3. Odontogenic & Non-Odontogenic Cysts

Question 1

Definitions
•  CYST
–  Pathologic cavity lined by ____
–  Epithelium may be of any ____

•  Odontogenic cysts
–  Epithelium derived from
remnants of \_\_\_\_ development
•  Non-odontogenic cysts
–  Entrapped epithelium during \_\_\_\_, surgery, etc

Odontogenic cysts: When we say its odontogenic, it implies this cyst is derived from structures that gave rise at some point to tooth structure. These are cysts within the jaw bone that are derived from epithelium that got left behind during tooth development Reads definition of a cyst

Soft tissue cysts are different category of cysts that we learned about before In the jaw bone we can see both odontogenic and non-odontogenic
If it is non-odontogenic, the epithelium that gave rise to cysts is not derived from epithelium
◦
that was left behind during tooth development
We will only talk about one of those today ◦

Answer 1

epithelium
type
tooth
embryogenesis

Question 2

But any epithelium in the picture, after development may be left behind to lay dormant in jaw bone Through whichever mechanism, once tooth becomes ____- that epithelium becomes reproliferative to give rise to cystic structure in jaw bones
There are a whole array of mechanisms that he wont ask us about

Answer 2

inflamed

Question 3

Paradental cyst: always/only found ____ to fully or partially impacted ____
Always ____ attached and distal to partial or fully impacted 3rd molar
Its ____ cyst

◦ Dentigerous cyst: always physically attached to fully ____ tooth, around crown of tooth
always attached at level of ____

Lateral periodontal cyst: always ____ (egg or ovoid shaped) lucency, between the roots of two teeth
Teeth are typically the ____

◦ Radicular cyst: cyst found at ____ of tooth typically
◦
By definition tooth is ____

Answer 3

distal
third molar
physically
inflammatory

impacted
CEJ

unilocular
mandibular premolars

apex
dead

Question 4

Primordial cyst: cyst that develops in the ____ of a tooth
Usually the teeth missing are ____ teeth. Instead of a tooth you see a well defined ____ lesion that is described as a primordial cyst
DX: For any of these lesions, can’t define these as cysts until we know they are cysts ____
Radiographically its differential diagnosis, not diagnosis
If you see this lesion radiographically, in place of missing third molar, think perhaps it’s a primordial
cyst, then you do bx, and you see its cystic, then you know its primordial cyst

Botroid cyst: same place where lateral periodontal cysts was located, between the roots of two teeth typically in the \_\_\_\_
\_\_\_\_ cyst (soap bubbles or bushel of grapes)

Eruption cyst: Basically ____ cyst that has partially erupted
Clinically you’ll see lesion in oral cavity, in soft tissue, in the gums, reflective of cystic lesion wrapped around tooth ____. ie. dentigerous cyst around tooth that is partially erupted
See ____ lesion and ____ lesion
◦ Cyst occurs only in ____, because teeth are still developing. Will never see this in adult pt

Residual cyst: Cyst that gets left behind after ____
Most commonly teeth are ____ because they are inflamed or dead or impacted teeth

Answer 4

place
third molar
unilocular
microscopically

mandibular premolar
multilocular

dentigerous
crown
bone
soft tissue
kids
extraction
extracted

Question 5

All of the above lesion except ____ (7), could be either 9 or 10 on list - glandular odontogenic cyst (GOC) or odontogenic keratocyst (OKC) These are the only lesions that look as expansive as this
OKC and GOC can look like anything except for number 7. ie. they don’t look like eruption cysts

◦
Eruption cyst in a kid can impede eruption of tooth fully - Make sure tooth gets fully errupted in oral cavity Inflammatory cysts: are ____, ____ and ____ cysts
the others are not inflammatory

Answer 5

eruption cyst

paradental
radicular
residual

Question 6

Learn differences or uniqueness NOT similarities

◦ radicular cysts

• what is not unique: epithelial lining is not unique, its just cystic structreu
  unique: always at ____ of tooth, and that tooth is always ____
• dentigerous cyst
  Always found around crown of impacted tooth, always a>ached at ____.
  What dis9nguishing that cyst versus radicular cyst is ____ LOCATION
  (around crown versus apex)
  Still a cyst- cyst itself is not dis9nct, any lining can line cysts
• botryoid cyst
  Always ____, always found between roots of two teeth, typically
  ____- that is unique
  If lesion is mul9locular, but in different loca9on, not considered botryoid ◦ Ex: den9gerous cyst

