Dr.

Ramesh
1st Yr PG
 Classification of cysts? Clinical features , diagnosis and management of okc/
dentigerous cyst -9marks
 Okc
 Marsupialisation 4marks
 Radicular cyst
 Stages of cyst formation
 Pathogenesis 2marks
 Definition
 Classification
 Description of Cysts
 Operative Procedures
Killey & Kay(1966)
A cyst is an abnormal cavity in hard or soft tissues which contain
fluid, semi fluid, or gas and often encapsulated and lined by epithelium.

Kramer (1974):
A cyst is a pathological cavity having fluid, semi fluid, gaseous
contents that are not created by the accumulation of pus : frequently, but
not always, is lined by epithelium.
Cysts are classified under:
I Cysts of the jaws.
II Cysts associated with the maxillary antrum.
III Cysts of the soft tissues of the mouth, face, neck and
salivary glands.
 I) Cysts Of the Jaws

A) Epithelial Lined B) Non-epithelial-lined cysts

1 Developmental origin 2 Inflammatory origin:
i Radicular cyst, apical and lateral Solitary bone cyst
(a) Odontogenic ii Residual cyst Aneurysmal bone cyst
i Gingival cyst of infants iii Paradental cyst & juvenile
ii Odontogenic keratocyst paradental cyst
iii Dentigerous cyst
iv Inflammatory collateral cyst
iv Eruption cyst
v Gingival cyst of adults
vi Lateral periodontal cyst
vii Botryoid odontogenic cyst
viii Glandular odontogenic cyst
ix Calcifying odontogenic cyst

(b) Non-odontogenic
i Midpalatal raphé cyst of infants
ii Nasopalatine duct cyst
iii Nasolabial cyst
II) Cysts associated with the maxillary antrum
1 Mucocele
2 Retention cyst
3 Pseudocyst
4 Postoperative maxillary cyst

III) Cysts of the soft tissues of the mouth, face and neck & Salivary Glands
1 Dermoid and epidermoid cysts
2 Lymphoepithelial (branchial) cyst
3 Thyroglossal duct cyst
4 Anterior median lingual cyst (intralingual cyst of foregut origin)
5 Oral cysts with gastric or intestinal epithelium (oral alimentary tract cyst)
6 Cystic hygroma
7 Nasopharyngeal cyst
8 Thymic cyst
9 Cysts of the salivary glands
10 Parasitic cysts
 Lesions are small, white or cream coloured.
 The frequency is high in new born infants but they are rarely seen after 3months
of age.
 Most of them undergo involution and disappear, or rupture through the surface
epithelium and exfoliate.
 Treatment :
There is no indication for any treatment of gingival cysts. Once their contents are
expelled, they atrophy and disappear.
Odontogenic keratocyst’ was introduced by Philipsen (1956).
 The designation ‘keratocyst’ was used to describe any jaw cyst in which
keratin was formed to a large extent.
 Belief in the origin of the cyst from primordial odontogenic epithelium
that led to the use of the term ‘primordial cyst’.
 Peak frequency in the second and third decades, with figures ranging from
40% to 60% with more frequently in femalemales
 Mandible is involved far more frequently than the maxilla
Clinical Features:
Pain, Swelling, Discharge, Occasionally, paraesthesia of the lower lip or teeth,
Pathological fractures.
 Patients are remarkably free of symptoms until the cysts have reached a large size,
involving the maxillary sinus and the entire ascending ramus, including the
condylar and coronoid processes. This occurs because the OKC tends to extend in
the medullary cavity and clinically observable expansion of the bone occurs late.

Possible reasons for recurrences:

 Their tendency to multiplicity in some patients, including the occurrence of
satellite cysts which may be retained during an enucleation procedure
 OKC linings are very thin and fragile and are therefore more difficult to enucleate
than cysts with thick walls. Portions of the lining may be left behind and
constitute the origin of a recurrence.
 SURGICAL MANAGEMENT OF THE ODONTOGENIC KERATOCYST
 They have pointed out that conservative methods of treatment such as enucleation
and marsupialisation have produced less than optimal results.
 Peripheral ostectomy was recommended. En bloc osseous resection may have to
be considered for some cases.
 The use of liquid nitrogen cryotherapy in the management of the odontogenic
keratocyst (Schmidt, 2003)
 Excision of the overlying, attached mucosa, in conjunction with cyst enucleation
and treatment of the bony defect with Carnoy solution (Stoelinga, 2003b)
 Decompression and marsupialisation as a treatment for the odontogenic
keratocyst.
 Marsupialization ( Partsch operation)
 Enucleation
Marupialization (Partsch operation-1892):
 A U-shaped incision outlines the area which is slightly larger than the eventual bony
opening. This will leave a narrow rim of oral mucosa which can roll over the edge of the
bone to become united to the cut edge of the cyst lining.

