Cysts of the Orofacial Region

Today we will talk about the surgical considerations in the management of jaw cysts. As you know the oral and maxillofacial cysts are divided into bone cysts and soft tissue cysts, the scope of this lecture will be about bone cysts. Now, what is the definition of a cyst? As you know we have compact bone and inside we have spongy bone so normally we dont have any cavities in the bone, but if we have a pathologic cavity which is normally not present that contains fluid or semi-fluid material or gas with epithelial lining (epithelial walling the covers the cavity) the this is called a cyst (a true/typical cyst). We have other variables of cysts like the pseudocyst which is a pathologic cavity in the bone that doesnt have epithelial lining. Im concentrating on the epithelial lining because in order to treat any cyst we have to remove the epithelial lining.

Key Features of Cysts Form sharply defined radiolucency with smooth borders Grow slowly, displacing rather than resorbing teeth If we saw on an OPG any resorbtion of teeth then we should suspect that its not a cyst, it might be an odontogenic tumor or something else) Asymptomatic unless infected Usually cysts are asymptomatic; we discover them when we take routine x-rays for a certain reason, we find the radiolucency and we start to investigate then we find that its a cyst. So infections are not associated to cysts, some people think that if they have a cyst then there is some sort of

infection, but no, the presence of cysts doesnt mean the presence of an infection. But if the cyst was infected then well have pain, other than that people with uninfected cysts dont experience pain. Rarely large enough to cause pathological fractures A pathological fracture is a fracture that happens due to a minor trauma that usually doesnt cause fracture but because of the presence of pathology whether its a cyst or a tumor that has caused resorbtion of the bone which facilitated fracture.

Signs & Symptoms of Cysts None (most common presentation) Swelling Intraoral discharge (either due to the content of the cysts which is fluid or semi-fluid material, or sometimes due to an infection inside the fluid so it will drain puss) Pain ( which is unusual unless its infected) Difficulties with dentures (because there will be swelling so the denture will not be easily fitted) Movement or tilting of adjacent teeth (because it will not resorb, it will displace the teeth) Missing teeth (sometimes it obstructs the path of eruption of teeth) Lower lip anesthesia which is rare ( usually it doesnt happen due to a cyst unless its infected, sometimes because of an infection of a cyst in the lower jaw, lower lip anesthesia happens which is reversible after the resolution of the infection. But if lower lip anesthesia was present

with a lesion in the mandible I have to think of 4 things, osteomyelitis., Ameloblastoma and sometimes Mets and maybe an infection of a cyst, but usually cysts dont cause lower lip anesthesia. You have to know that lower lip anesthesia is an alarming sign for any oral surgeon. *Note: Metastasis (Mets): is the spread of cancer from one organ or part to another non-adjacent organ or part. Pathological fracture (as we mentioned earlier)

Diagnosis History and examination: *inspection *palpation *percussion *auscultation -Of course we start but taking history and examination, inspection for any asymmetry, palpation because I have to feel if there is any swelling, percussion for teeth and this is very important because we have to check the vitality of teeth because it guides us towards a proper diagnosis, and finally auscultation which is the use of the stethoscope and this is very important as well in the radiolucent lesions in the mandible because some vascular lesions and hemangiomas may present as radiolucencies in the jaw so by listening to the bruit that may be caused by those vascular lesions I can exclude that this is a vascular lesion or not. There is another method other than the auscultation which is Aspiration which we will talk about shortly. *note: A bruit is an audible vascular sound associated with turbulent blood
flow, usually heard with the stethoscope, also such sounds may occasionally be palpated as a thrill.

