ORAL SURG cyst management Flashcards
Define a cyst?
a pathological cavity having fluid or semi-fluid contents, which has not been created by the accumulation of pus
they are often epithelial lined
Describe how cysts forms?
- remnants are located within alveolus
- they proliferate due to inflammation
- the central cells die to form fluid
- cyst expands (hydrostatic pressure) and can resorb bone
what may make a cyst feel like eggshell crackling intra orally?
boney expansion
what may make a cyst feel soft to touch intra orally?
fluctuant swelling
list symptoms that present in teeth which may be a sign of a cyst?
carious teeth
discoloured teeth
fractured teeth
tilted/ displaced teeth
loose teeth
hollow percussion note
missing teeth
what is used as the hermetic seal in periradicular surgery?
MTA
what are the desirable outcomes of periradicular surgery for a radicular cyst?
bone regeneration and formation of lamina dura
what are the investigations for cysts (4)?
- sensibility/ sensitivity testing
- radiology
- aspiration of cyst contents
- biopsy
what are the types of contents seen with aspiration of cysts for investigation (3)?
clear with crystals (radicular)
thick and viscous
blood (vascular lesion)
what are the management aims for cysts (3)?
eradicate the pathology
minimise surgical damage
restore function quickly
what are the treatment options for cysts (6)?
marsupialisation
enucleation
marsupialisation + enucleation
enucleation + currettage/ excision
en bloc resection- jaw continuity maintained
partial resection - continuity lost
what is the 1st line cyst tx?
enucleation
what does tx of a cyst depend on?
the type, size, site of the cyst (potential iatrogenic damage)
patients medical status (fitness for GA)
what is enucleation?
complete removal of the cyst lining
a large bony cavity is left which fills with blood clot, granulation tissue, then bone
following enucleation, how does the cavity heal?
primary healing
secondary healing: packing (and replacing until granulation tissue fills the whole cavity)
when may enucleation be contraindicated for cysts?
cyst is large
involves a large number of vital teeth
in a difficult anatomical site
involving potentially useful unerupted tooth
when enucleating a cyst, where should the incisions NOT be placed when raising a flap?
not resting over the osteotomy site that will be created
what is curettage?
scaping out the cyst lining
why must we eliminate dead space after enucleating a cyst?
to reduce reactionary haemorrhage
to reduce post operative infection
what can be used to eliminate dead space after enucleation?
drain placement
biological materials as fillers
collapse the walls of the cavity (only if soft tissue cyst)
secondary intention with antiseptic dressing (for older more frail pts)
what are the advantages of enucleation?
complete removal for histology
cavity heals without complications
what are the disadvantages of enucleation?
infection
incomplete removal of lining
damage to adjacent teeth or antrum
weakening of bone
why is there potential for infection with enucleation?
the large dead space
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
what is the treatment of choice for eruption cysts and why?
marsupialisation as they involve potentially useful teeth
where do you want the margins to be for marsupialisation?
directly over the area where you will remove bone
what type of flap is used for marsupialisation?
mucoperiosteal flap
what can be used to stop food packing after a cyst has been marsupialised?
an acrylic bung
how do marsupialisation sites heal?
by secondary intention - granulation tissue forms from the base upwards then concentric layers of bone
what is always left over after a cyst is marsupialised?
an undercut in the bone
what are the advantages of marsupialisation?
avoids pathological fracture
tx for medically compromised pts
avoids damage to adjacent structures
allows potentially useful teeth to erupt
what are the disadvantages of marsupialisation?
orifice closes and cyst reforms
repeat visits
manual dexterity and compliance needed
complete lining not available for histology
explain decompression of a cyst?
reduction of pressure within the cyst cavity
the opening into the cyst has to be kept open with a drain
what is the incidence of radicular cysts?
60-75%
what is the incidence of dentigerous cyst?
