Procedure

Marsupialisation can be performed either under general or local

anaesthesia. The cystic contents are aspirated in the beginning.

Elevation of flap
Usually an H-shaped incision is made on the cyst, the lining turned
outwards and sutured to the mucosa. Small area of lining epithelium may
be dissected and sent for biopsy at this stage. Alternatively, a circular,
elliptical or oval incision can also be used wherever essential.

Hydrostatic dissection
The mucoperiosteal flap can be easily elevated when it rests on bone.
However, in cases where the bone has been completely resorbed, the
mucoperiosteum lies in direct contact with the cyst. Here, the cyst can be
easily removed by the use of hydrostatic dissection. A cartridge syringe
with a fine needle is inserted through the mucoperiosteum and bone is
contacted from the lesion and injection at this point begins to raise the
mucoperiosteum from the underlying bone and cyst wall.

Removal of bone
Bone removal is done either by the use of a rotary bur or rongeurs
depending upon its thickness. Removal of the bone should be done to the
maximum diameter of the cyst whenever possible. The remaining of the
cyst lining is exposed to the mouth with raw edges at its circumference.
Sometimes this lining may be left to granulate and epithelialise, but most
often it is sutured to the mucoperiosteum at its periphery.

Packing of the cavity

After suturing the lining epithelium to the adjacent mucoperiosteum, the
cavity is packed with suitably medicated ribbon gauze (e.g. Whitehead’s
varnish) and sutured. Approximately 10 days after operation, the pack is
removed. In case of large cysts, sedation or analgesia should be
administered for changing the first dressing. The cavity is repacked. When
the wound has completely healed, it is usually possible to take an alginate
impression for the construction of an acrylic plug.

Indications for using plug

• In case of a small bony opening compared to the large size of the cyst
cavity. This kind of bony opening is made because of anatomic
consideration or to preserve adjacent teeth or other important structures.
• In case of opening surrounded by loose connective tissue (sulcus
mucosa) where in scar contracture reduces the size of the opening to one-
fourth of its original size. Therefore, the opening here should be
maintained with the use of a plug.

The slow process of bone regeneration now begins and the patient is seen
at monthly intervals for progressive reduction in the depth of the plug, but
the
diameter at the opening must be fully maintained. Bone replacement takes
place faster in the body and angle of mandible than in the maxilla.
However, in all large cysts the patient is usually under surveillance for 18–
20 months before he/she is able to discard the plug. Although there is often
extensive bone regeneration, the alveolar contour usually has a degree of
depression and distortion.

Features of a plug
• The plug should be retentive and maintain the patency of the cavity. It
should not irritate the mucosa.
• The plug should never reach till depth of the cavity, as this would
interfere with the bone regeneration and filling process.
• The plug can be attached to the dentures in case of edentulous patients.
• Intermittently, the plug should be vented to avoid pressure build up
within the cavity.
• The plug should be designed such that it is not swallowed or inhaled by
the patient.