Odontogenic tumor cysts of the jaws. Right ovarian cyst: causes of formation, types, symptoms, diagnosis, treatment

The following types of odontogenic cysts and some associated lesions will be presented here: 1) Root cyst, 2) Residual cyst, c) Paradental and maxillary infected buccal cysts, 3) Maxillary Infected Buccal Cyst, 4) Lateral periodontal cyst, 5) Glandular odontogenic cyst, 6) Odontogenic keratocyst, 7) Gorlin syndrome

A cyst can be defined as a soft, abnormal cavity within bone or soft tissue, with walls covered in connective tissue. The cavity within the mouth area is almost always lined with epithelium. Some cyst-like lesions, without epithelial lining, can also be observed in the maxillofacial region. The cyst cavity usually contains fluid, keratin, or cell debris.

In this schematic drawing, arrow A points to the connective tissue wall that borders the cyst. Arrows B indicate the different types of epithelium that may line a cyst developing within the oral cavity. It is important to remember that differentiated epithelium does not normally occur in bone. Therefore, when treating these cysts, the entire epithelium must be removed to prevent recurrence.

(Periapical cyst, apical cyst, root cyst) the most common cyst on the root surfaces of teeth, also called periapical or apical cyst. About 60% of all jaw cysts are radicular or residual cysts. Root cysts can form in the periapical region of any teeth, at any age, but rarely appear in the primary dentition. This cyst is classified as inflammatory because in most cases it is a consequence of pulp necrosis during caries, and the associated periapical inflammatory response. Other reasons may be: any causes that contribute to pulp necrosis such as tooth cracks and poor-quality restorations. The first line of defense for pulp necrosis is in the periapical region - a granuloma is formed. Granuloma is a highly vascularized tissue containing a rich infiltrate of immunological cells such as lymphocytes, macrophages, plasma cells, etc.

Arrow A in both images indicates the initial process of caries, which has already affected the dentin. Arrow B indicates a limited area of ​​inflammatory response in the coronal pulp as a response to caries. Malassez epithelial cells are remnants of Hertwig's vagina, which are very numerous in the periapical region of all teeth. These epithelial cells are derived from the ectoderm from which the tooth germ develops, and they retain their embryonic metaplastic potential. Therefore, they can differentiate into any type of epithelium, given the proper stimulus. These cells play a major role in the formation of root cysts. In the midst of the vascular-rich region provided by the periapical granuloma, Malassez cells proliferate and eventually form a large three-dimensional cell mass. Due to continuous growth, the internal cells are deprived of proper nutrition and they undergo liquefaction necrosis. This promotes the formation of a cavity that is located in the center of the granuloma, causing a root cyst. The radiological image of a root cyst can be peri- or paraapical: a round or oval-shaped formation, radiolucent of varying sizes, with well-defined and radiopaque edges. Other lesions such as granulomas, tumors of various origins and some bone diseases can also give a similar x-ray picture. Therefore, periapical radiolucency cannot automatically be considered a cyst. Several studies have indicated that the radiographic size of a periapical lesion cannot be relied upon to make the diagnosis of a cyst or granuloma unless the lesion is more than 2 cm in diameter. Rarely, root cysts stimulate root resorption of the affected tooth.

This is a typical example of an apical radiolucency on a radiograph. Note a well-defined cavity with a radiopaque border marked. A biopsy proved it was a root cyst. Note the corresponding roots of the lower first molar.

This is another example of a root cyst resulting from pulp necrosis. Note the large periapical radiolucency, which is located very close to the nasal cavity.

Periapical radiolucencies are a common finding in teeth undergoing endodontic treatment. Microscopic examination of those clearings can answer what it is: either it is the remains of a granuloma, a collagen scar as a consequence of endodontic treatment, or a root cyst. As stated earlier, it is not possible to make a correct diagnosis based on radiographs alone. It has been established that about 10% of periapical radiolucencies in endodontically treated teeth are cysts.

