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CYST OF THE JAWSOral and facial soft tissue CYST A cyst is a cavity occurring in either hard or soft tissue with a liquid ,semi liquid or air content .It is surrounded by a definitive connective tissue wall or capsule and usually has an epithelial lining. WHO histologic typing of jaw cyst (1992)CYST OF THE JAWS Epithelial lined cysts Developmental origin Odontogenic Gingival cyst of new born Odontogenic keratocyst Dentigerous cyst Gingival cyst of adult Developmental lateral periodontal cyst Botryoid odontogenic cyst

ContGlandidular odontogenic cyst Calcifying odontogenic cyst Non odontogenic cyst Mid palatal cyst of infants Nasopalatine duct cyst Nasolabial cyst 2.Inflammatory origin Radicular cyst apical or lateral Residual cyst

Cont Para dental cyst or juvenile para dental cyst Inflammatory co lateral cyst B.Non epithelial lined cyst Solitory bone cyst Anerysmal bone cyst Classification (Shear ,1983) Cyst of the jaw1.Intraosseous cyst 2.Soft tissue cyst 1.Intraosseous cyst Epithelial Non epithelial Cysts of the maxillary antrum Classification Epithelial cyst Odontogenic cyst Nonodontogenic cysts(Fissural ) Odontogenic cyst Developmental Inflammatory 1. ODONTOGENIC CYSTS

Primordial cystDentigerous cyst (follicular)Radicular cyst (periodontal, dental,periapical, inflammatory, infected)Lateral periodontal cystResidual cystOdontogenic keratocyst(2005 WHO classified as keratocystic odontogenic tumor)Calcifying odontogenic cyst (Gorlin cyst)2. NONODONTOGENIC CYSTS

Fissural cysts:Globulomaxillary cystMedian mandibular cyst (median alveolar)Nasopalatine duct cyst (incisive canal cyst)Nasopalatine canal cystMedian palatal cystNasolabial cyst (nasoalveolar)

Overview:

Odontogenic cysts & tumors arise from the odontogenic apparatus.

The odontogenic apparatus consists of:Epithelium: Remnants of dental lamina Reduced enamel epithelium Odontogenic rests Lining of odontogenic cysts Basal cell layer of oral mucosaEctomesenchyme: Dental papilla

An abnormal space within tissue lined by epithelium.

Aneurysmal bone cyst, Stafne bone cyst, Traumatic bone cyst, Simple bone cyst, Eruption cyst No epithelial lining!10Cyst Enlargment Increase in the volume of contents .Increase in the surface area of the sac or epithelial proliferation .Resorption of the surrounding bone and at times displacements of the surrounding soft tissues .The periosteum is stimulated to form a layer of new bone subperiosteal deposition.Cont-Increase in the volume of the contents Secretions transudation &exudation Increased hyperosmolarity , -further draws in the fluid from the surrounding tissues .Increased osmolarity osmotic difference between serum and cystic fluid in related to protein .(large molecule albumin,fibrnogen ,fibrin degradation products )Co factors lymphocytes release lymphocines ,osteoclast activating factors ,and monocytes release interleukin 1 which stimulates the fibroblast to to reslese the prostaglandin .these products produces hyperosmolar cyst fluid.12Cont-Epithelial proliferation mural growth in the form of epithelial proliferation is one of the essential process by which surface area of the sac increase basically by peripheral cell division or by accumulation of cellular contents.Multicentric pattern of cyst growth proliferation of local group of epithelial cells keratocyst Collagenase activity increased collagenolysis primodial or radicular cyst Unremitting growth due to high mitotic value keratocystPresence of low grade infection stimulate cells such as rest of Malassez. .

contBone resorption by release of bone resorbing factors from the capsules which stimulates osteoclast function like prostanoids like PGE2and PGI2 and certain leukotrienes. Difference in size possibly depends upon the quantity of release of protaglandins and other bone resorbing factors.Cyst Regression Any process that lead to the involution of the cyst epithelium -like extraction of tooth ,marsupialization may cause connective tissue to regress the cavity filled by tissue or bone.Aspirates Pathology Aspirates Other findings Dentigerous cyst Clear pale straw colored fluid Cholestrol crystals .Total protein excess of 4 grams/100ml .

Odontogenic keratocyst Dirty creamy white viscoid suspension Parakeratinized squames Total protein less than5gm/100ml Periodontal cyst Clear pale straw colored fluid

Cholestrol crystals .Total protein is between 5gm-11/100ml .

