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
What is MTA?
Components (phases in MTA) Mineral trioxide aggregate
- Tricacium silicate
- Dicalcium cilicate
- Tricalcium aluminate
- Tetracalcium aluminoferrite
- Gypsum
- 20% Bismuth oxide = makes it radiopaque
What is portland cement?
Tricalcium silicate Dicalcium silicate Tricalcium aluminate Tetracalcium aluminoferrite Gypsum
Difference between MTA and portland cement?
Bismuth oxide in MTA = makes it radiopaque
MTA more expensive
Keratocysts - gorlin goltz syndrome features?
Autosomal dominant
Chromosome 9q
Prevalence 1:60,000
Multiple odontogenic keratocysts
Multiple basal cell carcinomas, not limited to sun exposed areas = scarring on face
Cervical rib/skeletal deformities = rib coming off neck = puts pressure on nerves = sensation and motor issues of arms
Bifid ribs = splints into 2
Frontal bossing = prominent forehead
Hypertelorism = big distance between eyes
Calcified falx cerebri = risk of epilepsy
Treatment of odontogenic keratocysts and risk of recurrence (%)?
Curettage 19.2% Enucleation alone 28.7 Enucleation and carnoy's 1.6% Radical enucleation 16.7 Enucleation and cryotherapy 31.3 Marsupialisation 24.4 Resection 0% BUT destructive so not commonly done
Enucleation with therapy (carnoy’s) using vorschmidit’s technique most likely done
BUT is not used for every keratocyst as risk of fixating the surrounding tissues which can lead to nerve damage if directly done over the ID nerve IF not fixated before (which vorschmidts technique does)
What is vorschmidt’s technique - carnoy’s?
Technique to enucleate odontogenic keratocysts after it’s been fixed with carnoys
Access cyst through the mandible
Contents of keratocyst are removed and carnoys is placed in cyst cavity for 5 mins without enucleating the cyst
= cyst lining rubbery = less chance satellite cysts are left behind (and if they are they are fixated)
Fixate before enucleating to prevent carnoy’s from spreading through the bone and contact the ID nerve and fixate the nerve
How to treat dentigerous cysts?
Enucleate along with removing unerupted tooth (or coronectomy the tooth if risk of ID nerve damage or pathological fracture of Md)
Eruption cyst requires no treatment as should burst by itself (if it does not incise it) apart from erupting 8 = enucleate and erupt
What is a mucus extravasation cyst?
A cyst without a true epithelial lining
Tx of Mucus extravasation cyst? Why is this difficult?
Blunt dissection/excision
Difficulty with removing as:
- Housed in soft tissue so no hard tissue border
- Scarring/fibrosis
- Not epithelially lined
= Can lead to rupture of the cyst
and also remove minor salivary gland in surgical area so it does not reoccur
Can either shell them out or cut away a portion of tissue with it
Features of sebaceous (epidermoid cyst)?
Contain keratin
Punctum = induration of the cyst around the skin surface where trauma has occurred
Traumatic implantation of skin
Acquired
Blunt dissection of the cyst to remove it
What is the risk of using fixative to remove a keratocyst?
ID nerve damage
Management of an eruption cyst`?
Conservative advice, review
Long term success of apicectomy compared to re-RCT?
Re-RCT:
- 2-4yrs = 70.9%
- 4-6yrs = 83%
Apic:
- 2-4yrs = 77.8%
- 4-6yrs = 71.8%