These radiographs illustrate examples of periapical radiolucencies. The diagnosis of a root cyst or granuloma can only be made after a histological examination of the lesion. The size of these clearings is not an indicator for diagnosis, because any injury may produce variations in size, reflecting the amount of bone absorbed as a result of the pressure created by the increasing process in the bone. Islands of keratinizing epithelium that have developed from odontogenic remnants of Malassez may also be present in a periapical granuloma without developing into a cyst. Endodontists refer to these granulomas as “cove-shaped cysts.” The root cyst is finally formed by a mature collagen connective tissue wall. This connective tissue is the stroma of most cysts that form in the maxillofacial area. Excessive numbers of fibroblasts, the main cell of connective tissue, can be found within the cystic wall and are characterized by a dark colored nucleus in the center of the cytoplasm (nuclei of crystallization). Fibroblasts are seen within the wavy collagen fibers. The wall, as a whole, is an inflammatory infiltrate of varying intensity. Lymphocytes are generally the most prominent cells in the infiltrate and are characterized by a darkly colored nucleus that occupies most of the cytoplasm. Plasma cells are also present in large numbers in the walls of cysts and are mainly seen in chronic cysts. Plasma cells are considered "factories" of immunoglobulins. Other histologic findings of the cystic wall include: Red blood cells (Arrow 1) and areas of interstitial hemorrhage, occasional spicules of bone degeneration, multinucleated giant cells, and cholesterol crystals.

These are histological sections of the same cyst. On the left is a slight magnification, where Arrow 1 indicates hemorrhage within the cystic cavity and Arrow 2 indicates a capillary within the connecting wall. On the right - higher magnification, demonstrates the stratified squamous epithelium of the cyst. Also notice the underlying layer of connective tissue. The cavity of the root cyst is generally lined with stratified keratinizing epithelium; these cysts can be lined with respiratory epithelium, especially if they are located next to the maxillary sinus. Sometimes root cysts may be lined by mucus-producing epithelium on the upper or lower jaw. The mucous epithelium is the result of the degeneration of Malassez epithelial cells, which are multipotential.

The radiograph shows a lateral incisor with a carious cavity, where there was previously a filling placed 4 years ago, which recently fell out. The patient associates cases of pain in this tooth as well as changes in the periapical area. She also states that approximately 2 years ago there was an episode of swelling and intense pain in the same area. Treatment with antibiotics was carried out. No further treatment was carried out, because the patient did not come for examination. There is caries on the distal side of the tooth and a large periapical clearing. This lateral incisor was treated endodontically and, based on both biopsy and histological examination, a diagnosis of radicular cyst was made.

There is also a slight periapical clearing at the root of the central incisor. Note poor quality endodontic treatment. The patient did not have any complaints related to this tooth. The clearing on x-ray may be either a cyst, a granuloma, or a residual scar. Root cysts are generally asymptomatic unless they become secondarily infected, in which case they will be accompanied by pain, swelling and other inflammatory and infectious signs. Root cysts can vary in size from 0.5 to 2 centimeters or more in diameter. When the cyst reaches a large size, it can lead to intraoral or facial asymmetry and sometimes even paresthesia due to nerve compression. Sometimes a large cyst can destroy the cortical plate of the bone, and can also invade the maxillary sinus or nasal cavity. About 60% of all root cysts develop in the upper jaw and rarely spread to the hard palate. Patients with extremely large root cysts are at risk of spontaneous bone fractures.

This radiograph is of a 39-year-old man who complained of dull pain in the region of the mandibular right first molar. The molar was subjected to endodontic treatment and a crown was placed 3 years ago. Based on this radiograph, endodontic treatment seems to be of poor quality, because... the channel is not completely filled. In this case, the large periapical radiolucency could be caused by more than one etiological factor. In addition to poor endodontic treatment, there is resorption of the alveolar bone at various points. Histological examination, after surgical removal, established the diagnosis of a periapical cyst.

This is an x-ray of a molar that has a canal in the root that deviates to the side, which determined the lateral localization of the periapical process. EDI determined that the tooth was devitalized. The tooth was eventually removed and the photo on the right shows the molar with a mass of soft tissue attached to the mesial root. A biopsy of the soft tissue mass determined it to be a cyst. Careful examination of the extracted molar revealed that the canal in the mesial root opened laterally rather than apically. Therefore, the cyst was apical, with paraapical localization.