 A cross incision is made in the lining to expose the cyst lumen and cystic contents are
evacuated. The cavity is flushed gently with saline.

 The flap is now turned into the cavity and is sutured to the cyst lining along the bony margin.
The excess flap and cyst lining are trimmed away. The cavity is flushed again with sterile
saline and is packed with iodoform or tincture benzoate pack.
 After completely flushing the gauze with the chemical (iodoform etc.), excess fluid is squeezed out.
The pack is then unrolled and carefully placed into the cavity with two pairs of forceps.

 The gauze strip is first laid along the floor of the cavity and the remainder is inserted systematically in
layers running from side to side.

 This pack is left in place for 7- 14 days. By this time, the junction between the lining and mucosal flap
will be healed and an acrylic plug can be fabricated.

 This plug maintains the patency of the opening and prevents the foods particles from entering the
cavity. If the patient is denture wearing, this plug can be attached to the denture.

 The plug should be stable, adequately retained and large enough to prevent accidental swallowing.

 After this, daily irrigation should be done for a prolonged period.

Advantages:
 Simplicity and conservatism
 No risk of injuring neurovascular bundle
 No risk of creating oronasal or oroantral fistula
Disadvantages:
 Leaving pathologic tissue behind
 Take considerable time to fill
 Healing is slow.
 Before the incision is demarcated, the area should be infiltrated with a local anaesthetic
solution with a vasoconstrictor. This helps in easy separation of cystic lining from the
periosteum. Whenever possible, a buccal or labial approach is preferable because of superior
visibility and accessibility.

 A wide mucoperiosteal flap with margins on intact bone should be reflected.

 If the bone is thin, it can be peeled off with a periosteal elevator. Further clearance is done
using bone roungers till adequate access is obtained.

 The cyst lining is gently separated from the cavity with the broad end of periosteal elevator.
Depending upon the size of the cyst and its position, other instruments such as spoon
excavator and Mitchell’s trimmer can be used.
 Careful dissection should be done to separate the lining from the structures like
periosteum, nasal cavity wall, maxillary sinus, neurovascular bundles etc. Undue
pressure should not be used while doing this.

 After removing the cyst lining, the cavity is irrigated and well debrided and
inspected for any remnants of cyst lining. Hemostasis should be achieved before
closing.

 In large cysts, immediate control of bleeding may not be enough and further
oozing is managed by placing a gauze pack in the cavity till complete hemostasis
occurs. This pack is removed after 24 hours.
 An approach that recently has gained popularity in the management of keratocysts is a
combination of methods. The first step is to decompress the cyst.
 A plastic drain is secured in place to ensure that the opening remains patent. After 6 to 8
weeks, the lining of the cyst becomes generally thick and tough.
 The second step is to carefully enucleate the cyst. At this time, the thickened cyst wall is
much more easily removed than is the usual OKC.
 Perform a peripheral ostectomy with a large bone bur. A margin of 2 to 3 mm is taken,
depending on adjacent vital structures involved.
 Treat the residual bone bed with chemical cautery (Carnoy’s solution) and packing is done.
 This is an improvised method devised to combine the advantages of the two main techniques,
but in fact it combines the disadvantages of both enucleation and marsupialisation, yet the
advantages of primary closure are not achieved.
 A dentigerous cyst is one that encloses the crown of an unerupted tooth by
expansion of its follicle, and is attached to its neck.

