CYSTS OF ODONTOGENIC

ORIGIN
Surabhi Sarkar
What is a cyst?
 A cyst is defined as a pathologic cavity lined
by epithelium.
 Cyst is an entity that constitutes an epithelium
lined sac filled with fluid or semi-fluid material.
Killey & Kay (1966)
 A cyst is an abnormal cavity in hard or soft
tissues which contains fluid, semi-fluid, or gas
and is often encapsulated and lined by
epithelium. Killey & Kay (1966)
 A cyst is a pathologic cavity having fluid, semi-
fluid or gaseous contents that are not created
by the accumulation of pus; frequently, but not
always, is lined by epithelium. Kramer (1974)

Connective tissue Lumen Epithelial lining

 Classification, WHO 2017
A. Epithelial lined
I. Cysts of the jaws B. Not epithelial lined
II. Cysts associated with the maxillary antrum
III. Cysts of the soft tissues of the mouth, face, (a) Odontogenic
neck and salivary glands (b) Non-odontogenic

i. Dentigerous cyst 1. Developmental origin

ii. Odontogenic keratocyst i. Radicular cyst
2. Inflammatory origin
iii. Lateral periodontal and botryoid ii. Residual cyst
odontogenic cyst iii. Collateral inflammatory
iv. Gingival cyst cyst
v. Glandular odontogenic cyst
vi. Calcifying odontogenic cyst
vii. Orthokeratinized odontogenic cyst

4th Edition of the World Health Organization Classification of Head and Neck Tumours: Odontogenic and Maxillofacial Bone Tumors
What changes?
 Reincorporation of odontogenic keratocyst and calcifying
odontogenic cyst in the cyst classification when they had been
classified in 2005 as neoplasms.
 Under inflammatory cysts, inflammatory collateral cysts are
included.
 Primordial cysts have been dropped and are no longer used
synonymously for odontogenic keratocysts.
What changes?
 Orthokeratinized odontogenic cysts are now
recognized as an odontogenic cyst distinct from
OKC.
 New diagnostic criteria for glandular odontogenic
cysts (GOC) are presented, and the histologic
overlap between GOC and cystic
mucoepidermoid carcinomas acknowledged. No
MAML2 gene in GOC.
Histogenic Classification
The epithelial lining origins of odontogenic cysts
Epithelial residue Origin of Epithelium Cyst

Rests of Serres Dental lamina OKC, Glandular

odontogenic cyst,
Gingival cyst of
infants and adults

Reduced Enamel Enamel organ Dentigerous cyst,

Epithelium Eruption cyst, Botryoid
odontogenic cyst,
Paradental cyst

Rests of Malassez Hertwig’s root sheath Radicular cyst,

Residual cyst
Distribution of odontogenic cysts according to
diagnosis. From Jones et al. (2006), Sheffield.
Cysts Number %
Radicular cyst 3724 52.3
Dentigerous cyst 1292 18.1
Odontogenic keratocyst 828 11.6
Residual cyst 573 8.0
Paradental cyst 402 5.6
Unclassified odontogenic cysts 210 2.9
Lateral periodontal cyst 28 0.4
Calcifying odontogenic cyst 21 0.3
Gingival cyst 16 0.2
Eruption cyst 15 0.2
Glandular odontogenic cyst 11 0.2
Epstein pearl 1 0.0
Total 7121 100.00
Pathophysiology
“A Surgeon must be a pathologist who does
operations.” Eric Carlson
How does a cyst develop and grow?
Cyst formation in
the jaws requires
three elements: Odontogenic epithelium derived from the basal epithelium of the
a source of
stomatodeum.
epithelium,
• Remnants of the dental lamina(rests of Serres),
a stimulus for
epithelial
proliferation • Reduced enamel epithelium,
and the capacity
for bone • Hertwig’s epithelial rooth sheath(rests of Malassez)
resorption and
cyst growth.
Cyst Initiation
 From the Cell Rests of Mallasez
Cyst formation in (Hertwig’s Epithelial Root Sheath):
the jaws requires
three elements: From within apical granuloma(round/ovoid
a source of cellular islands) > extension of
epithelium, proliferating epithelium strands > the
arcades and rings surround the inflamed
a stimulus for
epithelial necrotic part. > a hollow sponge-like
proliferation structure which consolidates to form a
continuous epithelium lining to the cavity >
and the capacity
for bone forms barrier to pulpal irritants from
resorption and surrounding tissues.
cyst growth.
Eg: Radicular Cyst, Residual Cyst
Cyst Initiation
 From Reduced Enamel Epithelium Eg: Dentigerous cyst, paradental cyst,
Cyst formation in Lateral periodontal cyst, eruption cyst,
the jaws requires (Enamel organ):
three elements: botryoid odontogenic cyst
Clefts arise from within layers of REE
a source of > enlarges and encloses tooth crown
epithelium, > impaired tooth eruption, or a
disturbance in the mucosal epithelial
a stimulus for component of the eruption process,
epithelial
proliferation could lead to continued enlargement
of this programmed crevicular cleft
and the capacity arising from proliferation of the outer
for bone layers of the reduced enamel
resorption and epithelium, and hence to the formation
cyst growth.
of a follicular cyst.
Cyst Initiation
 From Cells Rests of Serre (Dental lamina): Develops from
Cyst formation in
the jaws requires remnants of dental lamina rather than from aborted primordial
three elements: tooth germs as it was believed before.
a source of  The abundance of these lamina remnants in the third molar
epithelium,
region correlates well with the high frequency of occurrence of
a stimulus for keratocysts in this area.
epithelial
proliferation  Impacted or absent wisdom teeth would predispose to the
and the capacity preservation of these rests and to cyst formation.
for bone
resorption and Eg: OKC, Glandular odontogenic cyst, gingival cyst
cyst growth.
Cyst Enlargement
Cyst formation in
The mechanisms concerned with their enlargement can be divided
the jaws requires roughly
three elements: into three groups:
a source of a. Mural growth
epithelium,
i. Peripheral cell division
a stimulus for ii. Accumulation of cellular contents
epithelial
proliferation b. Hydrostatic enlargement
i. Secretion
and the capacity
of cyst ii. Transudation and exudation
enlargement and iii. Dialysis
bone resorption.
c. Bone-resorbing factor
Mural Growth
Hydrostatic Enlargement
i. Secretion: Goblet
cells have
intracystic secretions

