Pseudotumors and Cysts

Assoc. Professor Jan Laco, MD, PhD

 Causes of swellings of jaws
• Cysts
– odontogenic x non-odontogenic
• Odontogenic tumors
• Giant cell lesions
• Fibro-osseous lesions
• Non-odontogenic tumors of bone
• Metastatic tumors
• Chronic osteomyelitis
 Cysts of jaws
• = pathological cavity lined by epithelium
• RTG: sharply-defined lucencies
• ± fluid
• slowly growth  teeth displacement
• asymptomatic x infection  painfull
• rarely: pathological fracture
• compressible and fluctuant swelling if extending
into soft tissues
• appear bluish when close to mucosal surface
 Cysts of jaws
• Odontogenic
– developmental
• dentigerous
• eruption
• gingival
• lateral periodontal
• odontogenic keratocyst
• calcifying odontogenic cyst
– inflammatory
• radicular / residual
• inflammatory collateral (paradental)
 Cysts of jaws
• Non-odontogenic
– nasopalatine duct
– nasolabial
– surgical ciliated cyst
• Pseudocysts
– solitary bone “cyst“
– aneurysmal bone “cyst“
– Stafne´s “cyst“
 Cysts of jaws – frequency (%)
• 1. radicular 65-70
• 2. dentigerous 15-20
• 3. keratocyst 10-20
• 4. nasopalatine 5-10
 Radicular cyst
• most common swelling of jaws / cyst
  males (M : F … 3 : 2)
• 20 - 60 years
• maxilla : mandible … 3 : 1
• painless swelling
• enucleation
 Radicular cyst
• at tip of root of tooth with necrotic pulp (caries)
• pulpitis  periodontitis  periapical granuloma 
proliferation of Malassez nests  central liquefaction
• Mi: hyperplastic non-keratinizing squamous epithelium
(net-like) ± hyaline (Rushton) bodies
wall: granulation tissue + fibrous tissue
mixed inflammation
hemosiderin, cholesterol clefts ± granulomas
 Odontogenic cysts
• residual cyst
– radicular cyst left behind after tooth extraction
– spontaneous regress

• lateral radicular cyst

– at side of nonvital tooth
– lateral branch of root canal
– enucleation
 Inflammatory collateral cyst
• inflammation around partially erupted tooth
• paradental cyst: lower M3
• mandibular buccal bifurcation cyst: lower M1 and
M2
  males, children or adults aged 20 - 25 years
• vital tooth with pericoronitis
• Mi: ~ radicular cyst
• enucleation
 Dentigerous (follicular) cyst
• cystic change of enamel organ after complete enamel
formation
• fluid accumulation between crown and collapsed enamel
organ
• surrounds crown + attached to tooth neck at amelo-
cemental junction  crown inside (RTG)
• M:F…2:1
• 20 - 50 years
• mandibular M3, maxillary C  prevents eruption
• Mi: thin squamous epithelium (2-3 layers)
fibrous wall with scanty inflammation
 Eruption cyst
• in soft tissue over tooth about to erupt
• from enamel organ (superficial dent. cyst)
• children
• teeth with no predecessors
• soft bluish swelling in gingiva
• spontaneously disappear
 Gingival cysts
• newborns (Bohn´s nodules)
• > 80 % of newborns
• gingiva - proliferation of Serres nests
• spontaneously resolve in months

• midline of palate (Epstein´s pearls)

• adults - rare
 Lateral periodontal cyst
• uncommon cyst beside vital tooth
• from nests of Malassez ?
• mandibular premolars
• Mi: thin squamous epithelium + plaque-like
thickenings with clear cells (glycogen)
 Lateral periodontal cyst
- variants
• botryoid odontogenic cyst
– multilocular variant of LPC
– lower P and C, may occupy major parts of jaw, > 50
years
– Mi: multilocular cyst with fibrous septa
squamous epithelium + clear cells (glycogen)
– recurrence (20 %)
Glandular odontogenic cyst
(sialo-odontogenic)
– multilocular cyst
– Mi: complex squamous epithelium ~ LPC and
BOC + mucous cells + intraepithelial glandular
spaces
– recurrence (30-50 %)
– diff. dg.: intraosseous mucoepidermoid
carcinoma
 Odontogenic cysts
• WHO classification 2005  WHO 2017
• odontogenic keratocyst
  keratocystic odontogenic tumor
  odontogenic keratocyst