 Vitality test of the teeth -As we said this is important because radicular cysts for example are associated with non-vital teeth, so this will help in the diagnosis and treatment plan. Aspiration Imaging Biopsy

Aspiration & Biopsy -Aspiration is actually considered as a type of Biopsy, what we do is we use a wide bow needle number 18 and we enter the cystic cavity and you see in the picture then we aspirate. For safety issues and this is very important, we have to exclude any vascular lesion or hemangiomas, imagine that this was a vascular lesion and we have opened into this cavity to do a biopsy or whatever, there will be massive bleeding and we wont be able to control it. Another thing is that the aspiration will help us in the diagnosis, how? If the aspirated material was:

Straw-colored fluid (like apple juice) and crystalinflammatory cyst radicular cyst or dentigerous cyst

Thick creamy fluidkeratocyst

 Blood hemorrhagic -Small amount (not a vascular lesion) this is because of the puncture of the needle itself, or a very small vessel. -Syringe filled with blood: indication for a vascular lesion. Airmaxillary sinus (in upper jaw), traumatic cyst (usually filled with gas) Nothing

So as we said we first have to exclude any vascular lesion and then from the color or nature of the aspirated material itself I can determine the type of cyst present, in addition to that, I can also send the aspirated material to the chemistry lab and from the level of the protein inside this aspirate we can know what type of cyst is present so it will help in the diagnosis. Soluble protein (albumins and globulins) determination of the aspirate (electrophoresis) 5-10g/dl: inflammatory cyst radicular (range of serum soluble protein) <4g/dl : keratocyst

Biopsy Depending on the size of the lesion its either: - Incisional

- Excisional We will talk about the biopsy techniques in the next lecture.

Treatment Modalities Marsupialization Enucleation Enucleation and curettage Enucleation with peripheral osteoctomy Enucleation with carnoys solution Marsupialization followed by enucleation Enucleation with bone grafting Resection * Marginal * Segmental

Now there are three main techniques: Marsupialization, Enucleation and Resection. The others are only modifications, and well talk about each one. Lets start with: 1-Marsupialization

 Opening a window Release of pressure and evacuation of the content Maintaining the continuity between the cyst and the oral cavity Incremental healing of the cystic cavity from the bottom and margins.

Its a technique that means that Im opening a window in the cystic wall, for example if I have a cyst in a boney cavity thats growing inside the bone, and because of the content of that cyst there will be pressure, therefore expansion and resorbtion of bone, so If I opened a window I will release the pressure inside this cystic cavity which is causing the resorbtion and I allow the bone to be deposited from the lower border of the mandible for example, like the case were going to talk about now. **the Dr started explaining on the picture Here on the radiograph we have a radiolucency that reaches almost to the lower border of the mandible, now if I wanted to remove the cyst by Enucleation (we will talk about It later), I will either cause fracture of the jaw or I will sacrifice the nerve which is the ID nerve and the patient will be in trouble, so first we did aspiration and it was a white cheesy creamy material which is an indication of keratocyst, so what we did is Marsupialization, we started by opening a flap, we then removed the tooth (made a hole) but we didnt remove the epithelial lining, the only portion of the cystic lining that was removed was the lining of the window and now inside we have a lining that is continuous with the mucosa of the oral cavity, then we suture the lining with the oral cavity mucosa ( with the peripheries of the flap), so it became one cavity, the oral cavity with the continuation of this cavity inside (cavity inside cavity), the idea from all of this is that we have released the

pressure and then the bone will be deposited from the bottom of the cyst and it will heal, now this is not guaranteed but this is what usually happens, we just have to keep the irrigation and maintaining the oral hygiene of the patient, and as we said the hole will be filled with bone from the bottom of the cyst and after that the epithelial lining of the cystic cavity will be continuous with the lining of the oral cavity. Now later on I can follow this by enucleation and removing the cystic lining or just keep it as it is.

