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