Cysts of the Oral cavity

True cyst

Pseudocyst

Definition:True cyst is a pathological cavity lined by epithelium & usually containing fluid or semi-fluid material. The epithelial lining may later degenerate under certain conditions , but the cyst may have been lined by epithelium at one stage of its development.

Pseudocyst are not lined by epithelium & may or may not contain fluid or other material.

Origin: True cysts of the jaw & related tissues arise from epithelial remnants of odontogenic or non-odontogenic origin within the maxilla & mandible.

A. Odontogenic Epithelium: Odontogenic epithelium may be derived from one of the following sources: 1. Possibly from cells of the basal layer of the oral epithelium , from which the dental lamina develops. 2. The dental lamina. 3. The epithelial rests of Serres , which represent remnants of the dental lamina.

4. The enamel organ. 5. The reduced enamel epithelium remaining on the surface of the crown after completion of enamel formation , representing the remains of the enamel organ. 6. The epithelial rests of Malassez , remnants of the epithelial root sheath of Hertwig.

B. Non-Odontogenic Epithelium(Surface secretory): 1. Epithelial cells remaining entrapped between embryonic processes at the line of fusion of these processes (fissural cysts).

2. Epithelium from remnants of the cervical sinus formed by overgrowth of the second branchial arch over the succeeding arches(i.e. Epithelium of branchial cleft origin).

3. Secretory glandular epithelium of minor mucous glands & of major salivary glands. 4. Remnants of the epithelium of the vestigial nasopalatine duct. 5. Remnants of epithelium of thyroglossal tract.

I. Odontogenic cysts: A- Inflammatory: 1. Apical inflammatory periodontal cyst. 2. Lateral inflammatory periodontal cyst. 3. Residual inflammatory periodontal cyst.

B- Developmental: 1. Follicular: i. Dentigerous cyst. ii. Primordial cyst(Odontogenic keratocyst). Basal cell nevus-bifid rib syndrome.

2. Extra-Follicular: i. Lateral developmental periodontal cyst. ii. Gingival cyst: a. Gingival cyst of the newborn. b. Gingival cyst of the adult. iii. Keratinizing & Calcifying Odontogenic cyst (Gorlin cyst, Cystic keratinizing tumor).

iv. Cystic degeneration of odontogenic tumors ( Cystic ameloblastoma, Cystic odontome).

II. Non-Odontogenic: A. Fissural Cysts: 1. Nasoalveolar ( nasolabial cyst) (soft tissue cyst related to the maxilla). 2. Median maxillary cysts i. Median alveolar cyst. ii. Median palatine cyst.

3. Median mandibular cyst. 4. Nasopalatine duct cyst: i. Incisive canal cyst. ii. Cyst of palatine papilla. 5. Globulomaxillary cyst.

B. Other developmental Cysts: 1. Branchial cleft cyst (Benign lymphoepithelial cyst of the neck). 2. Thyroglossal tract cyst. 3. Dermoid & Epidermoid cysts. 4. Heterotopic oral gastro-intestinal cyst.

III. Cysts of the salivary glands: 1. Mucous retention & extravasation cysts: i. Mucocele. ii. Ranula.

IV. Pseudocysts: 1. Traumatic bone cyst (haemorrhagic bone cyst; solitary bone cyst). 2. Aneurysmal bone cyst. 3. Static bone cyst (developmental salivary gland inclusion cyst; latent bone cyst; Stafnes idiopathic bone cavity).

Cyst-like lesions:

I. Normal anatomical landmarks: The following normal anatomical structures produce a radiolucent picture that may resemble the picture produced by a cystic lesion: 1. Maxillary sinus. 2. Mental foramen. 3. Hemopoietic bone marrow defect & physiologic osteoporosis. 4. Nasopalatine foramen & incisive canal.

II. Neoplastic & dysplastic lesions: 1. Odontogenic tumors such as simple ameloblastoma, adenomatoid odontogenic tumor, Pindborgs tumor. 2. Pleomorphic adenoma of salivary glands. 3. Odontogenic myxoma & fibroma. 4. Giant cell lesions & tumors. 5. Fibrous dysplasia of bone & cherubism.

6. Central non-ossifying fibromas of the jaws. 7. Early stage of cementifying fibroma. 8. Metastatic & invasive carcinomas to the jaws. 9. Osteolytic osteogenic sarcoma. 10. Central hemangioma of the jaws.

