Cystic and Odontogenic Tumours Lesions Of The Jaws

Dr Ashraf Abu Karaky

The University of Jordan Oral surgery Revision Course

2012

Definition
A cyst is defined as a pathological cavity containing fluid, semifluid or gaseous material other than pus. It is frequently but not always lined by epithelium.

Diagnosis of Radiolucent Lesions of the Jaws

Step 1 Systematically describe the RL . Site . Size . Shape . Outline/ edge or periphery . Relative radiodensity . Effects on adjacent surrounding structures . Time present

Step 2 Decide whether or not the RL is: 1- A normal anatomical structure

2- Artefactual
3- Pathological:
Developmental
a.Congenital. b. c. Acquired

Step 3

IF acquired RL: - Infection; Localized to apical tissue Spreading within the jaw - Traumatic lesions - Cysts - Tumours - Giant cell lesions - Fibro-cemento-osseous lesions - Idiopathic lesions

Step 4
Consider the classification and subdivision of cysts and other RL s within each of the other main disease categories

Step 5 Compare the radiological features of the unknown RL with the typical RG features of these possible conditions. Construct a list showing in order of likelihood all the conditions that the lesion might be (radiological differential diagnosis)

Odontogenic cysts

Developmental
1.Dentigerous cyst 2.Eruption cyst 3.Odontogenic keratocyst (keratocystic odontogenic tumor*) 4.Orthokeratinized odontogenic cyst 5.Gingival cyst of the newborn 6.Gingival cyst of the adult 7.Lateral periodontal cyst 8.Glandular odontogenic cyst

Inammatory origin
1.Periapicalcyst (radicular cyst; Apical periodontal cyst) 2.Residual periapical (radicular) cyst 3.Buccal bifurcation cyst

Non-Odontogenic Cysts

1. Fissural Cysts Nasopalatine duct cyst Nasolabial cyst Median Madibular Cyst Median Palatine Cyst Globulo-Maxillary Cyst

2. Bone Cysts - Solitary bone cyst - Aneurysmal bone cyst - Stafne Cyst ( Lingual Salivary Gland Inclusion Defect) 3. Soft tissue cyst - Dermoid - Branchial - Thyroglossal duct cyst - Salivary cyst

Inflammatory Odontogenic Cysts

Radicular Residual Lateral Paradental

Radicular Cyst

Develops from the epithelial remnants of Hertwig s sheath- the cell rests of Malassez Age usually adults, 20-50 yrs Frequency: most common of all jaw cysts (70%)

Typical radiographic features

Site: Apex of any non-vital tooth. Size: Usually 1.5-3cm in diameter Shape: Round Monolocular Outline: Smooth Well defined Well corticated if longstanding and continuous with the lamina dura of the associated tooth Radiodensity: Uniformly radiolucent

Cont.// Radiographic Features

Effect: Adjacent teethdisplaced, rarely resorbed Buccal expansion Displacement of the antrum

Residual Cyst
This term refers to radicular (dental) cyst remaining after the causative tooth has been extracted Age: Adults > 20yrs Site: Apical regions of tooth bearing portion of the jaws

Typical radiographic features

Size: Variable, 2-3 cm in diameter Shape: Round, Monolocular Outline: Smooth, Well defined Usually well corticated Radiodensity: Uniformly radiolucent

Effects: -adjacent teeth displaced, rarely resorbed -Buccal expansion -Displacement of the
antrum

Lateral Radicular Cyst

Form at the side of a non-vital tooth as a result of opening of a lateral branch of the root canal.

Paradental Cyst
Results from inflammation around partially erupted teeth, particularly mandibular third molars. Age: 20-25yrs Teeth VitalPericorinitis

Developmental Cysts - Odontogenic Keratocyst - Follicular cyst Dentigerous cyst

Eruption Cyst

- Lateral Periodontal cyst - Glandular Odontogenic Cyst - Gingival Cyst of Adults - Gingival Cyst of Newborn (Epstein Pearls)

Dentigerous (follicular cyst)

Develop from the remnants of the reduced dental epithelium Age: Usually adolescents or young adults (20-40yrs), occasionally the elderly. Frequency: About 20% of all Cysts

Typical radiographic features

Site: Associated with the crown of an unerupted and displaced tooth, typically teeth where eruption is impeded, e.g. upper 3, lower 8 Size: Very variable, cyst suspected if follicular space exceeds 3 mm but may grow to several cms in diameter and extend up into the ramus Shape: - Round or oval, typically enveloping the crown symmetrically - Monolocular - 3 varieties are described depending on the cyst crown relationship; central,lateral circumferential

