Management of Cystic Lesion

Cyst - an abnormal cavity in hard or soft tissue, which contains fluid or semi-fluid and is often encapsulated and lined with epithelium. -cystic lesions increase in size and destroy surrounding bone and may eventually become infected. - bone destroying lesions that closely simulate radiographic appearance of cysts are: ameloblastoma, adenoameloblastoma, central fibroma, central hemangioma, neoplasm

Complications that may arise from cystic growth: Possibility of a pathologic fracture of the jaw, especially the mandible due to weakening of the structure Involvement of adjacent erupted/unerupted teeth leading to its loosening, displacement and or resorption May impinge on the nasal cavity or antrum and cause nasal obstruction, recurrent sinusitis or occlusion of the

 Treatment of cists hinge on four salient principles:

Removal or the lining or rearrangement of the position of the abnormal tissue to ensure its elimination from the jaw Conservation of erupted healthy teeth or even those unerupted that may eventually serve a functional role Preservation of adjoining important structures (ex. Antrum, neuromuscular bundle) Restoration of affected area to its original form or near normal shape

 Diagnosis of Cysts: Clinical Findings: -usually asymptomatic unless it grows to a considerable size -small cysts are usually undetected clinically and are discovered only upon routine radiographic exam -Cysts may be associated with vital or non vital teeth depending on their etiology

 Radiographic Examination Classic appearance of an odontogenic cyst: well-defined round or ovoid area of radiolucency, circumscribed by a sharp radio opaque margin. Radiographs are essential in the diagnosis of cysts Aspirational biopsy -Aspiration of a suspected cyst is a valuable diagnostic tool. -a wide gauge needle is inserted into the cavity and the contents are aspirated. -If straw colored fluid containing cholesterol crystals is aspirated then this is pathognomonic of a cystic lesion.

Basic Surgical Goals

Eradication of Pathologic Condition

- to remove the entire lesion and leave no cells that could proliferate and cause a recurrence of the lesion

Basic Surgical Goals

Functional Rehabilitation of Patient

- dealing with the residual defects from the extirpative surgery

Surgical Management of Cysts and Cyst like lesions of the Jaws

Surgical management of oral pathologic lesions can best be discussed by broadly classifying pathologic lesions into the following categories:

Cyst and cystlike lesions of the jaws Benign tumors of the jaws Malignant tumors Benign lesions of oral tissues

METHODS:

Enucleation Marsupialization Enucleation after marsupialization Enucleation after curettage

ENUCLEATION

Total removal of cystic lesion Shelling out of the entire cystic lesion without rupture

PRINCIPLE OF ENUCLEATION

Enucleation allows cystic cavity to be covered by a mucoperiosteal flap and the space fills with blood, which will eventually organize and form normal bone.

TECHNIQUE IN ENUCLEATION

Mucoperiosteal flap is elevated from around necks of teeth. Bur is used to remove thinned cortical bone overlying cyst.
**Care is taken to prevent rupturing cystic contents during this. Spoon type of curette is used to strip cyst from bone. Concave

INDICATIONS

treatment of odontogenic keratocytes recurrence of cystic lesions of any cyst type should be employed with any cyst of jaw that can be safely removed unduly sacrificing adjacent structures

CONTRAINDICATIONS

Dentigerous cyst Young patients with erupting teeth Medically compromised or debilited patients Proximity to vital structure Very large cysts, may cause fracture of jaw

ADVANTAGES

Entire pathologic tissue is removed Tissue available for histopathological examination Chances of recurrence are

 Healing time is reduced Enucleation with primary closure eliminates need for repeated appointments for packing, irrigation, adjustment of plug

Disadvantages

After primary closure, it is not possible to observe healing of cavity In young patients, the unerupted teeth in a dentigerous cyst will be removed with the lesion

 Removal of large cyst may make mandible more prone to fracture Damage of adjacent vital structures May lead to pulpal necrosis Adjacent tooth may be devitalized

MARSUPIALIZATION Refers to creating a surgical window in the wall of the cyst, evacuating the contents of the cyst, and maintaining continuity between the cyst and the cavity, maxillary sinus or nasal cavity, also called decompression

 Can be used either as a sole therapy for a cyst or as a preliminary step in management, with enucleation

PRINCIPLE OF MARSUPIALIZATION Marsupialization refers to creating a surgical window in the wall of cyst and evacuation of cystic contents. This process decreases intracystic pressure and promotes shrinkage of cyst and bone fill.