*Advantages of Marsupialization: Simple procedure (not necessarily needs a specialist) Avoid damaging nerves Avoid pathological fracture

*Disadvantages of Marsupialization: Leaves pathological tissue (inconvenient for the patient because we are leaving pathological tissue inside, we havent removed the cyst, we only opened a window and we are waiting for the healing process to deal with the pathology) Needs great compliance (because the patient will have to maintain a high level of oral hygiene and he has to come every 2-3 days just to do irrigation to keep this cavity clean in order not to cause any infection) Inconvenience for the patient Hygiene demands

Indications for Marsupialization: Very large cyst near vital structure Very large cyst to avoid pathological fracture Cyst that contains tooth vital for function (because most likely the cyst will prevent the eruption of that tooth) Patient unfit for surgery unfit for greater surgery because this is considered as a minor surgery (poor medical status) Infected cyst (if there was an infection in the cyst some say that this is an indication for Marsupialization and I have to release the infection inside the cyst, and some people they remove the cyst and then give antibiotics, Im with removing the cyst in the presence of an infection and not by Marsupialization)

2-Enucleation It means the complete removal of the cystic sac, its like Im peeling the cyst with its epithelial lining and removing it as a whole. (Most commonly used) As you see in the picture here we have a cyst and we just open a flap and remove the cyst as one unit, (notice here this is the ID nerve), usually we remove some bone because its not totally exposed so we need to remove some bone and then using the curette we remove the cystic sac as one unit, you can see here this is the lingual plate of bone and the ID nerve, and we didnt leave any pathological tissue, we removed the cyst with its epithelial lining outside the cavity, leaving normal bone inside which would heal by itself.

*Advantages of Enucleation: Remove all pathological tissue & biopsy One stage procedure Little patient compliance needed

*Disadvantages of Enucleation:

Relatively difficult High morbidity to surrounding tissue (as we saw in the previous slide, the ID nerve was so close, so while Im enucleating I may injure the nerve, but in Marsupialization this is not a risk)

3-Enucleation with peripheral osteoctomy Now we have some cysts, and the father of those cysts is the Keratocyst, they have a high recurrence rate because we leave some remnants that cant be seen by the eye, and thats why the main focus of cyst management is to prevent this recurrence. One method that was suggested was Enucleation with peripheral osteoctomy, and what we do is after we remove the cyst as a whole sac with the lining, we bring a large round bur and we remove 3-4 mm of the surrounding bone all over the cavity, so we make sure that any remnants inside the cavity have been removed.

4-Enucleation & Carnoys

Another method is Enucleation & Carnoys, Carnoys is a solution composed of alcohol, chloroform and ferric chloride. This solution has the characteristic of penetration of bone to a depth of 1.54 mm after 3-5 min application. So what we do is we enucleate the cyst, after that we apply this Carnoys solution inside the bone (cystic cavity) and we wait for 3-5 minutes, then it will penetrate the bone as we said and it will kill the epithelial remnants of the dental lamina in the osseous margin that we could not see or remove.

Carnoys solution(alcohol 6 ml ,chloroform 3ml acid 1ml,ferric chloride 1gm). Penetrates the bone to a depth of 1.54 mm after 3-5 min application. Kills the epithelial remnants of dental lamina in the osseous margin. Mainly in OKC

So the idea is that we enucleate, and if we feel that there is a high recurrence rate for this cyst, I either remove 3-5 mm of bone by a large round bur or I can use Carnoys solution and wait for 3-5 minutes, it will enter whatever remnants inside the bone, kill those remnants and prevent the recurrence of the cyst mainly in Odontogenic Keratocyst (OKC) which is actually a problematic cyst in its management. They have stated now that the most commonly used and recommended method for the treatment of OKC is Enucleation & Carnoys.

5-Enucleation with Bone Grafting

Some people after Enucleation put a bone graft which is not recommended because its not needed actually, theres no need to put a bone graft especially if we did an autogenous bone graft, and what we mean by autogenous bone graft is that we are taking a bone graft from the patient himself and putting it in an another place, usually we take a bone graft from the iliac crest and we put it intraorally, so again, theres no need to increase the morbidity of the patient to another type of surgery when the healing process will happen by itself. Another thing is that if we added a synthetic bone graft, this will delay the healing and of course theres no need for that. All you have to know is that this is a technique used by some people but its not recommended.

