# Oral Maxillofacial Pathology – Surgical Management **MAGDALEN FOO** **DISCIPLINE LEAD ORAL MAXILLOFACIAL SURGERY** Magdalen Foo Discipline Lead Oral Maxillofacial Surgery # Oral Maxillofacial Pathology * Assumed knowledge of oral mucosal lesions * Assumed knowledge of common benign salivary gland tumours * Assumed knowledge of bone lesions * Assumed knowledge of dental anatomy and tooth development * Assumed knowledge of head and neck anatomy #### Prerequisite Knowledge Areas - Oral mucosal lesions - Common benign salivary gland tumours - Bone lesions - Dental anatomy and tooth development - Head and neck anatomy # Oral Maxillofacial Pathology * Learning outcomes – able to discuss the appropriate investigations e.g. imaging and biopsy * Learning outcomes – management of pathology e.g. surgery #### Clinical Competencies - Discuss appropriate investigations, including imaging and biopsy techniques. - Understand the surgical management of oral and maxillofacial pathology. # Jaw cysts - Cysts are pathological fluid-filled cavities lined by epithelium - Most cysts in the jaws are formed from epithelium (odontogenic cysts) - The most common odontogenic cyst of the jaws is the periapical (radicular) cyst - Non-odontogenic cysts are the nasopalatine duct cyst and the nasolabial cyst #### Definition and Characteristics - Cysts are pathological fluid-filled cavities lined by epithelium - Most cysts in the jaws are formed from epithelium (odontogenic cysts) - The most common odontogenic cyst of the jaws is the periapical (radicular) cyst - Non-odontogenic cysts include the nasopalatine duct cyst and the nasolabial cyst # Jaw cysts ## Relative frequency: * **Periapical:** 65–70% * **Dentigerous:** 15–18% * **Odontogenic keratocyst:** 3–5% * **Nasopalatine:** 5–10% * **Lateral periodontal:** <1% * **Paradental:** <1% <img src="" alt="Jaw cysts X-ray">  #### Relative Frequency - **Periapical:** 65–70% - **Dentigerous:** 15–18% - **Odontogenic keratocyst:** 3–5% - **Nasopalatine:** 5–10% - **Lateral periodontal:** <1% - **Paradental:** <1% An X-ray image of a jaw showing dental structures, used to illustrate jaw cysts as listed in the 'Relative frequency' data nearby. ### Title <span style="color: #A9DF04">Jaw cysts</span> ### List * <span style="color: #A9DF04">Sharply defined radiolucencies with smooth borders</span> * <span style="color: #A9DF04">Fluid may be aspirated</span> * <span style="color: #A9DF04">Slow growing, displacing rather than resorbing teeth</span> * <span style="color: #A9DF04">Symptomless unless infected and usually change radiographic findings</span>  #### Clinical Presentation - Sharply defined radiolucencies with smooth borders - Fluid may be aspirated - Slow growing, displacing rather than resorbing teeth - Symptomless unless infected and usually change radiographic findings A panoramic dental X-ray (orthopantomogram) of the lower jaw. Visible in the left molar region is a sharply defined, radiolucent lesion consistent with a jaw cyst. # Jaw cysts May have identical radiographic appearances and diagnosis ultimately depends on **histopathology** ---    May have identical radiographic appearances and diagnosis ultimately depends on **histopathology**. Dental radiograph labeled 'a' showing black triangular lesion at root apex, with green arrow on left background Radiograph displaying radiolucency under tooth, marked by vertical green arrow pointing upward Diagnosis Diagram showing an X-ray of a jawbone, with a green rectangle pointing to a certain spot   #### Diagnostic Identification Radiographic assessment is used to identify the specific location and extent of the lesion within the jawbone. Dental X-ray photo on the left showing the lower jaw. It is part of a 'Diagnosis' slide, and a green arrow points to a specific area on the bone. Dental X-ray photo on the right showing both the upper and lower teeth. It is part of a 'Diagnosis' slide, and a green arrow points to a specific area on the jawbone. ### Imaging – CT scan **COMMENT:** Lucent lesion in the right mandibular angle/body likely reflects an odontogenic keratocyst Appearances are not classical for a dentigerous cyst    #### Imaging – CT Scan Lucent lesion in the right mandibular angle/body likely reflects an odontogenic keratocyst. Appearances are