Oral Surgery Revision Course 1

8/2/2019 Oral Surgery Revision Course 1

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Cystic and Odontogenic Tumours LesionsOf The Jaws

Dr Ashraf Abu KarakyThe University of Jordan

Oral surgery Revision Course

2012


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Definition

A cyst is defined as a pathologicalcavity containing fluid, semifluid orgaseous material other than pus. It

is frequently but not always linedby epithelium.


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Diagnosis of Radiolucent Lesionsof the Jaws

Step 1

Systematically describe theRL

. Site

. Size

. Shape

. Outline/ edge or periphery

. Relative radiodensity

. Effects on adjacentsurrounding structures

. Time present


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Step 2

Decide whether or not the RLis:

1- A normal anatomicalstructure

2- Artefactual

3- Pathological:a.Congenital.

b.Developmental

c. Acquired


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Step 3IF acquired RL:- Infection; Localized to apical

tissueSpreading within the

jaw- Traumatic lesions- Cysts- Tumours- Giant cell lesions- Fibro-cemento-osseous

lesions- Idiopathic lesions


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Step 4

Consider the

classification andsubdivision of cystsand other RL s withineach of the other main

disease categories


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Step 5

Compare the radiologicalfeatures of the unknownRL with the typical RGfeatures of these possible

conditions.Construct a list showing in

order of likelihood all theconditions that the lesionmight be (radiologicaldifferential diagnosis)


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Odontogenic cysts

Developmental 1.Dentigerous cyst

2.Eruption cyst

3.Odontogenic keratocyst

(keratocystic odontogenictumor*)

4.Orthokeratinized odontogeniccyst

5.Gingival cyst of the newborn

6.Gingival cyst of the adult

7.Lateral periodontal cyst 8.Glandular odontogenic cyst

Inflammatory origin 1.Periapicalcyst (radicular cyst;

Apical periodontal cyst)

2.Residual periapical (radicular)cyst

3.Buccal bifurcation cyst


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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 SalivaryGland Inclusion Defect)

3. Soft tissue cyst

- Dermoid- Branchial- Thyroglossal duct cyst

- Salivary cyst


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Inflammatory OdontogenicCysts

Radicular

Residual

LateralParadental


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Radicular Cyst

Develops from the epithelial remnants ofHertwig s sheath- the cell rests ofMalassez

Age usually adults, 20-50 yrs

Frequency: most common of all jaw cysts

(70%)


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Typical radiographic features

Site: Apex of any non-vitaltooth.

Size: Usually 1.5-3cm indiameter

Shape: Round

Monolocular

Outline: Smooth

Well defined

Well corticated iflongstanding and

continuous with the laminadura of the associatedtooth

Radiodensity: Uniformlyradiolucent


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Cont.// Radiographic Features

Effect: Adjacent teeth-displaced, rarelyresorbed

Buccal expansion

Displacement of

the antrum


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Residual Cyst

This term refers to radicular (dental)cyst remaining after the causativetooth has been extracted

Age: Adults > 20yrs

Site: Apical regions of tooth bearingportion of the jaws


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Size: Variable, 2-3 cm indiameter

Shape: Round, Monolocular

Outline: Smooth, Welldefined

Usually wellcorticated


Effects: -adjacent teeth

displaced, rarelyresorbed

-Buccal expansion

-Displacement of the

antrum


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Lateral Radicular Cyst

Form at the side of anon-vital tooth asa result of opening

of a lateral branchof the root canal.


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Paradental Cyst

Results frominflammationaround partially

erupted teeth,particularlymandibular thirdmolars.

Age: 20-25yrs

Teeth Vital-Pericorinitis


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Developmental Cysts

- Odontogenic Keratocyst

- Follicular cyst Dentigerous cystEruption Cyst

- Lateral Periodontal cyst

- Glandular Odontogenic Cyst- Gingival Cyst of Adults- Gingival Cyst of Newborn (EpsteinPearls)


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Dentigerous (follicular cyst)

Develop from the remnants of the reduceddental epithelium

Age: Usually adolescents or young adults(20-40yrs), occasionally the elderly.

