BouquotBouquot’’s Desks DeskCirca 1971Circa 1971

The BouquotsThe Bouquots19811981

Oral & Maxillofacial Pathology IIOral & Maxillofacial Pathology IIDB 3702DB 3702

Thursdays, 10:00 – 11:50 amRoom DB 132

Course Director: Dr. J. E. BouquotCourse Director: Dr. J. E. BouquotRoom 3.094b; 713Room 3.094b; 713--500500--44204420Jerry.Bouquot@uth.tmc.eduJerry.Bouquot@uth.tmc.edu

Topic: Odontogenic Tumors and CystsTopic: Odontogenic Tumors and Cysts

Cells & TissuesCells & Tissuesof Originof Origin

Ameloblasts v. PreameloblastsAmeloblasts v. Preameloblasts

PreameloblastsPreameloblasts EnamelEnamel

AmeloblastsAmeloblasts

OdontoblastsOdontoblasts

Stellate ReticulumStellate Reticulum

Dental PapillaDental Papilla

Classification of Classification of Odontogenic TumorsOdontogenic Tumors

Odontogenic TumorsOdontogenic TumorsEpithelial TypesEpithelial Types

Ameloblastoma-- Conventional ameloblastoma-- Unicystic ameloblastoma-- Peripheral ameloblastomaMalignant ameloblastomaAmeloblastic carcinomaClear cell odontogenic carcinomaAdenomatoid odontogenic tumorCalcifying epithelial odontogenictumorSquamous odontogenic tumor

AmeloblastomaAmeloblastoma

AmeloblastomaAmeloblastoma

Odontogenic TumorsOdontogenic TumorsMixed Epithelial/Mesenchymal TypesMixed Epithelial/Mesenchymal Types

Ameloblastic fibromaAmeloblastic fibro-odontomaAmeloblastic fibrosarcomaOdontoameloblastomaOdontoma

Ameloblastic FibromaAmeloblastic Fibroma

Ameloblastic FibromaAmeloblastic Fibroma

Compound OdontomaCompound Odontoma

Odontogenic TumorsOdontogenic TumorsEctomesenchymal TypesEctomesenchymal Types

Central Odontogenic FibromaPeripheral OdontogenicFibromaGranular Cell OdontogenicTumorOdontogenic MyxomaCementoblastoma

CementoblastomaCementoblastoma

Odontogenic MyxomaOdontogenic Myxoma

AmeloblastomaAmeloblastoma

AmeloblastomaAmeloblastoma

Benign neoplasm of preameloblasts-- Epithelial rests of dental lamina-- Basal cells of alveolar mucosa-- Cyst lining epithelium

GALP: -- None-- Any age, usually 30-50 years-- Posterior mandible-- Most common of “aggressive”

odontogenic tumors

PreameloblastsPreameloblasts

AmeloblastomaAmeloblastomaRadiographic/Clinical FeaturesRadiographic/Clinical Features

Multilocular (soap bubble) radiolucency-- May be unilocularWell demarcated bordersExpands, thins cortexAsymptomatic

AmeloblastomaAmeloblastomaRadiographic FeaturesRadiographic Features

May extend far into ramusMay fill maxillary sinusMay be huge

AmeloblastomaAmeloblastoma

AmeloblastomaAmeloblastomaRadiographic FeaturesRadiographic Features

Often associated with crown of unerupted tooth Often resorbs adjacent rootsMay push roots asideMay push whole tooth

AmeloblastomaAmeloblastomaHistopathologyHistopathology

Islands of odontogenic epitheliumPeripheral palisading cells-- Vacuoles toward basement membrane--PreameloblastsCenter: stellate reticulumMature fibrous stromaOften cystic degeneration

AmeloblastomaAmeloblastomaHistopathologic SubtypesHistopathologic Subtypes

Follicular type-- Most common type-- Islands resemble tooth budsPlexiform type-- Intertwining strands of epithelial cells

