Surgical management of benign and cystic lesions

Benign lesion characteristics:

behaviour? (5)

• Slow growing (can be faster under influence of hormones)

• Cells maintain contact with one another

• Usually rounded (moulded by the surrounding tissues)

• Do not invade surrounding tissues or lymphatics

• Do not metastasize

Effects of benign lesions? (4)

• Excessive accumulation of cells

• Pressure atrophy - adjacent parenchyma (working cells) undergoes pressure atrophy, more resistant connective tissue produced a fibrous capsule

• Obstruction

• Can produce hormones if growing within endocrine organ

Atrophy (get smaller)

Indication for removal a benign/cystic lesions? (8)

• Pain

• Function

• Aesthetics

• Continual growth

• Pressure on adjacent structures

• Damage to adj structures including root resorption

• Weakening structures (fracture mandible e.g)

• Infection

What is this?

• Mucocele

Describe its presentation? (4)

• Sessile (broad based)

• Fluid filled

• Transparent blue

• Raised

History:

Often a history of what?

more common site/pt?

Why does it appear?

• Often history of trauma

• More common in children

• Lower lip - most common

• Associated with traumatised minor salivary glands duct

Indication for removal? (3)

• Disruptive of eating, pt self-conscious of appearance, can be uncomfortable

What is this?

Vascular abnormality - haemangioma

Presentation of haemangioma in the picture

• Sessile

• Pale blue

• Dorsum of the tongue - right side

• 3 mm in diameter

• Blanches on pressure

History of haemangioma? (3)

• Occasionally swells and becomes painful

• History of tongue biting

• Duration > 1 years

Indication of removal of haemangioma? (3

• Self-conscious about appearance

• Disrupts eating and or speech

• Pt concerned and requests reassurance with diagnosis

What is this?

Fibro epithelial polyp

Describe the lesion in the image?

• Right buccal mucosa, pedunculated

• keratotoic appearnce

• soft

• 8 mm diameter

History of polyp? (3)

• History of check biting/trauma

• Slow growing

• interferes with eating

• 
  

Indication of removal?

• Interferes with pts eating

• Self-conscious about appearance

Excising lesions - what shape is the excision and why?

• Elliptical

• As the two sides can be brought together in a straight line - get healing by primary intention rather than secondary intention which gives rise to scar tissue

• Ensures it can be closed with no gapping

• Complete excision is made by cutting around the lesion

Excision is for what lesions?

Superficial smaller lesions (Found within the oral epithelium and lamina propria)

What is used for suturing?

• Resorbable sutures - 4.0 or 5.0

Incision, dissection and excision: appropriate for what lesions?

• Appropriate for a benign lesion that is within the submucosa

What lesion could this be?

• Mucocele - (minor salivary gland cyst)

How is the removal carried out?

• A straight incision can be made over the lesion, and it can then be dissected out

• Increased risk associated with deeper layer excision

Pre-prosthetic surgery may be for what?

• Dentures

Why might pre-prosthetic surgery be needed?

• Palatal tori

• Fibrous ridge and/or tuberosity

Different types of laser excision?

How does laser work?

• Beam hits tissues

• Temperature rises proteins denature and thrombosis

• At 100 degrees water boils, steam ruptures cells and tissue vapourised

• The temperature can start to rise in adj desiccated tissues

• Tissue blackens, carbonisaiton

ADV of lasers? (4)

• Dry surgical field

• Reduction of blood loss

• Fibre-optic delivery

• Reduction in post-op oedema, pain and fibrosis

Dis of laser? (3)

• Cost

• Complexity of requirement

• No pathology specimen (as tissues are damaged)

What is cryotherapy?

how is it used?

This is good for what type of lesions?

• Tissue denaturation using application of cold medium - liquid nitrogen direct or via probes

• Freeze-thaw cycles

• Good for fluid filled lesions e.g saliva or blood

How does cryotherapy work in more detail?

• Direct or indirect application of liquid nitrogen

• Series of freeze-thaw cycles - form an ice-ball

• Intracellular ice formation - expansion of cell volume and disruption occurs on thawing

• Repeated cycles of freeze thawing results in the reduction of the cell mass of the lesion (dehydration of cell, increase in conc of electrolytes, rise in osmotic pressure, lipids and proteins denatured)

• Best if rapid freezes and slow thawing

ADV of cryotherapy? (4)

• No cutting

• Tissues intact at end - no bleeding

• can do without LA

• excellent for fluid filled

DIS of cryotherapy?

• cost of equipment

• no Pathological specimen

• post-op - swelling as adj tissues which cooled down suffer partial damage

• ulceration post-op and depigmentation

What are cysts?

How do cysts expand?

• Expansion via osmotic tension due to inflammatory process

Classification of cysts?

Aneurysmal bone cyst

Stafne bone cyst - normal anatomical variant , beneath alveolar nerve

Management of cysts of the jaws?

• Enucleation - Surgically remove intact from surrounding capsule

• Curettage - Scraping

• Marsupialisation - forming continuous surface from the exterior into the interior of a cyst/abscess

What is enucleation? what is it usually followed by?

successful tx is dependent on what?

• Removal of lesion with the lining

• Followed by closure

• Complete removal of the cyst lining, and uneventful healing of oral wound without secondary infection of the underlying clot

enucleation

Marsupialisation - explain it?

success of tx is dependent on?

• Decompression of the cyst by creating largest possible surgical window consistent with the surrounding anatomy

• decompression relieves intracystic pressure

• the cavity will then regress in size

• first - incomplete removal of the lining and marsupialisation into the mouth or antrum

• patient must keeps it clean

ADV of enucleation (3) and marsupialisation (2)?

Enucleation:

• Cyst cavity closed to the mouth

• little after care needed

• complete lining available for histopathological examination

Marsuialisation:

• Less bone removal, may avoid pathological fractures/damage to adjacent structures e.g IDC/mental foramen

• Cavity accessible to visual inspection

DIS of enucleation (6) and marsupialisation (7)

Enucleation:

• Large cyst removal weakens mandible - fracture risk

• Primary closure prevents visual inspection of the cavity post-op

• Apical of vital teeth interrupted, other structures damaged

• haemorrhage

• incomplete emoval

• clot in the cavity can become infected

Marsupialisation:

• pt needs to keep the area clean

• Whole lining not available for histology

• Bony infill may not occur

• Orifice may close-up allowing cyst to reform

• Need for further surgery

• several visits to repack cavity as it shrinks and repairs

• epithelial lining may be friable and difficult to suture