Cysts of the Maxillofacial Region and Neck: Clinical Guidelines

List of Abbreviations

Dr. Med. Sci. – Doctor of Medical Sciences

Cand. Med. Sci. – Candidate of Medical Sciences

CT – computed tomography

HCF – healthcare facility

MRI – magnetic resonance imaging

MC – medical care

ICD – International Classification of Diseases

Ministry of Health of the Russian Federation – Ministry of Health of the Russian Federation

MSCT – multislice computed tomography

OPTG – orthopantomogram

US – ultrasound examination

OMFS – oral and maxillofacial surgery

EPT – electric pulp testing

GBR – guided bone regeneration

MFR – maxillofacial region

EPT – electric pulp testing

Cystectomy – "Cystostomy or cystectomy" (A16.07.016)

Cystostomy – "Cystostomy or cystectomy" (A16.07.016)

Terms and Definitions

Cystostomy is the incision of the cyst wall for the purpose of evacuating its contents. This surgery is performed on an emergency basis in acute purulent-inflammatory processes. After the subsidence of acute inflammatory phenomena, the wound edges approximate (fuse together), the outflow of cyst contents ceases, which means the mechanisms of cyst growth are reactivated or a fistulous tract is formed.

Cystectomy is the removal of the entire epithelial-connective tissue lining (cyst capsule) from the bone cavity. The operation is completed either by approximating the edges of the alveolar mucosa wound (closed management of the bone cavity) or by packing the bone cavity with a tampon (open management).

Cystostomy (marsupialization) is the removal (excising) of a part of the cyst wall and the creation of conditions for a long-term communication (with the oral cavity, nasal cavity, maxillary sinus) that eliminates the main mechanism of cyst growth—increased hydrostatic pressure.

Cystorinosinusectomy is the complete removal of the cyst lining and connection of the maxillary sinus with the remaining bone cavity, followed by establishing a communication between the newly formed single cavity and the inferior nasal meatus. If the surgery is performed using an endoscope, an additional anastomosis is not created; instead, the natural one is widened.

Marsupialization is a two-stage operation combining cystostomy and cystectomy. At stage I, a decompression surgery is performed—a communication with the oral cavity is created similar to a cystostomy, but of a smaller diameter, yet sufficient for the outflow of contents from the cystic cavity for an extended period. With a significant volume of the cyst, its suppuration, or intimate proximity to important anatomical structures or the roots of intact teeth, a cystostomy is performed at the first stage. At stage II, a cystectomy is performed after a certain period of time (on average 0.5–1.5 years), which can be supplemented with bone grafting if necessary.

Cystosialoadenectomy is a radical operation involving the complete removal of the cyst lining and the salivary gland.

Endoscopically assisted/robot-assisted surgical intervention is an operation in which the cyst lining is removed using endoscopic visualization or robotic technology.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Cyst is a tumor-like formation representing a cavity whose capsule consists of an outer connective tissue layer and an inner layer lined predominantly by stratified squamous epithelium. The cyst cavity is usually filled with liquid or semi-liquid contents (serous fluid, pus, products of the epithelial lining's vital activity—colloids and crystalloids (cholesterol crystals)) [1,2,3,4,5,6].

The accumulation of vital products from the epithelial lining and inflammatory processes lead to an increased hydrostatic pressure within the cyst cavity. As a result, pressure on the surrounding bone increases. The pressure increase leads to partial deformation of the bone trabeculae, and the acidic environment resulting from pressure-induced hypoxia activates the work of osteoclasts. Osteoblast activity decreases. The predominance of bone tissue lysis over its formation leads to an increase in the volume of the bone cavity (cyst growth) and jaw deformation [7].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

A radicular (periapical) cyst occurs in the presence of a chronic inflammatory process in the periapical tissue of a tooth. Clinically, a radicular cyst is usually detected in the area of a destroyed or treated tooth, and sometimes in what appears to be a healthy tooth that was previously traumatized, less frequently in the area of an extracted tooth. In children, a cyst originating from a deciduous (milk) tooth developing over the bud of a permanent tooth is, according to A.A. Kolesov, an inflammatory odontogenic cyst. Other cysts are developmental disorders of the odontogenic epithelium. Among them are the primary cyst (keratocyst), dentigerous (follicular) cyst, eruption cyst, and gingival cyst [1,2,3].

Periapical (radicular) cysts

A cyst whose development is based on an inflammatory process in the periapical tissue is called a radicular cyst. It can be:

- apical (periodontal);

- periapical;

- residual radicular. About 30% of radicular cysts are residual and remain after tooth extraction or loss.

Follicular (dentigerous) cysts

These are a developmental defect (cystic degeneration) of the tooth-forming epithelium, developing from the enamel organ of an unerupted tooth. The clinical symptoms of a dentigerous cyst are similar to manifestations of other jaw cysts, but examination reveals the absence of one of the teeth in the localization area of the cyst, except when it develops from a supernumerary tooth.

- containing teeth – develops from the enamel organ of an unerupted tooth;

- eruption cysts – formed from the epithelium of the jaw alveolar mucosa during difficult eruption of the chewing teeth group in children. This forms a spherical formation at the eruption site [4,5,6,7,14].

Retromolar cysts, eruption cysts, gingival cysts

Retromolar cysts arise due to a chronic inflammatory process in the periodontal tissues caused by difficult tooth eruption.

Eruption cysts and gingival cysts are rare. An eruption cyst appears as a localized, small, bluish swelling in the area where a tooth is supposed to erupt, located over its crown [5,6,7,14].

Primary cyst (keratocyst)

Arises from the odontogenic epithelium, usually in areas where teeth are present, but has no connection to them.

Nasopalatine duct (incisive canal) cyst

It is an epithelial non-odontogenic cyst arising from epithelial remnants of the nasopalatine duct.

Cholesteatoma

A tumor-like cyst-like formation whose capsule is lined with epidermis, and whose contents appear as a mushy mass including keratin masses and cholesterol crystals. Cholesteatomas in the jaw region occur in two forms:

1) as a periapical follicular cyst containing no teeth;

2) a cyst with special contents surrounding the crown of an unerupted tooth.

Traumatic cyst

Rare. Belong to non-epithelial cysts. Pathogenesis is unknown. Histologically, the cyst walls are covered with thin fibrous tissue containing multinucleated giant cells and hemosiderin grains. Traumatic cysts may lack fluid contents or be filled with hemorrhagic fluid.