III. Metabolic & Systemic Dysfunction: 1. Osteitis fibrosa cystica (hyperparathyroidism, von Recklinghausens disease of bone). 2. Langerhans Cell Reticulo-endothelioses: a. Eosinophilic granuloma. b. Hand-Schuller-Christans disease. c. Leterrer-Siwes disease.

3. Lysosomal storage diseases: a. Gauchers disease. b. Nieman-Pick disease.

IV. Destruction of bone caused by microorganisms: 1. Chronic dentoalveolar abscess. 2. Osteomylitis: a. Acute non-specific suppurative osteomylitis. b. Septic osteomylitis: 1) Tuberculous osteomylitis.

2) Actinomycotic osteomylitis. 3) Syphilitic osteomylitis & periostitis.

V. Periapical lesions: 1. Chronic periapical abscess. 2. Periapical granuloma. 3. Early stage(osteolytic stage) of periapical cemental dysplasia. 4. Apical scar.

VI. Soft tissue benign tumors which may appear clinically as cysts: 1. Soft fibroma. 2. Lipoma. 3. Myoma. 4. hemangioma,. 5. Lymphangioma.

DIAGNOSIS OF THE CYST1. 2. 3. 4. 5. 6. Physical signs. Symptoms. Radiographic examination. Other radiological diagnostic techniques Aspiration. Biopsy.

Treatment of the cystsAim of treatment: 1- To remove the pathological epithelium that forms the lining or to enable the patients body to rearrange the position of the abnormal tissue so that its eliminated from within the jaw. 2- To do so with the minimum of trauma to the patient, consistent with a successful outcome to the operation.

3- To preserve adjacent important structures such as nerves & healthy teeth. 4- To achieve rapid healing of the operation site. 5- To restore the part to normal or near normal form & to restore normal function.

Surgical Techniques1- Enucleation or complete removal of the cyst capsule & lining with its contents. 2- Marsupialization (Partch operation) by which the cyst is uncovered or de-roofed by creating a large opening in the bone & the cystic lining so that the lining of the floor & walls becomes continuous with the oral cavity epithelium & the surrounding structures.

N.B:Sometimes the lesion is initially treated by marsupialization to decompress the intra-cystic pressure until the cyst is reduced in size & then a second operation is performed to enucleate the cystic membrane.

EnucleationIndications:1- Accessible cysts. 2- Small to moderate sized cysts that dont extensively involve vital teeth or important anatomical structures such as the maxillary sinus & inferior alveolar bundle. 3- Cysts that dont involve soft tissues.

Advantages:1- Removal of the entire pathological tissue. 2- Rapid healing than that which occurs with marsupialization. 3- Decreased need for post-operative care.

Disadvantages:1- Large cysts may be technically difficult to remove. 2- Possibility of damage to vital teeth.

3- Possibility of fracture of the mandible in large cysts involving the lower jaw, also injury to important anatomical structures could occur e.g. inferior alveolar nerve & vessels.In large maxillary cysts enucleation may lead to the creation of an oro-antral communication with subsequent effects on the maxillary antrum;involvement of the floor of the nose may also occur.

4- If the cyst extends to the soft tissues complete removal may not be possible sometimes, with a great possibility of recurrence.

The steps of the technique Enucleation can be done under general or local anaesthesia. In any case, before the incision is demarcated, the area should be infiltrated with a local anaesthetic solution with a vasoconstrictor. This helps in easy separation of cystic lining from the periosteum. Whenever possible, a buccal or labial approach is preferable because of superior visibility and accessibility. However, a cyst causing palatal expansion alone should be approached through this direction the associated pulpless teeth should be extracted or root-filled. A wide mucoperiosteal flap with margins on intact bone should be reflected. If the bone is intact, a window cut is made with chisel or bur without perforating the cystic wall. If the bone is thin, it can be peeled off with a periosteal elevator. Further clearance is done using bone roungers till adequate access is obtained. The cyst lining is gently separated from the cavity with the broad end of periosteal elevator. Depending upon the size of the cyst and its position, other instruments such as spoon escavator and Mitchells trimmer can be used. Edge of the instrument is applied on cavity wall with the concave surface facing the lining.

