Cyst management Flashcards
what is a cyst?
fluid/ semi filled pathological cavity often lined by epithelium.
Often found in the mandible.
what are the top 3 common cysts?
- Radicular cyst - rest cells of malassez
- Dentigerous cyst - reduced enamel epithelium
- Odontogenic keratocyst - dental lamina
What is the main driver for cyst expansion?
hydrostatic pressure
Describe the process that can happen as cysts enlarge?
- cells proliferate and growth exceeds nutrition as central cells die.
- hydrostatic pressure causes the erosion of the cortical plates by osteoclast stimulation.
- bone resorption occurs.
- cyst becomes so large = all overlying buccal cortex removed + expansion of mucosa –> fluctuant swelling.
when does a cyst become symptomatic?
cyst continues to enlarge through the mucosa and causes opening –> sinus allows infection.
give me 3 signs of cyst?
1) Asymptomatic = chance finding on radiograph.
2) Bony expansion [eggshell crackling] = bone resorbing!
3) Fluctuant swelling
4) sinus
5) pathological fracture
give me 3 symptoms of cyst?
1) Missing teeth
2) Carious, discoloured, fractured teeth.
3) Tilted/ displaced teeth/ loose teeth –> pressure from underlying cyst pushing apex out of the way.
4) discharge
5) mental hypoaesthesia
6) Pain + swelling
what does soft swelling show?
fluctuant cyst with no buccal cortex now
what does firm swelling show?
slow growing cyst
How could you treat a radicular cyst on UR1 with previous endo tx?
enucleation of cyst and peri radicular surgery carried out to hermetically seal the tooth with MTA.
What 4 investigations do you carry out for identifying cysts?
sensibility tests, radiology, aspiration of cyst contents, biopsy.
what do you call a suspicious lesion on radiopgrah that is bigger than 6mm?
Cyst like radiolucency - only can call cyst after biopsy pathology stage.
what are the aims for cyst management?
to eradicate the pathology
to minimise surgical damage
to restore function quickly
what is the first line option for cyst removal?
enucleation
what other optmarsupialisation
Enucleation (first line)
marsupialisation + enucleation
enucleation and currettage/ excision.
en bloc resection-jaw continuity maintained
partial resection
what factors do enucleation or marsupialisation depend on?
type
size
site
patients general medical status
what is enucleation?
complete removal of the cyst lining by removing overlying buccal bone and currettage cyst lining.
closure by primary or secondary means
when is enucleation contraindicated?
if the cyst is large, involving a number of vital teeth
in a difficult anatomical site
involving a potentially useful unerupted tooth.
describe the 5 stages of cyst removal to bone healing.
Enucleate cyst - blood clot - liquifies - granulation tissue - bone.
what feature is important in the flap design for enucleation of cyst?
excision must be well away from the osteotomy planned for removing the cyst.
suture the flap back in an area distant from osteotomy site and on crestal bone.
How to eliminate dead space?
drain placement
collapse cavity wall
biological material to fill the space
layered tissue closure or secondary intention packing
why do we need to eliminate dead space?
to reduce reactionary haemorrhage
to reduce post op infection
2 advantages of enucleation?
Complete removal for histology
Cavity heals without complications once primary closure secured.
4 disadvantages of enucleation
Infection
Incomplete Infection
Incomplete removal of lining
Damages to adjacent teeth or antrum
Weakening of bone – pathological fracture.
what is marsupialisation?
creation of a window in the cyst lining, suturing the flap to the remaining lining to allow shrinkage of the lesion which may become self cleansing or be subsequently removed.
Bone is placed in concentric layers.
treatment of choice in cases of eruption cysts involving potentially useful teeth.
what feature is important in the flap design for marsupialisation of cyst?
Flap margins are placed directly in the area where bone is removed
Raise mucoperiosteal flap so you have inferior and superior aspects to the flap to allow access to remove bone and access cyst.
Leave open and cover with acrylic bung
4 advantages of marsupialisation?
Avoids pathological fracture
Treatment for medically compromised patients
Avoids damage to adjacent structures
Allows potentially useful teeth to erupt – maxillary incisors and canines.
4 disadvantages of marsupialisation
Orifice closes and cyst reforms
Repeat visits
Manual dexterity and compliance
Complete lining not available for histology
what is decompression?
