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    Pseudocysts

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    Contents

    Introduction

    Aneurysmal bone cyst

    Simple bone cyst

    Static bone cyst

    Mucus extravasation cyst

    Antral pseudocyst

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    Aneurysmal bone cyst

    Long bones

    Jaffe & Lichtenstein 1942-

    blow out (radiographically)

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    Aneurysmal bone cyst

    Intraosseous accumulation of variable sized,

    blood filled spaces surrounded by cellular

    fibrous connective tissue that often isadmixed with trabeculae of reactive woven

    bone

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    Aneurysmal Bone Cyst

    First three decades;

    Most common in second decade

    Female predilection

    Mandible > maxilla (molar region >angle

    > ramus)

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    Aneurysmal Bone Cyst

    Painful swelling

    Malocclusion

    Rate of enlargement is progressively rapid

    Recent displacement of teeth ; which are vital

    Perforates the cortex and; covered byperiosteum

    Thin shell of boneSpringiness or egg shell crackling, BUT IS

    NOT PULSATILE

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    Radiographic appearance

    Well defined expansileosteolytic unilocular

    radiolucency

    Changes as it matures

    Soap bubble

    Honey bomb

    Moth-eaten

    Radiopaque

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    Etiology & Pathogenesis

    Traumatic event,

    Vascular malformationor

    Neoplasmthat disrupts the normalosseous hemodynamics & lead to anenlarging hemorrhage extravasation

    Preexisting bone lesion-secondaryphenomenon

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    Ewing (1940)

    Benign giant cell lesion tumor modified bycommunication with large blood vessels

    Jaffe (1950)

    Modification of some other lesion which hasbeen destroyed by hemorrhage

    Clough & Price (1968)Fibrous dysplasia & chondromyxoid fibroma

    Etiology & Pathogenesis

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    Solitary bone cysts, giant cell tumors &

    osteosarcomas

    More commonly with Fibro osseous lesionsWhat changes could have caused the

    formation of ABC in these lesions???

    Etiology & Pathogenesis

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    Formation of microcysts

    (Fibrous dysplasia, Central giant cell granuloma)

    Enlargement of the microcyst

    (stromal break down, giant cells)

    Connection with vascular compartment causes

    further expansion

    Etiology & Pathogenesis

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    Pressure on the bony wall

    (endosteal resorption)

    Thinning of cortex

    Etiology & Pathogenesis

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    Struthers &Shear

    Malignant lesion-breaking the bone

    Telangiectatic form of osteosarcomaTo conclude many think that it isNOT a

    secondary phenomenonas they did not findany precursor lesion.

    However both groups agreed that someareas similar to those of ABC were seen.

    Etiology & Pathogenesis

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    At operation an intact periosteum and a thin

    shell of bone

    Profuse bleeding

    Cyst contains number of blood filled locules

    and friable vascular tissue

    No direct communication with any vessels can bedemonstrated at operation

    Etiology & Pathogenesis

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    Capillaries, blood

    filled spaces, linedby flat spindle

    shaped cells

    Loosely textured

    fibrous tissue

    HISTOPATHOLOGY

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    Large number of

    multinucleate

    giant cells

    Fibroblasts,hemorrhage,

    hemosiderin

    Looks similar to

    giant cell

    granuloma

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    Differential diagnosis

    Giant cell lesions

    Osteosarcoma

    Rule out any lesion primarily associated

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    Treatment

    Depend on the nature of the associated

    lesion

    Curettage

    Bone grafting

    Can recur-

    if recur evaluate the case carefully to see any

    associated lesion

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    Simple bone cyst(Traumatic bone cyst; hemorrhagic bone cyst,

    idiopathic bone cavity; unicameral bone cyst)

    Benign , empty or fluid containing cavitywithin bone that is devoid of an epithelial

    lining

    Common in jaws

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    First described by Lucas (1929)

    Rushton defined : Avacant or fluid

    containing cystic lesion surrounded by a

    hard bony wall with no epithelial lining

    and no evidence of infection

    Simple bone cyst

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    Further Donkar and Punnia-Moorthy

    subclassified as:

    Idiopathic-EmptyFibrous or granulationsolid matter

    Extravasation cysts (containing biochemical

    profile similar to serum)

    Simple bone cyst

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    Younger patient; though (7-75 years)

    More in males

    Mandible mostly

    Body and symphysis (ramus also

    reported)

    Anterior region in maxilla

    Trauma prone areas

    Simple bone cyst

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    Asymptomatic; Diagnosed on Routine

    examination

    Sometimes may be associated withPain

    Swelling

    ParaesthesiaHistory of trauma (not always)

    Simple bone cyst

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    Smooth outlined radiolucentwith thin sclerotic border ,Root

    involved - lobulated

    Lamina dura may or may not

    be lost

    Radiographic appearance

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    Differential Diagnosis

    Periapical cemental dysplasia

    OKC

    Stafne cyst (Below canal)

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    Pathogenesis

    Olech, Sicher & Weinmann -

    Trauma - hemorrhage theory

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    Trauma

    intramedullary hemorrhage

    Necrosis of bone marrow and endosteum

    Osteoclastic resorption of trabeculae

    Liquefaction of hematoma(Before viable connective tissue formation)

    Some simple cyst contain blood or serosanguineous fluid

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    Breakdown products of hematoma

    Local rise in osmotic pressure

    (Toller study)

    Transudation into the cystic fluid

    Increase the intraosseous pressure

    Osteoclastic activity and swelling

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    Transudation progresses

    Fluid gets diluted

    Drop in the intracystic pressure(Further bleed may cause progression of the lesion)

    No more bleeding

    Gradual absorption or fluid occurs

    Empty cavity

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    Histologically Walls lined by athin band of vascular

    fibrous connectivetissue or demonstratea thickenedmyxofibromatous

    proliferation that

    often is intermixedwith trabeculae ofcellular & reactive

    bone

    Areas of

    vascularity, fibrin,erythrocytes &

    occasional giant

    cells adjacent to

    the bone surface

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    Diagnosis

    Can be confused with Giant cell lesions

    Surgical explorationnecessary

    EMPTY CAVITY

    SMOOTH SHINY WALL

    SEROSANGUINEOUS FLUID

    Mandibular neurovascular bundle may seen lying

    free in the cavity

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    Treatment

    Induce hemorrhage

    Some may resolve by itself

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    Stafne cyst(Lingual Mandibular bone defect, static bone cavity,

    latent bone cyst)

    1942- Stafne described asymptomaticradiolucent lesions located near the angle ofthe mandible

    Focal concavity of the cortical bone on thelingual surface of the mandible, remainstable in size , are not congenital

    All major salivary gland can cause suchdefect

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    Radiographic appearance

    Ovoid radiolucency between

    inferior alveolar canal and inferior

    border of mand inn 2ndor 3rdmolar

    Distinguished

    bet TBC-

    superior to

    inferior

    alveolar canal

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    Pathogenesis

    Pressure from the lobe of the gland

    Resorption of the bone

    Radiolucent defect

    1.

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    Pathogenesis

    Ischemic process in an area adjacent to the

    passage of the facial artery + tensile muscle

    forces + hemodynamic forces

    Pulled the artery from the lingual cortex

    Comprising it from nutrition

    Atrophy

    2.

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    Diagnosis

    Clinical basis

    CT & MRI, Sialography

    Biopsy

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    HistopathologyMuscle, Fatty Tissue or Normal salivary gland

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    Treatment

    No treatment required

    Mucous extravasation

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    Mucous extravasation

    cyst

    (Mucous escape reaction, mucous escapephenomenon )Two type

    Retention (less common) and extravasation

    Most commonly found on lower lip, canalso be seen onUpper lip

    Floor of mouth and ventral of tonguePalate

    Buccal mucosa

    Retro molar area

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    Mucous extravasation cyst

    Painless swelling (specially at meal times-on

    and off swelling)Round to oval

    Blue and fluctuant/ normal color

    Mistaken for lipoma, salivary gland tumor, fibro

    epithelial polyp

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    Pathogenesis

    Trauma to the salivary gland duct or the acini

    duct itself (parenchymatous type)

    Egress of mucous into the adjacent connective

    tissue

    Complete ductal obstruction Mucus extravasation cyst

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    Histopathology

    Usually received with a associated salivarygland and frequently a part of the superficialmucosa

    If cut-gelatinous material/ mucinous content

    Three distinct pattern (Robinson & Horting-Hansen)

    1stand 2ndextravasation

    3rdretention

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    Histopathology

    Mucous acini

    CONNECTIVE

    TISSUE STROMA

    MUCIN FILLED

    CAVITY

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    Histopathology

    Mucin filled cavity

    with mucinophages,

    neutrophils,histocyte

    C.T- B.V,

    inflammatory cell

    infitrates,

    Mucous acini

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    Treatment

    Surgical excision tends to recur

    Removal of the gland is advisable along

    with the mucocele

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    Antral

    Pseudocyst

    Antral cysts:

    True- secretory

    Pseudo-non secretory

    Dome shaped lesion of the sinus floor

    SINUS

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    Antral Pseudocyst

    Exudate (serum not mucin)

    Accumulated under the maxillary sinus

    mucosa causing sessile elevation

    SINUS

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    Antral Pseudocyst

    Odontogenic infection

    Sinus infection

    Allergies

    Winter months

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    Kwappis and Whitten(1971)

    Severe infection

    Alter the integrity of the gland duct in the

    sinus lining

    Mucus into the connective tissue

    Pathogenesis

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    Gardner and Gardner and Gullane

    Focal accumulation of inflammatory exudate that liftthe antral mucosa

    Endodontically treated teeth and periodontitishasalso been implicated

    Mechanical stress during coldsharp angle tissuegets rupture

    Increased IgG, IgA, and C3presence ofanaerobic infection

    Pathogenesis

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    Radiographic appearance

    Faintly radiopaque

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    Histopathology

    Calcifications and cholesterol crystals may be seen

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    No treatment-regress by itself

    If symptoms present

    Drain by acnnulationLarge cystremove by caidwell-Luc approach

    Treatment