ODONTOGENIC CYSTS OF THE JAWS

ODONTOGENIC CYSTS OF JAWS

DEFINITION
A cyst is a pathological cavity containing fluid, semifluid or gaseous contents which may or may not be lined by epithelium and is not created by the accumulation of pus .
(Kramer :1974)

CLASSIFICATION
By Kramer, Pindborg and Shear, 1992 in WHO's publication

ODONTOGENIC CYSTS

     

DEVELOPMENTAL Dentigerous cyst Eruption cyst Odontogenic keratocyst Gingival cyst of infants Gingival cyst of adults

   

INFLAMMATORY Periapical(Radicular) cyst Residual periapical cyst Buccal bifurcation cyst

ETIOPATHOGENESIS
Derived from epithelium associated with development of dental apparatus i.e. tooth germs, reduced enamel epithelium, rests of malassez, remnants of dental lamina, and basal layer of oral epithelium. 3 CONCEPTS OF ORIGIN :A) Spontaneous origin concept Cyst results when epithelium proliferates and organizes to protect exposed or irritated connective tissue elements and in turn connective tissue supports and nourishes epithelium. If it results in intact sac, it is called a cyst.

B)

Neoplastic origin concept It implies that the involved tissues materially deviate from normal in their power of proliferation and organization.

C) Pseudo neoplastic origin concept The epithelium, a simple cell, nest of cells, entire follicle degenerate under stimulation to basic proliferation resembling a neoplasia. Eventually a lumen is outlined and stratified epithelium membrane may form with organization of connective tissue.

ENLARGEMENT OF CYST
A) MURAL GROWTH

(i) Peripheral cell division peripheral enlargement is attributed to active cell division of lining epithelium in response to an irritant stimulus. (ii) Accumulation of cellular contents keratocysts enlarge by accumulation of mural squames as they are cast off the lining epithelium.

(B) HYDROSTATIC ENLARGEMENT Growth is attributed to distension of cyst wall by fluid accumulation through following processes:(i) Secretion (ii) Transudation and Exudation (iii) Dialysis
(C)

BONE RESORBING FACTOR

Is mixture of PGE2 and PGE3. The source can be capsule and leukocyte content, including a vascular contribution in vivo.

CLINICAL FEATURES
- Range from asymptomatic to incidental finding in radiographs to observable expansion of bone. - Paresthesia, displacement of teeth. - Egg shell crackling in large cysts. - Infection results in increased swelling, pain, discharge tenderness and redness.

RADIOLOGICALFEATURES
Classical appearance - well defined round / oval radiolucent area circumscribed by sharp radiopaque sclerotic margin.

- Ranges from unilocular eg. Radicular cyst to multilocular radiolucency eg Aneurysmal bone cyst.

HISTOLOGICAL FEATURES
- Lined by stratified squamous epithelium, varying in thickness and extent of keratinization depending on type of cyst. - Lumen may contain keratin, cholesterol crystals and various amount of protein contents as per the type of cyst. - Fibrous capsule may be present.

Treatment Considerations:Considerations:1)

Marsupialization(Partsch I , Decompression) : Defined as creating a surgical window in the wall of cyst, evacuating contents of cyst and maintaining continuity between cyst and oral cavity, maxillary sinus or nasal cavity.
(Peterson )

Very large cysts . Indications Cysts close to vital structures.

Advantages
Spares vital structures Reduces morbidity and neurological loss. Decreased risk of pathological fracture and orooro-antral fistula.

Disadvantages
Pathological lining left behind can transform into ameloblastoma or squamous cell carcinoma. Regular post-operative care required. postInfection if saliva and debris accumulates.

2) Enucleation :
It is process by which the total removal of cystic lesion is achieved .By Definition,it means shelling out of the entire cystic lesion without rupture. (Peterson) Small cysts

Indications
Potential for neoplastic changes.

Advantages
No pathological lining left behind Lesser chances of infection No regular follow-up appointments followUniform healing takes place Disadvantages Increased risk to adjacent vital structures Increased chances of pathological fracture

3) PARTSCH II
Marsupialization followed by Enucleation (For large cysts) First Marsupialization is done to evacuate the cystic contents. second stage surgery in the form of enucleation is performed to remove entire cystic lining. Vital structures spared
Advantages

No pathological lining left behind

ERUPTION CYST
INTRODUCTION It is the soft tissue analogue of dentigerous cyst which is the result of seperation of dental follicle from around the crown of an erupting tooth i.e. with in the soft tissues overlying the alveolar bone. PATHOGENESIS It develops due to accumulation of fluid within the follicular space of an erupting tooth. CLINICAL FEATURES Age - Children < 10 yrs. Site - Deciduous and permanent teeth may be involved, frequently anterior to first permanent molar.

