Inflammatory Odontogenic cysts

1. Inflammatory Odontogenic cysts Radicular cyst - is one which arises from the epithelial residues in the periodontal ligament as a result of inflammation. - also referred to as: periapical (periodontal) radicular cyst Lateral (periodontal) radicular cyst

2. Clinical features Age- 3rd-4th decade Sex- Males > Females. Site- Maxillary anterior teeth. Clinical presentation -symptomless unless infected. -associated with non-vital teeth. -may complain of slowly enlarging swelling. -initially bony hard swelling, as cyst increases in size bony covering becomes thin and swelling exhibits ‘springiness’, later fluctuation. Cyst content - Uninfected cystic fluid is straw coloured or brownish containing cholesterol clefts. - Small amount of keratin flakes maybe seen. - In long- standing infection, a dirty white caseous material or frank pus maybe expressed.

3. Radiological features -well-circumscribed unilocularradiolucency at apex or lateral aspect of tooth. Histopathological features - Inflammatory infiltrate of polymorphonuclear leucocytes seen in lining. - Epithelial lining may show presence of Rushton bodies, mucus or ciliated cells. .

4. Treatment Enucleation with primary closure. Associated non-vital teeth maybe extracted or endodontically treated. Very small cysts can be removed through tooth socket. Marsupialisation and decompression

5. Residual cyst - is a radicular cyst that remains behind in the jaws after the removal of the offending tooth. Clinical features Site- greater in maxilla typically seen in edentulous sites Clinical presentation - asymptomatic, discovered on radiographic examination. - pathologic fractures or signs of encroachment on associated structures in case of large residual cysts. Histopathologic features - similar to underlying process that was present. Treatment - similar to radicular cyst.

6. Dentigerous cyst (DC) It is defined as the one which encloses the crown of an Unerupted, Supernumery tooth and is attached to the neck

7. Clinical features (DC) • Frequency – 15-20% • Age – 2nd and 3rd decades of life • Sex – males > females; 1.6:1 • Race – whites > Blacks; 4:1

8. Dentigerous Cyst Site – Mandible > maxilla Mandible – 3rd molar Maxillary canine Mandibular premolars Maxillary 3rd molar Supernumerary

9. Features (DC) • Usually seen on radiographs when taken because of missing tooth, failure to erupt etc. • Patients become aware of cysts because of slowly enlarging swellings • Resorption of roots of adjacent teeth • Expansion of bone with facial asymmetry • Displacement of teeth: pain

10. Pathogenesis (DC) It originates after crown of tooth has been completely formed due to accumulation of fluid between reduced enamel epithelium and tooth crown

11. Radiographic features (DC) • Cyst is seen as radioluscent area associated in some fashion with an Unerupted tooth crown • Radioluscent area may appear to project laterally from tooth crown, if cyst is large or there has been displacement of teeth – lateral dentigerous cyst • Circumferential dentigerous cyst – cyst surrounds the entire crown of teeth without involving occlusal surface • Dentigerous cyst is usually a smooth unilocular lesion but occasionally multilocular also seen

12. Radiological presentation of Dentigerous cyst

13. Potential complications (DC) • Ameloblastoma • Epidermoid carcinoma • Mucoepidermoid carcinoma

14. Treatment (DC) • Enucleation together with involved tooth • Marsupialisation which in case of involved tooth might be brought to normal position in arch

15. Differential diagnosis • Ameloblastoma • AOT • OkC

16. Eruption cyst It is associated with erupting deciduous permanent teeth in children. It is essentially dilation of normal follicular space about crown of erupting tooth caused by accumulation of tissue fluid or blood. Clinically lesion appears as a circumscribed, fluctuant, often translucent swelling of alveolar ridge over site of erupting teeth

17. Odontogenic keratocyst The term OKC was introduced by Philipsen (1956) based on histologic appearance of cystic lining. Magitot (1872) – certain follicular cysts developing prior to formation of any dental hard tissues. Seward (1963) – redefined odontogenic cyst as those arising from odontogenic epithelium which has not taken a direct part in development of tooth

18. Pathogenesis (OkC) • It is a developmental anomaly arising from odontogenic epithelium derived from dental lamina or remnants • Because of high recurrence rate and soft tissue involvement the surgical management is like that of a tumor.