6- Resection Its usually used for Odontogenic Tumors and not for cysts, but sometimes if the cyst was recurrent or if it was an Odontogenic Keratocyst, some people they recommend doing Resection. What is Resection? (The Dr started explaining on the picture in the slides) This is a case one month ago, you can notice the radiolucency in the radiograph, it was a keratocyst and it was recurrent. The patient had told me that before a surgeon or whoever did Enucleation but now its recurrent, we compared the previous OPG which he had to this one, this one the cyst looks much bigger and it extends from the 6 to the 3, so we plan to do Resection. In Resection we have a certain tumor or a cyst; we cut from both ends without entering the cystic cavity itself and we remove that piece, now if I cut and involve the lower border of the mandible and remove this segment as one piece (continue to the case above) this will be called segmental resection, but if I maintain the lower border such as in this

case, this is called marginal resection. What determines that? The extension of the pathology, if its extending to the lower border I will go for segmental, if its not then I will go for marginal resection.

So back to the same case, in this case we did the submandibular approach (submandibular approach: we go two fingers below the lower border of the mandible to avoid injury to the marginal mandibular nerve branch of the facial nerve CN VII, we do an incision then dissection until we reach the mandible), now this is the lower border of the mandible and this is the lesion itself, we have dissected the segment with safety margin (5mm anteriorly and 5mm posteriorly) then we did the cut. This is the segment that we have removed but with maintaining the lower border of the mandible, and then we put a plate, its a prophylactic plate to prevent fracture. In the next year Ill show you the picture after we took a bone graft from the iliac crest and put it here, but this is an advanced topic for the 5th year.

*Common Clinical Cysts

Now we have talked about the techniques but now we will talk about the application of the clinically, we will talk about the most common cysts and how to treat them. What is the most common odontogenic cyst? The most common odontogenic cyst is the radicular cyst. Cysts are divided into: 1- inflammatory cysts, 2- developmental cysts.

Inflammatory cysts are much more common than developmental cysts; the most common one in the inflammatory cysts is the radicular cyst, and the most common one in the developmental cysts is the dentigerous cyst followed by odontogenic keratocyst.

-most common developmental cyst dentigerous -most common inflammatory cystradicular -most common odontogenic cyst radicular

Developmental
A-)Odontogenic: 90% Odontogenic keratocyst Dentigerous (follicular) cyst Eruption cyst Lateral periodontal cyst Gingival cyst of adult Glandular cyst B-)Non-odontogenic: -Epithelial lined: Nasopalatine duct cyst Nasolabial cyst Median palatine cyst Median mandibular cyst Globulomaxillary cyst -Nonepithelial lined: Solitary bone cyst Aneurysmal bone cyst Stafnes bone defect

Inflammatory
Radicular: (most common) -Residual -lateral paradental

-Radicular -Dentigerous -OKC -Nasoplatine -Lateral periodental -Paradental 1-Radicular Cyst

65-70% 15-18% 3-5% 5-10% 1% 1%

When I think of radicular cysts I have to remember certain keywords which specify this particular cyst: Most common Inflammatory (means its associated with a non vital tooth) Non vital tooth 3 types: apical, lateral, residual (apical related to the apical canals, lateral related to the lateral canals, residual means that there was a cyst and the dentist extracted the tooth without treating the cyst then the patient came back with complications or discovered on routine xrays) Well defined radioluceny related to non vital root enucleation+endodontic treatment+/_apicectomy Enucleation+extraction *remember when we talked about aspiration we said that the radicular cyst aspirate will be straw colored and the protein content is 5-10 g/dl * The gold standard for the treatment of cysts is the Enucleation, unless there was an indication for the Marsupliazation or an indication for Resection (if it was highly recurrent, if it was aggressive or if it was OKC).

If the associated tooth was non restorable then Ill do extraction, if it was restorable I would go for endodontic treatment +/- apicectomy. Usually if the tooth was endodontically treated very well then well do apicectomy in the same procedure as one stage, so usually its +apicectomy.

*the Dr is explaining on the pictures. Just to make sure that everythings clear, this is an apical radicular cyst, it usually has a big filling and the tooth is definitely non vital. This is another picture of the apical radicular cyst, we have to extract this remaining root and of course we have to remove the cyst, notice the well-defined radiolucency. Some people may thing that its a small cyst but it can cause severe expansion and resorbtion of teeth if left untreated. This radiolucency if it was continuous with the root of this adjacent tooth then it will be lateral periodontal cyst.