Clinical presentation
- Appears as soft, translucent swelling in gingival mucosa overlying erupting tooth. - Painless unless infected - Brief history of 3-4 wks duration during which enlarge to approximately 1.5 cm. - Exposure to masticatory trauma induces hemorrhage with in the cyst giving rise to eruption hematoma

HISTOPATHOLOGICAL FEATURES
- Superficial aspect covered by oral epithelium. - Underlying lamina propria shows variable inflammatory cell infiltrate. - Deep portion which represents roof of cyst, shows a thin layer of non-keratinizing squamous epithelium

Nonkeratinising squamous epithelium

Oral epithelium

RADIOLOGICAL FEATURES
- Cyst may throw a soft tissue shadow. - Usually no bone involvement except that dilated and open crypts may be seen.

TREATMENT AND PROGNOSIS

1) If cyst ruptures - no treatment . 2) If this does not occur Marsupialization.

ODONTOGENIC KERATOCYST
INTRODUCTION
Termed by philipsen (1956) Very well defined histologic criteria One clinical feature warranting its recognition and separation as a distinctive entity is its high rate of recurrence (5- 62% Neville)

CLINICAL FEATURES:
           

Frequency Age Gender Race Site

: : : : :

1% among all types of jaw cysts 2nd and 3rd decades of life Male > Females White > Black Mandible > Maxilla 50% cases occur at angle of mouth

PRESENTATION: INITIAL STAGES - No signs / Symptoms LARGER LESIONS - Swelling of jaw, facial asymmetry, pain in jaw, mobility and displacement of teeth. Expansion of bone in Anteroposterior direction.

 Expansion  Maxillary Lesions - Palatal Cortical plate (1/3 Cases)  Mandibular Lesions - Buccal cortical Plate (50%)  - Lingual Cortical Plate (30%)  Extraosseous lesions may develop in relation to gingiva  Discharge present if secondarily infected.  Larger cysts affecting maxillary sinuses leads to displacement or destruction of floor of orbit and protrusion of eyeball.

NEVOID BASAL CELL CARCINOMA SYNDROME

BASAL CELL NEVUS BIFIDRIB SYNROME GORLIN AND GOLTZ SYNDROME MULTIPLE JAW CYST SYNDROME Given by Binkley and Johnson (1951) Hereditary disease Autosomal dominant trait Mutiple Basal cell epitheliomas Multiple Basal Cell nevi. Multiple odontogenic keratocyst ofjaws Bifid ribs Ocular hypertelorism Frontal bossing CNS disturbances etc. hypogonadism in males Ovarian tumours

50% cases show multiple cyst formation

Radiological features Multilocular Radiolucent areas  Soap Bubble appearance  Crosses mandibular midline oftenly  Smooth / scalloped border  Displacement of unerupted teeth  Expansion and distortion of cortical plates
Types Replacement

Collateral

ODONTOGENIC KERATOCYST

Envelopmental

Extraneous
1. 2. 3. 4. Replacement type Envelopmental type Extraneous type Collateral type Cyst develops in place of developing normal tooth Entirely enclosing impacted tooth with in the bone. Develops away from tooth bearing areas of jaw Between Roots of a tooth.

Cystic Fluid
- Straw colored fluid contains soluble protein less than 3.5 gm / 100 ml. - Explained by Taller - Through electrophonetic studies - Due to altered degree of keratinisation. Increased Permeability of lining. - Results in mobility of soluble proteins.

Histopathology

Corrugated epithelial lining Cystic cavity lined by keratinized stratified odontogenic epithelium 6-8 cell 19 years thickness. thickness.

Basal layer Tall columnar cells/ cuboidal cells palisade arrangement.

Diffuse Chronic inflammatory cells

           

Differential Diagnosis - Ameloblastoma - Dentigerous cyst - Aneurysmal bone eyst - Odontogenic Myxoma - Stafne bone cyst. - Lateral periodontal cyst Treatment - Surgical enucleation - Marsupialization - Excise overlying oral epithelium - Repeated recurrence - Jaw resection

        

Prognosis RECURRENCE RATE IS VERY HIGH (5% to 62% - Neville) Possible Reasons: - Retained fragments of thin, delicate cystic lining - Penetration of the original cortex eventually, also the thin shell of new subperiosteal bone. - Spillage of its contents - Satellite cysts arising from epithelial residues.