Aneurysmal bone cyst

Belong to non-epithelial cysts. Etiopathogenesis is practically unstudied. Usually occurs in the area of intact teeth in the mandible during prepubertal and pubertal age. It represents a cavity, sometimes a multilocular lesion, filled with blood, hemorrhagic fluid, or lacking liquid contents. The bone cavity is usually lined with a fibrous tissue capsule devoid of epithelium and containing osteoblasts and osteoclasts.

Globulomaxillary and nasoalveolar cysts

Arise from epithelium at the junction of the intermaxillary bone with the maxilla. Contain yellowish fluid without cholesterol (V.V. Roginsky, 1987). The globulomaxillary cyst is located in the maxillary bone between the lateral incisor and canine. The nasolabial or nasoalveolar cyst is located on the anterior surface of the maxilla in the projection of the apex of the lateral incisor and canine root [5,6,7,14].

Dermoid cyst of the oral cavity

It forms as a result of facial developmental defects and malformations at the sites of fusion of the embryonic frontonasal, maxillary, and mandibular prominences. A dermoid cyst is a cystic lesion with a thick wall, filled with a foul-smelling, dirty-white, paste-like mass. The cyst contents consist of desquamated epidermis, sebaceous and sweat gland secretions, and hair follicles, sometimes containing hair.

Oral epidermoid cyst

It occurs in two types: toothless (resembling a radicular cyst) and tooth-containing (surrounding the crown of an unerupted tooth, resembling a follicular cyst). The cyst walls are lined with epidermis, and the contents consist of a paste-like mass composed of degenerated epithelial cells, keratin debris, and cholesterol crystals [5,6,7,14].

Oral lymphoepithelial cyst

It is an encapsulated dermal or submucosal papupa originating from epithelial remnants trapped within lymphoid tissue that have undergone cystic degeneration. When a lymphoepithelial cyst arises from degenerated tissue of the second pharyngeal arch, it is called a cervical lymphoepithelial cyst or branchial cleft cyst. Histologically, a lymphoepithelial cyst is lined with stratified squamous epithelium, rarely columnar or cuboidal, and surrounded by a fibrous connective tissue capsule. The central part of the cyst shows lymphoid aggregates with a prominent germinal center. The cyst is filled with a viscous yellow fluid due to the cheesy keratinaceous material it contains [5,6,14].

Morphologically, a distinction is made between dermoid and epidermoid cysts. The wall of dermoid cysts consists of all layers of the skin and its appendages (sebaceous glands, sweat glands, hair). The capsule of epidermoid cysts includes the epidermis and lacks skin appendages. Clinically, they are very difficult to differentiate. Dermoid cysts develop from embryonic clefts formed by ectodermal folds that are dystopic during embryonic development. The localization of a dermoid cyst can vary: on the lips, eyelids, nasolabial folds, bridge of the nose, near the ears, on the back of the head, in the upper neck, and in the floor of the mouth. The capsule of a dermoid cyst is dense, with a prominent papillary layer containing sebaceous glands and hair follicles. The inner surface of the capsule is lined with stratified squamous epithelium. The contents of dermoid cysts consist of a foul-smelling, grey, paste-like mass. The wall of an epidermoid cyst consists of dense fibrous connective tissue and contains no skin appendages. The inner lining is stratified squamous epithelium. The cyst contents are keratin flakes, undergoing degeneration in places, especially when complicated by secondary inflammation. The secretion is an opalescent, transparent yellow fluid containing cholesterol crystals [5,6].

Thyroglossal duct cysts (Median cervical cysts) are anomalies of the development of the branchial apparatus and its derivatives, as well as the thyroid and thymus glands. Some authors believe that median cysts and fistulae represent embryonic dysplasia associated with non-closure of the thyroglossal duct (N.A. Gruzdev, 1965; L.R. Episheva, 1972; Bettmann, 1971, etc.). This assumption is supported by the connection of median cervical cysts with the hyoid bone and the cecal foramen of the tongue root, as well as the correspondence of the tract of a complete median fistula to the topography of the thyroid gland primordium (V.S. Dmitrieva et al., 1968). Sometimes, histological examination of median cysts and fistulae of the neck reveals thyroid tissue inclusions in their walls. This confirms their origin from tissues of the non-regressed thyroglossal duct.

K.I. Cherenova (1963) and V.M. Bezrukov (1965) propose the branchiogenic theory of the origin of lateral neck cysts and fistulae, according to which these formations represent the second pharyngeal pouch located between the external and internal carotid arteries and opening via an internal orifice into the palatine tonsil region. Lateral cysts are located on the neurovascular bundle of the neck, most often at the level of the common carotid artery bifurcation. The term "branchiogenic" means that these formations develop from remnants of the pharyngeal pouches [8].

V.M. Bezrukov (1965), V.S. Dmitrieva (1968), and others consider parotid region cysts and fistulae to be a developmental defect of the first branchial cleft. They have typical topography and are located above the muscles attached to the styloid process, lateral to the facial nerve trunk. The cysts communicate with the external acoustic meatus at the transition of its cartilaginous part into the bony part. Microscopically (K.I. Cherenova, 1963), the cyst wall consists of dense fibrous and lymphoid tissues, within the thickness of which epithelial islands are present. The inner lining is represented by embryonic-type columnar and ciliated epithelium.

Cysts of the base of the tongue are developmental anomalies of the thyroglossal duct. However, they are more often classified into a separate group because they have specific features in localization, clinical presentation, and treatment methods. These lesions are quite rare in newborns. Large cysts located anterior to the epiglottis can interfere with feeding and cause respiratory compromise. Cysts located between the cecal foramen of the tongue root and the hyoid bone are clinically difficult to diagnose, and an infected cyst clinically resembles an abscess of the tongue base.

Sublingual salivary gland cyst (ranula) is more commonly observed in young individuals. S. Rauch (1959) classifies these cysts as dysontogenetic and believes they develop from diverticula of the submandibular (Wharton's) duct located near its orifice. During puberty, when dysontogenetic lesions are most often activated, congenital ranulas are manifested. They may also be associated with trauma to the lobules of the sublingual salivary gland or the ductal system.

