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Cysts of Odontogenic Origin
Cysts of Odontogenic Origin
Cysts of Odontogenic Origin
ORIGIN
Surabhi Sarkar
What is a cyst?
A cyst is defined as a pathologic cavity lined
by epithelium.
Cyst is an entity that constitutes an epithelium
lined sac filled with fluid or semi-fluid material.
Killey & Kay (1966)
A cyst is an abnormal cavity in hard or soft
tissues which contains fluid, semi-fluid, or gas
and is often encapsulated and lined by
epithelium. Killey & Kay (1966)
A cyst is a pathologic cavity having fluid, semi-
fluid or gaseous contents that are not created
by the accumulation of pus; frequently, but not
always, is lined by epithelium. Kramer (1974)
4th Edition of the World Health Organization Classification of Head and Neck Tumours: Odontogenic and Maxillofacial Bone Tumors
What changes?
Reincorporation of odontogenic keratocyst and calcifying
odontogenic cyst in the cyst classification when they had been
classified in 2005 as neoplasms.
Under inflammatory cysts, inflammatory collateral cysts are
included.
Primordial cysts have been dropped and are no longer used
synonymously for odontogenic keratocysts.
What changes?
Orthokeratinized odontogenic cysts are now
recognized as an odontogenic cyst distinct from
OKC.
New diagnostic criteria for glandular odontogenic
cysts (GOC) are presented, and the histologic
overlap between GOC and cystic
mucoepidermoid carcinomas acknowledged. No
MAML2 gene in GOC.
Histogenic Classification
The epithelial lining origins of odontogenic cysts
Epithelial residue Origin of Epithelium Cyst
ii. Transudation
and exudation:
owing to the protein
content of cystic
fluids
iii. Dialysis:
accumulation of
low-molecular
weight protein
forms a gradient
with net inflow of
fluid from
capillaries into
cystic lumen.
Bone Resorption
Vital cyst tissue(capsule and its leukocyte content,
contribution from vascular structures)
Surgically managed by
enucleation with extraction,
Marsupialisation(risk of neoplastic transformation of cyst lining)
Done either when it will allow tooth to spontaneously erupt or guided orthodontically, or
There is an identification of risk of damaging adjacent developing teeth or neurovascular bundles
during enucleation
Lateral Periodontal Cyst
Usually diagnosed as an incidental
radiographic finding.
Round or tear-drop shaped
unilocular radiographic
appearance at mid-root level.
Mostly in adults older than 21 and
has a male prediliction.
In both the jaws develops around
the premolar and canine regions.
D/D:
Botroid odontogenic cyst
Squamous odontogenic tumor(occurs
in premolar regions)
Lateral Periodontal Cyst
Botryoid Odontogenic Cyst
• Similar to lateral periodontal
cyst in pathogenesis
• Differs radiographically,
histologically and prognostically
• Differs in being multicystic-
grape cluster appearance on
radiograph
• Satellite or daughter cysts that
pinch off the cystic lining
• High rates of recurrence
• Presents with: Swelling,
Paresthesia, Pain, Discharge
• Complete surgical excision
Odontogenic Keratocyst- what’s the controversy about?
In 2005 the OKC was reclassified as a tumor based on “aggressive growth”,
recurrence after treatment, the rare occurrence of a “solid” variant of OKC, and
most importantly, mutations in the PTCH gene.
85% inherited mutated PTCH gene in NBCCS.
30% in non-NBCCS justified by somatic mutation to acquire the phenotype.
So, mutated would be neoplasm and non-mutated would be cysts???
But classically a neoplasm should continue to grow after the stimulus which produced
it is removed, should not regress spontaneously.
OKCs are well documented to completely regress following decompression and the
lining of many decompressed cysts appears more like oral mucosa than OKC
histologically.
Still lacking enough evidence to call it a tumor.
Odontogenic Keratocyst
Dental lamina remnants in the bony crypts.
Oral mucosa
Another variant that arises from the REE and is of dentigerous origin
Histopathology:
Parakeratinised stratified squamous epithelium which is 6-8 cells thick.
Absence of rete pegs.
Separation of epithelium from connective tissue due to metalloprotienases causing degradation of
collagen at the juxta epithelial regions.
Epithelial dysplasia present.
Fibrous connective tissue wall.
In case of infection/inflammation of the cyst the epithelium becomes non-keratinised and may lead of
an incorrect histopathological diagnosis.
Presense of daughter or satellite cysts in connective tissue.
Keratohyaline granules in the lumen.
