CYSTS OF MAXILLOFACIAL REGION
CYSTS OF MAXILLOFACIAL REGION
Dept. of Oral and Maxillofacial Surgery,
Govt. Dental College, Srinagar.
Associate Professor and Head,
Dept. of Oral and Maxillofacial Surgery,
Govt. Dental College, Srinagar.
Lecturer
Department of Oral Pathology and Microbiology,
Govt. Dental College, Srinagar.
J & K Health Services, SDH Banipora
Resident
C.D Hospital, Srinagar.
Dept. of Oral and Maxillofacial Surgery,
Govt. Dental College, Srinagar.
Introduction
A cyst has been traditionally defined as a pathologic epithelium-lined cavity usually containing fluid or semisolid material (Killey and Kay – 1966). The presently accepted definition is the one coined by Kramer in 1974 as ‘a pathologic cavity having fluid, semisolid or gaseous content and it is frequently, but not always lined by epithelium’.
Cysts of the jaws are often lined by a layer of epithelium and a layer of subjacent connective tissue and these layers can be dissected easily from bone. The thickness and configuration of this lining varies with the type of the cyst. These cysts develop either by the proliferation of epithelial remnants in the jaw or by cystic transformation of neoplastic tissue.
Classification
Numerous classifications have been published of cysts of the jaws. Most of them are perfectly satisfactory in clinical evaluation and practise.
I. Robinson’s classification (1945)
Developmental cysts
A) from odontogenic tissue
Periodontal cyst
(a) radicular or root apex type
(b) lateral type
(c) residual type
Dentigerous cyst Primordial cyst
B) from non-dental type of tissue
Median cyst (median palatal cyst) Incisive canal cyst Globulomaxillary cyst II. Kruger’s classification (1964)
A) Congenital cyst
Thyroglossal Branchiogenic Dermoid
B) Developmental cyst
non-dental origin
a) fissural type
Naso-alveolar Median Incisive canal cyst (Naso-palatine) Globulomaxillary
b) retention type
mucocoele ranula dental origin
a) periodontal
periapical lateral residual
b) primordial
c) dentigerous
III. Lucas’ classification (1964)
Intra-osseous cysts
A) Fissural cysts
a) median mandibular
b) median palatal
c) naso-palatine
d) globulomaxillary
e) naso-labial
B) Odontogenic cysts
a) Developmental
primordial dentigerous
b) inflammatory
c) radicular
C) Non-epithelial bone cysts
a) solitary bone cyst
b) aneurysmal bone cyst
IV. Gorlin’s classification (1970)
A) Odontogenic cysts
dentigerous cyst eruption cyst gingival cyst of the new-born infants lateral periodontal and gingival cyst keratinising and calcifying odontogenic cysts
(cystic keratinising tumour)
radicular (periapical cyst) odontogenic keratocyst
a) primordial cyst
b) Gorlin-Goltz syndrome
B) Non-odontogenic and fissural cysts
globulomaxillary (premaxilla-maxillary) cyst naso-alveolar (naso-labial / Klestadt’s) cyst naso-palatine (median anterior maxillary) cyst median mandibular cyst anterior lingual cyst dermoid and epidermoid cyst palatal cysts of new-born infants
C) Cysts of neck, oral floor and salivary glands
thyroglossal duct cyst lymphoepithelial (branchial cleft) cyst oral cyst with gastric / epithelial epithelium salivary gland cyst – mucocoele and ranula
D) Pseudocysts of jaws
aneurysmal bone cyst static (developmental / lateral) bone cyst traumatic (haemorrhagic / solitary) bone cyst V. WHO classification published in ‘Histologic typing of odontogenic tumours’ (Kramer, Pindborg, Shear – 1992)
I. Cysts of the jaws
A) Epithelial
developmental
a) odontogenic
gingival cysts of infants odontogenic keratocyst (primordial cyst) dentigerous (follicular) cyst eruption cyst lateral periodontal cyst gingival cyst of the adults botryoid odontogenic cysts glandular odontogenic (sialo-odontogenic / mucoepidermoid-odontogenic) cyst calcifying odontogenic cyst
b) non-odontogenic
naso-palatine duct (incisive canal) cyst naso-labial (naso-alveolar) cyst midpalatine raphae cyst of infants median palatine, median alveolar and median mandibular cysts globulomaxillary cyst inflammatoryradicular cyst (apical / lateral) residual cyst paradental (mandibular infected buccal) cyst inflammatory collateral cyst