AmeloblastomaAmeloblastomaHistopathologic SubtypesHistopathologic Subtypes

Acanthomatous type-- Squamous epithelium in center

Granular cell type-- Histiocyte-like cells -- Granular cytoplasm

Basal cell type-- Like basal cell carcinoma

AmeloblastomaAmeloblastomaTreatment & PrognosisTreatment & Prognosis

Enucleation: >50% recurrence rateEn bloc resection: <15% recurrence rate↑ Cystic > ↑ prognosisMain problem: local destruction-- May invade through base of skull-- May wrap around neck structuresRarely: piece breaks off @ surgery: aspirated-- Ameloblastoma grows in bronchial tree

AmeloblastomaAmeloblastomaVariantsVariants

Unicystic ameloblastoma-- Intraluminal ameloblastoma-- Mural ameloblastoma

Peripheral ameloblastoma-- Extraosseous ameloblastoma

Desmoplastic ameloblastoma

Ameloblastic carcinoma

Malignant ameloblastoma

AmeloblastomaAmeloblastomaVariantsVariants

Unicystic ameloblastoma-- Intraluminal ameloblastoma-- Mural ameloblastoma

Peripheral ameloblastoma-- Extraosseous ameloblastoma

Desmoplastic ameloblastoma

Ameloblastic carcinoma

Malignant ameloblastoma

Unicystic AmeloblastomaUnicystic Ameloblastoma

15% of all ameloblastomasDegenerated “ basket weave” cyst liningUnilocular radiolucency onlyResembles dentigerous cystYounger persons-- Avg. age = 23 yearsMuch less aggressivethan regular ameloblastoma

Peripheral AmeloblastomaPeripheral AmeloblastomaExtraosseous AmeloblastomaExtraosseous Ameloblastoma

1% of all ameloblastomasSame histology as internal ameloblastomaMass on gingiva-- Sessile-- AsymptomaticMinimal growth potential-- < 1 cm. diameterMay cup out underlying cortex-- Saucerization

Conservative surgical removalAlmost no recurrence rate

Desmoplastic Desmoplastic AmeloblastomaAmeloblastoma

Dense fibrous stroma-- Transforming growth factor ß“Squished” epithelial islandsMixed radiolucent/radiopaque-- From bone stimulationMoth-eaten radiolucencyUsually not multilocularMaybe less aggressivethan regular ameloblastoma

AmeloblastomaAmeloblastomaMalignant VariantsMalignant Variants

Ameloblastic Ameloblastic CarcinomaCarcinoma

Cells are dysplasticMetastizesMay look like salivaryadenocarcinoma

Malignant AmeloblastomaMalignant Ameloblastoma

Cells look benignMetastasizesCaution: this is not same as aspiration ofameloblastoma cells!

Ameloblastic Ameloblastic FibromaFibroma

Ameloblastic FibromaAmeloblastic FibromaJuvenile AmeloblastomaJuvenile Ameloblastoma

Benign neoplasm-- Epithelial & mesenchymal

originGAL:-- None-- First two decades of life-- Posterior mandible

Ameloblastic FibromaAmeloblastic FibromaAsymptomaticUsually multilocular radiolucency-- No calcifications centrallyWell demarcated-- Often: thin sclerotic rimUsually associated withcrown of unerupted toothMay expand cortexCan move teeth

Ameloblastic FibromaAmeloblastic Fibroma

Primitive mesenchymaltissues-- Immature stroma-- Large, stellate, spindled

nuclei-- Mild/Moderate cellularityDouble-layered strands of cuboidal odontogenic epitheliumAmeloblastoma-like islands

Ameloblastic FibromaAmeloblastic FibromaWith AmeloblastomaWith Ameloblastoma--Like IslandsLike Islands

Hyaline InductionHyaline Induction

Ameloblastic FibromaAmeloblastic FibromaTreatment & PrognosisTreatment & Prognosis

May become very largeConservative surgical removal or curettage40% risk of recurrence