Infected cyst Pus or brownish fluid ,seroprulent /sanguinopurulant fluid Polymorphonuclear leukocytes ,foam cells , Cholestrol clefts Cont-Mucocele ,Ranula MucusGingival cyst Clear fluid Solitary bone cyst Serous or sanguineous fluid ,blood or empty cavityNecrotic blood clot Stafne ,s bone cavity Empty cavity with air Dermoid cyst Thick sebaceous material Fissural cyst Mucoid fluid Vascular cyst wallsFresh blood Intramedullary cavernous haemangioma Syringe full of venous blood Arterial or A-V malformation Bright red blood ,pulsatile plungerTreatment 1.Marsupialization (decompression )Partsch IPartsch II(combined marsupialization+enucleation )Marsupialization by opening in to nose or antrum .2.Enucleation Enucleation and packing .Enucleation and primary closure Enucleation and primary closure with reconstruction /bone grafting.

Primodial cyst Developing toothfollicle of asupernumerary toothwith calcificationoccurring in thefollicle. If calcificationhad failed to occur,then it would haveformed a primordialcyst

Primordial cystPrimordial cyst arisingfrom the tooth bud ofthe fourth molar.Developing toothfollicles of the third molars may be misdiagnosed as primordial cysts

Radicular CystRadicular CystThe radicular (periapical) cyst is the most common cyst of the jaw .Age 30 and 50 years ,usually do not cause pain. A radicular cyst is the last step in a progression of inflammatory events following the formation of a periapical inflammatory lesion secondary to pulpal necrosis in a tooth. Over time, an inflammatory cyst can develop in the bone at the root apex of a carious tooth due to inflammatory stimulation and proliferation of the epithelial rests of Malassez (residual epithelial cells in the periodontal ligament).

Periapical cyst or granuloma (chronic localized osteitis)There are Rests of Malassez in the area of inflammation. The rest cells proliferate due to the inflammation The ball of cells gets too large, cells in the center die, center then has a higher protein concentration, water rushes in to equalize the osmotic pressure. Osmotic pressure can continue to grow the cyst independent of the inflammation.

Other unilocular radiolucencies located periapically: (early) periapical cemento-osseous dysplasia teeth are vital Dentin dysplasia type I teeth are vital, multiple radiolucencies

With a periapical cyst or granuloma, the tooth is NON-VITAL

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22The dentigerous (follicular) cystThe dentigerous (follicular) cyst is the most common type of noninflammatory odontogenic cyst The most common cause of a pericoronal area of lucency associated with an impacted tooth. A dentigerous cyst forms within the lining of the dental follicle when fluid accumulates between the follicular epithelium and the crown of the developing or unerupted tooth. Dentigerous cyst

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25 The lateral periodontal cyst is generally quite small and well demarcated. It occurs most frequently in the mandibular bicuspid area adjacent to vital teeth. Radiolucencies are generally small and ovoid

Derived from remnants of the dental lamina

Tt : conservative enucleation

Considered to be the intrabony counterpart to the Adult Gingival Cyst

Lateral Periodontal Cyst26Lateral periodontalcyst

Lateral periodontalcyst in itscharacteristic locationin the mandibularpremolar region.Teeth are vitalcyst whichhistologically had akeratin lining, that is,an odontogenickeratocyst developedfrom the lateralperiodontal cyst.

28Odontogenic Keratocyst(Keratocystic Odontogenic Tumor) A benign uni-or multicystic, intraosseous tumor of odontogenic origin Lining is parakeratinized stratified squamous epithelium Potential aggressive, infiltrative behavior Solitary or multiple (multiple usually related to Gorlin syndrome)

Three important things associated with this diagnosis:1. High recurrence rate (up to 60%)2. Highly aggressive (now considered by W.H.O. to be an odontogenic tumor)3. Relation to Gorlin syndrome

Arises from the dental lamina or its remnants

PTCH(patched ) gene is a significant factor in the development of KOT29Cont-

Odontogenic keratocysts are believed to arise from the dental lamina and other sources of odontogenic epithelium. They represent 5%15% of all jaw cysts. Most odontogenic keratocysts are found during the 2nd to 4th decades of life, although they can occur at any age. The lumen of the cyst often contains cheesy material and has a parakeratinized lining epithelium . Daughter cysts and nests of cystic epithelia are found outside the primary lesion; as a result, odontogenic keratocysts have the highest recurrence rate of any odontogenic cyst (50%) when treated conservatively with curettage .

