Cyst of the jaw Flashcards
what is a cyst
pathologicalcavity filled with fluid, semi fluid or gasous content. Not created by pus accumulation
how are cysts classified
- epithelial lined (most)
- odontogenic/non odontogenic
- inflam/developmental
appropriate further inv of a cyst
plain Rg - OPT/PA/occ
other views - occipitomental/PA mandible
CBCT
should a biopsy be taken - how
describe cystic fluid
wide bore needle - FNA
blood/cystic fluid/air/pus
-clear straw coloured fluid (crystals present)
what is the purpose of an incisional biopsy - when
- how
to take a sample of cyst lining for histological analysis
- during marsupilisation
- usually under L.A.; select place where “cyst” appears superficial; raise mucoperiosteal flap; remove bone as required – using rongeurs or a round bur; incise and remove a section of lining
name the types of cysts of the jaw
odontogenic
- radicular
- dentigerous
- keratocyst (keratocystic odontogenic tumour)
non odontogenic
- nasopalatine
- stafne cavity
- aneurysmal bone cyst
sources of epithelium for odontogenic cysts
- rests (debris)of malassez, hertwig’s root sheath
- rests of serres - lamina remnants
- reduced enamel ep
radicular cyst
- what
- synonyms
- aetiology
- features
periapical cyst attached to the apex of a NV tooth
inflammatory origin = pulpitis then PA granuloma then cyst
- periapical/dental cyst
-slow painless swelling, no symps until big enough to be noticed
-at first = hard and rounded, later eggshell thickness and cracking on pressure. Eventually wall resorbed leaving soft bluish swelling.
- originate from rests of malassez (hertwig’s root sheath)
radicular cyst - histology
epithelial lining (often incomplete), CT capsule,
plasma cells and macrophages - inflammation
-peripherally osteoclasts allow bony expansion, osteocblasts react to inflammation by depositing bone causing corticated margin.
name 2 variations of a radicuar cyst
residual cyst
inflamatory lateral periodontal cyst
what is a dentigerous cyst
a developmental cyst surrounding the crown of an unerupted tooth
who and where are dentigerous cysts most likely to occur
male>female
mandible>max
Lower 8’s and up 3’s
histology of a dentigerous cyst
thin non keratinised stratified squamous epithelium
- arises from separation of reduced enamel epithelium and fromation of follicular space - internal pressure causes expansion of this
clinical features of dentigerous cyst
Rg features
- grow by internal pressure - expansion and displacement of adjacent structures. Slow growing
- developmental but can be caused by inflammation of pericoronitis/adjacent NV teeth.
- Rg - circumscribed, rounded and unilocular. Contain crown of tooth.
what condition can appear with multiple dentigerous cysts
name one other feature of this condition
cleidocranial dysplasia
partly missing collarbones = hypermobility
prognathic mandible
hyperdontia - many supernumeraries
measurements of dentigerous cyst and follicle
-<2.5mm = follicle
-> 4.2mm = probable cyst
>10mm - definite cyst
asymmetrical radiolucency = cyst
what is an odontogenic keratocyst
who
clinical presentation
developmental cyst m>f mostly mandible -third molar and ramus multilocular - symptomless until infected recurrence issue
cyst aspirate of a keratocyst
histology
white keratin - contains sqaumes - low soluble protein content
-parakeratosis of cyst lining, basal palisading
why is recurrence likely to occur for a keratocyst
thin friable lining - left behind
many daughter cysts missed
cell nests
what syndrome is associated with multiple keratocysts
other features
gorlin-goltz syndrome (basal cell naevus)
autosomal dominant
skeletal abnormalities and basal cell carcinomas
-frontal & temporalparietal bossing hypertelorism
mild mandibular prognathism
Abnormalities of Ca & PO4 metabolism
appearance of a keratocyst on a Rg
growth pattern
well defined radiolucent area, scalloped margin , usually ramus/3rd molar, sharply demarcated
- pattern = extensive spread forwardand backward along medullary cavity. MINIMAL expansion
AP growth
pathogenesis of an odontogenic keratocyst
develop from rests of odontogenic epithelium left after tooth development - eg rests od serres
-Mutation/deletion/inactivation of ptch gene (tumour suppressor gene)
nasopalatine cyst
origin
where
presentation
found in midline - incisive canal
- epithelial reminants of nasopaltine duct
- dependant on canal affected - superficial soft tissue cyst, can grow primarily into nose - salty discharge
what differentiates odontogenic and non odontogenic cysts
distibution of cytokeratin in cyst epithelium
Rg and pathological features nasopalatine cyst
Radiograph
Well-defined round, ovoid or heart shaped radiolucency
Sclerotic margin
anterior region of palate
Pathology
Lined by st. squ. Respiratory or cuboidal epithelium
Neurovascular bundles found in capsule
solitary bone cyst (simple bone cyst)
clinical features -who, where
child & adults
premolar/molar region
asymp, chance finding on Rg
Rg features of solitary bone cyst
-surgical exploration findings
variable sized radiolucency, irregular margin, well defined. Scalloping!