2-dentigerous cyst Most common developmental cyst 3types:Central ,lateral, circumferential Mandibular 8 then maxillary 3 then mandibular premolars.(impacted teeth) Well defined unilocular radiolucency associated with crown of unerupted teeth (sometimes youll find in the lower 8s especially lower 8s in kids who are 17-18 years old a pericoronal radiolucency around 3-4 mm, if we found any pericoronal radiolucency that is more than 3-4 mm then we have to suspect dentigerous cyst. Usually the

follicle itself inside the bone presents as a pericoronal radiolucency so if it was large then we have to suspect that it might be a dentigerous cyst and its not only the follicle, so when I extract the wisdom tooth I have to send the soft tissue which I have removed to the histopathology lab). Pericoronal radiolucency 4-5 mm Gardners syndrome (the Dr didnt mention anything about it) From Wiki:
Gardner syndrome is a subtype of familial adenomatous polyposis (FAP or classic FAP). In people with Gardner syndrome, masses of noncancerous tissue tend to form in many different organs, such as: Multiple adenomatous colon polyps. An adenomatous polyp is an area where the normal cells that line the inside of the colon begin to make mucous and form a mass on the inside of the intestinal tract. Benign (noncancerous) tumors, including: sebaceous cysts (closed sac filled with liquid found under the skin) epidermoid cysts (lumps in or under the skin often filled with liquid) fibromas (fibrous tumors) desmoid tumors (fibrous tumors that can develop anywhere in the body) osteomas (bony growths, usually found on the jaw)

From 2009 script: its when patients they have multiple impacted teeth and multiple dentigerous cysts.

*Treatment options We said that the gold standard is the Enucleation and extraction of the tooth and usually we do curettage after we enucleate. Its done usually by surgeons; we bring the surgical curette and just scratch the walls of

the cystic cavity and sometimes we consider them as one procedure Enucleation and Curettage. And again if it was large or there was an indication to do Marsupialization then Ill do it, also if it was recurrent and aggressive Ill go for resection.

3-Keratocyst Developmental (2nd most common developmental cyst) Keratocystic odontogenic tumor (they have newly classified this cyst to keratocystic odontogenic tumor because its aggressive and it has a high recurrence rate) Post mandible Anterior posterior growth( this is the key word for the keratocyst, youll find a big radiolucency extending for example from the 3 up to the condyle its usually directed up to the condyle posterior mandible, so youll find a very big radiolucency with no or minimal expansion, the picture of the x-ray will be out of proportion to the clinical picture meaning that youll find a big radiolucency in the x-ray but clinically you wont or rarely find any expansion because it expands in the inside fills the medullary spaces in the mandible and not the bucco-lingual spaces High recurrence rate More likely to be multilocular radiolucency If multiple exclude basal cell nevus syndrome (gorlin goltz)

**gorlin goltz syndrome: an inherited medical condition involving defects within multiple body systems such as the skin, nervous system, eyes, endocrine system and bones.

*Treatment options for OKC Enucleation + curettage+ peripheral osteoctomy Enucleation + carnoys Resection (5 mm safety margin) Marsupialization ( if large and multiple)

Each and every one of them is acceptable but the gold standard is Enucleation & Carnoys carnoys solution penetrates the bone and kills the remnants of the dental lamina which are the cause of recurrence

*The Dr is explaining on the slides. Look at this keratocyst; it reaches the posterior mandible up to the condyle, and as we said youll find that the expansion here is minimal. This is another picture; here its multiple, and here its basal cell nevus.

4-Glandular Odontogenic Cyst Developmental (3rd most common) Potentially aggressive Unilocular & multilocular radiolucency

 Predilection for anterior mandible (may cross the midline) Locally invasive nature Tendency to recur 30% (its high but its less than the keratocyst) Treatment varies from enucleation and curettage to resection.