Cont-A single missing tooth from normal arch suspicion to KCOT.Buccal expansion commonly seen but palatal and lingual expansion is rare.Unilocular to multi locular,with sclerotic marginTreatment Enucleation followed by cryosurgery Enucleation followed by adjunctive chemical cauterization using Cornoy,s solution along with excision of overlying attached mucosa.Radical excision -reserved for multiple recurrent cases.Cornoys solution is fixative 60%ethannol 30%chloroform 10%glacial acetic acid.it is composed of 1gm of ferric acid dissolved in 24 ml of absolute alcohol 12 ml of chloroform and 4 ml of glacial acetic acid.31

(Vital teeth)

32Nevoid Basal CellCarcinoma Syndrome(Gorlin Syndrome)

Multiple basal cell carcinomas Multiple jaw cysts (odontogenic keratocysts) Numerous bone abnormalities including bifid ribs, intracranial calcification, vertebral anomalies

PTCH gene has been mapped to chromosome 9q22.3 - site of Gorlin Syndrome

Anyone with multiple KOTs should be tested for Gorlin Syndrome33Calcifying epithelialodontogenic cyst,

Calcifying epithelialodontogenic cyst,also known as Gorlincyst, showingradiographic evidenceof calcified material in\the radiolucency

Calcifying Epithelialodontogenic cyst.

Calcifying epithelialodontogenic cyst.radiolucencydoes not show anyradiographicevidence ofcalcified material in the present radiograph .Microscopically,calcific areas werepresent in theLesion in this case .Unicystic AmeloblastomaAccount for 10-15% of intraosseous ameloblastomas Usually occur in younger patients.

Because all of the ameloblastoma is inside the lumen of the cyst, Tt. is removal of the cyst (not jaw resection)

But If ameloblastoma is in the wall of the cyst, treatment must be standard for ameloblastoma = resection

Can often resemble a dentigerous cyst around an unerupted 3rd molar

37Non-odontogenic cystAlso called fissural cyst or occlusion cyst, because they arise from embryonic epithelium that become entrapped during embryogenesis.

2. NONODONTOGENIC CYSTS

Fissural cysts:Globulomaxillary cystMedian mandibular cyst (median alveolar)Nasopalatine duct cyst (incisive canal cyst,nasopalatine canal cyst)Median palatal cystNasolabial cyst (nasoalveolar)Nasopalatine Canal Cyst (Incisive Canal Cyst)Located within the nasopalatine canal or the incisive papillaMost commonly seen in men between 40 and 60 years oldUsually asymptomaticMay see a small, pink bulge near the apices and between the roots of the maxillary central incisors on the lingual surface.

Nasopalatine Canal Cyst (cont.)Cont--Its the most common & most important non-odontogenic cyst arises from embryonic remnants of the nasopalatine duct after its closure, it occur at any age, but mostly discovered in the 4th or 5th decay of life. It is asymptomatic discovered by routine X-ray or it may infected & cause pain & swelling in the incisive papilla.Cont--RadiographicA well-defined, radiolucent lesionMay be oval or heart-shapedHistologicLined by epithelium varying from stratified squamous to pseudostratified ciliated columnar epithelium TreatmentSurgical excisionMedian Palatine CystA well-defined, unilocular radiolucencyLocated in the midline of the hard palateHistologicLined with stratified, squamous epithelium surrounded by dense fibrous connective tissueTreatment Surgical removalMedian Palatine Cyst (cont.)

Globulomaxillary CystA well-defined, pear-shaped radiolucency found between the roots of the maxillary lateral incisor and cuspidWas thought to be a fissural cyst, now believed to be of odontogenic epithelial originTreatment Surgical removalGlobulomaxillary Cyst (cont.)

Median Mandibular CystA rare lesion located in the midline of the mandible Lined with squamous epitheliumRadiographicA well-defined radiolucency below the apices of mandibular incisorsTreatmentSurgical removalNasolabial CystA soft tissue cystThought to originate from the lower anterior portion of the nasolacrimal ductObserved in adults from 40 to 50 years of age4:1 ratio in favor of femalesNasolabial Cyst (cont.)ClinicalAn expansion or swelling in the mucobuccal fold in the area of the maxillary canine and the floor of the noseHistologicLined with pseudostratified, ciliated columnar epithelium and multiple goblet cellsTreatment Surgical excisions

PseudocystsStatic Bone CystSimple Bone CystAneurysmal Bone CystStatic Bone Cyst (Lingual Mandibular Bone Cavity) (Stafne Bone Cyst)A pseudocyst (not a true cyst)A well-defined cyst like radiolucency may be observed on radiograph in the posterior region of the mandible inferior to the mandibular canal.Caused by a lingual depression in the mandibleTreatmentNoneStatic Bone Cyst (Lingual Mandibular Bone Cavity) (Stafne Bone Cyst) (cont.)

