Oral surgery :: Large cyst in the maxillofacial area

The cysts in the maxillofacial area /MFA/ are the most common cysts in the human body. This is due to both abnormalities in embryonic development and ontogenetic factors, as well as frequent chronic inflammatory processes in this area. What is a Cyst? The cyst is a pathological cavity in the human body that has its own connective tissue sheath, upholstered with epithelium and filled with fluid. Usually this liquid called cystic fluid containing cholesterol crystals.



Abstract scheme of the cyst:
a / cystic cavity
b / multilayered epithelium
c / connective tissue capsule
d / jet area
When the cyst is infected, it contains pus or blood and pus. In addition, what about a large cyst? It is a relative term, but in dental practice, it accepted to say that a cyst is large when it covers the space below two or more teeth. The pathoanatomical and clinical diversity of cysts in the MFA is too great, but without going into unnecessary theorizing of the issue (something that you can read in textbooks and monographs), we will pay attention to the most common cysts in this area and their treatment in the past and present. One of the most common cysts in the MFA is the radicular cyst.



As shown in the schemes, the radicular cyst comes from the root (radix) of the tooth. Another common cyst in the MFA is the follicular cyst.



Scheme of a follicular cyst

This cyst derives of the crown of the tooth, and more precisely from the crown of the corresponding tooth germ (folliculus), from which, of course, its name originates. If we look at cursorily of the upper and lower schema immediately we can see the difference between the two types of cysts - in the radicular is the root of the tooth, and in the follicular the crown. This is also the main X-ray symptom of their recognition. However, if we look closely at the patient's mouth, we will notice in both cases the convergence of the crowns of the adjacent teeth, since the cyst has pushed the roots in the sides, except that at the radicular cyst there is a tooth in the mouth of the patient, while in the follicular missing a tooth. This is a clinical feature that should guide the dentist to take an X-ray because there is clearly a process in the jaw that is awaiting its diagnosis. This leads to finding a follicular cyst or ... Globulomaxillary cyst - the other, not as common as the first two cysts in the MFA.



Scheme of a globulomaxillary cyst

Here again we have convergence of the crowns, but there is no tooth in the mouth and radiographically no tooth is found in the cyst, which is natural since its development is not related to the tooth but is the result of irregularities in the embryonic development of the jaws. These types of cysts grow expansively, which is to say they push the tissues in their path, a major difference from the malignant tumors that destroy the tissues in their path. That is why cysts have a bone reactive zone, etc. "Osseo sclerotic shaft",  while in the tumors, it is absent. Moreover, the expansive growth answers the question why most of the small cysts are perfectly spherical in shape, but when they grow larger, their shape becomes irregular, usually with pear-shaped, due to the different resistance of the tissues. In this regard, the development of the cysts in the direction of body cavities, such as the maxillary sinus, is of diagnostic, clinical and, respectively, therapeutic interest.

 

In this diagram we can see a small radicular cyst bordering the maxillary sinus without pushing the sinus and a large, on the right, strongly pushing in the cranial direction the sinus floor, which we can not we seen to the left. The development of the cyst is asymptomatic as there is no resistance from the sinus and nothing can not to be affected. Too often, this creates diagnostic difficulty and hence a vicious treatment.                                                                  
Below, we will look at this case. When the cyst develops in the lower jaw and pushes the mandibular canal, in rare cases it can give the Vincent symptom - tingling of the corresponding end of the lower lip due to compression of the mandibular nerve, as well as pathological fracture of the jaw.


This is how a normal mandibular canal looks schematically
In addition, here is what a mandible canal from a developing cyst looks like.



All described cysts treated incorrectly are the cause of the other common cyst in the MFA, namely...

Residual cysts /residualis - residual/


X-ray of a residual cyst

At these cysts, it lacks a tooth or tooth root in both the mouth and the cyst.
A little about differential diagnosis ... Quite often, in practice, colleagues confuse maxillary sinus with a large cyst.


Two X-rays diagnosed with a radicular cyst.