Frequency: About 20% of all Cysts


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Site: Associated with the crown of anunerupted and displaced tooth,typically teeth where eruption isimpeded, e.g. upper 3, lower 8

Size: Very variable, cyst suspected iffollicular space exceeds 3 mm butmay grow to several cms in

diameter and extend up into theramusShape: - Round or oval, typically

enveloping the crownsymmetrically

- Monolocular- 3 varieties are described

depending on the cyst crown

relationship; central,lateralcircumferential


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Cont.// Radiographic Features

Outline: - Smooth- Well defined- Often Well Corticated

RD: Uniformly RL

Effects: - Associated tooth;unerupted and displaced

- Adjacent teeth:DisplacedRarely resorbed

- Buccal or medialexpansion, can be extensive

with large cysts causing facialasymmetry and displacementof the antrum


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Eruption Cystdentigerous cyst in the

soft tissue


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Odontogenic Keratocyst

Develop from the epithelium of the dentallamina (the cell rests of Serres)

Age: Very variable, 2nd and 4th decade

Frequency : less than 5% of all odontogenic

cysts


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Radiographic Features

Site: Posterior body / angleof the mandible extendingto the ramus

Anterior maxilla incanine regionSize: Variable, but often largein the mandibleShape: - Oval, extendingalong the body of themandible with littlemediolateral expansion

- Pseudolocular ormultilocularOutline: -Smooth

- Well defined- Often well

corticated


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Cont// Radiographic Features


Effects: - Adjacent teeth-minimal displacement,

rarely resorbed- Extensive

expansion

within cancellous bone

typically out of theproportion to the minimaldegree of medio-lateral

expansion.


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Gorlin s Syndrome (nevoidbasal cell carcinomasyndrome)

Multiple OdontogenicKeratocysts

Multiple Basal CellCarcinomas

Skeletal Anomalies, e.g. bifidribs and calcification of the

flax cerebri.


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Developmental Lateral PeriodontalCyst

Uncommon developmentalintraosseous cysts form beside avital tooth.

Age: Variable

Frequency: Uncommon


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Site: Between roots oflateral incisor andcanine

Size: Usually small in

sizeShape: Round

Outline: Well-demarcated

RD: RLEffect: Adjacent teeth-May be displaced

May erodethrough the bone to

extend into


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Glandular Odontogenic Cyst

Very rare

Age: Middle- aged adults49yrs

Site: 89% Mandible, anteriorregion

many cross the midlineSize: vary up to several cms

RD: Uniformly RL

Shape: multilocular stunilocular

Outline: Well demarcatedEffects: Expansion

Paresthesia


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Gingival Cyst

Dental lamina cystsof the newborn,(Bohns

nodules;Epsteinspearls)

Gingival cysts ofadults: st erode

the underlyingbone


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Non-Odontogenic Cysts

Developmental Cysts

Nasopalatine duct cystNasolabial cyst

Median Palatine Cyst

Globulo-Maxillary CystMedian Mandibular Cyst


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Nasopalatine Duct / Incisive Canal

CystDevelop from epithelial remnants ofNasopalatine Duct or Incisive Canal.

Age: Variable, but most frequentlydetected in middle age (40-60 yrsolds).

Frequency: Most Common of all non-

odontogenic cysts, 1% of totalpopulation


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Site: Midline, anterior maxillajust posterior to the uppercentral incisorsSize: Variable, but usually from6mm to several cm s indiameter.

Shape: Round or OvalMonolocularOutline: Smooth

Well definedWell corticated

RD: Uniformly RL but RO

shadows st superimposedEffects: -Adjacent teeth- distaldisplacement, rarely resorbed

-Palatal expansion


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Differentiation between NasopalatineDuct Cyst and a large normalNaopalatine foramen?

. Size

. Outline

. Relative RD

. Shape?


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Median mandibular cyst

Develop from embryonic epithelial remnants

in the symphyseal region of the mandible


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Median Palatine Cyst


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Globulo-Maxillary Cyst


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Nasolabial Cyst

Rare fissural cyst, ariseat the junction of theglobular process, thelateral nasal process

and the maxillaryprocess as a result ofproliferation ofentrapped epitheliumalong the fusion line.

X-ray findings arenegative


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2. Bone Cysts

-Solitary bone cyst- Aneurysmal bone cyst

- Stafne Cyst ( Lingual Salivary GlandInclusion Defect)


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Solitary (simple) bone cyst

Unknown aetiology, may be associated withtrauma.

Age: Children and young adults < 20yrs


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Site: Premolar and Molar region ofthe Mandible

Rarely, anterior MaxillaSize: Variable, up to several cmsShape: Monolocular

Irregular, upper borderarches between the roots of the

teethOutline: - Smooth and undulating

- Moderately well defined- Moderately well or poorly

corticatedRD: uniformly RLEffects: - Adjacent Teeth- minimal or

no displacement, v rarelyresorbed

- Minimal or no expansionof the jaw


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Aneurysmal Bone Cyst

More accurately classified as Giant CellLesion

Localized non-neoplastic proliferative lesionof vascular tissue, containing Giant Cells.

Age: Usually < 20yrs old

Frequency: Rare.