Careful dissection should be done to separate the lining from the structures like periosteum, nasal cavity wall, maxillary sinus, neurovascular bundles etc. Undue pressure should not be used while doing this. After removing the cyst lining, the cavity is irrigated and well debrided and inspected for any remnants of cyst lining. Hemostasis should be achieved before closing. In large cysts, immediate control of bleeding may not be enough and further oozing is managed by placing a gauze pack in the cavity till complete hemostasis occurs. This pack is removed after 24 hours. An alternate way is to pack the cavity loosely with iodoform gauze and to keep the pack for 7-10 days. A low-pressure suction drainage system may be used. Voorsmit, Stoelinga and van Haelst (1981) advised devitalising any fragments of lining left in the cavity after enucleation, either by swabbing the cavity with Carnoys solution or by freezing the bony wall. Carnoys solution is a powerful histological fixative made by mixing chloroform (3 parts), absolute alcohol (6 parts) and glacial acetic acid (1 part). An approach that recently has gained popularity in the management of keratocysts is a combination of methods. The first step is to decompress the cyst. A plastic (or other suitable material) drain is secured in place to ensure that the opening remains patent. After 6 to 8 weeks, the lining of the cyst becomes generally thick and tough. The second step is to carefully enucleate the cyst. At this time, the thickened cyst wall is much more easily removed than is the usual OKC. The next step is to perform a peripheral ostectomy with a large bone bur. A margin of 2 to 3 mm is taken, depending on adjacent vital structures involved. The final step is to treat the residual bone bed with chemical cautery (Carnoys solution

This systematically thorough method, although time consuming and demanding much patient co-operation, has achieved good results. To obliterate the cavity after cyst enucleation, various filling materials have been recommended for packing into the defect prior to closure of the wound. Primarily, these are forms of haemostatic resorbable sponge, some of which may be soaked in a solution containing an antibiotic or thrombin. These materials are inserted to prevent excessive bleeding and to form a scaffold into which granulation tissue can migrate. It is now recognised that grafting with autogenous cancellous bone can be performed successfully within oral wounds. In case of large defects, when pathologic fractures are possible or there would be considerable loss of contour in a future denturebearing area, this procedure can be used to obliterate the cavity and stimulate osteogenesis. Should grafting be indicated, autogenous bone provides the best results if a second wound is not a major consideration (Boyne-1970; Flint-1964; Mowlem-1944; Scott, Peterson and Grant-1949).

A risk of bone grafting cyst cavities is the possibility of bone fragments becoming infected if wound breakdown occurs. The risk of failure in these cases is greater than when grafts are introduced after resection of a segment of mandible, because of the greater difficulty in ensuring watertight wound closure. Enucleation and package This is an improvised method devised to combine the advantages of the two main techniques, but in fact it combines the disadvantages of both enucleation and marsupialisation, yet the advantages of primary closure are not achieved.

MarsupializationIndications:1- Large cysts that are weakening the jaw. 2- Soft tissue cysts. 3- Cysts approximating vital teeth. 4- Cysts related to maxillary sinus or inferior alveolar canal. 5- Dentigerous or eruption cysts to allow teeth to erupt. 6- In elderly patients.

Advantages:1- Preservation of vital structures from surgical damage (teeth, maxillary sinus, inferior alveolar nerve). 2- Minimizes bone removal ,thus the potential danger of surgical fracture of the mandible is avoided. 3- Bare bone is not exposed to infection. 4- Less traumatic procedure than enucleation, hence less risky for poor surgical risk patients.

5- Needs less surgical skill than enucleation. 6- Preserves the normal contour of the mouth.

Disadvantages:1- Leaves behind pathologic tissue with the possible potentiality of change into malignant neoplasm. 2- Slow healing. 3- Requires considerable post-operative care. a. The defect is sometimes difficult for the patient to keep clean during the healing period. b. The defect doesnt always fill completely with bone.

The steps of the techinque 1-The incision should be practiced according to the limits of the projection of cysts on the vestibular surface, therefore, a circular incision, and place it halfway between the sulcus and the free edge of the gums. It is preferable to incision is started at a point distal to the cyst, taking her to the medial. For these cases the bone has been completely destroyed, with no need for ostectomy, moving immediately to the incision of cystic membrane, following the same size circular incision of the vestibular mucosa. Should wherever possible be slightly larger than the horizontal diameter of the cyst in any depth to which the presence of bone.

