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Radiolucent Odontogenic Lesions Flashcards

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1
Q

Cysts

A
  • Pathologic sack or cavity w/ a central lumen lined by epithelium
    • We make dx based on epithelial lining
  • Slowly growing & asymptomatic (unless inflamed)
  • Persistent & progressive and can become large and destructive if not tx’d
    • They’ll keep growing until you remove them
  • Rad: Well-defined RL lesion, often corticated borders
  • Do not infiltrate surrounding bone
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2
Q

Components of cysts

A
  • Lumen
  • Epithelial lining
  • CT wall
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3
Q

Cyst Tx

A

Varies from enucleation to aggressive curettage

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4
Q

Where do the epithelial components of cysts come from inside the bone?

A
  • Dental lamina
  • Reduced enamel epithelium
  • Epithelial Rests (of Malassez) from HERS
    • Remnants of odontogenesis
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5
Q

Odontogenic cysts of the jaw: Origin of epithelial rests

A
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6
Q

T/F: Cysts & benign tumors have similar appearance. Inflammatory & malignancy have similar appearance.

A

True, true.

  • Cysts and benign tumors slowly push and displace anatomical structures
    • Can’t move tooth anymore, creates smooth resorption that looks like it follows hydraulic apperarance in directional resorption
  • Inflammatory lesions and malignancies are quick - grow around teeth quickly, area that is growing starts to get pushed out and expand = non-directional resorption
    • PDL space gone
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7
Q

Radicular (Periapical) Cyst

A
  • Assoc w/ necrotic debris & bacteria of non-vital pulp
  • Origin of epithelium is Epithelial Rests of Malassez
  • Pulp necrosis → Inflammation → Radicular granuloma → Keratinocyte GF → Proliferation of epithelial rests
  • Most grow slowly
  • Asymptomatic unless acutely inflamed
  • Rad: PA, well circumscribed, RL; loss of lamina dura; cannot be differentiated from PA granuloma & abscess
  • Healing Radicular Cyst
    • Original outline still seen
    • Bone grows inward
    • “Rolled border” appearance
      • After endo tx, bone starts filling back in from the outside to create rolled border
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8
Q

What is the most common developmental odontogenic cyst?

A

Dentigerous (Follicular) Cyst

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9
Q

Dentigerous (Follicular) Cyst

A
  • Most common developmental odontogenic cyst
    • ​2nd most common cyst
  • ​Pathogenesis: Proliferation of reduced enamel epithelium
  • Rad: Well-defined, unilocular RL around/associated w/crown of unerupted tooth, often corticated border
  • Attached to the CEJ of unerupted tooth or odontoma
  • Most common w/ M3s & MX K9s
  • Generally asymptomatic and discovered on routine radiographic exam
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10
Q

Dentigerous (Follicular) Cyst: Clinical features

A
  • Small cysts are asymptomatic
  • Can grow to large sizes and cause bony expansion
  • Pain and swelling if infected
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11
Q

Dentigerous (Follicular) Cyst: Radiographic features

A
  • Well-defined and often corticated border
  • May be extensive and destructive
  • Unilocular and multilocular
    • Usually unilocular but anything can become multilocular as it gets bigger
  • Can displace affected tooth
  • Can result in root resorption of adjacent teeth
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12
Q

Dentigerous (Follicular) Cyst: Tx

A
  • Enucleation and removal of affected tooth
  • Marsupialization followed by excision for larger lesions (not commonly done)
  • Little tendency to recur when completely removed
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13
Q

Eruption Cyst

A
  • ST analogue of dentigerous cyst
    • Only in ST around alveolar crest
  • Consists of cystic fluid and/or blood accumulated b/w erupting tooth and dental follicle
  • Appears as soft translucent swelling in gingival mucosa overlying crown of erupting tooth; traumatized, can lead to eruption hematoma
  • Purple if blood present
  • Most common in children <10yo
  • Dentigerous cyst that forms after it has broken through alveolar crest; cyst not in bone
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14
Q

Eruption Cyst Tx

A
  • Not usually tx’d bc tooth will erupt
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15
Q

What is the second most common cyst?