Rough bony-walled cavity devoid of any detectable lining. NO epithelial lining
Rapid healing follows
Although will resolve spontaneously without
Aneurysmal bone cyst
clinical
Rg
Clinical
Children or young adults
Mandible, post. part of body or angle
Firm, painless swelling
Radiograph
Uni- or mulitilocular radiolucency with a ballooned out appearance due to gross cortical expansion
Aneurysmal bone cyst
pathology
numerous, non-endothelial lined, blood-filled spaces varying size separated by cellular fibrous tissue multinucleated giant cells Pathogenesis unknown Many preceded by other 10 lesion of bone
Stafne idiopathic bone cavity - what
Rg features
developmental anomaly of mandible
asymptomatic
- Radiograph
Round or oval, well demarcated radiolucency
Between premolar region & angle of jaw
usually located below inferior dental canal
Stafne idiographic bone cavity -surgical exploration
Depression or concavity lingual aspect of mandible
Varying depth
Majority of cases, contains ectopic salivary tissue in continuity with SMG
Ameloblastoma features -age -features -site/shape -
Aggressive tumour
originates from remnants of odontogenic epithelium of enamel organ/dental lamina
PEAK AGE: adults (Usually >40 years old)
FREQUENCY: Rare, but still most common odontogenic tumour
SITE & SIZE: Posterior body/angle/ramus of mandible. Occasionally maxilla. Size very variable depending of age of lesion but can become very large and disfiguring
SHAPE: multilocular, occasionally monolocular at early stage. Well defined and well corticated.
Ameloblastoma
- radiodensity
- signs,symps
- treatment
RADIODENSITY: Radiolucent with internal radiopaque septae
SIGNS AND SYMPTOMS: early stages asymptomatic adjacent teeth displaced facial deformity extensive expansion in all directions expansion usually bony hard and non tender (latter stages may get “egg shell crackling”)
TREATMENT: Surgical resection with margin normal bone.
Ameloblastoma fibroma -age -frequency -site/shape clinical features
Rare, benign mixed odontogenic tumour originating from both odontogenic epithelium and connective tissue of developing tooth germ.
Radiographically closely resembles ameloblastoma but develops in younger age group
AGE: Children and adolescents
FREQUENCY: Rare
SITE & SHAPE: Usually mandible in premolar/molar region. Variable size. Multilocular (monolocular in early stages). Smooth outline. Well defined and well corticated
-adjacent teeth displaced
Calcifying odontogenic cyst
- age
- site
- size/shape
- radiodensity
- effect
AGE: wide age range but usually < 40 years old
SITE: 75% are intraosseous and either jaw may be involved. Majority arise anterior to first permanent molar.
SIZE&SHAPE: Usually small about 1-3 cm in diameter. Shape is variable but usually monolocular.
RADIODENSITY: initially radiolucent but in more advanced stage contains a variable amount of calcified radiopaque material
EFFECTS: adjacent teeth usually displaced +/or resorbed. Bony expansion.
odontogenic myxoma and fibroma
- age
- site
- shape/size
- Rg
Very similar non-invasive tumours which originate from odontogenic CT fibroblasts of the developing tooth germ, which produce either excessive fibrous collagen (FIBROMA) or excessive ground substance (MYXOMA). Radiographically often indistinguishable.
AGE: Young adults
SITE: Usually posterior mandible or maxilla
May arise in relation to root of tooth/crown or
unerupted tooth or may take place of tooth
missing from arch
SIZE&SHAPE: Size is variable but may become large if left untreated. Usually multilocular
-Rg -radiolucent with fine radiopaque septa
-adjacent teeth loosened/displaced
chondroma
- what
- where
Rare, benign slow growing tumour producing a rounded lobulated radiolucency of variable definition within the bone with a variable amount of internal calcification
Anterior maxilla and posterior mandible most common sites. Although can also occur in the condylar and coronoid process.
