Surgical management of odontogenic cysts

Preoperative assessment

• History and examination: swelling, infection, tooth vitality, cortical expansion.
• Radiograph: OPG with periapical radiographs. Use CBCT for large lesions or proximity to inferior alveolar nerve, maxillary sinus, nasal floor, or teeth.
• Aspiration, if indicated, and biopsy/histopathology to exclude odontogenic keratocyst (OKC), ameloblastoma, or malignancy.

Flowchart: choice of surgery

Odontogenic cyst diagnosed
            ↓
Assess size, site, relation to teeth/nerve/sinus,
cortical integrity, histological type and recurrence risk
            ↓
 ┌───────────────────────────────────────────────────────┐
 │ Small, accessible, non-aggressive cyst                │
 │ (radicular, small dentigerous, lateral periodontal)   │
 └───────────────────────────────────────────────────────┘
            ↓
Enucleation (cystectomy) + curettage
            ↓
Treat causative tooth:
RCT / apicectomy / extraction as appropriate
            ↓
Histopathology + radiographic follow-up

Large cyst / thin cortex / risk of fracture /
close to inferior alveolar nerve, sinus, or developing teeth
            ↓
Marsupialization or decompression
            ↓
Periodic irrigation and radiographic review
            ↓
Cyst shrinks and bone reforms
            ↓
Secondary enucleation, if required

Aggressive lesion or high recurrence risk
(especially OKC, recurrent lesion, cortical perforation)
            ↓
Enucleation + adjunctive peripheral ostectomy/curettage
            ↓
Consider chemical or cryo-adjuvant in selected cases
            ↓
Resection only for very extensive/recurrent destructive disease
            ↓
Long-term follow-up

Main procedures

1. Enucleation (cystectomy)
   • Complete removal of cyst lining through a mucoperiosteal flap.
   • The bony cavity is curetted and irrigated.
   • It is the usual treatment for most small-to-moderate odontogenic cysts.
   • Involved non-salvageable teeth are extracted; salvageable teeth may undergo root-canal treatment or apicectomy.
   • The cavity usually fills with bone spontaneously. Grafting may be considered for a very large defect.
2. Marsupialization
   • A window is created in the cyst wall and cyst lining is sutured to oral mucosa, converting it into a pouch.
   • Reduces intracystic pressure, permits gradual shrinkage, promotes bone formation, and protects adjacent structures.
   • Useful in large dentigerous cysts, especially in children, where eruption of the permanent tooth may be preserved.
3. Decompression
   • A drain or tube is retained through a small opening for continuous reduction of cyst pressure.
   • Used for very large lesions or where immediate enucleation risks nerve injury, pathological fracture, or damage to teeth.
   • Usually followed by definitive enucleation after reduction in lesion size.
4. Adjunctive or radical treatment
   • For odontogenic keratocyst, complete lining removal is important because satellite cysts can cause recurrence. Enucleation with peripheral ostectomy/curettage is commonly used.
   • Segmental or marginal resection is reserved for large, recurrent, or extensively destructive lesions.

Postoperative care

• Send the specimen for histopathological examination.
• Antibiotics and analgesics when indicated; advise oral hygiene and wound care.
• Review clinically and radiographically until bone healing is complete.
• Long-term follow-up is particularly important for OKC and recurrent lesions.