Treatment of a root cyst is surgical extirpation. When the affected tooth is removed, the cyst is most often attached to the root. If the cyst has become secondarily infected, the cyst wall may have thick collagen ligaments embedded deeply into the bone. When this happens, parts of the cyst may remain at the bottom of the cavity after the tooth is extracted. Gentle curettage is recommended after extraction in order to remove any possible remnants of cystic cells.

A residual cyst occurs as a consequence of improper surgical extirpation of the root cyst. Its clinical and histological characteristics are identical to those of a root cyst. Radiographically, this will appear as varying sizes of radiolucency in the area of ​​the previous tooth extraction.

This large residual cyst had existed for many years on the mandible of a 67-year-old man. Arrow A indicates the location of the jaw canal. Arrow B indicates expansion of the labial cortex produced by the cyst. Arrow C indicates the remainder of the root.

The radiograph on the left shows a well-defined radiolucency with a clear radiopaque border. This damage is not related to the adjacent premolar. Notice the roof of the cyst, which increases the level of the maxillary sinus. After surgical removal and biopsy, it was proven that this process was a cyst. This cyst developed as a result of caries in the first molar in the upper jaw. That molar was removed and parts of the cyst remained within the bone. These remnants caused a so-called residual cyst. Therefore, any cyst must be carefully removed in order to avoid relapses. The radiograph on the right is another example of a residual cyst. It is important to remember that on x-ray this lesion is radiolucent, and that the radiographic differential diagnosis may include various processes that may have the appearance of a clearing type: non-odontogenic benign tumors (such as hemangiomas, neuromas, etc.), odontogenic benign tumors ( such as: solitary ameloblastoma, adamantinoma, etc.), or other lesions primarily arising in the bone, like Langerhans histiocytosis. Therefore, biopsy plays a leading role in establishing a diagnosis.

A paradental cyst is an inflammatory cyst that develops on the lateral surface of a tooth root. Histologically, a paradental cyst cannot be differentiated from a radicular cyst. Some authors classify this cyst as an inflammatory periodontal cyst or a collateral cyst. This cyst has a rare localization and must be radiologically differentiated from a lateral cyst. Treatment is surgical desquamation, and the cyst does not recur.

The arrows point to the edge of the paradental cyst, fused to the distal wall of the 3rd molar in the mandible. These cysts are also considered to be cysts of inflammatory etiology.

Jaw cysts are tumor-like formations and are common in children.

Modern classification of cysts

Odontogenic cysts:

radicular (root);

follicular (tooth-containing);

eruption cyst;

primary cyst (keratocyst).

Non-odontogenic cysts:

fissural (incisive or nasopalatine canal; globulomaxillary or intermaxillary; nasolabial);

traumatic (solitary, hemorrhagic, non-shell).

Source: a guide to surgical dentistry and maxillofacial surgery. Ed. Bezrukova V.M., Robustova T.G. - M. - 2000.

Odontogenic cysts

The development of a radicular cyst almost always begins with chronic periodontitis, leading to the growth of granulation tissue around the apex of the tooth root. Subsequently, under the influence of periodic exacerbations of inflammation, necrosis of some areas of the formed granuloma occurs, as a result of which cavities are formed in its thickness, surrounded by epithelium, which is the future shell of the cyst. Further growth of the cyst occurs due to the pressure of the fluid accumulating in it, constantly produced by the cyst shell.

Eruption cyst

It occurs during the process of tooth eruption in young children and is characterized by the presence of a limited formation of red-bluish or bluish color located above the crown of an unerupted tooth containing serous or serous-hemorrhagic fluid. Occasionally, such cysts can become inflamed.

A follicular cyst develops from the follicle of an unerupted (usually permanent) tooth. The occurrence of this type of cyst is associated with the spread of the inflammatory process in the periodontium of temporary teeth to the permanent tooth, which is at the stage of development.

It is rare in children. The cyst shell, unlike other cysts, is represented by keratinizing epithelium.

As a rule, it is not possible to establish a connection between a cyst and dental pathology.

The cyst spreads along the length of the jaw and, as a rule, does not lead to significant deformation of the jaw. Obvious symptoms that allow one to suspect this type of cyst appear when the cyst reaches a significant size.

It is often detected incidentally during an X-ray examination for some other reason.

