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CYSTS OF maxillofacial region

CYSTS OF maxillofacial region

Author:

Dr. Altaf Malik H

Department of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

Co authors:

Dr. Shah Ajaz A

Associate Professor and Head of

Department of Oral and Maxillofacial Surgery,

Govt. School Dental, Srinagar.

 

Dr. Lato Suhail

Professor

Department of Pathology Oral Microbiology

Govt. Dental College, Srinagar.

Dr. Manzoor Ahmad Malik

J & K Services Health, SDH Banipora

 

Dr. Tabasum Rubeena

Resident

Hospital CD, Srinagar.

Dr. Shazia Qadir

Department of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

Introduction

A cyst is traditionally defined as a pathological cavity lined with epithelium, usually containing liquid material or semisolid (Killey and Kay – 1966). The currently accepted definition is coined by Kramer in 1974 as "a pathological cavity with the liquid, semisolid or content of gases and is often but not always lined by epithelium.

Cysts of the jaws are coated with a layer of epithelium and connective tissue layer underlying layers that can be dissected easily from the bone. The thickness and configuration of this coating varies with the type of cyst. These cysts develop either by the proliferation of epithelial rests in the jaw cyst or neoplastic tissue transformation.

Classification

classifications have been published numerous cysts of the jaws. Most of them are perfectly satisfactory in the clinical evaluation and practice.

I. Robinson classification (1945)

developmental cysts

A) from odontogenic tissue

1. Periodontal cyst

(A) or root type root apex

(B) lateral type

(C) Residual Type

1. Dentigerous cyst
2. Primordial cyst

B) type of tissue non-dental

1. The median cyst (cyst palatal media)
2. incisive canal cyst
3. Globulomaxillary cyst

II. Kruger classification (1964)

A) congenital cyst

1. Thyroglossal
2. Branchiogenic
3. Dermoid

B) Development of the cyst

1. dental origin

a) fissure-type

1. Naso-alveolar
2. Median
3. incisive canal cyst (naso-palatine)
4. Globulomaxillary

b) the rate of retention

1. mucocoele
2. ranula
3. dental origin

a) periodontal

1. periapical
2. lateral
3. residual

b) primary

c) dentigerous

III. Lucas classification (1964)

intra-osseous cysts

A) fissure cysts

a) Mean mandibular

b) the median palatal

C) naso-palatine

d) globulomaxillary

e) naso-labial

B) Odontogenic cysts

a) Development

1. primordial
2. dentigerous

b) inflammatory

c) root

C) Non-epithelial bone cysts

a) solitary bone cyst

b) aneurysmal bone cyst

Classification IV. Gorlin (1970)

A) Odontogenic cysts

1. dentigerous cyst
2. eruption cyst
3. gingival cyst of the newborn
4. lateral periodontal cyst and gingival
5. keratinization odontogenic cysts and calcification

(Cystic tumor keratinization)

1. radicular (periapical cyst)
2. odontogenic keratocyst

a) primordial cyst

b) The Gorlin-Goltz syndrome

B) non-odontogenic cysts and fissure

1. globulomaxillary (premaxillary-maxillary) cysts
2. naso-alveolar (naso-labial / Klestadt's) cyst
3. naso-palatine (median upper anterior) cyst
4. median mandibular cyst
5. anterior lingual cyst
6. dermoid and epidermoid cysts
7. palatal The cysts of newborn babies

C) The cysts of the neck, floor of the mouth and salivary glands

1. thyroglossal duct cyst
2. lymphoepithelial (branchial cleft) cyst
3. oral cyst with gastric / epithelial epithelium
4. salivary gland cyst – mucocoele and ranula

D) Pseudocysts of the jaws

1. aneurysmal bone cyst
2. static (development / lateral) bone cyst
3. Traumatic (hemorrhagic / solitary) bone cyst

V. WHO classification published in 'writing histology of odontogenic tumors (Kramer, Pindborg, Shear – 1992)

I. Jaw cysts

A) epithelial

1. developmental

a) Odontogenic

1. Gingival cysts of children
2. Odontogenic keratocyst (primordial cyst)
3. dentigerous (follicular) cyst
4. eruption cyst
5. lateral periodontal cyst
6. gingival cyst of adult
7. OC botryoides
8. glandular odontogenic (sialo-odontogenic / Mucoepidermoid-odontogenic) cyst
9. Odontogenic cyst calcifying

b) non-odontogenic

1. naso-palatine duct (incisive canal) cyst
2. naso-labial (naso-alveolar) cyst
3. Raphaà midpalatine cyst of infants
4. palatal alveolar median, median and median mandibular cysts
5. globulomaxillary cyst
6. inflammatory
   1. radicular cyst (apical / lateral)
   2. residual cyst
   3. paradental (mandibular infected buccal) cyst
   4. inflammatory collateral cyst

B) Non-epithelial

1. solo (traumatic / simple / hemorrhagic) bone cyst
2. aneurysmal bone cyst

II. Cysts associated with maxillary sinus

a) benign cyst of the maxillary sinus mucosa

b) post-operative maxillary cyst (surgical ciliated cyst of maxilla)