Odontogenic Keratocyst
Presents as: Aspirational biospy
Patients with OKCs complain of pain, swelling or Dirty, creamy white viscoid suspension.
discharge. Keratin squames
Occasionally, they experience paresthesia of the Total protein less than 4 g/00ml. Mostly albumin
lower lip or teeth.
Sometimes discovered fortuitously during dental COMPLICATIONS IN OKC :
examination when radiographs were taken. Malignant transformation of cyst lining rare, but has
Extend in the medullary cavity and clinically been reported.
observable expansion of the bone occurs late. Recurrence – high rate of recurrence.
Enlarging cyst may lead to displacement of tooth.
Odontogenic Keratocyst
Reasons for recurrence
Tendency to multiply
Satellite cyst
2. Marsupialization
3. A staged
combination of
the two
Apical cystectomy performed at time of tooth
procedures removal. A to C, Removal of a cyst with curette
via a tooth socket is visualized. An apical
4. Enucleation with cystectomy must be performed with care
because of the proximity of the apices of teeth
curettage. to other structures such as the maxillary sinus
and the inferior alveolar canal. D to J,
Removal of an apical cyst by flap reflection
and creation of osseous window is
demonstrated at the time of tooth removal.
Surgical Management
1. Enucleation
2. Marsupialization
3. A staged
combination of
the two
procedures
4. Enucleation with
curettage.
Photographs of a clinical case of apical cystectomy performed at time of tooth extraction. A, Pretreatment panoramic
radiograph showing large radiolucent lesion at the apices of teeth No. 18 and 20. B, Appearance of lesion after
buccal flap elevated. Note that the lesion has eroded the bone. C, Curette used to elevate the lesion from the bony
walls. D, Cyst being removed. E, Note the inferior alveolar neurovascular bundle passing along the inferior aspect of
the bony cavity. F, Surgical specimen. G, When opened, the specimen appeared to be cystic. H, Postoperative
panoramic radiograph showing defect. The patient should be monitored with periodic radiographs to ensure bone fill
and no recurrence of the lesion.
Surgical Management
Marsupialization, decompression, and INDICATIONS:
1. Enucleation the Partsch operation all refer to 1. Amount of tissue injury : Proximity of a cyst to vital
creating a surgical window in the wall structures can mean unnecessary sacrifice of tissue if
of the cyst, evacuating the contents of enucleation is used.
2. Marsupialization 2. Surgical access : If access to all portions of the cyst
the cyst, and maintaining continuity
between the cyst and the oral cavity, is difficult, portions of the cystic wall may be left
3. A staged maxillary sinus, or nasal cavity. behind, which could result in recurrence.
combination of • The only portion of the cyst that is 3. Assistance in eruption of teeth : If an unerupted
the two removed is the piece removed to tooth that is needed in the dental arch is involved with
produce the window. The remaining the cyst (i.e., a dentigerous cyst), marsupialization may
procedures allow its continued eruption into the oral cavity
cystic lining is left in situ.
• This process decreases intracystic 4. Extent of surgery : Marsupialization is a reasonable
4. Enucleation with alternative to enucleation, because it is simple and
pressure and promotes shrinkage of the
curettage. cyst and bone fill. Marsupialization can may be less stressful for the patient
be used as the sole therapy for a cyst 5. Size of cyst : In very large cysts, a risk of jaw
or as a preliminary step in fracture during enucleation is possible.
management, with enucleation It may be better to marsupialize the cyst and defer
deferred until later. enucleation until after considerable bone fill has
occurred.
Surgical Management
Advantages:
1. Enucleation • It is a simple procedure to perform.
Marsupialization also spare vital
2. Marsupialization structures from damage should
immediate enucleation be attempted.
Disadvantages:
3. A staged • Pathologic tissue is left in situ, without
combination of thorough histologic examination.
the two • Patient is inconvenienced in several
procedures respects
• The cystic cavity must be kept clean
to prevent infection, because the
4. Enucleation with
cavity frequently traps food debris.
curettage. • In most instances this means that the
patient must irrigate the cavity
several times every day with a syringe
Surgical Management
1. Enucleation
2. Marsupialization
Marsupialization technique. A, Cyst
within maxilla. B, Incision through
3. A staged oral mucosa and cystic wall into
combination of center of cyst. C, Scissors used to
the two complete excision of window of
procedures mucosa and cystic wall. D, Oral
mucosa and mucosa of cystic wall
4. Enucleation with sutured together around periphery
of opening.
curettage.
Surgical Management
Marsupialization of cyst in right mandible
1. Enucleation associated with unerupted teeth. A,
Photograph showing swelling around right
second deciduous molar. B, Radiographic
2. Marsupialization appearance before marsupialization.
Note the large radiolucent lesion and
displacement of the second right
3. A staged premolar toward the inferior border
combination of (compare with the opposite side).