TECHNIQUE OF MARSUPIALIZATION Incision through oral mucosa and cystic wall into center of cyst. Scissors used to complete excision of window of mucosa and cystic wall. Oral mucosa and mucosa of cystic wall sutured together around periphery of opening.

INDICATIONS Amount of tissue injury Surgical access Assistance in eruption of teeth Extent of surgery Size of cyst

CONTRAINDICATIONS Odontogenic keratocyst Recurring cyst Smaller cysts (2x2)

ADVANTAGES Simple procedure to perform Spares vital structures Even quiet large cyst can be dealt under local anesthesia as anesthesia of deeper recesses is not essential

 Simplest way to treat a fracture complicating a large cyst of mandible, s ribbon gauze and whiteheads varnish pack will splint the fragments Allows the eruption of teeth

DISADVANTAGES Pathologic tissue is left in situ Histologic examination of entire cystic lining is not done The need for regular postoperative care, occurs a substantial period of time

 The change in voice my occur when cavity is not obturated Unpleasant taste and smell may occur due to accumulation of stagnant saliva and food debris

ENUCLEATION AFTER MARSUPIALIZATION

Enucleation is frequently done after marsupialization. Initial healing is rapid after marsupialization, but the size of the cavity may not decrease appreciably past a certain point

 Secondary enucleation may be undertaken without injury to adjacent structures The combined approach reduces morbidity and accelerates complete healing of the defect

TECHNIQUE OF ENUCLEATION AFTER MARSUPIALIZATION

The cyst is first marsupialized, and osseaous healing is allowed to progress Once the cyst has decreased to a size that makes it amenable to complete surgical removal, enucleation is performed as the definitive treatment.

 The appropriate time for enucleation is when bone covering adjacent vital structures, which prevents their injury during enucleation, and when adequate bone fill has provided enough strength to prevent fracture during enucleation

 Once the cyst has been enucleated, the oral soft tissues must be closed over the defect. If possible, which may require the development and mobilization of soft tissue flaps that can be advanced.

 If complete closure of the wound cannot be achieved, packing the cavity with strip gauze impregnated with an antibiotic ointment is acceptable. This packing must be changed repeatedly with cleansing of the cavity until granulation tissue has obliterated the opening and epithelium has closed over the wound.

INDICATIONS Amount of tissue injury Degree of access for enucleation Assistance in eruption of teeth whether or not impacted teeth associated with the cyst would benefit from eruptional guidance with marsupialization

 Medical condition of the patient Size of lesion

ADVANTAGES Simple procedure that spares adjacent vital structures The entire lesion becomes available for histologic examination

 The development of thickened cystic lining-which makes the secondary enucleation an easier procedure

DISADVANTAGES Pathologic tissue is left in situ Histologic examination of entire cystic lining is not done

ENUCLEATION AFTER CURRETAGE After enucleation a curette or bur is used to remove 1 to 2mm of bone around the entire periphery of the cystic cavity. This is done to remove any remaining epithelial cells that may be present in the periphery of the cystic wall or bony cavity.

TECHNIQUE OF ENUCLEATION AFTER CURRETAGE

After the cyst has been enucleated and removed, the bony cavity is inspected for proximity to adjacent structures.

 A sharp curette or a bone bur with sterile irrigation can be used to remove a 1 to 2mm layer of bone around the complete periphery of the cystic cavity.

 This should be done with extreme care when working proximal to important anatomic structures The cavity is cleansed and closed.