Complaints

Usually complaints appear when the cyst reaches a sufficiently large size. The child or his parents indicate jaw deformation, as well as discomfort when chewing, mobility of several teeth; with a follicular cyst, children or parents pay attention not to the absence of a tooth in the dentition, which should have erupted in time.

When cysts suppurate, the complaints coincide with those of inflammatory diseases of the jaws (periostitis or osteomyelitis, see articles on odontogenic inflammation).

Clinical picture

The general condition of the child does not suffer, with the exception of the case of suppuration of the cyst. Local manifestations of a radicular or follicular cyst have common symptoms:

deformation of the alveolar process and the body of the jaw occurs and progresses gradually, without pain;

upon palpation of the deformed area of ​​the jaw, the formation of a dense consistency is determined;

when the cyst is large, its wall often becomes so thin that when pressure is applied to it, it sometimes bends with a characteristic crunch;

there are no changes in the oral mucosa above the cyst.

The main distinguishing feature of radicular and follicular cysts is the presence of a temporary or permanent cause tooth in the dentition. As already mentioned, with suppuration of odontogenic cysts, the clinical picture resembles acute periostitis or osteomyelitis of the jaw. The diagnosis is confirmed by x-ray examination.

Treatment

Two types of surgery are used to treat cysts: cystectomy (complete removal of the cyst shell) and cystotomy (opening the cyst shell without completely removing it).

During cystotomy after surgery, the cyst cavity is always tamponed (for example, with iodoform turunda).

During cystectomy, the cyst cavity is sutured, the blood filling the cavity is gradually replaced by bone.

In the case of a radicular cyst, a resection of the apex of the root of the tooth that is the source of the cyst is performed (the tooth canal must first be filled).

There is a third type of surgical intervention - open cystectomy, in which the cyst shell is removed completely or almost completely, but the remaining bone cavity is plugged. This operation is usually performed for suppurating cysts, when it is impossible to suture the bone cavity in which there was a purulent cyst, or when it is impossible to remove the cyst shell completely due to the risk of damage to the impacted tooth in the cyst.

During cyst tamponade, its cavity gradually decreases due to bone growth towards the cavity.

In addition to surgical treatment, festering cysts require antibiotic therapy.

Odontogenic formations are organ-specific, their origin is associated with tooth-forming tissues, and are localized only in the jaw bones. Among them, benign and malignant tumors, tumor-like lesions and odontogenic cysts are distinguished. The most common are ameloblastoma, ameloblastic fibroma, complex and compound odontomas, myxoma (myxofibroma), and various types of cementomas. The most common pathology of odontogenic formations is jaw cysts.

Odontogenic cysts of the jaws.

The cyst is a cavity having a shell, which consists of an outer connective tissue layer and an inner lining predominantly of stratified squamous epithelium. The cavity of the cyst usually contains a transparent yellow liquid, opalescent due to the presence of cholesterol crystals, sometimes a cheesy mass of grayish color (with a keratocyst). Its growth is due to the presence of intracystic pressure, which is created by the produced cystic fluid, which leads to atrophy of the surrounding bone tissue and proliferation of the epithelium.

The etiopathogenesis of odontogenic cysts is different. A cyst based on an inflammatory process in the periapical tissue is called a root (radicular) cyst; it can be apical (apical) or lateral (lateral). This also includes residual (residual) radicular cyst and paradental cyst. Other cysts are a malformation of odontogenic epithelium. Among them there are keratocyst (primary odontogenic cyst), tooth-containing (follicular) cyst, eruption cyst and gingival cyst.

Jaw cysts are ranked by frequency in first place among other odontogenic formations. Cysts occur in people of different ages; they occur on the upper jaw 3 times more often than on the lower jaw. There are many similarities in clinical and radiological manifestations and treatment methods for various odontogenic cysts. However, each type of cyst has its own characteristic features that allow them to be differentiated from each other.

Root (radicular) cyst. The occurrence of a root cyst is associated with the development of a chronic inflammatory process in the periapical tissue of the tooth, which leads to the formation of apical granuloma. Inside this granuloma, epithelial cells (islets of Malasse) of the periodontal ligament, activated by inflammation, proliferate and first lead to the formation of cystogranuloma, and then, lining the entire cavity, they form a cyst. The previous views of a number of authors (I.G. Lukomsky, Gravitz, Schuster) on another source of epithelium in the granuloma (gingiva, fistulous tract) have now lost their significance.