ii. Transudation
and exudation:
owing to the protein
content of cystic
fluids

iii. Dialysis:
accumulation of
low-molecular
weight protein
forms a gradient
with net inflow of
fluid from
capillaries into
cystic lumen.
Bone Resorption
Vital cyst tissue(capsule and its leukocyte content,
contribution from vascular structures)

prostaglandin E2 (PGEj) and prostaglandin

E3(PGE3)
That production takes place in the capsule under the influence of
epithelial proliferation, lysosomal phospholipases from fibroblasts
and polymorphonuclear leucocytes breaking down phospholipid
cell membranes to produce arachidonic acid, which is converted by
the ubiquitous enzyme prostaglandin synthetase to prostaglandin.

Keratocysts contain matrix-solubilizing enzyme, collagenase, in their

walls contributing to cyst growth.
Diagnosis
Clinical Presentation
Symptoms:
 Completely symptomless, chance finding,
swelling
 intraoral discharge- tasteless, salty or sweet,
 acute abscess of infected cysts, dull throbbing
pain in less severe infections,
 impaired sensation of lower lip in mandibular
cysts,
 discomfort or difficulty in wearing dentures in
edentulous patients,
 tilted or shifted teeth in the mouth.
On Examination
Signs:
 Swelling, frankly fluctuant or bony hard on palpation,
 egg-shell crackling effect, springy in consistency,
 bluish tinge or dark red colour of soft tissues,
 infected cysts tender on touch,
 rarely lingual plate involvement in mandible,
 sinus opening,
 glairy cholesterol containing fluid or yellow purulent discharge,
 vitality of teeth may be compromised.
Investigations
 RADIOLOGY
 CT SCAN
 MRI
 RADIOPAQUE DYES
 ASPIRATION
 BIOPSY
Radiographic Appearances
 Area of radiolucency
surrounded by radio-
opaque line of
condensed bone.
 Confirm with aspiration
of cystic fluid, diagnostic
biopsy.
Is it a cyst?
 Periapical Radiolucency
 Periapical granuloma
 Scar
 Chronic or acute dentoalveolar abcess
 Osteomyelitis
 Hyperplasia of maxillary sinus lining
 Periapical Cementoosseous Dysplasia in its lytic or fibroblastic stage
 Traumatic bone cyst
 Periodontal disease
Wide array of odontogenic cysts and tumors including carcinomas and fibro-
osseous diseases can begin and develop radiolucencies that may appear
periapically.
Is it a cyst?
 Pericoronal radiolucencies:
 Follicularspace
 Dentigerous cyst
 Unicystic Ameloblastoma(mural type)
 Adenomatoid odontogenic tumor
 Calcifying odontogenic cyst or tumor(early stage)
 Ameloblastic fibroma
Is it a cyst?
 Solitray radiolucencies not
contacting teeth
 Anatomic patterns
 Post extraction socket
 Residual cyst
 Traumatic bone cyst
 OKC
 Ameloblastoma
 Focal Osteoporotic defect
of the jaws
 Surgical defect
 Central Giant call
granuloma
 Giant cell lesion
 Focal cemento osseous
dysplasia
 Early stage of cementifying
and ossifying fibroma
 Benign non-odontogenic
tumors
 Aspiration and Biopsy
Cyst Aspirate Features
 Aspiration
Dentigerous cyst Clear, straw colour fluid Total protein more than
 Inability to 4mg/dl. Resembles serum.
aspirate, vacuum
OKC Dirty, creamy white, viscoid Keratin squames
on suction suspension Total protein less than 4mg/dl.
indicates a solid Albumin in excess.
mass within Periodontal cyst Clear, pale, straw colour fluid Cholesterol crystals
Total protein 5-11mg/dl
 Excisional biopsy
Infected cyst Pus, brownish fluid, foul PMNs, cholesterol clefts
for smaller cysts smelling