III.Cysts of the soft tissues of the mouth, face and neck

a) Dermoid cysts and epidermoid

b) lymphoepithelial (branchial cleft) cyst

c) Thyroglossal duct cyst

d) above the mean cyst lingual (Cyst intralingual bow-gut origin)

e) oral cyst with gastric / intestinal epithelium (oral alimentary tract cyst)

f) hygroma cystic

g) naso-pharyngeal cysts

h) thymic cysts

i) The salivary gland cysts

1. cyst mucous extravasation
2. mucus retention cyst
3. ranula
4. polycystic (degenerative) disease of the parotid

j) parasitic cysts

1. hydatid cyst
2. cysticerus cellulosae
3. trichinosis

Signs and symptoms

Signs

The physical sign of a cyst in the mandible depends on the size of the cyst. Small cysts produce no clinical symptom. They can be discovered only in a routine radiology. As the cyst becomes larger, the expansion of the alveolar bone occurs, usually in mouth / lips. This expansion takes place as a result of continued subperiosteal bone deposition in response to bone resorption caused by the expanding cyst. This produces a convex contour bulging.

In an early phase, the lateral expansion produces a smooth, hard, painless prominence. As the cyst grows, the bone in the center of the bulge turns soft consistency. This stage is described as "tennis ball" feeling.

Also causes thinning of the cortical bone becomes fragile and the outer layer of bone fragments into the pressure producing a sound or a feeling of "crackling shell egg. "Later, this bone disappears completely, causing the cyst wall to be attached to the periosteum. At this stage, the cyst appears as a smooth, shiny bluish swelling with a soft, fluctuent consistency.

The form and degree of expansion and clinical signs vary with the type of cyst. Keratocysts dentigerous cysts and less commonly cause bone expansion and destruction. The enlargement of the cyst is at the expense of spongy bone.

Mobility the teeth rarely occurs with a periapical cyst, while the dentigerous cyst and odontogenic keratocyst can cause tooth mobility due to its high degree of bone resorption. The absence of teeth usually indicates a dentigerous or primordial cyst. Displaced teeth rarely occurs in cases of OC while cysts globulomaxillary development such as cyst may cause displacement of adjacent tooth roots.

Large mandibular cysts involve always the neurovascular bundle and may even divert this structure to an abnormal position. It is rare to find the mental nerve anesthesia, but can occur in cases of infection sharp and sudden increase in intra-cystic pressure. This can cause nerve compression and paresthesias, which alleviates decompression by surgical drainage.

Periapical cysts are always associated with one or more non-vital teeth. In other cysts also increased intra-cystic pressure can cause loss of response of adjacent teeth vitality tests, although they have vital pulps.

A large anterior maxillary cyst is extended to the nasal floor nostril distortion of nasal congestion. The involvement of antrum by an infected cyst shows the characteristics of maxillary sinusitis.

The symptoms

Most cysts are asymptomatic until the jaw is extended or infected. When infected, causing intense pain and inflammation of the region involved. Sometimes the patient noted a painless lump. If the cyst has been completed on the mouth or infected, the patient may complain of bad taste and pain.

Any cyst may cause displacement of adjacent teeth causing the convergence of the crowns of the teeth. In the case of cysts in the anterior region, discoloration, extrusion or a misalignment of teeth symptoms.

Radiological features

The classic a common odontogenic cyst in the mandible is a well-defined round / oval radiolucency bounded by a sharp edge of radio-opaque. However, there are variations depending Site and type of cyst. There are also some other injury

radiolucency that can produce similar to that of a cyst (for example, some benign tumors can cause radiolucency similar to that of a cyst).

A small cyst in the marrow space normally round shape as it enlarges, becomes oval. More late resorption and cortical expansion takes place. In general, the buccal cortical plate is expanding rapidly. The exceptions are lower third molar region, where the lingual cortical plate is thin, and in the maxillary anterior region that produces an expansion of the palate. A cyst in the maxillary molar region may involve the maxillary sinus and extending within the breast without causing much of the cortical plate expansion.

When drilling of the cortical plates are produced, appears as a window or a radio-in a radio.

A large mandibular cysts can displace the shadow of the inferior alveolar canal down and out. Large cysts cause uneven across resorption margins, and a scalloped or lobed margin can be formed.

If an unerupted tooth with a large follicular space is on a radiograph, it should be compared with the X on the opposite side before the diagnosis of a dentigerous cyst is made, because the size of follicular space may vary. A difference of more than three Sometimes the opposite side indicates a cyst.

Infection of a cyst causes a decrease in radiolucency and blurs the margin of radio-opaque. Malignant transformation rare also produces similar results. While the cyst is cured after treatment, radio-opaque line fades, as the deposits of spongy bone the periphery.

Aspiration

Apart from the signs, symptoms and radiological features, an important aid in the diagnosis of a cyst aspiration is a technique. This also helps to distinguish between a cyst and maxillary sinus.

A large needle should be used for the procedure, which may performed in local anesthesia. The diagnosis of a cyst can be confirmed if it is pulled straw-colored fluid containing cholesterol crystals. These glittering crystals appear when the liquid takes a dry swab.

When infected, the fluid becomes cloudy and yellow. In Oklahoma, the color and consistency vary fluid depending on the concentration of keratin in suspension. Sometimes it will be too thick. Breathing pure blood raises the possibility of central hemangioma or bone cyst aneurysm. A liquid or gas may be withdrawn serosanguinous a simple bone cyst. Aspiration of air shows that the needles may be on the maxillary sinus. You can confirmed by injection of 20 ml of sterile water, which would come through the nostrils.