INDICATIONS The surgeon should perform curettage with enucleation in 2 instances:

If removing an odontogenic keratocystmore aggressive approach of enucleaion with curettage should be used, because odontogenic keratocyst exhibit aggressive clinical behaviour and a marked high rate of recurrence

Enucleation with curettage is indicated with any cyst that recurs after what was deemed a thorough removal.

ADVANTAGE If enucleation leaves epithelial remnants, curettage may remove them, thereby decreasing the likehood of recurrence

DISADVANTAGE Curettage is more destructive of adjacent bone and other tissues

 PRINCIPLES OF SURGICAL MANAGEMENT OF JAW TUMORS A discussion of the surgical management of jaw tumors is made easier by the fact that many tumors behave similarly and therefore can be treated in a similar manner THREE MODALITIES OF SURICAL EXCISION OF JAW TUMORS: Enucleation (with or without curettage) Marginal or Partial resection Complete resection

TYPES OF SURGICAL OPERATIONS USED FOR THE REMOVAL OF JAW TUMORS Enucleation an/or curettage- local removal of tumor by instrumentation in direct contact with the lesion. Used for every benign types of lesions Resection- removal of a tumor by incising through uninvolved tissues around the tumor, thus delivering the tumor without direct contact during instrumentation

 Marginal resection- resection of tumor without disruption of the continuity of the bone Partial resection- resection of tumor by removing a full-thickness portion of the jaw Total resection- resection of tumor with bone, adjacent soft tisues, and contiguous lymph node channels. Composite resection- resection of a tumor with bone, adjacent soft tissues and contiguous lymph node channels

Enucleation and/or curettage Odontogenic tumors Odontoma Ameloblastic fibroma ameloblastic fibroodontoma Adenomaoid odontogenic tumor Calcifying odontogenic cyst Cementoblastoma Central cementifying fibroma

Marginal or Partial resection Ameloblastoma Calcifying odontogenic tumor Myxoma Ameloblastic odontoma Squamous odontogenic tumor Complete resection Malignant ameloblastoma Ameloblastic fibrosarcoma Ameloblastic odontosarcoma Primary intraosseous carcinoma

TREATMENT MODALITIES FOR MALIGNACIES

 Radiotherapy

Tumor cells in stages of active growth are more susceptible to ionizing radiation than adult tissue. Radiation prevents the cells from multiplying by interfering with their nuclear material Fractionation of the delivery of radiation means that instead of giving the maximal amount of radiation a person can withstand at one time, smaller increments of radiation are given over several weeks, which allows the healthier normal tissues time to recover between doses.

 Chemotherapy

Chemicals that act by interfering with rapidly growing tumor cells are used for treating many types of malignancies. As with radiation the chemicals are not totally selective but affect normal cells to some extent. Most of these agents are given intravenously, patients undergoing chemotherapy are in delicate balance between effectiveness in killing the tumor cells and anemia, neutropenia and thrombocytopenia, infections and bleeding are therefore common

 Surgery

The surgical procedures for excision of oral malignancies vary with the type and extent of the lesion. Small epidermoid carcinomas that are inaccessible locations and are not associated with palpable lymph nodes can be excised. A larger lesion associated with palpable lymph nodes or a similar lesion in the area of the tonsillar pillar may require extensive surgery to adequately remove it and its local metastases

Odontogenic Cysts and Tumors

Introduction
Variety of cysts and tumors Uniquely derived from tissues of developing teeth May present to otolaryngologist

Odontogenic Cysts
Radicular Cyst Paradental Cyst Dentigerous Cyst Developmental lateral periodontal Cyst Odontogenic Keratocyst Glandular Odontogenic Cyst Primordial Cyst

Radicular (Periapical) Cyst

Most common (65%) Epithelial cell rests of Malassez Response to inflammation Radiographic findings
Pulpless, nonvital tooth Small well-defined periapical radiolucency

Histology Treatment extraction, root canal

Radicular Cyst

Paradental Cyst
Associated with partially impacted 3rd molars Result of inflammation of the gingiva over an erupting molar 0.5 to 4% of cysts Radiology radiolucency in apical portion of the root Treatment enucleation