Root cyst, as a rule, are found in the area of ​​a destroyed or treated tooth, or sometimes as if healthy, but subject to trauma, less often - in the area of ​​an extracted tooth (residual cyst) (Fig. 6). The cyst grows slowly, over many months and even years, unnoticed by the patient, without causing any discomfort. It spreads mainly towards the vestibule of the oral cavity, while thinning the cortical plate and leading to bulging of the jaw area. If a cyst arises from a tooth whose root faces the palate, thinning and even resorption of the palatal plate is observed. A cyst that develops within the boundaries of the maxillary and nasal cavities spreads towards them.

Examination reveals smoothness or bulging of the transitional fold of the arch of the vestibule of the oral cavity of a semicircular shape with fairly clear boundaries. When localized on the palate, limited swelling is noted. The skin and mucous membrane covering the cyst do not change in color. Regional lymph nodes do not enlarge. On palpation, the bone plate above the cyst bends; with its sharp thinning, the so-called parchment crunch (Dupuytren's symptom) is determined; in the case of bone resorption, fluctuation. The teeth located within the boundaries of the cyst may be displaced, and percussion of the causative tooth produces a dull sound. EDI of intact teeth located in the cyst area reveals a decrease in electrical excitability (the pulp reacts to a current of more than 6-8 mA) due to compression of the nerve endings by the cyst.

Often a cyst is diagnosed when its contents suppurate, when inflammation of the surrounding tissues develops like periostitis, when the cyst is localized on the lower jaw, Vincent's symptom is sometimes noted - numbness of the lower lip of the corresponding side due to involvement of the inferior alveolar nerve in the acute inflammatory process. Developing on the upper jaw, a cyst can cause inflammation of the maxillary sinus. We did not observe malignancy of the root cyst.

The X-ray picture is characterized by rarefaction of bone tissue of a round shape with clear boundaries. The root of the causative tooth faces the cavity of the cyst. The relationship of the roots of adjacent teeth with the cyst may vary. If the roots protrude into the cavity of the cyst, the periodontal fissure is absent on the radiograph due to resorption of the endplate of the sockets of these teeth. If the periodontal fissure is identified, then such teeth are only projected onto the area of ​​the cyst, but in fact their roots are located entirely or partially in one of the walls of the jaw. In some cases, the roots of the teeth are pushed apart by the growing cyst. Root resorption, as a rule, is not observed.

Lower jaw cyst reaching large sizes, thins its base and can lead to a pathological fracture. Growing towards the bottom of the nose, a cyst of the upper jaw causes destruction of its bone wall. Located within the maxillary sinus, the cyst has a different relationship with its bottom. A cyst penetrating into the sinus is characterized by the absence of a bone septum between them, while a dome-shaped soft tissue shadow is detected in the lumen of the maxillary sinus (Fig. 7, i, b). Preservation of an unchanged bone floor is observed with a cyst adjacent to the maxillary sinus (Fig. 7, b). A cyst that pushes back the maxillary sinus is characterized by thinning of the bone wall and a dome-shaped displacement into the sinus (Fig. 7, d). In the radiological diagnosis of cysts located on the lower jaw, radiography in the lateral projection, panoramic radiograph, orthopantomogram and targeted intraoral photographs are used. In the case of a cyst of the upper jaw A panoramic radiograph, an orthopantomogram, a survey radiograph of the paranasal sinuses and a targeted intraoral radiograph are performed. Contrast radiography is used mainly for cysts penetrating into the maxillary sinus. The choice of x-ray examination technique depends on the location and size of the cyst. A panoramic photograph is taken when the cyst is localized in the frontal part of the jaw; when the cyst is located in the lateral part (at the level of premolars and molars), an orthopantomogram is the most informative.

Diagnosis of a root cyst based on clinical and radiological data usually does not cause difficulties. In doubtful cases, cyst puncture and cytological examination of the contents are performed. The punctate is a characteristic yellowish opalescent liquid that flows freely into the syringe. Cytological examination reveals protein substances, cholesterol crystals and single cells of stratified squamous epithelium. When a cyst festers, pus is obtained.