Ameloblastic Ameloblastic FibrosarcomaFibrosarcoma

Ameloblastic Ameloblastic FibrosarcomaFibrosarcoma

Stroma shows malignancyEpithelial islands OKBehaves like fibrosarcoma

Ameloblastic Ameloblastic FibroFibro--OdontomaOdontoma

Enamel and dentin structuresMay be early stage of odontomaMay become very largeRadiolucent backgroundGlobular opacities centrallyPerhaps: tooth-like shapes

Ameloblastic FibroAmeloblastic Fibro--OdontomaOdontoma

Ameloblastic FibroAmeloblastic Fibro--OdontomaOdontoma

©Photo: WESTOP, Dr. Beatriz Aldape, National University of Mexico, Mexico City, Mexico

Ameloblastic Ameloblastic FibroFibro--OdontomaOdontoma

©Photo: WESTOP, Dr. Beatriz Aldape, National University of Mexico, Mexico City, Mexico

Adenomatoid Adenomatoid Odontogenic TumorOdontogenic Tumor

Adenomatoid Adenomatoid Odontogenic TumorOdontogenic TumorAOT; AdenoameloblastomaAOT; Adenoameloblastoma

Benign neoplasm-- Reduced enamel epithelium-- Maybe it’s a hamartoma

GAL:-- Female-- Second decade-- Anterior maxilla-- 5% of all

odontogenictumors

Reduced enamel Reduced enamel epitheliumepithelium

Adenomatoid Odontogenic TumorAdenomatoid Odontogenic TumorAOT; AdenoameloblastomaAOT; Adenoameloblastoma

Unilocular radiolucencyOften: thin sclerotic rimWell-demarcated peripheryMay expand cortexEventually globular radiopacities-- Or small “snowflake” opacities Asymptomatic Around crown ofimpacted toothInterferes witheruption1-2 cm. in size

Adenomatoid Odontogenic TumorAdenomatoid Odontogenic Tumor

Adenomatoid Odontogenic Adenomatoid Odontogenic TumorTumor

HistopathologyHistopathology

Spindle-shaped epithelial cells-- Form sheets and strandsWhorled masses and rosette structuresDuctal structures -- Peripheral palisading-- Polarization of nuclei

toward the basementmembrane

Adenomatoid Odontogenic Adenomatoid Odontogenic TumorTumor

HistopathologyHistopathology

Dystrophic calcificationAmyloidThin fibrous capsule

Adenomatoid Odontogenic TumorAdenomatoid Odontogenic TumorTreatment & Special VariantsTreatment & Special Variants

Treat: Surgical curettageAlmost no recurrence risk

Variant:Peripheral AOT-- Very mild behavior-- Like fibroma-- On gingiva-- No recurrence

Calcifying Epithelial Calcifying Epithelial Odontogenic TumorOdontogenic Tumor

Calcifying Epithelial Calcifying Epithelial Odontogenic TumorOdontogenic Tumor

CEOT; Pindborg TumorCEOT; Pindborg Tumor

Benign, aggressive neoplasmTooth bud cells-- Probably stellate reticulum

GALP:-- None-- 30-50 years-- Posterior mandible-- < 1% of all

odontogenic tumors

Calcifying Epithelial Odontogenic TumorCalcifying Epithelial Odontogenic TumorCEOT; Pindborg TumorCEOT; Pindborg Tumor

Well-demarcated radiolucency-- Unilocular or multilocularOften: globular calcified opacitiesFrequently associated with crownof impacted toothAsymptomaticExpands cortex

Calcifying Epithelial Calcifying Epithelial Odontogenic TumorOdontogenic Tumor

HistopathologyHistopathology

Islands, clusters, strands ofpolyhedral epithelial cellsOften: intercellular bridgesOften: large and dysplastic-looking cells-- Not true dysplasia-- No mitotic activityBackground fibrous stromaGlobular calcifications withLiesegang rings(onion skinning)