• calcifying odontogenic cyst

  calcifying cystic odontogenic tumor
  calcifying odontogenic cyst
 Odontogenic keratocyst
• 3rd most common cyst of jaw
• M > F; ~ 20-30Y + 50-70Y
• angle of mandible (80 %)
• RTG: multilocular cyst
• Mi: cyst – thin squamous epithelium (5-8 layers) with
wavy parakeratosis ± tiny daughter cysts in wall
• PTCH1 gene alteration
• recurrence (2-25 %) within first 5 years !!!
• treatment: complete enucleation
 Odontogenic keratocyst
• Gorlin-Goltz syndrome
– AD; PTCH gene 9q22.1-31; complete penetrance; 1 : 60,000
– multiple KOT + “naevoid“ basal cell carcinomas + skeletal
abnormalities + ectopic calcifications + various tumors + ocular
defects

• Orthokeratotic cyst
– rare
– RTG: monolocular cyst
– Mi: orthokeratotic layer
– recurrence 4 %
 Calcifying odontogenic cyst
• = Gorlin´s cyst
• M ~ F, ~ 5 - 92Y
• mandible ~ maxilla, incisor-cuspid area, gingiva
• Mi: cyst lined by ameloblastic epithelium
ghost cells  calcification
dentin
• recurrence (5 %)
• sometimes association with ameloblastoma
• treatment: enucleation
 Odontogenic cysts
• RTG diff. dg. of jaw radiolucency
– anatomical structures (maxillary sinus, foramina)
– odontogenic cysts
– odontogenic tumors, part. ameloblastoma
– giant cell granuloma / cherubism
• wall thickenings
– cholesterol clefts + granulomas
– carcinoma
– ameloblastoma
 Odontogenic cysts
• daily biopsy practice
• nonspecific findings – inflammation !!!

• x odontogenic keratocyst
• x calcifying odontogenic cyst
• x unicystic ameloblastoma
• x other cystic tumors
 Nasopalatine duct cyst
• uncommon, often asymptomatic
• from nasopalatine duct epithelium
• midline of palate
• position variants (to incisive canal)
– nasopalatine
– palatine papilla
– median alveolar
• Mi: squamous + respiratory epithelium
wall: mucous glands + neurovascular bundle
• enucleation
 Nasolabial cyst
• = Klestadt´s, nasoalveolar
• very uncommon
• middle-aged females
• from remnants of nasolacrimal duct
• in soft tissue deep in nasolabial fold
• excision
 Surgical ciliated cyst
• maxilla
• site of injury or operation (incl. extraction)
• Caldwell-Luc surgery
• cyst lining = mucosa of maxillary sinus
• respiratory epithelium
• enucleation
 Cysts of soft tissues
• thyroglossal duct cyst

• lymphoepithelial cyst

• lingual dermoid

• mucocele
 Thyroglossal duct cyst
• uncommon
• from remnants of any part of thyroglossal duct
• early age
• swelling in midline of mouth (foramen caecum) or
neck
• Mi: squamous + respiratory epithelium
wall: thyroid tissue, chronic inflammation
• removal + part of hyoid bone
 Lymphoepithelial cyst
• branchiogenic cyst ???
• cystic change of epithelium entrapped in LN
• early age
• lateral part of neck + mandible angle + parotid
• soft swelling
• fistula to skin / oral cavity / pharynx
• Mi: squamous + respiratory epithelium
wall: dense lymphoid tissue + germ centres
• enucleation
• diff. dg.: cystic metastasis of SCC !!!
 Sublingual dermoid
• developmental anomaly of branchial arches or
pharyngeal pouches
• between hyoid and jaws or beneath tongue
• no symptoms
• Mi: epidermoid cyst – NO dermal appendages
dermoid cyst – dermal appendages
• dissection
 Mucoceles
  minor salivary glands
  lower lip
• superficial, 1 cm swellings
• extravasation type – damage of duct
– saliva leak  inflammation + mucophages
– NO epithelium  mucofagic granuloma
• retention type – obstruction of duct
– epithelium of dilated duct
 Mucoceles
• ranula (Lat. “small frog“)
= mucocele of submandibular or sublingual
gland
• unilateral painless swelling, 2-3 cm
• floor of mouth