Answer 6

apex
dead

CEJ
anatomic

multilocular
mandibular premolar

Question 7

Radicular cyst

•   Most common ____ cyst
•   Most common ____ cyst

◦
By definition tooth is ____
Radicular cyst: cyst found at ____ of tooth typically

Answer 7

odontogenic
inflammatory
dead
apex

Question 8

Buccal bifurcation cyst
•  \_\_\_\_ cyst
•  \_\_\_\_ surface of molar teeth
•  Well-\_\_\_\_, unilocular
•  May not be visible on routine radiographs
–  Use \_\_\_\_ film

Buccal bifurcation cyst
This is inflammatory cyst with no distinctive histology
◦
Always on buccal root surface of ____ molar ◦ ◦
◦
Couldn’t show it in 2D representation summary slide, but can be seen here
The radiograph shown here is an occlusal film
◦
What is unique is that this cyst is typically found attached at area of tooth ____. This is where inflammation arises
This is always found at buccal surface - found in furcation area

◦ This maxillary molar tooth shown on the right picture- was extracted with buccal bifurcation cyst attached to tooth
In order to see this effectively need to take distinctive radiograph to see (occlusal film)
On ____ film cant see it - couldn’t be seen in cartoon before

Answer 8

inflammatory
buccal
defined
occlusal

lower first
furcation
2D

Question 9

Residual cyst
•  \_\_\_\_ cyst
•  Retained \_\_\_\_ or other cyst
–  Oftentimes history of \_\_\_\_
•  Well-defined, \_\_\_\_
•  Most common cyst associated with
\_\_\_\_ transformation

This was a cyst attached to tooth, at some point (radicular or other cyst), tooth gets extracted and cyst gets left behind, now it’s a residual cyst
Residual cyst is also an inflammatory cyst
Unique: Always unilocular, and always a hx of tooth extraction
Clinically the story is different. ____ has no hx of tooth extraction
If it was a third molar that was extracted then it is not primordial if its found in that area- that could be
residual cyst potentially
◦ Radiographically no diff from ____ cyst that forms in space of missing tooth
◦
◦
With residual cyst, there is always a history of tooth extraction ‣

◦ Repeats again: Of all the cysts in jaws- may be associated with transformation to cancer just because of ____ of it within the jaw, but not because of actual cyst itself What you see here is well defined unilocular lesion in the space where tooth would be History: tooth was extracted at some point in his life
Of all the cysts we talk about- this one is most commonly associated with eventual cancer formation
Its not a ____ lesion, but residual cysts get left behind perhaps for years without recognizing there
◦
is a lesion there
Because of its duration there is a risk (small) for cyst to become malignant

Answer 9

inflammatory
radicular
extraction
unilocular
malignant

primordial
primordial
duration
precancerous

Question 10

Dentigerous cyst
•  \_\_\_\_ cyst
•  Associated with crown of impacted tooth
–  \_\_\_\_  molars
–  \_\_\_\_ canines
–  \_\_\_\_  molars
–  \_\_\_\_  premolars
•  Attached at level of \_\_\_\_

Dentigerous cyst is always found around crown of impacted tooth This is considered developmental cyst, not inflammatory cyst. ____ didn’t cause this cyst, this cyst developed from tooth follicle This needs to be addressed because cyst can ____ the teeth- if left untreated the cyst can continue to expand, and may cause displacement of adjacent and associated teeth as well as root resorption
To treat this kid- deciduous molar had to be extracted, needed ortho treatment, exposed bone to help bring tooth into occlusion - surgical and ortho approach to therapy

the teeth that are most commonly impacted are associated with dentigerous cysts (reads list)
Any tooth that is ____ may harbor this kind of cyst around the crown ◦
‣
Draws this picture on the board: this is tooth, this is CEJ. its around, physically attached This was tooth follicle that became cystic over time