There is a risk of introducing infection during aspiration and, preferably, when this is done, you must be at least 48 hours before surgery and only under antibiotic coverage.

Potential complications

Besides the obvious problem of cystic enlargement of the jaw causing weakness, certain complications may be especially useful, should be mentioned, given its clinical relevance.

I. Infections:

Infection is the complication of a cyst in the mandible. Typically, if the cyst is completely confined within bone cavities or soft tissues, there is no chance of getting infected. microbes enter the cyst odontogenic through steps (ie, the cavities of caries, periodontal pockets, etc) or through small external lesions. Cysts of inflammatory origin, as periapical cyst, they are always infected. The infection causes the whites of the lesion border to get blurred radiograph.

Normally asymptomatic lesions are provided by a painful infection, which prompts the patient to seek treatment. Treatment includes antibiotic therapy and drainage, if necessary, followed by the extraction or root of the associated teeth, and complete curettage of the cyst cavity. When you open the cavity, an intact coating is not usually obtained.

II. Effects on associated teeth

The cysts usually do not cause root resorption of associated teeth and the vitality of these teeth is not affected in most cases. Surgical enucleation is associated with large lesions teeth can cause the interruption of blood supply resulting in pulp death and the lack of response to vitality tests.

Odontogenic cysts are often found to cause the displacement of the roots of associated teeth. globulomaxillary cyst that causes the divergence of the upper lateral incisor and canine roots is a typical example. Other OKC can also cause displacement of several teeth but externally perceptible inflammation may be minimal.

III. Pathological fracture

This is a direct consequence of weak jaw provided by the expanding cyst. This can be caused by enlargement of the canal and perforation of a cyst or minor trauma, to the weakened bone. Surprisingly, some fractures may be asymptomatic and the cyst acts as a splint tissue between the fractured segments.

A pathologic fracture is also a possibility in the case of a large defect is not adequately managed by the filling or graft after enucleation surgery.

IV. Recurrence after treatment

The recurrence of the lesion after treatment by enucleation is a relatively common occurrence. The keratocyst are especially known for this. This complication has to do with the perfection of the operation. If the cyst lining is removed by completely during treatment, the remains of the mucosa can proliferate because of the recurrence.

V. Malignant transformation

Most workers to advise the removal of the cyst lining as soon as possible after the injury is diagnosed, because the capacity to suffer pathological changes over time. The occurrences of ameloblastoma, squamous cell carcinoma and mucoepidermoid carcinoma have been well documented.

Specific types cyst

odontogenic keratocyst (OKC, primordial cyst)

In previous literature, the keratocyst is described as a cholesteatoma (Hauer, 1926; Kostecka-1929). The first account is by Mikulicz in 1876 and the odontogenic keratocyst term was introduced by Philipsen (1956).

Previous authors have tended to indicate all cysts containing keratin as keratocysts. But the issue here which is a distinct entity of origin of development, derived from primordial odontogenic epithelium.

Incidence

Browne (1969.1972) has shown that the CCA has a certain age distribution, the average age of 32.1 years with a peak in the second and third decades. 40-60% of all patients fall in this age group. OKC is estimated to account for about 11 percent of all cysts of the jaws. It occurs more in whites than in blacks.

Keratocysts usually found more often in men than in women and this predilection is most pronounced in blacks than targets. The mandible have been involved much more frequently than the maxilla (75%). About half of all keratocysts occur in the angle jaw extends to various distances.

Clinical Features

Keratocysts patients complain of pain, swelling or discharge. Paresthesia the lower lip and teeth and pathological fractures occur but are rare. Many patients have no symptoms until the cyst has reached a large involvement the maxillary sinus or the entire branch of the mandible, including the condylar and coronoid processes. This is because the keratocyst tends to extend into the medullary cavity and the expansion observable clinically bone occurs later.

The occurrence of large keratocysts involved in the maxillary sinus and led to the destruction of the orbital floor and caused proptosis of the eyeball have been reported (Voorsmit-1984).

Maxillary cysts can cause mouth expansion, but is also palatal expansion rarely seen. The lesions can cause mandibular buccal or lingual expansion.

Gorlin-Goltz syndrome (first described by Binkley and Johnson -1951) is transmitted as an autosomal dominant trait and is characterized by

1) abnormalities including cutaneous basal cell carcinoma, other and benign skin cysts, palmar pits, palmar and plantar keratoses and skin calcinosis

2) including dental and bone abnormalities keratocyst (often multiple), mild prognathism, rib anomalies (often bifida), vertebral anomalies and brachymetacarpalism.

3) eye disorders including hypertelorism with wide nasal bridge, canthorum dystopia, congenital blindness and strabismus procedure.

4) neurological abnormalities including mental retardation, dural calcification, agenesis of corpus callosum, congenital hydrocephalus and the appearance of medulloblastomas more often than normal and

5) sexual abnormalities including hypogonadism in males and ovarian tumors.

Recurrences

The keratocyst has a special tendency to recur after surgery. The recurrence rate in various published series found to vary between 11 and 62%. A high rate of recurrence was observed when cysts were located in the angle or ramus of the mandible. Those whose radiographic appearances are multilocular have a higher recurrence rate than those with unilocular appearance.

