Cysts of the Oral Cavity - General Principles of Treatment 2020 PDF

General Principles of Treatment of Cysts of the Oral Cavity  Cyst definition A Cyst is a pathologic cavity having fluid, semi fluid or gaseous content which are mostly but not always lined by epithelium. (KRAMER 1974)  Signs/Symptoms Clinical Presentation most cysts are...

General Principles of Treatment of Cysts of the Oral Cavity  Cyst definition A Cyst is a pathologic cavity having fluid, semi fluid or gaseous content which are mostly but not always lined by epithelium. (KRAMER 1974)  Signs/Symptoms Clinical Presentation most cysts are discovered accidentally on radiograph. smooth, rounded expansion of the jaw is noticeable, A change in the fitting of dentures in the presence of a swelling. Absence of a tooth from its place in the arch Presence of a carious, discolored, fractured or heavily filled tooth related to the swelling  Tilting of the crowns of the teeth suggests that their roots have been displaced cystic fluid may escape on extraction of a tooth, from the socket discharging sinuses in infected cysts may present as painful, tender swellings and may have dull or hollow sound on percussion of the teeth overlying a solitary bone cyst produces a  _f Peculiarities of some cysts small in size ---Fissural cysts occuring anywhere ---Periodontal cysts, associated with impacted teeth---Dentigerous cysts. more in mandible---Solitary bone cyst: Sound beneath the inferior dental canal---Static bone cavity. paresthesia and anesthesia -----Large cysts usually deflect the neurovascular bundle, neuropraxia--- rare Infected cysts. Expansion of cysts 1. As a cyst enlarges a smooth, hard, painless prominence generally on the labial side. 2. ramus or third molar region usually Expansion of the lingual aspect alone 3. Expansion of both cortical plates -- lesion, other than a cyst ñ 4. Egg-shell crackling : fragile outer shell of bone that has thinned out due to the expansion of the cyst I got 5. Fluctuation: when the cystic lining lies immediately beneath the mucosa Diagnosis  Vitality of Teeth  Should be done preoperative and postoperatively. Teeth involving  primordial cyst,  fissural cyst,  Lateral periodontal cyst  solitary bone cyst and  other nonodontogenic cysts are vital, unless there is coincidental disease of these teeth While as Apical periodontal cyst, radicular or periapical cysts In infected cysts are nonvital There may be temporary absence of a vital response in adjacent teeth, because of pressure interference with sensory transmission from the pulp  Radiographic Examination Periapical radiographs Occlusal films Extraoral radiographs, e.g. oblique lateral views OPG. PA mandible Water’s projection CT scans  Radiopaque Dyes It When the size and relations of a cyst are in doubt, its contents may be aspirated and radiopaque dye injected ,e.g. lipiodol, triosil, can be injected prior to further radiography. Precautions: no great force. avoid over flow into the soft tissues After taking the radiograph, remove the contrast material by aspiration  Aspiration É a valuable diagnostic aid that helps in distinguishing between: a maxillary cyst and the maxillary sinus, a cystic lesion and a solid tumor mass, a simple bone cyst and a central cavernous hemangioma. Technique  topical anesthesia or infiltration LA.  aspiration is done with a wide bore needle (18 gauge) and a 5 or 10 ml syringe.  Biopsy Biopsy is generally performed under local anesthesia or conscious sedation. Biopsy prior to surgery is generally advisable for large cystic lesions and when doubt exists. s  Assessment Estimation of the size of the cystic lesion Extent of bone loss to consider reconstructive plates or bone grafts. Risk of pathological fracture (IMF or immediate grafting) Relationship of the cyst to adjacent structures, i.e. floor of the nose, maxillary sinus, inferior dental nerve, infraorbital nerve, floor of the orbit Vital teeth should be preserved Nonvital teeth, which are embedded in sound bone, should be treated by root canal filling and apicoectomy  Nonvital, nonfunctional, mobile and beyond restoration teeth– extracted Acutely infected cysts---antibacterial drugs, or drainage prior to surgery In case of multicystic lesions--- identify a possible syndrome Postoperative monitoring of teeth by vitality tests until bone formation is complete Indications or reasons for Treatment of Benign Cysts tend to increase in size and produce facial disfigurement tend to get infected weaken the jaw and can cause pathological fractures some can undergo neoplastic changes so the tissue has to be examined histologically can prevent eruption of teeth causing disturbance of dentition  Operative Procedures 1. Marsupialization (decompression) 2. Enucleation Partsch I (marsupialization alone) Enucleation and packing 104 Partsch II (combined Enucleation and primary closure marsupialization and enucleation) Enucleation and primary closure Marsupialization by opening into with reconstruction/bone grafting nose or antrum.  Marsupialization (Decompression) Principle: creation of a surgical window in the wall of the cyst, and evacuation of the cystic contents.  decreases intracystic pressure and promotes shrinkage of the cyst and bone fill. The only portion that is removed is the piece removed to produce the window  Surgical Technique Partsch I Anesthesia: GA, conscious sedation or LA Aspiration: Cystic contents are aspirated. Incision: – A circular, oval or elliptic incision 1 cm or larger in size leaving a margin of 0. 