Root cyst in children from milk teeth c often on a radiograph it simulates a tooth-containing (follicular) cyst (Fig. 8). It must be emphasized that several rudiments or incompletely formed permanent teeth are projected into the cavity of this cyst, in contrast to the tooth-containing one, which, as a rule, is associated with a fully formed causative tooth. Dental cysts are extremely rare in children.

Microscopically, the shell of the root cyst consists of fibrous tissue, often with inflammatory round cell infiltration, and is lined with non-keratinizing stratified squamous epithelium. Treatment of root cysts is surgical; the techniques used are cystectomy, cystotomy and plastic cystectomy.

Paradental (inflammatory collateral, mandibular) cyst. Occurs with recurrent pericoronitis of the lower wisdom tooth in case of difficult eruption. X-ray is determined in the form of a cystic formation of larger or smaller sizes associated with the neck of an erupting or already erupted wisdom tooth, adjacent to and located directly behind it. After the tooth has completely erupted, the cyst continues to grow and can become inflamed. Surgical treatment is cystectomy with removal of the causative tooth.

Odontogenic keratocyst (primary cyst). In the domestic literature, reports of keratocyst are rare. In foreign sources, it was first described by Philipsen and called a keratocyst, since the epithelium of its membrane becomes keratinized. The cyst's ability to recur and the possibility of malignant transformation were noted.

It develops mainly in the lower jaw, corresponding to the third large molar, and spreads into the body, angle and ramus of the jaw, causing large destruction of the bone, as a result of which in the past it was often interpreted as ameloblastoma.

Primary cysts are relatively rare and are observed in people of all ages.

The cyst grows unnoticed and does not manifest itself for a long time. In some patients, the cyst is detected due to the addition of inflammation, sometimes it is discovered accidentally during an X-ray examination for other diseases. In the patient's anamnesis, no connection between the occurrence of the cyst and dental pathology can be noted.

As the keratocyst grows, it has a characteristic feature: it spreads along the jaw and does not cause pronounced deformation of the bone. Therefore, it is detected only when it reaches a large size, when the body, angle and branch of the jaw are affected.

The X-ray picture appears as an extensive loss of bone tissue with clear polycyclic contours, while the uneven resorption of bone tissue creates the impression of a multi-chamber formation (Fig. 9). Often the coronoid and condylar processes are involved in the process. The deformation of the jaw is usually not pronounced. The cortical plate becomes thinner and may be absent in some areas. An x-ray usually determines the preservation of the periodontal fissure of the roots of the teeth projected into the area of ​​the cyst.

Primary odontogenic cyst is diagnosed based on clinical and radiological manifestations. However, these symptoms are sometimes inherent in ameloblastoma, although the latter,

unlike keratocysts, it leads to pronounced swelling of the jaw. Therefore, the final diagnosis is established after a morphological examination of the biopsy specimen. If a cyst is suspected, an open biopsy is performed with mandatory excision of the bone tissue and its membrane, similar to a cystotomy. If the diagnosis of a cyst is confirmed, a biopsy is also the first stage of surgical treatment.

Macroscopically, the keratocyst is a single cavity with bay-shaped depressions into the surrounding bone, covered with a membrane and filled with an amorphous gray-white mass with an unpleasant odor.

Microscopically it is characterized by a thin fibrous capsule lined with keratinizing stratified squamous epithelium.

Treatment is surgical. Since the cyst is capable of recurrence and malignancy, complete removal of the membrane while maintaining intact bone walls is indicated. In other cases, a two-stage surgical method is used.

Dental (follicular) cyst. Develops from the enamel organ of an unerupted tooth, mainly the third molar and canine. The clinical symptoms of a tooth-containing cyst are similar to other cysts of the jaws, however, when examining the teeth, it is characteristic that one of them is absent in the area where the cyst is located, except in the case of its formation from a supernumerary tooth. The possibility of developing ameloblastoma and odontogenic cancer from a dental cyst has been noted, although rare.

X-ray reveals a rarefaction of bone tissue with clear, even boundaries similar to a monocystic lesion and the presence of an impacted tooth, the crown of which faces the cyst cavity (Fig. 10).