2. In cases where the cyst has externalized due to its large size, having already destroyed the external bony plate, with a cystic pouch in close contact with the periosteum, one must take care not to accidentally open the cyst and early, as this going to maneuver the detachment of the periosteum of the bag is not so simple, the difficulty to be individualized to the cystic wall. For dentigerous cysts in young patients with a scalpel blade number 5, or with an electric scalpel, it eliminates a piece mucosa, the periosteum and the bone and adjacent cystic membrane, cutting deeply into the thin tissue mass

3. For the flap displacement uses is a highlight periosteum or a blunt spatula and should be folded carefully, preferably with the aid of a bandage until the upper limits of the cyst, which were guided by radiography. In the case of the disappearance of bone tissue, the flap must be separated gently until it found the cystic membrane. The bone can fracture very papyraceous or mortify them out, and can act as a foreign body, causing suppuration, requiring further surgery, as the goal of being eliminated sequestration

4. The ostectomy can be performed with the aid of various instruments. When the bone is very thin, can be eliminated with the aid of a straight chisel gently, and when it is partially destroyed, its elimination is completed with the forceps gouges. If the bone is still compact, practices the ostectomy with chisel to hand pressure or with the aid of drills for bone. This maneuver allows for good results and are less traumatic than the chisel and hammer. Are charged holes that match the diameter of the cyst to the fullest extent of the injury, and these holes together with their drill with a chisel or else the manual pressure being eliminated this bony plate with the aid of a chisel straight through movements lever.

5. Eliminated the bone covering the cyst empties and the interior, it is an irrigation with saline, not to produce lesions in the cystic epithelium. Some authors practice touches inside the bag with cystic alcohol, iodine or with other medications unnecessary or harmful to the cystic epithelium. Opens widely followed, the full extent of the cyst, and this opening is larger or at least equal to the diameter of the cyst to prevent the edges from closing and give relapses or at least one cavity that does not disappear in a long time ago. To be avoided drawbacks just mentioned, some authors use buffer with which obliterate the cavity, a procedure not put into practice today. For the conservative method of Partsch, there is no need to fear for the integrity of the sinus or nasal cavity, much less the inferior alveolar nerve. The cystic membrane acts as a wall of security that defends these organs, where there is bone cyst separating these important 530 DECOMPRESSION TECHNIQUE TO SURGICAL TREATMENT OF THE ORAL CAVITY CYSTS anatomical structures. Neighboring teeth displaced by excessive growth of the cyst should be kept for some time, in order to not fracture the alveolar portion and not creating invaginations in alveolar border, whose aesthetic and functional result

6. Suture of the buccal mucosa with the periphery of the bag cystic wired Dexon 3-0 or 3-0 vicryl. Some authors say there is no need for this type of suture, because they think that the coaptation of both entities are produced whenever there are easily taken the precaution of not letting the bone tissue between them. However, it seems important and necessary that this suture is performed in order to better repair scarring, less risk of recurrence.

Periapical Cyst Most

common odontogenic cyst Probably arises due to inflammatory stimulus for proliferation of rests of Malassez Typically asymptomatic, but may become secondarily inflamed

Periapical Cyst Radiographically

present as a round to ovoid radiolucency Apex of non-vital tooth non Less commonly between teeth lateral radicular cyst Most are < 1.5 cm in diameter

Radicular cyst: ill-defined lesion subjacent to carious tooth root (arrow).

Radicular cyst: Note continuity between cyst cortex and periodontal ligament space of grossly carious (C4) right mandibular first molar. Cyst is a well-delineated unilocular radiolucency. Note lower cortex expansion.

Radicular cyst on carious right maxillary lateral incisor. The lesion is a well-delineated unilocular homogeneous radiolucency.

Radicular cyst on left mandibular first permanent molar tooth. It is a well-delineated homogeneous radiolucency.

Radicular cyst possibly of right mandibular premolar tooth (or residual following extraction of first molar) is a well-demarcated unilocular homogeneous radiolucency (arrow).

Residual cyst: unilocular homogeneous radiolucency in edentulous right maxillary molar region (periapical radiograph). zygoma lateral wall of nasal passage cyst

Periapical Cyst Variably

thick, non-keratinized nonstratified squamous epithelial lining Usually a significant degree of inflammation present

PERIAPICAL CYST Radiographic features Well-delineated radiolucency Loss of the lamina dura Root resorption May become quite large

Periapical Cyst Enucleation,

with either extraction or endodontic therapy of the involved tooth If the lesion is not removed, a residual cyst may result Recurrence is unlikely

RESIDUAL PERIAPICAL CYST

Well-defined radiolucency within the alveolar ridge at the site of a previous tooth extraction

RESIDUAL PERIAPICAL CYST

Histopathologic features Same as the periapical cyst Treatment Surgical excision

Lateral Periodontal Cyst Derived

from dental lamina rests Middle aged adults, males (2:1) (2 Asymptomatic, usually unilocular radiolucency, mandibular canine/premolar region, < 1 cm

Lateral periodontal cyst: unilocular well-corticated radiolucency distal to right mandibular canine.