Possible reasons for recurrences are

1) development of satellite cysts, are maintained during enucleation procedures,

2) thin coatings and brittle, causing difficulty enucleation completely

3) OKC epithelial linings have an intrinsic growth potential (Toller 1967) and may be considered as benign tumors,

4) innate tendency in some patients to develop OKC from the remains of the dental lamina and

5) new cysts can develop from epithelial rods the basal layer of oral epithelium.

Enlargement

Toller (1967) keratocysts seen as benign neoplasms. They tend to spread along trabecular bone component without producing significant expansion of the cortical plates. Often reach a large size, especially in the angle of the jaw, before being diagnosed. Main (1970) showed that the value of mitosis keratocyst linings ranged from 0-19 with an average of 8.0. This figure is similar to that in ameloblastomas and dental lamina, and higher than observed in non-odontogenic cysts (2.3) and radicular cysts (4,5).

As postulated that the osmolarities Toller raised (in comparison with serum osmolality) play an important role in the expansive growth of keratocysts, felt that the main growth in the form of mural epithelial proliferation the process is essential in this regard.

Radiographic Features

Radiologically, keratocysts first appear as small, round or oval areas that are well-defined radiolucent with a sclerotic margin distinct. Some of these unilocular lesions with scalloped margins and these lesions can be confused with multilocular. However, it is true multilocular lesions are common. Several studies have shown 23% of all be multilocular OKC. In general, these are significantly larger than unilocular. Multilocular variety is likely to be misdiagnosed as ameloblastoma.

In addition, OKCs may occur in the periapical regions vital permanent teeth, giving the appearance of a radicular cyst. In other cases, can prevent the eruption of related teeth resulting in a dentigerous "Appearance radiographically.

Pathogenesis

It is generally accepted that a keratocyst is a developmental anomaly arising from odontogenic epithelium, the sources are dental lamina or its remnants. The term 'primordial cyst' was first used by Robinson to describe a jaw cyst suggested was derived from the enamel organ in the early stages of development by degeneration of the stellate reticulum before calcified structures planned. It general agreement that most so-called primordial cysts can, in fact, keratocysts.

Pathology

The linings of odontogenic keratocysts are rarely received intact in the laboratory. They are usually thin-walled, collapsed and folded. The histologic features are characteristic.

1) They are lined by a regular keratinized stratified squamous epithelium, which is usually about 5-8 cell layers thick and without papillae. The tire of keratinization is parakeratin in 80-90% of cases.

2) The epithelium is of uniform thickness, with a well-defined, often palisaded basal layer composed of columnar or cuboidal cells, or a mixture of both.

3) The nuclei of columnar basal cells tend to be oriented out of the basement membrane, and in most cases, are intensely basophilic.

4) keratin is present in most cystic cavities.

Treatment

Due to the high rate of recurrence, enucleation simple is not considered sufficient. The excision of the lesion, along with a small margin of surrounding bone would be a more reasonable plan.

Cyst and the cyst midpalatine gingival Raphaà of infants

These two types of cysts are discussed together because they share clinical features, although one is of odontogenic origin and second, developmental odontogenic origin. Two specific varieties that can be included in this category are "Epstein's pearls," which occur Raphaà along midpalatine and Bohn nodules, which are around the dental ridges.

Clinical Features

The frequency of gingival cysts is high in newborns, but are rarely seen after 3 months of age. It is clear that most of them regress and disappear, or if rupture of the surface epithelium and exfoliate.

The nodules are 2-3 mm in diameter. They are white or cream.

Some of the open gingival cysts on the surface or may be through the development of teeth. Very few become clinical problems.

Pathogenesis

Gingival cysts of children arising from the lamina dental. The epithelial rests of dental lamina (glands of Serres) have the ability, from the earliest stage in the development of 10 weeks in utero to proliferate and form small cysts keratinise.

In morphodifferentiation stage (late follicular phase) of tooth development, the disintegration of dental lamina begins to occur and many islands and strands of odontogenic epithelium were observed between the tooth germ and the oral epithelium. Epithelial remnants have formed microcysts, are expanding rapidly at this stage (15-20 weeks in utero)

Cysts along Raphaà midpalatine arise from epithelial inclusions in the line of fusion of the folds of the palate and the nasal process. These general atrophy and become reabsorbed after birth. Some may, however, produce containing keratin microcysts.

Pathology

Both types of cysts under discussion have similar histological features. The cysts are round or ovoid and can have a smooth or wavy pattern in histological sections. There is a thin layer of stratified squamous epithelium and keratin fills the cavity. The basal cells are flat.

Treatment

There is no indication for the treatment of gingival cysts or cysts midpalatine RaphaÃ.

Gingival cysts of adults

This rare condition accounts for only 0.5% of all cysts of the jaws. The actual incidence may be higher, since many patients do not report for treatment. Most cases occur in recent decades 5 and 6 and there has been no significant gender predilection. Gingival cysts occur much more frequently in mandible than in maxilla.

The patient may give a history of slow growing, painless swelling. The cysts are well circumscribed inflammation by usually less than 1 cm in diameter and can occur in gingiva and interdental papilla, always on the facial appearance. You may have no radiographic change or only a round shadow indicating mild bone erosion surface.

A number of suggestions have been made on the pathogenesis. The most plausible theory is that they arise nest of odontogenic epithelial cells derived from the dental lamina.