not classical for a dentigerous cyst. A medical CT scan image of the mandible shows a lucent lesion in the right mandibular angle/body, highlighted by a green arrow. The accompanying text comments that these appearances likely reflect an odontogenic keratocyst rather than a classical dentigerous cyst. A blank, light green rectangular shape is present in the upper right corner, likely serving only as a graphical design element for the document layout. # Odontogenic cysts Cyst lining derived from **epithelium** involved in tooth development * Periapical cyst (inflammatory) * Dentigerous cyst (developmental) * Odontogenic keratocyst (developmental) Cyst lining derived from **epithelium** involved in tooth development. - Periapical cyst (inflammatory) - Dentigerous cyst (developmental) - Odontogenic keratocyst (developmental) **Periapical cyst** - Rounded, well circumscribed, corticated radiolucency at apex of nonvital tooth - Enucleation after extraction or endodontic treatment  #### Clinical and Radiographic Features - Rounded, well circumscribed, corticated radiolucency at apex of nonvital tooth #### Management - Enucleation after extraction or endodontic treatment Radiograph showing a large, rounded radiolucency in the mandibular region, identified as a periapical cyst. # **Dentigerous cyst** - Odontogenic cyst that surrounds the crown of an impacted tooth - Accumulation of fluid between the reduced enamel epithelium and the enamel surface - This results in a cyst with the crown inside the lumen and the roots outside <img src="UNKNOWN" alt="Dental radiograph showing a Dentigerous cyst. The image features an anterior-posterior view of dental radiographic anatomy highlighting the presence of erupted teeth, with a yellow arrow indicating the area of interest. This caption ensures integrity only from the image to prevent hallucination."/>  #### Pathogenesis and Presentation - Odontogenic cyst that surrounds the crown of an impacted tooth - Accumulation of fluid between the reduced enamel epithelium and the enamel surface - This results in a cyst with the crown inside the lumen and the roots outside A grayscale dental radiograph displaying a panoramic view of the jaw. A yellow arrow points to a large black radiolucent area (cyst) adjacent to the roots of a tooth, consistent with the provided slide title 'Dentigerous cyst'. # Dentigerous cyst * Treatment is surgical enucleation * The associated tooth is extracted at the time of cyst enucleation * Or the cyst is marsupialized +/- the tooth brought into alignment in the arch with orthodontic appliance # Dentigerous cyst - Treatment is surgical enucleation - The associated tooth is extracted at the time of cyst enucleation - Or the cyst is marsupialized +/- the tooth brought into alignment in the arch with orthodontic appliance   #### Surgical Management - Treatment is surgical enucleation - The associated tooth is extracted at the time of cyst enucleation - Alternatively, the cyst is marsupialized +/- the tooth brought into alignment in the arch with orthodontic appliance An X-ray image of a patient's teeth and jaw, showing a large dentigerous cyst in the lower jaw near a molar, as referenced in the title section of the slide. # Marsupialization of jaw cyst <img src="https://i.imgur.com/9qP3z6e.png" alt="Panoramic dental X-ray showing a large radiolucent area in the lower jaw">  #### Marsupialization of Jaw Cyst Radiographic imaging (panoramic X-ray) demonstrates the application of marsupialization for large radiolucent areas in the lower jaw. A panoramic dental X-ray showing the maxillary and mandibular arches. A large radiolucent area is clearly visible in the posterior region of the lower jaw, labeled contextually as a jaw cyst prior to marsupialization, appearing as a dark, opaque void in the bone density. Odontogenic keratocyst (OKC) * Wide age range (1-80), peak incidence 10-30 years * Multiple OKCs a feature of Gorlin-Goltz syndrome * OKC appear as well-defined solitary lesion or as a multilocular, polycystic radiolucency Radiograph showing *Odontogenic keratocyst (OKC)* with *arrow* pointing to *radiolucency* in *mandible*.  #### Clinical Features - Wide age range (1-80), peak incidence 10-30 years - Multiple OKCs are a feature of Gorlin-Goltz syndrome - OKC appears as a well-defined solitary lesion or as a multilocular, polycystic radiolucency Dental radiograph showing a radiolucency in the mandible indicated by a green arrow. The image illustrates the appearance of an Odontogenic keratocyst (OKC) as described in the slide. # Odontogenic keratocyst (OKC) * Histologically OKC has 4 characteristic – uniform lining of parakeratinized squamous epithelium (6-10 cells thick), palisaded columnar or cuboidal basal cells, corrugated layer of parakeration on its luminal surface and lack of rete pegs * Treatment is surgical enucleation * Recurrence rate of OKC up to 30% * Clinicopathological factors such as large size, cortical perforation, tooth involvement in the lumen of the cyst, and daughter cysts appear to predict a high risk for recurrence * Reduce recurrences with peripheral ostectomy, cryotherapy or application of Carnoy’s solution #### Histopathology Histologically, OKC has 4 characteristics: 1. Uniform lining of parakeratinized squamous epithelium (6-10 cells thick) 2. Palisaded columnar or cuboidal basal cells 3. Corrugated layer of parakeratin on its luminal surface 4. Lack of rete pegs #### Treatment and Prognosis - Treatment is surgical enucleation - Recurrence rate of OKC is up to 30% - Clinicopathological factors predicting high risk for recurrence: - Large size - Cortical perforation - Tooth involvement in the lumen of the cyst - Presence of daughter cysts - Recurrence can be reduced with peripheral ostectomy, cryotherapy, or application of Carnoy’s solution Odontogenic keratocyst (OKC)   Odontogenic keratocyst (OKC) Surgical intraoral photo showing the extraction socket of a patient with an Odontogenic keratocyst (OKC) under orange perioperative lighting. Surgical intraoral photo showing a bloodied extraction site and exposed tooth roots, accompanied by the text 'Odontogenic keratocyst (OKC)' in the associated slide footer. # Bone lesions * Benjamin fibro-osseous lesions e.g. cemento-osseous lesions, fibrous dysplasia, cherubism * Metabolic conditions e.g. Paget disease, hyperparathyroidism * Benign tumours e.g. torus, osteoma, giant cell lesion (aneurysmal bone cyst, central giant cell lesion, peripheral giant cell granuloma), traumatic bone cyst * Malignant tumours e.g. chondrosarcoma, Ewing sarcoma [Image Description](Image Description: A case is illustrated showing a patient with a specific pathology. Conditions & Lesions Mentioned: 1. **Benign fibro-osseous lesions**: * cemento-osseous lesions (often associated with Paget's) 2. **Metabolic conditions**: * Paget disease * hyperparathyroidism 3. **Benign tumours**: * torus (likely complicated) * osteoma * giant cell lesion, cyst, giant cell granuloma, traumatic * aneurysmal bone cyst 4. **Malignant tumours**: * chondrosarcoma * Ewing sarcoma ) #### Classification of Bone Lesions - **Benign Fibro-Osseous Lesions** - Cemento-osseous lesions - Fibrous dysplasia - Cherubism - **Metabolic Conditions** - Paget disease - Hyperparathyroidism - **Benign Tumours and Cysts** - Torus - Osteoma - Giant cell lesions (Aneurysmal bone cyst, central giant cell lesion, peripheral giant cell granuloma) - Traumatic bone cyst - **Malignant Tumours** - Chondrosarcoma - Ewing sarcoma # Cemento-osseous lesions Benign fibro-osseous lesions of the jaws associated with apices of teeth * Periapical cemental dysplasia * Florid cemento-osseous dysplasia | Context: X-ray showing teeth with apical lesions | | :--- | | <img title="X-ray showing teeth with apical lesions" src="https://b.st纵横_pic/optimised_image_2221779872221458847.jpg"/> |  #### Cemento-Osseous Lesions These are benign fibro-osseous lesions of the jaws specifically associated with the apices of teeth. Types include: - Periapical cemental dysplasia - Florid cemento-osseous dysplasia X-ray image of teeth with apical lesions, associated with benign fibro-osseous lesions such as periapical cemental dysplasia and florid cemento-osseous dysplasia. # Juvenile fibrous dysplasia * **Most common monostotic deformity in the head and neck** * **Slow-growing distortion of the affected bone** * **Overgrowth continues until body growth ceases in late teens or early twenties** * **Treatment for cosmesis or lesion interfering with sight, breathing, mastication or speech** #### Juvenile Fibrous Dysplasia - **Prevalence:** This is the most common monostotic deformity in the head and neck. - **Progression:** Characterized by a slow-growing distortion of the affected bone. Overgrowth typically continues until body growth ceases in the late teens or early twenties. - **Indications for Treatment:** Intervention is performed for cosmesis or when the lesion interferes with vital functions such as sight, breathing, mastication, or speech. **Polyostotic fibrous dysplasia** Another form of fibrous dysplasia is craniofacial fibrous dysplasia, a polyostotic fibrous dysplasia where lesions occur in the bones of the jaws and cranium or diffuse throughout skeleton <img>  #### Polyostotic Fibrous Dysplasia Craniofacial fibrous dysplasia is a form of polyostotic fibrous dysplasia. In this condition, lesions occur in the bones of the jaws and cranium or may be diffused throughout the entire skeleton. A grayscale medical CT scan image illustrating craniofacial fibrous dysplasia. The scan shows multiple irregular bone lesions in the maxillary and mandibular regions, consistent with the text describing polyostotic fibrous dysplasia where lesions occur in the bones of the jaws and cranium.   X-ray image of a human skull showing radiographic features consistent with Paget disease. The maxillary and mandibular regions display complex bone architecture. Four cropped X-ray images showing detailed dental radiographs with signs of Paget disease affecting the jawbone, including expanded alveolar bone and altered root morphology. Hyperparathyroidism  Hyperparathyroidism A medical radiograph (dentagram) of the maxilla and mandible titled 'Hyperparathyroidism'. The image displays the teeth and surrounding jawbone structures in grayscale, highlighting the lower facial skeleton and dental arches relevant to the condition. # Hyperparathyroidism * Treatment depends on the cause * **Surgery** - **parathyroidectomy** and **Subtotal parathyroidectomy** can correct excessive parathyroid hormone secretions * Medical management in milder forms in patients over 50 and no progressive bone loss * Newer therapeutic options - **calcitriol** and **hormone replacement** to maintain **bone mineral density** in patients with **end-stage renal disease** * **Bisphosphonates** for patients at risk of bone fracture #### Management of Hyperparathyroidism Treatment strategies depend on the underlying cause of the condition: - **Surgical Intervention** - Parathyroidectomy and subtotal parathyroidectomy are used to correct excessive parathyroid hormone secretions. - **Medical Management** - Utilized for milder forms in patients over 50 with no progressive bone loss. - Therapeutic options for patients with end-stage renal disease include calcitriol and hormone replacement to maintain bone mineral density. - **Pharmacological Support** - Bisphosphonates are indicated for patients at risk of bone fracture. # Central giant cell granuloma * Patient presented with swelling on the left side of the mandible (expansion of buccal cortex) and mobility of associated teeth <img src="https://i.imgur.com/qeXoKjJ.jpg" alt="Panorex X-ray showing a mandibular lesion." width="600">  #### Central Giant Cell Granuloma Presentation Clinical presentation typically includes: - Swelling (e.g., on the left side of the mandible). - Expansion of the buccal cortex. - Mobility of the associated teeth. A panoramic dental X-ray (Panorex) of the mandible. According to the slide text, this image visualizes a 'Central giant cell granuloma' which presents as a swelling and expansion of the buccal cortex on the left side of the mandible, causing mobility of the associated teeth. # Central giant cell granuloma - Intraosseous destructive lesion which expand cortical plates, cause movement of teeth and produce root resorption - Lesion composed of multinucleated giant cells - Treatment is curettage <img src="https://i.imgur.com/gT4dZ6l.jpeg" alt="Ancient Roman bath house interior with tiled walls and wooden structures">  #### Characteristics and Treatment of Central Giant Cell Granuloma - **Pathology:** An intraosseous destructive lesion composed of multinucleated giant cells. - **Clinical Effects:** Causes expansion of cortical plates, movement of teeth, and root resorption. - **Treatment:** The standard treatment is