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BDS4 ORAL SURGERY > Cysts of the Jaws > Flashcards

Cysts of the Jaws Flashcards

1
Q

What is a cyst by definition?

A

A pathological cavity having fluid, semi-fluid or gaseous contents & which is not created by the accumulation of pus

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2
Q

Are cysts characteristically filled with pus?

A

NO
- only when cyst infected

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3
Q

What is usually the rate of progression of cysts?

A

Slow growing (but cyst dependant)

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4
Q

What are the common symptoms of odontogenic cysts?

A
  • eggshell crackling (when pt presses area)
  • mobility of adjacent teeth
  • sensitivity of teeth in area
  • absence of teeth in area
  • numbness or neurological change
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5
Q

What special investigations may you do to investigate potential cystic lesions?

A
  • take radiographs
  • sensibility testing of adjacent teeth
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6
Q

What are some typical radiographic features of cysts?

A
  • spherical or egg-shaped
  • well defined margins
  • corticated
  • can be unilocular or multilocular
  • may include unerupted teeth
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7
Q

How do most cysts grow generally?

A

by hydrostatic pressure

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8
Q

What effect on surrounding anatomy may cysts have that can be seen on radiographs?

A

Displacement of:
- cortical plates
- adjacent teeth
- maxillary sinus
- IAN canal

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9
Q

How could the locularity of this cyst be described?

A

Pseudolocular

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10
Q

What might cause a cyst to lose definition & cortication of margins?

A

Infection of cyst

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11
Q

What is the most common cause of bony swelling in the jaws?

A

Odontogenic cysts
- >90% of all cysts in the oral and maxfax region

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12
Q

How can the lining of odontogenic cysts be described?

A

Lined with epithelium

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13
Q

What are some odontogemic sources of epithelium?

A
  • Rests of Malassez (remnants of Hertwig’s epithelial rooth sheath)
  • Rests of Serres (remnants of the dental lamina)
  • Reduced enamel epithelium (remnants of enamel organ)
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14
Q

Why might epithelium remnants become activated to form cysts?

A
  • idiopathic
  • infections
  • cytokine infiltrations
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15
Q

What type of cysts can arise from the reduced enamel epithelium?

A

Dentigerous cyst

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16
Q

What are the most common odontogenic cysts?

A
  • radicular cysts (60%)
  • dentigerous cysts (18%)
  • odontogenic keratocyst (12%)
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17
Q

What causes radicular cysts?

A

Initiated by chronic inflammation at apex of tooth due to pulp necrosis
- always associated with a non-vital tooth

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18
Q

What is the incidence of radicular cysts?

A
  • most common in 4th&5th decades
  • 60% maxilla: 40% mandible
  • can involve any tooth
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19
Q

How do radicular cysts present?

A
  • often asymptomatic (can become painful if infected)
  • typically slow-growing with limited expansion
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20
Q

How do you tell between a periapical granuloma vs radicular cyst?

A
  • radicular cysts typically larger (usually >15mm)
  • radicular cysts typically have defined corticated margins on radiograph
  • can only tell under microscope
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21
Q

What are the radiographic features of a radicular cyst?

A
  • well defined, round/oval radiolucency
  • corticated margin continuous with lamina dura of non-vital tooth
  • larger lesions displace adjaecent structures
  • long standing lesions may cause external root resorption &/or dystrophic calcification
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22
Q

What are the histological features of a radicular cyst?

A
  • epithelial lining
  • connective tissue capsule
  • inflammation in capsule

(dark dots are inflammatory cells)

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23
Q

What cell types proliferate in periapical granulomas?

A

Epithelial rests of Malassez

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24
Q

What can radicular cysts form by?

A
  • proliferating epithelium with central necrosis
  • epithelium surrounds fluid area
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25
Q

How can the growth patten of radicular cysts be described?

A

Infiltration growth pattern

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26
Q

What is mucous metaplasia?

A

Epithelial cells become mucous secreting cells during cystic change

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27
Q

What is viewed here?

A

Hyaline/rushton bodies

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28
Q

What is viewed histologically here?

