Cysts of the Oral cavity

True cyst

Pseudocyst

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cyst-like lesions: .

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

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

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

Eosinophilic granuloma. Langerhan¶s Cell Reticulo-endothelioses: a. Hand-Schuller-Christan¶s disease. Metabolic & Systemic Dysfunction: 1.III. Osteitis fibrosa cystica (hyperparathyroidism. . Leterrer-Siwe¶s disease. von Recklinghausen¶s disease of bone). b. c. 2.

Nieman-Pick disease. . Gaucher¶s disease.3. Lysosomal storage diseases: a. b.

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

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

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

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

4. Other radiological diagnostic techniques Aspiration. Physical signs. 2. Symptoms.DIAGNOSIS OF THE CYST 1. Radiographic examination. . 5. 6. 3. Biopsy.

Treatment of the cysts Aim of treatment: 1.To do so with the minimum of trauma to the patient. 2.To remove the pathological epithelium that forms the lining or to enable the patient¶s body to rearrange the position of the abnormal tissue so that it¶s eliminated from within the jaw. consistent with a successful outcome to the operation. .

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

Enucleation or complete removal of the cyst capsule & lining with its contents. 2. .Marsupialization (Partch operation) by which the cyst is uncovered or de-roofed by creating a large opening in the bone & the cystic lining so that the lining of the floor & walls becomes continuous with the oral cavity epithelium & the surrounding structures.Surgical Techniques 1.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

non-keratinized nonstratified squamous epithelial lining  Usually a significant degree of inflammation present .Periapical Cyst  Variably thick.

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

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

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RESIDUAL PERIAPICAL CYST  Well-defined radiolucency within the alveolar ridge at the site of a previous tooth extraction .

RESIDUAL PERIAPICAL CYST   Histopathologic features ± Same as the periapical cyst Treatment ± Surgical excision .

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

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

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

Lateral periodontal cyst: well-delineated multilocular (botryoid or ³grape-like´) homogeneous radiolucency between roots of left mandibular premolar teeth.

Lateral Periodontal Cyst 
Identical

to gingival cyst of the

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

Lateral Periodontal Cyst 
Curettage,

conservative enucleation  Excellent prognosis

Botryoid Odontogenic Cyst 
Probably

represents variant of lateral periodontal cyst  Similar clinical setting; middlemiddleaged to older adults, mandibular canine and premolar region  Multilocular radiolucency, ³grape³grapelike´ (botryoid) (botryoid)

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Botryoid Odontogenic Cyst  Conservative surgical excision with curettage  Slight recurrence potential .

a cyst that forms around the crown of an impacted tooth  This is a developmental (as opposed to an inflammatory) cyst  Arises from reduced enamel epithelium .Dentigerous Cyst  Second most common odontogenic cyst  By definition.

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

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

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

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

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

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

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

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

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

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

DENTIGEROUS CYST ‡ Treatment ± Enucleation with removal of the unerupted tooth ± Marsupialization .

ERUPTION CYST (ERUPTION HEMATOMA) .

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

ERUPTION CYST ‡ Eruption hematoma: blood accumulates in the cystic fluid .

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ERUPTION CYST ‡ Treatment ± Excision of the roof of the cyst to permit eruption .

a developmental odontogenic cyst that arises in place of a tooth. usually a mand. 3rd molar  Should be no history of extraction of a tooth in the area  Most are OKC¶s microscopically .Primordial Cyst  By definition.

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

multilocular lesions . unilocular lesions  More aggressive therapy for larger.Primordial Cyst  Essentially the same treatment that is rendered for the OKC  Enucleation and curettage for small.

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

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

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

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

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

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

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

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

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

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

Odontogenic keratocyst: unilocular homogeneous radiolucency lesion:

lateral topographical occlusal of mandible.

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

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

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

thin stratified squamous epithelial lining  Luminal parakeratin production  Palisaded (³picket fence´) appearance of the basal cell nuclei  Features altered with inflammation  Satellite cyst formation may be seen .Odontogenic Keratocyst  Uniform.

the nevoid basal cell carcinoma syndrome should be considered .Odontogenic Keratocyst  33% 33% recurrence rate overall  With occurrence in the first decade. or with multiple OKC¶s.

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

NEVOID BASAL CELL CARCINOMA SYNDROME (GORLIN SYNDROME) .

and intracranial calcifications ‡ 40% of patients have ocular hypertelorism . multiple OKC¶s.GORLIN SYNDROME ‡ Autosomal dominant trait ‡ Multiple basal cell carcinomas of the skin. rib and vertebral anomalies.

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

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

Facial Asymmetry-Gorlan·s AsymmetrySyndrome .

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Nevoid BCCa Syndrome
Cutaneous features:
± Basal cell carcinomas, early onset ± Palmar/plantar pitting

Nevoid BCCa Syndrome Skeletal features: ± calcified falx cerebri ± increased cranial circumference ± bifid ribs .

