Management of suppurated cysts
Infection and the development of purulent inflammation are key complications requiring emergency intervention. During this period, it is strictly forbidden to perform radical removal of the lesion. The physician must manage the acute stage by ensuring drainage.
Management depends on the type of pathology:
- Radicular cyst. If the causal tooth is severely destroyed and cannot be restored therapeutically, it is extracted. In this case, the socket serves as an excellent pathway for pus evacuation. The cavity must be washed with antiseptic solutions.
- Residual and follicular cysts. There is a strict rule: it is forbidden to make incisions in the area where a mucoperiosteal flap is planned to be raised in the future for elective surgery.
Algorithm for creating outflow in follicular and residual lesions:
- Incision of the mucous membrane strictly along the alveolar ridge.
- Careful detachment of the mucoperiosteal flap.
- Perforation of the jaw bone wall to access the cavity.
- Placement of a drain. A rubber tube cut longitudinally is considered the optimal choice.
Elective surgical treatment
Radical intervention is initiated exclusively after the complete resolution of all inflammatory phenomena. The choice of a specific technique depends on the dimensions of the lesion.
- Cystectomy (complete enucleation of the capsule) is used for small sizes.
- Cystotomy is indicated for large lesions.
Features of endodontic preparation: The extent of preliminary root canal filling directly depends on the chosen surgery. If cystectomy is planned, the doctor must fill the canals of all teeth whose roots face the cystic cavity. In cystotomy, it is sufficient to properly treat the canals of only the single causal tooth.
During the surgical treatment of radicular cysts, after successful canal filling of the causal tooth, root-end resection (apicoectomy) is mandatory. It is important to remember that even after technically correct cystectomy, there is a risk of a local long-term complication — recurrence of the disease.
X-ray presentation and differential diagnosis
To choose the correct treatment tactics, it is necessary to accurately interpret X-ray (Rg) data and puncture results.
X-ray features:
- Radicular cyst: visualized as a focus of bone tissue destruction with clear margins, localized in the region of the apices of one or more teeth.
- Follicular (dentigerous) cyst: also has clear margins of bone destruction, but its distinguishing feature is the presence of the shadow of an unerupted tooth directly within the cavity.
When making a diagnosis, a follicular cyst must be differentiated from an ameloblastoma.
If a puncture of a radicular cyst is performed outside the inflammatory stage (before purulent complications develop), the syringe will fill with characteristic contents — a clear fluid in which cholesterol crystals are determined.
Briefly: answers to topical questions
What clinical symptoms are characteristic of a suppurated jaw cyst?
A suppurated jaw cyst is characterized by symptoms of intoxication, pronounced signs of inflammation, and a deterioration of the patient's general condition.
Local clinical manifestations include:
- Displacement and mobility of teeth — affects a group of teeth in the lesion area.
- Bulging of the jaw segment — most often observed in the vestibular area.
- Giveaway of the bone wall — determined upon palpation due to thinning or destruction of the bone tissue.
- Purulent discharge — abundant discharge of pus or cystic contents upon widening of the apical foramen of the causal tooth.
Suppuration may also be accompanied by fistula formation, the development of periostitis, osteomyelitis, and regional lymphadenitis.
What are the indications for cystotomy?
Indications for cystotomy are large jaw cysts and the mixed dentition period.
The following main indications are distinguished:
- Large maxillary cysts — lesions sprouting into the maxillary sinus and accompanied by destruction of the palatal plate or the bony floor of the nasal cavity.
- Extensive mandibular cysts — lesions causing significant thinning of the bone walls with the threat of a pathological fracture.
- Mixed dentition — situations where an attempt at complete enucleation of the cyst capsule is associated with the risk of damaging the permanent tooth buds, which can lead to impaired formation of a normal bite.
What types of odontogenic jaw cysts are distinguished according to the WHO classification?
According to the WHO classification among developmental cysts, the following types of odontogenic jaw cysts are distinguished:
- «Gingival cyst» of infants — Epstein pearls.
- Odontogenic keratocyst — primordial cyst.
- Dentigerous cyst — follicular cyst.
- Eruption cyst.
- Lateral periodontal cyst.
- Gingival cyst of adults.
- Glandular odontogenic cyst — sialo-odontogenic cyst.
To remember the difference in preparation: «ECTOMY — Extra (all teeth in the cavity), TOMY — Only one (causal tooth)».
Class and exam questions
What will be in the syringe during a puncture of an uninflamed radicular cyst?
Outside the exacerbation stage, the puncture fluid is a clear liquid containing cholesterol crystals.
With which condition must a follicular cyst be differentially diagnosed?
A follicular cyst must be differentiated from an ameloblastoma.
What is the difference in endodontic preparation for cystectomy and cystotomy?
Before cystectomy, the canals of all teeth whose roots face the cavity are filled. Before cystotomy, only the causal tooth.
What else to study on this topic
- Methodology of cystectomy and cystotomy
- Root-end resection technique
- Differential diagnosis with ameloblastoma
- Causes of recurrence after cystectomy
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Other topics in "Chapter 7. Jaw Cysts (T.G. Faizov)"
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