A

cholesterol clefts

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29
Q

What can cause numbness of IAN?

A
  • infection
  • trauma
  • injury to nerve
  • tumours
  • cysts
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30
Q

What can cause radiopaque artifacts on receptors?

A

pressure from fingerprints

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31
Q

What are different variants of radicular cysts?

A
  • residual cysts [when cyst persists after loss of tooth]
  • lateral radicular cyst [radicular cyst associated with an accessory canal, located at side of tooth instead of apex]
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32
Q

What type of cyst is pictured here?

A

Residual radicular cyst

33
Q

What type of cyst is pictured here?

A

Lateral radicular cyst

34
Q

What are inflammatory collateral cysts?

A

Inflammatory odontogenic cysts
- associated with a vital tooth

35
Q

What is a dentigerous cyst?

A

Developmental odontogenic cyst that is associated with the crown of unerupted [usually impacted] tooth

36
Q

What are some symptoms of a dentigerous cyst?

A
  • missing tooth
  • swelling in area
37
Q

What causes a dentigerous cyst?

A

cystic change of dental follicle

38
Q

Where are radiolucent areas related to a dentigerous cyst seen?

A

around crown of the tooth extending to the ACJ

39
Q

What are the radiographic signs of a dentigerous cyst?

A
  • corticated margins attached to CEJ of tooth
  • may displace involved tooth
  • tend to be symmetrical initially
  • variable displacement of cortical bone
40
Q

How do dentigerous cysts present histologically?

A
  • thin non-keratinised stratified squamous epithelium [may resemble radicular cyst if inflamed]
41
Q

How do you decide between dentigerous cyst vs enlarged follicle?

A

Consider cyst if follicular space 5mm or more
- measure from surface of crown to edge of follicle
- assume cyst if >10mm

Also consider cyst if radiolucency is asymmetrical

42
Q

How big is the normal follicular space?

A

2-3mm

43
Q

How do you treat an eruption cyst?

A
  • cut through cyst to allow tooth to erupt
44
Q

What is the biggest problem associated with odontogenic keratocysts?

A

Recurrence!!!

45
Q

What is a odontogenic keratocyst?

A

Developmental odontogenic cyst but NO specific relationship to teeth

46
Q

What is the incidence of odontogenic keratocysts?

A
  • most common in 2nd & 3rd decades
  • male > female
  • mandible > maxilla (3:1)
  • posterior > anterior
47
Q

How do odontogenic keratocysts present radiographically?

A
  • often have scalloped margins
  • 25% are multilocular
  • often cause displacement of adjacent teeth
  • enlarged markedly in medullary bone space BEFORE displacing cortical bone
48
Q

What pre-operative diagnostic tests would you do to assess a potential OKC? What would this show?

A

Cyst aspirate
- contains squames
- low soluble protein content !

49
Q

How do odontogenic keratocysts present histologically?

A
  • epithelial lining WITH keratin formation [parakeratosis]
  • basal palisading = nuclei are all at same level/height [uniform appearance]
  • daughter cysts
  • very thin friable lining so not attached very well to underlying tissue
50
Q

What syndrome is associated with odontogenic keratocysts?

A

Basal cell naevus syndrome (Gorlin Goltz syndrome)

51
Q

What is the presentation of Basal cell naevus syndrome?

A
  • multiple odontogenic keratocysts
  • multiple basal cell carcinomas
  • palmar & plantar pitting
52
Q

What are some examples of non-odontogenic cysts?

A
  • nasopalatine duct cyst [most common]
  • solitary bone cysts
  • aneurysmal bone cyst
53
Q

What is a nasopalatine duct cyst?

A

Developmental non-odontogenic cyst
- arises from nasopalatine duct epithelial remnants
- occurs in anterior maxilla

54
Q

What is pictured here?

A

Nasopalatine duct cyst

55
Q

How do nasopalatine duct cysts present?

A
  • often asymptomatic
  • patient may notice ‘salty’ discharge
  • larger cysts may displace teeth or cause palatal swelling
  • always involve midline but not always symmetrical
56
Q

How does the histology of a nasopalatine duct cyst present?