Cont.// Radiographic Features

Outline: - Smooth - Well defined - Often Well Corticated RD: Uniformly RL Effects: - Associated tooth; unerupted and displaced - Adjacent teeth: Displaced Rarely resorbed - Buccal or medial expansion, can be extensive with large cysts causing facial asymmetry and displacement of the antrum

Eruption Cyst
dentigerous cyst in the soft tissue

Odontogenic Keratocyst

Develop from the epithelium of the dental lamina (the cell rests of Serres) Age: Very variable, 2nd and 4th decade Frequency : less than 5% of all odontogenic cysts

Radiographic Features
Site: Posterior body / angle of the mandible extending to the ramus Anterior maxilla in canine region Size: Variable, but often large in the mandible Shape: - Oval, extending along the body of the mandible with little mediolateral expansion - Pseudolocular or multilocular Outline: -Smooth - Well defined - Often well corticated

Cont// Radiographic Features

Radiodensity: Uniformly radiolucent Effects: - Adjacent teethminimal displacement, rarely resorbed

expansion within cancellous bone typically out of the proportion to the minimal degree of medio-lateral expansion.

- Extensive

Gorlin s Syndrome (nevoid basal cell carcinoma syndrome) Multiple Odontogenic Keratocysts Multiple Basal Cell Carcinomas Skeletal Anomalies, e.g. bifid ribs and calcification of the flax cerebri.

Developmental Lateral Periodontal Cyst

Uncommon developmental intraosseous cysts form beside a vital tooth. Age: Variable Frequency: Uncommon

Radiographic Features
Site: Between roots of lateral incisor and canine Size: Usually small in size Shape: Round Outline: Welldemarcated RD: RL Effect: Adjacent teethMay be displaced May erode through the bone to extend into

Glandular Odontogenic Cyst

Very rare Age: Middle- aged adults 49yrs Site: 89% Mandible, anterior region many cross the midline Size: vary up to several cms RD: Uniformly RL Shape: multilocular st unilocular Outline: Well demarcated Effects: Expansion Paresthesia

Gingival Cyst
Dental lamina cysts of the newborn, (Bohns nodules;Epsteins pearls) Gingival cysts of adults: st erode the underlying bone

Non-Odontogenic Cysts
Developmental Cysts Nasopalatine duct cyst Nasolabial cyst Median Palatine Cyst Globulo-Maxillary Cyst Median Mandibular Cyst

Develop from epithelial remnants of Nasopalatine Duct or Incisive Canal. Age: Variable, but most frequently detected in middle age (40-60 yrs olds). Frequency: Most Common of all nonodontogenic cysts, 1% of total population

Nasopalatine Duct / Incisive Canal Cyst

Radiographic Features
Site: Midline, anterior maxilla just posterior to the upper central incisors Size: Variable, but usually from 6mm to several cm s in diameter. Shape: Round or Oval Monolocular Outline: Smooth Well defined Well corticated RD: Uniformly RL but RO shadows st superimposed Effects: -Adjacent teeth- distal displacement, rarely resorbed -Palatal expansion

Differentiation between Nasopalatine Duct Cyst and a large normal Naopalatine foramen? . Size . Outline . Relative RD . Shape?

Median mandibular cyst

Develop from embryonic epithelial remnants in the symphyseal region of the mandible

Median Palatine Cyst

Globulo-Maxillary Cyst

Nasolabial Cyst
Rare fissural cyst, arise at the junction of the globular process, the lateral nasal process and the maxillary process as a result of proliferation of entrapped epithelium along the fusion line. X-ray findings are negative

2. Bone Cysts
- Solitary bone cyst - Aneurysmal bone cyst - Stafne Cyst ( Lingual Salivary Gland Inclusion Defect)

Solitary (simple) bone cyst

Unknown aetiology, may be associated with trauma. Age: Children and young adults < 20yrs

Radiographic Features
Site: Premolar and Molar region of the Mandible Rarely, anterior Maxilla Size: Variable, up to several cms Shape: Monolocular Irregular, upper border arches between the roots of the teeth Outline: - Smooth and undulating - Moderately well defined - Moderately well or poorly corticated RD: uniformly RL Effects: - Adjacent Teeth- minimal or no displacement, v rarely resorbed - Minimal or no expansion of the jaw

Aneurysmal Bone Cyst

More accurately classified as Giant Cell Lesion Localized non-neoplastic proliferative lesion of vascular tissue, containing Giant Cells. Age: Usually < 20yrs old Frequency: Rare.

