GREETINGS
SWAMI VIVEKANAND SUBHARTI UNIVERSITY.
MEERUT
CYSTS OF THE JAWS
DIAGNOSIS AND MANAGEMENT
Dr.VISHAL BANSAL
(Professor and Head)
Subharti Dental College
Latin - Cystis Greek – Kurtis Meaning a pouch, bag, bladder
A “cyst” is defined as a pathological
cavity usually but not always lined
by epithelium containing fluid,
semisolid or gaseous material and
which is not formed by accumulation
of pus.
Pathogenesis of cyst
1. Initiation
2.Cyst formation
3.Cyst enlargement
Dental lamina will proliferate and forms the tooth
OKC GINGIVAL CYST OF NEW BORN GINGIVAL CYST OF ADULT LATERAL PERIODONTAL CYST GLANDULAR ODONTOGENIC CYST
CELL RESTS OF SERRES
DENTIGEROUS CYST
ERUPTION CYST
LATERAL PERIODONTAL CYST
AOC
CEOC REDUCED ENAMEL EPITHELIUM REMNANTS
OKC
Offshoots of basal cells of Oral epithelium
PERIAPICAL CYST
RESIDUALCYST
RESTS OF MALASSEZ
Cyst Enlargement
1. Attraction of fluid into the cystic cavity
2. Retention of fluid within the cavity
3. Production of raised internal hydrostatic pressure
4. Resorption of surr. bone with an increase in size of bony cavity
According to Harris cyst enlargement
1. Mural growth
Peripheral cell division
Accumulation of cellular content
2. Hydrostatic enlargement
Secretion
Transudation/exudation
Dialysis
3. Bone resorbing factors
Peripheral enlargement of a cyst Enlargement results from division of the lining epithelial cells
Peripheral cell division
Cyst of Oral & Maxillofacial tissues
Cysts of jaws
Cysts associated with maxillary antrum
Cysts of soft tisuues of face, neck and
salivary glands
Cysts of Jaws
Epithelial
Developmental
Odontogenic
(arising from odontogenic tissue)
Non-odontogenic
(arising from ectoderm involved in development of facial tissues)
Inflammatory
Non-epithelial
Classification A. Epithelial Lined Cysts
1. Developmental
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
b. NON-ODONTOGENIC
i. Midpalatal raphe cyst of infants
ii. Nasopalatine Duct (Incisive Canal) Cyst
iii. Nasolabial Cyst
2. Inflammatory origin
i. Radicular cyst, apical and lateral
ii. Residual cyst
iii. Paradental cyst and juvenile paradental cyst
iv. Inflammatory collateral cyst
B. Non-Epithelial cysts
1. Solitary bone cyst
2. Aneurysmal bone cyst
II. Cysts associated with the maxillary antrum
1. Mucocele
2. Retention cyst
3. Pseudocyst
4. Postoperative maxillary cyst
III Cysts of the soft tissues of mouth, face and neck 1. Dermoid and epidermoid cyst
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 cysts; cysticercus cellulosae; trichinosis
Clinical Presentation of cysts Asymptomatic when small (less than 2cm)
Swelling- slowly enlarging, painless unless infected
Facial asymmetry; obliteration of furrows on face
Frequent fractures of dentures or displacement of dentures
Migration/mobility of adjacent teeth/non-vital
teeth/retained/missing tooth
Pain- only when acutely infected
Discharge- salty taste/maxillary sinusitis
Paresthesia-if fracture occurs or infection causes sudden
increase in pressure over nerve
To rule out solid/cystic lesions
Differentiate between antrum and lesion
Straw- coloured with shiny cholesterol crystals- Dentigerous cyst
Golden-yellow colored fluid---- Radicular cyst
Whitish- if infected or keratocyst
Blood – hemangioma/ aneurysmal bone cyst
Serosanguinous or gas – simple bone cyst/ maxillary antrum
Putty like – keratocyst/dermoid
ASPIRATION
Straw- colored fluid
Golden yellow fluid – Radicular cyst
White cheesy material
Black-colored fluid
CYST CONTENTS
• Fluid comprising cellular breakdown products:
• Serum proteins (usually <4gm/100ml in OKC)
• Water and electrolytes
• Cholesterol crystals
• Parakeratinized squames(OKC)
Radiological Features
Round structureless radiolucency with continuous radiopaque margin.
Infection causes loss of radio opaque margin
Root resorption may be seen
Inferior dental nerve may be displaced
Differential anatomic landmarks
Mental foramen
Incisive foramen
Maxillary antrum
Nasal fossa
Reasons to treat cyst --
Increase in size – cause – facial deformity & destroy surrounding bone
Eventually become infected.