Gingival cysts have a variable histological pattern. The epithelium may be thin, thick stratified squamous nature, or even atrophic. Some may have epithelial thickening, which can be small and flat, or that protrude in the lumen of the cyst. The wall of fibrous connective tissue tends to be relatively non-flammable.

The gingival cyst removed by local excision.

Periodontal lateral cyst

The designation is limited to cysts that occur in periodontal lateral position, which is inflammatory in origin and in which case the diagnosis OKC is excluded. This is also a rare condition, which represents less than 1% of all cysts of the jaws. Patients are usually adults (average age 50) with a peak in the age group of 40-69 years.

The most common location is the mandibular premolar area, followed by the anterior maxilla. The lateral periodontal cyst may be asymptomatic. Sometimes a sale can occur in gingival facial appearance. Pain and tenderness at the site have been reported.

X-rays show a round or oval well-circumscribed radiolucent area, usually with a sclerotic margin. The cysts are among the apex and the cervical margin tooth.

The lateral periodontal cyst of odontogenic origin and the general agreement is that they are source of development. An enlarged follicle on the surface side crown eruption may be the cause.

Microscopically, it is bordered by a thin layer and keratinization of squamous epithelium or cuboidal with nuclei small and pyknotic. plates and drusen are common.

The lesion was treated by surgical enucleation without, if possible, elimination the associated tooth.

Botryoid odontogenic cyst

Widely regarded as a variant of lateral periodontal cyst, odontogenic cyst botryoides is multilocular and hence the term 'botryoides "which means" bunch of grapes ". This cyst occurs in adults, mainly in the anterior of the mandible.

The cyst cavities are varied in size and are covered by a thin non-keratinized epithelium with thin fibrous tissue septa connective.

The injury requires careful removal because there have been numerous reports of recurrences.

Glandular odontogenic cyst

This has some features of lateral periodontal cyst and odontogenic cyst botryoides, but is fairly typical histological features. secretory elements and stratified squamous epithelium are observed in the coating.

Dentigerous (follicular) cyst

This type of cyst usually encloses the crown an unerupted tooth by expansion of its follicle and is inserted into the neck of the tooth.

Dentigerous cyst accounts for approximately 16% of all cysts jaws. It is most in2nd and third decades of life and the frequency is higher in men and in whites. A most important involve the mandibular third molar.

Clinical presentation and radiographic

Dentigerous cysts can grow to a large size before being diagnosed. Many patients first become aware of the slow-growing cyst or swelling. An unerupted tooth is a mandatory feature.

Radiographically, the common finding is an area unilocular radiolucency associated with the crowns of unerupted teeth. They have well-defined sclerotic margins, unless it becomes infected. There are three variants radiology.

1) The crown is wrapped symmetrically.

2) Expansion of the follicle is seen on one side of the crown (lateral dentigerous cyst).

3) Each tooth is involved (circumferential dentigerous).

Dentigerous cyst is more likely than others to produce resorption cysts the roots of adjacent teeth.

Pathogenesis

It has been suggested that dentigerous cysts may be of extra-follicular origin and intra-follicular, and the latter can develop by the accumulation of fluid between reduced enamel epithelium and enamel or inside the enamel organ. It is suggested that the pressure exerted by a potentially affected tooth eruption in a follicle causing obstructed venous flow, rapid transduction of serum across the capillary walls.

Pathology

The thin fibrous cyst wall, which is derived from dental follicle is composed of young fibroblasts and widely separated by stroma-rich ground substance mucopolysaccharides acids. The epithelial lining consists of 2-4 layers of flat or cuboidal cells. Typically, the keratinized epithelial lining.

Treatment

Small lesions can be surgically removed in its entirety. Larger cysts that involve a serious loss of bone is often treated by inserting by surgical drainage or marsupialisation.

Potential complications

Several potential complications exist relatively, which can arise from dentigerous cysts, apart from the possibility of recurrence. These include

a) development of ameloblastoma,

b) the development of squamous cell carcinoma and

c) Mucoepidermoid carcinoma development.

Eruption cyst

A dentigerous cyst occurring in the soft tissues, the eruption cyst is formed when a tooth is hampered in its path of eruption with soft tissue covering the bone.

This cyst was found in children of different ages. Deciduous and permanent teeth may be involved, most often in front of the first permanent molar.

It produces a mild swelling of the tooth eruption color can be normal or blue gum. Usually painless unless infected, and smooth and fluctuent. No bone involvement, but the cyst may give an soft shadow on radiographs. Transillumination help to distinguish it from an eruption hematoma.

Pathogenesis is similar to the cyst dentigerous

The part surface is covered by keratinized stratified squamous epithelium of the gingiva. The cyst is separated by a strip of connective tissue dense usually shows a chronic inflammatory cell infiltrate.

Calcifying odontogenic cyst (COC)

Despite an injury well recognized, an AOC is not commonly found (around 1% of all jaw cysts). This cyst occurs in a wide range of ages but there is a distinct peak in the second decade. There is an equal gender distribution and no racial predilection is evident. Maxilla and mandible are involved with almost equal frequency, but the front of any one site is more common.

Inflammation is the most common symptom. intra-osseous lesions can result in a hard bone, which can be extensive. Occasionally, cortical plate can be drilled. The pain is a rare and many cases have been asymptomatic.

The calcifying odontogenic cyst occurs mainly in radiographs as a radiolucent area with regular edges or poorly defined. Irregular calcified bodies of different sizes and opacity can be seen in the radiolucent area.