DENTIGEROUS CYST
         

Follicular Cyst Coined by Paget (1963) Definition: Cyst enclosing crown of unerupted tooth by expansion of its follicle, attached to the neck Clinical Features Frequency : 20-25% Age : Third and forth decades Gender : Male : Female :: 1.6:1 (Brown et al) Race : White > Black Site : Mand 3rd Molar > Max . Canine >Mand. Premolar > Max 3rd molar

        

Presentation May grow large before diagnosis Slowly enlarging swelling associated with missing teeth / tooth failed to erupt Painful if infected. Lesions 4-5 cms in 3-4 years . Radiological features Unilocular Radiolucent Associated with crowns of unerupted teeth. Well defined sclerotic margins unless infected
Types Central

Dentigerous cyst

Lateral Circumferential

        

Presentation May grow large before diagnosis Slowly enlarging swelling associated with missing teeth / tooth failed to erupt Painful if infected. Lesions 4-5 cms in 3-4 years . Radiological features Unilocular Radiolucent Associated with crowns of unerupted teeth. Well defined sclerotic margins unless infected
Types Central

Dentigerous cyst

Lateral Circumferential

Dental Lamina Cyst of newborn:

   

     

Gingival cyst of Newborn Epstein pearls Bohn's Nodules Definition : Multiple, occasionally solitary nodules on alveolar ridge of new born / very young infants, Representing cyst originating from remnants of dental lamina. - Epstein Pearls : Cystic Keratin filled nodules. Along midline raphe Derived from entrapped epithelial remnants along line of fusion. - Bohn's Nodules Keratin filled cysts scattered over palate Numerous along junction of hard and soft palate Derived from palatal salivary gland structures.

              

CLINICAL FEATURES - Obvious small discrete white swelling of alveolar ridge - Blanched Internal pressure - Asymptomatic - No discomfort Histologic Features - True cyst with a thin epithelial lining. - Lumen filled with desquamated keratin. - Inflammatory cells present - Dystrophic calcification found - Hyaline bodies of Rushton found Treatment - No treatment required - Lesions disappear By Opening into surface Disruption by erupting teeth

Gingival cyst of Adult

 

Uncommon cyst of gingiva Etiology and pathogenesis - Heterscopic glandular tissue. - Degenerative changes in proliferating epithelial retepeg. - Remnants of dental lamina, enamel organ or epithelial islands of periodontal membrane. - Traumatic implantation of epithelium. Clinical features Frequency : 0.5% Age : adults over 40 years Location : Bicuspidcuspid incisor area (Mandibular) Representation : Small, well circumscribed painless swelling of gingiva. Color : Same as of normal mucosa Size : Less than 1 cm in diameter may occur in free, attached or interdental gingiva.

           

Histological Features : True cyst Stratified squamous epithelial lining In lumen fluid present Glycogen rich clear cells present. Radiological Features Soft tissue lesion No Radiographic Manifestation Differential Diagnosis - Mucocele - Local periodontal cyst Treatment - Local surgical excision Prognosis - Lesions do not recur.

LATERAL PERIODONTAL CYST

INTRODUCTION This designation is confined to those cysts which occur in the lateral periodontal position and in which an inflammatory etiology and a diagnosis of collateral keratocyst have been excluded
(Shear and Pindborg 1975).

PATHOGENESIS Arise from reduced enamel epithelium, remnants of dental lamina and cell rests of Malassez

CLINICAL FEATURES
Frequency Age Sex Site 0.7% (Mervyn Shear 1989) 1989) 5th to 7th decade Male > Female Mandibular premolar area. area.

Clinical presentation
(a) Asymptomatic and discovered during radiographic examination. (b) When on labial surface of roots, slight mass obvious, although mucosa is normal. (c) Tooth is vital. (d) If infected, it may resemble lateral periodontal abscess. 2

RADIOLOGICAL FEATURES
Well circumscribed radiolucent area lateral to root of vital tooth. Most cysts < 1 cm diameter. When polycystic, known as botryoid odontogenic cyst.

HISTOPATHOLOGICAL FEATURES
- Hollow sac with connective tissue wall lined on inner surface by stratified squamous epithelium which is single to several cells thick. - Foci of glycogen rich clear cells in epithelial cells.