A

Dentigerous (Follicular) Cyst

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16
Q

What is the 3rd most common cyst?

A

Keratocystic Odontogenic Tumor (Odontogenic Keratocyst)

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17
Q

Other name for Keratocystic Odontogenic Tumor

A

Odontogenic Keratocyst

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18
Q

Keratocystic Odontogenic Tumor

A
  • AKA Odontogenic Keratocyst
  • 3rd most common cyst
  • Odontogenic cyst w/ specific microscopic features and clinical features
  • Arises from dental lamina
  • Relatively aggressive behavior & tx
  • High recurrence rate
  • Associated w/ nevoid basal cell carcinoma syndrome
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19
Q

Keratocystic Odontogenic Tumor: Clinical features

A
  • Can occur in any odontogenic location
  • Most common in MN body & ramus
  • Tends to grow in anterior-posterior direction in MN
    • Does not cause expansion in MN body typically
  • More growth potential than other odontogenic cysts
  • Higher rate of recurrence
  • Large OKCs may be associated w/ pain, drainage, paresthesia
  • Large OKCs do not tend to expand jaws
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20
Q

Keratogenic Odontogenic Tumor: Rad

A
  • Assoc w/ unerupted tooth in 25-40% of cases
  • Well-defined RL area
  • Smooth corticated margin
  • Unilocular or multilocular
    • ​Smaller lesions = unilocular
    • Larger lesions = multilocular
  • Usually displaces teeth
  • Little to no expansion, despite large size; but CAN cause expansion, esp in ramus
  • Frequently mimics other lesions
  • Daughter cysts: Mini cysts around main cysts that get left behind when we enucleate the cyst
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21
Q

Why do OKCs occur often and have tumoral characteristics?

A

Daughter cysts: Mini cysts around main cysts that get left behind when we enucleate the cyst

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22
Q

OKC Tx

A
  • Surgical excision w/ peripheral ostectomy, Carnoy solution
  • Avg recurrence rate of 30%
  • Most recur in 5yr, but may not until >10yr → long term clinical & radiographic f/u
  • Occasionally, local resection and bone grafting are necessary
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23
Q

What would you include in differential dx along w/ OKC?

A
  • Dentigerous (Follicular) Cyst
  • Lateral Periodontal Cyst
  • Nasopalatine Cyst
  • Radicular Cyst
  • Residual Cyst
  • Primordial Cyst
  • “Globulomaxillary” Cyst
  • Idiopathic Bone Cavity
  • Ameloblastoma & other benign odontogenic tumors
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24
Q

What is the only cyst that can be MIXED, while all others are ALWAYS RADIOLUCENT?