curettage. A panoramic dental X-ray showing a maxillofacial structure with teeth. According to the accompanying text, this image illustrates a central giant cell granuloma, which is an intraosseous destructive lesion causing cortical plate expansion and root resorption. # Aneurysmal bone cyst * **Giant cell lesion** * Contains large blood-filled spaces separated by bands of fibrous tissue containing giant cells * Occurs in 1-30 year olds, peak incidence 10-19 year olds * Most lesions in posterior mandible * Treatment is **curettage** * Lesions recur in 20% of cases and retreated #### Aneurysmal Bone Cyst - **Classification:** A giant cell lesion. - **Composition:** Contains large blood-filled spaces separated by bands of fibrous tissue containing giant cells. - **Demographics:** Occurs in individuals aged 1–30 years, with a peak incidence between 10–19 years. - **Location:** Most lesions are found in the posterior mandible. - **Management:** - Primary treatment is curettage. - Recurrence occurs in approximately 20% of cases, requiring retreatment. # Traumatic bone cyst * **Patients** under 20 and slight female predilection * Asymptomatic intraosseous empty cavity primarily in the mandible * Lined by thin loose connective tissue membrane * Appears as well-circumscribed radiolucency extending between roots of associated teeth to produce a characteristic scalloped appearance * Haemorrhage during biopsy and **curettage** usually achieves complete resolution of the lesion <img src="" alt="A panoramic radiograph (X-ray) of a human jaw displaying a scalloped radiolucent area in the left mandible, separated from the tooth roots by thin septa."/>  #### Clinical Features and Management - **Demographics:** Typically affects patients under age 20 with a slight female predilection. - **Presentation:** An asymptomatic intraosseous empty cavity, primarily located in the mandible. - **Histology:** Lined by a thin, loose connective tissue membrane. - **Radiographic Appearance:** Appears as a well-circumscribed radiolucency extending between the roots of associated teeth, producing a characteristic scalloped appearance. - **Treatment:** Hemorrhage during biopsy and subsequent curettage usually achieves complete resolution of the lesion. A panoramic radiograph (X-ray) of the human jaw showing a scalloped radiolucent area in the left mandible, separated from tooth roots by thin septa. It illustrates the characteristic appearance of a traumatic bone cyst as described in the bullet points. # Odontogenic tumours * Unique to the jaws and originate from tissue associated with tooth development * Benign epithelial neoplasms e.g. Ameloblastoma, Calcifying epithelial odontogenic tumour, * Benign mixed epithelial and connective tissue neoplasm e.g. Ameloblastic fibroma * Benign connective tissue neoplasm e.g. Cementoblastoma, Odontogenic myxoma * Malignant odontogenic neoplasm e.g. Odontogenic carcinoma, Primary intraosseous carcinoma Odontogenic tumours are unique to the jaws and originate from tissue associated with tooth development. They are classified based on their tissue of origin: #### Classification of Odontogenic Tumours - **Benign Epithelial Neoplasms** - Ameloblastoma - Calcifying epithelial odontogenic tumour - **Benign Mixed Epithelial and Connective Tissue Neoplasms** - Ameloblastic fibroma - **Benign Connective Tissue Neoplasms** - Cementoblastoma - Odontogenic myxoma - **Malignant Odontogenic Neoplasms** - Odontogenic carcinoma - Primary intraosseous carcinoma # Ameloblastoma * Most common neoplasm of the jaws * Neoplasm of odontogenic epithelium * Locally invasive but does not metastasize * Asymptomatic and appears as multilocular radiologically * Commonly forms in posterior mandible * Unilocular or solid/multicystic type * Treated by curettage or radical excision <img src="https://qbuserbucketstatic.staging.playback.qbu.cloud/4f8525a952c198d63232632a1bdf6139.jpg" data-prefix="026F-" alt="Panoramic radiograph showing an amoloblastoma pointed by the green arrow">   #### Clinical Characteristics - Most common neoplasm of the jaws. - Neoplasm of odontogenic epithelium. - Locally invasive but does not metastasize. - Typically asymptomatic. - Commonly forms in the posterior mandible. #### Radiographic and Pathological Presentation - Appears as multilocular radiologically. - Can be unilocular or solid/multicystic type. #### Management - Treated by curettage or radical excision. A panoramic radiograph showing an ameloblastoma in the posterior mandible, indicated by a green arrow. A lime green decorative graphic element. Imaging – OPG and CT <span style="color: #84bc35;">**↓**</span> <span style="color: #84bc35;">**→**</span> <img src="" alt="Imaging – OPG and CT: Side-by-side radiographic views of the mandible showing dental anatomy with highlighted areas."