Management of Cysts Flashcards
Approaches to managing cysts?
Enucleation = removal of cyst entirely without cutting it. Drill into bone to access cyst and then separate it from the surrounding bone without cutting it. Curettage = removal of tissue by scraping or scooping it out of the cystic cavity. Cyst is taken out in portions. Resection = removal of part of an organ, takes pathology and margin of normal tissue. Reserved for more aggressive cysts as destructive. Marsupialisation = creation of a pouch by suturing cyst lining to external surface (difficult). Can be done in larger cysts to dilate them. May resolve them or need further surgery once reduced in size.
What is the approach for most cysts?
Enucleate
What to do if the cyst falls to bits?
Curettage
What cysts may be manageable in dental practice?
Radicular
Dentigerous
What cysts are likely to reocurr?
Odontogenic keratocyst
What cysts are common in MOS?
Mucocele
Sebaceous (epidermoid) cyst
Management of radicular cysts?
- RCT or re-RCT and monitor - if cyst does not resolve then further management needed
- Extract causative tooth (cyst likely to come with it or resolve if small)
- Extract causative tooth then enucleate (if large or retained enucleate the cyst via the socket or by taking an apical approach via the bone)
- Rarely, marsupialise +/- further therapy (if exceedingly large)
- Apicet
- Anterior tooth (mainly)
- Acceptable orthograde RCT
- Pt accepts risk (e.g. recession)
- Consider implant first before apicetomy due to bone removal in apicetomy
Indications for apicetomy?
- Persistent symptoms /pathology in a non-vital tooth
- Apical cyst
- Buccal swelling = re-RCT
- Discharge
- Mobility - indication of ongoing infection: If grade I, II or III = prognosis decreases with increased mobility (do not apicet a tooth if more than grade II)
- Pain - (re)RCT or initial RCT is an unfeasible solution as may not be achievable or reRCT could have failed in past e.g. not feasible when:
- Sclerotic canal - cannot instrument
- Adequate re-RCT has failed
- Very large cyst (query if RCT will resolve it?)
- Curvature and accessory canals
- Post crown, cannot be removed or risk of damaging the tooth when removing a post crown
- Complex crown/bridge, likely perforation rather than instrumentation (different orientation of tooth compared to crown)
- Fractured instrument in tooth
- Root perforation
- Fractured root
Absolute contraindications to apicetomy?
Severe bleeding disorder
- But if haemophiliac and have appropriate cover will be fine
Endocarditis risk
Unrestorable tooth
Post-crown retrievable (first option should be remove post crown and re-root treat it)
Relative contraindications to apicetomy?
Previous apicetomy - Root gets shorter and shorter Molars - ID nerve risk - Access - Tooth morphology: multiple roots - OAC Poor OH Active caries Sinus disease (recurrent sinusitis and Mx posterior tooth = risk of contacting sinus and exacerbation of sinusitis Implant as removing bone where the implant would be during apicetomy Unwilling to have LA High mobility index - Prognosis decreases Advanced perio = further loss of bone support
Types of flap design for apicetomy?
Mucoperiosteal = around gingival margin and relieving incision (reverse hatchet incision) Semilunar = no longer recommended - risk incision will overly cyst = wound breakdown, scarring Leubke-Oschenbein = incision at mucoginigival junction to hide scar
What to do after creating a flap in an apicectomy?
Enucleate cyst, apicect, retrograde root treatment placed in apical portion of remaining root
- May resort to curettage if friable
- Apical 3mm of root removed (apical delta)
- No need to remove to base of bone cavity
- 90 degrees to long axis of tooth
- IRM or MTA as retrograde RCT
LEUBKE-OSCHENBEIN flap features?
Incision at mucoginigival junction to hide scar
4mm below gingival margin but in attached mucosa - If patient has very thin attached mucosa this is not feasible.
As with semilunar = scarring but follows the natural interface of the mucogingival junction so is less obvious
Consider where the gingival sulcus is - bone level may be lower in an infected tooth then where you plan your incision = leaves a bridge of mucosa at risk of breakdown
Where is the crestal bone on a tooth that is non-vital and infected?
Where are you going to stitch this flap? = make sure incision goes below the sulcus
What do you think of the blood supply to the marginal gingivae? = make sure 4mm from ginigval margin to not impact blood supply
Mucoperiosteal flap features?
Best access as broader flap
Minimal scarring as incision around the gingival margin
Risk of gingival recession from where flap has been raised
What is the apical delta?
What happens at the tip of a root canal = it spreads out at the apical 3mm of the tooth = cut 3mm tip of root off at 90 degrees = removes apical delta and ensures the tooth still has support