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Lateral periodontal cysts: bilateral lesions (rare example) in mandible between canine and first premolar teeth

Lateral periodontal cyst: well-delineated multilocular (botryoid or grape-like) homogeneous radiolucency between roots of left mandibular premolar teeth.

Lateral Periodontal Cyst Identical

to gingival cyst of the

adult Non-keratinized epithelium, focal Nonnodular thickenings, clear cells

Lateral Periodontal Cyst Curettage,

conservative enucleation Excellent prognosis

Botryoid Odontogenic Cyst Probably

represents variant of lateral periodontal cyst Similar clinical setting; middlemiddleaged to older adults, mandibular canine and premolar region Multilocular radiolucency, grapegrapelike (botryoid) (botryoid)

Botryoid Odontogenic Cyst Conservative

surgical excision with curettage Slight recurrence potential

Dentigerous Cyst Second

most common odontogenic

cyst By definition, a cyst that forms around the crown of an impacted tooth This is a developmental (as opposed to an inflammatory) cyst Arises from reduced enamel epithelium

Dentigerous Cyst Usually

detected in young adults Most common sites mand. 3rd molar region and max. canine region Pericoronal radiolucency, sometimes with resorption of adjacent tooth roots

DENTIGEROUS CYST Radiographic features Unilocular radiolucency associated with the crown of an unerupted tooth Central variety Lateral variety Circumferential variety Radiolucency should be at least 3-4 mm. in diameter

Dentigerous Cyst Thin,

nonnon-keratinized stratified squamous epithelial lining Connective tissue wall is usually uninflamed, although secondary inflammation may be present Mucous cells may also be seen in the cyst lining

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Dentigerous cyst seen as well-delineated homogeneous radiolucency surrounding crown of distally inclined third mandibular molar.

Dentigerous cyst: expansile unilocular homogeneous radiolucency attached at enamel-cemental junction of right molar.

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Dentigerous cyst: left mandubular ramus. well-demarcated, unilocular homogeneous radiolucency envelopes third molar tooth.

Dentigerous cyst: well-delineated radiolucency Surrounding and displacing in left mandibular canine causing displacement and root resorption of adjacent teeth.

Dentigerous cyst: axial CT from previous patient. Note buccal and lingual expansion of mandible.

Dentigerous cyst: 0.5 Tesla,T2-weighted MRI image of same patient. Note high signal intensity of cyst contents.

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Dentigerous cyst: welldelineated unilocular homogeneous radiolucency displacing left maxillary third molar.

DENTIGEROUS CYST Treatment Enucleation with removal of the unerupted tooth Marsupialization

ERUPTION CYST (ERUPTION HEMATOMA)

ERUPTION CYST Soft tissue analoque of the dentigerous cyst Swelling of the gingival mucosa overlying the crown of an erupting deciduous or permanent tooth; usually the first permanent molars or maxillary incisors Children < 10 years of age

ERUPTION CYST Eruption hematoma: blood accumulates in the cystic fluid

ERUPTION CYST Treatment Excision of the roof of the cyst to permit eruption

Primordial Cyst By

definition, a developmental odontogenic cyst that arises in place of a tooth, usually a mand. 3rd molar Should be no history of extraction of a tooth in the area Most are OKCs microscopically

Primordial Cyst The

overwhelming majority of these cysts prove to be odontogenic keratocysts on microscopic examination Thin, uniform lining that produces parakeratin and exhibits palisading of the basal cell layer

Primordial Cyst Essentially

the same treatment that is rendered for the OKC Enucleation and curettage for small, unilocular lesions More aggressive therapy for larger, multilocular lesions

Odontogenic Keratocyst Benign

but locally aggressive developmental odontogenic cyst Probably arises from dental lamina rests Affects a wide age range, beginning in the second decade of life Asymptomatic until swelling develops

Odontogenic Keratocystcommonly seen in the posterior mandible, but any segment of the jaws can be affected clinically may mimic a wide variety of jaw cysts Unilocular radiolucency when small Multilocular appearance often develops as the lesion enlarges Most

ODONTOGENIC KERATOCYST Radiographic features Unilocular or multilocular radiolucency 25-40% associated with an unerupted tooth Root resorption is less common compared to the dentigerous cyst

Odontogenic keratocyst: unilocular homogeneous radiolucency in right mandibular ramus (detail from panoramic radiograph).

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Odontogenic keratocyst: large crenulated homogeneous radiolucency enveloping third molar tooth in left mandibular ramus.

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Odontogenic keratocyst: multilocular homogeneous radiolucency in left mandibular body is well demarcated with little expansion.