Objective of treating cyst--
Removal of lining or re-arrangement of position of
abnormal tissue to ensure its elimination from the jaw
Conservation of healthy teeth
Preservation of adjoining vital structures like
neurovascular bundle, integrity of maxillary antrum
Restoration of affected area to its original form and
shape by enucleation or marsupialization
General Principles of Management
Parstch I (1892) Marsupialization
Old & Medically compromised patients; cyst involving apices of many teeth, involved teeth need to erupt in oral cavity. Large cyst where enucleation may cause # of jaw
Whole lining cannot be removed or required for histopath; may result in incomplete removal
Long term care
Parstch II (1910) Enucleation
Small cyst; mural lesion, fissural cyst or OKC
Full specimen available for histo path
Early restoration of function
Other considerations in treatment
Extraction of involved teeth
RCT and apicoectomy of involved teeth
Drainage of dead space
Marsupialization of large maxillary cyst into
antrum - Nasal Antrostomy may be required
GINGIVAL CYST OF INFANTS • Small, superficial keratin-filled cysts
• Found on the alveolar mucosa of infants.
•Appears discrete white swelling
•Can be single or multiple.
•Arise from remnants of the dental lamina.
• Disappear spontaneously by rupture into the oral cavity
• Similar inclusion cysts (e.g., Epstein' s pearls and Bohns nodules) are also found in the midline of the palate or laterally on the hard and soft palate.
DENTIGEROUS CYST / FOLLICULAR CYST
Coined by Paget in 1863
The dentigerous cyst is defined as a cyst that originates by the
separation of the follicle from around the crown of an unerupted
tooth .
Most common type of developmental odontogenic cyst
Develops by accumulation of fluid between the reduced enamel
epithelium and the tooth crown.
Frequency --- 1.44 cyst for every 100 unerupted tooth.
The cyst nearly always involves or is associated with the crown of
a normal permanent tooth.
Seldom involves a deciduous tooth.
CLINICAL FEATURES With the crown of impacted tooth, may be found with
complex or compound odontoma or involving the
supernumery teeth.
Most common site mandibular and maxillary molar area
and maxillary cuspids .
Most lesions present in second and third decade with slight
male predilection
Male female ratio 3:2
Most dentigerous cyst are solitary,,Bilateral and multiple cyst
found in association with number of syndromes including cleido
cranial dysplasia, maroteaux- lamy syndrome
Potentially capable of becoming an aggressive lesion.
Expansion of bone with subsequent facial asymmetry, extreme
displacement of teeth, root resorption of adjacent teeth and
pain are possible sequel by continued enlargement of cyst.
RADIOLOGICAL FEATURES Unilocular radiolucent area that is associated with the
crown of an unerupted tooth.
The radio lucency usually has a well-defined and often
sclerotic border, but an infected cyst may show ill -
defined borders.
A large dentigerous cyst may give the impression of a
multilocular process because of the persistence of bone
trabeculae within the radiolucency.
Infected Dentigerous cyst
The Central variety
The lateral variety is usually associated with mesioangular impacted mandibular third molars that are partially erupted.
In the circumferential variant, the cyst surrounds the crown and extends for some distance along the root so that a significant portion of the root appears to lie within the cyst .
DIFFERENTIAL DIAGNOSIS
Ameloblastoma or ameloblastic fibroma
If the cyst involving the anterior maxilla
adenomatoid odontogenic cyst would be
the prime consideration in young patient
Cyst involving maxillary antrum
ODONTOGENIC KERATOCYST /KOT
Robinson-----term primordial cyst.
The term Keratocyst was coined by Philipsen in 1956 based on
the histologic appearance of the lining.
In 2005 WHO - KOT because of High mitotic activity, Epithelial
turnover rate and prostaglandin induced bone resorption.
More common in the mandibular third molar and ramus region.
CLINICAL FEATURES
Peak incidence in second and third decade.
More frequently in males specially in black
Asymptomatic unless infected .
On aspiration odourless creamy or caseous content.
Maxillary OKC tends to be secondarily infected due to
close proximity to maxillary sinus.
Multiple OKC found in:-
Gorlin goltz syndrome
Marfan syndrome
Ehler-Danlos syndrome
RADIOGRAPHIC FEATURES
Mainly unilocular presenting well defined
peripheral rim, may contains the crown of
retained tooth.
Multilocular OKC also observed with scalloping of
borders.
In some cases produce the root resorption.
DIAGNOSIS Aspiration – cheesy material
keratin flakes
Protein content - <4 gm/100 ml
Lactoferin also present some times in
keratocyst fluid
Biopsy- Parakeratinized and Orthokeratinized.
DIFFERENTIAL DIAGNOSIS Dentigerous cyst
If cyst in ant region- adenomatoid odontogenic cyst
Unilocular primordial origin keratocyst resembles a lateral periodontal cyst, if located b/w premolars
Multilocular presence with ameloblastoma/odontogenic myxoma/ central giant cell tumor
Less common but well known to be central arteriovenous hemangioma.