In fact, this is the maxillary sinus and the grounds are 2:

    • At such a large cyst always have a clinic - swelling in the vestibulum, which easily felt and even noticed, as well as the crepitus, typical of such a cyst - parchment cracking on palpation. There were no such symptoms in the clinic.
    • If we follow X-ray Linea albuginea, which outlines the periodontium, we will see that it is continuous. In a cyst in the sinus, Linea albuginea breaks at the point where the contour of the cyst floor begins and reappears on the other side of the root.





In addition, one example of a lower jaw, though the clinic is full of similar ones. Both the X-ray and the diagram show that there are no cysts, but the dentist diagnosed them and referred the patient for surgery. Black arrows indicate one large cyst and white arrows indicate one small and one large cyst. In fact, what the colleague considered a large cyst is a malformation of the mandibular canal, in which the lower part limited by the compact, and the upper, adjacent to the apexes of the roots, which appear to be “immersed” in the “cyst”, which in turn proceeds from them. , is simply a variation on the anatomy of the canal. The dark spot that indicates the back white arrow is the mental aperture, and that indicated by the front white arrow is an artifact due to the X-ray orthopantomography technique.
How can we be convinced of this:
The teeth are intact, but we can make an electro diagnosis that will show normal values.
    We make dental x-rays of suspicious areas and if the image does not repeat, there is no pathology. On the contrary, if confirmed, there is some pathology, which we have to clarify.

There are two methods of treating cysts:
Conservative
Surgically
The conservative method is indicate for radicular cysts of small size, from 1 - 1.5 cm.
Exact root canal treatment is apply according to modern endodontic methods, which usually leads to healing. In larger cysts, the method is surgical. Here we have two varieties:
     Parch I method - Cystotomy / Marsupialization /.
     Parch II method - Cystectomy.




  This scheme shows the older method of Parch - Marsupialization, namely, the formed flap, the resected apex, and the suturing of the cystic sac to the flap, thus making the cystic cavity adjacent to the oral cavity. There has been a modification of the said Wasmund method, in which the cystic sac is curated, the flap is „cover“ into the cystic cavity as far as it can reach and the cavity is tamped with iodine gauze to epithelialize the exposed bone. These methods are indicated for too large and infected cysts, but they are hardly practiced today because they give major defects to the jaws and, naturally, due to the presence of more modern methods.



In this scheme, from left to right and from top to bottom, the radicular cyst, the repaired flap, the cystectomy and resection of the apex, and the stitched the flap can be seen. The method is classic /Parch II/ and is used in the operation of any cyst, small and large, and is practically no different from the so-called. "Apical osteotomy" for granuloma surgery.
For particularly large cysts, Nastev suggested modifying the method by placing a "mattress" suture in it to reduce the cavity and coagulum.

Here is the diagram:



We can see that the "mattress" suture has significantly reduced the cavity, which guarantees that the blood coagulum will not decompose.

The modern method of surgery for large cysts does not differ from the method of Parch II, without the need for modification of Nastev, since antibiotics are improved / more powerful and purified / than those of the past, and to reduce the coagulum we put bone a substitute that also initiates and promotes osteogenesis. The membrane, in turn, prevents mucosal invasion and allows the bone to become organized.
We will show you some interesting cases of the above cysts before and after surgery.


Small cyst operated on Parch I and filled with bone replacement



Large radicular cysts operated by a modern method



The x-ray above shows a small radicular cyst emanating from 44-th teeth and one large residual. The large one operated by a modern method, while the small one simply extracted the root of the tooth and made a curettage.


This x-ray shows a large follicular cyst emanating from 35 teeth. The medial root of 36 teeth stands "hanging" in the cavity of the cyst. The examination vestibularly feels a strong bump without crepitus.


We performed the operation using a modern method, extracted 35-th tooth   and made hemi section on 36. Then we extracted the pulp from the distal root immediately and subjected to obturation by a liquid photo polymer.


A huge globulomaxillary cyst, extending from 15-th to 23-rd teeth, at its typical location between the lateral incisor and the canine tooth. The convergence of the crowns of the teeth is evident clearly.


An x - ray after cyst surgery using a modern method. First, we extracted 12-th tooth due to high mobility. After that, we devitalized the teeth adjacent to the cyst in advance. In conclusion, it should be said that the pathology described is not rarity in our daily practice and knowledge of this pathology is of particular importance for early diagnosis, and therefore for early and competent treatment.

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