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Odontogenic Cysts

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					Odontogenic Cysts
       1. Periapical (radicular)
       2. Residual
       3. Dentigerous
       4. Eruption
       5. Gingival: adult and newborn
       6. Lateral periodontal and Botryoid
       7. Glandular odontogenic
       8. Odontogenic Keratocyst(OKC)
       9. Calcifying Odontogenic Cyst(COC)
       10. Paradental

2.Radicular Cyst

  1.   An odontogenic cyst of inflammatory origin
  2.   That is preceded by a chronic periapical granuloma and
  3.   Stimulation of epithelial rests of Malassez
  4.   present in the periodontal membrane

Radiographic Feature of Radicular Cyst

  1.   rounded,
  2.   well-circumscribed radiolucency
  3.   At the apex of a non-vital tooth
  4.   Often with a distinct thin line of cortication
  5.   globulomaxillary radiolucency
  6.    If occurring in the apical region of a lateral anterior maxillary
       incisor tooth

Differential Diagnosis:

  1.   periapical granuloma
  2.   periapical scar
  3.   traumatic bone cyst
  4.   radicular cyst
  5.   periapical cemento-osseous dysplasia

Histologic Features of Radicular Cyst

                                                                            1
   1. cholesterol clefts (left by fatty material)
   2. Rushton bodies (eosinophilic structures)
   3. chronic inflammatory cells (plasma cells, lymphocytes,
      macrophages)
   4. Necrotic debris
   5. Stratified squamous epithelial lining

Treatment:

   1. enucleation after extraction or
   2. endodontic treatment

2. Residual Cyst

A cyst that remains at the site of a previously extracted tooth

Residual Cyst Differential Diagnosis:

   1.   hemangioma
   2.   unicystic ameloblastoma
   3.   adenomatoid odontogenic tumor
   4.   Langerhans cell histiocytosis
   5.   neurilemmoma

Treatment of Residual Cyst:
excision


3.Dentigerous Cyst (Follicular Cyst)

   1. Most common developmental odontogenic cyst (20% of all jaw
      cysts)
   2. Develops due to an accumulation of fluid between the crown of
      the tooth and reduced enamel epithelium (follicle),
   3. with the reduced enamel epithelium eventually forming the
      epithelial lining of cyst.
   4. Increase in size due to increased osmolarity as result of
      passage of inflammatory cells and
   5. desquamated epithelial cells into cyst lumen results in
      centrifugal growth of cyst (slow process)



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Clinical/Radiographic Signs

  1. Dentigerous Cyst associated with crown of unerupted tooth as
     a radiolucency
  2. Most lesions present in 2nd and 3rd decades
  3. 3:2 male predilection
  4. Asymptomatic May produce swelling or resorption of adjacent
     tooth root



Most common site

  1. maxillary and mandibular third molar region and
  2. maxillary canine region,
  3. corresponding to most frequently impacted teeth

Radiologically appears as,

  1. Well defined radiolucency,
  2. unilocular
  3. associated with crown of an impacted tooth

Histology of Dentigerous Cyst

  1. Fibrous connective tissue wall
  2. lined by uniformly thin layer
  3. of non-keratinized stratified squamous epithelium
  4. 2-4 cells thick
  5. Epithelial-Connective tissue interface usually flat
  6. 5% have scattered mucous cells in the cyst lining
  7. Islands of odontogenic epithelium are often found
  8. May be secondarily inflammed and thickened epithelial layer
  9. Should hitologically rule out OKC
  10.      Ameloblastoma, 15-20% develop in dentigerous cysts,
  11.       may occur as early as 5 years old
  12.      Mucoepidermoid carcinoma Squamous Cell carcinoma
     (2nd-3rd decade) CEOT

Treatment of Dentigerous Cyst



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  1. Extraction of tooth and
  2. enucleation of cyst

4. Eruption Cyst

  1. Soft tissue counterpart to dentigerous cyst
  2. Separation of dental follicle from the crown of an erupting tooth
     that is within soft tissue of alveolus



Clinical Signs Eruption Cyst

  1.   Soft translucent swelling in gingival mucosa
  2.   Usually in children, 10yrs
  3.   Most commonly seen in mandibular molar region
  4.   Surface trauma may cause collection of blood within cyst
       "eruption hematoma"

Histology Eruption Cyst

  1. Seldom submitted for analysis
  2. Variable inflammatory infiltrate
  3. Thin layer non-keratinized squamous epithelium

Treatment Eruption Cyst

  1. Usually none indicated,
  2. Will rupture independently If not,
  3. Simple excision of roof permits eruption of tooth

5. Lateral Periodontal Cyst:

  1.   A slow-growing,
  2.   non-expansile developmental odontogenic cyst
  3.   derived from one or more rests of the dental lamina,
  4.   containing an embryonic lining of 1 to 3 cuboidal cells and
  5.   distinctive focal thickenings (plaques).