Dentigerous (follicular) Cyst

Most common developmental cyst (24%) Fluid between reduced enamel epithelium and tooth crown Radiographic findings
Unilocular radiolucency with well-defined sclerotic margins

Histology
Nonkeratinizing squamous epithelium

Treatment enucleation, decompression

Dentigerous Cyst

Developmental Lateral Periodontal Cyst

From epithelial rests in periodontal ligament vs. primordial cyst tooth bud Mandibular premolar region Middle-aged men Radiographic findings Histology
Interradicular radiolucency, well-defined margins Nonkeratinizing stratified squamous or cuboidal epithelium

Treatment enucleation, curettage with preservation of adjacent teeth

Odontogenic Keratocyst
11% of jaw cysts May mimic any of the other cysts Most often in mandibular ramus and angle Radiographically
Well-marginated, radiolucency Pericoronal, inter-radicular, or pericoronal Multilocular

Odontogenic Keratocyst

Odontogenic Keratocyst
Histology
Thin epithelial lining with underlying connective tissue (collagen and epithelial nests) Secondary inflammation may mask features

High frequency of recurrence (up to 62%) Complete removal difficult and satellite cysts can be left behind

Treatment of OKC

Depends on extent of lesion Small simple enucleation, complete removal of cyst wall Larger enucleation with/without peripheral ostectomy Bataineh,et al, promote complete resection with 1 cm bony margins (if extension through cortex, overlying soft tissues excised) Long term follow-up required (5-10 years)

Glandular Odontogenic Cyst

More recently described (45 cases) Gardner, 1988 Mandible (87%), usually anterior Very slow progressive growth (CC: swelling, pain [40%]) Radiographic findings
Unilocular or multilocular radiolucency

Glandular Odontogenic Cyst

Histology
Stratified epithelium Cuboidal, ciliated surface lining cells Polycystic with secretory and epithelial elements

Treatment of GOC
Considerable recurrence potential 25% after enucleation or curettage Marginal resection suggested for larger lesions or involvement of posterior maxilla Warrants close follow-up

Primordial Cyst -Cystic changes that occur in the enamel organ before the formation of calcified structures results in a Primordial cyst - The cyst is found in place of a tooth instead of being associated with one -It may also develop from a supernumerary tooth organ Incidence: - least common type of odontogenic cyst -usually seen at the 3rd molar area

 Clinical Features: -asymptomatic unless it reaches considerable size or becomes secondarily infected -has the potential to expand bone and displacing adjacent teeth by pressure Radiographic Findings: - appears as a round or ovoid well-demarcated radiolucency which may show a sclerotic border -may be unilocular or multilocular

Nonodontogenic Cysts Globulomaxillary Cyst Nasolabial Cyst Nasopalatine Cyst Incisive Canal Cyst Stafne Bone Cyst Traumatic Bone Cyst Surgical Ciliated Cyst (of Maxilla)

Non- Odontogenic Cystic Lesions Globulomaxillary Cyst Clinical Features: -well-defined radiolucency often producing divergence of the roots of the maxillary lateral incisor and the canine - adjacent teeth are vital -incidence is rare -pear-shaped radiolucency

Treatment: -enucleation

Nasolabial Cyst Clinical Features: - rare lesion found among 40-50 yr old patients -predilection for females -seen as a soft tissue swelling in the canine area -teeth near the affected area are vital Treatment: -surgical excision

Nasopalatine Cyst Also known as incisive canal cyst Etiology: -proliferation of epithelial remnants of paired embryonic nasopalatine ducts within the incisive canal Clinical Features: -symmetric swelling in the anterior region of the palatal midline is characteristic of the lesion -asymptomatic unless it reaches considerable size -may produce divergence of the roots of maxillary incisors

Radiographic findings: Heart shaped radiolucency Treatment: Surgical incision

Nasopalatine duct cyst

Incisive Canal Cyst

Derived from epithelial remnants of the nasopalatine duct (incisive canal) 4th to 6th decades Palatal swelling common, asymptomatic Radiographic findings Histology
Well-delineated oval radiolucency between maxillary incisors, root resorption occasional Cyst lined by stratified squamous or respiratory epithelium or both