 Incisional biopsy if Vascular lesion Blood

Needle in vessel
cyst is bigger
Traumatic bone cyst Air
Antrum
Inflammatory Odontogenic Cysts
 Radicular Cyst
 The most common odontogenic cyst Inflammatory origin
 Usually symptomless, the most common cause of slow growing swellings in the jaw.
 Pain and infection, Sinus opening
 A sine qua non for the diagnosis of a radicular cyst is the related presence of a
tooth with a non-vital pulp.
 Radiographically only apical radiolucency. Rarely any bony expansion until
secondary infection is there. Sclerotic bone lining d/d from periapical granuloma.
 Usually 0.5 to 1.5 cm but can become 5cm or larger.
 Infected radicular cysts will show resorption of adjacent tooth root.
 Radicular Cyst
 D/D:
 periapical granuloma
 In the anterior mandible, early osteolytic phase of periapical cemento-
osseous dysplasia
 Aspiration: Soft brown material with glistening oily yellow flecks. Nodules of
cholesterol.
 Histopathology:
 Proliferative nonkeratinising stratum squamous epithelium with plexiform
arrangement.
 Dense rich inflammatory infiltrate
 Most odontogenic cysts that become infected can show similar features.
 Residual Cyst
 Refers to a radicular cyst that fails
to involute after endodontic therapy
or tooth removal.
 Failed endodontic treatment,
residual periapical infection, tooth
removal without radicular cyst
enucleation.
 D/d:
 Radicular cyst of another tooth
 OKC and Ameloblastoma or
myxoma to be considered in case
where it is present even after tooth
removal.
Collateral Inflammatory Cyst
 The inflammatory collateral cyst has previously been described as the
inflammatory paradental cyst, the inflammatory lateral periodontal cyst, the
paradental cyst, or the mandibular infected buccal cyst.
 It is an inflammatory odontogenic cyst which occurs in association with the
root surface of partially or fully erupted vital tooth.
 Origin:
 Rests of malassez
 Reduced enamel epithelium
 Etiology: Inflammation due to periodontitis
 Pathogenesis: Occurs due to unilateral enlargement of dental follicle due to
inflammatory destruction of periodontium and alveolar bone.
 The consistent finding of a hyperplastic, nonkeratinized stratified squamous
epithelium with an intense inflammation in the connective tissue is in
accordance with the hypothesis that inflammation is important for the
development of these cysts.
Developmental Odontogenic Cysts
 Dentigerous Cyst
 A dentigerous cyst is one that encloses the crown of an
unerupted tooth by expansion of its follicle, and is attached
to its neck.
 The dentigerous cyst is attached to the tooth at the
cementoenamel junction.
 Clinical Features:
 AGE : 1st to 3rd decades.
 GENDER : More frequently in males than in females.
 SITE : 2/3rd of follicular cyst associated with unerupted mandibular
teeth, primarily III molar, Maxillary canine, Mandibular premolar,
Maxillary 3rd Molar, Supernumerary tooth also can be involved
Dentigerous Cyst
Clinical presentation:
 Dentigerous cysts may grow to a large size before they are diagnosed. Most of them are
discovered on radiographs when these are taken because a tooth has
1. Failed to erupt, or a tooth is missing, or
2. Because teeth are tilted or are
otherwise out of alignment.
 Most common form of presentation:
Slowly enlarging swelling.
They are seldom painful unless infected.
Usually does not lead to paraesthesia
Dentigerous Cyst
 Radiographically:
 Well demarcated radiolucency
asso with crown of unerupted
tooth.
 Tooth may be displaced to the
inferior border of mandible, even
upto the level of condylar neck,
nasal floor, maxillary sinus,
approaching the orbit.
 Displace adjacent erupted teeth.
 Root resorption in radiographs.
 Dentigerous Cyst
Types: a) Central b) Lateral c) Circumferential
Aspirational biopsy gives:
 Clear, pale straw colour fluid, Cholesterol crystals.
 Total protein in excess 4 g/100ml. Resembles serum