Radiographic Features
Site: Body/ posterior mandible Maxilla occasionally Size: Variable, up to several cms Shape: - Mono or Multilocular - Faint internal trabeculation, may produce a soap-bubble appearance. Outline: - Smooth - Moderately well defined - Peripheral cortex even when large RD: RL with evidence of faint, random internal trabeculations Effects: - Adjacent teeth- displaced, rarely resorbed - Buccal and lingual expansion of the cortex, often marked and described as Ballooning or Blow-Out

Stafne Cyst ( Lingual Salivary Gland Inclusion Defect)

Well defined depression in the lingual surface of the posterior body of the mandible Usually asymptomatic and are incidental RG finding

Radiographic Features
Site: usually near the angle of the mandible, above the inferior border, inferiof to the mandibular canal and posterior to the third molar Size: can penetrate the mandible to depths extending from the lingual to the buccal cortex Shape: Ovoid or Rectangular Outline: - Well defined RD: Uniformly RL Effects : Incidental

3. Soft tissue cyst - Dermoid - Branchial - Thyroglossal duct cyst - Salivary cyst

Dermoid Cyst

Branchial Cyst

Thyroglossal Duct Cyst

Salivary Cysts

Calcifying Odontogenic Cyst (Gorlin Cyst)

Classified by WHO as odontogenic tumour Presents typically as radiolucency resembling other odontogenic cysts As it develops, a variable amount of calcified material becomes evident, scattered throughout the RL. The RO can range from small flecks to large masses. Age: Variable, usually adults < 40 yrs old

Radiographic Features
Frequency: rare Site: Usually mandible (70%)anterior or premolar regions, occasionaly associated with an odontome or errupted tooth. Size: Usually small, 1-3 cm in diameter but can become very large, involving much of the mandible. Shape: Variable, but usually monolocular Outline: Smooth, well defined Often corticated RD: initially RL, in advanced lesions variable amount of calcified RO material Effects: - Adjacent teeth usually displaced and / or resobed - Bony expansion

Odontogenic Tumours

A complex group of lesions of diverse histopathologic types and clinical behavior Some are true neoplasms and may rarely exhibit malignant behavior, others may represent tumour- like malformations.

WHO Classification

Benign

Odontogenic epithelium without odontogenic ectomesenchyme Odontogenic epithelium with odontogenic ectomesenchyme, with or without dental hard-tissue formation Odontogenic ectomesenchyme with or without included odontogenic epithelium

Neoplasms and other lesions related to bone

Other tumours

Osteogenic neoplasms Non-neoplastic bone lesions

Malignant

melanotic neuroectodermal tumour of infancy (melanotic progonoma)

Odontogenic carcinomas Odontogenic sarcomas Odontogenic carcinosarcomas

Amelobastoma
The Most Important and The Most Common Clinically Significant Frequency equals the combined frequency of all other odontogenic tumours excluding odontomas. Arise from: rests of dental lamina developing enamel organ Epithelial lining of an odontogenic cyst Basal cells of oral mucosa Slow growing, locally invasive, benign course in most cases

Three different clinicoradiographic situations 1. Conventional solid or multicystic (86%) 2. Unicystic (13%) 3. Peripheral (extraosseous 1%)

Conventional solid or Multicystic Intraosseous Amelobastoma

Age: 3rd to 7th decade Gender: M=F Race: Some studies > Blacks Site: 85% Mandible molar-ascending ramus 15% Maxilla

Clinical presentation: Often Asymptomatic Painless swelling or expansion If untreated may grow to massive proportions Pain and Paraesthesia only if large and are uncommon

RG: Multilocular RL lesion Buccal and lingual expansion Root resorption is common Often associated with an unerrupted tooth (3rd molar)

Histopathology
Most tumours has a varying combinations of cystic and solid features Has several microscopic patterns, generally has little bearing on the behavior of the tumour Large Tumours show a combination of microscopic patterns Most common: Follicular and plexiform Less common: Acanthomatous, granular cell, desmoplastic and basal cell types.

Treatment and Prognosis

Simple Enucleation and Curettage: Recurrence rate 50-90% En-Block or Marginal Resection with 1cm safety margin Recurrence rate up to 15% Radiotherapy seldom used; secondary induced malignancy esp. in young patients If untreated: spread to vital structures Metastasis and Malignant behavior

Unicystic Amelobastoma
10-15% of Conventional Amelobastoma Age: 50% in second decade Site: 90% Mandible (posterior area) Clinically: Asymptomatic, large lesions cause painless swelling of the jaws. RG: Unilocular lesion, often associated with an impacted 3rd molar. Diagnosis only after microscopic examination

Histopathology: 3 types: 1- Luminal 2- Intra- luminal 3- Mural Treatment and Prognosis: Enucleation and Curettage 10-20% recurrence rate