-Focal nodular thickenings of lining epithelium composed chiefly of clear cells. - Fibrous wall contains clear cell epithelial rests

DIFFERENTIAL DIAGNOSIS
Lateral periodontal abscess/granuloma Radicular cyst Lateral dentigerous cyst Collateral type of primordial cyst

TREATMENT AND PROGNOSIS

- Conservative enucleation without damaging the associated tooth. - Recurrence unusual except in botryoid variant since of polycystic nature.

CALCIFYING ODONTOGENIC CYST (Gorlin Cyst)

INTRODUCTION
-Uncommon epithelial lesion characterized by unusual keratin production and dystrophic calcification. -First described by Gorlin in 1962, who drew attention to an entity that they described as Calcifying odontogenic cyst likening it to the calcifying epithelioma of Malherbe.

CLASSIFICATION - by Praetorious and co-workers

Type I A Simple unicystic type Type I B Odontome producing type Type IC Ameloblastomatous proliferating type II Neoplasm like lesion

PATHOGENESIS
Develops from reduced enamel epithelial cells or remnants of odontogenic epithelium in dental follicle,gingiva or bone

CLINICAL FEATURES
Age Sex Race Site 2nd decade Male = Female No predilection equal frequency in maxilla and mandible Common in incisor and canine areas.

Clinical presentation
(a) Mostly asymptomatic. (b) Swelling is the most frequent complaint. (c) Rarely painful (d) Intraosseous lesions may produce a hard bony expansion, may perforate cortex and extend into soft tissue.

RADIOLOGICAL FEATURES
(a)Intraosseous lesions appear as radiolucent area with well defined margins.

(b)Irregular calcifications seen in radiolucent area. (c) Root resorption of adjacent teeth is seen

HISTOPATHOLOGICAL FEATURES
Well-defined cystic lesion with fibrous capsule and a lining of odontogenic epithelium

1 Odontogenic epithelium
a) 4-10 cells thick. Basal cells may be cuboidal / columnar.
Ghost cells

(c) Overlying layer of loosely arranged epithelium resembles stellate reticulum of ameloblastoma (d) Characteristic feature - "ghost cells" within epithelial component. (e) Calcified tissues in epithelial cells. Consist of ameloblastoma - like strands and islands of odontogenic epithelium Infiltrating into mature connective tissue

2 Connective tissue -

3. Capsule-

Ameloblastoma - like proliferations in connective tissue of fibrous capsule and lumen of cyst Ghost cells and varying amount of dentinoid in contact with odontogenic epithelium.

TREATMENT AND PROGNOSIS

 Surgical enucleation because of propensity for continued growth.  Lack of recurrence dependent upon completeness of excision.  Carcinomatous transformation into squamous cell carcinoma has been recorded.

GLANDULAR ODONTOGENIC CYST (Sialo - odontogenic cyst)

The term most descriptive of the lesion is mucoepidermoid odontogenic cyst because of presence of both secretory elements and stratified squamous epithelium.

CLINICAL FEATURES
- Age - Site Middle aged adults with a mean age of 49 yrs. Mandibular anterior region.

Clinical Presentation (a) Small cysts asymptomatic (b) Large cysts produce clinical expansion, sometimes associated with pain or paresthesia.

RADIOLOGICAL FEATURES

(a) Unilocular or commonly multilocular radiolucency. (b) Margins well defined with a sclerotic rim.

HISTOPATHOLOGICAL FEATURES
(a) Squamous epithelium of varying thickness. (b) Interface between epithelium and fibrous connective tissue wall is flat. (c) Fibrous cyst wall devoid of inflammatory infiltrate. (d) Superficial epithelial cells are columnar / cuboidal, occasionally with cilia and epithelium has glandular/ pseudoglandular structure with

intraepithelial crypts or microcysts or pools lined by cells similar to those on surface.

Squamous epithelium with cilia Microcyst

(a) Enucleation or curettage have been commonly done. (b) Because of its propensity for recurrence and aggressive nature, some authors advocate enbloc resection.

TREATMENT AND PROGNOSIS

INFLAMMATORY CYSTS
PERIAPICAL CYST (RADICULAR CYST; APICAL PERIODONTAL CYST)
Epithelium at apex of a non vital tooth can be presumably stimulated by inflammation to form a true epithelium-lined cyst or periapical cysts. epitheliumcysts.

INTRODUCTION

PATHOGENESIS Occurs in several phases: - Phase of initiation

Pulpal inflammation of nonvital tooth reaches to periapical region and stimulates epithelial cell rests of Malassez present there.