Odontogenic keratocyst: detail from panoramic radiograph showing homogeneous radiolucency that surrounds roots of right premolar and molar. The definitive diagnosis awaits histopathology in such cases.

Odontogenic keratocyst (true occlusal radiograph): homogeneous radiolucency without expansion of the buccal plate of the mandible.

Odontogenic keratocyst: note lack of jaw expansion and lack of tooth resorption by this large well-delineated homogeneous radiolucency crossing the midline of the mandible (topographic occlusal view).

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Odontogenic keratocyst: PA radiograph showing multilocular radiolucency in right side of mandible. Expansion as seen in this case is a late feature of this disease process.

Odontogenic keratocyst: unilocular homogeneous radiolucency lesion:

lateral topographical occlusal of mandible.

Odontogenic keratocyst: panoramic view of lesions in both jaws from multiple nevoid basal cell carcinoma syndrome.

Odontogenic keratocyst: unilocular homogeneous radiolucency lesion that does not cross the midline (distinguishing it from the nasoplaatine duct cyst) and causes neither resorption nor marked displacement of adjacent teeth.

Odontogenic keratocyst (recurrent): well-delineated multilocular homogeneous radiolucency lesion (arrow) at right mandibular angle. Unlike most odontogenic lesions this case did extend below the mandibular canal.

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Odontogenic Keratocyst Uniform,

thin stratified squamous epithelial lining Luminal parakeratin production Palisaded (picket fence) appearance of the basal cell nuclei Features altered with inflammation Satellite cyst formation may be seen

Odontogenic Keratocyst 33% 33%

recurrence rate overall With occurrence in the first decade, or with multiple OKCs, the nevoid basal cell carcinoma syndrome should be considered

ODONTOGENIC KERATOCYST Treatment and prognosis Enucleation, curettage, or peripheral ostectomy Multiple recurrences are not unusual; often 5-10 years after the initial surgical procedure

NEVOID BASAL CELL CARCINOMA SYNDROME (GORLIN SYNDROME)

GORLIN SYNDROME Autosomal dominant trait Multiple basal cell carcinomas of the skin, multiple OKCs, rib and vertebral anomalies, and intracranial calcifications 40% of patients have ocular hypertelorism

GORLIN SYNDROME Basal cell carcinomas 2nd-3rd decades of life Occur on the midface area and on non-sun exposed skin Palmar and plantar pits Occur in 65% of patients Represent a localized retardation in the maturation of basal epithelial cells

GORLIN SYNDROME Skeletal anomalies Occur in 60%-75% of patients Bifid ribs or splayed ribs Lamellar calcification of the falx cerebri Odontogenic keratocysts Occur in 75% of patients Occur at an earlier age than isolated OKCs Often multiple

Facial Asymmetry-Gorlans AsymmetrySyndrome

Nevoid BCCa SyndromeCutaneous features: Basal cell carcinomas, early onset Palmar/plantar pitting

Nevoid BCCa SyndromeSkeletal features: calcified falx cerebri increased cranial circumference bifid ribs

Nevoid BCCa Syndromescreens Excision of basal cell carcinomas as needed Monitor for and excise OKCs Genetic counseling Sun

Glandular Odontogenic CystMore recently described (45 cases) Gardner, 1988 Mandible (87%), usually anterior Very slow progressive growth (CC: swelling, pain [40%]) Radiographic findings

Unilocular or multilocular radiolucency

Glandular Odontogenic Cyst

Glandular Odontogenic Cyst

Histology Stratified epithelium Cuboidal, ciliated surface lining cells Polycystic with secretory and epithelial elements

Treatment of GOCConsiderable recurrence potential 25% after enucleation or curettage Marginal resection suggested for larger lesions or involvement of posterior maxilla Warrants close follow-up

Gingival Cyst of the Newbornfrom dental lamina rests 1-2 mm whitish papules on alveolar ridge mucosa in newborns, maxilla No treatment needed Derived

Gingival Cyst of the Newborn Similar

inclusion cysts are found near midline palatal raphe (Epsteins pearls) or more laterally along hard and soft palate (Bohns nodules)

Palatal Cysts of the Newborn(Epsteins Pearls, Bohns Nodules)

As palatal shelves fuse to form secondary palate, small islands of epithelium may become trapped below surface Or may arise from epithelial remnants from development of minor salivary glands

Epsteins pearls occur along median palatalraphe

Bohns nodules are scattered over the hardpalate. No treatment required self-healing

