Cystotomy

Surgical Treatment of Jaw Cysts

Surgical treatment is the only way to eliminate cystic lesions. There are two main types of interventions: cystotomy and cystectomy.

Cystectomy is a surgical procedure aimed at the radical (complete) removal of the cyst lining, followed by primary wound closure. To ensure drainage, a rubber drain is left in the wound for 24 hours. Over time, reparative bone regeneration occurs in the resulting bone cavity.

Indications for radical removal include odontogenic and non-odontogenic cysts of any age, measuring no more than 3 centimeters.

Advantages of the radical approach:

• Complete removal of the entire cyst lining.
• The possibility of performing a full pathomorphological examination of the removed tissues.

Disadvantages and risks:

• High invasiveness of the intervention.
• Risk of damage to the neurovascular bundle.
• Probability of accidental opening of the nasal cavity wall or maxillary sinus.

Surgical technique (cystectomy)

Mandatory preoperative preparation is carried out before the intervention. The roots of the causal tooth (subject to root-end resection) and adjacent teeth projecting into the cyst cavity must be filled. This is done immediately before the operation to prevent the exacerbation of inflammation, after which a control radiograph is taken. If the causal tooth cannot be saved, it is extracted.

Course of the surgical procedure:

1. Anesthesia and incision. The operation is performed under local anesthesia with premedication. The incision (arcuate, angular, or trapezoidal) is made on the vestibular surface of the alveolar process. The incision line should extend 0.5 cm beyond the bone boundaries of the lesion (above the boundaries in the maxilla and below in the mandible). The mucosa and periosteum are dissected down to the bone.
2. Access to the pathology. A mucoperiosteal flap is reflected using a periosteal elevator. Access to the bone cavity is formed by trephination or by enlarging an existing bone defect.
3. Enucleation (shelling out). The lining is carefully separated from the bone walls with a periosteal elevator, starting from the edges. It is important not to tear it and not to leave fragments. In the area of the roots, tissues are curetted with a curette, paying special attention to the space beyond the root apices.
4. Antiseptic treatment. To ensure sterility, the cavity is treated with a 5% iodine solution, then immediately washed with isotonic $NaCl$ solution and 3% $H_2O_2$ solution.
5. Completion. The surgeon examines the cavity, performs final hemostasis, and smooths sharp bone edges with a bur. If necessary, resection of the root apex of the causal tooth is performed at this stage.

Types and morphology of cystic lesions

Before surgery, it is necessary to differentiate the type of lesion. Both solitary (bone) and fissural (non-odontogenic) cysts occur.

Solitary bone cyst A rare pathology localized in the posterior body of the mandible. It is asymptomatic and detected incidentally. On X-rays, it appears as a well-demarcated cavity with sclerotic borders, unrelated to teeth. Morphology: The cavity has no epithelial lining, is filled with blood, and is divided by connective tissue septa (containing bone trabeculae, osteoid tissue, osteoclasts). The bone walls are covered with a fibrous capsule containing multinucleated giant cells and hemosiderin. Sometimes the lesion is difficult to distinguish from a giant cell tumor.

Non-odontogenic (fissural) jaw cysts They arise due to facial embryogenesis disorders and are located in the maxilla. Unlike tumor-like lesions, they have an epithelial lining.

• Nasopalatine (incisive canal) cyst. The most common fissural cyst. It develops from epithelial remnants between the upper central teeth. It manifests as a painless swelling with clear borders and fluctuation, causing resorption of the palatine process. On X-rays, it shows bone radiolucency between the roots of the incisors with a preserved periodontal ligament space. It contains yellowish fluid with cholesterol. It is lined with stratified squamous epithelium (on the oral side) and respiratory (pseudostratified ciliated) epithelium (on the nasal side).
• Globulomaxillary cyst. Located between the roots of the maxillary lateral incisor and canine (teeth are intact). On X-rays, it has an "inverted pear" shape, separates the roots, and the periodontal ligament space is preserved. Inside, there is yellowish opalescent fluid. It requires differentiation from a radicular cyst.
• Nasolabial (nasoalveolar) cyst. Projects into the area of the roots of the lateral incisor and canine, causing bulging of the external cortical plate. It is palpated under the base of the alar base of the nose as a mobile, rounded, painless mass not fixed to surrounding tissues. It is not visible on a panoramic radiograph; contrast injection into the cavity is required for detection.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Features of bone tissue reparative regeneration after radical cyst enucleation.
• Morphological differential diagnosis of solitary bone cyst and giant cell tumor.
• Pathogenesis of impaired facial embryogenesis during the formation of fissural cysts.
• Histological features of the nasopalatine duct cyst lining (transition from stratified squamous to ciliated epithelium).

Other topics in "Chapter 7. Jaw Cysts (T.G. Faizov)"

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