Incisive Canal Cyst

Treatment consists of surgical enucleation or periodic radiographs Progressive enlargement requires surgical intervention

Stafne Bone Cyst

Submandibular salivary gland depression Incidental finding, not a true cyst Radiographs small, circular, corticated radiolucency below mandibular canal Histology normal salivary tissue Treatment routine follow up

Traumatic Bone Cyst

Empty or fluid filled cavity associated with jaw trauma (50%) Radiographic findings Histology thin membrane of fibrous granulation Treatment exploratory surgery may expedite healing
Radiolucency, most commonly in body or anterior portion of mandible

Surgical Ciliated Cyst

May occur following Caldwell-Luc Trapped fragments of sinus epithelium that undergo benign proliferation Radiographic findings
Unilocular radiolucency in maxilla

Histology
Lining of pseudostratified columnar ciliated

Treatment - enucleation

Odontogenic Tumors
Ameloblastoma Squamous Odontogenic Tumor Calcifying Epithelial Calcifying Odontogenic Odontogenic Tumor Tumor Adenomatoid Odontogenic Tumor

Ameloblastoma
Most common odontogenic tumor Benign, but locally invasive Clinically and histologically similar to BCCa 4th and 5th decades Occasionally arise from dentigerous cysts Subtypes multicystic (86%), unicystic (13%), and peripheral (extraosseous 1%)

Ameloblastoma
Radiographic findings
Classic multilocular radiolucency of posterior mandible Well-circumscribed, soap-bubble Unilocular often confused with odontogenic cysts Root resorption associated with malignancy

Ameloblastoma
Histology
Two patterns plexiform and follicular (no bearing on prognosis) Classic sheets and islands of tumor cells, outer rim of ameloblasts is polarized away from basement membrane Center looks like stellate reticulum Squamous differentiation (1%) Diagnosed as ameloblastic carcinoma

Treatment of Ameloblastoma
According to growth characteristics and type Unicystic
Complete removal Peripheral ostectomies if extension through cyst wall Mandibular adequate normal bone around margins of resection Maxillary more aggressive surgery, 1.5 cm margins Radical surgical resection (like SCCa) Neck dissection for LAN

Classic infiltrative (aggressive)

Ameloblastic carcinoma

Calcifying Epithelial Odontogenic Tumor

a.k.a. Pindborg tumor Aggressive tumor of epithelial derivation Impacted tooth, mandible body/ramus Chief sign cortical expansion Pain not normally a complaint

Calcifying Epithelial Odontogenic Tumor

Radiographic findings
Expanded cortices in all dimensions Radiolucent; poorly defined, noncorticated borders Unilocular, multilocular, or moth-eaten Driven-snow appearance from multiple radiopaque foci Root divergence/resorption; impacted tooth

Calcifying Epithelial Odontogenic Tumor

Histology
Islands of eosinophilic epithelial cells Cells infiltrate bony trabeculae Nuclear hyperchromatism and pleomorphism Psammoma-like calcifications (Liesegang rings)

Treatment of CEOT
Behaves like ameloblastoma Smaller recurrence rates En bloc resection, hemimandibulectomy partial maxillectomy suggested

Adenomatoid Odontogenic Tumor

Associated with the crown of an impacted anterior tooth Painless expansion Radiographic findings
Well-defined expansile radiolucency Root divergence, calcified flecks (target)

Histology
Thick fibrous capsule, clusters of spindle cells, columnar cells (rosettes, ductal) throughout

Treatment enucleation, recurrence is rare

Adenomatoid Odontogenic Tumor

Squamous Odontogenic Tumor

Hamartomatous proliferation Maxillary incisor-canine and mandibular molar Tooth mobility common complaint Radiology triangular, localized radiolucency between contiguous teeth Histology oval nest of squamous epithelium in mature collagen stroma Treatment extraction of involved tooth and thorough curettage; maxillary more extensive resection; recurrences treat with aggressive resection