Sebaceous cyst (atheroma)

Obstruction of the sebaceous gland duct leads to the formation of atheroma, driven by external (trauma) and internal factors (endocrine disorders).

Retention cyst of minor salivary gland

The etiology is associated with ductal trauma leading to scarring and saliva retention. The accumulating secretion compresses the glandular parenchyma, resulting in its thinning and the formation of a saliva-filled cavity.

Cyst of major salivary glands (parotid salivary gland, submandibular salivary gland)

This is a rare condition localized in the superficial and deep layers of the gland. The cyst grows slowly and is often discovered incidentally. Their formation is a consequence of dysontogenetic disorders of the parenchyma and develops from duct diverticula or aberrant areas of glandular tissue. The cyst content is a yellowish fluid, sometimes turbid, with an admixture of mucus. Histologically, the wall of a parotid salivary gland cyst does not differ from the walls of cysts in other salivary glands [33,38].

1.3 Epidemiology of the Disease or Condition

Cyst-like lesions, including tumors and tumor-like conditions of the jaws, occupy a significant place in the practice of dental surgeons and maxillofacial surgeons. Odontogenic jaw cysts account for 8–10% of all diseases of the maxillofacial region (Bakiev, 1986; Mirsaeva, 1999) [9].

According to a number of researchers (J. Klammt, G.A. Vasilyeva, F.E. Hopper, V. Fassaner, B. Hoffmeister, H-G. Rudelt, V.V. Panikarovsky, A.M. Solntsev), among jaw tumors and tumor-like neoformations, odontogenic cysts account for 80–85%, and among odontogenic cysts, approximately 95% are radicular (inflammatory). Jaw keratocysts account for 5.4 to 17.4% of all odontogenic cysts [10,11].

In children, branchial apparatus developmental anomalies account for 17 to 20% of all neck pathology. The most common (90–95%) are developmental anomalies of the second branchial cleft. 75% of all second branchial cleft anomalies are cysts. According to G.V. Falileev's classification (1978) and recent classifications of human soft tissue tumors, tumors of dysembryonic genesis, specifically cysts, account for 34.9%. According to Krasnov V.G. (1991) and Litvinov L.Ya. (1994), tumors of dysembryonic genesis are significantly less common, accounting for 7% [8,12,13].

1.4 Features of Coding the Disease or Condition

K04.8 Radicular cyst

K09 Oral cysts, not elsewhere classified

K09.0 Developmental odontogenic cysts

K09.1 Developmental (non-odontogenic) cysts of oral region

K09.2 Other cysts of jaw

K09.8 Other specified cysts of oral region, not elsewhere classified

K09.9 Cyst of oral region, unspecified

K11.6 Mucocele of salivary gland

Q18.0 Branchial cleft sinus, fistula and cyst

Q18.1 Preauricular sinus and cyst

Q18.2 Other branchial cleft malformations

Q18.8 Other specified malformations of face and neck

L72.0 Epidermal cyst

1.5 Classification of the disease or condition

Classification of jaw cysts

The most detailed is the clinical and morphological classification of jaw tumors and tumor-like lesions, in the development of which a working group consisting of I.I. Ermolaev, V.V. Panikarovsky, A.I. Paches, B.D. Kabakov, V.M. Bentsianova, and S.Ya. Balsevich (1975) participated [7]. Jaw cysts are presented in section "B – Tumor-like lesions" and are divided into:

I. Epithelial:

1. Odontogenic cysts:

a) primordial cyst (primordial keratocyst);

b) eruption cyst;

c) paradental (periodontal);

d) gingival;

e) tooth-containing;

f) follicular;

g) radicular.

2. Non-odontogenic cysts:

a) incisive canal cyst (nasopalatine duct cyst);

b) deep maxillary cyst (fissural);

c) nasolabial cyst (nasoalveolar, of the oral vestibule);

d) cholesteatoma.

II. Non-epithelial:

bone cysts (aneurysmal, traumatic, hemorrhagic).

A.K. Iordanishvili clinical classification of jaw cysts (2000):

I. Peridental cysts:

- periradicular (periapical, apical, radicular);

- residual;

- pericoronal (follicular, eruption cysts);

- retromolar (paradental).

II. Primordial cyst (keratocyst, primordial cyst).

III. Nasopalatine duct cyst (incisive foramen cyst).

IV. Jaw cholesteatomas.

V. Traumatic (simple, hemorrhagic, or solitary bone cysts).

VI. Aneurysmal bone cyst.

VII. Globulomaxillary cyst.

VIII. Nasolabial (nasoalveolar, extraosseous) cyst [5,6,7].

Classification of benign cystic lesions of the soft tissues of the maxillofacial region and neck

Benign cystic lesions of the soft tissues of the maxillofacial region do not represent a genetically homogeneous group. Some of them are congenital lesions resulting from impaired embryological development, while others are acquired (retention cysts of sebaceous glands [atheromas], traumatic cysts, salivary gland cysts).

Congenital soft tissue cysts are divided into two groups:

- those resulting from embryogenesis anomalies (thyroglossal duct cysts, branchial cleft cysts, cysts of the parotid region and tongue base, sublingual salivary gland cysts);

- those resulting from ectodermal developmental defects (dermoid and epidermoid cysts).

Branchial cleft cysts (lateral neck cysts) were first classified by H. Bailey in 1929; his classification was modified by Proctor in 1955.

Type I - located most superficially along the anterior surface of the sternocleidomastoid muscle beneath the platysma, but does not come into contact with the carotid sheath.

Type II - the most common "classic" type, where the cyst is located anterior to the sternocleidomastoid muscle and posterior to the submandibular salivary gland, lying laterally adjacent to the carotid sheath.

Type III - located midway between the bifurcation of the internal and external carotid arteries, lateral to the lateral pharyngeal wall.

Type IV - located deeper than the carotid sheath in the parapharyngeal space and opens into the pharynx, with potential extension to the skull base [21].

1.6 Clinical presentation of the disease or condition

When examining patients with an infected cyst, facial asymmetry due to edema of the perimaxillary soft tissues and skin hyperemia may be detected. Mouth opening may be preserved in full, but when a follicular cyst is infected in the region of an impacted mandibular third molar, mouth opening may be restricted. Percussion of the "causative" tooth is usually painful; the causative tooth may have a filling, crown, or be destroyed. Comparative percussion of adjacent teeth is painless.

