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cysts, tumours, bone pathology > cysts of the jaws > Flashcards

cysts of the jaws Flashcards

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1
Q

definition

A

a pathological cavity containing fluid, semi-fluid or gaseous contents and which is not created by the accumulation of pus
sterile fluid - not abscess
can get pus in cysts if infected but not initial cause

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2
Q

how are cysts diverse?

A

asymptomatic/symptomatic - often asymptomatic unless infected
slow/fast growing
indolent/destructive

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3
Q

are most cysts benign or malignant?

A

benign

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4
Q

describe usual cyst shape and the reason why

A

often spherical or egg-shaped

most grow by hydrostatic pressure - accumulation of fluid causes cyst to grow in a certain direction

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5
Q

usual cyst margins

A

well-defined and corticated

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6
Q

locularity of cysts

A

often unilocular

can be multilocular (or pseudolocular)

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7
Q

what might multiple cysts indicate?

A

a syndrome

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8
Q

describe effects cysts can have on surrounding anatomy

A

displacement of cortical plates, adjacent teeth, MS, IAC
variable degree and pattern of growth - along bone through trabecular bone - get more MD expansion in mandible than BL as dense cortical bone
RR may occur with chronic cysts

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9
Q

what can be included in cysts?

A

UE teeth

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10
Q

secondary infection

A

cysts may lose definition and cortication of margins if secondarily infected
typically associated with clinical S+S

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11
Q

classification

A

structure - epithelial lined vs no epithelial lining
origin - Odontogenic vs non-odontogenic
pathogenesis - developmental vs inflammatory

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12
Q

Odontogenic developmental cysts

A 
dentigerous cyst (+eruption cyst)
Odontogenic keratocyst
lateral periodontal cyst
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13
Q

Odontogenic inflammatory cysts

A

radicular (+residual) cyst
inflammatory collateral cysts
- paradental cyst
- buccal bifurcation cyst

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14
Q

non-odontogenic developmental cyst

A

nasopalatine duct cyst

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15
Q

non-odontogenic other cysts

A

solitary bone cyst
aneurysmal bone cyst
no epithelial lining

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16
Q

where do Odontogenic cysts occur?

A

in tooth bearing areas

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17
Q

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

A

Odontogenic cysts
>90% of all cysts in the oral and MF region
2nd most common group of oral and MF lesions in adults (14-15%)

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18
Q

what are all Odontogenic cysts lined with?

A

epithelium

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19
Q

Odontogenic sources of epithelium

A

Rests of Malassez
Rests of Serres
reduced emamel epithelium

epithelial rests get switched on (often by inflammation)

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20
Q

Rests of Malassez

A

remnants of Hertwig’s epithelial root sheath

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21
Q

Rests of Serres

A

remnants of the dental lamina

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22
Q

reduced enamel epithelium

A

remnants of the enamel organ

covers crown of UE tooth then breaks down as tooth erupts

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23
Q

most common Odontogenic cysts

A

radicular (+residual) - 60%
dentigerous (+ eruption) - 18%
Odontogenic keratocyst - 12%

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24
Q

what type of cyst is a radicular cyst?