Squamous Odontogenic Tumor

Calcifying Odontogenic Cyst

Tumor-like cyst of mandibular premolar region are peripheral gingival swelling Osseous lesions expansion, vital teeth Radiographic findings Histology
Radiolucency with progressive calcification Target lesion (lucent halo); root divergence Stratified squamous epithelial lining Polarized basal layer, lumen contains ghost cells

Treatment enucleation with curettage; rarely recur

Mesenchymal Odontogenic Tumors

Odontogenic Myxoma Cementoblastoma

Odontogenic Myxoma
Originates from dental papilla or follicular mesenchyme Slow growing, aggressively invasive Multilocular, expansile; impacted teeth? Radiology radiolucency with septae Histology spindle/stellate fibroblasts with basophilic ground substance Treatment en bloc resection, curettage may be attempted if fibrotic

Cementoblastoma
True neoplasm of cementoblasts First mandibular molars Cortex expanded without pain Involved tooth ankylosed, percussion Radiology apical mass; lucent or solid, radiolucent halo with dense lesions Histology radially oriented trabeculae from cementum, rim of osteoblasts Treatment complete excision and tooth sacrifice

Cementoblastoma

Mixed Odontogenic Tumors

Ameloblastic fibroma, ameloblastic fibrodentinoma, ameloblastic fibro-odontoma, odontoma Both epithelial and mesenchymal cells Mimic differentiation of developing tooth Treatment enucleation, thorough curettage with extraction of impacted tooth Ameloblastic fibrosarcomas malignant, treat with aggressive en bloc resection

Related Jaw Lesions

Giant Cell Lesions
Central giant cell granuloma Brown tumor Aneurysmal bone cyst

Fibroosseous lesions
Fibrous dysplasia Ossifying fibroma

Condensing Osteitis

Central Giant Cell Granuloma

Neoplastic-like reactive proliferation Common in children and young adults Females > males (hormonal?) Mandible > maxilla Expansile lesions root resorption Slow-growing asymptomatic swelling Rapid-growing pain, loose dentition (high rate of recurrence)

Central Giant Cell Granuloma

Radiographic findings
Unilocular, multilocular radiolucencies Well-defined or irregular borders

Histology
Multinucleated giant cells, dispersed throughout a fibrovascular stroma

Central Giant Cell Granuloma

Treatment
Curettage, segmental resection Radiation out of favor (risk of sarcoma) Intralesional steroids younger patients, very large lesions Individualized treatment depending on characteristics and location of tumor

Brown Tumor
Local manifestation of hyperparathyroid Histologically identical to CGCG Serum calcium and phosphorus More likely in older patients

Aneurysmal Bone Cyst

Large vascular sinusoids (no bruit) Not a true cyst; aggressive, reactive Great potential for growth, deformity Multilocular radiolucency with cortical expansion Mandible body Simple enucleation, rare recurrence

Fibrous Dysplasia
Monostotic vs. polystotic Monostotic
More common in jaws and cranium

Polystotic
McCune-Albrights syndrome Cutaneous pigmentation, hyper-functioning endocrine glands, precocious puberty

Fibrous Dysplasia

Painless expansile dysplastic process of osteoprogenitor connective tissue Maxilla most common Does not typically cross midline (one bone) Antrum obliterated, orbital floor involvement (globe displacement) Radiology ground-glass appearance

Fibrous Dysplasia
Histology irregular osseous trabeculae in hypercellular fibrous stroma Treatment
Deferred, if possible until skeletal maturity Quarterly clinical and radiographic f/u If quiescent contour excision (cosmesis or function) Accelerated growth or disabling functional impairment - surgical intervention (en bloc resection, reconstruction)

Ossifying Fibroma
True neoplasm of medullary jaws Elements of periodontal ligament Younger patients, premolar mandible Frequently grow to expand jaw bone Radiology
radiolucent lesion early, well-demarcated Progressive calcification (radiopaque 6 yrs)

Ossifying Fibroma
Histologically similar to fibrous dysplasia Treatment
Surgical excision shells out Recurrence is uncommon

Condensing Osteitis
4% to 8% of population Focal areas of radiodense sclerotic bone Mandible, apices of first molar Reactive bony sclerosis to pulp inflammation Irregular, radiopaque Stable, no treatment required

Case Presentation
20 year-old hispanic female with several month history of lesion in right maxilla, treated initially by oral surgeon with multiple curettage. Has experienced recent onset of rapid expansion, after pregnancy, with complaints of loose dentition and pain.