Cystectomy would probably injure or
the two necessitate the removal of premolars,
procedures so it was decided to perform
marsupialization of the cyst instead. C,
Aspiration performed to determine
4. Enucleation with whether the lesion was fluid filled (cystic).
curettage. D, The lower right deciduous second molar
was removed, and the cyst was opened
through the socket (decompressed). E,
Panoramic radiograph taken 5 months
after surgery showing bone fill and
eruption of the premolars.
Surgical Management
Marsupialization of an odontogenic
keratocyst in right mandible associated
1. Enucleation with an impacted third molar. A,
Panoramic radiograph showing large
2. Marsupialization multilocular radiolucent lesion associated
with tooth No. 32. B, Aspiration of the
lesion reveals a creamy liquid (keratin).
3. A staged C, Exposure and removal of bone behind
the second molar reveals the impacted
combination of third molar crown. D, The impacted tooth
the two was removed, and additional bone was
procedures removed to provide a large window into
the lesion. A portion of the lining was
excised and sent for pathologic
4. Enucleation with examination. The cavity was inspected
through the opening to ensure there was
curettage. no solid mass that might indicate tumor.
E, Holes were drilled around the
periphery of the bony opening to pass
sutures from the oral mucosa, through the
holes in the bone, and through the cyst
lining. This provided a stable opening
from the oral cavity into the cyst.
Surgical Management
1. Enucleation INDICATIONS
• When bone has covered the adjacent vital structures.
2. Marsupialization • Adequate bone fill. Prevents fracture during enucleation.
• When patients find it difficult to cleanse the cavity.
3. A staged • To detect any occult pathological condition.
combination of ADVANTAGES
the two • Spares adjacent vital structures
procedures • Accelerates healing process
• Development of thick cystic lining – enucleation easier
4. Enucleation with • Allows histopathological examination of residual tissue.
curettage. • Combined approach reduces morbidity
DISADVANTAGES
• Patient has under go second surgery and any possible complicatton associated with
surgery.
Surgical Management
Enucleation with curettage means that Indications :
1. Enucleation after enucleation a curette • In this case the more aggressive
or bur is used to remove 1 to 2 mm of approach of enucleation with curettage
2. Marsupialization bone around the entire should be used.
periphery of the cystic cavity • Daughter, or satellite, cysts found in the
3. A staged • Any remaining epithelial cells that periphery of the main cystic lesion may
combination of may be present in the periphery be incompletely removed
the two of the cystic wall or bony cavity must • The second instance in which enucleation
procedures be removed. with curettage is indicated is with any cyst
• These cells could proliferate into a that recurs after what was deemed a
4. Enucleation with recurrence of the cyst. thorough removal.
curettage. Advantages :
• If enucleation leaves epithelial
remnants, curettage may remove them,
thereby decreasing the likelihood of
recurrence.
Enucleation with Peripheral Ostectomy
A peripheral ostectomy with rotary instruments enables
the surgeon to remove as much bone as necessary to
ensure that all residual lining is gone.
One of the inherent problems with a peripheral
ostectomy, just like curettage, is the ‘‘immeasurability’’
of the amount of osseous resection.
Use of methylene blue to identify dysplastic tissue.
Enucleation and use of Carnoy’s solution
The first use of Carnoy’s solution in surgery was reported by Cutler and Zollinger in 1933.
They used it as a fixative, haemostatic and cauterising agent and mentioned its action in
penetrating cancellous spaces of bone, devitalising tissue and fixing tumor cells.
Carnoy’s solution otherwise was being used otherwise in fixing lymph nodes in cadavers and
as fixative in histopathological fields.
Success of the application of this medicament after enucleation of OKC is thought to be due to
both penetration and fixation action.
The application of Carnoy's solution promotes a superficial chemical necrosis and is intended
to reduce recurrence rates of jaw cysts and tumors.
• Cutler EC, Zollinger R. Sclerosing solutionin the treatment of cysts and fistulae. Am JSurg;19:411, (1933).
• Lau SL, Samman N. Recurrence related to treatment modalities of unicystic amelo-blastoma: a systematic review.Int. J. Oral Maxillofac. Surg.
2006; 35: 681–690
Carnoy’s Solution
Composition: This led to the reformulated carnoy’s solution
Carnoy’s solution II (Recommended by Cutler and without chloroform and is now being accepted.