◦ How did that happen- we don’t know it’s the ____ most common thing you’ll see in clinical practice ◦
But its physically attached to tooth at the level of the CEJ

Answer 10

developmental
mand third
max
max third
mand second
CEJ

inflammation
displace
impacted
second

Question 11

Dentigerous cyst

•   Well-defined, ____
•   Crown projects into cyst lumen

____, ____, and other odontogenic tumors may also be associated with impacted teeth

Answer 11

unilocular
OKCs
ameloblastomas

Question 12

These cysts are well defined and unilocular, so these aren’t distinctive features that you need to memorize (???) This statement in yellow- will come into clarity in the next lecture
This is canine that was extracted with dentigerous cyst attached to tooth Base of this lesion attached at level of where crown meets the root
◦
Cut lesion open to show crown of tooth is sitting inside cyst itself, physically attached at level of the CEJ

DX: Dentigerous cyst is not radiographic diagnosis. It is radiographic plus ____ diagnosis
Need to see ____ to call it a cyst, need to see cystic lining
◦ DDX: It could be ____, true tumor- neoblastoma or other possibilities that manifest as radiolucency around the tooth
Dentigerous cyst will be included in differential diagnosis but its not diagnosis. Until you know its ____, just differential diagnosis
◦

Answer 12

pathologic
histo
odontogenic keratocyst
cyst

Question 13

Eruption cyst
•  Usually ____ and kids
•  ____ gingival mass
•  No ____ needed unless infected

Eruption cyst is a dentigerous cyst, but its ____ erupted These need intervention
Lesion is preventing ____ of tooth completely
Can see from picture this is a young kid, lateral hasn’t erupted yet

◦ Within differential diagnosis would include the ____
This warrants biopsy, because it looks like 3Ps, but its not
This warrants a radiograph to ensure its not coming from within jaw bone
If it was (in this case it is) -not 3Ps (I’m not sure what he’s talking about here)

Often these will ____ on their own
If tooth keeps erupting, it may go away
◦
It tooth not erupting properly, may warrant taking a scalpel and make a little hole- release fluid
◦
that is preventing tooth from erupting. Then tooth will erupt

Answer 13

infants
bluish-purple
treatment

preventing
eruption
3Ps

resolve

Question 14

Lateral periodontal cyst
•  MD \_\_\_\_ region
–  MX \_\_\_\_ region
•  Well-defined, \_\_\_\_
–  Multilocular 
– \_\_\_\_ odontogenic cyst
•  Teeth are \_\_\_\_

Lateral periodontal cyst, is also not inflammatory cyst unique:
This one has a ____ histology (see below)
Diagnose cyst, without knowing location radiographically lining is characteristic: that feature you need to know for this cyst
Also has distinct anatomic location
mandible: most commonly canine, premolar maxilla: lateral incisor, canine found between roots (distinctive)
always unilocular

lesion shown is well circumscribed, unilocular lesion between ____ roots vitality of the teeth eliminates radicular cyst from ddx
If one of 2 teeth is non vital, doesn’t rule of ____ cyst
◦
Summary: Lateral periodontal cyst is non ____, commonly found between vital teeth. If teeth vital, it is
never ____ cyst by definition. If one or both are non vital - doesn’t rule out lateral periodontal cyst

Answer 14

canine-premolar
lateral-canine
unilocular
botryoid
vital

distinctive
two
lateral periodontal
inflammatory
radicular

Question 15

(BOC) botryoid cyst: same ____, same distinctive histo
Only difference- botryoid is ____
◦
Location and histo are the same (between teeth) ◦
◦
Last picture shows botryoid cyst next to root of tooth

What else might be included in differential of the right picture
____: Looks like tooth extracted
◦
‣
Residual cysts are ____- but would be included in differential because in the place of previously extracted tooth

Answer 15

location
multilocular
residual cyst
unilocular

Question 16

LPC / BOC
•  Distinct histology
–  Thin \_\_\_\_ lining
–  \_\_\_\_-like thickenings
•  Higher recurrence for \_\_\_\_

Don’t need to recognize histo for this but know there is distinct histo Areas that are thin lining- thinly lined areas with areas of thickening Alternating thin thick identifies cyst under scope “focal plaque like thickenings”

Answer 16

epithelial
focal plaque
BOC

Question 17

Gingival cyst
• Usually ____ gingiva
• 70% MD ____ region
• No ____ findings

There is a soft tissue counterpart to that cyst that occurs only in the gingiva in the same region being premolar or canine region in the mandible and maxillary jaw usually lateral incisor or canine region.