Physical Examination

Physical Examination

Radiographs
Plain films facial series Computerized Tomography of facial series

Pathology

Treatment

Treatment

Non-odontogenic Cysts

Developmental Cysts
a.k.a. fissural cysts Exact pathogenesis of some of them uncertain Generally, slow increase May be identified incidentally

Palatal and gingival cysts of newborns

Common (more than half of neonates) Small, occasionally in clusters Embryogenesis Entrapped epithelium during formation of 2 palate Epithelial remnants of salivary glands Epstein pearls: midline Bohns nodules: hard/soft palate Gingival cysts: keratin filled No treatment, spontaneous rupture

Palatal and gingival cysts of newborns

Median mandibular cyst

Controversial There are no epithelial lined processes Midline of mandible Most of them periapical or lateral periodontal cysts or odontogenic keratocysts

Epidermoid cyst
a.k.a. infundibular cyst, sebaceous cyst (wrong term); epidermal inclusion cyst (after trauma) More frequent in acne-prone areas DERIVE FROM HAIR FOLLICLE Unusual before puberty except when associated with Gardner syndrome Nodular, fluctuant subcutaneous lesion, white or yellow Cavity lined by epithelium containing keratin

Epidermoid cyst

Dermoid cyst
Benign cystic teratoma (tissue form all three embryonic layers) Dermoid cyst is a forme fruste Intraoral epidermoid cyst Midline of floor of mouth or rarely displaced laterally above the genyohyoid muscle Submental swelling below the genyohyoid muscle Few mm to several cm Children and young adults Doughy or rubbery mass; may drain

Dermoid cyst

Thyroglossal duct (tract) cyst

Review thyroid development Remnants of the thyroglossal duct epithelium Have been described in families Midline (foramen cecum-suprasternal notch) Except if they are located in the area of thyroid cartilage More frequently below the hyoid ! Base of tongue-airway obstruction Clue: If it maintains attachment to hyoid bone or tongue it will move vertically during swallowing or protrusion of the tongue; can cause fistulous tract Thyroid tissue may be absent histologically

Thyroglossal duct (tract) cyst

Branchial cleft cyst

a.k.a. cervical lymphoepithelial cyst From branchial clefts (2nd arch), or cystic change of parotid gland epithelium entrapped in upper cervical lymph nodes (not valid) Lateral upper neck along the anterior border of the sternocleidomastoid muscle Young adults, fluctuant, between 1-10 cm, more frequently on the left Occasionally a fistula Contain lymphoid tissue (occasionally not though) Rare examples of malignant transformation

Oral lymphoepithelial cyst

Invaginations of epithelium resulting in pouches or crypts that may fill with keratin debris Salivary gland or surface epithelium that becomes entrapped Less than 1 cm Firm or soft to palpation White or yellow DD: lipoma

Oral lymphoepithelial cyst

Antral pseudocysts
Antral pseudocyst Sinus mucocele Surgical ciliated cyst Obstruction (ostium) mucocele Retention cyst Obstruction of ducts of seromucous glands Invagination of epithelium

Antral pseudocyst
Common finding of mostly panoramic radiographs Dome-shaped, slightly radiopaque Floor of maxillary sinus NOT A CYST Inflammatory exudate; probable odontogenic origin Other causes may be: allergy, sinus infection No treatment necessary if not associated with signs and symptoms (enlargement; headache) EVALUATION OF TEETH

Antral pseudocyst

Sinus mucocele
Whole sinus is cloudy when ostium obstructed Post surgical cysts can enlarge Surgical removal or meatal antrostomy

Retention cyst Very small to be detectable

THANK YOU !!

Reporters: