BouquotBouquot’’s Desks Desk
Circa 1971Circa 1971
The BouquotsThe Bouquots
19811981
Oral & Maxillofacial Pathology IIOral & Maxillofacial Pathology II
DB 3702DB 3702
Thursdays, 10:00 – 11:50 am
Room DB 132
...
Cells & TissuesCells & Tissues
of Originof Origin
Ameloblasts v. PreameloblastsAmeloblasts v. Preameloblasts
Preameloblasts
Preameloblasts EnamelEnamel
AmeloblastsAmeloblas...
Classification ofClassification of
Odontogenic TumorsOdontogenic Tumors
Odontogenic TumorsOdontogenic Tumors
Epithelial TypesEpithelial Types
Ameloblastoma
-- Conventional ameloblastoma
-- Unicy...
Odontogenic TumorsOdontogenic Tumors
Mixed Epithelial/Mesenchymal TypesMixed Epithelial/Mesenchymal Types
Ameloblastic fib...
Odontogenic TumorsOdontogenic Tumors
Ectomesenchymal TypesEctomesenchymal Types
Central Odontogenic
Fibroma
Peripheral Odo...
AmeloblastomaAmeloblastoma
AmeloblastomaAmeloblastoma
Benign neoplasm of preameloblasts
-- Epithelial rests of dental lamina
-- Basal cells of alveol...
AmeloblastomaAmeloblastoma
Radiographic/Clinical FeaturesRadiographic/Clinical Features
Multilocular (soap bubble)
radiolu...
AmeloblastomaAmeloblastoma
Radiographic FeaturesRadiographic Features
May extend far into ramus
May fill maxillary sinus
M...
AmeloblastomaAmeloblastoma
AmeloblastomaAmeloblastoma
Radiographic FeaturesRadiographic Features
Often associated with crown of unerupted tooth
Often...
AmeloblastomaAmeloblastoma
HistopathologyHistopathology
Islands of odontogenic epithelium
Peripheral palisading cells
-- V...
AmeloblastomaAmeloblastoma
Histopathologic SubtypesHistopathologic Subtypes
Follicular type
-- Most common type
-- Islands...
AmeloblastomaAmeloblastoma
Histopathologic SubtypesHistopathologic Subtypes
Acanthomatous type
-- Squamous epithelium in c...
AmeloblastomaAmeloblastoma
Treatment & PrognosisTreatment & Prognosis
Enucleation: >50% recurrence rate
En bloc resection:...
AmeloblastomaAmeloblastoma
VariantsVariants
Unicystic ameloblastoma
-- Intraluminal ameloblastoma
-- Mural ameloblastoma
P...
AmeloblastomaAmeloblastoma
VariantsVariants
Unicystic ameloblastoma
-- Intraluminal ameloblastoma
-- Mural ameloblastoma
P...
Unicystic AmeloblastomaUnicystic Ameloblastoma
15% of all ameloblastomas
Degenerated “ basket weave” cyst lining
Unilocula...
Peripheral AmeloblastomaPeripheral Ameloblastoma
Extraosseous AmeloblastomaExtraosseous Ameloblastoma
1% of all ameloblast...
DesmoplasticDesmoplastic
AmeloblastomaAmeloblastoma
Dense fibrous stroma
-- Transforming growth factor ß
“Squished” epithe...
AmeloblastomaAmeloblastoma
Malignant VariantsMalignant Variants
AmeloblasticAmeloblastic
CarcinomaCarcinoma
Cells are dysplastic
Metastizes
May look like salivary
adenocarcinoma
Malignant AmeloblastomaMalignant Ameloblastoma
Cells look benign
Metastasizes
Caution: this is not same
as aspiration of
a...
AmeloblasticAmeloblastic
FibromaFibroma
Ameloblastic FibromaAmeloblastic Fibroma
Juvenile AmeloblastomaJuvenile Ameloblastoma
Benign neoplasm
-- Epithelial & mese...
Ameloblastic FibromaAmeloblastic Fibroma
Asymptomatic
Usually multilocular radiolucency
-- No calcifications centrally
Wel...
Ameloblastic FibromaAmeloblastic Fibroma
Primitive mesenchymal
tissues
-- Immature stroma
-- Large, stellate, spindled
nuc...
Ameloblastic FibromaAmeloblastic Fibroma
With AmeloblastomaWith Ameloblastoma--Like IslandsLike Islands
Hyaline InductionH...
Ameloblastic FibromaAmeloblastic Fibroma
Treatment & PrognosisTreatment & Prognosis
May become very large
Conservative sur...
