Maharana Pratap Dental College and HospitalMaharana Pratap Dental College and Hospital Department of Oral SurgeryDepartment of Oral Surgery

MARSUPIALIZATION & ENUCLEATION IN MARSUPIALIZATION & ENUCLEATION IN TREATMENT OF CYSTS OF ORAL CAVITYTREATMENT OF CYSTS OF ORAL CAVITY

UNDER GUIDANCE OF-UNDER GUIDANCE OF-

DR. AKSHAY DR. AKSHAY GURRAHAGURRAHADR.HEMANT BAJPAIDR.HEMANT BAJPAIDR. NISHANT SINGHDR. NISHANT SINGHDR. UMANG DR. UMANG AGARWALAGARWAL

Submitted by-Submitted by-

AMOL CHATURVEDIAMOL CHATURVEDI BDS FINAL YEARBDS FINAL YEAR

CONTENTSCONTENTS

DefinitionDefinitionPrinciplePrincipleIndicationsIndicationsContraindicationsContraindicationsAdvantagesAdvantagesDisadvantagesDisadvantagesConclusionConclusion

MARSUPIALIZATION MARSUPIALIZATION (Cystotomy)(Cystotomy)

Marsupilium = PouchMarsupilium = PouchFirst introduced by Partsch in 1892First introduced by Partsch in 1892Definition – “An operation for the cure of a hydatid or other cyst , Definition – “An operation for the cure of a hydatid or other cyst , the sac of tumour is opened & emptied of its contents and then its the sac of tumour is opened & emptied of its contents and then its edges are stiched to the edges of external incision ,which is kept edges are stiched to the edges of external incision ,which is kept open while inferior of cyst suppurates & closes by granulation”open while inferior of cyst suppurates & closes by granulation” -Stedman’s medical dictionary-Stedman’s medical dictionary

PRINCIPLEPRINCIPLE

Marsupialization refers to creating a Marsupialization refers to creating a surgical window in the wall of cyst & surgical window in the wall of cyst & evacuation of cystic contents. This evacuation of cystic contents. This process decreases intracystic pressure & process decreases intracystic pressure & promotes shrinkage of cyst & bone fill. promotes shrinkage of cyst & bone fill.

INDICATIONSINDICATIONSAmount of tissue injury – Proximity of cyst to vital Amount of tissue injury – Proximity of cyst to vital structures could create an oronasal or oroantral fistula, structures could create an oronasal or oroantral fistula, injure neurovascular structures or vital teeth during injure neurovascular structures or vital teeth during enucleation.enucleation.Surgical access – If access to all portions of cyst is Surgical access – If access to all portions of cyst is difficult ,portion of cystic wall may be left behind.difficult ,portion of cystic wall may be left behind.Assistance in erupton of teeth – In a young patient with a Assistance in erupton of teeth – In a young patient with a dentigerous or pseudofollicular keratocyst, it permits dentigerous or pseudofollicular keratocyst, it permits eruption of unerupted teeth.eruption of unerupted teeth.Extent of surgery – Marsupialization is preferred in a Extent of surgery – Marsupialization is preferred in a unhealthy or debilited patient , because it is simple & unhealthy or debilited patient , because it is simple & less stressful for patient.less stressful for patient.Size of cyst – in very large cyst,there is a risk of fracture Size of cyst – in very large cyst,there is a risk of fracture of jaw during enucleation.of jaw during enucleation.

CONTRAINDICATIONSCONTRAINDICATIONS

ODONTOGENIC KERATOCYSTODONTOGENIC KERATOCYSTRECURRING CYSTSRECURRING CYSTSSMALLER CYSTS( < 2X2 cm)SMALLER CYSTS( < 2X2 cm)

ADVANTAGESADVANTAGESSimple procedure to perform.Simple procedure to perform.Spares vital structures eg. blood vessels,nervesSpares vital structures eg. blood vessels,nervesEven quite large cyst can be dealt under Local anaesthesia as Even quite large cyst can be dealt under Local anaesthesia as anaesthesia of deeper recesses is not essential.anaesthesia of deeper recesses is not essential.Simplest way to treat a fracture complicating a large cyst of Simplest way to treat a fracture complicating a large cyst of mandible, as ribbon gauze & Whitehead’s varnish pack will splint mandible, as ribbon gauze & Whitehead’s varnish pack will splint the fragments.the fragments.Allows eruption of teeth.Allows eruption of teeth.Prevents oronasal,oroantral fistulae.Prevents oronasal,oroantral fistulae.Prevents pathological fractures.Prevents pathological fractures.Reduces operating time.Reduces operating time.Reduces blood loss,helps in shrinkage of cystic lining.Reduces blood loss,helps in shrinkage of cystic lining.Allows for endosteal bone formation to take place.Allows for endosteal bone formation to take place.Alveolar ridge is preserved.Alveolar ridge is preserved.