A

inflammatory Odontogenic cyst

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25
what is a radicular cyst always associated with?
a non-vital tooth
26
cause of a radicular cyst
non-vital tooth | initiated by chronic inflammation at apex of tooth due to pulp necrosis
27
incidence of radicular cyst
most common in 4th and 5th decade M=F 60% maxilla, 40% mandible can involve any tooth
28
presentation of radicular cyst
often asymptomatic - may become infected - pain typically slow growing with limited expansion can produce alveolar bone expansion +/- discharge
29
what is the only way to confirm if a lesion has progressed to a radicular cyst?
surgically excise
30
stages of radicular cyst formation
pulpal necrosis periapical periodontitis periapical granuloma radicular cyst
31
radicular cyst vs periapical granulomas
difficult to differentiate radiographically - radicular cysts typically larger if radiolucency diameter >15mm - 2/3 of cases will be radicular cysts
32
radiographic features of a radicular cyst
well-defined, round/oval radiolucency corticated margin continuous with lamina dura of non-vital tooth larger lesions may displace adjacent structures long-standing lesions may cause external root resorption and/or contain dystrophic calcification unilocular uniform radiolucency
33
histology of radicular cysts
epithelial lining (often incomplete) - can get ulceration/hyperplasia - usually non-keratinised SSE 2-10 layers thick fibrous CT vascular capsule inflammation in capsule - inflammatory infiltrate can get cholesterol clefts
34
growth of a radicular cyst
radicular cyst from granuloma - Epithelial rests of malassez in PDL become active, divide and proliferate radicular cysts may form by: - proliferating epithelium with central necrosis - centre of granuloma cut off from blood supply - OR epithelium surrounds fluid area continued growth - osmotic effect with semi-permeable wall - cytokine mediated growth - also ILs - activation of osteoclasts variable inflammation cholesterol clefts mucous metaplasia hyaline/rushton bodies (only in Odontogenic epithelium)
35
cholesterol clefts
cholesterol in fluid due to rbcs breaking down | may get calcification within cholesterol
36
variants of a radicular cyst
residual cyst | lateral radicular cyst
37
residual cyst
when radicular cyst persists after loss of tooth (or after tooth is successfully RCT) clinical history is important to avoid misdiagnosis
38
lateral radicular cyst
radicular cyst associated with an accessory canal | located at side of tooth instead of apex
39
cyst S+S
"egg shell" crackling on palpation - cyst thins cortical bone so when you press it cracks slightly tingling/altered sensation - presses on nerve - nasopalatine n (anterior palate) - IO nerve (side nose, cheek, U lip) movement/displacement of adjacent teeth mobility change in occlusion sinus involvement - muffling sound, postural changes discomfort diplopia - v large cyst in maxilla can push up orbital floor painless swelling of buccal cortex can get fluctuant swelling if bone completely resorbed hollow percussion note
40
what type of cyst is an inflammatory collateral cyst?
inflammatory Odontogenic cyst
41
what are inflammatory collateral cysts associated with?
a vital tooth
42
incidence of inflammatory collateral cysts
2-7% of Odontogenic cysts
43
what is the pouch lined with in inflammatory collateral cysts?
non-keratinised epithelium
44
what is included in inflammatory collateral cysts?
paradental cyst | buccal bifurcation cyst
45
where does a paradental cyst typically occur?
distal aspect of PE L8
46
where does a buccal bifurcation cyst typically occur?
the buccal aspect of L6 | roots go lingually, crowns go buccally - affects occlusion
47
what type of cyst is a dentigerous cyst?
developmental Odontogenic cyst
48
what are dentigerous cysts associated with?
crown of UE (+ usually impacted) tooth e.g. L8s, U3s cystic change of dental follicle
49
what is a dentigerous cyst the result of?
cystic change of the dental follicle
50
incidence of dentigerous cysts
most common in 2nd-4th decades M>F mandible>maxilla
51
features of a dentigerous cyst
corticated margins attached to CEJ of tooth (where dental follicle usually attaches) - larger cysts may begin to envelope root of tooth - be careful not to misinterpret may displace involved tooth tends to be symmetrical initially - larger cysts may begin to expand unilaterally variable displacement of cortical bone (i.e. bony expansion) tooth missing from arch round/ovoid well-defined unilocular, uniform radiolucency
52
histology of dentigerous cysts
thin non-keratinised SSE | - may resemble radicular cyst if inflamed
53
dentigerous cyst vs enlarged follicle