But the cyst in this case is strictly in the gingiva, NOT within the bone, not perforating thru the bone. We call these gingival cysts, which have the same ____ as the lesions occurring in the bone, but these occur in the soft tissue.

Back in Mod 1, the online tutorial had gingival cysts in the newborn, those are different since those are tiny lesions on the ridges of the newborn babies that are Orthokeratinized cysts which do resolve on their own. These cysts are NOT ____ cysts

Answer 17

buccal
canine-premolar
radiographic

histology
keratinizing

Question 18

Glandular odontogenic cyst
• Develops most commonly in ____ jaws
• Contains ____ cells and “____” spaces in epithelial lining

This is a glandular odontogenic cyst. It is thought that the LPC, BOC and glandular odontogenic cyst are part of a common clinical and pathological spectrum, this lesion being on the far end of that spectrum.

This lesion (as described in earlier cartoon, in the previous lecture?) being a lesion which manifests in any which way it wants to: around the ____ of a tooth, at the apex of a tooth, between teeth, completely ____ of tooth structure. How these lesions present themselves is NOT the defining criteria for this pathology.

Answer 18

anterior
mucous
pseudocystic
crown
independent

Question 19

Glandular odontogenic cyst

At one point the endodontist referred the patient to the oral surgeon for biopsy only to find a whole, different diagnosis all together, not ____ pathology in nature, this being a glandular odontogenic cyst. This has distinct histology (which he can diagnosis without looking at the ____) and what is most distinctive is (two features) the cyst-lining includes mucous cells aka ____ cells, which are the purple-ish/blue-ish cells (yellow arrows) and the second defining feature are the presence of spaces within the cyst-lining (red stars), they may not be entirely empty but there are spaces.

These are pseudo cystic spaces, they are not cysts within the cysts, just ____ within the lining itself. These two features: mucous cells within the lining and pseudo cystic spaces are what define this lesion microscopically, not radiographically, but ____. This is the far end of the spectrum that includes LPC, BOC and this lesion as well. Thought to have all been derived from a common ____ using the same pathogenic mechanism but in this case they grow a bit differently and have a somewhat different histology than the other two lesions.

Answer 19

inflammatory
radiograph
goblet
spaces
microscopically
precursor

Question 20

I can talk a bit about treatment, when you treat an intraosseous, radiolucent lesion (this will be discussed further later in the lecture), just like in soft tissue we have patient’s who can develop hemangiomas which are benign vascular tumors which are biopsied in a controlled setting (not in the office) for fear of significant bleeding, you can also get ____ within the jaw bone (basically, any bone). When they occur in the bone, they manifest no differently than what is seen here as a ____ lesion either unilocular or multilocular and before you biopsy a fairly large lesion (as shown the left most image on the previous slide) surgeons will always ____ first

Answer 20

hemangiomas
radiolucent
aspirate

Question 21

When you aspirate, if it is ____ blood like going to a vein, then you would want to stop the procedure and take the patient to the OR or hospital setting where that procedure can be performed under a more controlled setting, in case there is a more significant bleed.

Answer 21

free flowing

Question 22

If there is no blood that you are aspirating, then you can go on with the biopsy. That is a critical step before biopsy of radiolucency’s. That
extra step only applies to ____ it does not apply to radiopacities because radiopacities are not ____ by definition

Answer 22

radiolucencies

hemangiomas

Question 23

In this case,
____ applies to when you take a huge chunk of bone around the lesion or you take a curette and scoop the lesion out creating a little
window in the bone/hole in the bone to gain access and this serves, potentially, as both a diagnostic and curative procedure, if it was removed entirely and benign. alternatively, the patient with the lesion in the left most picture would entail an ____ biopsy.