Calcifying Epithelial Calcifying Epithelial Odontogenic TumorOdontogenic Tumor

HistopathologyHistopathology

Masses of hyalinized material-- Amyloid-- Congo red-- Thioflavin T immunostaining

Calcifying Epithelial Calcifying Epithelial Odontogenic TumorOdontogenic Tumor

TreatmentTreatment

Less aggressive than ameloblastoma--But may be aggressive locallyConservative local resection-- Narrow rim of normal bone15% recurrence rate

Peripheral Pindborg TumorPeripheral CEOT

Attached gingivaAnterior regionMay erode bone-- SaucerizationLow biological behaviorTumor may be attached to surfaceepithelium

OdontomaOdontoma

OdontomaOdontomaComplex Odontoma; Compound OdontomaComplex Odontoma; Compound Odontoma

Developmental hamartoma-- Maybe benign neoplasmGALP:-- None-- First two decades of life-- Compound variant = anterior maxilla-- Complex variant = molar regions

(both jaws)-- Most common odontogenic tumor

OdontomaOdontomaComplex Odontoma; Complex Odontoma;

Compound OdontomaCompound Odontoma

Well-demarcated radiolucency-- With irregular or tooth-like opacities Thin sclerotic rimmingAsymptomaticUsually associated with crownof unerupted toothPrevents eruption

OdontomaOdontomaComplex Odontoma; Compound OdontomaComplex Odontoma; Compound Odontoma

Complex odontoma-- Unorganized calcified tooth-related tissuesCompound odontoma-- Tooth-like structures are presentCombined odontoma-- Mixture of complex and compoundCystic odontoma-- In wall of dentigerous cyst

Compound OdontomaCompound Odontoma

Compound OdontomaCompound Odontoma

Cystic OdontomaCystic Odontoma

Complex OdontomaComplex OdontomaMay interfere with eruptionMay interfere with eruption

OdontomaOdontomaHistopathologyHistopathology

Mature fibrous stomaContaining irregular masses ofdentin with areas of enamel matrix Cementum and pulp tissueMasses may be tooth-likeEncapsulated

OdontomaOdontomaTreatmentTreatment

Usually “burn out”May become hugeEnucleation/curettageNo recurrence

A Kick in the OlA Kick in the Ol’’ OdontomaOdontomaIs this a good way to treat an odontoma?!!Is this a good way to treat an odontoma?!!

OdontoOdonto--AmeloblastomaAmeloblastoma

OdontoameloblastomaOdontoameloblastomaCollision Tumor: Ameloblastoma & OdontomaCollision Tumor: Ameloblastoma & Odontoma

Odontogenic Odontogenic MyxomaMyxoma

Odontogenic MyxomaOdontogenic Myxoma

Benign neoplasm-- Of odontogenic ectomesenchymeGAL:-- None-- Second - fourth decades-- RareExclusively in the jaws-- There are soft tissue myxomas

(e.g. cardiac myxoma)

Odontogenic MyxomaOdontogenic Myxoma

Multilocular radiolucency-- Occasionally unilocular

(Especially odontogenic fibromyxoma)Poorly or well-demarcated peripheryAsymptomaticExpands and thins cortexMaybe: push teethMaybe: resorb rootsOften associated withcrown of impacted tooth

Odontogenic Odontogenic MyxomaMyxoma

Odontogenic MyxomaOdontogenic MyxomaHistopathologyHistopathology

Background fibromyxoid stromaRather acellular, with few stellateor bipolar mesenchymal cells-- Similar to primitive pulpNot encapsulatedIf stroma is dysplastic:-- Odontogenic myxosarcoma

Odontogenic Odontogenic MyxofibromaMyxofibroma

TeenagersAround crown of impacted toothMuch less aggressive than routine myxoma

Odontogenic MyxomaOdontogenic MyxomaTreatment & PrognosisTreatment & Prognosis

May be locally aggressive-- Does not metastasize Small lesions: curettageOdontogenic myxofibroma: curettageLarge lesions: resection with 0.5 cm. margins