consider cyst if follicular space >4mm - measure from surface of crown to edge of follicle - assume cyst if >10mm consider cyst if radiolucency is asymmetrical
54
what is an eruption cyst?
variant of dentigerous cyst contained within ST rather than bone Rests of Serres
55
presentation of an eruption cyst
associated with an erupting tooth more commonly incisors/FPMs almost exclusive to children bluish over an erupting tooth may/may not need intervention - tx conservatively and tooth often erupts surgical excision of cyst sometimes required ST
56
what type of cyst is an Odontogenic keratocyst?
development Odontogenic cyst
57
does an OK have a relationship to teeth?
no specific one
58
incidence of OK
most common in 2nd and 3rd decades M>F mandible>maxilla (3:1) 70-80% mandible, esp 3rd molar region posterior>anterior
59
what was OK previously called?
keratocystic Odontogenic tumour
60
describe OK margins
often scalloped
61
what % of OKs are multilocular?
25%
62
what do OKs often cause of adjacent teeth?
displacement | root resorption uncommon
63
characteristic expansion of OKs
can enlarge markedly in medullary bone space before displacing cortical bone i.e. can have significant MD expansion without BL expansion
64
pre-op diagnostic test - cyst aspirate for OK
contains squames | low soluble protein content: 40g/l (other cysts >50)
65
histology of OK
``` corrugated wavy epithelium parakeratosis loss of keratin if inflamed no rete pegs - can detach quite easily basal palisading - nuclei same level epithelium tends to grow in clusters ```
66
recurrence of OKs
high recurrence rate (aggressive) - need close monitoring thin friable lining - difficulty of surgery daughter/satellite cysts - small cysts in lining of main cyst - don't leave in lining of bone as will grow - recurrence cell nests (esp retromolar)
67
presentation of Basal cell naevus syndrome
``` multiple OKs multiple basal cell carcinomas palmar and plantar pitting calcification of intracranial dura mater skeletal abnormalities - ribs and vertebrae bifid ribs characteristic facial features - frontal and temporal parietal bossing, hypertelorism, mild mandibular prognathism abnormalities of Ca and PO4 metabolism etc ``` aka Gorlin-Goltz syndrome, bifid rib syndrome cysts histologically identical to non-syndromic form but often occur at younger age e.g. 15yrs autosomal dominant trait
68
non-odontogenic cysts
nasopalatine duct cyst solitary bone cyst aneurysmal bone cyst
69
what is the most common non-odontogenic cyst?
nasopalatine duct cyst
70
what type of cyst is a nasopalatine duct cyst?
developmental non-odontogenic cyst
71
what does a nasopalatine duct cyst originate from?
nasopalatine duct epithelial remnants
72
where does a nasopalatine duct cyst occur?
anterior maxilla
73
incidence of nasopalatine duct cyst
most common in 4th-6th decades | M>F
74
presentation of nasopalatine duct cyst
often asymptomatic pt may note "salty" discharge larger cysts may displace teeth or cause swelling in palate always involve midline but not always symmetrical
75
histology of nasopalatine duct cyst
variable epithelial lining: non-keratinised stratified squamous and modified respiratory
76
radiography for a nasopalatine duct cyst
PA and/or standard maxillary occlusal - corticated radiolucency between/over roots of central incisors - often unilocular - may appear "heart shaped" due to superimposition of ant nasal spine CBCT - indicated if better visualisation of cyst needed for surgical planning
77
cyst vs incisive fossa
incisive fossa - may/may not be visible on radiographs - midline/oval shaped radiolucency - typically not visibly corticated in absence of clinical issues, consider transverse diameter - <6mm assume incisive fossa - 6-10mm consider monitoring - >10mm suspect cyst
78
solitary bone cyst
non-odontogenic cyst without an epithelial lining | aka simple/traumatic/haemorrhagic bone cyst
79
incidence of a solitary bone cyst
most common in 2nd decade M>F mandible>maxilla can occur in association with other bone pathology e.g. fibro-osseous lesions
80
clinical presentation of solitary bone cyst
usually asymptomatic - incidental finding | rarely pain or swelling
81
radiographic presentation of solitary bone cyst
majority in premolar/molar region of mandible - can also occur in non-tooth bearing areas variable definition and cortication may have scalloped margins giving a pseudolocular appearance may project up between the roots of adjacent teeth
82
Stafne cavity
not a cyst but commonly mistaken as one | actually a depression in the bone - cortical bone preserved
83
where does a Stafne cavity occur?
only in mandible, almost exclusively lingual
84