Clinical features:
 2nd and mainly 3rd decade with a male prediliction
 Majority involved the mandibular third molar followed by maxillary permanent
canine, mandibular premolars and the maxillary third molar.
 Dentigerous cysts may grow to a large size before they are diagnosed.
 Pain in case of infection.
 Mostly solitary, but bilateral multiple cysts are usually found in syndromes like
cleidocranialdysplasia..
 Hollowing of ramus extending to the coronoid process and condyle as well as
expansion of the cortical plate due to pressure exerted by
the lesion.
 In the central variety, the crown is enveloped symmetrically- In these instances, pressure is
applied to the crown of the tooth and may push it away from its direction of eruption. In this
way, mandibular third molars may be found at the lower border of the mandible
 The lateral type of dentigerous cyst is a radiographic appearance that results from dilatation
of the follicle on one aspect of the crown. This type is commonly seen when an impacted
mandibular third molar is partially erupted so that its superior aspect is exposed
 The so-called circumferential dentigerous cyst in which the entire tooth appears to be
enveloped by cyst, results when the follicle expands.

 Conservative Surgical Treatment

 Cyst enucleation along with extraction of the impacted was indicated.
 Decompression can also be used in only in case there’s an extensive cyst.
 An eruption cyst is in essence a dentigerous cyst occurring in the soft tissues. The eruption cyst occurs
when a tooth is impeded in its eruption within the soft tissues overlying the bone.

Clinical features:

 Children of all ages and occasionally in adults if there is

delayed eruption with a male prediliction.

 Deciduous and permanent teeth may be involved, most frequently anterior to the first permanent molar.
The mandibular central primary incisors and first permanent molars were the teeth most frequently
involved.

 The eruption cyst produces a smooth swelling over the erupting tooth. It is usually painless unless
infected and is soft and fluctuant
• May show a soft tissue shadow since the cyst is usually confined with init and
usually no bone involvement.

Eruption cysts are most frequently treated by marsupialisation.

The dome of the cyst is excised, exposing the crown of the tooth which is allowed
to erupt.
 The gingival cysts may certainly occur without bone involvement and may
produce a gingival swelling
 Peak frequency in the sixth decade,
 Female prediliction.
 More frequently in the mandible, and particularly in the premolar–canine region
of the mandible
 No radiographic changes except a faint round shadow.

Treatment:
Local surgical excision and there is no
tendency for recurrence.
 Lateral periodontal cyst’ is confined to those cysts that occur in the lateral periodontal
position and in which an inflammatory aetiology
 6th decade,
 Equal Sex prediliction
 Mandibular premolar area, followed by the anterior region of the maxilla.
 These are symptomless, the associated teeth will be vital.
 Radiographs of the lateral periodontal cyst showed a round or oval well circumscribed
radiolucent area, usually with a sclerotic margin.
 Treatment
Surgical enucleation.
 It is a variant of lateral odontogenic cyst, but that the term ‘botryoid odontogenic
cyst’ should be retained because of the tendency of this variant to recur if
inadequately removed.
 Even small lateral periodontal cysts may be bicystic or polycystic.
 5th , 6th & 7th decades, Predominantly in the anterior region, mostly occurred in the
mandible than maxilla, Usually asymptomatic.
 All the lesions showed multilocular and unilocular radiolucencies on radiological
examination.
 Treatment: Careful excision.
 It is a rare lesion.
 Peak frequency in the 6th decade
 Male prediliction.
 Anterior mandible, maxilla, and also mandible from incisor
or canine to the molar regions.
 Swelling is the main feature.
Radiological Features:
Well defined multilocular and unilocular radiolucencies are seen.
Treatment:
 Small lesions- enucleation
 Large lesions- biopsy before treatment plan. After that, peripheral ostectomy, marginal resection or
partial jaw resection, depending on the size of the lesion, integrity of the jaw border and proximity to
vital structures.
 Midpalatal raphe cyst of infants.
 Nasopalatine duct cyst.
 Nasolabial cyst.
 The cysts along the midpalatal raphe have a different origin. They arise from epithelial inclusions
at the line of fusion of the palatine shelves and the nasal processes
 Midpalatine raphe cysts have a similar histological appearance with the gingival cysts of infants.
 Treatment: There is no indication for any treatment of gingival cysts or of midpalatal raphe cysts
in infants.
 It may occur within the nasopalatine canal or in the soft tissues of the palate, at the
opening of the canal, where it is called the ‘cyst of the palatine papilla’.
 The term ‘nasopalatine duct cyst’ is preferred to the synonymous ‘incisive canal
cyst’.
 the majority occurred in the third to the sixth decades with a male prediliction.
 Swelling is the most common symptom, sometimes pain and discharge may also
present.
 Radiographic feature: The nasopalatine duct cyst occurs in the incisive canal and
it may be difficult to decide whether a radiolucency in that area is a cyst or a large
incisive fossa.
 Treatment: Surgical enucleation.
 Nasolabial cysts are rare lesions.
 Peak frequency in the 4th & 5th decades.
 Female predilection
 Frequent symptom is swelling, sometimes pain in case of infected cysts and difficulty in
nasal breathing.
 Radiographic Feature: There was a localised increase in radiolucency of the alveolar process
above the apices of the incisor teeth. This radiolucency resulted from a depression on the
labial surface of the maxilla.
 Treatment: Surgical enucleation
Synonyms: periapical cyst, apical periodontal cyst, root end cyst.
•Most common odontogenic cyst
 60% of all cysts are all radicular cysts.
 It represents a chronic inflammatory process and develops only over a prolonged
period of time.
 Long standing cyst may undergo a acute exacerbation of the inflammatory process
and develop rapidly into an abscess.