Macroscopically, the cyst is a single-chamber cavity, lined with a membrane and containing a yellowish liquid with cholesterol crystals, in the depths of which the crown of the causative tooth can be found.

Microscopically, the cyst shell is represented by a thin layer of connective tissue, covered with stratified squamous epithelium, 2-3 layers thick.

Treatment of a tooth-containing cyst is surgical - cystectomy with removal of the impacted tooth or a two-stage operation.

Eruption cyst and gingival cyst. They are rare. An eruption cyst appears as a limited, small bluish swelling of the gums in the area where the tooth is about to erupt, and is located above its crown. Surgical treatment is required if tooth eruption is delayed.

A gingival cyst develops from the remains of epithelial cells of the gum and has the appearance of small nodules located in the soft tissues covering the tooth-containing areas of the jaw. Treatment is usually not required.

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Odontogenic cysts- are cavity formations, lined with a membrane, connected to the tooth and located in the jaw bones. There are cysts associated with the root of a tooth with devitalized pulp (inflammatory) - radicular cysts (80-90% of all jaw cysts) and cysts formed as a result of a developmental defect - follicular cyst and keratocyst (primordial).

Radicular cystscan develop in any part of the alveolar process of the upper or lower jaw (within the dentition); follicular cysts and keratocysts are most often located in the area of ​​the angle or ramus of the lower jaw.

Clinical picture:Radicular cysts are related to the size of the cyst and its location.

If the cyst is small in size and develops deep within the alveolar process, the diagnosis of the cyst can only be made on the basis of an x-ray examination.

On the upper jaw, cysts occur 2 times more often than on the lower jaw. Cysts from the upper central incisors and fangs can grow towards the nasal cavity - this forms a protrusion into the cavity of the lower nasal passage or under the lower nasal concha (Gerber sign). Sometimes there may be growth towards the hard palate, in which case a hemispherical swelling appears on the hard palate. If the cyst grows towards the maxillary sinus, no external manifestations are observed for a long time. The diagnosis in this case is usually made when the cyst suppurates, symptoms of periostitis and sinusitis appear, and based on radiographic data. Also on the upper jaw, growth of the cyst towards the vestibule of the mouth may be observed, with bulging and deformation of the alveolar process.

In the lower jaw, cyst growth is mainly observed towards the vestibule of the mouth. Both on the lower and upper jaw, in these cases there is an elastic bulging of the alveolar process above the dome of the cyst, the mucous membrane above the cyst is not changed. As the cyst grows, the compact layer is eroded, the edge becomes pliable and springs upon palpation, causing the appearance of the “parchment crunch” symptom. In some cases, displacement of teeth located in the cyst area is possible.

If you suspect the presence of a radicular cyst, it is necessary to conduct an x-ray examination: an orthopantomogram or panoramic x-ray, a targeted photograph of the causative tooth, and, if indicated, an x-ray of the paranasal sinuses. The radiograph shows a round or oval shadow with clear boundaries associated with the apex of the tooth. The continuity of the compact layer of the alveoli in the area of ​​the apex of the “causal tooth” is broken. The dynamics of radicular cysts can be complicated by sinusitis and fracture. However, suppuration of cysts occurs most often.

If the inflammation of the cyst is acute, then the process proceeds as acute periostitis. However, there are often cases when the initial inflammatory process is chronic. In this case, the formation of a fistula on the gum with periodic purulent discharge is often observed. Cysts, the wall of which is in contact over a long distance with the mucous membrane of the maxillary sinus, can cause chronic polypous sinusitis, also with periodic exacerbations.

In rare cases, malignancy is possible.

Histological picture: the inner shell of the cysts is lined with stratified squamous epithelium without signs of keratinization. The cyst wall is fibrous, infiltrated with lymphocytes and plasma cells. This histological picture is typical only for radicular cysts. During inflammation, the epithelium hyperplasias and network-like processes are formed, directed towards the wall of the cyst.

Follicular cyst- develops from the tissue organ of an unerupted tooth. The cyst wall is thin, lined with stratified squamous epithelium. The cyst cavity contains one or more teeth, formed or rudimentary.