Clinical Features lateral Periodontal Cyst:



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     1.   50-70 years of age
     2.   caucasian male predilection
     3.   most often in mandibulr premolar canine lateral incisor area
     4.   slow growing
     5.   non-expansile
     6.   most often asymptomatic

Histologic Features:

1.   1-5 squamous cuboidal cell thick
2.   clear cells filled with glycogen
3.   peripheral zone of hyalinization
4.   lack of inflammatory cells
5.   weak adherence to the surrounding connective tissue

Differential Diagnosis Lateral Periodontal Cyst:

     1.   mental foramen
     2.   lateral periodontal cyst
     3.   periapical abscess
     4.   maxillary sinus shadow
     5.   cyst of pulpal origin
     6.   glandular odontogenic cyst

Botryoid Odontogenic Cyst:

     1. A type of lateral periodontal cyst that
     2. shows a multilocular growth pattern.

Treatment of Lateral Periodontal Cyst:

curettage or enucleation

7.Gingival Cyst of the Adult

     1. A small developmental odontogenic cyst of the gingival soft
        tissue
     2. derived from the rests of the dental lamina,
     3. containing a lining of embryonic epithelium of cuboidal cells and
     4. distinctive focal thickenings similar to the lateral periodontal
        cyst.

                                                                         5
Clinical Features Gingival cyst of adult:

   1.   5th and 6th decades of life
   2.   uncommon
   3.   asymptomatic
   4.   firm, compressible
   5.   usually less than 0.5 cm
   6.   dome-like swelling often bluish or blue-gray filled with fluid
   7.   facial gingiva or alveolar mucosa
   8.   mandibular canine-premolar area

Histologic Features gingival cyst of adult:

   1. lined by thin epithelium,
   2. 2 to 5 cells thick
   3. may have plaques that contain clear cells both in the epithelium
      and connective tissue

Differential Diagnosis gingival cyst of adult:

   1.   parulis
   2.   pyogenic granuloma
   3.   peripheral ossifying fibroma
   4.   peripheral giant cell granuloma
   5.   irritation fibroma
   6.   peripheral ameloblastoma
   7.   traumatic neuroma


8. Gingival Cyst of Newborn

Small superficial Keratin filled cyst

found on alveolar mucosa

Arises from remnants of dental lamina

Seldom noticed due to spontaneous rupture into oral cavity

Clinical Signs Gingival Cyst of Newborn



                                                                         6
  1.   Small,
  2.   multiple whitish papules
  3.   overlying alveolar process in newborn
  4.   Smaller than 2mm diameter Maxilla more common

Treatment Gingival Cyst of Newborn
Not indicated

9.Glandular Odontogenic Cyst

  1.   Originally described by Gardner, 1988
  2.   38 reported cases
  3.   Replaced terms mucoepidermoid odontogenic cyst
  4.   and sialo-odontogenic cyst

Clinical/Radiographic Signs Glandular Odontogenic Cyst

  1.   Slight male predilection, 55.3%
  2.   Mandible 87.2%,
  3.   anterior mandible 79.4%
  4.   Age range 14-90 yrs,
  5.   mean 49.5
  6.   Well defined
  7.   uni- or multilocular radiolucency
  8.   May have bony expansion,
  9.   slow growing

Histology Glandular Odontogenic Cyst

  1.   Squamous epithelial lining of varying thickness
  2.   Interface between epithelium and connective tissue are flat
  3.   Without inflammatory infiltrate
  4.   Cuboidal cells line the cavity,
  5.   may or may not have cilia
  6.   Mucous cells may be present
  7.   Some histopathological overlap with intraosseous low-grade
       mucoepidermoid carcinoma

Treatment Glandular Odontogenic Cyst



                                                                     7
  1.   Curettage,
  2.   with good follow up
  3.   0f cases reported with adequate follow up
  4.   6 (25%) recurred range for 24-84 months


Odontogenic Keratocyst (OKC)