what does a Stafne cavity contain?
salivary or fatty tissue
85
Stafne cavity presentation
``` most common in 5th and 6th decades often in angle or posterior body often inferior to IAC asymptomatic well-defined, often corticated radiolucency rarely displaces adjacent structures ```
86
obtaining material for histology
aspiration biopsy - drainage of contents incisional biopsy - partial removal excision biopsy - complete removal
87
aspiration biopsy equipment
wide bore needle | 5-10ml syringe
88
aspiration biopsy - what you can get
air blood pus cyst fluid - clear straw coloured fluid in inflammatory or developmental cysts - white or cream semi-solid may indicate keratocyst may be unable to withdraw plunger
89
purpose of incisional biopsy
to obtain a sample of the lining for histological analysis
90
incisional biopsy method
usually under LA select place where lesion appears superficial raise mucoperiosteal flap remove bone as required - using rongeurs or a round bur incise and remove a section of lining procedure may be combined with marsupialisation (a tx option)
91
limitations of radiology
can only do provisional diagnosis | histology to confirm
92
tx - surgical options
enucleation | marsupialisation
93
what is enucleation?
all of the cystic lesion is removed - lining and contents
94
what is marsupialisation?
creation of a surgical window in the wall of the cyst, removing the contents of the cyst and suturing the cyst wall to the surrounding epithelium encourages cyst to decrease in size and may be followed by enucleation at a later date
95
what is the tx of choice for most cysts?
enucleation
96
advantages of enucleation
whole lining can be examined pathologically primary closure little aftercare needed
97
disadvantages of enucleation
risk of mandibular fracture with v large cysts dentigerous cyst? wish to preserve tooth old age, ill health clot filled cavity may become infected incomplete removal of lining may lead to recurrence damage to adjacent structures
98
healing following enucleation
around 36m - need long-term follow up | clot gradually replaced with bone
99
indications for marsupialisation
if enucleation would damage surrounding structures e.g. IDC difficult access to area may allow eruption of teeth affected by dentigerous cyst elderly/medically compromised pts unable to withstand extensive surgery v large cysts which would risk jaw fracture if enucleation was performed can combine with enucleation as a later procedure
100
advantages of marsupialisation
simple to perform | may spare vital structures
101
contraindications/disadvantages of marsupialisation
opening may close and cyst may reform complete lining not available for histology difficult to keep clean and lots of aftercare needed long time to fill in
102
obturator
plastic tray used to keep marsupialisation window open
103
non-epithelial cysts
solitary bone cyst aneurysmal bone cyst Stafne idiopathic bone cavity
104
epithelial non-odontogenic cysts
nasolabial cyst nasopalatine cyst globulomaxillary cyst median cyst
105
epithelial Odontogenic developmental cysts
``` dentigerous cyst - eruption cyst OK lateral periodontal cyst - Botryoid Odontogenic cyst gingival cysts - adults - infants (alveolar cyst) glandular Odontogenic cyst calcifying Odontogenic cyst orthokeratinised Odontogenic cyst ```
106
epithelial Odontogenic inflammatory cysts
``` radicular cyst - residual inflammatory collateral cysts - paradental - mandibular buccal bifurcation ```
107
3 ways in which cysts grow
epithelium differentiates and grows inflammatory process osmotic pressure
108
Odontogenic cysts of inflammatory origin
``` radicular cyst - residual inflammatory collateral cysts - paradental - mandibular buccal bifurcation ```
109
Odontogenic cysts of developmental origin
``` dentigerous cyst - eruption cyst OK lateral periodontal cyst - subtype: Botyroid Odontogenic cyst gingival cysts - of adults - of infants (alveolar cyst) glandular Odontogenic cyst calcifying Odontogenic cyst orthokeratinised Odontogenic cyst ```
110
what is a Botryoid Odontogenic cyst a subtype of?
lateral periodontal cyst
111
non-odontogenic epithelial cysts
nasolabial cyst nasopalatine cyst globulomaxillary cyst median cyst
112
nasolabial cyst
ST cyst invasive can distort nose
113
non-epithelial cysts
solitary bone cyst aneurysmal bone cyst Stafne's idiopathic bone cavity
114
what is the most common broad category of cysts?
Odontogenic cysts of inflammatory origin
115
what does a radicular cyst form from the proliferation of?
epithelium (rests of malassez) | originate from Hertwigs root sheath (dental follicle)
116
usual treatment of a radicular cyst