 Surgically managed by
 enucleation with extraction,
 Marsupialisation(risk of neoplastic transformation of cyst lining)
Done either when it will allow tooth to spontaneously erupt or guided orthodontically, or
There is an identification of risk of damaging adjacent developing teeth or neurovascular bundles
during enucleation
Lateral Periodontal Cyst
 Usually diagnosed as an incidental
radiographic finding.
 Round or tear-drop shaped
unilocular radiographic
appearance at mid-root level.
 Mostly in adults older than 21 and
has a male prediliction.
 In both the jaws develops around
the premolar and canine regions.
 D/D:
 Botroid odontogenic cyst
 Squamous odontogenic tumor(occurs
in premolar regions)
Lateral Periodontal Cyst
 Botryoid Odontogenic Cyst
• Similar to lateral periodontal
cyst in pathogenesis
• Differs radiographically,
histologically and prognostically
• Differs in being multicystic-
grape cluster appearance on
radiograph
• Satellite or daughter cysts that
pinch off the cystic lining
• High rates of recurrence
• Presents with: Swelling,
Paresthesia, Pain, Discharge
• Complete surgical excision
Odontogenic Keratocyst- what’s the controversy about?
 In 2005 the OKC was reclassified as a tumor based on “aggressive growth”,
recurrence after treatment, the rare occurrence of a “solid” variant of OKC, and
most importantly, mutations in the PTCH gene.
 85% inherited mutated PTCH gene in NBCCS.
 30% in non-NBCCS justified by somatic mutation to acquire the phenotype.
 So, mutated would be neoplasm and non-mutated would be cysts???
 But classically a neoplasm should continue to grow after the stimulus which produced
it is removed, should not regress spontaneously.
 OKCs are well documented to completely regress following decompression and the
lining of many decompressed cysts appears more like oral mucosa than OKC
histologically.
 Still lacking enough evidence to call it a tumor.
 Odontogenic Keratocyst
 Dental lamina remnants in the bony crypts.
 Oral mucosa
 Another variant that arises from the REE and is of dentigerous origin
Histopathology:
 Parakeratinised stratified squamous epithelium which is 6-8 cells thick.
 Absence of rete pegs.
 Separation of epithelium from connective tissue due to metalloprotienases causing degradation of
collagen at the juxta epithelial regions.
 Epithelial dysplasia present.
 Fibrous connective tissue wall.
 In case of infection/inflammation of the cyst the epithelium becomes non-keratinised and may lead of
an incorrect histopathological diagnosis.
 Presense of daughter or satellite cysts in connective tissue.
 Keratohyaline granules in the lumen.
Odontogenic Keratocyst
 Presents as:
Patients with OKCs complain of pain, swelling or
discharge.
Occasionally, they experience paresthesia of the
lower lip or teeth.
Sometimes discovered fortuitously during dental
examination when radiographs were taken.
Extend in the medullary cavity and clinically
observable expansion of the bone occurs late.
Enlarging cyst may lead to displacement of tooth.
 Aspirational biospy
Dirty, creamy white viscoid suspension.
Keratin squames
Total protein less than 4 g/00ml. Mostly albumin
 COMPLICATIONS IN OKC :
Malignant transformation of cyst lining rare, but has
been reported.
Recurrence – high rate of recurrence.
Odontogenic Keratocyst
 Reasons for recurrence
 Tendency to multiply

 Satellite cyst

 Cystic lining is very thin and fragile, portions of which

may left behind
 Epithelial lining of OKC has intrinsic growth potential

 Cyst can arise from basal cells of oral mucosa

Odontogenic Keratocyst
Multiple OKC’s are seen in Gorlin’s
syndrome or Gorlin-Goltz
syndrome or Nevoid Basal Cell
Carcinoma syndrome
 Multiple nevoid basal cell
epitheliomas
 Multiple OKCs of the jaws
 Bifid ribs
 Plantar & palmar pits
 Occular hypertelorism
 Frontal bossing
 Ectopic calcifications
Odontogenic Keratocyst
Surgical Management
 Enucleation with curettage
 Enucleation with peripheral ostectomy
 Excision of attached mucosa with
enucleation and carnoy’s solution for
bony defect.
 Decompression with marsupialisation.
 Liquid nitrogen cryosurgery.
 Osseous resection (rim ostectomy or
marginal resection) or with segmental
resection(continuity defect) – Best –
Zero recurrence rate.
Orthokeratinised Odontogenic Cyst
 The cystic lining consists of a mature stratified squamous epithelium without
rete ridge development which exhibits orthokeratosis and a prominent
granular cell layer. The basal cells tend to be flattened to cuboidal but not
palisaded and hyperchromatic.
 In contradistinction to OKCs, orthokeratinized odontogenic cysts are
 not particularly aggressive biologically,
 do not have a significant recurrence rate after removal and
 are typically not associated with the nevoid basal cell carcinoma syndrome.
Gingival Cyst
• Arise from odontogenic epithelial cell rests; or
by traumatic implantation of surface
epithelium; or by cystic degeneration of deep
projections of surface epithelium.
• Clinically presents as dome shaped soft,
fluctuant swelling which is <1cm in diameter
• Slow growing and painless
• Appears usually on facial aspect of gingiva,
adjacent teeth usually vital
• Surgical excision
Gingival Cyst of Newborn
 This cyst occurs in infants a
few hours to a few months old.
 Cysts appear as multiple, firm,
white gingival nodules on the
edentulous maxillary or
mandibular ridges.
 They arise from proliferation
of the dental lamina.
 They usually involute, and no
treatment is required except
parent reassurance.
 Glandular Odontogenic Cyst
 Rare lesion
 Intrabony and multilocular radiologically
 Could recur if not adequately excised
 Multicystic, with the cystic spaces lined by a non-
keratinised epithelium akin to that of reduced enamel
epithelium.
 Epithelial thickenings or plaques were present in the
cyst linings and mucous and cylindrical cells formed
an integral part of the epithelial component.
 Mucinous material within the cystic spaces was a
prominent feature.
 Eneucleation, peripheral ostectomy, marginal
resection or partial jaw resection.
 Calcifying odontogenic cyst
 Presents as:
Swelling, hard bony expansion that may be fairly extensive;
Lingual expansion; Perforation of cortical plate; Displacement of
teeth; Pink to red, circumscribed elevated masses measuring up to
4cm in diameter
 As defined in the WHO classification of 1992, it is: ‘A cystic lesion
in which the epithelial lining shows a well-defined basal layer of
columnar cells, an overlying layer that is often many cells thick
and that may resemble stellate reticulum, and masses of “ghost”
epithelial cell that may be in in the epithelial lining or in the
fibrous capsule. The “ghost” epithelial cells may become calcified.
Dysplastic dentine may be laid down adjacent to the basal layer
of the epithelium, and in some instances the cyst is associated with
an area of more extensive dental hard tissue formation
resembling that of a complex or compound odontoma.’
Calcifying odontogenic cyst
• Radiographs show well-demarcated margin and
calcifications suggestive of tooth material.
• Surgical enucleation
General Principles of Surgical Management
Surgical Management
Enucleation is the process by
1. Enucleation which the total removal of a
cystic lesion is achieved.
2. Marsupialization • Enucleation of cysts should be
performed with care, in an
3. A staged attempt to remove the cyst in one
combination of piece without fragmentation,
the two which reduces the chances of
procedures recurrence by increasing the
likelihood of total removal.
4. Enucleation with • However, maintenance of the
curettage. cystic architecture is not always
possible, and rupture of the cystic
contents may occur during the
procedure.
Advantages:
• pathologic examination of the entire
cyst can be undertaken
• the initial excisional biopsy (i.e.,
enucleation) has also appropriately
treated the lesion.
• The patient does not have to care for a
marsupial cavity with constant irrigations.
Disadvantages:
• Normal tissue may be jeopardized
• Fracture of the jaw
• Devitalization of associated teeth
• Impacted teeth that the clinician may
wish to save could be removed.
Surgical Management
Enucleation of a cyst. A, Mild
1. Enucleation swelling in area of periapical
cyst. B, A mucoperiosteal flap
2. Marsupialization is elevated from around the
necks of teeth, and a bur is
used to remove thinned cortical
3. A staged bone overlying the cyst. Care
combination of is taken to prevent rupturing of
the two cystic contents during this and
procedures the following steps. C and D, A
spoon-type curette is used to
strip the cyst from bone. Note
4. Enucleation with
that the concave side of the
curettage. curette is kept in contact with
bone. The convex surface is the
working end of the instrument.
E, Closure.
Surgical Management
1. Enucleation

