

Question 22

Marsupialization
(4)

Answer 22

 Marsupilium = Pouch
 First introduced by Partsch in 1892
 Marsupialization refers to creating a surgical window in the wall of cyst & evacuation
of cystic contents.
 This process decreases intracystic pressure & promotes shrinkage of cyst & bone fill
(endosteal bone formation)

Question 23

Odontogenic Keratocyst – Other Management options
 Enucleation followed by use of Carnoys solution
(3)

Answer 23

• Carnoy’s solution is a substance used as a complementary treatment after the conservative excision of odontogenic
  keratocyst. The application of Carnoy’s solution promotes a superficial chemical necrosis and is intended to reduce recurrence
  rates. The application of Carnoy’s solution, a chemical solution composed of 60% ethanol, 30% chloroform, and 10% acetic
  acid, in conjunction with surgery, is known to reduce the rate of KOT recurrence. An FDA ban in 2013 on the use of
  chloroform for compounding led a number of surgeons to adopt a modified Carnoy’s solution in the use of Odontogenic
  Keratocyst
• Enucleation followed by peripheral ostectomy and removal of overlying attached mucosa + use of
  Carnoys solution
• Surgical resection for very large –recurrent lesions

Question 24

Marsupialization: Indications
(5)

Answer 24

 Anatomical considerations – Proximity of cyst to vital structures like maxillary sinus,
Neurovascular bundle.
 Surgical access – If access to all portions of cyst is difficult.
 Assistance in eruption of teeth – In a young patient with a dentigerous cyst, it permits
eruption of unerupted teeth.
 Extent of surgery – Marsupialization is preferred in a unhealthy or debilitated patient ,
because it is simple & less stressful for patient.
 Size of cyst – In a very large cyst, there is a risk of fracture of jaw during enucleation
procedure.

Question 25

 Anatomical considerations –

Answer 25

Proximity of cyst to vital structures like maxillary sinus, Neurovascular bundle.

Question 26

 Surgical access –

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If access to all portions of cyst is difficult.

Question 27

 Assistance in eruption of teeth –

Answer 27

In a young patient with a dentigerous cyst, it permits eruption of unerupted teeth.

Question 28

 Extent of surgery –

Answer 28

Marsupialization is preferred in a unhealthy or debilitated patient , because it is simple & less stressful for patient.

Question 29

 Size of cyst –

Answer 29

In a very large cyst, there is a risk of fracture of jaw during enucleation procedure.

Question 30

Marsupialization: Relative Contraindications (3)

Answer 30

Recurrent Odontogenic Keratocyst Recurring Cysts Smaller Cysts (< 2X2 cm)

Question 31

Marsupialization: Advantages (10)

Answer 31

 Simple procedure to perform.  Spares vital structures eg. blood vessels, nerves  Even quite large cyst can be dealt under Local anesthesia as anesthesia of deeper recesses is not essential.  Allows eruption of teeth.  Prevents oronasal, oroantral fistulae in the maxilla  Reduces operating time.  Prevents intraoperative fractures.  Reduces blood loss, helps in shrinkage of cystic lining.  Allows for endosteal bone formation to take place.  Alveolar ridge is preserved

Question 32

Marsupialization: Disadvantages (7)

Answer 32

 Pathologic tissue is left in situ.  Histologic examination of entire cystic lining is not done.  The need for regular postoperative care, occurs over a substantial period of time.  Unpleasant taste and smell may occur due to accumulation of stagnant saliva & food debris in cystic cavity.  Changing of pack and adjustment of plug.  Secondary surgery may be needed.  Longer healing time.

Question 33

Enucleation (3)

Answer 33

 Enucleation means shelling out the entire cystic lesion without rupture.  This procedure is usually indicated for removal of cyst that is not very large in size and has minimum risk of injury to vital anatomical structures during the surgical procedure.  Enucleation allows for cystic cavity to be covered by a mucoperisteal flap & the space fills with blood clot, which will eventually organize & form normal bone

Question 34

Enucleation: Indications (3)

Answer 34

 Treatment of Common types of odontogenic cysts (odontogenic keratocysts, Radicular cysts, Dentigerous cyst etc.,)  Recurrence of cystic lesions of any cyst type.  Should be employed with any cyst of jaw that can be safely removed without unduly sacrificing the adjacent structures.

Question 35

Enucleation: Relative Contraindications (5)

Answer 35

 Dentigerous cyst associated with teeth other than the third molars that would erupt normally in the oral cavity and be functional.  Young patients with erupting teeth.  Medically compromised or debilitated patients who require extensive surgical procedure to treat the cyst.  Proximity to vital structures.  Very large cysts, may cause fracture of jaw.

Question 36

Enucleation: Advantages (5)

Answer 36

 Entire pathological tissue is removed.  Tissue available for histopathological examination.  Chances of recurrence are less.  Healing time is reduced.  Enucleation with primary closure eliminates need for repeated appointments for packing, irrigation, adjustment of plug etc.

Question 37

Enucleation: Disadvantages (4)

Answer 37

 In young patients, the unerupted teeth in a dentigerous cyst will have to be removed with the lesion.  Removal of large cyst may make mandible more prone for fracture.  Damage to adjacent vital structures.  Adjacent tooth may be devitalized.

Question 38

Combination of Marsupialization and Cystectomy

Answer 38

 Cystectomy after Marsupialization (decompression) is a conservative technique that decreases the size of the cystic cavity and reduces the risk of intrabony defects, which could be induced by primary enucleation.

Question 39

 In addition, it can also save the adjacent anatomic structures- As the surgery is carried out in 2 stages.  Stage 1 –  Stage 2 -

Answer 39

Marsupialization Cystectomy

Question 40

Combination of Marsupialization and Cystectomy  Stage 1 (2)

Answer 40

 In these cases, the Marsupialization(decompression) is performed usually on on huge cystic lesions of the mandible.  During this process, a decrease in the size of the lesion and the growth of normal oral tissues was observed. The size of the lesion decreased until the time of cystectomy.

Question 41

 Stage 2

Answer 41

 Cystectomy is carried out later after the size of the cyst decreases considerably in size over a period of time and surgery could be performed under local anesthesia.

Question 42

Curretage followed by Peripheral ostectomy

Answer 42

 Peripheral ostectomy is defined as a peripheral bone. reduction with powered hand-piece and rotary instruments, done after enucleation of the cystic lesion.