Post on 18-Apr-2020
IN THE NAME OF GOD
Dr.kheirandish DDS,MSCOral and maxillofacial pathology
ODONTOGENIC CYSTS AND TUMORS
Chapter 15
I. DENTIGEROUS CYST
II. ERUPTION CYST
III. ODONTOGENIC KERATOCYST
IV. Orthokeratinized Odontogenic Cyst
V. Nevoid Basal Cell Carcinoma Syndrome
VI. Gingival (Alveolar) Cyst of the Newborn
VII. Gingival Cyst of the Adult
VIII. lateral Periodontal Cyst
IX. CALCIFYING ODONTOGENIC CYST
X. GLANDULAR ODONTOGENIC CYST
XI. BUCCAL BIFURCATION CYST
XII. CARCINOMA ARISING IN ODONTOGENIC CYSTS
Odontogenic cysts
Odontogenic tumors
Epithelium-lined cysts in bone are seen only in the jaws
Inclusion of epithelium along embryonic lines of Fusion
Odontogenic epithelium … odontogenic cysts
Odontogenic cysts Developmental or Inflammatory
DENTIGEROUS CYST
(FOLLICULAR CYST)
Separation of the follicle from around the crown of an unerupted tooth
Most common type of developmental odontogenic cyst (20%)
Unerupted tooth
Cementoenamel junction
Inflammatory pathogenesis…
Mandibular third molars(65%)
Maxillary canines / third molars / mandibular second premolars
Deciduous teeth
10 - 30
Vary size
Unilocular radiolucent (welldefined / corticated border)
Infected cyst (ill-defined borders)
Radiographic variations
Central variety (most common)
Lateral variety
Circumferential variant
Displace the involved tooth
Root resorption
3 to 4 mm in diameter
Not diagnostic
Non inflamed :
Fibrous connective
Inactive-appearing odontogenic epithelial rests
Epithelial lining (2-4)
Flattened nonkeratinizing cells
Interface (flat)
Inflamed :
Fibrous wall is more collagenized
Inflammatory cells
Epithelial lining
Keratinized surface
Mucous cells
Ciliated columnar cells
Sebaceous cells
Multipotentiality of the odontogenic epithelial lining
Enucleation
Unerupted tooth
Marsupialization
o Neoplastic transformation
Ameloblastoma
Squamous cell carcinoma
Intraosseous mucoepidermoid carcinomas
ERUPTION CYST
(ERUPTION HEMATOMA)
Soft tissue analogue of the dentigerous cyst
Erupting deciduous or permanent tooth
Age 10
Deciduous mandibular central incisors, first permanent
molars, deciduous maxillary incisors
Blue to purplebrown color
Eruption hematomas
Oral epithelium (superior aspect)
Variable inflammatory cell
Thin layer of nonkeratinizing squamous epithelium
ODONTOGENIC KERATOCYST
Specific histopathologic features and clinical behavior
Cell rests of the dental lamina
Different growth mechanism and biologic behavior
Increased osmotic pressure within the lumen
Genetic factors inherent in the epithelium itself or
enzymatic activity in the Fibrous wall.
Benign cystic neoplasm
Who
Keratocystic odontogenic tumor (kcot).
PCNA
KI-67
PTCH1
Hedgehog signaling pathway
Loss of heterozygosity (tumor suppressor genes)
(P16, p53)
1. Greater growth potential than most other
odontogenic Cysts
2. Higher recurrence rate
3. Possible association with the nevoid basal cell
carcinoma Syndrome
3% to 11%
10 - 40
Male
Mandible
Small
Larger
Anteroposterior
Expansion
Multiple okcs
Well-defined radiolucent
Multilocular
Unerupted tooth (25% to 40%)
Root resorption
Diagnosis
Peripheral
Thin, friable wall
Cystic lumen
Epithelial lining
Interface
Detachment
Parakeratotic epithelial cells
Corrugated appearance
Palisaded layer
Satellite cysts, cords, or islands
INFLAMMATION
o Recur (5% to 62%)
Number of cases
Length of follow-up
Inclusion or exclusion of orthokeratinized cysts
o 30%
o Posterior body and ramus
o Longterm clinical and radiographic follow-up
Bone bur
Chemical cauterization (carnoy’s solution)
Polyethylene drainage tube
o Malignant alteration
Orthokeratinized Odontogenic Cyst
Young adults
2:1 male-to-female
Mandible : twice
Posterior
Unilocular radiolucency ( multilocular)
Two thirds involve an unerupted mandibular
third Molar tooth (dentigerous cyst)
Size :1-7 cm
Stratified squamous epithelium
Orthokeratotic surface
Keratohyaline granules
Palisaded basal layer (not present)
o Enucleation with curettage
o Recurrence (2%)
o Malignant transformation
o Nevoid basal cell carcinoma syndrome
Nevoid Basal Cell Carcinoma Syndrome
Gorlin Syndrome
Autosomal dominant
Mutations in patched(PTCH) : a tumor
Suppressor gene
Basal cell carcinomas
Odontogenic keratocysts
Intracranial calcification
Rib and vertebral anomalies
1 in 60,000
Characteristic facies :
o Frontal and temporoparietal
bossing
o Increased cranial circumference
o Hypertelorism
o Mandibular prognathism
Basal cell carcinomas
o Major component
o Non syndromic basal cell carcinoma
o Less aggressive
o Puberty or in the second and third decades
o Fleshcolored papules to ulcerating plaques
o Not exposed to sunlight
o Midface
o Number : vary
o Blacks
Palmar and plantar pits
65% to 80%
localized retardation of the maturation of
basal epithelial cells