2. Marsupialization

3. A staged
combination of
the two
Apical cystectomy performed at time of tooth
procedures removal. A to C, Removal of a cyst with curette
via a tooth socket is visualized. An apical
4. Enucleation with cystectomy must be performed with care
because of the proximity of the apices of teeth
curettage. to other structures such as the maxillary sinus
and the inferior alveolar canal. D to J,
Removal of an apical cyst by flap reflection
and creation of osseous window is
demonstrated at the time of tooth removal.
Surgical Management
1. Enucleation

2. Marsupialization

3. A staged
combination of
the two
procedures

4. Enucleation with
curettage.
Photographs of a clinical case of apical cystectomy performed at time of tooth extraction. A, Pretreatment panoramic
radiograph showing large radiolucent lesion at the apices of teeth No. 18 and 20. B, Appearance of lesion after
buccal flap elevated. Note that the lesion has eroded the bone. C, Curette used to elevate the lesion from the bony
walls. D, Cyst being removed. E, Note the inferior alveolar neurovascular bundle passing along the inferior aspect of
the bony cavity. F, Surgical specimen. G, When opened, the specimen appeared to be cystic. H, Postoperative
panoramic radiograph showing defect. The patient should be monitored with periodic radiographs to ensure bone fill
and no recurrence of the lesion.
Surgical Management
Marsupialization, decompression, and
1. Enucleation the Partsch operation all refer to
creating a surgical window in the wall
of the cyst, evacuating the contents of
2. Marsupialization
the cyst, and maintaining continuity
between the cyst and the oral cavity,
3. A staged maxillary sinus, or nasal cavity.
combination of • The only portion of the cyst that is
the two removed is the piece removed to
produce the window. The remaining
procedures
cystic lining is left in situ.
• This process decreases intracystic
4. Enucleation with
pressure and promotes shrinkage of the
curettage. cyst and bone fill. Marsupialization can
be used as the sole therapy for a cyst
or as a preliminary step in
management, with enucleation
deferred until later.
INDICATIONS:
1. Amount of tissue injury : Proximity of a cyst to vital
structures can mean unnecessary sacrifice of tissue if
enucleation is used.
2. Surgical access : If access to all portions of the cyst
is difficult, portions of the cystic wall may be left
behind, which could result in recurrence.
3. Assistance in eruption of teeth : If an unerupted
tooth that is needed in the dental arch is involved with
the cyst (i.e., a dentigerous cyst), marsupialization may
allow its continued eruption into the oral cavity
4. Extent of surgery : Marsupialization is a reasonable
alternative to enucleation, because it is simple and
may be less stressful for the patient
5. Size of cyst : In very large cysts, a risk of jaw
fracture during enucleation is possible.
It may be better to marsupialize the cyst and defer
enucleation until after considerable bone fill has
occurred.
Surgical Management
Advantages:
1. Enucleation • It is a simple procedure to perform.
Marsupialization also spare vital
2. Marsupialization structures from damage should
immediate enucleation be attempted.
Disadvantages:
3. A staged • Pathologic tissue is left in situ, without
combination of thorough histologic examination.
the two • Patient is inconvenienced in several
procedures respects
• The cystic cavity must be kept clean
to prevent infection, because the
4. Enucleation with
cavity frequently traps food debris.
curettage. • In most instances this means that the
patient must irrigate the cavity
several times every day with a syringe
Surgical Management
1. Enucleation