A

Calcifying odontogenic cyst

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25
Lateral Periodontal Cyst
* Arise from dental lamina along lateral surface of the root * **From previous epithelium and normal around PMs** * **Does not mess w/ PDL/lamina dura** * \<2% of all jaw cysts * Asymptomatic * **75-80% in PM-K9-LI area** * **MN \> MX** * **Assoc w/ vital or non-vital teeth**
26
Lateral Periodontal Cyst: Rad
* Well-defined RL lesion * Relatively small, **usually \<1cm** * Rad features are not dx'c
27
Lateral Periodontal Cyst: Tx
* Enucleation
28
Other names for Gorlin Syndrome
Nevoid Basal Cell Carcinoma Syndrome Gorlin-Goltz Syndrome
29
Gorlin Syndrome
* AKA Nevoid BCC Syndrome, Gorlin-Goltz Syndrome * **​Autosomal Dominant** * **​PTCH1 gene mutation**
30
What syndrome would a mutation in PTCH1 produce?
Gorlin Syndrome AKA Nevoid BCC Syndrome AKA Gorliln-Goltz Syndrome
31
Gorlin Syndrome: Most common clinical findings (\>50%)
* **Multiple BCCs** * **Multiple odontogenic keratocysts** * **Calcified falx cerebri** * **Rib abnormalities** * **Palmar plantar pits** * Ocular hypertelorism * Enlarged head * Spina bifida
32
Gorlin Syndrome: Px
* **​Most anomalies are minor and non-life threatening** * **Px depends on behavior of skin cancers** * **Keratocysts tx'd w/ enucleation** * Pts should avoid sunlight * Jaw cysts tx'd by enucleation * Deformities may result from operations
33
Gingival cyst of the adult
* ST counterpart of lateral periodontal cyst * Predilection for MN K9/PM area * Pts in 5th & 6th decades of life * Found on facial gingiva or alveolar mucosa * Technically a peripheral lateral periodontal cyst * Painless, dome-like bluish or blue grey swelling
34
Gingival cyst of the adult: Tx
* Simple excision * Excellent px * No recurrence
35
Gingival cyst of the newborn: Bohn's nodules; Epstein's pearls
* Reported in up to 50% of all newborns * Small, superficial, keratin-filled cysts on alveolar mucosa * Alveolar mucosa of infants * More common in MX alveolus
36
Gingival cyst of the newborn: Tx Bohn's nodules; Epstein's pearls
* Lesions spontaneously rupture * Excellent px * No tx indicated * Rarely seen after 3mo * No recurrence
37
Tumor
Mass of tissue; no lumen
38
Odontogenic tumors arise from one or more tissues present in tooth development, which are:
* **Dental lamina** * **Enamel organ** * Ameloblasts, enamel * **Dental papilla** * Odontoblasts, dentin, pulp * **Dental follicle** * Cementoblasts, cementum, PDL, alveolar bone
39
WHO classification of odontogenic tumors tissue of origin
* **Odontogenic epithelium** w/ mature stroma w/o odontogenic ectomesenchyme * **Odontogenic epithelium w/ ectomesenchyme** w/ or w/o HT * **Mesenchyme and/or ectomesenchyme** w/ or w/o odontogenic
40
**Odontogenic epithelium** w/ mature stroma w/o odontogenic ectomesenchyme
* Ameloblastoma, central or peripheral * Calcifying epithelial odontogenic tumor * Adenomatoid odontogenic tumor * Keratocystic odontogenic tumor * Squamous odontogenic tumor
41
**Odontogenic epithelium w/ ectomesenchyme** w/ or w/o HT
* Ameloblastic fibroma * Ameloblastic fibro-odontoma * Odontoma: Compouund & complex * Calcifying cystic odontogenic tumor (calcifying odontogenic cyst)
42
**Mesenchyme and/or ectomesenchyme** w/ or w/o odontogenic epithelium
* Odontogenic fibroma * Odontogenic myxoma * Cementoblastoma
43
Where would you find odontogenic tumors?
* **Areas where teeth can form** * Most are central (w/in jaws) * Others are peripheral (on the gingiva)
44
RL Odontogenic Tumors
* **Ameloblastoma** * **Ameloblastic fibroma** * **Central odontogenic firbroma** * **Odontoenic myxoma**
45
Prevalence of ameloblastic subtypes
**Multicystic \> Unicystic \> Peripheral**
46
Ameloblastoma
​RL Odontogenic Benign Tumor * **Most common in molar/ramus area of the MN** * **20-40yo**, but occurs across all age ranges - don't go based on age for this one * **No mineralized pdt** ⇒ RL * Unilocular or multilocular * **Classically multilocular** * **​Key: Soap bubble w/ round septations and expansions** * Always RL * **Slowly growing; locally aggressive** * **Locally infiltrates** surrounding bone * Painless swelling of the jaw * **Significant expansion of cortices and fracture on lingual**