Gingival Cyst of the Adult Derived

from dental lamina rests Middle-aged adults (5th-6th Middle(5thdecades) Mandibular canine/premolar region most common Bluish-translucent swelling, Bluishoften centered in attached gingiva

Gingival Cyst of the Adult Thin,

nonnon-keratinized cuboidal to stratified squamous epithelium Occasional clear cells Nodular thickenings of epithelial lining may be seen

GINGIVAL CYST OF THE ADULT Treatment and prognosis Surgical excision Prognosis is excellent

Calcifying Odontogenic Cyst Also

known as the Gorlin cyst Most common in 2nd-3rd nddecades, but wide age range seen Anterior portions of jaws (65%) (65%) Usually intrabony, but peripheral lesions make up 13-30% 13-30%

Calcifying Odontogenic Cyst Radiographically:

defined unilocular radiolucency +/+/variable radiopacities Resorption and divergence of adjacent roots often seen 1/3rd present with impacted tooth 20% present with odontoma 20%

CALCIFYING ODONTOGENIC CYST Radiographic features Presents as a well-defined unilocular or multilocular radiolucency 1/3 to 1/2 of cases are associated with radiodensities 1/3 of cases are associated with an impacted tooth, often a canine

Calcifying odontogenic Cyst:

salt and pepper calcifications within an expansile unilocular otherwise lucent lesion (true occlusal)

Calcifying odontogenic cyst:

Welldelineated unilocular mixed radiolucency and radiopacity enveloping unerupted tooth.

Calcifying Odontogenic Cyst Cystic

epithelial lining with resemblance to ameloblastoma (peripheral columnar cells and stellate reticulum-like areas) reticulum Variable numbers of ghost cells and dystrophic calcifications

CALCIFYING ODONTOGENIC CYST Treatment and prognosis Enucleation Prognosis is good

Developmental Cysts

Nasolabial Cyst (Nasoalveolar Cyst)

Nonpainful swelling of upper lip lateral to midline, resulting in elevation of ala of nose May result in nasal obstruction or may interfere with denture. May rupture and may drain into oral cavity or nose Complete surgical excision is preferred treatment

Nasolabial cyst: note displacement of ala on right side.

Nasolabial cyst: lateral view shows antero-posterior dimensions of contrast-enhanced cyst.

Nasolabial cyst with and without contrast (topographical occlusal views).

Nasopalatine Duct Cyst(Incisive Canal Cyst)

Most common non-odontogenic cyst of oral cavity Canals of Scarpa, organs of Jacobson Presenting symptoms include swelling of interior palate, drainage and pain Well circumscribed radiolucency in or near the midline of the anterior maxilla between and apical to the central incisor teeth

Nasopalatine duct cyst causing palatal expansion, a common finding.

Nasopalatine duct cyst less frequently causes sublabial swelling.

Nasopalatine duct cyst: a well delineated ovoid unilocular radiolucency in the midline of the maxilla. The teeth are all vital. (topographic occlusal view).

Nasopalatine duct cyst: Well-delineated unilocular radiolucency in the midline of the maxilla. Adjacent teeth are vital.

Nasopalatine duct cyst: large unilocular radiolucency occupies much of the palate and is causing tooth displacement (topographic occlusal view).

Incisive Canal CystDerived from epithelial remnants of the nasopalatine duct (incisive canal) 4th to 6th decades Palatal swelling common, asymptomatic Radiographic findings

Well-delineated oval radiolucency between maxillary incisors, root resorption occasional

Histology Cyst lined by stratified squamous or respiratory epithelium or both

Incisive Canal Cyst

Incisive Canal CystTreatment consists of surgical enucleation or periodic radiographs Progressive enlargement requires surgical intervention

Globulomaxillary Cyst

Well-circumscribed unilocular radiolucency between and apical to the teeth resembling an inverted pear Some are consistent with periapical cysts, some have features of odontogenic keratocyst, or developmental lateral periodontal cyst Treatment consists of surgical enucleation, endodontic therapy

GMC

Median Palatal Cyst

True median palatal cyst presents as firm or fluctuant swelling of the midline of the hard palate posterior to the palatine papilla Well circumscribed radiolucency in the midline of the hard palate Treatment is surgical removal

Median Mandibular Cyst

Most of odontogenic origin Midline radiolucency found between or apical to the mandibular central incisor teeth, cortical expansion Treatment is surgical enucleation

Epidermoid Cyst of the Skin

Nodular, fluctuant, subcutaneous lesions that may or may not be associated with inflammation Most common in the acne-prone areas of the head, neck, and back May be associated with Gardner syndrome Treatment is conservative surgical excision

Dermoid Cyst

Benign cystic form of teratoma Teratoma is a developmental tumor composed of tissue from ectoderm, mesoderm, and endoderm. In most complex form, teratomatous malformations produce multiple types of tissue arranged in a disorganized fashion

Dermoid Cyst,

cont.

Teratoid cyst cystic form of teratoma thatcontains a variety of germ layer derivatives (skin appendages, connective tissue elements, and endodermal structures)

Dermoid cysts are simpler in structure than complex teratomas or teratoid cysts

Dermoid Cyst,

cont.

Occur in midline of floor of mouth. Usually slow growing and painless, presenting as a doughy or rubbery mass that retains pitting after application of pressure Secondary infection may occur, treatment is surgical removal

Dermoid cyst

Neck: dermoid cyst

Thyroglossal Duct Cyst(Thyroglossal Tract Cyst)

60%-80% of cysts develop below hyoid bone Usually presents as painless, fluctuant, movable swelling unless complicated by secondary infection Best treated by removal of cyst, midline section of hyoid bone, and muscular tissue

Thyroglossal Cyst Midline mass Age 10 20yrs Most common cystic embryological remnant in head/neck 65% infrahyoid Elevate on protrusion of tongue

Cervical Lymphoepithelial Cyst(Branchial Cleft Cyst)

Developmental cyst that occurs in upper lateral neck along anterior border of the sternocleidomastoid muscle Soft fluctuant mass ranging from 1-10 cm Increased numbers reported in persons with HIV infection Treatment is surgical removal

LumpsWhat can you describe? Site Size Shape Surface Edge Consistency Colour Transillumination Fixation / tethering Pulsation

Thyroid Lumps Goitre Single nodule Multiple nodules Elevate on swallowing May have features of hyper / hypothyroidism Eye signs Rarely midline

Carotid Body Tumour Slow growing Carotid bifurcation Transmits carotid pulse May be pulsatile itself Moves side side, not up down

Branchial Cleft Cyst Junction of upper 1/3 lower 2/3 SCM Painless Contain cholesterol crystals

Parotid Tumours Pre and post auricular May elevate earlobe May involve facial nerve

Summary list of lumps Thyroglossal cyst Dermoid cyst Thyroid lump Carotid body tumour Lymph node Parotid tumour Elevates when tongue out Midline, fixed to skin Elevates on swallowing Pulsatile, side side mvmt

Lifts earlobe

Oral Lymphoepithelial Cyst

Waldeyers ring palatine tonsils, lingualtonsils and pharyngeal adenoids Small asymptomatic submucosal mass, firm or soft, white or yellow, on floor of the mouth Treatment is surgical excision

Pseudocysts

Stafne Bone Cyst

Submandibular salivary gland depression Incidental finding, not a true cyst Radiographs small, circular, corticated radiolucency below mandibular canal Histology normal salivary tissue Treatment routine follow up

Stafne Bone Cyst

Traumatic Bone CystEmpty or fluid filled cavity associated with jaw trauma (50%) Radiographic findings

Radiolucency, most commonly in body or anterior portion of mandible

Histology thin membrane of fibrous granulation Treatment exploratory surgery may expedite healing

Traumatic Bone Cyst

Traumatic bone cyst extending from right premolar to left canine (mandibular true occlusal view). Note lack of expansion.

Traumatic bone cyst: axial CT shows only minor expansion of mandible in molar region (arrow).

Traumatic bone cyst

Normal follicle space. Lesion.

Traumatic bone cyst showing typical scalloped appearance from extension between tooth roots. Note partial loss of lamina dura.

Traumatic bone cyst in mandibular premolar region (detail from panoramic radiograph). This is a well-delineated noncorticated lucency.

Aneurysmal Bone Cyst

etiology is unknown it may be due to failure of attempted repair of a haematoma in bone in which a circulatory connection with the damaged vessels persists leading to a slow flow of blood through the lesion

Aneurysmal bone cyst: PA view showing buccal expansion in left mandibular angle.

R

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Aneurysmal bone cyst: PA view of lesion in right mandibular ramus, the most common site for this condition in the jaws (more than 99% of this lesion are found elsewhere in the skeleton).

Surgical Ciliated CystMay occur following Caldwell-Luc Trapped fragments of sinus epithelium that undergo benign proliferation Radiographic findingsUnilocular radiolucency in maxilla

HistologyLining of pseudostratified columnar ciliated

Treatment - enucleation

Surgical Ciliated Cyst