Most often, a follicular cyst associated with the mandibular third molars or any unerupted tooth is asymptomatic. They are usually discovered by chance during an X-ray examination; such cysts rarely suppurate. The radiograph shows round or oval bone resorption associated with an unerupted tooth.

KeratocystIt is also asymptomatic and detected incidentally during radiography. Keratocyst treatment is best done in a hospital setting.

The clinical and radiological picture of odontogenic cysts is very characteristic and does not require differential diagnosis.

Treatment: surgical - cystotomy or cystectomy. The extent of the operation depends on the size of the cyst.

If the cyst is large and has penetrated into the nasal cavity, a cystotomy is performed. The same operation is performed when more than three teeth stand in the cyst cavity. Before surgery, electroodontodiagnostics of the teeth located in the cyst cavity is performed. Teeth with devitamized pulp are filled. The operation is performed under local anesthesia. A flap is cut out from the side of the vestibule of the mouth, with its base facing the transitional fold. The size of the flap should exceed the size of the cyst cavity by 1 cm. Next, a bone window is cut out with a drill according to the size of the cyst. A window is also cut out in the cyst shell, the contents of the cystic cavity are removed, and the roots of the teeth located in the cyst cavity are resected. The flap is screwed into the cyst cavity and packed with iodoform turunda. Iodoform turundas are changed every 5-7 days until epithelization of the wound edges occurs. If necessary, obturators are made. Cystotomy is also performed when the cyst is suppurated.

In other cases, a cystectomy is performed. Preoperative preparation is the same as for cystotomy. After anesthesia, a mucoperiosteal flap is formed, which must be cut so that the suture line is located on the bone base. The bone in the projection of the cyst is trepanned and the apices of the roots of the teeth located in the cyst cavity are resected. The cyst shell is carefully peeled off. According to indications, any osteogenic substance is injected into the cyst cavity: hydrosicallopol granules, demineralized or lyophilized bone, allogra, etc. The flap is placed and fixed with interrupted sutures. An external pressure bandage is applied according to indications.


"Diseases, injuries and tumors of the maxillofacial area"
ed. A.K. Iordanishvili

Benign soft tissue tumors and facial bones are classified into four groups: cystic formations, odontogenic tumors and tumor-like formations, benign soft tissue tumors, osteogenic tumors of the jaws. Cystic formations of the face, oral cavity and neck include odontogenic cysts, congenital cysts and fistulas, as well as salivary gland cysts.

Odontogenic cysts divided into periroot (radicular) and coronal (follicular). Perihilar cysts are much more common than follicular cysts and account for 94-96% of all odontogenic cysts. The cyst is a hollow formation, lined with an epithelial membrane and filled with yellow or brown liquid (transudate) containing cholesterol crystals. With large cysts, resorption of the walls of the mandibular canal occurs.

Perihilar cyst increases slowly over a number of years. As it grows, it reaches 2-5 cm in diameter. As the cyst grows, resorption and restructuring of the surrounding bone tissue occurs. The alveolar process or body of the jaw usually increases in volume. At the same time, the thinned bone “springs” when pressed, and sometimes crepitus appears. Subsequently, a bone tissue defect is formed. In this case, fluctuation is detected upon palpation. The pressure of the cyst on the dental tissue causes a change in the direction of the tooth axis. The roots fan out (divergence), and the crowns lean toward each other.

When suppuration occurs, clinical symptoms appear signs acute inflammatory process (swelling, tissue infiltration, and then the formation of fistulas).
Big value in the diagnosis of cysts have radiography and electroodontometry. Using an x-ray, the size, location of the cyst, its relationship with the nasal cavity, maxillary sinus, mandibular canal and teeth are determined. A perihilar cyst is characterized by a focus of bone tissue destruction with smooth, clear edges of a round or oval shape. The cavity of the cyst contains the roots of the tooth, which caused the disease. A feature of a follicular cyst is retention - a delay in tooth eruption. An x-ray in the cyst cavity reveals the contours of an unerupted tooth or the rudiment (follicle) of a tooth or its crown.

In case of difficulty in making a diagnosis Contrast cystoradiography is performed. Electroodontometry allows you to identify the tooth that is the cause of the root cyst. Even when such a tooth is exposed to an electric current above 100 μA, the patient does not feel pain, which indicates complete necrosis of the pulp.