A

variable epithelial lining

57
Q

What are the radiographic findings of a nasopalatine duct cyst?

A
  • corticated radiolucency between/over roots of cental incisors
  • often unilocular
  • “heart shaped”
58
Q

How can you differentiate between a nasopalatine duct cyst vs the incisive fossa?

A

Consider the transverse diameter:
- <6mm: assume incisive fossa
- 6-10mm consider monitoring
- >10mm suspect cyst

59
Q

What is a solitary bone cyst?

A

Non-odontogenic cyst WITHOUT an epithelial lining
- more common in mandible than maxilla
- occurs in teenagers [most common in 2nd decade]

60
Q

How do solitary bone cysts present clinically?

A
  • usually asymptomatic [tends to be an incidental finding]
  • rarely pain or swelling
61
Q

How do solitary bone cysts present radiographically?

A
  • majority in premolar/molar region of mandible
  • variable definition & cortication
  • may have scalloped margins giving a pseudolocular appearance
  • may project up between the roots of adjacent teeth?
62
Q

How are solitary bone cysts managed?

A

These cysts go away on their own!
- always monitor incase you see any significant change
- ensure you don’t misdiagnose [could be a keratocyst]

63
Q

What is a Stafne cavity?

A

NOT A CYST but commonly mistaken as one!
- depression in the bone of the mandible
- contains salivary or fatty tissue

64
Q

Where do Stafne cavities typically lie?

A
  • angle or posterior body of mandible
  • often inferior to inferior alveolar canal
  • asymptomatic
  • well defined, often corticated radiolucency
65
Q

How might we obtain material for histopathological analysis?

A
  • Aspiration biopsy [drainage of contents]
  • Incisional biopsy [partial removal]
  • Excisional biopsy [complete removal]
66
Q

What is used to undertake an aspiration biopsy?

A
  • wide bore needle
  • 5-10ml syringe
67
Q

What can you get from an aspiration biopsy of a cyst?

A
  • air
  • blood
  • pus
  • cyst fluid
68
Q

What cystic lesion can you aspirate blood from?

A

Aneurysmal cyst

69
Q

How does cyst fluid of keratocysts typically present?

A

white or cream semi-solid fluid

70
Q

What are the clinical steps of taking an incisional biopsy of a cyst?

A
  • done under LA
  • select place where lesion appear superficial
  • raise mucoperiosteal flap
  • remove bone as required
  • incise & remove a section of lining
71
Q

What are the surgical options for removal of cysts?

A
  • Enucleation
  • Marsupialisation
72
Q

What is meant by enucleation surgery?

A

All of the cystic lesion is removed

73
Q

What is meant by marsupialisation surgery?

A
  • creation of surgical window in the wall of the cyst, removing contents of the cyst & suturing the cyst wall to surrounding epithelium
  • encourages the cyst to decrease in size & may be followed by enucleation at a later date
74
Q

What are the advantages of enucleation surgery of cysts?

A
  • whole lining can be examined pathologically
  • primary closure
  • little aftercare needed
75
Q

What are the contraindications/disadvantages of enucleation surgery of cysts?

A
  • risk of mandibular fracture with very large cysts
  • old age: ill health
  • clot-filled cavity after surgery may become infected
  • damage to adjacent structure
  • incomplete removal of lining may lead to recurrence
76
Q

When would marsupialisation surgery of a cyst be indicated?

A
  • in enucleation would damage surrounding structures
  • difficult access to area
  • may allow eruption of teeth affected by a dentigerous cyst
  • if enucleation would risk jaw fracture
  • elderly or medically compromised pt unable to withstand extensive surgery
77
Q

What are the advantages of marsupialisation?

A
  • simple to perform
  • may spare vital structures
78
Q

What are the contraindications/disadvantages of marsupialisation of cysts?

A
  • opening may close & cyst may reform
  • complete lining not available for histology
  • difficult to keep clean & lots of aftercare needed
  • takes a long time to fill in
79
Q
A

BDS4 ORAL SURGERY (16 decks)

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