Chapter 12
	Surgical Treatment	12
	of Radicular Cysts
	C. Alexandridis

Radicular (periapical) cysts are pathological cavities, lined with epithelium, and contain fluid or semi-fluid material.

They are the most common cystic lesions of the jaws and originate from the epithelial remnants of

Malassez rests, which are stimulated after inflammation at the apices of nonvital teeth.

Diagnosis of radicular cysts is based on clinical and radiographic examination, as well as aspiration of the contents of the cystic sac.

12.1

Clinical Presentation

The majority of radicular cysts are asymptomatic, especially those small in size. They are discovered after radiographic examination, unless they are suppurated, whereupon pain as well as other symptoms occur. Large cysts present swelling buccally and more rarely lingually or palatally. This swelling is due to expansion of the buccal cortical plate, which becomes thinned and may demonstrate a crackling sound (crepitus). If the bone is completely destroyed, the cyst is connected to the periosteum and the mucosa in this area looks bluish-red.

12.2

Radiographic Examination

Radiographically, radicular cysts present as osteolytic or radiolucent lesions (round or oval in shape) with well-defined radiopaque borders, unless they have been infected, whereupon the radiopaque periphery does not exist.

12.3

Aspiration of Contents of Cystic Sac

In addition to the clinical and radiographic examination, aspiration of the contents of the cystic sac may be

a valuable diagnostic aid. In cysts whose size is larger than 1.5–2 cm, thin or thick fluid may be aspirated, which precludes the presence of other more solid lesions.

12.4

Surgical Technique

Two techniques are employed in clinical practice for the surgical removal of cysts: enucleation and marsupialization.

Enucleation. This technique involves complete removal of the cystic sac and healing of the wound by primary intention. This is the most satisfactory method of treatment of a cyst and is indicated in all cases where cysts are involved, whose wall may be removed without damaging adjacent teeth and other anatomic structures.

The surgical procedure for treatment of a cyst with enucleation includes the following steps:

ΟReflection of a mucoperiosteal flap.

ΟRemoval of bone and exposure of part of the cyst.

ΟEnucleation of the cystic sac.

ΟCare of the wound and suturing.

After taking a radiograph to determine the exact localization and size of the lesion, a trapezoidal flap is created, whose extent must ensure adequate access and visualization of the surgical field (Figs. 12.1– 12.4).

After reflection of the mucoperiosteum, the bone covering the lesion is evaluated, which, as mentioned above, may be normal, thinned, or completely destroyed.

In normal bone, a round bur is used to remove a portion of the buccal cortical plate covering the cyst, and, depending on its extent, a rongeur may be used to enlarge the osseous window created (Figs. 12.5, 12.6).

The osseous window must be large enough so that all parts of the cystic cavity may be accessed and removed without particular difficulty.

302 C. Alexandridis

If the bony wall is thinned or perforated, it is removed peripherally with a rongeur, until it reaches compact bone. A curette is used for enucleation of small cysts, while for larger cysts, the broad end of a periosteal elevator is preferred, which is placed inside the cavity pressing gently between the cystic wall and bone, while the cyst is carefully grasped with forceps (Fig. 12.7).

After removal of the cysts, a curette is used to inspect the cavity for the presence of remnants of the cyst, and copious irrigation with saline solution and suturing of the flap follow (Figs. 12.8–12.10).

The surgical technique for removal of mandibular cysts is exactly the same as that described above

(Figs. 12.11–12.18).

Marsupialization. This method is usually employed for the removal of large cysts and entails opening a surgical window at an appropriate site above the lesion.

Surgical Removal of Maxillary Cyst

In order to create the surgical window, initially a circular incision is made, which includes the mucoperiosteum, the underlying perforated (usually) bone, and the respective wall of the cystic sac (Figs. 12.19– 12.23). After this procedure, the contents of the cyst are evacuated, and interrupted sutures are placed around the periphery of the cyst, suturing the mucoperiosteum and the cystic wall together (Fig. 12.24).

Afterwards, the cystic cavity is irrigated with saline solution and packed with iodoform gauze (Figs. 12.25, 12.26), which is removed a week later together with the sutures. During that period, the wound margins will have healed, establishing permanent communication.

Irrigation of the cystic cavity is performed several times daily, keeping it clean of food debris and averting a potential infection.

Healing of the wound is by secondary intention, and the epithelium of the cyst is thus transformed into oral mucosa.

Fig. 12.1. Panoramic radiograph showing an extensive ra- Fig. 12.2. Clinical photograph of case of Fig. 12.1 dicular lesion at the region of teeth 22, 23, 24

Chapter 12 Surgical Treatment of Radicular Cysts

303

Fig. 12.3 a, b. Removal of maxillary cyst, with labial access. Incision for creating a trapezoidal flap. a Diagrammatic illustration. b Clinical photograph

Fig. 12.4 a, b. Reflection of flap and exposure of surgical field. a Diagrammatic illustration. b Clinical photograph

Fig. 12.5 a,b. Removal of bone at the labial aspect respective to the lesion. a Diagrammatic illustration. b Clinical photograph

304 C. Alexandridis

Fig. 12.6 a, b. Osseous window created to expose part of the lesion. a Diagrammatic illustration. b Clinical photograph

Fig. 12.7 a, b. Removal of cyst from bony cavity, using hemostat and curette. a Diagrammatic illustration. b Clinical photograph

Fig. 12.8 a,b. Surgical field after removal of lesion. a Diagrammatic illustration. b Clinical photograph

Chapter 12 Surgical Treatment of Radicular Cysts

305

Fig. 12.9 a, b. Operation site after placement of sutures. a Diagrammatic illustration. b Clinical photograph

Fig. 12.10 a, b. Panoramic radiograph (a) and clinical photograph (b) of the area taken 2 months after the surgical procedure

Surgical Removal of Mandibular Cyst

Fig. 12.11. Radiograph showing radicular lesion at area of Fig. 12.12. Clinical photograph of case of Fig. 12.11 mandibular first molar

306 C. Alexandridis

Fig. 12.13. Incision and reflection of mucoperiosteum	Fig. 12.14. Holes drilled for removal of buccal alveolar
	plate

Fig. 12.15. Osseous window completed, after joining of	Fig. 12.16. Removal of lesion with help of hemostat and
holes with fissure bur	curette

Fig. 12.17. Surgical field after removal of lesion

Fig. 12.18. Suturing of wound with interrupted sutures

Chapter 12 Surgical Treatment of Radicular Cysts

307

Marsupialization of Cyst

Fig. 12.19. Radiograph showing extensive mandibular cyst. The marsupialization method is indicated for its treatment

Fig. 12.21. Exposure of buccal cortical plate and removal of portion of bone with round bur

Fig. 12.20. Treatment of mandibular cyst with marsupialization method. Circular incision includes mucosa and periosteum

Fig. 12.22. Enlargement of osseous window with rongeur

Fig. 12.23. Exposure of cyst after removal of bone

Fig. 12.24. Suturing of wound margins with cystic wall