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

1988  Mandible (87%). pain [40%])  Radiographic findings  ± Unilocular or multilocular radiolucency . usually anterior  Very slow progressive growth (CC: swelling.Glandular Odontogenic Cyst More recently described (45 cases)  Gardner.

Glandular Odontogenic Cyst .

ciliated surface lining cells ± Polycystic with secretory and epithelial elements .Glandular Odontogenic Cyst  Histology ± Stratified epithelium ± Cuboidal.

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

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

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Gingival Cyst of the Newborn  Similar inclusion cysts are found near midline palatal raphe (Epstein¶s pearls) or more laterally along hard and soft palate (Bohn¶s nodules) .

small islands of epithelium may become trapped below surface Or may arise from epithelial remnants from development of minor salivary glands ‡ ‡ ‡ Epstein¶s pearls occur along median palatal raphe Bohn¶s nodules are scattered over the hard palate.Palatal Cysts of the Newborn (Epstein¶s Pearls. Bohn¶s Nodules) ‡ ‡ As palatal shelves fuse to form secondary palate. No treatment required ± self-healing .

Bluishoften centered in attached gingiva .Gingival Cyst of the Adult  Derived from dental lamina rests  Middle-aged adults (5th-6th Middle(5thdecades)  Mandibular canine/premolar region most common  Bluish-translucent swelling.

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Gingival Cyst of the Adult  Thin. nonnon-keratinized cuboidal to stratified squamous epithelium  Occasional clear cells  Nodular thickenings of epithelial lining may be seen .

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

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

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

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

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Calcifying odontogenic Cyst: ³salt and pepper´ calcifications within an expansile unilocular otherwise lucent lesion (true occlusal) .

Calcifying odontogenic cyst: Welldelineated unilocular mixed radiolucency and radiopacity enveloping unerupted tooth. .

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

CALCIFYING ODONTOGENIC CYST ‡ Treatment and prognosis ± Enucleation ± Prognosis is good .

Developmental Cysts .

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

.Nasolabial cyst: note displacement of ala on right side.

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

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

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

a common finding. Nasopalatine duct cyst less frequently causes sublabial swelling. .Nasopalatine duct cyst causing palatal expansion.

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

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

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

asymptomatic  Radiographic findings  ± Well-delineated oval radiolucency between maxillary incisors.Incisive Canal Cyst Derived from epithelial remnants of the nasopalatine duct (incisive canal)  4th to 6th decades  Palatal swelling common. root resorption occasional  Histology ± Cyst lined by stratified squamous or respiratory epithelium or both .

Incisive Canal Cyst .

Incisive Canal Cyst Treatment consists of surgical enucleation or periodic radiographs  Progressive enlargement requires surgical intervention  .

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

GMC .

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

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

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

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

connective tissue elements.Dermoid Cyst. ‡ cont. Teratoid cyst ± cystic form of teratoma that contains a variety of germ layer derivatives (skin appendages. and endodermal structures) ‡ Dermoid cysts are simpler in structure than complex teratomas or teratoid cysts .

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

Dermoid cyst .

Neck: dermoid cyst .

movable swelling unless complicated by secondary infection Best treated by removal of cyst. and muscular tissue ‡ . fluctuant. midline section of hyoid bone.Thyroglossal Duct Cyst (Thyroglossal Tract Cyst) ‡ ‡ 60%-80% of cysts develop below hyoid bone Usually presents as painless.

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

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Cervical Lymphoepithelial Cyst (Branchial Cleft Cyst) ‡ Developmental cyst that occurs in upper lateral neck along anterior border of the sternocleidomastoid muscle Soft fluctuant mass ranging from 1-10 cm Increased numbers reported in persons with HIV infection Treatment is surgical removal ‡ ‡ ‡ .

Lumps What can you describe? ‡ ‡ Site ‡ ‡ Size ‡ Shape ‡ ‡ Surface ‡ ‡ Edge Consistency Colour Transillumination Fixation / tethering Pulsation .

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

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

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

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

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

white or yellow.Oral Lymphoepithelial Cyst ‡ Waldeyer¶s ring ± palatine tonsils. lingual tonsils and pharyngeal adenoids Small asymptomatic submucosal mass. firm or soft. on floor of the mouth Treatment is surgical excision ‡ ‡ .

Pseudocysts .

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

Stafne Bone Cyst .

Traumatic Bone Cyst Empty or fluid filled cavity associated with jaw trauma (50%)  Radiographic findings  ± Radiolucency. most commonly in body or anterior portion of mandible Histology ± thin membrane of fibrous granulation  Treatment ± exploratory surgery may expedite healing  .

Traumatic Bone Cyst .

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

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

Lesion. .Traumatic bone cyst Normal follicle space.

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

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

Aneurysmal Bone Cyst .

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

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

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

enucleation .Surgical Ciliated Cyst May occur following Caldwell-Luc Trapped fragments of sinus epithelium that undergo benign proliferation Radiographic findings Unilocular radiolucency in maxilla Histology Lining of pseudostratified columnar ciliated Treatment .

Surgical Ciliated Cyst .

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