generally simple enucleation and removal of associated tooth - can do endo and intracanal medicament while waiting for referral appt - as a min need RCT but warn that if they keep tooth cyst may recur
117
radicular cyst content
varies from watery, straw-coloured fluid through to semi-solid brownish material
118
where do inflammatory collateral cysts usually occur?
lateral (usually buccal) aspect of PE, vital tooth - originate from pericoronal tissue so to side of crown
119
what % of Odontogenic cysts are inflammatory collateral?
5%
120
what % of inflammatory collateral cysts are paradental?
60%
121
what is the usual inflammatory stimulus for paradental cysts?
pericoronitis
122
how does a paradental cyst relate to the tooth?
well-defined radiolucency is related to the neck of tooth and coronal 1/3 of root
123
what does the pathology of a paradental cyst resemble?
inflammatory radicular cyst
124
what % of inflammatory collateral cysts are mandibular buccal bifurcation cysts?
>35%
125
mandibular buccal bifurcation cysts in children
usually buccal aspect of erupting first molar | can cause delayed eruption of 6s
126
what is the most common developmental Odontogenic cyst?
dentigerous cyst
127
what % of odontogenic cysts are dentigerous?
20%
128
what are dentigerous cysts lined with?
epithelium derived from reduced enamel epithelium (from enamel organ)
129
what is the usual tx for a dentigerous cyst?
often cyst enucleation with associated tooth or marsupialisation if large
130
contents of a dentigerous cyst
proteinaceous yellowish fluid | cholesterol crystals common
131
histopathology of an eruption cyst
synonymous to a dentigerous cyst
132
what % of all MF cysts are OKs?
12%
133
what does an OK arise from?
cell rests of Serres (originates from remnants of dental lamina)
134
unusual growth pattern of OKs
enlarges in AP direction | can reach large size without causing gross bony expansion
135
reviewing a pt after an OK
keep reviewing pt for 5 years | radiographic review annually as such high risk of recurrence due to satellite cysts
136
do OKs usually cause symptoms?
no
137
radiographic presentation of an OK
oval well-defined, uniform radiolucency uni or multilocular
138
OK contents
thick grey/white cheesy material with keratinous debris
139
basal cell naevus syndrome management
MDT - dentists, OMFS, neurologists, dermatologists adequate tx of cysts removal of tumours and regular screening suggestion of annual OPGs dermatological examination 3-6m, avoidance of UV light neurological review if child
140
orthokeratinised odontogenic cyst
uncommon developmental cyst, used to be considered a variant of OKC similar presentation to OKC but histologically distinct with prominent orthokeratinisation and flattened basal cell layer unilocular without epithelial proliferations or satellite cysts no recorded case of occurrence with naevoid basal cell carcinoma syndrome rarely recur following simple enucleation now a distinct entity to OKC in WHO 2017 classification
141
lateral periodontal cyst incidence
rare - 0.4% of odontogenic cysts
142
how are lateral periodontal cysts related to teeth?
associated with lateral surface of tooth root - canine and premolar region in mandible, followed by anterior maxilla - vital tooth, usually asymptomatic and incidental findings
143
what age group usually have lateral periodontal cysts?
middle aged
144
what do pts with lateral periodontal cysts usually present with?
may present with expansion | well-demarcated radiolucent area
145
histopathology of a lateral periodontal cyst
thin lining SSE | similar to gingival cysts
146
how are lateral periodontal cysts often treated?
simple enucleation
147
Botryoid odontogenic cyst
multilocular variant of LPC often larger more likely to recur than LPC
148
what are gingival cysts derived from?
remnants of the dental lamina (rests of Serres) in gingival or alveolar soft tissues
149
gingival cysts in adults
mandibular attached gingiva as <1cm pink/bluish sessile swellings
150
histology of gingival cysts in adults
thin lining of SSE
151
gingival cysts in infants
Bohn's nodules common - up to 90% of neonates small yellow/cream nodules on edentulous alveolar mucosa similar cysts present on palate - Epstein's pearls, but aren't odontogenic naturally degenerate, no tx required
152
incidence of glandular odontogenic cyst
rare - 0.2% of odontogenic cysts
153
glandular odontogenic cyst presentation
mainly anterior mandible slow growing, painless unilocular/multilocular radiolucency may reach large size with erosions of cortical plate
154
glandular odontogenic cyst histology
uninflamed fibrous wall lined by glandular cuboidal epithelium
155
problems with glandular odontogenic cyst