During the remission phase of inflammatory phenomena, clinical manifestations may be absent; sometimes a fistulous tract can be found on the skin of the face and neck or the oral mucosa. When the cyst reaches a significant size, jaw deformation is possible, which visually manifests as facial asymmetry or a bulge in the oral cavity. Palpation of the oral mucosa in the area of cyst localization may reveal the "percussion crackling" (parchment crunch) sign or fluctuation. A large cyst can cause displacement of erupting teeth and pathological fracture of the mandible [1,6,7,12,15,19].

Thyroglossal duct cysts are located along the midline of the neck between the cecal foramen of the tongue and the isthmus of the thyroid gland. They are characterized by slow growth, appear as a painless rounded protrusion, move upward during swallowing only, following the hyoid bone, and have a smooth surface and elastic consistency. Their mobility is restricted due to attachment to the body of the hyoid bone. The overlying skin is unchanged and mobile [37].

Lateral neck cysts are located anterior to the sternocleidomastoid muscle at the level of the mandibular angle. They most commonly manifest in adolescence. They present as a rounded, elastic, and movable mass.

Dermoid cysts can occur beneath the tongue and within the tongue itself, beneath the muscles of the floor of the mouth, in the root of the nose, the outer and inner angles of the orbit, and the supraorbital region. They are identified by a localized bulge. Their consistency is soft, and their shape is round or oblong. The cysts are not adherent to the skin and are movable; the cyst capsule may be connected to the periosteum [23,37].

Cysts of the major salivary glands present as a localized, painless swelling in the parotid-masseteric or submandibular regions with a soft-elastic consistency. The skin over the cyst is of normal color and can be easily pinched into a fold. Unaltered saliva is secreted from the gland duct [33].

Sublingual salivary gland cysts (ranulae) grow slowly without causing discomfort to the patient. Occasionally, the cyst empties spontaneously into the oral cavity and then slowly refills with contents. Ranulae may be localized in the middle and posterior parts of the sublingual region. They present as a rounded, bluish-translucent, elastic, and painless mass upon palpation.

Retention cyst of a minor salivary gland: upon examination, a rounded, translucent, sometimes bluish-tinted mass protruding above the mucosal surface is detected. It has an elastic consistency, is well-demarcated from surrounding tissues, movable, and painless [8].

When soft tissue cysts of the maxillofacial region become infected, swallowing, breathing, and tongue movement may be difficult, accompanied by pain upon head rotation and palpation of the mass. Destruction of the cyst wall by the suppurative-inflammatory process may result in the formation of a fistulous tract with discharge.

2. Diagnostics, medical indications and contraindications for diagnostic methods

The criteria for diagnosing a cyst include the detection of a cystic cavity in the bone or soft tissues using physical and instrumental examinations undertaken as a result of analyzing the patient's complaints, and the exclusion of other pathology with a similar clinical picture.

2.1 Complaints and Anamnesis

Comment: at the initial stage of development, when there are still no externally noticeable deformations of the alveolar process or the jaw body, the cyst is asymptomatic.

When taking the medical history for jaw cysts, the following should be ascertained: whether there was a tooth injury, the degree of tooth destruction by caries, the quality of endodontic treatment performed, and the presence of impacted teeth. When a cyst extends from the maxillary central incisors into the inferior nasal meatus, patients report persistent nasal congestion. Compression of the nasolacrimal duct causes unilateral spontaneous epiphora [6,7,14,15].

Comment: in cases of suppuration of any type of cyst, all these objective symptoms are accompanied by redness, swelling, and infiltration of the surrounding tissues, as well as patient complaints of varying degrees of pain in the cyst area and fever. Suppuration of cysts growing into the maxillary sinus is accompanied by pain in the maxilla and unilateral nasal discharge [6,14,15].

Comment: in case of suppuration, redness, edema, and infiltration of the surrounding tissues join all these objective symptoms, along with patient complaints of more or less pronounced pain in the cyst area and elevated body temperature. Inflammation of median, lateral, and dermoid cysts may lead to dysphagia with speech disorders [6,12].

2.2 Physical Examination

Comment: general examination involves assessing general physical condition, height, and body weight. Examination of the maxillofacial region focuses on the patient's appearance, facial and neck configuration, skin color, presence of asymmetry and defects, the state of regional lymph nodes (size, consistency, surface, mobility, adhesion to the skin, presence of pain). Following the external examination, the examination of the oral cavity is initiated, during which smoothing or bulging of the transitional fold of the oral vestibule vault or bulging on the palate is revealed, of a rounded shape with fairly clear boundaries.

The emerging expansion of the alveolar process often causes facial asymmetry. Over time, the "papery crepitation" sign (Dupuytren's sign) appears; upon palpation of the thinned bony wall of the cyst, a springy sensation of the wall is felt. Progressively increasing bone atrophy leads to the appearance of a "window" in the bone wall of the cyst, over which only the periosteum and mucous membrane remain stretched. As a result, a new sign appears – fluctuation (fluid thrill) of the cyst contents [6,7,14,15].

In cases of large dermoid cysts of the floor of the mouth, impairments in tongue mobility, swallowing, and speech are noticeable. The consistency of the formation is elastic or doughy, the surface is smooth, and the borders are clear. When the cyst is attached to the hyoid bone, it manifests as a hemispherical protrusion in the submental region. In the neck, congenital dermoid cysts are localized between the anterior border of the sternocleidomastoid muscle and the posterior belly of the digastric muscle. Parotid region dermoid cysts are usually located deep, beneath the main trunk of the facial nerve or its branches, attaching to surrounding bone structures and causing soft tissue deformation that is barely noticeable from the outside [6,12].

2.3 Laboratory Diagnostics

Comment: the definitive diagnosis of maxillofacial cysts is morphological and is established based on histological analysis of postoperative routine histological examination.

2.4 Instrumental Diagnostics

At the diagnostic stage

Comment: a dental probe is used to determine the condition of hard dental tissues, previously placed fillings and dentures, and the depth of periodontal pockets. The degree of tooth mobility is determined using D.A. Entin's classification. Instrumental percussion (horizontal and vertical) is used to assess the condition of the tooth and the surrounding periapical tissues [7].

Comment: when the cyst extends toward the lower wall of the piriform aperture, rhinoscopy reveals a ridge-like protrusion ("Gerber's ridge") on the floor of the nasal cavity [6,14,15].