19. Clinical features (OkC) • Age – 2nd and 3rd decade of life; bimodal age distribution • Sex – males > females; black > whites • Site – Mandible > maxilla • Varying distance into ascending ramus and body • Maxilla – can occur into sinus; globulomaxillary area • Patient complains of pain, swelling or discomfort • Occasionally parasthesia of lower lip • Usually symptomless unless infected • Displacement of adjacent teeth

20. Radiological features (OkC) • Appears small, avoid, or normal radioluscent areas • Unilocular / multilocular; smooth periphery • Well demarcated with sclerotic margin • Rarely expansion of bone seen • Spread along medullary spaces of bone than buccolingullay

21. Histopathology (OkC) • Cyst is lined by regular keratinized stratified squamous ep about 5-8 cell layers thick and no rete pegs: usually parakeratotic and orthokeratotic type can also be seen • Corrugated appearance of parakeratotic layer • Polished basal cells may be columnar / cuboidal • Nuclei of columnar cell in parakeratotic lining tend to be oriented away from basement membrane and are basophilic. This is a distinguishing feature from other keratinized jaw cyst

22. Treatment (OkC) • Small single lesions can be completely enucleated provided access is good (Intra oral approach) • Larger cyst – careful enucleation and done by extraoral approach; if an intraoral approach may lead to blind curettage

23. Treatment (OkC) • Large multilocular lesions – excision of immediate bone graft is treatment of choice at first operation • Resection of involved bone and reconstruction with stainless steel, vitallium, titanium • More conservative approach – enucleation / excision and cauterization of bone defect with carnoy’s solution prevents recurrence

24. OkC • Recurrence • Pindborg and Hansen (1963) reported a recurrence of 62% in 16 cysts

25. Reason for recurrence (OkC) • Tendency to multiplicity • Satellite cyst • Cystic lining is very thin and fragile, portions of which may left behind • Epithelial lining of OKC has intrinsic growth potential • Cyst can arise from basal cells of oral mucosa

26. Nevoid basal cell carcinoma syndrome(Gorlin-Goltz Syndrome) • First reported by Jarisch, detailed description given by Gorlin. • Also known as Gorlin’s syndrome. • Presenting features: • Facies -Frontal and temporoparietal bossing -Prominent supraorbital ridges in men -Hypertelorism -Mandibular prognathism • Skeletal abnormalities -Bifid, fused rudimentary ribs - Occult spina bifida - Bridging of sella tursica -Shortening of metacarpals -Calcification of falx cerebri

27. Skin lesions • Milia, around eyes. • Dyskeratosis (palms and soles) • Epidermal cysts • Basal cell nevi • Basal cell carcinomas • Cyst -50%show multiple OKCs. • Soft tissue anomalies • Ovarian fibromata • Lipomas

29. Calcifying epithelial odontogenic cyst (Gorlin cyst) Development odontogenic cyst, first described by Gorlin and associates in 1962. Incidence: - Very few cases have been reported - No sex predilection - More common in children, young adults. Site: - Common site of occurrence is Ant. Part of mandible.

30. Clinical features (Gorlin cyst) • Mostly symptomless and discovered accidentally. • Swelling is a frequent complain • A peripheral or intraosseous lesion may be seen. • Produce a hard bony expansion.

31. Radiological features (Gorlin cyst) • Periphery may be well demarcated or irregular • Cortical perforation may be seen • Calcification as irregular radioopaque specks may be seen in cavity.

33. Non-odontogenic cysts

34. Nasopalatine duct cyst - Incisive canal cyst/ Median ant. max. cyst. Clinical features Age- 4th-6th decades. Sex- Males > Females. Site- within nasopalatine canal - in soft tissues of palate, at the opening of the canal (cyst of the incisive papilla).

35. Clinical presentation -swelling in the anterior region of midline of palate or in the midline on the labial aspect of alveolar ridge. -’through and through’ fluctuation maybe elicited between labial and palatal swellings. -maybe associated with pain and discharge. - discharge- mucoid- salty taste purulent- foul taste. - In cysts of palatine papilla, history of recurrent swellings which periodically discharge and reduce in size. - Displacement of teeth maybe present.

36. Radiological features - well-defined cystic outline, between or above the roots of the maxillary central incisors. - maybe round, ovoid or heart-shaped. - roots of central incisors may show divergence and intact lamina dura around tooth apices.

37. Histopathological features - cystic lining- varies at different levels, stratified squamous at a lower level; more superiorly pseudostratified columnar, cuboidal as well as ciliated. - presence of mucous glands, goblet cells and cilia, nerves and blood vessels in the fibrous capsule. Cyst contents Mucous fluid content- maybe mucoid or purulent (if infected). Treatment Enucleation by raising a palatal flap.

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