2. Marsupialization
Marsupialization technique. A, Cyst
within maxilla. B, Incision through
3. A staged oral mucosa and cystic wall into
combination of center of cyst. C, Scissors used to
the two complete excision of window of
procedures mucosa and cystic wall. D, Oral
mucosa and mucosa of cystic wall
4. Enucleation with sutured together around periphery
of opening.
curettage.
Surgical Management
Marsupialization of cyst in right mandible
1. Enucleation associated with unerupted teeth. A,
Photograph showing swelling around right
second deciduous molar. B, Radiographic
2. Marsupialization appearance before marsupialization.
Note the large radiolucent lesion and
displacement of the second right
3. A staged premolar toward the inferior border
combination of (compare with the opposite side).
Cystectomy would probably injure or
the two necessitate the removal of premolars,
procedures so it was decided to perform
marsupialization of the cyst instead. C,
Aspiration performed to determine
4. Enucleation with whether the lesion was fluid filled (cystic).
curettage. D, The lower right deciduous second molar
was removed, and the cyst was opened
through the socket (decompressed). E,
Panoramic radiograph taken 5 months
after surgery showing bone fill and
eruption of the premolars.
Surgical Management
Marsupialization of an odontogenic
keratocyst in right mandible associated
1. Enucleation with an impacted third molar. A,
Panoramic radiograph showing large
2. Marsupialization multilocular radiolucent lesion associated
with tooth No. 32. B, Aspiration of the
lesion reveals a creamy liquid (keratin).
3. A staged C, Exposure and removal of bone behind
the second molar reveals the impacted
combination of third molar crown. D, The impacted tooth
the two was removed, and additional bone was
procedures removed to provide a large window into
the lesion. A portion of the lining was
excised and sent for pathologic
4. Enucleation with examination. The cavity was inspected
through the opening to ensure there was
curettage. no solid mass that might indicate tumor.
E, Holes were drilled around the
periphery of the bony opening to pass
sutures from the oral mucosa, through the
holes in the bone, and through the cyst
lining. This provided a stable opening
from the oral cavity into the cyst.
Surgical Management
1. Enucleation INDICATIONS
• When bone has covered the adjacent vital structures.
2. Marsupialization • Adequate bone fill. Prevents fracture during enucleation.
• When patients find it difficult to cleanse the cavity.
3. A staged • To detect any occult pathological condition.
combination of ADVANTAGES
the two • Spares adjacent vital structures
procedures • Accelerates healing process
• Development of thick cystic lining – enucleation easier
4. Enucleation with • Allows histopathological examination of residual tissue.
curettage. • Combined approach reduces morbidity
DISADVANTAGES
• Patient has under go second surgery and any possible complicatton associated with
surgery.
Surgical Management
Enucleation with curettage means that Indications :
1. Enucleation after enucleation a curette • In this case the more aggressive
or bur is used to remove 1 to 2 mm of approach of enucleation with curettage
2. Marsupialization bone around the entire should be used.
periphery of the cystic cavity • Daughter, or satellite, cysts found in the
3. A staged • Any remaining epithelial cells that periphery of the main cystic lesion may
combination of may be present in the periphery be incompletely removed
the two of the cystic wall or bony cavity must • The second instance in which enucleation
procedures be removed. with curettage is indicated is with any cyst
• These cells could proliferate into a that recurs after what was deemed a
4. Enucleation with recurrence of the cyst. thorough removal.
curettage. Advantages :
• If enucleation leaves epithelial
remnants, curettage may remove them,
thereby decreasing the likelihood of
recurrence.
Enucleation with Peripheral Ostectomy
 A peripheral ostectomy with rotary instruments enables
the surgeon to remove as much bone as necessary to
ensure that all residual lining is gone.
 One of the inherent problems with a peripheral
ostectomy, just like curettage, is the ‘‘immeasurability’’
of the amount of osseous resection.
 Use of methylene blue to identify dysplastic tissue.
 Enucleation and use of Carnoy’s solution
 The first use of Carnoy’s solution in surgery was reported by Cutler and Zollinger in 1933.
They used it as a fixative, haemostatic and cauterising agent and mentioned its action in
penetrating cancellous spaces of bone, devitalising tissue and fixing tumor cells.
 Carnoy’s solution otherwise was being used otherwise in fixing lymph nodes in cadavers and
as fixative in histopathological fields.
 Success of the application of this medicament after enucleation of OKC is thought to be due to
both penetration and fixation action.
 The application of Carnoy's solution promotes a superficial chemical necrosis and is intended
to reduce recurrence rates of jaw cysts and tumors.

• Cutler EC, Zollinger R. Sclerosing solutionin the treatment of cysts and fistulae. Am JSurg;19:411, (1933).
• Lau SL, Samman N. Recurrence related to treatment modalities of unicystic amelo-blastoma: a systematic review.Int. J. Oral Maxillofac. Surg.
2006; 35: 681–690
 Carnoy’s Solution
Composition:  This led to the reformulated carnoy’s solution
 Carnoy’s solution II (Recommended by Cutler and without chloroform and is now being accepted.
Zollinger - 1933):  Ferric chloride - 1gram
 Ferric chloride - 1 gram  Glacial acetic acid - 1ml
 Chloroform - 3ml  Absolute alocohol - 6ml
 Glacial acetic acid - 1ml
 Absolute alocohol - 6ml
 Extensive studies have proved that exposure to
chloroform has been associated with cancer and
reproductive toxicity thus banning the use of the
medicament in many parts of the world.