Comment: the use of targeted intraoral periapical radiography may be sufficient for diagnosing radicular tooth cysts up to 7-10 mm in diameter. For larger radicular cysts (over 11 mm in diameter), when examining mandibular premolars and molars, or when certain anatomical structures (incisive and mental foramina, maxillary sinuses, large bone cells) are projected onto the tooth apex and periapical lesion, methods such as orthopantomography, panoramic radiography of the mandible, and radiography of the paranasal sinuses should be employed [7].

2.5 Other Procedures

Differential diagnosis of jaw cysts is carried out with ameloblastoma, hemangioma, myeloma, eosinophilic granuloma, central giant cell granuloma, giant cell tumor, fibrous dysplasia, soft odontoma, chondroma, osteoma, Stafne bone defect, sarcoma, and metastatic carcinoma. Computed tomography, angiography, three-phase soft tissue and bone scintigraphy, cytological examination of fine-needle aspiration biopsy micropowder/smear, core-needle biopsy of external tumors and visually guided lymph nodes, and incisional biopsy with pathomorphological examination of the biopsy material help to verify the diagnosis [7,18,22].

Differential diagnosis of parotid region cysts is most often performed with cysts and tumors of the parotid salivary gland and branchial cleft cysts of the neck. Magnetic resonance imaging of soft tissues and cytological examination of fine-needle aspiration biopsy micropowder help to verify the diagnosis [6,12,19].

Differential diagnosis of dermoid and epidermoid cysts is carried out:

– with tuberculous lymph node involvement. There are clinical signs of the underlying disease—pulmonary involvement. If regional lymph nodes of the maxillofacial region and neck are involved, the diagnosis is established by cytological examination of a fine-needle aspiration biopsy micropowder, as well as an excisional biopsy of the lymph node followed by pathomorphological examination of the biopsy (surgical) material;

Comments: in primary tuberculosis, pulmonary involvement may be absent.

– with malignant tumors of the reticuloendothelial system (lymphosarcoma, reticulosarcoma). Rapid growth of formations with multiple lymph node involvement and distant metastasis is characteristic [19];

– with hematologic malignancies in the absence of generalized disease symptoms. Emphasis is placed on differentiating the punctate based on cytological data from fine-needle aspiration biopsy micropowder;

– with adenolymphomas of the salivary glands. Contrast sialography, magnetic resonance imaging of soft tissues of the maxillofacial region and neck, and computed tomography of the maxillofacial region help clarify the diagnosis. Fine-needle aspiration biopsy followed by cytological examination reveals tumor cells that are absent in a cyst;

– with lateral and median cysts of the neck. The punctate of dermoid cysts is atheroma-like with flakes. Cytological examination of the micropowder reveals cholesterol crystals and desquamated epithelial cells;

– with abscessed lymph nodes. Macroscopically, it is difficult to distinguish the punctate of suppurating dermoid and epidermoid cysts from the contents of an abscessed lymph node. The medical history and cytological examination of fine-needle aspiration biopsy micropowder will help clarify the diagnosis;

– with atheromas. Clinically, dermoid and epidermoid cysts are very similar to atheromas, but unlike the latter, they are not adherent to the skin.

Differential diagnosis of lateral and median cysts is carried out:

– with chronic specific and nonspecific cervical lymphadenitis. Physical examination, magnetic resonance imaging of soft tissues, computed tomography of the maxillofacial region, and cytological examination of fine-needle aspiration biopsy micropowder will help clarify the diagnosis;

– with dermoid cysts of the maxillofacial region;

– with salivary gland tumors. Important diagnostic points include contrast sialography, magnetic resonance imaging of soft tissues, and computed tomography of卡的 the maxillofacial region;

– with carotid chemodectoma. Magnetic resonance angiography (one region) and computed tomography angiography of a single anatomical region will help clarify the diagnosis;

– with metastatic neck tumors, branchiogenic carcinoma, lymphosarcoma, reticulosarcoma, hemangiomas, and lymphangiomas;

– lateral cervical fistulas are also differentiated from fistulas resulting from suppuration of cervical lymph nodes. Magnetic resonance imaging of soft tissues, cystography, fistulography, cytological examination of fine-needle aspiration biopsy micropowder, visually guided core-needle biopsy of external tumors and lymph nodes followed by pathomorphological examination of the biopsy (surgical) material, and incisional biopsy followed by pathomorphological examination of the biopsy (surgical) material help to clarify the diagnosis.

Differential diagnosis of atheromas

Atheroma should be differentiated from epidermoid cyst, lipoma, soft fibroma, chronic lymphadenitis, furuncle, and retention cyst. A pathognomonic sign of atheroma that distinguishes it from all the listed pathological processes is the presence of punctiform skin depression (crater) in the area of the gland excretory duct and adhesion of the skin to the cyst capsule at the same site.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

The main treatment method for maxillofacial cysts is surgical. The cyst capsule is removed within healthy tissues, guided by its membrane.

3.1 Conservative treatment. Therapeutic preparation for surgical treatment

Comment: root canal filling is necessary up to the level of root apex resection, at least 2/3 of its length, and is performed before surgical intervention. If the root is visualized within the cyst during surgery, root apex resection of an already filled tooth should be performed [19].

Comments [30]:

Values of electric pulp testing in various dental pathologies

3.2 Methods of surgical treatment for jaw cysts

Criteria for initiating surgical treatment:

1. Signed informed consent for treatment from the patient.

2. Absence of chronic diseases in the stage of decompensation and severe organ dysfunctions.

Comment: during cystectomy, the cyst capsule is completely enucleated. After resection of the anterior bone wall, unlike cystotomy, the entire cystic capsule along with its contents is completely enucleated and removed. Cystectomy is performed for cysts whose capsule can be removed without the risk of damaging adjacent anatomical structures: neighboring teeth, neurovascular bundles (nerves), walls of the maxillary sinus and nasal cavity [6,7,19].

During cystectomy, defect replacement using osteoplastic materials is possible [34].

In the presence of a mandibular or maxillary defect during cystectomy, bone-grafting procedures may be performed:

The choice of rehabilitation technique depends on the size of the defect [34]

Comments: cystostomy is a surgical procedure aimed at creating an anastomosis between the cyst cavity and the oral cavity.