47
Ameloblastoma: Tx
​RL Odontogenic Benign Tumor * Marked tendency to recur if tx'd by curettage * More extensive surgical removal is necessary: **Removal of 1-2cm of surrounding bone past rad margins** * Tumor islands infiltrate bone, so we want to make sure that we remove them all
48
Unicystic Ameloblastoma
​RL Odontogenic Benign Tumor * A variant of ameloblastoma that resembles an odontogenic cyst * **All tumor lines the cystic cavity and grows into the lumen; no invasion of CT wall** * Cystic cavity lined by ameloblastic epithelium * Less aggressive than solid type * Affects younger pts (10-20yo) * Circumscribed RL around molar * Mimics other lesions
49
Unicystic Ameloblastoma: Tx
​RL Odontogenic Benign Tumor * Dx is difficult - need rads, gross and microscopic confirmation * **Enucleation or curettage** * **Initially enucleated** * **10% recurrence** * Careful enucleation w/ removal of unerupted tooth; usually resection no necessary * Tooth can be left in some cases
50
Peripheral Ameloblastoma
​RL Odontogenic Benign Tumor * Painless lesion of gingiva or alveolar mucosa * Same histopathology as intra-osseous form
51
Peripheral Ameloblastoma: Tx
​RL Odontogenic Benign Tumor * **Innocuous behavior** * **Tx'd w/ local excision**
52
Ameloblastic Fibroma
​RL Odontogenic Benign Tumor * Consists of **both odontogenic epithelium and ectomesenchyme** * Occurs in younger pts - **1st or 2nd decade** * **​Occur in pts YOUNGER THAN 20yo** * Slightly more common in males * Small lesions are asymptomatic; large lesions cause swelling * **Typical location is posterior MN**
53
Ameloblastic Fibroma: Rad
​RL Odontogenic Benign Tumor * Typical odontogenic RL lesion * Does not infiltrate surrounding bone * Well-defined, RL, well corticated, expansion of the MN, displaced teeth, directional resorption of roots
54
Ameloblastic Fibroma: Tx
**​RL Odontogenic Benign Tumor** * **Enucleation or curettage** * **Good px** * **​Lower recurrence rates** * **​Initial tx more conservative** * More aggressive tx for recurrent lesions * A rare malignant variant exists
55
If you see multilocular, think..
**Ameloblastoma** **OKC** **Myxoma**
56
Central Odontogenic Fibroma
**RL Odontogenic Benign Tumor** * Consists of **ectomesenchymal** tissue similar to dental follicle
57
Central Odontogenic Fibroma: Rad
​RL Odontogenic Benign Tumor * **Typical RL** odontogenic cyst/tumor * Does not infiltrate bone
58
Central Odontogenic Firboma: Tx
​RL Odontogenic Benign Tumor * **Conservative surgical removal -- enucleations, curettage**
59
Odontogenic Myxoma
​RL Odontogenic Benign Tumor * Ectomesenchymal tumor * Found in young adults (25-30yo) * No gender predilection * If small, no changes; larger lesions cause asymptomatic swelling * **Gelatinous appearance** * **Infiltrates surrounding bone** * Dental papilla-like tissue
60
Odontogenic Myxoma: Rad
​RL Odontogenic Benign Tumor * Well-defined or poorly defined borders * **"Honeycomb" or "tennis racket"** appearance * **Infiltrates surrounding bone** * **Key: Straight perpendicular septations** * **​Multilocular or septated appearance**
61
Odontogenic Myxoma: Tx
​RL Odontogenic Benign Tumor * **Need to remove some normal surrounding bone** * Req's more aggressive tx
62
What are the RL Odontogenic Lesions?
* Inflammatory * Radicular (Periapical) Cyst * Residual Cyst * Buccal Bifurcation Cyst * Developmental * Dentigerous (Follicular) Cyst * Eruption Cyst * Keratocystic Odontogenic Tumor * AKA Odontogenic Keratocyst * Lateral Periodontal Cyst * Gorlin Syndrome * AKA Nevoid BCC Syndrome, Gorlin-Goltz Syndrome * Gingival Cyst of the Adult * Gingival Cyst of the Newborn * Tumors * Ameloblastoma * Unicystic Ameloblastoma * Peripheral Ameloblastoma * Ameloblastic Fibroma * Cental Odontogenic Fibroma * Odontogenic Myxoma

Oral Path 2 (11 decks)

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