Simple Bone Cyst,Solitary bone cyst (Traumatic Bone Cyst)A pathologic cavity in bone that is not lined with epitheliumMay be associated with trauma.10-20 yr of age More common in male More common in mandible above the inferior canal in the cuspid and molar region

RadiographicA well-defined unilocular or multilocular radiolucencyCharacteristically shows scalloping around roots of teeth Treatment

Curettage on the wall lining, stimulates hemorrhage leads to healing of cavity .

Simple Bone Cyst(Traumatic Bone Cyst) (cont.)

Aneurysmal Bone CystWHO classifies ABC as a tumor like lesion and defines it as an expanding osteolytic lesion consisting of blood filled spaces of variable sizes separated by connective tissue septa containing trabeculae of osteoid tissue and osteoclast giant cells.Aneurysmal Bone CystA pseudocystName is misleading as it does not contain vascuar aneurysm and it is not a true bone cyst.Often seen in long bone and spine.Consists of blood filled spaces surrounded by multinucleated giant cells and fibrous connective tissueEtiology h/o of trauma , relation ship with giant cell lesion Variation in the hemodynamic of the area Sudden venous occlusion Aneurysmal Bone Cyst (cont.)More common in mandible posterior region .Usually seen in persons less than 30 years oldSlight predilection for females

RadiographicMultilocular appearance honeycomb, soap bubble/unilocular Dark venous blood can be aspirated .TreatmentSurgical excisionRadiotherapy is contra indicated .Intralesional calcitonin in combination with methylprednisolone ContIntra lesional fibrosing agent Ethioblocethicon .Arterial embolization followed by enblock resection .

Soft tissue cystsGingival Cyst: is located in the gingival soft tissues outside of the bone, & is derived from the rests of the dental lamina .2 types of gingival cyst:1-Gingival cyst of the adult: Occurs as a firm but compressible, swelling on the mand. or max. facial gingiva in the premolar, canine, incisor region.The cyst not appear on radiograph because it confined to the gingival soft tissue.Histopathologically, include a thin lining of non-keratinized epith. about 1-3 cells in thickness with a number of clear cells.Treatment: by conservative surgical enucleation. 2- Gingival cyst of the newborn:Generally seen on the alveolar ridges of newborn infants as small, often multiple swelling, & appear whitish in color.Microscopically, consist of a thin walled cystic lesion lined by a thin, stratified squamous epith., & containing compact desquamated keratin.The lesion resolved spontaneously in response to normal function, therefore no treatment required.

Gingival Cyst: is located in the gingival soft tissues outside of the bone, & is derived from the rests of the dental lamina .

Thyroglossal Tract CystForms along the tract the thyroid gland follows in developmentMost often found in young individuals under 20 years of ageNo sex predilectionTreatmentExcision of the cyst and tract 1- Thyroglossal tract cyst: its an uncommon developmental cyst that formed any were along the embryonic thyroglossal tract between the foramen caecum of the tongue & the thyroid gland.

Clinically:Occur in young person, but may occur at any age.Forming a mobile cystic mass which may lie on one side of the midline, but mostly in midlineIt is asymptomatic, but when occur high near the tongue it may cause dysphagia, sometime infected causing abscess with fistula.Histopathology:The cyst lined by stratified squamous epith., ciliated columnar epith., transitional epith, or a mixture of epith. Types.The capsule include lymphoid aggregation, thyroid tissue, mucus gland.Treatment: complete surgical excision.

Thyroglossal cyst

Thyroglossal Tract Cyst (cont.)

Lymphoepithelial cystIt develop either from epithelial invaginations that detached from the surface mucosa & entrapped within the lymphoid tissue, or from epithelium of minor salivary gland ducts that traverse oral lymphoid tissue.Clinically:Most commonly found on the anterior floor of the mouth & posterior lateral borders of the tongue.Its an asymptomatic, yellowish, superficial submucosal mass, usually less than 1cm in diameter.Histopathology:The cyst lined by a thin layer of parakeratinized squamous epith. Surrounded by a well defined mass of normal lymphoid tissue showing variable numbers of germinal centers.

Branchial Cleft Cyst (Lymphoepithelial Cyst) Most commonly found in major salivary glandsA stratified squamous epithelial lining surrounded by a well-circumscribed component of lymphoid tissueAppears to arise from epithelium trapped in a lymph node during developmentBranchial Cleft Cyst (Lymphoepithelial Cyst) (cont.)