• Frerich B, Cornelius CP, Wietholter H. Critical time of exposure of the rabbit inferior alveolar nerve to Carnoy’s solution. J Oral Maxillofac Surg
1994: 52: 599–606.
 Carnoy’s Solution
 Mechanism of action:
 Absolute alcohol hardens the tissue by shrinking it,
 glacial acetic acid swells tissue and prevents over-hardening,
 chloroform increases the speed of fixation and
 ferric chloride acts as a dehydrating agent.
 Uses in Maxillofacial Surgery:
 Used to fix the tissue after enucleation of the OKC
 Used to fix the tissue after enucleation of few types of
ameloblastoma
• Carnoy’s solution as a surgical medicament in the Treatment of keratocystic odontogenic tumour. Dr. Madhulaxmi. M, Dr. P.U. Abdul
Wahab. Int J Pharm Bio Sci 2014 Jan; 5(1): (B) 492 – 495
Carnoy’s Solution
 The usual practice is the application
of Carnoy's solution after enucleation
and peripheral ostectomy with
application of methylene blue.
Carnoy’s solution with cotton
applicators or ribbon gauze for 3– 5
min, rinse the bony cavity and pack the
wound open for healing by secondary
intention. Primary closure is likely to
precipitate infection of necrotic debris.
 It is assumed that carnoy’s solution eradicates epithelial rests from the bony cyst wall. Its average depth of
penetration is 1.54mm after 5 mins of application.
 However, FRERICH et al. suggested the application of Carnoy’s solution should not exceed 3 min. They showed
that the critical time to nerve impairment of the inferior alveolar nerve was 3 min, and that Carnoy’s solution
should not be applied directly over the nerve. Though this still remains a matter of study.
 Carnoy’s Solution
 Adverse effects
 Among all the ingredients of carnoys solution, chloroform is considered to be
very hazardous and should be used in a ventilated hood by wearing masks.
Exposure to chloroform has been associated with cancer and reproductive
toxicity.
 Alteration in the neural conductivity after direct application of carnoys solution
over 2 minutes.
 Carnoy’s solution does not maintain the osseous structure where as cryotherapy
maintains bony architecture and facilitates new bone formation.
 It lowers the recurrence rate after enucleation of Keratocystic odontogenic
tumour. To overweigh the risks, reformulated carnoy’s solution can be used
and avoid using the carnoy’s solution in close vicinity to the nerve.
• Surgical treatment of keratocystic odontogenic tumour: A review article; The Saudi Dental Journal (2011) 23, 61–65
• Carnoy’s in Aggressive Lesions: Our Experience; J. Maxillofac. Oral Surg. (Jan-Mar 2013) 12(1):42–47
 Enucleation and liquid nitrogen cryotherapy
 Liquid nitrogen has the ability to devitalize bone in situ while leaving the inorganic
framework untouched, as a result of this, cryotherapy has been used for a number
of locally aggressive jaw lesions, including OKC, ameloblastoma and ossifying
fibroma.
Principles of cryosurgery
The mechanism of cell and tissue death with cryosurgery involves the following
mechanisms:
 intracellular and extracellular ice crystal formation,

 osmotic and electrolyte disturbances,

 denaturation of proteins complexed with lipids,

 and vascular stasis.

• The use of liquid nitrogen cryotherapy in the management of the odontogenic keratocyst. Brian L. Schmidt. Oral
Maxillofacial Surg Clin N Am 15 (2003) 393–405
Cryotherapy
 Tissues freeze at approximately -2.2C; temperatures
below -20C are believed to cause cell death on a
consistent basis.
 Liquid nitrogen cryotherapy can weaken the bone
significantly with resultant pathologic fractures.
 Synchronous grafting with cancellous bone can be
accomplished after cryotherapy. Sensory nerves within
the field may show paresthesia; however, the majority
recover within 3 to 6 months.
Cryotherapy
 Indications for management cysts with cryotherapy
 Recurrent OKC
 Large complex mandibular lesions
 Conventional treatment might involve vital structures
 Noncompliant patient
 Oral cryosurgical techniques
 Protection of extraoral soft tissues
 Enucleation
 Exposure and retraction of intraoral soft tissues
 Cryosurgical technique
 Cryoprobe with water soluble jelly
 Liquid nitrogen spray
Cryotherapy
Technique Advantages Disadvantag
es

Cryoprobe Able to Non-uniform

with freeze freezing
water- irregular,
soluble gravity
jelly dependent
portions
of the cavity

Liquid Potent, Damage to

Nitrogen thorough surrounding
Spray freezing tissues
 BIPP
 BIPP is a bright yellow paste of sub nitrate
250mg/g, iodoform 500mg/g and liquid paraffin
250 mg/g.
 This paste is usually placed in cavities and left in
place till the cavities heals or a graft is taken.
 Bismuth has topical antiseptic properties and can be
used as an astringent. This property contributes to the
antibacterial properties of BIPP by releasing dilute
nitric acid on hydrolysis.
 Iodoform decomposes to release iodine which is an
antiseptic.
 Paraffin is added into BIPP as a lubricant which aids
in atraumatic placement and removal of pack.

Int J Dent Med Res | JULY-AUGUST 2014 | VOL 1 | ISSUE 2; Agrawal R et al: Bismuth Iodoform and Paraffin Paste in
Keratocystic Odontogenic Tumor
Jaw Resection
Block resection, with or without preservation of the continuity of the
jaw
 Resection refers to either segmental resection (surgical removal of a
segment of the mandible or maxilla without maintaining the
continuity of the bone) or marginal resection (surgical removal of a
lesion intact, with a rim of uninvolved bone, maintaining the continuity
of the bone).
 Extreme technique, that results in considerable morbidity,
particularly because reconstructive measures are necessary to
restore jaw function and aesthetics.
Methods of mandibular resection
 Two basic methods:
 In the marginal or rim resection, the integrity of the
lower or upper border of the mandible is kept intact.
 In the full or segmental resection of the mandible,
both the upper and lower border are included in the
resection so that there is a loss of continuity of the
mandible.
MARGINAL OR RIM RESECTION
 Infective or osteonecrotic disorders- general debridement.
 Odontogenic tumors- resection with wider margins.
Segmental Resection
 Indicated for
 Infiltrative lesions
 Lesions involving lower and posterior
border
 Recurrent lesions
 Complete segment from alveolus to
inferior border is resected.
 Deviation of mandible to resected side,
occlusion derranged, marked facial
deformity.
 Need for reconstruction.
Resecting the Maxilla
 Maxillary resection is guided by the  Class 1 (alveolectomy)
extent of cyst.  Class 2 (low level maxillectomy)
 Pre-operative imaging will include an  Class 3 (high level maxillectomy
orthopantomogram (opg) and a CT maintaining the orbit)
scan and often an additional MRI will
be useful to assess the skull base.  Class 4 (radical maxillectomy with
orbital exenteration)
 The main issues in maxillary resection
involve the removal of the orbit and
the extent of the disease into the
infratemporal fossa.
Conclusion
 Cysts are a common clinical condition and frequently encountered in
practice.
 They can be a window to the diagnosis of underlying symptoms in a
subject.
 The initial surgical treatment and the subsequent follow-up of cysts
of the oral and maxillofacial region depend on several factors:
 The patient’s age and overall health condition
 Size and location of the cyst
 Histologic diagnosis of the lesion gained by excisional, incisional, or FNA
biopsies.
 References
 4th Edition of the World Health Organization Classification of Head and Neck Tumours: Odontogenic and Maxillofacial Bone Tumors, 2017
 Cysts of the Oral and Maxillofacial Regions Fourth edition Mervyn Shear, Paul Speight
 Oral And Maxillofacial Surgery Volume II Trauma, Surgical Pathology, Temporomandibular Disorders - Eric R. Carlson, Raymond J. Fonseca, Gregory M. Ness - 3rd Edition (2017)
 DIFFERENTIAL DIAGNOSIS of ORAL and MAXILLOFACIAL LESIONS; NORMAN K. WOOD, PAUL W. GOAZ
 Odontogenic Cysts and Tumors Brad W. Neville, Douglas D. Damm, Carl M. Allen, and Angela C. Chi; Oral and Maxillofacial Pathology, 15, 632-689
 THE PATHOGENESIS OF DENTAL CYSTS MALCOLM HARRIS; Br.Med.BuU. 1975; Vol. 31 No. 2
 The pathogenesis of odontogenic cysts: a review; R. M. BROWNE Jottrtial of Oral Pathology 1975: 4: 31-46
 Controversies in Oral and Maxillofacial Pathology Zachary S. Peacock, DMD, MD; Oral Maxillofacial Surg Clin N Am 29 (2017) 475–486
 Odontogenic cysts; Lisette Martin, Paul M Speight; DIAGNOSTIC HISTOPATHOLOGY 21:9; MINI-SYMPOSIUM: PATHOLOGY OF THE JAWS
 Surgical treatment of keratocystic odontogenic tumour: A review article Walid Ahmed Abdullah; The Saudi Dental Journal (2011) 23, 61–65
 An analysis of the clinical and histopathologic parameters of the odontogenic keratocyst Thomas P. Pay, Atlanta, DEPARTMENT OF ORAL PATHOLOGY, EMORY UNIVERSITY
SCHOOL OF DENTISTRY
 The use of liquid nitrogen cryotherapy in the management of the odontogenic keratocyst; Brian L. Schmidt; Oral Maxillofacial Surg Clin N Am 15 (2003) 393–405
 JAW CYSTS: DIAGNOSIS AND TREATMENT GORDON W. SUMMERS; HEAD & NECK SURGERY 1:243-256 1979
 Surgical treatment of keratocystic odontogenic tumour: A review article; The Saudi Dental Journal (2011) 23, 61–65
 Carnoy’s in Aggressive Lesions: Our Experience; J. Maxillofac. Oral Surg. (Jan-Mar 2013) 12(1):42–47