*keratocyst anterioposterior expansion *glandular odontogenic cystanterior expansion and may cross the midline *radicularnon vital *dentigerousimpacted

*dentigerous and radicular: most common, non aggressive, enucleation and treatment of the tooth is enough. *keratocyst and glandular odontogenic cyst: aggressive tumors and need to be treated aggressively

5-Lateral Periodontal Cyst Developmental Arises alongside root of tooth Associated with vital teeth Mandibular premolar area

 Well-defined radiolucent area with sclerotic margin Botyroid resembles bunch of grapes (more than one multiple)

6-Nasopalatine Duct Cyst Most common non-odontogenic cyst > 7 mm heart shaped radiolucency between the maxillary centrals Soft swelling behind the upper anterior teeth Enucleation + curettage

**not any radiolucency between the two maxillary central incisors is a nasopalatine duct cyst, because theres a normal structure that exists between the two centrals which is the incisive foramen also called nasopalatine or anterior palatine foramen, it lies in the midline of the palate behind the central incisors at the junction of the median palatine and incisive sutures.

We mentioned that we have a true cyst which is with an epithelial lining, and we have a pseudocyst which is without any epithelial lining, and It includes 3 cysts: traumatic solitary, simple, aneurysmal and stafnes bony cavity and well talk about each one.

7- TRAUMATIC BONE /SOLITARY/SIMPLE CYST

Pseudocyst

 Post mandible (premolar and molar) Well defined radiolucency with scalloped borders (for example a 25 year old male comes to the clinic with a history of trauma, he takes an x-ray and there appears to be radiolucency inside the bone which doesnt resorb, so its like a soft tissue mass inside the bone which is scalloped its alongside the roots Biopsy is curative (when we enter the cyst and do a biopsy we will induce bleeding, and then healing and replacement by bone, of course you have to follow up the patient as well).

8-Aneurysmal Bone Cyst Remember when we talked about the keratocyst we said that it goes through anterioposterior growth, but the aneurysmal is the opposite, it goes through buccal expansion and makes balloons severe expansion, so its an expansile lesion. Pseudocyst Posterior mandible (body and angle) Well circumscribed soap bubble type lesion Expansile with ballooning -this is associated with another type of category, meaning that even if its categorized between cysts as a pseudocyst, it also follows another category which is giant cell lesions, ((which include : aneurysmal bone cyst, central giant cell granuloma, giant cell tumor, brown tumor of Hyperparathyroidism, cherubism)) so if we send it to the histopathology lab it will appear to have giant cells, this is important in the management of the cyst, because theres one of the giant cell lesions which is the

brown tumor of hyperparathyroidism and its the only one that doesnt need surgical treatment , even if there appears to be radiolucency in the x-ray but the problems lies in the parathyroid so if we correct the problem in the parathyroid, the lesion will heal spontaneously.

Enucleation and aggressive curettage Here in the picture you can notice that there is expansion in the lower border of the mandible.

9- Stafnes Idiopathic Bone Cavity

Its a pseudocyst, it doesnt need treatment because its an ectopic salivary tissue in continuity with the submandibular salivary gland and has caused resorbtion to the lingual plate below the ID canal as you seen in the picture, heres the canal, and right below it theres a radiolocency, so what happened here is that lingualy the submandibular gland caused some pressure over the bone so theres a little bit of soft tissue that entered the bone and it appears as a radiolucency so thats why it doesnt need treatment. Pseudocyst Symptomless Round at oval, well-demarcated radiolucency between premolar region & angle of jaw Usually beneath inferior dental canal Bilateral anomaly

 Saucer-shaped depression at lingual bone defect Contain ectopic salivary tissue in continuity with submandibular salivary gland Sialography identify salivary inclusions No treatment required *Apical

Radicular Cyst Images

*Residual

Radicular Cyst images

*Dentigerous Cyst Images

*Keratocyst Images

*Lateral Periodontal Cyst images

*Nasopalatine Duct Cyst

I tried to include everything in the script Sorry for any mistakes Done by: Ruby Daoud <3 <3 <3