Surgical Management of Odontogenic Cysts Flashcards
What are the odontogenic cysts commonly treated in clinical practice
- periapical cyst
- residual cyst
- dentigerous cyst
- odontogenic keratocyst
what is a cyst
a benign pathologic cavity within bone or in soft tissues, generally formed by a connective tissue wall
what is the cystic cavity lined by
epithelium
what does the cysts lumen contain
fluids, keratin, or cellular debris
what is an odontogenic cyst
a cyst in which lining of lumen is derived from epithelium produced during tooth development
what is the classification of odontogenic cysts based on
- histogenic classification (where cyst derived from)
- inflammatory vs developmental
what are the histogenic classifications of odontogenic cysts and which cysts are in each category
- cyst derived from rest of malassez: periapical cyst, residual cyst
- cyst derived from reduced enamel epithelium: dentigerous cyst, eruption cyst
- cyst derived from dental lamina (rest of serrae): odontogenic keratocyst, dental lamina cyst of new born, lateral peridontal, glandular cyst
- unclassified: paradental cyst
what are the inflammatory cysts
- radicular cyst
- paradental cyst
what are the development cysts
- dentigerous cyst
- odontogenic keratocyst
- developmental lateral periodontal cyst
- glandular odontogenic cyst
what is done in the dx of odontogenic cysts
- complete hx: pain, loose teeth, occlusion, swellings, delayed tooth eruption, dysesthesia and paresthesia
- thorough clinical exam: inspection and palpation
- plain radiographs: pano, occlusal, PA radiographs
- CT scan/MRI: for larger lesions
what is aspiration used for in odontogenic syst diagnosis
- to rule out vascular lesions, cystic lesions, solid tumors and inflammatory conditions
- establish a DDX
how do you dx an odontogenic cyst
- obtain tissue sample
- incisional biopsy; larger lesions prior to definitive therapy
- excisional biopsy: smaller cysts
what are the common surgical treatment options for odontogenic cysts
- curettage
- enucleation
- marsupialization
- marsupialization followed by cystectomy
- enucleation followed by peripheral osteoctomy
what is curettage
- a surgical scraping of the cyst from the bony walls of the maxilla or mandible with a special instrument called a curette that has a scoop at its tip
what is important in curettage
to create a bony window to expose the cyst in the maxilla or mandible
what is marsupialization
creating a surgical window in the wall of cyst and evacuation of cystic contents
what does marsupialization do
decreases intracystic pressure and promotes shrinkage of cyst and bone fill (endosteal bone formation)
use ____ to cover marsupialization site
acrylic plug
what are the other management options for odontogenic keratocyst
- enucleation followed by use of carnoys solution
- enucleation followed by peripheral ostectomy and removal of overlying attached mucosa and use of carnoys solution
- surgical resection for very large and recurrent lesions
what is carnoys solution and what does it do
- carnoy’s solution is a substance used as a complemetary treatment after the conservation excision of odontogenic keratocyst.
- promotes superficial chemical necrosis and is intended to reduce recurrence rates
- composed of 60% ethanol, 30% chloroform, and 10% acetic acid reduces the rate of KOT recurrence
what are the indications for marsupialization
- anatomical considerations: proximity of cyst to vital structures
- surgical access: if access to all portions of cyst is difficult
- assistance in eruption of teeth: in a young patient with a dentigerous cyst, it permits eruption of unerupted teeth
- extent of surgery: marsupialization is preferred in an unhealthy or debilitated patient, because it is simple and less stressful for the patient
- size of cyst: in a very large cyst, there is a risk of fracture of jaw during enucleation procedure
what are the contraindications for marsupialization
- recurrent odontogenic keratocyst
- recurring cysts
- smaller cysts (smaller than 2x2 cm)
what are the advantages of marsupialization
- simple procedure to perform
- spares vital structures
- even quit large cyst can be dealt under LA as anesthesia of deeper recesses is not essential
- allows eruption of teeth
- prevents oronasal, oroantral fistula in the maxilla
- reduces operating time
- prevents intraoperative fractures
- reduces blood loss, helps in shrinkage of cystic lining
- allows for endosteal bone formation to take place
- alveolar ridge is preserved
what are the disadvantages of marsupialization
- pathologic tissue is left in situ
- histologic examination of entire cystic lining is not done
- the need for regular postoperative care occurs over a substantial period of time
- unpleasant taste and smell may occur due to accumulation of stagnant saliva and food debris in cystic cavity
- changing of pack and adjustment of plug
- secondary surgery may be needed
- longer healing time
what is enucleation
shelling out the entire cystic lesion without rupture
what is enucleation indicated for
removal of cyst that is not very large in size and has minimum risk of injury to vital anatomical structures during the surgical procedure
enucleation allows for:
cystic cavity to be covered by a mucoperiosteal flap and space fills with blood clot, which will eventually organize and form normal bone
what are the indications for enucleation
- treatment of common types of odontogenic cysts
- recurrence of cystic lesions of any cyst type
- should be employed with any cyst of jaw that can be safely removed without unduly sacrificing the adjacent structures
what are the contraindications to enucleation
- dentigerous cyst associated with teeth other than the third molars that would erupt normally in the oral cavity and be functional
- young patients with erupting teeth
- medically compromised or debilitated patients who require extensive surgical procedure to treat the cyst
- proximity to vital structures
- very large cysts, may cause fracture of jaw
what are the advantages of enucleation
- entire pathological tissue is removed
- tissue available for histopathological examination
- chances of recurrence are less
- healing time is reduced
- enucleation with primary closure eliminates need for repeated appointments for packing, irrigation, adjustment of plug
what are the disadvantages of enulceation
- in young patients, the unerupted teeth in a dentigerous cyst will have to be removed with the lesion
- removal of large cyst may make mandible more prone for fracture
- damage to adjacent vital structures
- adjacent tooth may be devitalized
describe the combination of marsupialization and cystectomy
- cystectomy after marsupialization (decompression) is a conservative technique that decreases the size of the cystic cavity and reduces the risk of intrabony defects which could be induced by primary enucleation
- can save the adjacent anatomic structures as surgery is carried out in two stages
- stage 1: marsupialization
- stage 2: cystectomy
describe stage 1 of combination of marsupialization and cystectomy
- marsupialzation is performed usually on huge cystic lesions on the mandible
- a decrease in the size of the lesion and the growth of normal oral tissues was observed, the size of the lesion decreased until the time of cystectomy
describe stage 2 of combination of marsupialization and cystectomy
- cystectomy is carried out later after the size of the cyst decreases considerably in size over a period of time and surgery could be performed under LA
what is curretage followed by peripheral ostectomy
- peripheral bone reduction with powered hand piece and rotary instruments done after enucleation of the cystic lesion
