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Home , Cysts of the jaws

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 “” 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 OKC  OF NEW BORN CELL GINGIVAL CYST OF ADULT RESTS  OF GLANDULAR ODONTOGENIC SERRES CYST

ERUPTION CYST

LATERAL PERIODONTAL CYST

AOC REDUCED CEOC ENAMEL EPITHELIUM REMNANTS Offshoots of basal cells of Oral OKC epithelium  RESTS OF MALASSEZ RESIDUALCYST

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. 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 EnlargementPeripheral results cell from division division of the lining epithelial cells

Cyst of Oral & Maxillofacial tissues of jaws

Cysts associated with maxillary antrum

Cysts of soft tisuues of face, neck and

salivary glands Cysts of Jaws

Non- Epithelial epithelial

Developmental Inflammatory

Odontogenic Non-odontogenic (arising from odontogenic (arising from ectoderm involved in tissue) development of facial tissues) Classification A. Epithelial Lined Cysts 1. Developmental a. ODONTOGENIC i. Gingival Cyst of infants ii. Odontogenic iii. Dentigerous Cyst iv. Eruption Cyst v. Gingival Cyst of adults vi. Developmental lateral periodontal cyst vii. Botryoid viii. Glandular odontogenic cyst ix. Calcifying odontogenic cyst b. NON-ODONTOGENIC

i. Midpalatal raphe cyst of infants

ii. Nasopalatine Duct (Incisive Canal) Cyst

iii. 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 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. 7. Nasopharyngeal cyst 8. Thymic cyst 9. Cysts of the salivary glands: mucous extravasation cyst; mucous retention cyst; ; 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 causes sudden increase in pressure over nerve ASPIRATION

To rule out solid/cystic

Differentiate between antrum and

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

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 II (1910) Parstch I (1892) Enucleation Marsupialization Small cyst; mural lesion, Old & Medically compromised fissural cyst or OKC patients; cyst involving apices of many teeth, involved teeth need to erupt in oral cavity. Large cyst where enucleation may cause # of jaw Full specimen available for Whole lining cannot be removed histo path or required for histopath; may result in incomplete removal

Long term care 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 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 or involving the supernumery teeth.

Most common site mandibular and maxillary 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

If the cyst involving the anterior adenomatoid odontogenic cyst would be the prime consideration in young patient

Cyst involving maxillary antrum /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 /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 Marsupialization

Recurrence rate 14.3% in 28 patients (Paul Edwards JOMS 2006) 0% IN 10 cases Pogrel et al JOMS 62:651:2004

ENUCLEATION AND CURETTAGE recurrence rate 17.79% (Zaho et.al 000 2002) Pre op 18% Stoelinga PW (JOMS 63;1662; 2005)

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 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 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 . 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/

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 . 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  3. Tubercular lymph nodes Treatment- Excised by pericapsular dissection. 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. THANK YOU