Odontogenic fibromyxosarcoma-- Radical surgery

Odontogenic Odontogenic FibromaFibroma

Odontogenic FibromaOdontogenic Fibroma

Benign neoplasm -- Odontogenic mesenchymal cells

GALP:-- Females-- Second - fourth decades of life-- Anterior maxilla and posterior mandible-- Rare

Odontogenic FibromaOdontogenic Fibroma

Well-demarcated radiolucencyUsually unilocular-- Larger: often multilocularOften surrounding crown ofimpacted toothAsymptomaticMay resorb rootsMay expand cortexMay move teethCaution!Must distinguish fromhyperplastic dentalfollicle

Odontogenic FibromaOdontogenic FibromaHistopathologyHistopathology

Background stroma:-- Mature fibrous tissueStellate and spindled fibroblastsOften with whorled pattern Stroma may be quite loose-- Like odontogenic myxomaOdontogenic epithelial restsDystrophic calcifications -- Or cementum-like globules -- Or dentin-like globulesEncapsulated

Odontogenic FibromaOdontogenic FibromaTreatment and Special VariantsTreatment and Special Variants

Enucleation or curettageRecurrence is rareSimple odontogenic fibroma-- Almost all fibrous-- Small epithelial islands-- Small dystrophic calcificationWHO type of odontogenic fibroma-- Many epithelial islands-- Calcified globulesPeripheral odontogenic fibroma-- Innocuous gingiva mass

CementoblastomaCementoblastoma

CementoblastomaCementoblastomaBenign CementoblastomaBenign Cementoblastoma

Benign neoplasm of cementumAttached to toothBone counterpart:-- Osteoblastoma

GALP:-- Female-- Second-fourth decades-- Mandibular molar-- Rare

CementoblastomaCementoblastomaBenign CementoblastomaBenign Cementoblastoma

Enlargement of root apexRounded or irregular radiopacity-- May be some radiolucency Well-demarcatedThin capsule, may be irregular-- Continuous with PDLOften: tender/painfulMay expand cortex

CementoblastomaCementoblastomaHistopathologyHistopathology

Cementoid or osseous calcified massesBackground stroma of fibrous tissueCementoblasts/cementoclastsEncapsulated (PLD?)

CementoblastomaCementoblastomaTreatment; PathophysiologyTreatment; Pathophysiology

May become 7 cm acrossDestroys root; tooth remains viableMaybe: pressure resorption of adjacent rootExtractionRecurrences are rare

Central Cementifying Central Cementifying FibromaFibroma

Central Cementifying FibromaCentral Cementifying Fibroma

Odontogenic or bone tumor?Benign tumor of alveolusTeens to 35 years of ageAsymptomaticRadiolucent background, globular radiopacities in centerGets more opaque over timeCapsule around itUsually <3 cm. in sizeMay expand cortexHistopathology:--Like cementoblastoma

Central Central Cementifying FibromaCementifying Fibroma

Early lesionEarly lesion

Late lesionLate lesion

Classification of Classification of Odontogenic CystsOdontogenic Cysts

Odontogenic Cysts Odontogenic Cysts

Dentigerous Cyst-- Eruption CystPrimordial CystLateral Periodontal CystBuccal Bifurcation CystOdontogenic Keratocyst-- Gorlin SyndromeOrthokeratinized Odontogenic CystGingival Cyst of the NewbornGingival Cyst of the AdultCalcifying Odontogenic CystGlandular Odontogenic Cyst

Odontogenic KeratocystOdontogenic Keratocyst

Dentigerous CystDentigerous Cyst

With rare exceptions, epithelium-lined cysts in bone

are seen only in the jaws

Dentigerous CystDentigerous Cyst

Dentigerous CystDentigerous Cyst

Usually developmentalMaybe: from inflammationCleft in reduced enamel epitheliumSeparation from crownDegenerated stellate reticulum