B) Non-epithelial
solitary (traumatic/simple/haemorrhagic) bone cyst aneurysmal bone cyst
II. Cysts associated with the maxillary antrum
a) benign mucosal cyst of the maxillary antrum
b) post-operative maxillary cyst (surgical ciliated cyst of the maxilla)
III.Cysts of the soft tissues of the mouth, face and neck
a) dermoid and epidermoid cyst
b) lymphoepithelial (branchial cleft) cyst
c) thyroglossal duct cyst
d) anterior median lingual cyst (intralingual cyst of fore-gut origin)
e) oral cyst with gastric / intestinal epithelium (oral alimentary tract cyst)
f) cystic hygroma
g) naso-pharyngeal cysts
h) thymic cysts
i) cysts of the salivary glands
mucous extravasation cyst mucous retention cyst ranula polycystic (degenerative) disease of parotid
j) parasitic cysts
hydatid cyst cysticerus cellulosae trichinosis Signs and symptoms Signs
The physical sign of a cyst in the jaw depends on the size of the cyst. Small cysts do not produce any clinical signs. They may be discovered only on a routine radiologic examination. As the cyst becomes larger, expansion of alveolar bone occurs, usually on buccal / labial aspect. This expansion takes place as a result of continuous deposition of sub-periosteal bone in response to the bone resorption caused by the expanding cyst. This produces a bulged convex contour.
At an early stage, this lateral expansion produces a smooth, hard, painless prominence. As the cyst grows, the bone at the centre of the convexity becomes soft in consistency. This stage is described as ‘tennis ball’ feeling.
Further thinning of the cortical plate causes the bone to become fragile and outer shell of bone becomes fragmented on pressure producing a sound or feeling of ‘egg-shell crackling’. Later, this bone completely disappears, causing the cyst wall to be attached to the periosteum. At this stage, the cyst appears as a smooth, shining, bluish swelling with a soft, fluctuent consistency.
The way and degree of expansion and clinical signs vary with the type of cyst. Keratocysts and dentigerous cysts commonly cause less expansion and more bone destruction. The enlargement of the cyst is at the expense of cancellous bone.
Mobility of teeth rarely occurs with periapical cyst whereas dentigerous cyst and odontogenic keratocyst may cause mobility of teeth because of their high degree of bone resorption. Absence of teeth generally indicates a dentigerous cyst or a primordial cyst. Displacement of teeth rarely occurs in cases of odontogenic cysts whereas developmental cysts such as globulomaxillary cyst can cause displacement of roots of adjacent teeth.
Large mandibular cysts invariably involve the neurovascular bundle and may even deflect this structure to an abnormal position. It is unusual to find anaesthesia of mental nerve, but it may occur in cases of acute infection and sudden increase in intra-cystic pressure. This may produce nerve compression and paresthesia, which is relieved on decompression by surgical drainage.
Periapical cysts are always associated with one or more non-vital teeth. In other cysts also, an increase in the intra-cystic pressure may cause loss of response of adjacent teeth to vitality tests, even though they have vital pulps.
A large maxillary anterior cyst will expand under nasal floor causing distortion of nostril and nasal congestion. Involvement of antrum by an infected cyst will show features of maxillary sinusitis.
Symptoms
Most of the cysts are asymptomatic till it expands the jaw or gets infected. When infected, it causes severe pain and swelling of the involved region. Sometimes the patient notices a lump, which is painless. If the cyst has discharged in to the mouth or has become infected, the patient may complain of bad taste and pain.
Any cyst may cause
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