Answer 23

excisional

incisional

Question 24

Odontogenic keratocyst Keratocystic odontogenic tumor
• Mutation in \_\_\_\_ tumor suppressor gene
• Aggressive \_\_\_\_ potential
• Greater tendency to \_\_\_\_
• May be associated with \_\_\_\_

This is probably the most recognized of all the cystic lesions that occur within the jaw bone because this too has a very distinct histology. In the second to last WHO monograph of odontogenic (jaw bone) pathology, the scientist who reviewed all the jaw bone lesions decided that OKC warranted a reclassification as a ____ tumor and not just a developmental cyst, which historically it was thought to be a developmental cyst. This was done because it turns out that almost all these lesions harbor a mutation in tumor suppressor gene called PTCH.

When a fetus is developing with this mutation in their germline, will go on to develop a syndrome, once it is born, called ____ syndrome. In those patients, PTCH is mutated in the germline, much like neurofibromatosis – neurofibroma is mutated in the germline, Cowden’s syndrome – PTEN is mutated in the germline. In patient’s with nevoid basal cell carcinoma syndrome, PTCH is mutated in the germline and that syndrome is a system-wide disease.

Those patients specifically get ____ within the jaw bones which is PATHOGNOMONIC for that syndrome. Multiple OKCs occurring either at the same time or occurring at ____ times over the course of the patient’s life (two distinct OKCs in the jaw bone either now or later) is pathognomonic for that syndrome/genetic disease even in the absence of any other ____ clinically.

Answer 24

PTCH
growth
recur
syndrome

benign
nevoid basal cell carcinoma

multiple OKCs
different
manifestations

Question 25

OKC

This lesion, on its own, without any other complications, this lesion can occur sporadically as a single lesion either at the apex of the tooth, around the tooth, between teeth, independent of tooth structure, so the ____ presentation is not unique to this lesion.

In the image on the PREVIOUS slide you see a multilocular lesion between two teeth. Radiographically, what else could that be? ANS: a ____. A BOC could look exactly like the lesion shown in the radiographic on the previous slide. He would argue that the lesion on the previous slide was a BOC before an OKC, but without a biopsy you won’t know what it is. In that case it was multilocular but these can be ____ or ____, around the crown, at the base of a tooth, between teeth, independent of tooth structure, these lesions can look almost like ____.

Answer 25

radiographic
BOC

unilocular
multilocular
anything

Question 26

OKC

The difference between these cysts and the other cysts, beyond the fact that they are somewhat unique, is that we have historically know that these cysts have an ____ growth potential. Now going back to finish the story with the WHO monograph (not the one from last year, but the one before that), they re-classified this lesion as KOT (keratocystic odontogenic tumor) to reflect what they thought was neoplastic pathology. In the current WHO update of jaw tumors, they have gone back to original nomenclature of OKC (both are included here, because our board exams are not the most up-to-date, thus they may use either nomenclature, so know both, but he & most refer to these are OKCs – odontogenic keratocysts).

Since we know that tumors do grow & can have an aggressive growth pattern, these lesions, if not treated properly, have a greater tendency to ____ than all of the cysts that occur within the jaw bone. Again this is the only cyst that occurs within the jaws that is known to be associated with a ____ syndrome

This is a radiograph to illustrate this massive multilocular radiolucency in the posterior mandible that shows some proximity/association with this impacted 3rd molar (red star). At the end of the next lecture we will get the most common differential for this type of manifestation which includes OKC. This was an ____ finding, this radiograph was taken, not because there was some kind of swelling, but rather to check the status of these impacted teeth. When we saw the radiograph we saw this lesion (yellow star), that took up the length of his angle extending up until the condyle and coronoid.

Answer 26

aggressive
recur
genetic

incidental

Question 27

OKC

These lesions do not follow a buccal-lingual growth pattern, but rather follow the jaw bone from ____ (up and down & NOT side to side, he draws a picture of the angle of the mandible, inserted above).