Radiological Features:
 Round or oval radiolucency which is well delineated with a marked radio-opaque
rim
 Rarely causes resorption of the root of the infected teeth.
 Surgical Decompression:

a) Enucleation- The affected tooth is extracted or preserved by RCT with apicocetomy and
enucleation is performed

b) Marsupialisation- There are always chances of closing the orifice and reformation of cyst.
The main application is for temporary decompression of exceptionally large cyst where
fracture of jaw is a risk factor. When enough new bone is formed, cyst can be enucleated.
 Retined periapical cysts from teeth that have been removed.
 Found in any of the tooth bearing areas of maxilla and mandible
Radiological features:
 Well defined radiolucency that can vary from few mm to several cm
 Treatment : surgical curettage
A cyst of uncertain origin found primarily on the distal or facial aspect of vital mandibular 3 rd molar
consisting of intensely inflamed connective tissue epithelial lining.

Clinical Features:
Develops in lateral surface of a root
Mostly in 3rd decade of life, male predielction,
Located distally or disto buccally to the third molar.

Radiological features:
These are the non widening of the periodontal ligament space & the lesion was superimposed on the buccal
root.

Treatment:
Enucleation and extraction of third molar
The aneurysmal bone cyst is an uncommon lesion which has been found in most bones of the
skeleton, although the majority occur in the long bones and in the spine.
Peak frequency in the 2nd decade.
Female predilection.
Mandibular molar is the most common site.
Radiological features: Characteristic ‘ballooning’ growth pattern which results in a radiolucent
area with the typical ‘blown-out’ cortical expansion. Lesions are usually unilocular but longer-
standing lesions may show a ‘soap-bubble’ appearance.
Treatment: the most frequent form of treatment
in reported cases of aneurysmal bone cysts of
the jaws has been curettage.
 Solitary bone cysts are fluid-filled or empty intra-osseous lesions found most commonly in the
proximal metaphyseal region of the long bones in children and adolescents.
The solitary bone cyst is not a common lesion
 Peak frequency in the 2nd decade, with an equal gender distribution.
These occur in the mandible.
Swelling was the presenting symptom, sometimes pain, labial paraesthesia & and some patients, there
was both pain and swelling.
Radiographic features: The cyst appears as a radiolucent area with an irregular but definite edge and
slight cortication.
Treatment: cyst wall is then curetted but caution is
needed so as not to damage the tooth roots or
inferior alveolar nerve.
Synonyms: Mucous extravasation cysts and mucous retention cysts.
Peak frequency in 2nd & 3rd decade with equal sex predilection
Majority of mucocoeles are found in the lower lip.
Patients with mucocoeles usually complain of a painless swelling which is
frequently recurrent.
Treatment:
Small mucocoeles - no surgical treatment required.
Larger lesions - surgical removal, usually through a small
vertical incision. The cyst and its associated lobules
of salivary gland should, be removed together and intact.
Mucocoeles occurring on the floor of the mouth.
Usually unilateral.
2 varieties- Superficial and plunging.

Treatment:
Surgical management - extremely difficult and hazardous.
So, surgical removal of the sublingual gland through the
mouth without any cervical approach is the initial form of
treatment. This removes the secreting source, thereby
preventing recurrences.