10-15%
what is the order of incidence rate of cysts?
radicular cyst
dentigerous cyst
keratocyst
paradental cyst
gingival/ lateral periodontal cyst
nasopalatine cyst
other
of what origin is a radicular cyst?
inflammatory
what is a radicular cyst associated with?
a non vital tooth
at what part of the tooth will you find a radicular cyst ?
at the apex of the tooth
what other type of cyst may a radicular cyst turn in to?
residual cyst
what are the 2 types of collateral cysts?
paradental
mandibular bifurcation cyst
how would you describe a radicular cyst on a pathology request form?
well circumscribed
unilocular
radiolucent
spherical
associated with non vital tooth
note the size and location
what would be the tx for a radicular cyst where the tooth associated has been RCT but the root filling material if insufficient in length?
enucleation of the cyst and periradicular surgery for a root fill
what is the general tx for radicular cysts?
enucleation with either xLA of associated tooth or apicectomy following endo tx
what is the general tx of choice for lateral cysts?
enucleation with either xLA of associated tooth or apicectomy following endo treatment
what is the general tx of choice for residual cysts?
enucleation or marsupialisation
if a radicular cyst is very large and removing it will compromise the adjacent teeth, what is tx of choice?
marsupialise then enucleate
what are the types of developmental cysts (5)?
dentigerous
eruption
odontogenic keratocyst
lateral periodontal
gingival
what is the key feature of a dentigerous cyst?
always attached to the ACJ of a tooth
what is the tx of choice for a dentigerous cyst associated with a wisdom tooth?
enucleation with removal of tooth
what is the tx of choice for a dentigerous cyst associated with an unerupted potentially function tooth?
marsupialisation
align the tooth orthodontically
on a radiograph, how may you tell that a cyst is chronic?
well defined corticated margins
on a radiograph, how may you tell that a cyst is acute?
No lamina dura
what is the tx of choice for a keratocyst?
enucleation, paying particular attention to ensuring removal of an intact lining to reduce recurrence, and tooth removal
currettage of cavity (Carnoy’s solution)
en bloc resection
what happens to a keratocyst if the whole lining is not removed? and why?
recurrence as daughter cysts are in the lining
what may root resorption in relation to a suspected cyst imply?
that it is potentially an odontogenic tumour
what is the name of the condition which presents with multiple keratocysts?
Gorlin-Goltz
Nevoid basal cell carcinoma syndrome
other than multiple keratocysts, what are other features of Gorlin-Goltz/ Nevoid basal cell carcinoma?
basal cell carcinomas of the skin
genetic
wide space between eyes
skeletal abnormalities
frontal bossing
what test may you perform to differentiate a developmental and inflammatory odontogenic cyst?
vitality test the tooth associated
what is tx of choice for gingival cysts?
enucleation or excision with overlying mucosa
what are types of epithelial non-odontogenic cysts?
nasopalatine duct cyst
nasolabial cyst
what are clinical features of nasopalatine duct cyst?
vitality of adjacent teeth
associated with a salty taste
tx of choice for nasopalatine duct cyst?
enucleation through palatal flap
what are clinical features associated with nasolabial cyst>
fullness in cheek and elevation of base of the nose
what is tx of choice for nasolabial cyst?
marsupialisation after incision in the nasolabial fold
what is Staphne’s idiopathic bone cyst?
a non-epithelialised primary ‘bone cyst’
- a developmental anomaly
- ectopic salivary tissue in concavity in the medial aspect of the mandible
what is the tx of choice for Staphnes defect?
no active tx required
How is Staphnes defect described on a radiograph?
well demarcated unilocular radiolucency on inferior aspect of posterior mandible below IAN
Name 2 types of bone cysts?
aneurysmal bone cyst
solitary (haemorrhagic) bone cyst
histopathology of an aneurysmal bone cyst?
a mass of blood-filled spaces with scattered giant cells
tx of choice for an aneurysmal bone cyst?
currettage
aetiology of an aneurysmal bone cyst?
unknown
where are you most solitary (haemorrhagic) bone cyst?
teenagers
F>M
mandible
describe radiographically a solitary (haemorrhagic) bone cyst?
large radiolucency arching up between roots of teeth
tx of choice for solitary (haemorrhagic) bone cyst?
resolves spontaneously
what is an ameloblastoma?
benign odontogenic tumour - can be locally aggressive and invasive
what are the possible radiographic features of an ameloblastoma?
uni or multi locular
defined or diffuse edged
usually displaces adjacent structures
where would you find majority of ameloblastomas?
mandible
what are the 3 subtypes of ameloblastomas?
uni cystic
extraosseous
conventional
adenoid (this is new)
what is en bloc resection?
removal of a whole lesion without disrupting its capsule, resecting with a margin of healthy tissue
what are types of bone that can be used for en bloc resection of the mndible?
fibula
scapula