5 to 1 cm from the gingival margins of the teeth or alveolar crest in the edentulous patient, or an inverted U shaped incision can be done. marsupilization  Removal of cystic lining specimen: for histological examination. Visual examination of residual cystic lining Irrigation of the cystic cavity Suturing: The remaining cystic lining is sutured with the edge of the oral mucosa by continuous sutures or interrupted sutures Packing: one inch width ribbon gauze with an antibiotic ointment, White head’s varnish, tincture of benzoin or bismuth iodoform paraffin paste (BIPP). to prevent contamination of the cavity with food debris  provides coverage of the wound margins. All packs are generally secured by sutures and left inside for 7 to 14 days. By the end of 2 weeks, the junction between the lining of the cyst and the oral mucosa around the periphery of the window will have healed  Maintenance of cystic cavity: Careful instructions (cleansing and irrigation with oral antiseptic rinse, preferably with a disposable syringe.) Use of plug: to prevent the Ñ contamination of the cystic cavity and preserve the patency of the cyst orifice. The plug should be stable, retentive and of a safe design so that it cannot be inhaled or swallowed.  Indications Age: 1. In a young child, with developing tooth germs, or when development of the displaced teeth has not progressed St 2. In the elderly, debilitated patient, marsupialization-- less stressful. Proximity to vital structures: to avoid creation of an oronasal or oroantral fistula, injure neurovascular structures or damage vital teeth.  Reading Eruption of teeth: In a young patient to permit the eruption of the unerupted teeth. Size of cyst: In very large cysts: enucleation --a pathological fracture. Vitality of teeth: When the apices of many adjacent erupted teeth, are involved within a large cysts.  Advantages Simple procedure to perform Spares vital structures Allows eruption of teeth Prevents oronasal, oroantral fistulae Prevents pathological fractures Reduces operating time Reduces blood loss Helps shrinkage of cystic lining Allows for endosteal bone formation to take place. Alveolar ridge is preserved  Disadvantages Pathologic tissue is left in situ Histologic examination of the entire cystic lining is not done Prolonged healing time, Inconvenience to the patient Prolonged follow up visits due to Periodic irrigation of cavity, Regular adjustments of plug or Periodic changing of pack Secondary surgery may be needed Formation of slit-like pockets that may harbor foodstuffs Risk of invagination and new cyst formation.  Modifications of Marsupialization 11 ips Waldron’s method (1941) or Partsch II: This is a two stage technique 1. first marsupialization is performed 2. at a later stage, when the cavity becomes smaller, enucleation is performed and the entire tissue is examined histopathologically.  Indications Bone has covered the adjacent vital structures Adequate bone fill has strengthened the jaw to prevent fracture during enucleation Patient finds it difficult to clean the cavity In For detection of any occult pathologic condition. Advantages Development of a thickened cystic lining-- enucleation easier Spares adjacent vital structures Combined approach reduces morbidity Accelerated healing process Allows histopathological examination of residual tissue. Disadvantages Patient has to undergo secondary surgery and the possible complications that are involved with any surgical procedure Marsupialization by Opening into Nose or Antrum Advantages Primary closure of the oral wound Cystic cavity is opened into the maxillary sinus or nasal cavity---reducing intracystic pressure 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. Disadvantages Development of an oroantral or oronasal fistula, if there is a breakdown of the wound.  Enucleation Principle: Enucleation allows for the cystic lining removal and cavity to be covered by a mucoperiosteal flap so that the space fills with blood clot then to be organized and form normal bone. Surgical Technique Enucleation and packing Enucleation with Primary Closure Surgical Technique small 0 1. Enucleation of small cystic lesions from an intraoral approach: Large 2. Enucleation of large, inaccessible mandibular lesions from an extraoral approach: Large cystic lesions like the pseudofollicular dentigerous cysts that involve the ascending ramus, body and angle mandible. 3. Enucleation and primary closure with reconstruction/bone grafting Reflection of a mucoperiosteal flap.  Removal of bone and exposure of part of the cyst  Enucleation of the Care of the wound and cystic sac. suturing Indications Treatment of small odontogenic cysts Recurrence of any cyst type contraindications Large cysts Adjacent vital structures  Advantages Primary closure of the wound Healing is rapid Postoperative care is reduced Thorough examination of the entire cystic lining can be done. Disadvantages After primary closure, it is not possible to directly observe the healing of the cavity In young persons, the unerupted teeth in a dentigerous cyst will be removed with the lesion Removal of large cysts will weaken the mandible-- prone to jaw fracture Damage to adjacent vital structures like teeth , nerves and sinus  Complications of a cystic lesions Fracture (pathological) Infection prior to surgery may be acute or chronic Postoperative wound dehiscence Loss of vitality of teeth Neuropraxia in infected cysts Postoperative infection Recurrence in some cysts Dysplastic, neoplastic or even malignant changes.  Suggested follow up Long term follow up, at least up to 8 years for primordial cysts for early detection of dealing with any recurrence To check postoperative vitality of teeth Unerupted teeth that may require orthodontic assistance for eruption Long term follow up of patients with Gorlin’s Syndrome