The main indications for surgery are:

1) a cyst projecting into the cavity of 3 or more intact teeth, with no periodontal ligament space visible radiographically at the roots of these teeth;

2) large maxillary cysts with destruction of the bony floor of the nasal cavity and palatine process;

3) extensive mandibular cysts with marked thinning (bone thickness less than 0.5 cm) of the mandibular base, where partial preservation of the cyst lining serves as a measure to prevent pathological fracture [33].

This surgery is recommended when there is a risk of damaging the inferior alveolar neurovascular bundle, as well as in cases where the cyst invades the maxillary sinus or nasal cavity [6,7,19,20].

Comment: the marsupialization method is based on the effect of appositional bone growth following the decompression of a closed cavity. The cyst cavity is irrigated through a fixed elastic tube inserted via a fistulous tract or the socket of an extracted tooth, after which the remnants of the cyst lining are removed and the fistulous tract is excised. It is generally accepted that the restoration of jaw bone tissue after cystotomy occurs through appositional growth. Postoperatively, retraction of the cyst lining and shrinkage of the fibrous capsule occur. The duration of this process depends on the size of the defect and the patient's general condition. Complete removal of the cyst lining and excision of the fistulous tract must then be performed [25].

Comment: the following "causal" teeth are subject to extraction during organ-preserving surgeries:

– all deciduous teeth;

– permanent teeth that caused the development of the cyst, in cases where root apex resection cannot be performed;

– permanent teeth whose roots project more than ½ into the cyst cavity [19,20];

– tooth mobility and alveolar process atrophy in the region of its roots exceeding grade II–III;

– the coronal part of the tooth is destroyed to such an extent that it cannot be restored using orthopedic methods;

– significant curvature of the tooth roots [7].

Comment: cystorhinosinusostomy is indicated:

- for intrasinusal cysts whose upper pole displaces the floor of the maxillary sinus upward by 1/3 of its height or more, i.e., medium and large-sized cysts;

- for small intrasinusal cysts with marked thinning of the bony partition between the cyst and the sinus, due to the high probability of sinus floor perforation during elevation of the cyst lining [32].

3.3 Methods of surgical treatment for soft tissue cysts

Conventional surgical methods

Criteria for initiating surgical treatment:

1. Signed informed consent for treatment from the patient.

2. Absence of chronic diseases in the stage of decompensation and severe organ dysfunctions.

Comment: the treatment of thyroglossal duct cysts is exclusively surgical. The operation is performed under combined endotracheal anesthesia. Dissection of the cyst is performed using blunt instruments, striving not to damage the cyst lining during the procedure. The skin incision for thyroglossal cysts and fistulas is horizontal along the natural skin folds at the level of the hyoid bone. In cases of scarring around the external fistula opening, it is advisable to supplement the horizontal incision with an elliptical one around the fistula opening. After elevation of the skin flaps on both sides of the cyst or fistulous tract, at a distance of at least 2–3 cm, the pathological formation is dissected down to the body of the hyoid bone. The latter is wedge-resected at a distance of 0.5 cm on both sides of the fistulous tract. To excise the body of the hyoid bone, vertically curved blunt-pointed scissors or a dental burr are used [6,22,23].

Comment: the treatment of branchial cleft cysts is exclusively surgical. The operation is performed under combined endotracheal anesthesia. The incision should be made along the anterior border of the sternocleidomastoid muscle or along the upper cervical skin crease. The first incision is considered safer, as major blood vessels and veins run in this direction, whereas the second incision is more cosmetic [34]. The operation is completed by layered closure of the wound. A rubber dam drain is inserted into the wound and removed on the 2nd–3rd postoperative day [6,22,23].

Comments: in cases of a significant ranula size or damage to the cyst lining during surgery, complete removal is not feasible. In such cases, the surgical technique of "marsupialization" can be applied. The "dome" of the cyst is excised, the cyst wall is sutured to the oral mucosa of the floor of the mouth, and a gauze strip (turunda) is fixed inside the cyst cavity. Alternatively, cystectomy combined with removal of the salivary gland (sublingual or submandibular) may be performed.

3.4 Minimally invasive surgical techniques

Criteria for initiating minimally invasive treatment

1. Signed informed consent for treatment from the patient.

2. Absence of chronic diseases in the stage of decompensation and severe organ dysfunctions.

Comment: the operation is performed under combined endotracheal anesthesia. Access is achieved via an incision in the retroauricular and occipital regions (retroauricular hairline incision [RAHI], face-lift type approach). In the retroauricular region, the skin flap is elevated, and in the lateral neck region, a subplatysmal elevation is performed. The outer surface of the sternocleidomastoid muscle is visualized. Dissection, isolation, and removal of the cyst lining are performed under endoscopic (surgical robot) guidance [21,27,28]. The operation to remove a branchial cleft cyst can also be performed via a linear incision in the hair-bearing area of the occipital region with the creation of a "tunnel" approach. Dissection, isolation, and removal of the cyst lining are performed under endoscopic (surgical robot) guidance. The operation is concluded by wound closure. A vacuum drain is inserted into the wound and removed on the 1st–2nd postoperative day [21,27,28].

Comment: the surgery is performed under combined endotracheal anesthesia. The extent of the surgery (cystectomy or cystosialoadenectomy / cystectomy combined with salivary gland resection) depends on the size and location of the cyst. Access may be achieved through an incision in the retroauricular and occipital regions (retroauricular hairline incision – RAHI, or face-lift type approach). A minimally invasive approach via a linear incision in the occipital scalp with the formation of a "tunnel" access may also be used. Dissection, isolation, and removal of the cyst wall or salivary gland are performed under endoscopic (surgical robot) guidance. The surgery is completed by wound closure. A vacuum drain is placed in the wound and removed on the 1st–2nd postoperative day [21,27,28,29].

3.5 Prevention of infectious wound complications after surgical treatment:

Comments: due to the limited number of direct studies evaluating perioperative antibiotic prophylaxis (PAP) regimens in adult and pediatric patients who underwent surgery for maxillofacial and neck cysts, SSI prophylaxis should be implemented in accordance with the national guidelines of "SKAT" (Antimicrobial Stewardship), "NASKI" (National Association of Nosocomial Infections), and international guidelines on PAP [44,47-57].