-intrinsic primary benign bone tumour
Central haemangioma
- what is it
- age
- radiograph appearance
Rare benign tumour that occasionally affects the jaws, particularly the mandible. It is usually a developmental malformation (hamartoma) of the blood vessels in the marrow spaces.
Can present at any age but usually adolescents
Variable radiograpgic appearance including;
moderately well defined zone of radiolucency within which trabeculae spaces are enlarged. Lesion presents therefore as multicystic “saop bubble or honecomb” appearance
Osteosarcoma
- age
- site
- signs/symptoms
Commonest primary malignant tumour of bone but is relatively rare in jaws.
AGE: Usually around 30 years old at diagnosis. Occasionally, tumour presents in older patients eg in association with Paget’s disease of bone.
SITE: Slightly more common in mandible than maxilla
SIGNS + SYMPTOMS: Fairly rapidly enlarging swelling that may be accompanied by pain, numbness of lip, trismus and displacement of teeth. Ulceration of overlying skin and mucosa is a late feature.
Osteosarcoma
Rg features
prognosis
RADIOGRAPHIC APPEARANCE: variable and depends on amount of normal bone destroyed by tumour and amount of neoplastic bone formed within lesion.
Predominately osteolytic tumours produce irregular areas of radiolucency wheras sclerosing types in which tumour bone is formed, produce irregular areas of radiopacity. The two patterns may co-exist in the same tumour. A symmetrically widened PDL space has been reported as a feature of very early lesions
PROGNOSIS: Overall 5 year survival for osteosarcoma of jaws is about 40%. Jaw lesions,in contrast to osteosarcomas at other sites, metastasise infrequently. However local recurrence rates are high.
Multiple myeloma
- age
- site
- site/shape
- radiodensity
- effects
AGE: Adults, middle aged
SITE: Multiple lesions affecting
- skull vault
- posterior part of mandible
- other parts of skeleton
SIZE&SHAPE: Variable size. Round monolocular shape
though multifocal. Well defined outline.
Not corticated.
RADIODENSITY: Radiolecent
EFFECTS: Enlargement/Coalescence may lead to pathological fracture
central giant cell granuloma
- age
- site
- size/shape
- radiodensity
- effect
Uncommon, non neoplastic mass in the jaws producing an expansile radiolucent lesion.
AGE: Variable but usually young adolescents and adults under 30 years old.
SITE: Anterior mandible. In region of deciduous dentition, often crossing midline.
SIZE&SHAPE: Variable size. Can be up to 10 cm. Usually multilocular with well defined and well corticated outline.
RADIODENSITY: Radiolucent
-adjacent teeth displaced or resorbed
cherubism
- age
- site
- size/shape
- radiodensity
- effect
Inherited disorder. Usually autosomal dominant but many cases appear spontaneously. Radiographically lesions resemble closely other giant cell containing lesions.
AGE: Children 2-6 years old
SITE: Angle/Posterior mandible - bilateral
SIZE&SHAPE: Variable size, up to several cms diameter. Multilocular with bilateral lesions typically symmetrical.
RADIODENSITY: Radiolucent with internal radiopaque septa
EFFECTS: Gross displacement of deciduous/permanent teeth. Extensive buccal/lingual expansion
Fibrous dyplasia
- age
- site
- size/shape
- radiodensity
- effect
Considered to represent a developmental tumour like lesion. Most cases (80%) are monostotic (limited to a single bone, often the jaw).
AGE: 10 - 20 years of age
SITE: Usually posterior maxilla
SIZE&SHAPE: Variable size. Round shape. Poorly defined outline with no cortiaction
RADIODENSITY: Initially radiolucent. Gradually becomes radiopaque to produce “ground glass” or “orange peel”
-teeth displaced
what cysts are best treated by enucleation
-complications
keratocyst / dentigerous cys t/ radicular and residual cyst
Complications: Mainly related to size, position and type of cyst interference with IDC communication with Maxillary sinus pathological fracture Recurrence
Masurpilisation
for?
complications
Fenestration’ +/- grommet insertion
Useful for large simple cysts, keratocyst, dentigerous cysts
Complications: Needs further surgery for removal cyst Long treatment before completion chance of re-infection? Uncomfortable with grommet in situ?
ameloblastoma/sarcoma treatment
Removal of cyst with margin of ‘normal’ bone.
Mainly used for ameloblastoma/sarcoma cases
Normally have to have secondary procedure for reconstruction of defect