This reduces the pressure within the cyst cavity
The opening into the cyst has to be kept open with a drain sutured in place.
better for frail patients to avoid GA.
incidence of radicular cyst?
60-75%
incidence of dentigerous cyst?
10-15%
incidence of OKC cyst?
5-10%
Incidence of nasopalatine cyst?
5-10%
incidence of paradental cyst?
3-5%
what type of cyst is radicular cyst and what is one associated with?
inflammatory cyst
apex of non vital tooth
what type of cyst may occur after xla?
residual cyst
Tx option for radicular cyst?
enucleation + extraction of associated tooth or apicectomy following endodontic treatment
large radiolucency distal to L8?
paradental cyst
management of dentigerous cyst?
enucleation with removal of associated tooth [wisdom teeth]
or
marsupialisation if unerupted tooth is potentially fuctional and can be aligned orthodontically [maxillary canines]
management of OKC?
enucleation
curettage of cavity
radiographic follow up
what worrying radiographic sign suggests odontogenic tumour?
root resorption of teeth in cyst cavity
what syndrome is associated with multiple OKC?
Gorlin-Goltz / Nevoid basal cell carcinoma syndrome - PTCH gene mutation, skeletal abnormalities.
where do nasopalatine cysts affect and what is symptom by pt?
anterior maxilla
vital teeth
salty taste
what does a heart shape appearance suggest and what type of flap is needed?
nasopalatine cyst as cyst formed on either side of incisive foramen.
Palatal flap
what gland can cause a staphne bone cavity?
sublingual gland
treatment for aneurysal bone cyst?
curettage and resolves
treatment for solitary bone cyst?
resolves spontaneously
what does ameloblastoma arise from?
dental lamina
what are the 3 subtypes of ameloblastoma?
luminal - conservative tx
intraluminal - conservative tx
mural - en bloc
+ve and -ve of en bloc?
eliminates pathology
vey invasive, disfiguring, sacrifices nerve so permanent numbness of lower lip, requires reconstruction.
A 54 year old man attends for replacement of a metal ceramic crown on tooth 11 as it is cracked and he is unhappy with the appearance. You take a periapical film and find this endodontically treated post crowned tooth has a 1cm unilocular cyst like radiolucency associated with the apex of the tooth
radicular cyst – non vital tooth
A 54 year old man attends for replacement of a metal ceramic crown on tooth 11 as it is cracked and he is unhappy with the appearance. You take a periapical film and find this endodontically treated post crowned tooth has a 4mm unilocular cyst like radiolucency associated with the apex of the tooth.
a periapical granuloma
A 54 year old man attends for replacement of a metal ceramic crown on tooth 11 as it is cracked and he is unhappy with the appearance. You take a periapical film and find this endodontically treated post crowned tooth has a 3cm heart shaped unilocular cyst like radiolucency associated with the apex of this tooth and tooth 21.
nasopalatine cyst
A 56 year old female patient has been having pain from her partially erupted LL8. You take a DPT which shows a 2cm unilocular radiolucency associated with the non-carious crown of the LL8.
dentigerous cyst
A 56 year old female patient has been having pain from her partially erupted LL8. You take a DPT which shows a 2cm multilocular radiolucency which includes the LL8.
A keratocyst
A 56 year old female patient has been having pain from her partially erupted LL8. You take a DPT which shows a 2cm multilocular radiolucency which includes the LL8 and there is root resorption of the LL6 and LL7.
ameloblastoma
A 57 year old man attends with a discharging sinus associated with a post-crowned tooth 11. You take a PA film which shows a 12mm unilocular radiolucency associated with the apex of this tooth. He is keen to save the tooth, How would this be managed?
enucleation of the lesion and peri-radicular surgery of tooth 11
A frail 94 year old attends with pain and swelling from an area on the lower right mandible. There is pus discharging intra-orally and a DPT shows a 6cm residual cyst in the angle of the mandible. How could this be managed?
decompression – less dexterity required, make hole into cyst lumen and apply drain for shrinkage of the lesion, under LA
what is an Adenoid ameloblastoma (AA)?
the only new entity added in the odontogenic lesions
epithelial odontogenic neoplasm composed of cribriform architecture and ductlike structures, and frequently includes dentinoid.