  1.   Behaves in more aggressive fashion compared to others
  2.   Associated with nevoid basal cell carcinoma syndrome
  3.   Thought to arise from cell rests of dental lamina
  4.   Growth thought to be due to enzymatic activity in fibrous wall or
  5.   unknown factors in epithelium

Clinical/Radiographic Signs OKC

  1. Slight male predilection 3:2
  2. Rarely seen under 10 years old
  3. Peak incidence in 2nd-3rd decade,
  4. with declining incidence in subsequent years
  5. 2:1 mandible predilection over maxilla
  6. Mandibular lesions posterior mandible/ramus,
  7. while maxillary lesions in 3rd molar region or canine region
  8. OKC May be seen in dentigerous cyst location, lateral
     periodontal cyst location
  9. Usually asymptomatic, although larger ones may produce
     swelling or pain

Radiologically :

       1. Majority present as unilocular radiolucencies with well-
          demarcated margins,
       2. thin sclerotic border 20% exhibit multilocular,
       3. expansile radiolucent appearance,
       4. usually related to the size of the lesion 40% adjacent to
          impacted tooth

Histology of OKCÝ

  1. Three criteria Palisaded basal cell layer
  2. Corrugated surface layer of parakeratin 85-95%

                                                                       8
  3.   Uniformly thin epithelial lining (stratified squamous)
  4.   8-10 cells thick
  5.   No rete ridges
  6.   Connective tissue wall usually uninflammed,
  7.   but inflammation is present,
  8.   will markedly alter histology or epithelium
  9.   May be presence of multiple small satellite "daughter" cysts


Treatment of OKC

  1. Depends on size of lesion
  2. Smaller lesion attempt to enucleate in one piece
  3. Larger lesion marsupialize follow by enucleation with peripheral
     ostectomy

Prognosis

  1. GUARDED Reported recurrence rate from 3-62%
  2. 40-50% recurrence
  3. 5 yr minimum follow up
  4. Patient should be followed for at least 7 years post surgery to
     detect recurrence
  5. 7% of Patients with OKCís have nevoid basal cell syndrome

Nevoid Basal Cell Carcinoma Syndrome (Gorlin Syndrome)

  1.   Complex Syndrome
  2.   exhibiting many associated anomalies
  3.   related to skin, CNS, and skeletal system
  4.   Autosomal Dominant

Clinical/ Radiographic Signs Nevoid Basal Cell Ca Syndrome

       1. Medulloblastoma /Meningioma
       2.  Bridged Sella (68%)
       3. Calcified Falx Cerebri (65%)
       4. Fronto/Tempo/Parietal Bossing (27%)
       5. Basal Cell Carcinomas (Multiple, can occur in unexposed
          and exposed skin)
       6. Ocular Hypertelorism (42%)

                                                                       9
       7. Cleft Lip and Palate
       8. Mandibular Prognathism
       9. Multiple Odontogenic Keratocysts (74%)
       10. Kyphoscoliosis(50%)
       11. Bifid Rib (26%)
       12. Palmar/Plantar Pitting (87%)
       13. Shortened Fourth Metacarpals (20%)
       14. Ovarian Fibromas (17%)
       15. Hypogonadism

Treatment Basal Cell Ca Syndrome

  1.   Genetic Counseling
  2.   Treat OKCís as needed
  3.   Remove basal cell ca as needed
  4.   Patient should use sunscreen to lower risk of basal cell ca

Calcifying Odontogenic Cyst(COC) (Gorlinís Cyst)

  1. Described as being either cystic of a more solid neoplastic
     proliferation
  2. Thought to arise from odontogenic epithelial remnants within
     the jaws

Clinical/Radiographic Signs of COC

  1.   No sex predilection
  2.   Equal distribution mandible/maxilla
  3.   Occur at any age;
  4.   Peak in 2nd decade
  5.   "Anytime, Anywhere" Asymptomatic
  6.   Salt/Pepper calcifications with equal and diffuse distribution

Radiologically COCÝ :

  1.   30% associated with Impacted tooth
  2.   Resorption of roots seen in 80%
  3.   Usually unilocular,
  4.   well demarcated margins



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Histology COCÝ :

  1. Fibrous connective tissue wall surrounding lumen
  2. lined by odontogenic epithelium
  3. In more solid lesions significant intraluminal epithelial
     proliferation
  4. obscures cyst lumen Lining similar to ameloblastoma
  5. Most unique feature "Ghost cells"-pale, eosinophilic basal
     cells with swollen cytoplasm, loss of nucleus

Treatment COCÝ

  1. Enucleation
  2. Recurrence rare




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