Histologically, the lining has its own characteristics of each odontogenic with a prominent basal layer composed of columns and lattice or cubic cells, hyperchromatic nuclei polarized away from the basement membrane. the feature AOC notable is the presence of ghost cells, which are enlarged, domed, oval or elongated epithelial cells of intestine. Calcification may occur in some cells ghost, initially as a fine powder or coarse basophilic granules and later as spherical bodies.

The COC is treated by surgical enucleation. If odontogenic tumor associated with a wider excision is necessary.

Nasopalatine duct (incisive canal) cyst

Waste Derived Embryonic epithelial or epithelium nasopalatine channel included in the lines of fusion of the face, which occurs within the duct or tissue nasopalatine soft palate.

This is the most common non-odontogenic cysts. Most occur in 4th, 5th and 6th decades. The symptom common is inflammation, usually in the anterior midline of the palate. Inflammation may also occur in the midline on the buccal alveolar ridge. You may have a lump in the floor of the nose. There may be pain and / or unloading. saltiness, and displacement of teeth may be other characteristics.

It can be difficult to determine whether an X-ray radiolucency in the area is a cyst or a large incisive fossa. Any x-ray shows a shadow pit less than 6 mm width can be considered to be within normal limits. Incisive canal cysts are located in the midline of the palate, above or between the roots of the incisors plants. They are round, ovoid or sometimes heart-shaped. The margins are well defined.

The incisive canal cyst is treated by surgical enucleation.

mean and median palatal cysts of alveolar

In recent years, the existence of these cysts as separate entities have been questioned and were subsequently excluded from the WHO classification (1992). Previously it was thought that developed epithelial cysts trapped in the process of fusion of the embryo. Now considered to represent a further extension of a cyst incisive canal in the case of a median palatine cyst and the anterior extension in case of cyst alveolar medium. The so-called median alveolar cyst may also, in some cases, be a keratocyst arising from the dental lamina in the midline of the maxilla.

Median mandibular cyst

A cyst sometimes occurs in the midline of the mandible. There is a well-defined round, oval or irregular radiolucent area and can separate the roots of the lower teeth. The presence of a cyst associated with vital teeth tempted some to suggest their origin from epithelial inclusions trapped in the area during embryonic development. The concept is not tenable as the as the forms in the lower jaw process that develops as a single unit. Most cysts considers that the median mandibular cysts are root, lateral dermoid periodontal intra-osseous or variety keratocyst.

Globulomaxillary cyst

This has been reported as a cyst inside the bone fissure between the lateral incisors and canines. It makes the roots of these teeth to diverge. There is now considerable opinion against the theory that it is a fissure cyst.

A wide variety of lesions presenting clinically and radiographically as a cyst globulomaxillary have been found to be OKCs, adenoameloblastoma, myxoma and hemorrhagic bone cyst.

Nasolabial (nasoalveolar) cyst

The nasolabial cyst occurs outside the bone in the nasolabial folds under the wing of the nose nose. These are very rare lesions with a wide age distribution (maximum 40-60 years old) and a predilection to occur in females (75-80%).

Clinically, a swelling in the nasolabial fold is the biggest complaint common. Some patients complain of pain and difficulty in nasal breathing. The cyst grows slowly.

Radiographically, there may be an increase in radiolucency localized alveolar process resulting from a depression on the buccal surface of the maxilla.

The nasolabial cyst pathogenesis is unresolved, although we agree that development is home.

Histologically, is lined by ciliated columnar epithelium not pseudo-stratified and has walls of collaginous or loose connective tissues.

Radicular (periapical) and residual cysts

A radicular cyst is one that arises from the epithelial rests in periodontal ligament as a result of inflammation. The inflammation usually follows the death of dental pulp and cysts that arise in this way are most commonly found at the tips of the teeth involved.

Clinical Presentation

The radicular cyst is the most common type between maxillary cysts. They occur in all areas with teeth, but more often seem to occur in the anterior maxilla. Many cysts are asymptomatic, but are slow-growing root swellings often invoked. Initially, swelling is bone-hard, but as it becomes larger, fluffiness and fluctuence arise. In the upper jaw, swelling may be oral / labial. The pain and infection are other characteristics likely. A vital tooth is an essential variable. In the case of residual cysts, a history of tooth extraction.

Radiographic Features

Radiologically, it is difficult to differentiate between radicular cysts and periapical granulomas. But when lesion is 2 mm in diameter or larger, the diagnosis of a cyst can be made.

Pathogenesis

The pathogenesis of radicular cysts may be considered in three phases

a) the initiation stage – because of the inflammatory infiltrate vital non-proliferation of epithelial cells.

b) training phase cyst – a cystic cavity forms within the mass proliferation epithelial degeneration and death of cells in the center.

c) the expansion phase – The difference between the osmolarity of the cystic fluid and serum plays a role in cyst enlargement.

Pathology

radicular cysts are lined by stratified squamous epithelium. Inflammatory infiltrate is a common finding. drusen and secreting cells are also common.

Treatment

Radicular cysts are treated by enucleation with extraction or root filling of teeth associated. An intact coating can not be obtained because of the infection.

solitary bone cyst

This injury, which occurs in the mandible and rarely in the maxilla is very rare and occurs in young people (Maximum frequency in the second decade).