GAL:-- None-- 10-30 years of age-- Third molar areas-- Especially mandible

Dentigerous CystDentigerous CystClinical FeaturesClinical Features

Well-demarcated radiolucencyUsually: unilocularOften: thin sclerotic rimmingAround crown, by definitionTeeth can be pushedMay: resorb rootsOften: prevents eruptionThree types-- Central-- Lateral-- Circumferential

Dentigerous Cyst or Not?Dentigerous Cyst or Not?The 1.5 mm. ruleThe 1.5 mm. rule

Dentigerous CystDentigerous CystOnce Called Cystic CarcinomaOnce Called Cystic Carcinoma

Multiple Dentigerous CystsMultiple Dentigerous CystsWorry About Gorlin SyndromeWorry About Gorlin Syndrome

Dentigerous CystDentigerous CystHistopathologyHistopathology

Atrophic stratified squamous epithelial lining-- Usually parakeratin-- Maybe: mucus metaplasiaFibrous/fibromyxomatous stroma-- Often hyperplastic-- Maybe inflamedAttached at cervical regionMaybe: ulcerated epithelial lining

Dentigerous CystDentigerous CystHistopathologyHistopathology

Cholesterol granuloma:-- Cholesterol clefts-- Foreign body reaction-- Multinucleated giant cellsWaldron type dentigerous cyst-- If reduced enamel epithelium-- If no epitheliumOrthokeratinized odontogenic cyst

Dentigerous CystDentigerous CystTreatment; PathophysiologyTreatment; Pathophysiology

Enucleation-- Maybe: extraction-- Maybe: orthodontic guidanceMarsupialized (large lesions)Special Problems:-- Odontogenic keratocyst-- Carcinoma in epithelial lining-- Eruption cyst

Orthokeratinizing Orthokeratinizing Odontogenic CystOdontogenic Cyst

Orthokeratinizing Orthokeratinizing Odontogenic CystOdontogenic Cyst

Parakeratinizing OdontogenicParakeratinizing OdontogenicKeratocystKeratocyst

Usually dentigerous cystOnce thought to be a variant of odontogenic keratocyst-- But histology is different!Same biological behavior asdentigerous cyst

Eruption CystEruption Cyst

Eruption CystEruption CystEruption Hematoma; Dentigerous CystEruption Hematoma; Dentigerous Cyst

Dentigerous cyst of erupting toothBlue or bluish-red colorCortex completely missing Fibrous stroma between epitheliaNo treatment needed-- Unless infected-- Tooth erupts normallyMay erupt into pericoronitis:-- Paradental cyst

Eruption CystEruption CystEruption Hematoma; Dentigerous CystEruption Hematoma; Dentigerous Cyst

Cortex completely missing -- Fibrous stroma between epitheliaBlue or bluish-red color-- Maybe: clear fluid inside

Eruption CystEruption CystDentigerous CystDentigerous Cyst

Odontogenic Odontogenic KeratocystKeratocyst

Odontogenic KeratocystOdontogenic Keratocyst

Developmental cystic degeneration-- Of odontogenic epithelial rests-- Sometimes triggered by

inflammation?

GAL:-- None-- 10-40 years-- Posterior mandible-- Ramus

Odontogenic KeratocystOdontogenic KeratocystClinical FeaturesClinical Features

Well-demarcated radiolucencyMultilocular or unilocularAsymptomaticOften associated with crown of impacted toothSeldom expands cortex, may thin it--Except: superior-inferiorMay become very largeMay push teethMay resorb roots, perforate cortex

Odontogenic KeratocystOdontogenic Keratocyst

Odontogenic KeratocystOdontogenic KeratocystMay be hazy opacity if in sinus; May become inflamedMay be hazy opacity if in sinus; May become inflamed

Odontogenic KeratocystOdontogenic KeratocystClinical SubtypesClinical Subtypes

Dentigerous cyst typePrimordial cyst typeLateral periodontal cyst typePeriapical cyst type

Odontogenic KeratocystOdontogenic KeratocystHistopathologyHistopathology

Uniform 4-7 cell thicknessLoss of rete ridges/processesThin corrugated parakeratin layerPolarized basal cell nucleiHyperchromatic basal cell nucleiPulling away frombasement membrane

Orthokeratizing odontogenic cyst looks different!