potentially aggressive, locally invasive nature | high recurrence rate
156
calcifying odontogenic cyst family
member of ghost cell family of odontogenic lesions ('ghost' epithelial cells in histopathology) - originally considered variant of calcifying cystic odontogenic tumour but now regarded as developmental cyst
157
clinical presentation of calcifying odontogenic cyst
wide age range but usually <40years old 75% are intraosseous and either jaw may be involved majority arise anterior to FPM usually small about 1-3cm in diameter shape is variable but usually monocular adjacent teeth usually displaced +/or resorbed. bony expansion
158
radiographic presentation of calcifying Odontogenic cyst
initially radiolucent, unilocular or multilocular | in more advanced stage contains a variable amount of calcified radiopaque material
159
recurrence of calcifying odontogenic cyst
rarely recur, mainly benign course
160
what is the most common non-odontogenic cyst?
nasopalatine duct (incisive canal) cyst 5-10%
161
origin of nasopalatine duct cyst
epithelial remnants of nasopalatine duct
162
clinical presentation nasopalatine duct cyst
M>F, 5th-6th decades salty discharge/taste slowly enlarging swelling anterior palate midline heart shaped may be asymptomatic and found during routine Rx investigation
163
radiographic presentation of nasopalatine duct cyst
well-defined round, ovoid or heart shaped radiolucency | sclerotic margin
164
histopathology of nasopalatine duct cyst
lined by stratified squamous and respiratory/cuboidal epithelium NV bundles found in capsule - from incisive nerves
165
non-epithelial jaw cysts
occur most often in long bones occasionally found in jaws (almost exclusively in mandible) e.g. solitary bone cyst, aneurysmal bone cyst, Stafne's idiopathic bone cavity
166
solitary bone cyst
simple/haemorrhagic/traumatic bone cyst | aetiology unknown
167
solitary bone cyst clinical presentation
children and adults, no sex predilection premolar/molar region of mandible asymptomatic, chance radiographic finding bony expansion in around 25% cases
168
solitary bone cyst radiographic presentation
radiolucency of variable size, irregular outline, moderately well-defined scalloping prominent feature
169
surgical exploration of solitary bone cyst
rough bony-walled cavity devoid of any detectable lining rapid healing follows although will resolve spontaneously without
170
Stafne's idiopathic bone cavity
developmental anomaly of mandible | asymptomatic, chance finding
171
Stafne's idiopathic bone cavity - radiographic presentation
round or oval, well-demarcated radiolucency between premolar region and angle of jaw usually located below IDC (occasionally bilateral)
172
Stafne's idiopathic bone cavity - surgical exploration
saucer-shaped depression of concavity lingual aspect of mandible varying depth majority of cases, contains ectopic salivary tissue in continuity with SMG
173
non-cystic radiolucent lesions for differential diagnoses
odontogenic tumours giant cell lesions fibrocementoosseous lesions radiolucent non-odontogenic tumours
174
management of cysts
``` referral initial consultation special investigation? - plain film radiograph/CBCT/CT? biopsy - LA or GA? diagnosis tx plan and discussion tx options - enucleation - ideal - marsupialisation/decompression - surgical resection ```
175
what does cyst enucleation depend on?
size of cyst and type
176
what type of cysts is enucleation useful for?
radicular/residual cysts, dentigerous cysts, keratocysts
177
what is enucleation not suitable for?
ameloblastoma
178
complications of enucleation
mainly related to size, position and type of cyst - damage to IAN - communication with MS (OAC) - pathological fracture of mandible - risk of recurrence
179
marsupialisation
'fenestration' +/- tube/grommit insertion
180
what can sometimes occur after a biopsy?
marsupialisation
181
what is marsupialisation useful for?
useful for large simple cysts, keratocyst, dentigerous cysts | - if v concerned about jaw fracture
182
complications of marsupialisation
``` needs further surgery for cyst removal long tx before completion chance of reinfection uncomfortable need to clean cyst themselves out regularly ```
183
segmental resection
removal of cyst with margin of 'normal' bone
184
what is segmental resection mainly used for?
ameloblastoma | sarcoma
185
what secondary procedure does segmental resection normally require?
reconstruction of defect
186
Carnoy's solution
acetic acid, chloroform, ethanol | kills epithelial cells and satellite cells
187
usually why wouldn't you need a biopsy?
if associated tooth needs extraction

cysts, tumours, bone pathology (4 decks)

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