Comments: considering the presence of multiple aggravating factors that increase the risks of development and prolong contamination of the surgical wound due to prolonged communication with the oral cavity, the likelihood of saliva ingress, and unfavorable features of the oral microbiome, the duration of PAP may be extended up to 48 – maximum 72 hours, similarly to PAP protocols for cardiac and orthopedic surgeries.

Table 1 — Antibacterial drugs for surgical site infection PAP [70,71]

¹Cefazolin** (J01DB04) + ²Metronidazole** (J01XD01) are prescribed intravenously to children from 1 month of age for the prevention of intraoperative infections. Dosing regimen according to the instructions.

³#Clindamycin** (J01FF01) is prescribed to adults at a dose of 600–900 mg IV before surgery [44,47-57,59,64,65,70,71].

¹#Cefazolin** (J01DB04) + ²#Metronidazole** (J01XD01) are prescribed to adults: 2 g of #Cefazolin** + 500 mg of #Metronidazole** intravenously 60 minutes before surgery [44,47-57,59,64,65,70,71].

³Amoxicillin + [Clavulanic acid]** (J01CR02) is prescribed intravenously to adults and adolescents over 12 years of age for the prevention of postoperative infections. Dosing regimen according to the instructions.

Comments: in the postoperative period, the patient should receive therapeutic doses of drugs according to the medical product labeling, taking into account the patient's weight, age, and renal and hepatic function. When choosing the antimicrobial therapy regimen, it is recommended to consider the severity of the infectious process, the risk of resistant pathogens, and local microbiological monitoring data. For all patients with an "infected" wound, performing a microbiological study is advisable.

The recommended drugs of choice are:

- J01CR Beta-lactam antibacterials, penicillins, including combinations with beta-lactamase inhibitors

- J01D Other beta-lactam antibacterial drugs

- J01EE Combinations of sulfonamides and trimethoprim, including derivatives

- J01FF Lincosamides

- J01GB Other aminoglycosides

- J01M Quinolone antibacterials

- J01XA Glycopeptide antibacterials

- J01XD Imidazole derivatives

- J01XX Other antibacterials

Comments: pain medication may be used during preparation for and/or performance of any surgical interventions in the head and neck region from the standpoint of the modern "Pain management" concept in surgery on an "off-label" basis.

Comments: the prescription of drugs must be carried out taking into account age restrictions and contraindications for use.

Comments: the prescription of drugs must be carried out taking into account age restrictions and contraindications for use.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• All patients who have undergone surgical treatment for a maxillofacial cyst are recommended to undergo multi-stage rehabilitation measures aimed at the complete social and physical recovery of the patient [1,2,3,4,5,6,15,20].

LoE 5Grade of recommendation – C (Level of evidence – 5)

Comment: stages of patient rehabilitation after surgical treatment:

Administration of antibacterial therapy in the postoperative period as indicated. Daily examinations and dressings are performed. Sutures are removed on the 7th–10th day after surgery, and the patient is discharged from the clinic for subsequent outpatient follow-up for 3–4 days.

Hospital stay:

• Preoperative bed-days – 0–2 days (the majority of clinical investigations should be performed at the outpatient stage);

• Postoperative bed-days – 4–10 days.

5–6 days after cystotomy or cystectomy, the iodoform gauze packing is changed. Such changes are performed up to 3, less frequently 4 times. By the end of the 3rd week, the wound edges typically epithelialize, and an accessory cavity forms, communicating with the oral vestibule or oral cavity. The patient rinses it independently with antiseptic solutions (D08 Antiseptics and disinfectants). Gradually, over 1.5–2 years, depending on the size of the postoperative cavity, the latter decreases and flattens due to appositional bone growth.

In the presence of a large cavity, radiographic examination over a prolonged period (up to 1–2 years) reveals a radiolucent area that tends to decrease in size, followed by complete bone regeneration. In case of blood clot infection in the postoperative period, an inflammatory process develops. It is necessary to establish an outflow of exudate between the sutures, while rinsing the bone cavity with antiseptic solutions using a syringe with a blunt curved needle (D08 Antiseptics and disinfectants). Daily rinses for 3–4 days often resolve the inflammation. If the purulent process continues, the wound edges are spread apart, the wound is rinsed, the mucoperiosteal flap is turned into the bone cavity, and a loose iodoform pack or turunda with an antiseptic is then inserted into it (D08 Antiseptics and disinfectants). As the wound granulates (2–3 weeks), the pack is expelled, replaced several times, and subsequently removed.

5. Prevention and Dispensary Observation

• All patients presenting with the initial symptoms of cysts of the jaws and soft tissues of the maxillofacial region and neck are recommended a consultation with a maxillofacial surgeon to determine the tactics of preventive measures aimed at preventing disease progression and the occurrence of complications [1,2,3,4,5,6].

Level of Consensus 5Level of Recommendation – C (Level of Evidence – 5)

Comment: prevention of inflammatory odontogenic cysts consists in timely and high-quality treatment of temporary and permanent teeth with complicated caries and management of pericoronitis.

Patients identified with odontogenic cysts should be referred for an appointment (examination, consultation) with a maxillofacial surgeon. However, a general dentist should keep in mind that surgical treatment is, as a rule, the primary but not the only method in the complex management of a cyst. An appointment (examination, consultation) with a general dentist consists of active disease detection, clarifying the involvement of permanent teeth whose roots project into and abut the cyst area based on a comparison of radiological and electric pulp testing data. Filling of permanent teeth (root canal filling) in the area of a radicular cyst precedes surgical treatment.

The optimal approach is when dental filling (root canal filling) is performed on the eve of or immediately before surgery. This helps avoid potential post-filling exacerbations caused by the excess extrusion of filling material into the cyst cavity, which is difficult to prevent in the absence of bone in the periapical region over a significant extent. Oral sanitation is performed before surgery. The affected teeth are extracted during the course of the surgery.

Following surgical treatment of tooth-containing cysts, permanent teeth erupting in this zone may exhibit various manifestations of local hypoplasia, i.e., cysts of temporary teeth are a risk factor for abnormal maturation of permanent tooth tissues. Therefore, during routine health check-ups (dispensary monitoring), these teeth must be monitored by the district dentist (dental appointment (examination, consultation)).

In the case of paradental, follicular, and primordial cysts, clinical and radiological monitoring until complete restoration of bone structures after cystectomy is best performed 6 months after surgery.