/> - OPG image - CT scan image   #### Diagnostic Imaging Comprehensive imaging for assessment typically includes: - **OPG (Orthopantomogram):** Provides a panoramic radiographic view of the mandible and dental anatomy. - **CT Scan:** Offers detailed cross-sectional imaging for surgical planning and assessment of bone involvement. An OPG (Orthopantomogram) radiographic image of the mandible showing dental anatomy, indicated by a green downward arrow. A CT scan axial image of the mandible indicated by a green rightward arrow. # Ameloblastoma - Solid/multicystic type most clinically significant odontogenic tumour - Tumour often locally aggressive and may have significant impact on patient's morbidity and mortality ### Histopathology Report #### Clinical Details: Cyst associated with unerupted tooth. #### Macroscopic Description: Right mandible cyst: Multiple tan irregular mucosal fragments measuring from 6 up to 21mm in greatest dimension. The largest mucosal fragment has been trisected and processed in block A while the remaining fragments are processed in block B. X-2A TPM #### Microscopic Description: The sections show a partially cystic lesion lined by thin epithelium with a thick fibrous wall. Islands and strands of epithelium with the typical morphological features of a follicular ameloblastoma are seen in the connective tissue wall. These include columnar peripheral cells surrounding stellate reticulum-like epithelium with some cystic degeneration. Fragments of calcified tissue are also present. A sparse chronic inflammatory cell infiltrate is present. The features are consistent with a solid/multicystic ameloblastoma. Please correlate with the clinical and radiology findings. #### Conclusion: Mandible: Consistent with solid/multicystic ameloblastoma. #### Pathologist: Dr Jason Lau, [jlau@clinipath.net](mailto:jlau@clinipath.net) , 08 9371 4519 Dr Norman Firth, [NFirth@clinipath.net](mailto:NFirth@clinipath.net) , 0452 527 097 Clinipath Specialist Oral Pathology Service.  #### Clinical Significance - The solid/multicystic type is the most clinically significant odontogenic tumour. - The tumour is often locally aggressive and may have a significant impact on patient morbidity and mortality. #### Histopathology Case Study **Clinical Details** - Cyst associated with unerupted tooth. **Macroscopic Description** - Right mandible cyst: Multiple tan irregular mucosal fragments measuring from 6mm up to 21mm in greatest dimension. - Processing: Largest mucosal fragment trisected (Block A); remaining fragments (Block B). **Microscopic Description** - **Lesion Architecture:** Partially cystic lesion lined by thin epithelium with a thick fibrous wall. - **Epithelial Features:** Islands and strands of epithelium showing typical morphological features of follicular ameloblastoma within the connective tissue wall. - **Cellular Detail:** Columnar peripheral cells surrounding stellate reticulum-like epithelium with evidence of cystic degeneration. - **Additional Findings:** Fragments of calcified tissue and a sparse chronic inflammatory cell infiltrate. **Conclusion** - Mandible: Consistent with solid/multicystic ameloblastoma. - Recommendation: Correlate with clinical and radiology findings. A composite image containing a grid of histology slides taken from the pathology report. The thick fibrous wall. Islands and strands of epithelium with the typical morphological features of a follicular ameloblastoma are seen in the connective tissue wall. # Radical resection and reconstruction <img src="" alt="X-ray repair of mandible with osteotomy and plate and screws">  #### Surgical Intervention Management of aggressive odontogenic tumours often requires radical resection and complex reconstruction. This typically