Here you see the same type of lesion as on the previous slide. A massive lesion that extended all the way to the coronoid process (yellow arrow) and condyle (orange arrow). He had almost no evidence of any kind of ____ and had almost no idea that the lesion was there. If you have a massive lesion & there is no clinical evidence of the lesion, beyond the radiographic findings, the very top of your differential diagnosis should have ____ (it may not always be OKC, but your differential diagnosis should have OKC at the top). Example question for the radiograph on the PREVIOUS slide: what is your best guess diagnosis? Ans: OKC (& the history would be very clear, if it was that case)

Answer 27

anterior to posterior
swelling
OKC

Question 28

OKC
• \_\_\_\_
– Maybe associated with \_\_\_\_ tooth
• Uni- or \_\_\_\_
• \_\_\_\_ growth pattern

Location points to first bullet point is irrelevant because these lesions can occur ____. That said they do most commonly occur in the posterior mandible. OKCs can occur around the crowns of impacted teeth as can dentigerous cysts (mentioned in previous lecture?). OKCs frequently occur around the crowns of impacted teeth (yellow star indicates impacted tooth). If you have a lucency around the crown of an impacted tooth, you are NOT just thinking ____, you are also thinking OKC & ____ (different pathology, will learn about soon)

Answer 28

posterior mandible
impacted
multilocular
anterior-posterior

anywhere
dentigerous cyst
ameloblastoma

Question 29

OKC- histology
Thin, uniform stratified squamous epithelial lining
Palisaded basal cell layer
Parakeratosis of luminal cells

OKC- histology
Thin, uniform ____ epithelial lining
____ basal cell layer
____ of luminal cells

This pathology has a distinctive histology characterized by 3 main features:

• Most importantly, parakeratosis of the cyst-lining. This is the only cyst that occurs in the jaw bone that is parakeratinized. This parakeratosis of the cyst-lining is pathognomonic for OKC.
• Beyond that, what you will see in biopsy is a rather thin, uniform lining (points to the lining to show the width is fairly uniform as you move from left side to right side) (draws a picture here, included above). Composed of anywhere from ____ cells thick at most between the basal layer and top layer, pretty uniform across the entire cyst lining.
• The luminal cells or surface cells are parakeratinized which is a pathognomonic feature
• The basal cells contain palisading nuclei (aka parallel arrangement of the nuclei in the basal cells)
• This a biopsy that came out as strips, the next slide has a better looking biopsy

Answer 29

stratified squamous
palisaded
parakeratosis
8-15

Question 30

The width of the lining looks fairly ____ all the way across (green arrows) and the surface layer of cells which is seen in bright pink here (yellow arrows) is the parakeratosis. Just as in the skin or mucosa when you have a dermoid or epidermoid cyst that is keratinizing, within the lumen of the cyst you have ____ (the keratin coming off of the surface of the cyst, where the yellow arrows are) is accumulating in the lumen of the cyst. Thus if you aspirate, which you do before, you will definitely not aspirate blood, but what you will aspirate is a thick, cottage cheese-like/cheese ____-like material that smells ____. What you are aspirating is keratin which has accumulated in the lumen of the cyst

When you aspirate a dentigerous cyst, radicular cyst or any other cyst, you will aspirate a “____” fluid which is basically yellowish tan or brownish color, whereas if you aspirate this cyst you get a thick cheese-like material which is only aspirated from OKCs

Answer 30

uniform
keratin
curd
nasty

hay-colored

Question 31

Treatment
• Various approaches
• High \_\_\_\_ rate
– Most recur within first 5 years
• Close long-term follow-up

These lesions do require intervention because they will keep growing if left untreated. The intervention is always ____ but it may vary from a very conservative type of procedure where they take a curette and curette out the lesion to a more extensive procedure which may require resecting half of the mandible as part of treatment.

The problem is that these lesions tend to recur if not treated properly and when they do recur, they tend to recur within the first ____ years after initial therapy, which is why these lesions warrant close long term follow-up radiographically.