DISADVANTAGESDISADVANTAGESPathologic tissue is left in situ.Pathologic tissue is left in situ.Histologic examination of entire cystic lining is not done.Histologic examination of entire cystic lining is not done.The need for regular postoperative care, occurs a substantial period The need for regular postoperative care, occurs a substantial period of time.of time.The change in voice may occur when cavity is not obturatedThe change in voice may occur when cavity is not obturated Unpleasant taste and smell may occur due to accumulation of Unpleasant taste and smell may occur due to accumulation of stagnant saliva & food debris in cavity.stagnant saliva & food debris in cavity.Regular adjustment of plug.Regular adjustment of plug.Periodic changing of pack.Periodic changing of pack.Secondary surgery may be needed.Secondary surgery may be needed.Formation of slit like pockets that may harbour foodstuffs.Formation of slit like pockets that may harbour foodstuffs.Risk of invagination & new cyst formation.Risk of invagination & new cyst formation.Longer healing time.Longer healing time.

ENUCLEATIONENUCLEATION(Cystectomy)(Cystectomy)

DEFINITION – “The removal of a tumour DEFINITION – “The removal of a tumour or other body entire without rupture,as one or other body entire without rupture,as one shell out the kernel of a nut”shell out the kernel of a nut”

Introduced by Partsch in 1910.Introduced by Partsch in 1910.

PRINCIPLEPRINCIPLE

Enucleation allows for cystic cavity to be Enucleation allows for cystic cavity to be covered by a mucoperisteal flap & the covered by a mucoperisteal flap & the space fills with blood clot,which will space fills with blood clot,which will eventually organize & form normal bone.eventually organize & form normal bone.

INDICATIONSINDICATIONS

Treatment of odontogenic keratocysts.Treatment of odontogenic keratocysts.Recurrence of cystic lesions of any cyst Recurrence of cystic lesions of any cyst type.type.Should be employed with any cyst of jaw Should be employed with any cyst of jaw that can be safely removed unduly that can be safely removed unduly sacrificing adjacent structures.sacrificing adjacent structures.

CONTRAINDICATIONSCONTRAINDICATIONS

Dentigerous cyst.Dentigerous cyst.Young patients with erupting teeth.Young patients with erupting teeth.Medically compromised or debilited Medically compromised or debilited patients.patients.Proximity to vital structures.Proximity to vital structures.Very large cysts,may cause fracture of Very large cysts,may cause fracture of jaw.jaw.

ADVANTAGESADVANTAGES

Entire pathological tissue is removed.Entire pathological tissue is removed.Tissue available for histopathological Tissue available for histopathological examination.examination.Chances of recurrence are less.Chances of recurrence are less.Healing time is reduced.Healing time is reduced.Enucleation with primary closure Enucleation with primary closure eliminates need for repeated appointments eliminates need for repeated appointments for packing,irrigation,adjustment of plug for packing,irrigation,adjustment of plug etc.etc.

DISADVANTAGESDISADVANTAGES

After primary closure,it is not possible to observe After primary closure,it is not possible to observe healing of cavity.healing of cavity.In young patients,the unerupted teeth in a In young patients,the unerupted teeth in a dentigerous cyst will be removed with the lesion.dentigerous cyst will be removed with the lesion.Removal of large cyst may make mandible more Removal of large cyst may make mandible more prone for fracture.prone for fracture.Damage to adjacent vital structures.Damage to adjacent vital structures.May lead to pulpal necrosis.May lead to pulpal necrosis.Adjacent tooth may be devitalized.Adjacent tooth may be devitalized.

CONCLUSIONCONCLUSIONEnucleation is definately a better alternate than Enucleation is definately a better alternate than marsupialization because of complete removal of marsupialization because of complete removal of pathological cystic lining.pathological cystic lining.Marsupializaton could be preferred in cases with Marsupializaton could be preferred in cases with increased morbidity & mortality and impaired host increased morbidity & mortality and impaired host defense mechanism.defense mechanism.Marsupialization can also be employed in cases of large Marsupialization can also be employed in cases of large cysts, promixity to vital structures & young patients with cysts, promixity to vital structures & young patients with a dentigerous cyst as it allows eruption of unerupted a dentigerous cyst as it allows eruption of unerupted tooth & prevents tooth bud injury.tooth & prevents tooth bud injury.While enucleation should be used for cyst having high While enucleation should be used for cyst having high recurrence potential as odontogenic keratocyst & other recurrence potential as odontogenic keratocyst & other recurring cyst.recurring cyst.

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