Zollinger - 1933): Ferric chloride - 1gram
Ferric chloride - 1 gram Glacial acetic acid - 1ml
Chloroform - 3ml Absolute alocohol - 6ml
Glacial acetic acid - 1ml
Absolute alocohol - 6ml
Extensive studies have proved that exposure to
chloroform has been associated with cancer and
reproductive toxicity thus banning the use of the
medicament in many parts of the world.
• Frerich B, Cornelius CP, Wietholter H. Critical time of exposure of the rabbit inferior alveolar nerve to Carnoy’s solution. J Oral Maxillofac Surg
1994: 52: 599–606.
Carnoy’s Solution
Mechanism of action:
Absolute alcohol hardens the tissue by shrinking it,
glacial acetic acid swells tissue and prevents over-hardening,
chloroform increases the speed of fixation and
ferric chloride acts as a dehydrating agent.
Uses in Maxillofacial Surgery:
Used to fix the tissue after enucleation of the OKC
Used to fix the tissue after enucleation of few types of
ameloblastoma
• Carnoy’s solution as a surgical medicament in the Treatment of keratocystic odontogenic tumour. Dr. Madhulaxmi. M, Dr. P.U. Abdul
Wahab. Int J Pharm Bio Sci 2014 Jan; 5(1): (B) 492 – 495
Carnoy’s Solution
The usual practice is the application
of Carnoy's solution after enucleation
and peripheral ostectomy with
application of methylene blue.
Carnoy’s solution with cotton
applicators or ribbon gauze for 3– 5
min, rinse the bony cavity and pack the
wound open for healing by secondary
intention. Primary closure is likely to
precipitate infection of necrotic debris.
It is assumed that carnoy’s solution eradicates epithelial rests from the bony cyst wall. Its average depth of
penetration is 1.54mm after 5 mins of application.
However, FRERICH et al. suggested the application of Carnoy’s solution should not exceed 3 min. They showed
that the critical time to nerve impairment of the inferior alveolar nerve was 3 min, and that Carnoy’s solution
should not be applied directly over the nerve. Though this still remains a matter of study.
Carnoy’s Solution
Adverse effects
Among all the ingredients of carnoys solution, chloroform is considered to be
very hazardous and should be used in a ventilated hood by wearing masks.
Exposure to chloroform has been associated with cancer and reproductive
toxicity.
Alteration in the neural conductivity after direct application of carnoys solution
over 2 minutes.
Carnoy’s solution does not maintain the osseous structure where as cryotherapy
maintains bony architecture and facilitates new bone formation.
It lowers the recurrence rate after enucleation of Keratocystic odontogenic
tumour. To overweigh the risks, reformulated carnoy’s solution can be used
and avoid using the carnoy’s solution in close vicinity to the nerve.
• Surgical treatment of keratocystic odontogenic tumour: A review article; The Saudi Dental Journal (2011) 23, 61–65
• Carnoy’s in Aggressive Lesions: Our Experience; J. Maxillofac. Oral Surg. (Jan-Mar 2013) 12(1):42–47
Enucleation and liquid nitrogen cryotherapy
Liquid nitrogen has the ability to devitalize bone in situ while leaving the inorganic
framework untouched, as a result of this, cryotherapy has been used for a number
of locally aggressive jaw lesions, including OKC, ameloblastoma and ossifying
fibroma.
Principles of cryosurgery
The mechanism of cell and tissue death with cryosurgery involves the following
mechanisms:
intracellular and extracellular ice crystal formation,
• The use of liquid nitrogen cryotherapy in the management of the odontogenic keratocyst. Brian L. Schmidt. Oral
Maxillofacial Surg Clin N Am 15 (2003) 393–405
Cryotherapy
Tissues freeze at approximately -2.2C; temperatures
below -20C are believed to cause cell death on a
consistent basis.
Liquid nitrogen cryotherapy can weaken the bone
significantly with resultant pathologic fractures.
Synchronous grafting with cancellous bone can be
accomplished after cryotherapy. Sensory nerves within
the field may show paresthesia; however, the majority
recover within 3 to 6 months.
Cryotherapy
Indications for management cysts with cryotherapy
Recurrent OKC
Large complex mandibular lesions
Conventional treatment might involve vital structures
Noncompliant patient
Oral cryosurgical techniques
Protection of extraoral soft tissues
Enucleation
Exposure and retraction of intraoral soft tissues
Cryosurgical technique
Cryoprobe with water soluble jelly
Liquid nitrogen spray
Cryotherapy
Technique Advantages Disadvantag
es
Int J Dent Med Res | JULY-AUGUST 2014 | VOL 1 | ISSUE 2; Agrawal R et al: Bismuth Iodoform and Paraffin Paste in
Keratocystic Odontogenic Tumor
Jaw Resection
Block resection, with or without preservation of the continuity of the
jaw
Resection refers to either segmental resection (surgical removal of a
segment of the mandible or maxilla without maintaining the
continuity of the bone) or marginal resection (surgical removal of a
lesion intact, with a rim of uninvolved bone, maintaining the continuity
of the bone).