Jaw cysts
75%
Odontogenic keratocysts
Isolated keratocysts
Multiple (ten) separate
Younger
Often associated unerupted teeth (Mimic dentigerous
cysts)
More satellite cysts, solid islands of epithelial
proliferation, and odontogenic epithelial rests
Skin tumors
Jaw cysts
Gingival Cyst of the Newborn
Small
Multiple
Whitish papules
Alveolar processes
Maxilla
2 to 3 mm
keratin-filled
Remnants of the dental lamina
Common
Disappear spontaneously
Inclusion cysts (e.g., Epstein's pearls and
Bohn's nodules)
Thin, flattened epithelial lining with a
parakeratotic luminal surface
Gingival Cyst of the Adult
o Uncommon lesion
o Soft tissue counterpart of the LPC
o Rests of the dental lamina (rests of Serres)
o Epithelial inclusion cysts
o Mandibular
o Canine and premolar area (60% to 75%)
o 5-6 decades
o Facial gingiva
o Painless
o Domelike swellings
o Bluish or blue-gray
o "cupping out"
Lateral periodontal cyst
Thin, flattened epithelial lining
With or without focal plaques
Dilated blood vessel
lateral Periodontal Cyst
Uncommon
Lateral root
Rests of the dental lamina
Intrabony counterpart of the gingival cyst
of the adult
o Asymptomatic
o Radiographic examination
o 5-7 decades
o Mandibular (premolar , canine , lateral incisor )
Well-circumscribed
Laterally to the root
Vital teeth
o Epithelial lining that is only one to three cells
thick in most areas
o Flattened squamous cells
o Foci of glycogen-rich clear cells
o Focal nodular thickenings
Botryoid odontogenic cysts : polycystic
appearance( Grossly and microscopically)
Grape like cluster of small individual cysts
Multilocular
Enucleation
Recurrence : botryoid variant
CALCIFYING ODONTOGENIC CYST
(COC)
• CALCIFYING CYSTIC ODONTOGENIC TUMOR
• GOLIN CRYST
• DENTINOGENIC GHOST CELL TUMOR
• GHOST CELL ODONTOGENIC CARCINOMA)
Cystic
Solid (tumorlike)
WHO classification :
1. Calcifying cystic odontogenic tumor
2. Dentinogenic ghost cell tumor
3. Ghost cell odontogenic carcinoma
Intraosseous
Cystic lesions
Less than 5% ... solid dentinogenic ghost cell tumors
Peripheral
One-third … solid
o Associated with other odontogenic tumors :Odontomas
Adenomatoid odontogenic tumors
Ameloblastomas
Intraosseous :
Maxilla = mandible
Incisor and canine areas
30 years
Associated with odontomas (younger patients)
• Unilocular
• Well-defined
• 1/2 -1/3 … radiopaque structures
• 1/3 … unerupted tooth (canine)
Vary size (12cm)
Root resorption
Divergence of adjacent teeth
Extraosseous
5% to 17%
Gingival
Sixth to eighth decades
Ghost cells :
Altered epithelial cells
Loss of nuclei
Basic cell outline
1. Coagulative necrosis
2. Accumulation of enamel protein
3. Normal or aberrant keratinization of odontogenic epithelium
o Cystic lesion
o Fibrous capsule
o Lining of odontogenic epithelium
o Basal cells … cuboidal or columnar (ameloblasts)
o Overlying layer of loosely arranged epithelium (stellate
reticulum)
o Most characteristic : “ghost cells” Within the epithelial
component
Calcification within the ghost cells (basophilic granules)
Dentinoid (eosinophilic)
Malignant epithelial odontogenic ghost cell
tumors (ghost cell odontogenic carcinoma)o Cellular pleomorphism
o Mitotic activity
o Recurrence
o Local disease or metastases
o 5-year survival … 73%
Associated with odontogenic tumor
Peripheral
GLANDULAR ODONTOGENIC CYST
(SIALO-ODONTOGENIC CYST)
Rare
Aggressive behavior
Pluripotentiality
Middle-aged
Mandible
Anterior
Vary size
Large (expansion, pain or paresthesia)
Unilocular or multilocular
Corticated rim
Squamous epithelium of varying thickness
Interface (flat)
Superficial epithelial cells … cuboidal to columnar
Mucinproducing goblet cells
Cilia
Ductlike spaces within the epithelial lining (lined by cuboidal
cells and often contain mucicarmine-positive fluid)
Spherical nodules
Cystic mucoepidermoid carcinomas
LPC
Recurrence(multilocular)
Enbloc resection
BUCCAL BIFURCATION CYST
Inflammatory odontogenic cyst
Buccal aspect of the mandibular first
permanent molar
Buccal enamel extensions
Tooth eruption
Children from
Slight-to-moderate tenderness
Swelling
Foultasting discharge
Bilateral … 1/3
Unilocular radiolucency
Occlusal radiograph
Proliferative periostitis
Nonspecific
Nonkeratinizing stratified squamous epithelium
Chronic inflammatory cell
Enucleation
Tooth extraction … unnecessary
CARCINOMA ARISING IN
ODONTOGENIC CYSTS
Odontogenic tumors
De novo
Odontogenic cysts
Intraosseous mucoepidermoid
1% to 2%
• Wide age range
• Men
• Pain and swelling
• Margins of the radiolucent defect are usually irregular and
ragged
I. Residual
II. Dentigerous cyst
III. Okc
IV. Lateral periodontal cyst
Well-differentiated or moderately well-differentiated
squamous cell carcinomas
Local block excision to radical resection
Radiation or adjunctive chemotherapy
Metastases