Swelling, pain and Lip paresthesias are the presenting symptoms, but in most cases, there will be no symptoms. More than half of patients have a history of trauma in the region.

The x-ray, the cyst appears as a zone radiolucency with an irregular but defined and cortical slight edge. scalloped marginal condensation and can also be seen.

Pathogenesis of solitary bone cyst not known, although a consensus is a traumatic etiology. This indicates that (Olech, Sicher and Weinmann) after trauma to a bone, causing bleeding intramedullary lack of organization in the early hematoma after marrow spaces and liquefaction of the clot, leading to the formation of traumatic bone cyst.

When the cyst cavity is opened in the operation, it is often found to be empty. The cyst membrane is formed by a loose vascular fibrous tissue. adjacent bone may show osteoclastic resorption.

Aneurysmal bone cyst

This is a rare lesion that appears in the first three decades of life. More cases are seen in the mandible than in the maxilla.

Clinically, the aneurysmal bone cyst produces a firm swelling is painful in some cases. Sometimes, the swelling and malocclusion is becoming worse. This cyst produces a radiolucent oval area that produces a fusiform expansion bone. Some are multilocular, or honeycomb-like.

When the bone covering is removed, the bleeding can be heavy.

It is generally agreed that treatment is curettage. Usually there is no communication with all large ships.

Management of cysts

Some small cysts return if the remaining root necrotic pulp and / or eliminate bacteria causing tooth root canal and the canal filled with effectiveness. This approach should be used only in injury small with discretion and must be controlled by careful monitoring.

Surgical treatment should be based on the conservation of structures Dental and bone as far as possible. Wherever possible, functional teeth should be preserved. This will require a careful evaluation of all teeth in relation with the cyst. teeth without root pulp should be filled within 24 hours before the operation.

Regardless of the etiology, nature or location cyst, two treatment methods are generally accepted. Son

1. enucleation of the cyst and the sac
2. marsupialisation (Partsch operation).

Marsupialisation

The name of Partsch (1892) is usually associated with this operation though is also described enucleation. Cysts are very large can be treated through an opening in the cyst as large as is practical and packing of the cavity. This ensures complete drainage and decompression.

Advantage

a) Technically simple

b) Local anesthesia is sufficient even for large cysts as the anesthesia for the deeper tissues not necessary.

c) Associated vital structures are not damaged.

d) Teeth in a dentigerous cyst may be conserved and allowed its eruption.

e) Since the package can act as a splint, may be a favorable procedure in cases of pathologic fractures.

Disadvantages

a) The need of a regular post-operative care.

b) Long duration of treatment.

c) pathological tissue is left behind, which can lead to complications unfavorable.

d) Normal Contour can not be achieved leading to a depression that is not self-cleaning. This can lead to relapse.

Procedure

It makes a U-shaped incision outlines the area that is slightly larger than the eventual bony opening. This will leave a narrow rim of the oral mucosa, which can roll on the edge of the bone to join the cutting edge of the lining of the cyst. Mucoperiosteal flap elevation begins in the bone intact. In case of perforation, periosteum must be carefully dissected without damaging the lining of the cyst. A cross cut in the lining to expose the lumen of the cyst and the cyst contents are evacuated. The cavity gently washed with saline.

The flap is now turned into the cavity and sutured to the lining of the cyst along the bony margin. The upper flap the lining of the cyst is cut. The cavity is washed again with sterile saline and was filled with iodoform benzoate or package dyeing. Pack also Whitehead varnish can use.

After completely washing the chemical gauze (iodoform etc), excess liquid is squeezed out. The packet is then carefully unrolled and placed in the cavity with two pairs of pliers. The gauze strip is the first requirement along the floor of the cavity and the rest is inserted systematically layers running from side to side. This package is left in place for 7-14 days. By then, the bond between the lining and mucosal flap will heal and an acrylic cap can be manufactured.

This plug maintains the permeability of the opening and prevents food particles entering the cavity. If the patient is using the prosthesis, this plug can be connected to the prosthesis. The plug must be stable, properly maintained and large enough to avoid accidental ingestion.

After this, daily irrigation should be done for a long time.

Waldron (1941) recommends enucleation of the cyst after partially filled cavity following marsupialisation. Considerable thickness is when the bone is formed or when the cyst becomes relatively minor and there is no danger of damaging important structures or the provision of weaker jaw by enucleation. This will reduce the healing time and help avoid the possibility of default residual.

Enucleation

This is the most rational and most popular method used for the treatment of cysts. After removal the lining of the cyst and primary closure, the bone cavity is filled with blood clot, which eventually organized to form normal bone.

Advantage

a) All the lining is removed and the complete histopathological examination is possible.

b) Less likelihood of occurrence of residual deformity.

c) Decreases discomfort the patient (using a plug.)

d) Less overall treatment time

e) There is no need for frequent monitoring and irrigation.

possibilities f) Less future complications such as malignant transformation.

Procedure

Enucleation can be done under general or local anesthesia. In any case, before the incision is demarcated, the area should be infiltrated with a solution of local anesthetic with a vasoconstrictor. This helps in the easy separation of membrane Cystic periosteum. Whenever possible, an approach is preferable because vestibular superior visibility and accessibility. However, a cyst that causes the expansion of palate only be addressed through this direction as the associated teeth without pulp must be removed or filled root.

