3. Odontogenic & Non-Odontogenic Cysts Flashcards
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
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that was left behind during tooth development
We will only talk about one of those today ◦
epithelium
type
tooth
embryogenesis
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
inflamed
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
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By definition tooth is ____
distal
third molar
physically
inflammatory
impacted
CEJ
unilocular
mandibular premolars
apex
dead
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
place
third molar
unilocular
microscopically
mandibular premolar
multilocular
dentigerous crown bone soft tissue kids extraction extracted
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
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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
eruption cyst
paradental
radicular
residual
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
apex
dead
CEJ
anatomic
multilocular
mandibular premolar
Radicular cyst
- Most common ____ cyst
- Most common ____ cyst
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By definition tooth is ____
Radicular cyst: cyst found at ____ of tooth typically
odontogenic
inflammatory
dead
apex
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
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Always on buccal root surface of ____ molar ◦ ◦
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Couldn’t show it in 2D representation summary slide, but can be seen here
The radiograph shown here is an occlusal film
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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
inflammatory
buccal
defined
occlusal
lower first
furcation
2D
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
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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
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is a lesion there
Because of its duration there is a risk (small) for cyst to become malignant
inflammatory radicular extraction unilocular malignant
primordial
primordial
duration
precancerous
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 ◦
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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
developmental mand third max max third mand second CEJ
inflammation
displace
impacted
second
Dentigerous cyst
- Well-defined, ____
- Crown projects into cyst lumen
____, ____, and other odontogenic tumors may also be associated with impacted teeth
unilocular
OKCs
ameloblastomas
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
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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
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pathologic
histo
odontogenic keratocyst
cyst
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
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It tooth not erupting properly, may warrant taking a scalpel and make a little hole- release fluid
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that is preventing tooth from erupting. Then tooth will erupt
infants
bluish-purple
treatment
preventing
eruption
3Ps
resolve
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
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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
canine-premolar lateral-canine unilocular botryoid vital
distinctive two lateral periodontal inflammatory radicular
(BOC) botryoid cyst: same ____, same distinctive histo
Only difference- botryoid is ____
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Location and histo are the same (between teeth) ◦
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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
◦
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Residual cysts are ____- but would be included in differential because in the place of previously extracted tooth
location
multilocular
residual cyst
unilocular
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”
epithelial
focal plaque
BOC
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
buccal
canine-premolar
radiographic
histology
keratinizing
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.
anterior mucous pseudocystic crown independent
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.
inflammatory radiograph goblet spaces microscopically precursor
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
hemangiomas
radiolucent
aspirate
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.
free flowing
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
radiolucencies
hemangiomas
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.
excisional
incisional
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.
PTCH
growth
recur
syndrome
benign
nevoid basal cell carcinoma
multiple OKCs
different
manifestations