Odontogenic KeratocystOdontogenic KeratocystHistopathology

Fibrous/fibromyxomatous stromaOften: islands of benignodontogenic epitheliumMaybe: daughter cysts

Odontogenic KeratocystOdontogenic KeratocystLoss of Classical Microscopic Features in Inflamed Area

Odontogenic KeratocystOdontogenic KeratocystTreatment; Special ProblemsTreatment; Special Problems

Enucleation and curettage-- Up to 62% recurrence-- Usually within 5 yearsOstectomy/En bloc resectionHemimandibulectomy Chemical cauterization-- Carnoy’s solution

Marsupialization (large lesions)Rare: carcinoma developsProblem: Gorlin syndrome

Gorlin SyndromeGorlin Syndrome

Gorlin SyndromeGorlin SyndromeNevoid Basal Cell Carcinoma SyndromeNevoid Basal Cell Carcinoma Syndrome

Mutation of PATCH (PTCH, patched)-- Tumor suppressor gene-- Chromosome 9q22.3-q31Multiple keratocysts-- Often dentigerous cyst type-- May be hugeMultiple basal cell carcinomas and nevi

Gorlin SyndromeGorlin SyndromeNevoid Basal Cell Carcinoma SyndromeNevoid Basal Cell Carcinoma Syndrome

Frontal bossingPalmar/plantar pitsBifid ribsSplayed ribsFused ribsMissing ribsCalcified falx cerebriSpina bifida occulta

Gorlin CystGorlin Cyst

Calcifying Odontogenic CystGorlin Cyst; COC

Cross between:-- Developmental cyst-- Benign neoplasm

GAL:-- None-- Anterior maxilla/mandible

(65% of cases)

Calcifying Odontogenic Cyst Clinical Features

Unilocular radiolucency-- May be multilocular Well-demarcated borders-- Often: thin sclerotic rimmingEventually: irregular radiopacities-- Or tooth-like structuresAround crown of tooth-- 1/3 of casesUsually 2-4 cm.-- Maybe: much larger

The Original Gorlin CystThe Original Gorlin CystCalcifying Odontogenic CystCalcifying Odontogenic Cyst

©Photos: Dr. R. J. Gorlin, University of Minnesota, Minneapolis, Minnesota

Calcifying Odontogenic Cyst

Histopathology

Stratified squamous epitheliumliningFibrous stromaAbundant keratin production-- Eosinophilic ghost cells--Dystrophic calcificationBasal cells might be cuboidal-- Look like preameloblastsEpithelium may proliferate-- Into lumen-- Into fibrous stroma

Calcifying Odontogenic CystSpecial Cases

Peripheral Gorlin cyst-- Attached gingiva-- Not aggressive-- May represent 30% of total

Epithelial odontogenic ghost cell tumor-- No cyst formation; solid tumor-- 2-14% of all “Gorlin cysts”-- More aggressive

Gorlin cyst phenomenon

Odontogenic ghost cell carcinoma-- Very rare-- 73% 5-year survival

Calcifying Odontogenic Cyst

Treatment & PrognosisTreatment & Prognosis

Enucleation for smaller lesionsSome recurrencesMore solid = more aggressiveLarge/aggressive lesion:-- Resection

Gingival Cyst of Gingival Cyst of NewbornNewborn

Gingival Cyst of NewbornGingival Cyst of NewbornEpstein Pearls; Bohn NodulesEpstein Pearls; Bohn Nodules

Developmental cyst-- Remnants of dental lamina100+ tooth buds to create 32 teethPrevalence: up to 50% of newborns

GAL:-- None -- Congenital-- Alveolus-- Palate

Gingival Cyst of Gingival Cyst of NewbornNewborn

Clinical FeaturesClinical Features

Small, superficial whitish blebsSingle or maybe dozensOn posterior hard/soft palate:-- Epstein pearls-- Bohn nodules

Gingival Cyst of NewbornGingival Cyst of NewbornHistopathology and TreatmentHistopathology and Treatment

Cyst lining of stratified squamous epitheliumLumen filled with sloughed keratin

No treatment required-- Cysts rupture spontaneously within days-- May last until teeth erupt-- Cysts do not interfere with eruption

Gingival Cyst of AdultGingival Cyst of Adult

Gingival Cyst of AdultGingival Cyst of Adult

Developmental, degenerative cyst-- Rests of Serres in gingival stroma

GAL:-- None-- 40-60 years-- Attached gingiva (facial)-- Mandibular cuspid/premolar area

(70% of cases)

Gingival Cyst of AdultGingival Cyst of AdultClinical FeaturesClinical Features

Painless mass of attached gingivaDome-shaped (sessile)Fluctuant

<.5 cm diameterMaybe: blue colorMaybe: saucerizationRound radiolucency-- Well demarcated

Gingival Cyst of AdultGingival Cyst of AdultHistopathology; TreatmentHistopathology; Treatment

Stratified squamous epithelial cyst liningDense fibrous stromaLumen: filled with fluid or keratinEnucleation-- No recurrence

Lateral Periodontal Lateral Periodontal CystCyst

Lateral Periodontal CystLateral Periodontal Cyst

Developmental-- Cystic degeneration of

odontogenic epithelial rests

GALP:-- None-- 40-70 years-- Mandibular premolar area

(80% of all cases)-- <2% of all odontogenic cysts

Lateral Periodontal CystLateral Periodontal CystClinical FeaturesClinical Features

AsymptomaticTeeth are viableCenter: inter-radicular bone-- Not periodontal ligament-- Midpoint halfway between premolarsWell-demarcated radiolucency-- UnilocularUsually < 5 mm. diameter May push roots out of wayDoes not resorb roots

Lateral Periodontal CystLateral Periodontal CystHistopathologyHistopathology

Cyst with clear fluid in lumen-- Lumen is empty on H&E slide Thin stratified squamous epitheliumFocal epithelial nodules (unique!)-- Extend into lumenSeldom inflamed

Lateral Periodontal CystLateral Periodontal CystTreatmentTreatment

EnucleationSmall recurrence rateCaution! Make sure it’s notmental foramen!Caution! Must send for biopsy diagnosis-- Odontogenic keratocyst

can have similar x-ray presentation

Botryoid Lateral Periodontal CystBotryoid Lateral Periodontal CystClinical FeaturesClinical Features

Multilocular radiolucency-- Like a grape cluster (”botryoid”) May be very large May be more aggressiveHigher recurrence rateMay require block resection

Buccal Bifurcation Buccal Bifurcation CystCyst

Buccal Bifurcation CystBuccal Bifurcation Cyst

Inflammatory stimulation of epithelial restsAlways: in furcation region of mandibular molar

GALP:-- None-- Middle-aged-- First mandibular molar area-- Rare

Buccal Bifurcation CystBuccal Bifurcation Cyst

Asymptomatic or tenderPoorly demarcated furcation radiolucencyWithout periodontal pocketTooth is viableSessile, moderately firm gingival mass-- Facing toward the facial-- < 8 mm. diameter

Buccal Bifurcation CystBuccal Bifurcation Cyst

Degenerated stratified squam. epitheliumFocally edematous fibrous stroma Numerous chronic inflammatory cellsPMNs in and beneath epitheliumTreat: Enucleation-- May have to extract toothCaution! Check vitality of the toothCaution Probe for periodontal pockets