Recurrence Thin fragile epithelium
Incomplete removal/ residual cystic lesion gives rise to
new cyst formation (microcysts, daughter cysts)
New keratocyst develop from epithelial offshoots of basal
layer of oral epithelium – satellite cysts
High recurrence is seen in area associated with teeth
were not removed during surgery.
Continuous formation of new cysts in patients with basal
cell nevus syndrome
TREATMENT
Recurrence rate
14.3% in 28 patients
(Paul Edwards JOMS
2006)
0% IN 10 cases Pogrel
et al JOMS
62:651:2004
Marsupialization
ENUCLEATION AND CURETTAGE recurrence rate 17.79% (Zaho et.al 000 2002)
18% Stoelinga PW (JOMS 63;1662; 2005)
Pre op
Post op
ENUCLEATION AND PERIPHERAL OSTECTOMY Recurrence rate is 18.2% (Morgan et al JOMS 63;635:2005
ENUCLEATION AND CHEMICAL CAUTERIZATION result in cell death and necrosis and penetrates bone depth 1.54 mm after 5 minutes. Common disadvantage is injury to nerve if exposure >5 min and necrosis of surrounded tissue. Recurrence rate 2.5% in 40 cases Voorsmit et al( JOMS 1981) 6% (Stoelinga PW. JOMS;63:1662: 2005)
Carnoy’s Solution Absolute alcohol 6 ml Chloroform 3 ml Glacial acetic acid 1 ml Ferric chloride 1gm
ENUCLEATION AND CRYOTHERAPY
Liquid nitrogen produce cellular necrosis in bone while preserving in organic osseous framework and maintain the osteogenic and osteoconductive properties.
Cycles - 1- 5- 1- 5 F – T - F- T
Bone depth 0.82 mm <20 degree
centigrade cell death . Recurrence rate 11.5 % in 26
cases Brain et al (JOMS 2001)
Advantages of Marsupialization followed by Enucleation
Keratocyst lining is transformed into nonkeratinizing epithelium-less aggressive nature.
Decrease interleukin alpha level one of the factor in OKC enlargement.
Cyst lining becomes thickened and thus easy to enucleate.
Cost effective.
RESECTION Marginal or segmental in most extensive form 0% recurrence rate used in aggressive and recurrent cases.
ERUPTION CYST
The eruption cyst is the soft tissue analogue of the
dentigerous cyst.
Mostly seen in children with eruption of primary or
permanent incisors and molars.
Manifestate as expansile and compressible swelling.
Lateral periodontal cyst/OKC 1.Primordial cyst arises from dental lamina rests.
2.Lies within the interadicular crestal or mid root level bone.
3.Tear drop unilocular radiolucency, no root resorption and
divergence of roots.
4.Tooth will be vital, no mobility of teeth.
Calcifying odontogenic cyst COC like OKC clinically, radiographically and
histopathologically is a unique specific cyst.
Unlike OKC it has a less aggressive behavior with
little recurrence potential.
Pathogenesis- cell responsible are dental lamina
rests(rests of Serres). COC are of primordial origin
and are not associated with impacted teeth.
Radiographic features- 3 types of pattern-
A. Salt and pepper pattern of flecks
B. Fluffy cloud like pattern throughout
C. Crescent shaped pattern on one side of radiolucency in a New Moon like configuration.
Odontogenic ghost cell tumor
ADENOMATOID ODONTOGENIC CYST
Cystic hamartoma arising from odontogenic epithelium.
It has a lumen lined by epithelium from which proliferation fill much and some time all the lumen space mimicking a solid tumor.
CLINICAL FEATURES
Cyst will present expansile lesion usually in anterior region of either jaw.
some time referred as two third tumor because two third occur in maxilla ,
In young women ,
two third in anterior maxilla
two third with canine tooth. It may be discovered by rapid clinical expansion
NASOPALATINE DUCT CYST / INCISIVE CANAL CYST/MEDIAN PALATINE CYST
Arise from the epithelial remnants of the two embryonic nasopalatine ducts.
Tooth Vitality test
DIFFERENTIAL DIAGNOSIS Periapical granuloma
Radicular cyst
Mesiodens
Rare entity chondrosarcoma
TREATMENT
Best treated by enucleation
NASOLABIAL CYST / NASOALVEOLAR CYST
Soft tissue cyst originating from embryonic epithelial elements of nasolacrimal duct.
Swelling of the upper lip lateral to the midline, resulting in elevation of the ala of the nose.
Obliterates the maxillary mucolabial fold .
RADICULAR CYST Most common cyst.