Patients with follicular and paradental cysts also require additional follow-up and treatment by an orthodontist.

Patient monitoring is continued until complete normalization of the clinical and radiological picture [20].

• All patients presenting with the initial symptoms of soft tissue cysts of the maxillofacial region and neck are recommended an ultrasound examination of the soft tissues of the neck (one anatomical zone) to determine the tactics of preventive measures aimed at preventing disease progression and the occurrence of complications [41,42].

LoE 5Grade of recommendation – C (Level of evidence – 5)

• All patients presenting with the initial symptoms of a maxillary cyst extending into the nasal cavity and/or maxillary sinus are recommended an otolaryngologist consultation to determine the tactics of preventive measures aimed at preventing disease progression and the occurrence of complications [1,2,3,4,5,6,7].

LoE 5Level of Recommendation – C (Level of Evidence – 5)

• All patients presenting with initiating symptoms of a neck soft tissue cyst with a fistulous tract in the pharynx or tongue root region are recommended an otolaryngologist consultation to determine the tactics of preventive measures aimed at preventing disease progression and the occurrence of complications [13,26].

LoE 5Level of Recommendation – C (Level of Evidence – 5)

6. Organization of Medical Care

Type of medical care: specialized medical care. Conditions for providing medical care:

For small-sized cysts (involving fewer than 3 teeth) – outpatient.

Indications for hospitalization in a medical organization:

1) For small-sized cysts (involving fewer than 3 teeth) in patients with severe comorbid conditions;

2) For large-sized cysts (involving more than 3 teeth) and in case of suppuration;

Indications for patient discharge from a medical organization

1) Relief of the acute inflammatory process;

2) Absence of postoperative bleeding risks;

Form of medical care:

In case of cyst suppuration – emergency.

In all other cases – elective.

7. Additional Information

Negative factors affecting treatment outcomes include:

1. Development of infectious complications;

2. Patient's non-compliance with the restrictive regimen in the early postoperative period;

3. Patient's non-compliance with dietary recommendations.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Kulakov, A. A. – Academician of the Russian Academy of Sciences, MD, Professor, President of the Association of Maxillofacial Surgery Specialists LLC.

2. Drobyshev A.Yu. – MD, Professor, Vice President of the Association of Maxillofacial Surgeons.

3. Yaremenko A.I. – MD, Professor, Vice President ofцвет the Association of Maxillofacial Surgeons.

4. Bagnenko A.S. – Candidate of Medical Sciences, Associate Professor, Member of the "Association of Specialists in Maxillofacial Surgery".

5. Bayrikov, I. M. – Corresponding Member of the Russian Academy of Sciences, MD, Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.

6. Belchenko V.A. – MD, Professor, Board Member of the Association of Maxillofacial Surgeons.

7. Braylovskaya T.V. – MD, Associate Professor, Executive Secretary of the Association of Maxillofacial Surgeons.

8. Durnovo E.A. – MD, Professor, Board Member of the Association of Maxillofacial Surgeons.

9. Ivanov, S. Yu. – Corresponding Member of the Russian Academy of Sciences, MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists LLC.

10. Epifanov S. A. – MD, PhD, Associate Professor, Member of the Association of Maxillofacial Surgeons.

11. Lepilin A.V. – MD, Professor, Board Member of the Association of Maxillofacial Surgeons.

12. Roginsky V.V. – MD, Professor, Member of the Association of Maxillofacial Surgeons.

13. Savelyev A.L. – PhD, Assistant Professor, Department of Maxillofacial Surgery and Dentistry, Samara State Medical University.

14. Stolyarenko, P.Yu. – PhD in Medical Sciences, Associate Professor, Member of the LLC "Association of Specialists in Maxillofacial Surgery".

15. Sysolyatin P.G. – MD, Professor, Board Member of the Association of Maxillofacial Surgeons.

16. Tarasenko S.V. – MD, Professor, Member of the Association of Maxillofacial Surgeons.

17. Topolnitsky O.Z. – MD, Professor, Board Member of the Association of Maxillofacial Surgeons.

18. Kutukova Svetlana Igorevna – MD, Associate Professor, Member of the Association of Maxillofacial Surgeons.

19. Razumova Alexandra Yaroslavovna – PhD, Associate Professor, Member of the Association of Maxillofacial Surgeons.

There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of the clinical guidelines:

• Maxillofacial surgeon;

• Oral and maxillofacial surgeon;

• Medical students, residents, postgraduate students.

In these clinical guidelines, all data are ranked by level of reliability (evidence) depending on the quantity and quality of studies on the issue.

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2.  Scale for assessing levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for assessing grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

• Decree of the Government of the Russian Federation No. 1387 dated November 5, 1997, "On measures to stabilize and develop healthcare and medical science in the Russian Federation" (Collected Legislation of the Russian Federation, 1997, No. 46, Art. 5312).

• Order of the Russian Ministry of Health No. 804n dated October 13, 2017, "On approval of the nomenclature of medical services" (as amended on September 24, 2020, with amendments dated October 26, 2022).

• Federal Law No. 323-FZ dated November 21, 2011, "On the fundamentals of protecting the health of citizens in the Russian Federation" (as amended on August 8, 2024, with amendments dated September 26, 2024) (Collected Legislation of the Russian Federation).

Appendix B. Physician Action Algorithms

Algorithm for managing a patient with jaw cysts

Algorithm for managing a patient with cysts of the head and neck soft tissues

Appendix C. Patient Information

Timely diagnosis, the use of modern treatment methods for jaw cysts, and adequate postoperative rehabilitation make it possible to achieve optimal results in restoring the anatomical integrity, shape, function, and aesthetics of organs and tissues of the maxillofacial region, restoring working capacity, and eliminating psychological and moral impairments.

Clinical and radiological manifestations of various odontogenic cysts and methods for their treatment have much in common. However, each type of cyst has characteristic features that allow them to be differentiated from one another.

Diagnosis of a radicular cyst based on the clinical and radiological picture is usually straightforward. In doubtful cases, cyst puncture and cytological examination of the contents are performed.

Surgical treatment of patients with radicular jaw cysts is fundamental, but only comprehensive, timely, and systematically implemented specialized care for patients can ensure the optimal anatomical and functional effect of treatment and complete rehabilitation.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not applicable.