Peripheral (Extraosseous) Amelobastoma

Uncommon, < 1% Age: Middle Age (52 yrs) Site: Posterior gingival and alveolar mucosa, Mandible>Maxilla Clinically: Painless, nonulcerated sessile or pedunculated lesion Histo: Same as Conventional Amelobastoma Treatment and Prognosis: Local surgical excision

Malignant Amelobastoma and Amelobastic Carcinoma

Very rare < 1% Malignant Amelobastoma Amelobastic Carcinoma Age: 4 to 75 yrs (mean age 30) Metastasis: from 1-30 yrs usually after 10yrs Metastasis: Lung > Cervical lymph nodes > vertebrae and other bone Histo and RG: Malignant same as conventional Amelobastic; Features of Malignancy RG; more aggressive Treatment and Prognosis: Enblock resection Very poor > 50% die in 5yrs

Adenomatoid Odontogenic Tumour

3-7% of odontogenic tumours WHO 1992 classify as Mixed Clinically and RG: 2/3 in pts 10-19 yrs

Uncommon > 30 Maxilla:Mandible 2:1 Anterior >> Posterior

Usually small in size < 3cm Usually Asymptomatic, Large lesions cause expansion RG: in 70% unilocular RL associated with unerrupted tooth (often canine) Histo: Well defined surrounded by thick fibrous capsule, central part is solid or may show a varying degree of cystic change Treatment and

Calcifying Epithelial Odonotgenic Tumour (Pindborg Tumour)

Uncommon < 1% Age: 30-50 Site: 2/3 mandible, posterior area Clinically: Painless, slowly growing RG: Usually Multilocular RL, may contain RO calcified structures May be associated with unerrupted tooth, third molar Treatment: Conservative local resection to include narrow rim of surrounding bone

Odontoma
The most common type of odontogenic tumours Some consider as Hamartomas When fully developed: chiefly consist of enamel dentin with variable amount of pulp and cementum Two types: 1- Compound Odontoma: multiple small toothlike structures 2- Complex Odontoma: Conglomerate mass of enamel and dentin, no anatomic resemblance to to a tooth Compound>Complex Some lesions show features of both

Age: First two decades (ave. age 14) Clinical: Majority are Asymptomatic Most are small in size, few can be large and cause jaw expansion Can interrupt teeth eruption Site: Maxilla>Mandible Compound can be< anterior maxilla Complex can be < molar region Occasionally develop completely within gingival soft tissue

RG: Compound: collection of tooth like structures of varying size and shape surrounded by a narrow radiolucent zone Complex: Calcified mass with the radiodensity of tooth structure surrounded by a narrow radiolucent zone Unerrupted tooth frequently associated with odontomas Treatment: Simple local excision

Odonotgenic Myxoma
Age: young adults M=F Mandible>Maxilla Asymptomatic, if large painless expansion RG: Uni or Multilocular RL with bone trabeculae ill defined margins Large lesions: May show Soap Bubble Appearance Treatment: Curettage if small Excision if large Prognosis: Good, Recurrence 25%

Cementoblastoma (True Cementoma)

Less than 1% of odontogenic Tumours Site: Mandible >>> Maxilla Premolar and Molar Region 50% First Molar F=M Age: Children and Young adults Clinical: > 2/3 of cases Pain and Swelling RG: RO mass fused to one or more tooth roots surrounded by a RL rim Treatment: Surgical excision with root amputation and RCT Or with extraction of tooth Prognosis: Excellent

Management
History Investigations Biopsy Diagnosis Treatment plan

Enucleation and Curettage Surgical Excision Excision with Safety Margin En-Block Excision

Eucleation and Curettage

Resection Removal of a tumour by incising through uninvolved tissues around the tumour, thus delivering the tumour without direct contact during instrumentation (also known an enblock resection)

Marginal resection (i.e., segmental) resection: resection of a tumour w/o disruption of the continuity of the bone. Partial resection; resection of a tumour by removing a full-thickness portion of the jaw, ex: hemimandibulectomy. Total resection; removal of a tumour by removal of the involved bone (e.g. maxillectomy) Composite resection; resection of a tumour with bone, adjacent soft tissue, and contiguous lymph nodes channels. (this is an ablative procedure used most commonly for malignant tumours).

Factors used to determine type of treatment

Aggressiveness of lesion Anatomic location of lesion Maxilla vs mandible Vital structures Size of the tumour Intra vs extra-osseous Duration of lesion Reconstructive efforts

Immediate Vs delayed reconstruction

Advantages of immediate reconstruction: Single surgical procedure Early return to function Minimal compromise to facial esthetics Disadvantages; Loss of the graft from infection Recurrence

Thank you