involves: - **Radical Resection:** Removal of the affected portion of the jaw with appropriate margins to prevent recurrence. - **Reconstruction:** Restoration of the mandible using osteotomy techniques, stabilized with surgical plates and screws to maintain function and facial profile. A medical X-ray image displaying the lower mandible after reconstruction. The jawbone features a metal fixation plate with multiple screw heads, highlighting the repair work. This image is presented under the heading 'Radical resection and reconstruction'. [^1]: Original PDF page 1: [[W3 Surgery and Aggressive cysts.pdf#page=1|W3 Surgery and Aggressive cysts, p.1]] [^2]: Original PDF page 2: [[W3 Surgery and Aggressive cysts.pdf#page=2|W3 Surgery and Aggressive cysts, p.2]] [^3]: Original PDF page 3: [[W3 Surgery and Aggressive cysts.pdf#page=3|W3 Surgery and Aggressive cysts, p.3]] [^4]: Original PDF page 4: [[W3 Surgery and Aggressive cysts.pdf#page=4|W3 Surgery and Aggressive cysts, p.4]] [^5]: Original PDF page 5: [[W3 Surgery and Aggressive cysts.pdf#page=5|W3 Surgery and Aggressive cysts, p.5]] [^6]: Original PDF page 6: [[W3 Surgery and Aggressive cysts.pdf#page=6|W3 Surgery and Aggressive cysts, p.6]] [^7]: Original PDF page 7: [[W3 Surgery and Aggressive cysts.pdf#page=7|W3 Surgery and Aggressive cysts, p.7]] [^8]: Original PDF page 8: [[W3 Surgery and Aggressive cysts.pdf#page=8|W3 Surgery and Aggressive cysts, p.8]] [^9]: Original PDF page 9: [[W3 Surgery and Aggressive cysts.pdf#page=9|W3 Surgery and Aggressive cysts, p.9]] [^10]: Original PDF page 10: [[W3 Surgery and Aggressive cysts.pdf#page=10|W3 Surgery and Aggressive cysts, p.10]] [^11]: Original PDF page 11: [[W3 Surgery and Aggressive cysts.pdf#page=11|W3 Surgery and Aggressive cysts, p.11]] [^12]: Original PDF page 12: [[W3 Surgery and Aggressive cysts.pdf#page=12|W3 Surgery and Aggressive cysts, p.12]] [^13]: Original PDF page 13: [[W3 Surgery and Aggressive cysts.pdf#page=13|W3 Surgery and Aggressive cysts, p.13]] [^14]: Original PDF page 14: [[W3 Surgery and Aggressive cysts.pdf#page=14|W3 Surgery and Aggressive cysts, p.14]] [^15]: Original PDF page 15: [[W3 Surgery and Aggressive cysts.pdf#page=15|W3 Surgery and Aggressive cysts, p.15]] [^16]: Original PDF page 16: [[W3 Surgery and Aggressive cysts.pdf#page=16|W3 Surgery and Aggressive cysts, p.16]] [^17]: Original PDF page 17: [[W3 Surgery and Aggressive cysts.pdf#page=17|W3 Surgery and Aggressive cysts, p.17]] [^18]: Original PDF page 18: [[W3 Surgery and Aggressive cysts.pdf#page=18|W3 Surgery and Aggressive cysts, p.18]] [^19]: Original PDF page 19: [[W3 Surgery and Aggressive cysts.pdf#page=19|W3 Surgery and Aggressive cysts, p.19]] [^20]: Original PDF page 20: [[W3 Surgery and Aggressive cysts.pdf#page=20|W3 Surgery and Aggressive cysts, p.20]] [^21]: Original PDF page 21: [[W3 Surgery and Aggressive cysts.pdf#page=21|W3 Surgery and Aggressive cysts, p.21]] [^22]: Original PDF page 22: [[W3 Surgery and Aggressive cysts.pdf#page=22|W3 Surgery and Aggressive cysts, p.22]] [^23]: Original PDF page 23: [[W3 Surgery and Aggressive cysts.pdf#page=23|W3 Surgery and Aggressive cysts, p.23]] [^24]: Original PDF page 24: [[W3 Surgery and Aggressive cysts.pdf#page=24|W3 Surgery and Aggressive cysts, p.24]] [^25]: Original PDF page 25: [[W3 Surgery and Aggressive cysts.pdf#page=25|W3 Surgery and Aggressive cysts, p.25]] [^26]: Original PDF page 26: [[W3 Surgery and Aggressive cysts.pdf#page=26|W3 Surgery and Aggressive cysts, p.26]] [^27]: Original PDF page 27: [[W3 Surgery and Aggressive cysts.pdf#page=27|W3 Surgery and Aggressive cysts, p.27]] [^28]: Original PDF page 28: [[W3 Surgery and Aggressive cysts.pdf#page=28|W3 Surgery and Aggressive cysts, p.28]] [^29]: Original PDF page 29: [[W3 Surgery and Aggressive cysts.pdf#page=29|W3 Surgery and Aggressive cysts, p.29]] [^30]: Original PDF page 30: [[W3 Surgery and Aggressive cysts.pdf#page=30|W3 Surgery and Aggressive cysts, p.30]] [^31]: Original PDF page 31: [[W3 Surgery and Aggressive cysts.pdf#page=31|W3 Surgery and Aggressive cysts, p.31]] [^32]: Original PDF page 32: [[W3 Surgery and Aggressive cysts.pdf#page=32|W3 Surgery and Aggressive cysts, p.32]] [^33]: Original PDF page 33: [[W3 Surgery and Aggressive cysts.pdf#page=33|W3 Surgery and Aggressive cysts, p.33]]