Extreme technique, that results in considerable morbidity,
particularly because reconstructive measures are necessary to
restore jaw function and aesthetics.
Methods of mandibular resection
Two basic methods:
In the marginal or rim resection, the integrity of the
lower or upper border of the mandible is kept intact.
In the full or segmental resection of the mandible,
both the upper and lower border are included in the
resection so that there is a loss of continuity of the
mandible.
MARGINAL OR RIM RESECTION
Infective or osteonecrotic disorders- general debridement.
Odontogenic tumors- resection with wider margins.
Segmental Resection
Indicated for
Infiltrative lesions
Lesions involving lower and posterior
border
Recurrent lesions
Complete segment from alveolus to
inferior border is resected.
Deviation of mandible to resected side,
occlusion derranged, marked facial
deformity.
Need for reconstruction.
Resecting the Maxilla
Maxillary resection is guided by the Class 1 (alveolectomy)
extent of cyst. Class 2 (low level maxillectomy)
Pre-operative imaging will include an Class 3 (high level maxillectomy
orthopantomogram (opg) and a CT maintaining the orbit)
scan and often an additional MRI will
be useful to assess the skull base. Class 4 (radical maxillectomy with
orbital exenteration)
The main issues in maxillary resection
involve the removal of the orbit and
the extent of the disease into the
infratemporal fossa.
Conclusion
Cysts are a common clinical condition and frequently encountered in
practice.
They can be a window to the diagnosis of underlying symptoms in a
subject.
The initial surgical treatment and the subsequent follow-up of cysts
of the oral and maxillofacial region depend on several factors:
The patient’s age and overall health condition
Size and location of the cyst
Histologic diagnosis of the lesion gained by excisional, incisional, or FNA
biopsies.
References
4th Edition of the World Health Organization Classification of Head and Neck Tumours: Odontogenic and Maxillofacial Bone Tumors, 2017
Cysts of the Oral and Maxillofacial Regions Fourth edition Mervyn Shear, Paul Speight
Oral And Maxillofacial Surgery Volume II Trauma, Surgical Pathology, Temporomandibular Disorders - Eric R. Carlson, Raymond J. Fonseca, Gregory M. Ness - 3rd Edition (2017)
DIFFERENTIAL DIAGNOSIS of ORAL and MAXILLOFACIAL LESIONS; NORMAN K. WOOD, PAUL W. GOAZ
Odontogenic Cysts and Tumors Brad W. Neville, Douglas D. Damm, Carl M. Allen, and Angela C. Chi; Oral and Maxillofacial Pathology, 15, 632-689
THE PATHOGENESIS OF DENTAL CYSTS MALCOLM HARRIS; Br.Med.BuU. 1975; Vol. 31 No. 2
The pathogenesis of odontogenic cysts: a review; R. M. BROWNE Jottrtial of Oral Pathology 1975: 4: 31-46
Controversies in Oral and Maxillofacial Pathology Zachary S. Peacock, DMD, MD; Oral Maxillofacial Surg Clin N Am 29 (2017) 475–486
Odontogenic cysts; Lisette Martin, Paul M Speight; DIAGNOSTIC HISTOPATHOLOGY 21:9; MINI-SYMPOSIUM: PATHOLOGY OF THE JAWS
Surgical treatment of keratocystic odontogenic tumour: A review article Walid Ahmed Abdullah; The Saudi Dental Journal (2011) 23, 61–65
An analysis of the clinical and histopathologic parameters of the odontogenic keratocyst Thomas P. Pay, Atlanta, DEPARTMENT OF ORAL PATHOLOGY, EMORY UNIVERSITY
SCHOOL OF DENTISTRY
The use of liquid nitrogen cryotherapy in the management of the odontogenic keratocyst; Brian L. Schmidt; Oral Maxillofacial Surg Clin N Am 15 (2003) 393–405
JAW CYSTS: DIAGNOSIS AND TREATMENT GORDON W. SUMMERS; HEAD & NECK SURGERY 1:243-256 1979
Surgical treatment of keratocystic odontogenic tumour: A review article; The Saudi Dental Journal (2011) 23, 61–65
Carnoy’s in Aggressive Lesions: Our Experience; J. Maxillofac. Oral Surg. (Jan-Mar 2013) 12(1):42–47