A wide mucoperiosteal flap margins on intact bone should be reflected. If the bone is intact, a window is cut with a chisel or drill without perforating the cyst wall. If the bone is thin, it may come off with a periosteal elevator. further clearance is done by roungers bone until there is adequate access.

The coating cyst is slightly separated from the cavity with the broad end of the elevator. Depending on the size of the cyst and its position, other instruments such as spoon and Mitchell escavator trimmer can be used. Edge of the instrument is applied in the wall of the cavity with the concave surface of the coating.

Careful dissection must do to separate the walls of the structures as periosteum, nasal cavity wall, maxillary sinus, neurovascular bundles etc. undue pressure should not be used during the making this.

After removing the lining of the cyst, the cavity is well irrigated and debridement and inspected the remains of the cyst lining. Hemostasis must be achieved before closure. In large cysts, the immediate control of hemorrhage may not be enough and it exudes is managed by placing gauze packing in the cavity until there is complete hemostasis. This pack was removed after 24 hours.

An alternative is to pack the cavity loosely with gauze iodoform and to keep the package of 7-10 days. A low-pressure suction drainage system can be used.

Voorsmit and van Haelst Stoelinga (1981) advises devitalising fragments of the lining of the cavity left after enucleation, either by swabbing the cavity with Carnoy solution or by freezing the bone wall. Carnoy fixative solution is a powerful histological made by mixing chloroform (three parts), absolute alcohol (6 parts) and glacial acetic acid (1 part).

One approach that has gained popularity in the treatment of keratocysts is a combination of methods. The first step is to decompress the cyst. A plastic (Or other suitable material) to drain is secured in place to ensure that the opening remains patent. After 6-8 weeks, the lining of the cyst becomes general, thick and strong. The second step is the careful enucleation of the cyst. At this time, the thickened cyst wall is much easier to remove what is normal OKC. The next step is to perform a peripheral ostectomy with a large bone bur. A margin of 2-3 mm is taken, depending on adjacent vital structures involved. The final step is to treat the residual bone bed chemical cautery (Carnoy solution). This method systematically in depth, although time consuming and demanding patients much co-operation has been successful.

To clear the cavity after enucleation of the cyst, various fillers have been recommended for packing in the defect before wound closure. Primarily, these are forms of absorbable hemostatic sponge, some of which can be embedded in a solution containing an antibiotic or thrombin. These materials are added to prevent excessive bleeding and to form a scaffold in which the granulation tissue can migrate.

It is now recognized that autologous cancellous bone graft can be performed successfully in oral wounds. In the case of large defects, when pathological fractures are possible or there would be a considerable loss of contour in a future prosthesis support area, this procedure can be used to clear the cavity and stimulate osteogenesis. If the graft was indicated, autogenous bone provides the best results if a second injury is not an important consideration (Boyne, 1970, Flint-1964-1944 Mowlem, Scott, Peterson and Grant, 1949).

The risk of graft bone cyst of tooth decay is the possibility of becoming infected bone fragments if wound dehiscence occurs. The risk of failure in these cases is greater than when the grafts are inserted after resection of a segment of the mandible, because of the greater difficulty in ensuring tight closure of wounds.

Enucleation and the package

This is an improvised method designed to combine the advantages of both techniques main, but actually combines the disadvantages of both enucleation and marsupialisation, however, the advantages of primary closure is not reached.

Treatment of large cysts of the jaws

Marsupialisation and complete removal of the cyst lining and the opening of the cystic cavity in the nose, was described by Seward (1969). This is done by intra-oral incision to each mouth / lip or palate. After reflecting the flap, the cyst lining is carefully separated sinus and orbital floor. Care must be taken not to damage the orbital floor and infraorbital nerve.

Along with the cyst lining, all adjacent antral mucosa is removed. The cavity is covered with iodoform gauze. An intranasal antrostomy was made just below the anterior inferior turbinate. The end of the load or drain can be removed through this and sticks to the skin. The flap is sutured intraoral suture interrupted. The drain or gauze can be removed after 24 hours.

Post-operative care

All patients treated for cysts should be observed after the operation for a long time to make a good recovery sure occurs. This includes clinical examination and radiographic examination intervals at regular intervals. The vitality of impacted teeth should be checked during visits to remember. If not recovered vitality, proper treatment should be given.

Conclusion

Cystic lesions are very common in the jaws and which includes both of odontogenic and non-odontogenic origin. Odontogenic cysts are unique to the jaws, and often results in considerable destruction of these bones. The diagnosis of these injuries is often delayed due to its presentation innocent. At the time of diagnosis, most cysts will expand considerably weakened bones. This leads to several consequences, such as fractures. Eventhough Other rare complications such as malignant transformation of cystic lining is of great importance of the various surgical methods available, enucleation with primary closure should be the treatment of choice whenever possible due to less adverse consequences.

References

1. HC Killey & Kay
2. HC Killey, GR Seward and LW Kay (1992), an outline of oral surgery-Part II.
3. Geoffrey L. Howe, Textbook of minor oral surgery.
4. Moore (1985), Surgery of the mouth and jaws.
5. Gustav O. Kruger (1990), Textbook oral and maxillofacial surgery.
6. Lucas RB (1984) Pathology of tumors of the oral tissues.
7. A Leon Assael. Surgical treatment odontogenic cysts and tumors. In Principles of Oral and Maxillofacial Surgery Vol. II. (Eds) Peterson, Marciani, Indresano. 1997.

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