Answer 31

recurrence
surgical
couple

Question 32

Nevoid basal cell carcinoma syndrome

• Autosomal ____
– Mutation in ____ tumor suppressor

• Features
– Multiple \_\_\_\_
– Multiple OKC
– \_\_\_\_ ribs
– Palmar-plantar pitting
– \_\_\_\_ calcifications
– Other benign and malignant tumors

This is a patient with multiple lesions (marked by orange arrows). Certainly 3, maybe 4 distinct lesions that were each diagnosed as OKC. This, on it’s own with the biopsy diagnosis, is ____ for nevoid basal cell carcinoma syndrome. This is an autosomal dominant disease characterized by mutations in the germline of PTCH and it is characterized by a number of different manifestations that include skin cancer, primarily basal cell carcinomas (BCC) except in this case the BCCs occur not exclusively in sun-exposed areas, they also occur in ____ areas. We learned in the last module that BCCs are the most commonly occurring ____ cancer resulting from chronic sun-exposure (sun-exposed areas in those patients are where they get cancer).

Answer 32

dominant
PTCH
basal cell carcinomas
bifid
intracranial

pathognomonic
non sun-exposed

Question 33

Beyond that, there are additional manifestations:
- -
These patients get these ____ (yellow arrow) on their hands and their feet
The patient in the center has little nodules on the nose. These are all examples of basal carcinomas on his nose

• The patient in the image on the right, the black arrow on top shows how these patients may get calcifications in the midline of their brain called ____. The white arrow is meant to represent OKC in the jaw bone

Answer 33

pits

calcification of falx cerebri

Question 34

We have learned that BCC are NOT the most ____ form of cancer but they are cancer and can become aggressive if left untreated which she did since there was 25 years of growth allowed since she got tired of going to doctors as routinely as she did when she was young. A very sad story

Answer 34

aggressive

Question 35

Non-odontogenic cysts

So that disease (nevoid basal cell carcinoma syndrome) only warrants intervention when it needs intervention like neurofibromatosis, like Cowden’s syndrome, like MEN type III you only treat the lesions if they warrant treatment and they cause patients problems. But these patients warrant a biopsy diagnosis to confirm what the lesions are & you intervene when necessary
The next topic is non-odontogenic cysts
These are lesions that, include ____ which are not true cysts, and are not derived from ____ that gave rise to tooth development

Answer 35

pseudo-cysts

epithelium

Question 36

Nasopalatine duct cyst

• ____ / heart-shaped radiolucency
• Rule of thumb
– If <6 mm then probably just the ____ duct
• Nerve bundles and large ____ in cyst wall

These are lesions that are NOT derived from epithelium that gave rise to tooth development, but in this case, they are occurring in the jaw. There are 2 or 3, but we have been asked to only know this one.
This is the intraosseous parallel to the ____ cyst which is a cyst in the incisive papilla that is strictly in the soft tissue (That papilla looks red/blue and large often times painful). The nasopalatine duct cyst is it’s parallel except it occurs in the ____ only. It may perforate the jaw but it is usually only found in a routine radiograph

Radiographically, it has a very characteristic appearance in that it takes on an ovoid or heart-shaped radiolucency (the ones shown here are not great examples of heart-shaped, more ovoid-shaped)
How do you know that this is pathology?
Rule of thumbif there is lucency between the maxillary incisors, which is where the nasopalatine duct is located that is <6 mm in diameter, then you are probably just looking at the normal nasopalatine duct
If it is > 6mm in diameter, then it warrants a biopsy to confirm you are dealing with a nasopalatine duct cyst

Answer 36

oval
nasopalatine
blood vessels

incisive papilla
jaw bone

Question 37

Nasopalatine duct cyst

Microscopically it is just a cyst-lining, there is no distinctive cyst-lining for these lesions. What is distinctive is that within the wall of these cysts you have large nerve bundles and large blood vessels which indicates where it us located anatomically because the ____ thru which the nerves & blood vessels enter and exit are within that structure itself. This is how we know where we are anatomically.

