Cyst Of Jaw

Cysts Of The Oral AndMaxillofacial Region

• Defination• Types Of Cysts• Parts Of A Cyst• Classification Of Jaw Cysts• Clinical, Radiological, Histological Features And

Differential Diagnosis Of Important Jaw Cysts.

OVERVIEW

• A Cyst is a pathological cavity having fluid, semifluid or gaseous contents and which is not created by the accumulation of pus. Most cysts, but not all, are lined by epithelium. (KRAMER 1974).

DEFINATION OF CYST

• TRUE CYSTS: that which is lined by epithelium e.g dentigerous cyst, radicular cyst etc.

• PSEUDO CYSTS: not lined by epithelium, e.g. Solitary bone cyst, Aneurismal bone cyst etc

TYPES OF CYSTS

Cyst has following parts:

• WALL (made of connective tissue)

• EPITHELIAL LINING• LUMEN OF CYST

PARTS OF A CYST

CLASSIFICATION

1 Developmental Origin(a) Odontogenic

i. Gingival cyst of infants

ii. Odontogenic keratocyst

iii. Dentigerous cyst

iv. Eruption cyst

v. Gingival cyst of adults

vi. Developmental lateral periodontal cyst

vii. Botryoid odontogenic cyst

viii. Glandular odontogenic cyst

ix. Calcifying odontogenic cyst

I. CYSTS OF THE JAWS

A. EPITHELIAL-LINED CYSTS

b) Non-odontogenic

i. Midpalatal raphé cyst of infants

ii. Nasopalatine duct cyst

iii. Nasolabial cyst

2 INFLAMMATORY ORIGINi. Radicular cyst, apical and lateral

ii. Residual cyst

iii. Paradental cyst and juvenile paradental cyst

iv. Inflammatory collateral cyst

B. NON-EPITHELIAL-LINED CYSTS1. Solitary bone cyst

2. Aneurysmal bone cyst

I. CYSTS OF THE JAWS

1. Mucocele2. Retention cyst3. Pseudocyst4. Postoperative maxillary cyst

II. CYSTS ASSOCIATED WITH THE MAXILLARY ANTRUM

1. Dermoid and epidermoid cysts

2. Lymphoepithelial (branchial) cyst

3. Thyroglossal duct cyst

4. Anterior median lingual cyst (intralingual cyst of foregut origin)

5. Oral cysts with gastric or intestinal epithelium (oral alimentary tract cyst)

6. Cystic hygroma

7. Nasopharyngeal cyst

8. Thymic cyst

9. Cysts of the salivary glands: mucous extravasation cyst; mucous retention cyst; ranula; polycystic (dysgenetic) disease of the parotid

10. Parasitic cysts: hydatid cyst; Cysticercus cellulosae; trichinosis

III. CYSTS OF THE SOFT TISSUES OF THE MOUTH, FACE AND NECK

TWO STAGES

1. Cyst initiation2. Cyst enlargement or expansion

PATHOGENESIS

a. Initiation b. Formationc. Enlargement

• Initiation results in the proliferation of the epithelial cells and the formation of small cavity.

a. Cell Rests of Malassez : Remanants of Hertwigs epithelial root sheath in the PDL after the root formation is completed.

b. Reduced Enamel Epithelium :Residual epithelial cells surrounds the crown of the tooth after enamel formation is complete.

c. Cell Rests of Serres (Dental Lamina) :Islands of epithelial cells that originate from the oral epithelium and remain in the tissue after inducing tooth development.

CYST INITIATION

THEORY

Harris (1974) Postulated the theories

1) Mural growth a) Peripheral cell division b) Accumulated contents

2) Hydrostatic a) Secretion b) Transuduation & exudation c) Dialysis

CYST ENLARGEMENT

1. Increase in the volume of its contents.2. Increase in the surface area of the sac or epithelial

proliferation.3. Resorption of surrounding bones.

MECHANISM REGARDING ENLARGEMENT

FACTORS

1. Secretions:Mucus secreting cyst – Lining secretes mucus – accumulation of mucus – increase in volume

2. Transudation & exudation: Inflammatory cyst or Presence of infection.

a. Inflammatory cells release cofactors

b. Lymphocytes release lymphokine

c. Osteoclast activating factor (OAF) &

d. Monocytes release interleukin- I

3. Increased osmolarity:a. Raises internal hydrostatic pressure.b. Attracts fluid into the cavity.c. Retention of fluid within the cavity

INCREASE IN THE VOLUME

• Toller suggested the role of osmolarity by the cyst fluid in enlargement of cyst. The Mean Osmolarity was 296 mosmol compared with Serum Osmolarity of 282 mosmol.

• The increase in the osmotic pressure is related to proteins present in the cyst fluid such as large molecules of albumin, globulin, fibrinogen.

• Desquamated epithelial cells of cyst lining undergo autolysis & produce a larger number of molecules of lower molecular weight, raising the osmolarity of the fluid.

RAISED INTERNAL HYDROSTATIC PRESSURE

• DIALYSIS : It results from the higher osmolarity of cyst fluid than serum.

• OSMOTIC PRESSURE : It’s related to the number of dissolved particles in a solution.

• OSMOLARITY : It’s the number of these dissolved particles.

• Fluid is attracted into the cyst cavity by products of epithelial cell autolysis.

• Water from the tissue fluid (surrounding tissue) is attracted into the cyst to raise the internal pressure.

• This hydrostatic pressure is transmitted to the adjacent bone.

ATTRACTION OF FLUID INTO THE CAVITY

• Semi permeable membrane – governs access into the cyst prevents the escape of certain

substances from the contents.

• Attracted fluid are unable to diffuse out of the cavity.

• The products of epithelial autolysis could effect both osmotic attraction and retention within the cavity.

RETENTION OF FLUID WITHIN THE CAVITY

Mural growth 1) Peripheral cell division 2) Accumulated contents

• Presence of low grade infection -- stimulate cells – cell rests of Malassez – to proliferate and form arcades of epithelium.

• Collagenase activity – increased collagenolysis – in primordial & radicular cyst.

• Proliferation of local group of epithelial cells – as in keratocysts

• Unremitting growth – epithelial lining in keratocysts due to high mitotic value.

EPITHELIAL PROLIFERATION

• Increased internal pressure – transmitted to the adjacent bone – bone undergoes resorption – bony cavity enlarged.

• Due to the above changes, the surface area of cyst lining is increased by cell multiplication.

• Epithelial cells divide – cyst enlarges within bony cavity by the release of bone resorbing factors from the capsule.

• Stimulate osteoclast function – eg: prostaglandins like PGE2 & PGI2.

BONE RESORPTION

52.30%

18.10%

11.60%

8.00%

5.60%

4.20% SHEAR 2006Radicular cyst

Dentigerous cyst

Odontogenic keratocyst

Residual cyst

Paradental cyst

Unclassified odontogenic cysts

FREQUENCY OF EPITHELIAL CYSTS OF JAWS

DENTIGEROUS CYST

• The dentigerous cyst is defined as a cyst that originatesby the separat ion of the follicle from around the

crownof an unerupted tooth

• The dentigerous cyst encloses the crown of an unerupted tooth and is attached to the tooth at the cementoenamel junction

• The pathogenesis of this cyst is uncertain, but apparently it develops by accumulation of fluid between the reduced enamel epithelium and the tooth crown.

Click icon to add picture

Gross specimen of a dentigerous cyst. Cyst encloses the crown of the tooth and is attached to its neck

DENTIGEROUS CYST

AGE : 1st to 3rd decades.

GENDER : more frequently in males than in females.

SITE : • 2/3rd of follicular cyst associated with unerupted mandibular

teeth, primarily III molar.• Maxillary canine• Mandibular premolar• Maxillary 3rd Molar• Supernumerary tooth also can be involved

CLINICAL FEATURES

• Most cysts grow to a large size before being discovered accidentally while observing a dental x ray to detect the cause of an unerupted tooth.

• Large lesions can cause cortical expansion, leading to facial asymmetry, teeth displacement, root resorption, even pain, if infected.

SIGNS & SYMPTOMS

• Manifests as unilocular, well defined, ‘lucency with sclerotic margins, associated with crown of impacted / unerupted tooth.

• A large DC may show persistence of boney trabeculae, giving the appearance of multilocularity.

RADIOLOGICAL FEATURES

• CENTRAL TYPE:

• LATERAL TYPE :

• CIRCUMFERENTIAL TYPE :



A central type of dentigerous cyst. Note resorption of the root of the first mandibular molar

RADIOGRAPHIC FEATURES


Radiograph of two dentigerous cysts in the same patient. The cyst on the right is a lateral type; that on the left is a circumferential type


CT scan of a maxillary dentigerous cyst extending to, and impinging on, the floor of the nose.


HISTOLOGICAL FEATURES

A. NON INFLAMMED TYPE:

• Lining derived from reduced dental epithelium, consists of 2-4 cell layers of non keratinized epithelium, without rete ridges.

• Wall composed of thin fibrous connective tissue appearing immature, as it is derived from the dental papilla.

NON INFLAMED dentigerous cyst shows a thin. nonkerat inized epithelial lining.

NON INFLAMMED TYPE


A. INFLAMED TYPE :

• Lining shows varying degrees of hyperplasia with rete ridges and occasionally even keratinization.

• Wall is composed of mature connective tissue which shows infiltration by chronic inflammatory cells.

• Focal areas of mucous cells can be seen in the lining. Small odontogenic epithelial islands can be seen in the wall.

INFLAMED DENTIGEROUS CYST shows a thicker epitheliallining with hyperplastic rete ridges. The fibrous cyst capsule shows a diffuse chronic inflammatory infiltrate

INFLAMED TYPE

DIFFERENTIAL DIAGNOSIS

Although it presents a unique feature, yet some lesions must be considered in its differential diagnosis :

1. Unicystic ameloblastoma2. Adenomatoid odontogenic tumor.

COMPLICATIONS

1. Recurrence due to incomplete surgical removal.

2. Development of ameloblastoma either from lining epithelium or from odontogenic islands in the connective tissue wall.

3. Development of squamous cell carcinoma from same two sources.

4. Development of mucoepidermoid carcinoma from mucus secreting cells in the lining.

ODONTOGENIC KERATOCYST

• The odontogenic keratocyst is a distinctive form of developmental odontogenic cyst that deserves special consideration because of its specific histopathologic features and clinical behavior.

• There is general agreement that the odontogenic keratocyst arises from cell rests of the dental lamina.

• This cyst shows a different growt h mechanism and biologic behavior from themore common dentigerous cyst and radicular cyst.

• odontogenic kerato cysts. and th eir growth may be related to unknown facto rs inherent in the epit helium itself or enzym atic activity in the fibrous wall.

• Several investigators suggest that odontogenic keratocysts be regarded as benign cystic neoplasms rather than cysts

AGE : occur over a wide age range and cases have been recorded as early as the first decade and as late as the ninth. In most series there has been a pronounced peak frequency in the second and third decades.

GENDER : more frequently in males than in females.SITE : The mandible is involved far more frequently than

the maxilla 50% cases occur in angle region and extend to ascending ramus and forwards to body of mandible.

CLINICAL FEATURES

Relative distribution ofodontogenic keratocysts in the jaws.

SITE DISTRIBUTION

• Pain, swelling or discharge.• Occasionally, paraesthesia of the lower lip or teeth. • Some are unaware of the lesions until they develop

pathological fractures.• In many instances, patients are remarkably free of

symptoms until the cysts have reached a large size, involving the maxillary sinus and the entire ascending ramus, including the condylar and coronoid processes.

• occurs because the OKC tends to extend in the medullary cavity and clinically observable expansion of the bone occurs late.

CLINICAL FEATURES

GORLIN-GOLTZ syndrome, characterized by

• Multiple nevoid basal cell epitheliomas• Odontogenic Keratocyst of the jaws• Bifid ribs– sixth rib• Plantar & palmar pits• Occular hypertelorism• Frontal bossing• Ectopic calcifications

• OKC demonstrate a well-defined radiolucent area with smooth and often corticated margins.

• Large lesions, particularly in the posterior body and ascending ramus of the mandible, may appear multilocular

• An unerupted tooth is involved in the lesion in 25% to 40% of cases; in such instances, the radiographic features suggest the diagnosis of dentigerous cyst


Radiograph of a small odontogenic keratocyst.


Radiograph of an odontogenic keratocyst with scallopedmargins.



Radiograph of a multilocular odontogenic keratocyst.


Radiograph of an odontogenic keratocyst that has enveloped an unerupted tooth to produce a ‘dentigerous’ appearance.


• The epithelial lin ing is composed of a uniform layer of stratified squamous epithelium,usually six to eight cells in thickness.

• The epithelium and connective tissue interface is usually flat, and rete ridge formation is inconspicuous.

• The basal cell layer has columnar / cuboidal cells with reversely polarized nuclei, imparting a “picket fence” or “tombstone” appearance.

• The luminal surface shows flattened parakeratotic epithelial cells, which exhibit a wavy or corrugated appearance.

• Small satellite cysts, cords, or islands of odontogenic epithelium may be seen within the fibrous wall .

HISTOLOGIC FEATURES

Epithelial lining is 6 to 8 cells thick, with a hyperchromatic and palisaded basal cell layer. Note the corrugated parakeratotic surface.

OKC

Satellite microcysts in the wall of an odontogenic keratocyst that appear to be arising directly from an active dental lamina.

SATELLITE MICROCYSTS


• In case of unilocular ‘lucencies – Dentigerous cyst, Eruption cyst, COC, AOT, Unicystic ameloblastoma etc.

• In case of multilocular ‘lucencies – Conventional ameloblastoma, CEOT, Central giant cell granuloma, Aneurysmal bone cyst etc.

• COMPLICATIONS IN OKC :

1. Malignant transformation of cyst lining rare, but has been reported.

2. Recurrence – high rate of recurrence.

• REASONS FOR RECURRENCE :

1. Thin, fragile lining is very difficult to remove completely.2. New cysts develop from satellite cysts left behind.3. Some cysts may be left behind in cases of Gorlin – Gotz

syndrome.4. New cysts can also develop from basal cells of overlying oral

epithelium, especially in ramus – 3rd molar region.

ERUPTION CYST

• Typical c/f of an eruption cyst. Note a bluish colored, dome shaped swelling over the unerupted molar.

• The dentigerous cyst develops around the crown of an unerupted tooth lying in the bone,

• The eruption cyst occurs when a tooth is impeded in its eruption within the soft tissues overlying the bone.

ERUPTION CYST

Eruption cysts involving the maxillary permanentincisors.

The circumscribed cavity contains blood (due to surface trauma on biting with opposite tooth )

It imparts purple / deep blue color

Hence known as

• ERUPTION HEMATOMA

PATHOGENESIS

CLINICAL FEATURES

AGE : found in children of different ages, and occasionallyin adults if there is delayed eruption

SITE : most commonly associated with the first permanentmolars and the maxillary incisors


• The cyst may throw a soft-tissue shadow, but there isusually no bone involvement except that the dilated andopen crypt may be seen on the radiograph.

• Show surface oral epithelium on the superior aspect. The underlying lamina propria shows a variable inflammatory cell infiltrate.

• The deep portion of the specimen, which represents the roof of the cyst, shows a thin layer at nonkeratinizing squamous epithelium


A cystic epithelial cavity can be seen below the mucosal surface.

GINGIVAL CYST OF ADULTS

PATHOGENESIS

• A number of suggestions have been made about thepathogenesis of the gingival cyst in adults.

• It was originallyproposed that they may arise from odontogenicepithelial cell rests; or by traumatic implantation ofsurface epithelium; or by cystic degeneration of deep projectionsof surface epithelium

ORIGIN

• Cystic transformation of dental lamina, traumatic implantation of surface epi

• Dome shaped soft, fluctuant swelling which is <1cm in diameter

• Lesion is slow growing and painless

• Adjacent teeth usually vital

Signs and symptoms:• Slowly enlarging, well

circumscribed painless swelling.

• Invariably occurs on facial aspect of free / attached gingiva.

• Surface of lesion is smooth and of normal color.

• Fluctuant lesion, adjacent teeth are vital

CLINICAL FEATURES

Clinical photograph of a gingival cyst of an adult

AGE : 5th – 6th decade of life

SITE : mand. canine and Pre Molar area; attached gingiva or I/D papilla

Radiograph of a gingival cyst in an adult. There is a faint radiographic shadow (marked with arrows) indicative of superficial bone erosion.


• H/p features identical to Lateral periodontal cyst.

• Some cysts lined by thin, flattened stratified squamous epithelium.

• Sometimes, focal thickenings (Plaques) may be found within the lining.

HISTOLOGY

The epithelial lining of a gingival cyst of the adult (G) lying contiguous to the junctional epithelium (J) of an adjacent tooth.

LATERAL PERIODONTAL CYST

• Uncommon, but well recognized type of odontogenic cyst.

• The designation ‘lateral periodontal cyst’ is confined to those cysts that occur in the lateral periodontal position and in which an inflammatory etiology and a diagnosis of collateral OKC have been excluded on clinical and histological grounds

(Shear and Pindborg, 1975).

LATERAL PERIODONTAL CYST

• Age : 20 – 60 years, peak in 6th decade.

• Sex : Male predilection.

• Site : Lateral PDL regions of mandibular premolars, followed by anterior maxilla

CLINICAL FEATURES

• Usually asymptomatic as it occurs on the lateral aspect of root of tooth.

• Occasionally pain and swelling may occur.

• Associated teeth are vital, unless otherwise affected.

• Cysts rarely < 1cm in size, except for BOTRYOID VARIETY which is larger and also a multilocular lesion.

SIGNS & SYMPTOMS

• Round to ovoid ‘lucency with sclerotic margins.

• Cyst can be present anywhere between cervical margin to root apex.

• Radiographically, it can be confused with collateral OKC.


Radiograph of a lateral periodontal cyst lying between the mandibular premolar teeth. The margins are well corticated, indicative of slow enlargement.


Lateral periodontal cyst. Radiolucent lesionbetween the roots of a vital mandibular canine and first premolar.

Lateral periodontal cyst. A larger lesion causingroot divergence.

• The lateral periodontal cysts were lined by a thin, non-keratinising layer of squamous or cuboidal epithelium usually ranging from 1 to 5 cell layers wide, which resembled the reduced enamel epithelium

• The epithelial cells were sometimes separated by intercellular fluid. Their nuclei were small and pyknotic.

• An interesting feature seen in many of the lateral periodontal cysts was the presence of what appear to be localised plaques or thickenings of the epithelial lining

• Small epithelial nests may be seen in connective tissue wall, which may show signs of mild inflammation.



Lateral periodontal cyst which in part has a thin, nonkeratinised stratified squamous epithelial lining resembling reduced enamel epithelium. Two epithelial plaques are seen. The one on the right is convoluted

Diagram illustrating the possible mode of formation of epithelial plaques by localised proliferation of cells. (a) Cyst lined by thin epithelium resembling reduced enamel epithelium. (b) Early epithelial thickening by basal cell proliferation. (c) Basal cells continue to proliferate. Superficial cells swell by accumulation of intracellular fluid. (d) and (e) Basal proliferation ceases or slows down. Superficial cells are waterlogged and swollen. Plaque protrudes into cyst cavity and cyst wall where it can undermine and raise adjacent cyst lining. (f) Epithelial plaque can form convolutions. Protrusions into cyst wall as in (c–f) may be ‘pinched off’ and develop into daughter cysts, leading to the formation of the botryoid variety of lateral periodontal cyst.

CALCIFYING ODONTOGENIC CYST

• Also called as Odontogenic ghost cell cyst or Gorlin cyst.

• It Has many features of odontogenic tumor, therefore it is placed in the category of tumors in the latest WHO classification of odontogenic cysts and tumors.

• In the latest WHO publication on odontogenic tumours (Prætorius and Ledesma-Montes, 2005) it was classified as a benign odontogenic tumour and was renamed calcifying cystic odontogenic tumour (CCOT).

CALCIFYING ODONTOGENIC CYST

• Age : Wide range, peak in 2nd decade.

• Sex : Equal.

• Site : Anterior segment of both jaws

CLINICAL FEATURES

• COC is a unicystic process and develops from the reduced dental epithelium or remnants of dental lamina.

• The cyst lining has the potential to induce formation of dentinoid or even odontoma in adjacent CT wall.

PATHOGENESIS

• Group 1 : ‘Simple’ cysts Calcifying odontogenic cyst (COC)

• Group 2 : Cysts associated with odontogenic hamartomas or benign neoplasms: calcifying cystic odontogenic tumours (CCOT).

• Group 3 : Solid benign odontogenic neoplasms with similar cell morphology to that in the COC, and with dentinoid

Formation

• Group 4 : Malignant odontogenic neoplasms with features similar to those of the dentinogenic ghost cell tumour Ghost cell odontogenic carcinoma

CLASSIFICATION OF THE ODONTOGENIC GHOST CELL LESIONS

• Swelling is the commonest complaint, seldom associated with pain.

• Intraosseous lesions can cause hard bony expansion and resulting facial asymmetry.

• Displacement of teeth can also occur.

SIGNS & SYMPTOMS

• Intraosseous lesions produce well defined lucency which is usually unilocular.

• Irregular calcified masses of varying sizes may be seen within the lucency.

• Displacement of root/roots with or without root resorption and expansion of cortical plates also seen


Radiograph of a calcifying odontogenic cyst of the maxilla. There is a well-demarcated margin and calcifications suggestive of tooth material.

Radiograph of a calcifying odontogenic cyst with well-demarcated margins extending from the right to the left premolar regions of the mandible. Numerous calcifications are present, some suggestive of small denticles.


• Lining is usually thin about 6 – 8 cell thick, may be thickened in other areas.

• Lining shows characteristic odontogenic features with reversely polarized basal cell layer.

• TYPICALLY – GHOST CELLS may be seen in thicker areas of lining.• Ghost cells are enlarged, ballooned, ovoid, eosinophilic cells with well

defined cell boundaries.• Some times many cells may fuse.• They represent abnormal keratinization and frequently calcify.• Tubular dentinoid and even complex odontome may be found in

connective tissue wall close to epithelial lining.


Histological features of a calcifying odontogenic cyst with clusters of fusiform ghost cells and focal calcifications, lying in a stratified squamous epithelium.


In this calcifying odontogenic cyst, there are sheets of ghost cells and a focal area in which there has been induction of a strip of dysplastic dentine (dentinoid).


• Based on radiographic appearance, following lesions must be included in the provisional diagnosis –• Ameloblastoma

• CEOT

• AOT

• Ameloblastic fibro odontoma


NASOPALATINE DUCT (INCISIVE CANAL) CYST

• Also classified as “FISSURAL CYSTS”.

• Believed to be derived from epithelial remnants included during closure of embryonic facial processes.

• Controversy – actual “closure” of embryonic processes does not occur. Grooves between processes is smoothed by proliferation of underlying mesenchyme.

• Usually occurs within the nasopalatine canal or in soft tissue of palate at the opening of canal.


• Age : 4th, 5th & 6th decades.

• Sex : More in females

• Frequency: Commonest non odontogenic developmental cyst

CLINICAL FEATURES

• In lower animals, the NP duct concerned with olfactory sensation – in humans only vestigial remnants persist in incisive canal in form of epithelial islands, ducts, cords etc.

• These nests can show central degenration to form cysts. Etiology for cyst transformation is yet unclear.

• Some believe, it may arise spontaneously like an OKC.

PATHOGENESIS

• Commonest symptom is swelling, usually in anterior region of mid palate.

• Swelling can also occur in midline on labial aspect of alveolar ridge.

• If pressure on NP nerves – pain

• Exclude possibility of periapical cyst by testing vitality of incisors.

SIGNS & SYMPTOMS


Small nasopalatine cyst presenting as a soft ovoidswelling in the midline of the maxilla, posterior to the central incisor teeth.

Large nasopalatine duct cyst extending laterally andposteriorly to involve much of the hard palate.

• Seen as lucency usually in incisive canal – DIFFICULT TO DISTINGUISH FROM A NATURALLY LARGE INCISIVE CANAL.

• Lucency with AP dimension upto 10 mm considered as enlarged incisive canal, but if lucency < 14 mm, then NP duct cyst.

• The lucency appears well defined with sclerotic borders, in midline of palate between roots of incisors.


Radiograph of a nasopalatine duct cyst showing a pear-shaped radiolucency in the anterior maxilla. The lamina dura on the left is intact although the apex appears to be in the cyst.


Shows a large round radiolucency. The roots of the maxillary incisor teeth are displaced laterally.


• Lining epithelium extremely variable, consisting of stratified squamous, pseudo stratified columnar, simple columnar or cuboidal epithelium.

• Most commonly lining is stratified squamous followed by pseudo stratified columnar.

• A useful diagnostic aid – presence of large nerve and vascular bundles in connective tissue wall.



Neurovascular bundle in the wall of a nasopalatineduct cyst.

• Radicular cyst, if it is associated with a pulpally involved tooth.

• Large incisive canal.


NASOLABIAL CYST

• The nasolabial cyst occurs outside the bone in the nasolabial folds below the alae nasi.

• It is traditionally regarded as a jaw cyst although strictly speaking it should be classified as a soft tissue cyst.

NASOLABIAL CYST

• Age : Peak incidence in 4th & 5th decades.

• Sex : More in females.

• Frequency: Rare in occurrence.

CLINICAL FEATURES

• Commonest complaint – slowly growing swelling and occasionally, pain and difficulty in nasal breathing.

• Extra orally – filling out of nasolabial fold and may lift ala nasi.

• Intra orally – bulge in labial sulcus.

• Fluctuant lesion.

SIGNS & SYMPTOMS

Nasolabial cyst producing a swelling of the right upper lip, forming a bulge in the labial sulcus.

• Believed to develop from lower anterior portion of nasolacrimal duct.

• When margins of lateral and maxillary processes fuse, ectoderm along boundary between them gives rise to solid cellular rod which first develops as a linear surface elevation (Nasolacrimal ridge) and then sinks into underlying mesenchyme.

• This solid rod canalizes to form NL duct.

• The NL cysts are located such that it is possible that they develop from embryonic remnants of NL duct.

• Importantly, a mature NL duct is lined by pseudo stratified columnar epithelium, which is also the lining of NL cyst.

PATHOGENESIS

• Difficult to interpret on radiograph.

• May be seen as localized increased lucency of alveolar process above apices of incisors.

• Lucency results from pressure resorption on labial surface of maxilla.


Standard occlusal radiograph of a patient with a nasolabial cyst. There is a posterior convexity of the left half of the radiopaque line that forms the bony border of the nasal aperture.

• Cyst lined by non ciliated pseudo stratified columnar epithelium.

• Goblet cells also seen in some cases.

• Occasionally, part of lining may be cuboidal / flat squamous.

• Conncetive tissue wall is fibrous, relatively acellular with fibers arranged loosely or compactly.


Nasolabial cyst lined by a pseudostratified columnar epithelium containing many goblet cells. In the example illustrated here, mucous glands are present in the wall.

RADICULAR CYST

• Also called APICAL PERIODONTAL CYST

• Radicular cysts are the most common inflammatory cysts and arise from the epithelial residues in the periodontal ligament as a result of periapical periodontitis following death and necrosis of the pulp.

• Quite often a radicular cyst remains behind in the jaws after removal of the offending tooth and this is referred to as a residual cyst.

RADICULAR CYST

1. PHASE OF INITIATION:• Accepted generally that rests of Malassez included within a

developing periapical granuloma proliferates to form the lining of radicular cyst.

• How these cells are stimulated is not clear.

• Some product of non vital pulp can be responsible which simultaneously evokes an inflammatory response in CT.

• Immune factors also held responsible as plenty of plasma cells are seen in a periapical granuloma.

PATHOGENESIS

2. PHASE OF CYST FORMATION:• Can occur in two possible ways.

• One theory states that epithelium proliferates and covers the bare connective tissue surface of the abscess cavity.

• Another theory – cyst cavity forms within proliferating epithelium as the cells in center move away from their nutrient source.

PATHOGENESIS

3. PHASE OF ENLARGEMENT:• Enlargement occurs by collection of fluid within

the lumen of the cyst.

• Osmosis plays an important role here as the cyst wall appears to have the properties of a semi permeable membrane.

PATHOGENESIS

• Age : peak in 3rd, 4th and 5th decades.

• Sex : Slightly more in males.

• Site : Maxillary anterior region.

• Frequency: Commonest cystic lesion of jaws.

CLINICAL FEATURES

• Primarily symptom less.

• Discovered accidentally during routine dental X ray exam.

• Slowly enlarging hard bony swelling initially. Later, if cysts breaks through cortical plates, lesion becomes fluctuant.

• Diagnostic criteria – associated teeth are non vital

• Rare in deciduous teeth.

SIGNS & SYMPTOMS

• Classically presents as round / ovoid lucency with sclerotic borders and associated with pulpally affected tooth / teeth.

• If infection supervenes, the margins become indistinct, making it impossible to distinguish it from a peripaical granuloma.


Radiograph of a radicular cyst. The lesion is a well defined radiolucency associated with the apex of a non-vital root filled tooth.

• Lined partly / completely by non keratinized epithelium of varying thickness.

• Epithelium usually shows arcading around the connective tissue.

• The connective tissue wall shows inflammatory infiltrate mainly in the form of lymphocytes and plasma cells.

• Hyaline / Rushton bodies are found in epithelium and rarely in connective tissue wall.

• These are curved or linear structure with eosinophilic staining properties


• Cholesterol crystals in from of clefts are often seen in the connective tissue wall, inciting a foreign body giant cell reaction.

• Originate from disintegrating RBC’s in presence of inflammation.

• Different types of dystrophic calcification are also seen in connective tissue wall.

• Mucus cell metaplasia as well as respiratory cells may be seen in the epithelial lining.

• Keratinization if found is due to metaplasia and must not be confused with an OKC.



Quiescent epithelium lining a mature, long-standing radicular cyst (H & E).

Mucous cells in the surface layer of the stratified squamous epithelial lining of a radicular cyst (H & E).


Hyaline bodies in the epithelial lining of a radicularcyst (H & E).

Mural nodule of cholesterol-containing granulationtissue fungating into the cavity of a radicular cyst (H & E).

Radiographic appearance of a large residual cyst left behind after extraction of 1st mandibular molar.

• The histopathological features of the residual cyst are similar to those described above for conventional radicular cysts. However, because the cause of the cyst has been removed, residual cysts may progressively become less inflamed so that eventually the cyst wall is composed of uninflamed

• The epithelial lining may be thin and regular and indistinguishable from a developmental cyst such as a dentigerous cyst or lateral periodontal cyst. collagenous fibrous tissue.

RESIDUAL CYSTS

Following lesions must be distinguished from other periapical radiolucencies–

1. Periapical granuloma2. Peripaical cemento – osseous dysplasia (early lesions)

DIFFERENTIAL DIAGNOSIS:

PARADENTAL CYSTS

• A cyst of inflammatory origin- occurring on lateral aspect of root of partially erupted mandibular 3rd molar with an associated history of pericoronitis

• Age : 20-40 years

• Tooth is vital

• Facial swelling

• Facial sinus in some cases

PARADENTAL CYSTS

• Affected tooth is tilted Well demarcated RadioLucency Distal to partially erupted tooth

• Lamina Dura is intact

• New bone may be laid down


a

b

(a,b) Two cases of bilateral paradental cysts associated with erupting mandibular third molar teeth. The cysts are distal and buccal to the involved teeth. Note that the periodontal ligament space is not widened and that the distal part of the cyst is separate from the distinct distal follicular space.

• The cysts are lined by a hyperplastic, non-keratinised, stratified squamous epithelium which may be spongiotic and of varying thickness.

• An intense inflammatory cell infiltrate was present associated with the hyperplastic epithelium and in the adjacent

• fibrous capsule is the seat of an intense chronic or mixed inflammatory cell infiltrate. fibrous capsule


Paradental cyst adjacent to the root of an impacted mandibular third molar. The cyst is lined by non-keratinised stratified squamous epithelium of variable thickness and showing areas of proliferation (H & E).

ANEURYSMAL BONE CYST

• Uncommon cyst, found mostly in long bones and spine.

• CLINICAL FEATURES: -1. Age : First 3 decades.

2. Sex : Mainly females.

3. Site : molar regions of mandible & maxilla.

• Signs & symptoms:

Hard, rapidly growing swelling which can cause malocclusion.

If lesion perforates cortical plates, can cause “egg shell crackling”.

ANEURYSMAL BONE CYST

• Controversy whether lesion arises de novo or from a vascular disturbance in the form of sudden venous occlusion or development of an AV shunt occurring secondarily in a pre existing lesion like central giant cell granuloma, Osteosarcoma etc.

• Due to the malformation, change in hemodynamic forces occurs which can lead to ABC.

PATHOGENESIS

• Classically seen as a unilocular, ovoid / fusiform lucency which balloons the cortical plates.

• Teeth displacement and root resorption also observed.

• Lesions are usually unilocular but longer-standing lesions may show a ‘soap-bubble’ appearance and may become progressively calcified


Radiograph of an aneurysmal bone cyst involving the angle and ascending ramus of the mandible. There is a ballooning expansion of the cortex.

• It consist of many capillaries and blood-filled spaces of varying size lined by flat spindle cells and separated by delicate loose-textured fibrous tissue

• Most lesions contain small multinucleate cells and scattered trabeculae of osteoid and woven bone.

• In some of the solid areas, sheets of vascular tissue, containing large numbers of multinucleate giant cells, fibroblasts, haemorrhage and haemosiderin, look very much like giant cell granuloma of the jaws

• The diagnosis is made primarily on the basis of the clinical and radiological features because histologically such solid lesions may be indistinguishable from giant cell granuloma.



Aneurysmal bone cyst in which the solid areas have histological features identical to those of the central giant cell granuloma of the jaws (H & E).

Aneurysmal bone cyst of the mandible. The solid areas show the features of cemento-ossifying fibroma and a portion of one of the many cystic spaces is present at the top of the photomicrograph(H & E).

• Conventional ameloblastoma• CEOT• Central giant cell granuloma


SOLITARY BONE CYST

• Also called as Hemorrhagic bone cyst, or Traumatic bone cyst.

• Commonly seen in mandible, rare in maxilla.

• Identical to solitary bone cyst of humerus in children and adolescents.

SOLITARY BONE CYST

• Age : Young individuals

• Sex : Equal

• Site : Body and symphysismenti of mandible.

CLINICAL FEATURES

• None of the theories are certain about exact cause.

• First theory – cyst may follow trauma to bone which causes intra medullary hemorrhage which fails to organize. This clot subsequently liquefies - CYST.

• Recent theory osteogenic cells fail to differentiate locally and thus instead of bone, the undifferentiated cells form synovial tissue.

PATHOGENESIS

• Asymptomatic.

• Rarely, swelling and pain may be seen.

• Half of all patients give a history of trauma to the area.

SIGNS & SYMPTOMS

• Appears as a lucency with irregular but well defined edges and slight cortication.

• On occlusal view the ‘lucency is seen to extend along cancellous bone.


Radiograph of a solitary bone cyst involving anextensive area in the right body of the mandible. Thisexample has a well-defined margin with cortication.Interradicular scalloping is a prominent feature.

• Lumen not lined by any epithelium (Pseudo cyst).

• Wall shows loose fibro vascular connective tissue.

• Hemorrhage and hemosiderin pigment usually present.

• Multinucleated giant cells scattered within the connective tissue.

• Adjacent bone shows osteoclastic resorption on inner surface.


A solitary bone cyst of the jaw. The lining is composed of loose vascular fibrous tissue with osteoclastic activity on the surface of the adjacent bone (H & E).

TREATMENT

REASONS

• Cysts tend to increase in size.• Cysts tend to get infected.• Cysts weaken the jaw. ( pathological fracture)• Some cysts undergo changes. Eg: Ameloblastoma,

Mucoepidermoid carcinoma ( histological study to be done) • Cysts prevent eruption of teeth. (dentigerous cyst)• Involvement of neighboring structures.( maxillary sinus, nose,

adjacent tooth)

PRINCIPLES OF TREATMENT

1. To remove the lining totally or to remove a part of lining to enable the body to rearrange the position of abnormal tissue so that it is eliminated from within the jaws.

2. To preserve important adjacent structures such as nerves and healthy tissues.

3. To achieve rapid healing of the operation site.

4. To restore the part to a near normal form and to restore normal function.

1. AIMS OF TREATMENT

1. Marsupialization (Partch 1 Operation) (Cystotomy) Combined Decompression & enucleation Marupialization through nose or antrum

2) Enucleation (Partch 2 Operation) (Cystectomy)) a) Enucleation & packing b) Enucleation & primary closure c) Enucleation & primary closure with reconstruction / bone grafting

TREATMENT

• RADIOLOGYa. Periapical x-raysb. Occlusal view x-raysc. Lateral oblique view x-raysd. Panoramic x-rayse. P.A view x-raysf. Sinus view x-rays• C.T.SCAN• RADIOPAQUE DYES• ASPIRATION• BIOPSY

DIAGNOSIS

VARIOUS ASPIRATES

PATHOLOGY ASPIRATE Other Findings of Aspirates

Dentigerous Cyst Clear, pale straw colour fluid

Cholesterol crystals. Total protein in excess 4 g / 100ml. Resembles serum

Odontogenic Keratocyst Dirty, creamy white viscoid suspension

Para keratinized squames. Total protein less than 4 g /100ml. Mostly albumin

Periodontal Cyst Clear, pale yellow straw colour fluid

Cholesterol crystals. Total protein 5 — 11g / 100ml

Infected Cyst Pus, brownish fluid Polymorphonuclear leukocytes, ,Cholesterol clefts

Mucocele, Ranula Mucus -----

Gingival Cysts Clear fluid -----

VARIOUS ASPIRATES

PATHOLOGY ASPIRATE Other Findings of Aspirates

Solitary Bone Cyst Serous fluid, blood or empty cavity

Necrotic blood clot

Stafne’s Bone Cyst Empty cavity – yield air ---

Dermoid Cyst Thick sebaceous material ---

Fissural Cyst Mucoid fluid ----

Cysts of the jaws are treated in one of the following four basic methods:

(1) Enucleation, (2) Marsupialization, (3) A staged combination of the two procedures, and (4) Enucleation with curettage.

TREATMENT

• Enucleation is the process by which the total removal of a cystic lesion is achieved.

• By definition, it means a shelling- out of the entire cystic lesion without rupture.

• Enucleation of cysts should be performed with care, in an attempt to remove the cyst in one piece without frag-mentation, which reduces the chances of recurrence by increasing the likelihood of total removal.

• However, maintenance of the cystic architecture is not always possible, and rupture of the cystic contents may occur during manipulation.

1. ENUCLEATION

Indications : • Enucleation is the treatment of choice

Advantages : • pathologic examination of the entire cyst can be undertaken• the initial excisional biopsy (i.e., enucleation) has also appropriately treated the

lesion. • The patient does not have to care for a marsupial cavity with constant irrigations.

Disadvantages• Normal tissue may be jeopardized • Fracture of the jaw • Devitalization of associated teeth • Impacted teeth that the clinician may wish to save could be removed.

ENUCLEATION

TECHNIQUE :

• Aspiration Biopsy of Radiolucent Lesions • Mucoperiosteal Flaps • Osseous Window • Removal of Specimen

ENUCLEATION

Aspiration Biopsy of Radiolucent Lesions : • Any radiolucent lesion should be aspirated before surgical exploration.• This provides the dentist with valuable diagnostic information regarding

the nature of the lesion

Mucoperiosteal Flaps : • Several varieties of mucoperiosteal flaps are available; the choice

depends chiefly on the size and location of the lesion. • Access may necessitate extension of the irmcoperiosteal flap. The

location of the lesion dictates where the flap incisions are to be made. • the flap design should provide 4 to 5 mm of sound bone around the

anticipated surgical margins • mucoperiosteal flaps for biopsies in or on the jaws she be full thickness

and incised through mucosa, submucosa, and periosteum

ENUCLEATION

Osseous Window : • once the flap has been elevated, a rotating bur should be used to

remove an osseous window • The size of the window depends on the size of the lesion and the

proximity of the window to normal anatomic structures such as roots and neurovascular bundles.

ENUCLEATION

Technique : • A dental curette is used to peel the connective tissues wall of the

specimen from surrounding bone. • The concave surface of the instrument should always be kept in contact

with the osseous surfaces of the bone cavity • The bony cavity is inspected after irrigation with sterile saline • Any residual fragments of soft tissue within the cavity should be

removed with curettes. • Once the cavity is devoid of residual pathologic tissue, it is irrigated and

the flap is replaced and sutured in its proper location.

ENUCLEATION

ENUCLEATION OF CYST

• Marsupialization, decompression, and the Partsch operation all refer to creating a surgical window in the wall of the cyst, evacuating the contents of the cyst, and maintaining continuity between the cyst and the oral cavity, maxillary sinus, or nasal cavity.

• The only portion of the cyst that is removed is the piece removed to produce the window. The remaining cystic lining is left in situ.

• This process decreases intracystic pressure and promotes shrinkage of the cyst and bone fill. Marsupialtzatron can be used as the sole therapy for a cyst or as a preliminary step in management, with enucleation deferred until later.

2. MARSUPIAIIZATION

1. Amount of tissue injury : Proximity of a cyst to vital structures can mean unnecessary sacrifice of tissue if enucleation is used.

2. Surgical access : If access to all portions of the cyst is difficult, portions of the cystic wall may be left behind, which could result in recurrence.

3. Assistance in eruption of teeth : If an unerupted tooth that is needed in the dental arch is involved with the cyst (i.e., a dentigerous cyst), marsupialization may allow its continued eruption into the oral cavity

4. Extent of surgery : Marsupialization is a reasonable alternative to enucleation, because it is simple and may be less stressful for the patient

5. Size of cyst : In very large cysts, a risk of jaw fracture during enucleation is possible. It may be better to marsupialize the cyst and defer enucleation until after considerable bone fill has occurred.

INDICATION

Advantages : • It is a simple procedure to perform. Marsupiaiization also spare vitalstructures from damage should immediate enucleation be attempted.

Disadvantages :• Pathologic tissue is left in situ, without thorough histologic

examination. • Patient is inconvenienced in several respects • The cystic cavity must be kept clean to prevent infection, because the

cavity frequently traps food debris. • In most instances this means that the patient must irrigate the cavity

several times every day with a syringe

MARSUPIAIIZATION

1) Anaesthesia2) Aspiration3) Incision Circular, oval or elliptic. Inverted U shaped incision with broad base to the buccal sulcus. Mucoperioteum is reflected in this case.4) Removal of bone5) Removal of cystic lining specimen6) Visual examination of residual cystic lining7) Irrigation of cystic cavity8) Suturing Cystic lining sutured with the edge of oral mucosa. In U shaped incision the mucoperiosteal flap can be turned into cystic cavity covering the margin. The remaining is sutured to oral mucosa.

TECHNIQUE OF MARSUPIAIIZATION

9) Packing-- Prevents food contamination & covers wound margins. Done with ribbon gauze soaked with WHITEHEAD VARNISH. COMPOSTION: Benzoin – 10g Iodoform – 10g Storax - 7.5g Balsam of Tolu – 5g Solvent ether to 100ml Pack removed after 2 weeks.10) Maintenance of cystic cavity Instruct the patient to clean and irrigate the cavity regularly with oral antiseptic rinse with a disposable syringe.

CONTINUE…

11) Use of plug Prevents contamination. Preserves patency of cyst orifice. Plug should be stable, retentive and safe design. Should be made of resilient material ( avoid irritation) like acrylic.12) Healing Cavity may or may not obliterate totally. Depression remains in the alveolar process.

CONTINUE…

3. ENUCLEATION AFTER MARSUPIALIZATION

INDICATIONS• When bone has covered the adjacent vital structures.• Adequate bone fill. Prevents fracture during enucleation.• When patients find it difficult to cleanse the cavity.• To detect any occult pathological condition.ADVANTAGES• Spares adjacent vital structures• Accelerates healing process• Development of thick cystic lining – enucleation easier• Allows histopathological examination of residual tissue.• Combined approach reduces morbidityDISADVANTAGES• Patient has under go second surgery and any possible complicatton

associated with surgery.

4. ENUCLEATION WITH CURETTAGE

• Enucleation with curettage means that after enucleation a curette or bur is used to remove 1 to 2 mm of bone around the entire periphery of the cystic cavity

• Any remaining epithelial cells that may be present in the periphery of the cystic wall or bony cavity must be removed.

• These cells could proliferate into a recurrence of the cyst.

Indications : • In this case the more aggressive approach of enucleation with curettage

should be used.• Daughter, or satellite, cysts found in the periphery of the main cystic

lesion may be incompletely removed • The second instance in which enucleation with curettage is indicated is

with any cyst that recurs after what was deemed a thorough removal. Advantages :• If enucleation leaves epithelial remnants, curettage may remove them,

thereby decreasing the likelihood of recurrence.

ENUCLEATION WITH CURETTAGE

Disadvantages :• Curettage is more destructive of adjacent bone and other tissues • The dental pulps may be stripped of their neurovascular supply when

curettage is performed close to the root tips• Adjacent neurovascular bundles can be similarly damaged

ENUCLEATION WITH CURETTAGE

ENUCLEATION OF OKCCONSERVATIVE TREATMENT

SURGICAL MANAGEMENT OF OKCRADICAL TREATMENT

• Large cystic lesion involving left ramus of Mandible and extending up.

• There are areas of cortical break.

Transverse View

SURGICAL PROCEDURE

Post operative after 1 month Healed incision area

Post operative Ortho Pantomogram

PREPARED AND SUBMITTED BY : • RAVIRAJ PATEL• YASIN VAJA

GUIDED BY : • DR. TARNJEET KAUR (HEAD OF THE DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY, GOV. DENTAL COLLEGE AND HOSPITAL, JAMNAGAR)

Cyst Of Jaw

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