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Site: Body/ posterior mandibleMaxilla occasionally

Size: Variable, up to several cmsShape: - Mono or Multilocular

- Faint internal trabeculation, mayproduce a soap-bubble appearance.Outline: - Smooth

- Moderately well defined- Peripheral cortex even when

largeRD: RL with evidence of faint, randominternaltrabeculationsEffects: - Adjacent teeth- displaced, rarelyresorbed

- Buccal and lingual expansion of

the cortex, often marked anddescribed as Ballooning or Blow-Out

S f C ( Li l S li


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Stafne Cyst ( Lingual SalivaryGland Inclusion Defect)

Well defined

depression in thelingual surface ofthe posterior bodyof the mandible

Usuallyasymptomatic andare incidental

RG finding


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Site: usually near the angleof the mandible, above theinferior border, inferiof tothe mandibular canal andposterior to the third molar

Size: can penetrate themandible to depthsextending from the lingualto the buccal cortex

Shape: Ovoid or Rectangular

Outline: - Well defined

RD: Uniformly RL

Effects : Incidental


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3. Soft tissue cyst

- Dermoid- Branchial

- Thyroglossal duct cyst

- Salivary cyst


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Dermoid Cyst


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Branchial Cyst


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Thyroglossal Duct Cyst


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Salivary Cysts

C l if i Od t i C t


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Calcifying Odontogenic Cyst(Gorlin Cyst)

Classified by WHO as odontogenic tumour

Presents typically as radiolucencyresembling other odontogenic cysts

As it develops, a variable amount of calcifiedmaterial becomes evident, scattered

throughout the RL. The RO can range fromsmall flecks to large masses.

Age: Variable, usually adults < 40 yrs old


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Frequency: rareSite: Usually mandible (70%)-anterior or premolar regions,occasionaly associated with anodontome or errupted tooth.Size: Usually small, 1-3 cm indiameter but can become verylarge, involving much of themandible.Shape: Variable, but usuallymonolocularOutline: Smooth, well defined

Often corticatedRD: initially RL, in advanced lesions variable amount of calcified RO

materialEffects: - Adjacent teeth usuallydisplaced and / or resobed

- Bony expansion


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Odontogenic Tumours


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A complex group of lesions of diversehistopathologic types and clinicalbehavior

Some are true neoplasms and mayrarely exhibit malignant behavior,others may represent tumour- like

malformations.


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WHO Classification

BenignOdontogenic epithelium without

odontogenic ectomesenchyme

Odontogenic epithelium withodontogenic

ectomesenchyme, with orwithout dental hard-tissueformation

Odontogenic ectomesenchymewith or without includedodontogenic epithelium

MalignantOdontogenic carcinomas

Odontogenic sarcomas

Odontogenic carcinosarcomas

Neoplasms andother lesionsrelated to bone

Osteogenic neoplasmsNon-neoplastic bone lesions

Other tumoursmelanotic neuroectodermal tumour

of infancy (melanotic progonoma)
http://radiopaedia.org/articles/missing?article%5Btitle%5D=melanotic+neuroectodermal+tumour+of+infancyhttp://radiopaedia.org/articles/missing?article%5Btitle%5D=melanotic+neuroectodermal+tumour+of+infancyhttp://radiopaedia.org/articles/missing?article%5Btitle%5D=melanotic+progonomahttp://radiopaedia.org/articles/missing?article%5Btitle%5D=melanotic+progonomahttp://radiopaedia.org/articles/missing?article%5Btitle%5D=melanotic+neuroectodermal+tumour+of+infancyhttp://radiopaedia.org/articles/missing?article%5Btitle%5D=melanotic+neuroectodermal+tumour+of+infancy


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Amelobastoma

The Most Important and The MostCommon Clinically Significant

Frequency equals the combinedfrequency of all other odontogenictumours excluding odontomas.

Arise from: rests of dental laminadeveloping enamel

organ Epithelial lining of anodontogenic cyst

Basal cells of oralmucosa

Slow growing, locally invasive,benign course in most cases

Three different clinicoradiographicsituations

1. Conventional solid or multicystic(86%)

2. Unicystic (13%)3. Peripheral (extraosseous 1%)

Conventional solid or Multicystic


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Conventional solid or MulticysticIntraosseous Amelobastoma

Age: 3rd to 7thdecade

Gender: M=F

Race: Some studies> Blacks

Site: 85% Mandiblemolar-ascendingramus

15% Maxilla


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Clinical presentation:Often AsymptomaticPainless swelling or

expansionIf untreated may growto massiveproportions

Pain and Paraesthesiaonly if large and areuncommon


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RG: Multilocular RLlesion

Buccal and

lingual expansionRoot resorption

is common

Oftenassociated with anunerrupted tooth(3rd molar)


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Histopathology

Most tumours has a varying combinations ofcystic and solid features

Has several microscopic patterns, generallyhas little bearing on the behavior of thetumour

Large Tumours show a combination ofmicroscopic patterns

Most common: Follicular and plexiformLess common: Acanthomatous, granularcell, desmoplastic and basal cell types.