Branchial Cleft Cyst (Lymphoepithelial Cyst) (cont.)Most commonly found intraorally on the floor of the mouth and the lateral borders of the tongueAppears as a pinkish, yellow raised noduleTreatmentSurgical excisionDermoid & Epidermoid cystThese represents a simple form of cystic teratoma derived from skin epith. entrapped during embryonic development.Most of these cysts occur in the head & neck region, primarily in the skin around the eyes & the anterior upper neck, extending superiorly into the floor of the mouth.Clinically:Mostly occur in young adults, present as painless swelling exhibiting a doughy consistency on palpation,& may cause elevation of the tongue & can interfere with eating & speaking.Histopathology:The cyst lined by a layer of orthokeratinized squamous epith., surrounding by C.T. capsule.In dermoid cyst in addition to these the lesion exhibiting variable numbers of dermal appendages including hair follicles, sebaceous glands.Treatment: this is best treated by surgical excision.Epidermal CystA raised nodule on the skin of the face or neckMay be noted intraorally on occasion HistologicLined by keratinizing epithelium the resembles the epithelium of the skinThe lumen is usually filled with keratin scalesTreatmentSurgical excision

Dermoid Cyst and Benign Cystic TeratomaA developmental cyst often present at birth or noted in young childrenIt is usually found on the floor of the mouth when it is located in the oral cavity.May have a doughy consistency when palpatedDermoid CystHistologicLined by orthokeratinized, stratified squamous epithelium surrounded by a connective tissue wallThe lumen is usually filled with keratinHair follicles, sebaceous glands, and sweat glands may be seen in the cyst wallBenign cystic teratomaResembles a dermoid cystTreatmentSurgical excisionIllusion of a cyst

The radiolucency between the radiopaque external and internal oblique lines produces the illusion of a cyst Illusions of Cysts

Osteoporotic bonemarrow defect in theedentulous region. Itis an area ofhematopoietic or fattymarrow and is seenusually in sites ofabnormal healingfollowing extraction,trauma or localinflammationMaxillary sinus maybe misdiagnosed

Maxillary sinus maybe misdiagnosed as acyst. On a radiographof the maxillarycanine region, themaxillary sinus maybe misinterpreted asa radicular cyst. Theperiodontal ligamentspace is normal andthe tooth is vital

Parasitic cystsRarely may involve oral tissues .Hydatid cyst occurs in hydatid disease or echinococcosis caused by the larvae of E granulosus (dog tape worm).Cysticercosis -develop because of the pork tape worm (Taenia solium ).The spread to the oral tissue occurs when larvae penetrate the intestinal mucosa and blood and lymphatics may localized in the orofacial tissues . Heterotopic Cysts Oral cyst with gastric or intestinal epithelium Infants and young children .Sublingual ,apex and dorsum of tongue.

Complications Fracture (Pathological ).Infection Post operative wound dehiscence .Loss of vitality of teeth.Neuropaxia in infected cyst.Recurrence Dysplastic ,neoplastic,or even malignant changes.ADVISE LONG TERM FOLLOW UP 1

Not a cyst it was ossifying fibroma 2

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MCQ.1

1.Factors responsible for cyst formations are A.Proliferation of the epithelial lining .B.fluid accumulation with in the cyst cavity .Bone resortpion .All of the above 22.Follicular or dentigerous cyst results A.because of enlargment of the follicular space of the whole or part of the crown of an impacted or unerupted tooth and its attachment to the neck of the tooth .The above statement True False

3Stafne,s idiopathic bone cavity A.is mandibular salivary gland depression B.true cyst Psedudocyst Filled with dark venous blood. 4Aneurysmal bone cyst commonly present A.posterior mandible region Anterior mandible Anterior maxilla .Posterior maxilla 5Hydaytid cyst

Parasitic cyst Caused by E Granulosus Tape worm worm All of the above are correct 6Cysticercosis is Parasitic cyst Caused by pork tape worm Taenia solium All of the 7In keratocystic odontogenicTotal protein content Less than 5 gm /100 ml More than 5 gm /100 ml More than 15 gm / 100ml More than 20 gm/100.ml 8In dentigerous cyst total protein content is More than 4.0 gm /100 ml Less than 2 gm /100 ml More than 10 gm /100 ml More than 14 gm /100 ml 9The incidence of dentigerous cyst is More common than primodial cyst but less common than apical cyst .Less common than primodial cyst bot more common than periapical cyst .More common than primodial and periapical cyst Less common than primodial and periapical cyst 10Residual cyst is one Present after extraction of causative root /tooth In relation to impacted tooth In presence of supernumerary toot Not a true cyst