It doe not have a distinctive histological presentation beyond the fact that it has nerves and blood vessels from the wall. This is a ____ cyst based on retention of epithelium after ____ fusion of the midline (thus after the palate and midline fuse, it is thought that some epithelium is left behind and at some point later in life, for some reason, it will proliferate to form this cystic structure

Answer 37

foramen

developmental
pre-embryonic

Question 38

Focal osteoporotic bone marrow defect
• ____ finding
• Usually ____
• Normal hematopoietic ____

These are NOT ____, they are not lined by epithelium
We might characterize them as pseudo-cysts just because radiographically they can mimic cysts but they are NOT cystic structures

Beginning with something called a focal osteoporotic bone marrow defect
This is an incidental finding on a routine radiograph and what you might see is an irregular ____ (yellow arrows) within the jaw bone almost always in the area of an ____ or healed extraction socket

These usually occur in the posterior mandible, so site predilection is pretty distinctive to this pathology and what this represents is normal bone marrow. So after the extraction, for some reason the bone did not heal properly while the gingiva healed and the socket closed up, but radiographically you see a lucency. If you were to biopsy this, and it does warrant a biopsy to make sure, what you will see is just bone marrow (next slide)

Answer 38

incidental
posterior MD
bone marrow

cysts
radiolucency
extraction socket

Question 39

Focal osteoporotic bone marrow defect

This is what you would see if you biopsied it, bone marrow tissue

He is not going to ask us to recognize bone marrow tissue microscopically, but this is what it looks like

Bone marrow tissue would include all the pre-cursor ____, eosinophils, ____ precursor, fat, so everything you would see in bone marrow you would see in this pathology biopsy

Once you biopsy it, these tend to resolve on their own (just like ____). Once you biopsy it, you re-stimulate the ____ process to help resolve the lesion spontaneously (in this case the wound healing should heal the bone)

Answer 39

neutrophils
WBC
TUGSE
wound healing

Question 40

Traumatic bone cyst
\_\_\_\_>F, usually 10 – 20 years
≈ 90% in MD, usually \_\_\_\_
– MX lesions–often in \_\_\_\_ region 
Well-circumscribed, \_\_\_\_
– \_\_\_\_ between roots No \_\_\_\_ lining

This is not really a cyst but rather a pseudocyst, but radiographically it looks like a lot of the other lesions we just looked at
It is a well-defined radiolucency, the different being the radiolucency tends to scallop the roots. This means it tends to hug/follow some of the ____ pretty tightly = scalloping. The image shows scalloping (orange line show the lesion following the roots). This highly characteristic but not pathognomonic

This occurs thru some previous history of ____. Trauma isn’t reported in all cases, but many cases and typically this occurs in young people (young people are typically the ones that have trauma)
Most occur in the posterior mandible because that is where ____ frequently occurs (getting punched in the face). Maxillary lesions are in the anterior region because if you get trauma straight to your face, typically the anterior region of your maxilla it is affected first)

Answer 40

M
posterior
anterior
multilocular
scalloping
cyst

roots
trauma
trauma

Question 41

Traumatic bone cyst

What this represents, because it is likely traumatic or always traumatic in origin is a ____ that never healed properly, so biopsy may reveal a ____ OR if the blood clot resolved itself, what the surgeons say is that when they opened up the bone, they fell into a big ____ and that is the characteristic story from a surgical standpoint
Finding a big cavity is usually one of the first signs that you are dealing with a traumatic bone cyst

Answer 41

blood clot
blood clot
empty space/cavity

Question 42

Stafne bone defect Static bone cyst
• 80-90% in \_\_\_\_, asymptomatic
• Diagnostic presentation
– Well-defined, \_\_\_\_
– \_\_\_\_
– \_\_\_\_ inferior alveolar canal

This is a lesion that does not warrant a ____, one of the few bone pathologies that doesn’t warrant a biopsy and why, because it’s location is pathognomonic, in that it is below the inferior alveolar canal. It is found below the mandibular canal space

Not a lesion, but rather a ____ in the bone adjacent to where the sub-mandible gland is typically located anatomically. In some male patients, less likely female, the gland is pushed up right against the bone so during development when the bone grows around the gland or vice versa, the bone is a little thinner on the ____ aspect that is adjacent to the gland and that is what you are seeing radiographically.

Answer 42

males
unilocular
posterior MD
below

biopsy
depression
lingual