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Treatment and Prognosis

Simple Enucleation andCurettage: Recurrence

rate 50-90%En-Blockor Marginal

Resection with 1cm

safety marginRecurrence rate up to15%

Radiotherapy seldomused; secondary

induced malignancyesp. in young patientsIf untreated: spread to

vital structuresMetastasis

and Malignantbehavior


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Unicystic Amelobastoma

10-15% of ConventionalAmelobastoma

Age: 50% in seconddecade

Site: 90% Mandible(posterior area)

Clinically: Asymptomatic,large lesions causepainless swelling of thejaws.

RG: Unilocular lesion, oftenassociated with animpacted 3rd molar.

Diagnosis only aftermicroscopic examination


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Histopathology: 3 types:

1- Luminal

2- Intra- luminal

3- Mural

Treatment and Prognosis:

Enucleation and Curettage 10-20%recurrence rate

Peripheral (Extraosseous)


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Peripheral (Extraosseous)Amelobastoma

Uncommon, < 1%Age: Middle Age (52 yrs)

Site: Posterior gingivaland alveolar mucosa,

Mandible>MaxillaClinically: Painless, non-

ulcerated sessile orpedunculated lesion

Histo: Same asConventionalAmelobastoma

Treatment andPrognosis: Local

surgical excision-

Malignant Amelobastoma and


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Malignant Amelobastoma andAmelobastic Carcinoma

Very rare < 1%Malignant AmelobastomaAmelobastic Carcinoma

Age: 4 to 75 yrs (mean age 30)Metastasis: from 1-30 yrs

usually after 10yrs

Metastasis: Lung > Cervicallymph nodes > vertebrae andother bone

Histo and RG: Malignant sameas conventional

Amelobastic; Features ofMalignancy

RG; more aggressiveTreatment and Prognosis: En-

blockresectionVery poor > 50% die

in 5yrs


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Adenomatoid Odontogenic Tumour

3-7% of odontogenictumours

WHO 1992 classifyas Mixed

Clinically and RG:2/3 in pts 10-19yrs

Uncommon > 30

Maxilla:Mandible 2:1

Anterior >>

Posterior


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Usually small in size ComplexSome lesions show features of

both


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Age: First two decades (ave. age 14)Clinical: Majority are Asymptomatic

Most are small in size, few can belarge and cause jaw expansion

Can interrupt teeth eruption

Site: Maxilla>Mandible

Compound can be< anterior maxilla

Complex can be < molar regionOccasionally develop completely within

gingival soft tissue


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RG:Compound: collection

of tooth like structuresof varying size andshape surrounded by a

narrow radiolucent zoneComplex: Calcified masswith the radiodensity oftooth structuresurrounded by a narrow

radiolucent zoneUnerrupted tooth

frequently associatedwith odontomas

Treatment: Simple local

excision

O


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Odonotgenic Myxoma

Age: young adultsM = FMandible>MaxillaAsymptomatic, if large painless

expansionRG: Uni or Multilocular RL with

bone trabeculaeill defined marginsLarge lesions: May show

Soap Bubble AppearanceTreatment: Curettage if small

Excision if large

Prognosis: Good, Recurrence25%

Cementoblastoma (True


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Cementoblastoma (TrueCementoma)

Less than 1% of odontogenicTumoursSite: Mandible >>> Maxilla

Premolar and Molar Region50% First Molar

F=M

Age: Children and Young adultsClinical: > 2/3 of cases Pain and

SwellingRG: RO mass fused to one or

more tooth roots surroundedby a RL rim

Treatment: Surgical excisionwith root amputation and RCT

Or with extractionof tooth

Prognosis: Excellent

M


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Management

History

Investigations

Biopsy

Diagnosis

Treatment plan


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Enucleation and Curettage

Surgical Excision

Excision with Safety Margin

En-BlockExcision

E l i d C


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Eucleation and Curettage


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Resection

Removal of a tumour by incisingthrough uninvolved tissues around

the tumour, thus delivering thetumour without direct contact duringinstrumentation (also known an en-

blockresection)


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Marginal resection (i.e., segmental)resection: resection of a tumour w/odisruption of the continuity of the bone.

Partial resection; resection of a tumour byremoving a full-thickness portion of the jaw,ex: hemimandibulectomy.

Total resection; removal of a tumour byremoval of the involved bone (e.g.maxillectomy)

Composite resection; resection of a tumourwith bone, adjacent soft tissue, andcontiguous lymph nodes channels. (this is anablative procedure used most commonly formalignant tumours).


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Factors used to determine type of


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acto s used to dete e type otreatment

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


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yreconstruction

Advantages of immediatereconstruction:

Single surgical procedure

Early return to function

Minimal compromise to facial esthetics

Disadvantages;

Loss of the graft from infection

Recurrence

Thank you


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Thank you

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Oral Surgery Revision Course 1