Phase of proliferation

Stimulation to cell rests of Malassez leads to excessive and exuberant proliferation of these cells, which leads to formation of a large mass .

Phase of cystification. cystification.

The centrally located cells become necrosed due to lack of nutritional supply giving rise to cyst-like cyststructure, that contains hollow space inside and peripheral lining of epithelial cells around it.

Phase of enlargement
Small cyst formed enlarges by higher osmotic and hydrostatic tension and through bone resorbing factor

CLINICAL FEATURES
60% - 70% 3rd to 5th decades Males > Females Whites > Blacks Maxilla> Mandible (60%) (40%) Predilection for maxillary anterior region. Frequency Age Sex Race Site -

Mostly asymptomatic and discovered on roentgenographic examination of nonvital teeth. (b) At first enlargement is bony hard but fluctuation results from complete erosion of bone. (c) In maxillary buccal or palatal enlargement occurs. In mandible buccal enlargement is common. (d) Pain and infection may be present.

(a)

Clinical presentation

Swelling

RADIOLOGICAL FEATURES (a) Round ./ ovoid radiolucency surrounded by a narrow radiopaque margin which extends from lamina dura of involved tooth is seen at apex. (b) Root resorption is common

HISTOPATHOLOGICAL FEATURES
(a) Stratified squamous epithelium which may demonstrate Rushton bodies. (b) Lumen filled with fluid and cellular debris. Dystrophic calcification, cholesterol clefts with multinucleated giant cells, RBCs and areas of hemosiderin pigmentation may be present in lumen wall or both. (c) Wall consists of dense fibrous connective tissue, often with inflammatory infiltrate containing lymphocytes, neutrophils. plasma cells, histiocytes and (rarely) mast cells and eosinophils.

DIFFERENTIALDIAGNOSIS
Periapical granuloma Periapical abscess Cementoma (stageI) Traumatic bone cyst Bony artifact

TREATMENT AND PROGNOSIS

(a) Extraction and curettage. (b) Root canal therapy with apicoectomy of involved tooth. (c) Residual cysts may develop later. (d) Epidermoid carcinoma develops from lining epithelium.

RESIDUAL PERIAPICAL CYST

INTRODUCTION
When a radicular cyst remains behind in the jaws after removal of offending tooth , it is referred to as residual cyst.

ETIOLOGY
- Develops upon either a deciduous tooth / retained root that later exfoliates or is extracted. - Tooth associated with dentigerous cyst is removed but cyst is unrecognized, the residual cyst will persist and increase in size.

- Incomplete removal of periapical cyst / granuloma

CLINICAL FEATURES
Incidence - less common than radicular cyst. (Daniel E. Waite) Age - middle aged / elderly Sex - Equal Site - Maxilla > Mandible

Clinical presentation
- Present in edentulous area. - Majority asymptomatic . - Found on routine radiographic examination.

- Pathologic fracture or encroachment on associated structures.

RADIOLOGICAL FEATURES
- Round to oval radiolucency of variable size within alveolar ridge at site of a previous tooth extraction. - As the cyst ages, dystrophic calcification and central luminal radiopacity results from degeneration of luminal cellular contents.

TREATMENT
- Same as for apical cyst but preserve contour of edentulous ridge.

BUCCAL BIFURCATION CYST

INTRODUCTION
It is an uncommon inflammatory cyst that characteristically develops on buccal aspect of mandibular first permanent molar.

PATHOGENESIS
When tooth erupts, an inflammatory response may occur in surrounding follicular tissues that stimulate cyst formation.

CLINICAL FEATURES Age Children from 5-11 yrs

Clinical presentation
(a) Slight to moderate tenderness on buccal aspect of erupting mandibular first molar. (b) Clinical swelling and a foul tasting discharge present. (c) Periodontal probing reveals pocket formation on buccal aspect.

RADIOLOGICAL FEATURES
Well circumscribed unilocular radiolucency involving buccal bifurcation and root area of involved tooth.

1.2 2.5 cm in diameter. Occlusal radiograph is helpful. Root apices of molar are tipped towards the lingual mandibular cortex. Many cases associated with proliferative periosteitis of overlying buccal cortex.

HISTOPATHOLOGICAL FEATURES
Non-specific Lined by nonkeratinizing stratified squamous epithelium with areas of hyperplasia. A prominent chronic inflammatory cell infiltrate in connective tissue wall.

TREATMENT AND PROGNOSIS (a)

(b) Usually enucleation ; extraction unnecessary. Complete healing with in 1 year.