Inflammatory cyst associated with the root apex of non vital tooth due to high incidence of pulpal pathology
Can occur at any age but seldom seen in children despite the high incidence of pulpal and periapical pathology in this group, which implies that these are few in any epithelial rests that result from the development of primary teeth.
Causes—carious tooth, previous restoration, failure of RCT, trauma.
CLINICAL FEATURES 60% of jaw cyst are radicular cyst
The tooth is seldom painful or even sensitive to percussion. Rarely produce expansion of cortical bones . In some cases such a cyst of long standing may undergo acute exacerbation of the inflammatory process and develop rapidly into an abscess that may proceed to cellulitis or form a draining fistula. The incidence is high in maxilla most frequently located anteriorly Male prediliction .
Radiographic features Round or oval RL with marked sclerotic
margin.
Less than 2 cm is periapical granuloma.
Rarely root resorption is seen.
Differential Diagnosis
Periapical granuloma
In early osteolytic phase-----Periapical cemento-osseous dysplasia
RESIDUAL CYST
Radicular cyst that is retained in the jaws after removal of the associated tooth.
SOLITARY BONE CYST/ HEMORRHAGIC BONE CYST/ TRAUMATIC BONE CYST
Benign, empty, or fluid containing cavity within bone
that is devoid of an epithelial lining.
Proposed theory - Trauma to the bone that is insufficient
to cause a fracture results in an intraosseous hematoma.
If the hematoma does not undergo organization and
repair, it may liquefy, resulting in a cystic defect.
CLINICAL FEATURES Simple bone cysts with in the jaws are
common more common in the premolar and molar areas. Mostly in patients between 10 and 20 years of age. The lesion is rare in children under age 5 yrs Seldom seen in patients over age 35. Simple bone cysts of the jaws are essentially restricted to the mandible. May be seen in maxilla.
DIFFERENTIAL DIAGNOSIS Odontogenic keratocyst confirm by aspiration Enlarged medullary cavity and Gauchers disease.
CAVITY CONTENTS Cavities are usually empty but may contain
golden yellow fluid, clot when present indicates a recent haemorrhage.
MANAGEMENT Intra lesion steroid injections or thorough surgical curettage.
Simple surgical exploration to establish the diagnosis is usually sufficient therapy.
ANEURYSMAL BONE CYST Term first used by Jaffe and Lichtenstein in 1942.
Term Aneurysmal used in context relates to Blow Out distension of
affected bone area.
Etiopathogenesis-
1.Modification of some other lesion of bone most of which had been
destroyed by haemorrhage(CGCG and fibrosseous lesion).
2. Result of some of the vascular disturbances.
C/F-
1. Peak incidence in 2nd and 3rd decade of life.
2. Most common site is
angle and ramus of mandible.
3. Rapid growth.
4. Pain?
5. History of trauma?
6. Mobility of teeth
Treatment modalities
1. Curettage – 53% - 68% of recurrence.
2. Curettage with cryotherapy- decrease recurrence
3. Radiotherapy- chances to develop sarcomatous changes
4. Resection and reconstruction- 8% of recurrence
Thyroglossal tract cyst
Arise from stimulated residual epithelial cells from
descent of embryonic oral epithelial cells.
60% occur in midline over the thyrohyoid
membrane.
2% occur in tongue deep to foramen cecum
23% occur in midline below the level of thyrohyoid
membrane.
Clinical features
Doughy round mass with smooth
rounded surface
Moves with hyoid bone when
patient swallows
Diagnostic radiographs
CT, MRI can confirm cyst’s fluid
filled center
Treatment
SISTRUNK PROCEDURE Horizontal neck incision- will protrude from between two sternohyoid muscles. Fluid is aspirated and equal volume of soft tissue liner or alginate is filled. It prevents collapse of cystic spaces and helps pericapsular dissection, thus cyst is separated from its surrounding tissues. Body of hyoid is resected and residual tract deep to it is clamped and ligated.
Branchial cyst
Residual or buried epithelium from branchial cleft.
Alternative- epithelium of salivary origin, becomes embryonically entrapped with in cervical lymph nodes and later undergoes cystic degeneration.
Arise rapidly 1-3 weeks as a mass in neck, just anterior and deep to SCM.
Diagnostic- 1.Brown watery fluid on aspiration. 2.FNAC
Diagnostic workup- 1. Metastatic squamous cell carcinoma 2. Hodgkin’s lymphoma 3. Tubercular lymph nodes
Treatment- Excised by pericapsular
dissection.
Dermoid Cyst Uncommon in maxillofacial region- 2% Most commonly found in submental triangle external or oral to mylohyoid muscle. Painless compressible and mobile. Double chin appearance. Displace the tongue and interferes
with speech.
Diagnostic work up- straw coloured fluid or semisolid mixture of keratin
D/D-
Ranula
Sublingual salivary gland tumor
T/T-
Removed by transoral and transcutaneous approach.
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