AmeloblasticAmeloblastic
FibrosarcomaFibrosarcoma
AmeloblasticAmeloblastic
FibrosarcomaFibrosarcoma
Stroma shows malignancy
Epithelial islands OK
Behaves like fibrosarcoma
AmeloblasticAmeloblastic
FibroFibro--OdontomaOdontoma
Enamel and dentin structures
May be early stage of odontoma
May become very large
Radiolucent background
Globular opacitie...
Ameloblastic FibroAmeloblastic Fibro--OdontomaOdontoma
©Photo: WESTOP, Dr. Beatriz Aldape, National University of Mexico, ...
AmeloblasticAmeloblastic
FibroFibro--OdontomaOdontoma
©Photo: WESTOP, Dr. Beatriz Aldape, National University of Mexico, M...
AdenomatoidAdenomatoid
Odontogenic TumorOdontogenic Tumor
AdenomatoidAdenomatoid
Odontogenic TumorOdontogenic Tumor
AOT; AdenoameloblastomaAOT; Adenoameloblastoma
Benign neoplasm
-...
Adenomatoid Odontogenic TumorAdenomatoid Odontogenic Tumor
AOT; AdenoameloblastomaAOT; Adenoameloblastoma
Unilocular radio...
Adenomatoid Odontogenic TumorAdenomatoid Odontogenic Tumor
Adenomatoid OdontogenicAdenomatoid Odontogenic
TumorTumor
HistopathologyHistopathology
Spindle-shaped epithelial cells
-- ...
Adenomatoid OdontogenicAdenomatoid Odontogenic
TumorTumor
HistopathologyHistopathology
Dystrophic calcification
Amyloid
Th...
Adenomatoid Odontogenic TumorAdenomatoid Odontogenic Tumor
Treatment & Special VariantsTreatment & Special Variants
Treat:...
Calcifying EpithelialCalcifying Epithelial
Odontogenic TumorOdontogenic Tumor
Calcifying EpithelialCalcifying Epithelial
Odontogenic TumorOdontogenic Tumor
CEOT; Pindborg TumorCEOT; Pindborg Tumor
Ben...
Calcifying Epithelial Odontogenic TumorCalcifying Epithelial Odontogenic Tumor
CEOT; Pindborg TumorCEOT; Pindborg Tumor
We...
Calcifying EpithelialCalcifying Epithelial
Odontogenic TumorOdontogenic Tumor
HistopathologyHistopathology
Islands, cluste...
Calcifying EpithelialCalcifying Epithelial
Odontogenic TumorOdontogenic Tumor
HistopathologyHistopathology
Masses of hyali...
Calcifying EpithelialCalcifying Epithelial
Odontogenic TumorOdontogenic Tumor
TreatmentTreatment
Less aggressive than amel...
Peripheral Pindborg Tumor
Peripheral CEOT
Attached gingiva
Anterior region
May erode bone
-- Saucerization
Low biological ...
OdontomaOdontoma
OdontomaOdontoma
Complex Odontoma; Compound OdontomaComplex Odontoma; Compound Odontoma
Developmental hamartoma
-- Maybe b...
OdontomaOdontoma
Complex Odontoma;Complex Odontoma;
Compound OdontomaCompound Odontoma
Well-demarcated radiolucency
-- Wit...
OdontomaOdontoma
Complex Odontoma; Compound OdontomaComplex Odontoma; Compound Odontoma
Complex odontoma
-- Unorganized ca...
Compound OdontomaCompound Odontoma
Compound OdontomaCompound Odontoma
Cystic OdontomaCystic Odontoma
Complex OdontomaComplex Odontoma
May interfere with eruptionMay interfere with eruption
OdontomaOdontoma
HistopathologyHistopathology
Mature fibrous stoma
Containing irregular masses of
dentin with areas of ena...
OdontomaOdontoma
TreatmentTreatment
Usually “burn out”
May become huge
Enucleation/curettage
No recurrence
A Kick in the OlA Kick in the Ol’’ OdontomaOdontoma
Is this a good way to treat an odontoma?!!Is this a good way to treat ...
OdontoOdonto--
AmeloblastomaAmeloblastoma
OdontoameloblastomaOdontoameloblastoma
Collision Tumor: Ameloblastoma & OdontomaCollision Tumor: Ameloblastoma & Odontoma
OdontogenicOdontogenic
MyxomaMyxoma
Odontogenic MyxomaOdontogenic Myxoma
Benign neoplasm
-- Of odontogenic ectomesenchyme
GAL:
-- None
-- Second - fourth deca...
Odontogenic MyxomaOdontogenic Myxoma
Multilocular radiolucency
-- Occasionally unilocular
(Especially odontogenic fibromyx...
OdontogenicOdontogenic
MyxomaMyxoma
Odontogenic MyxomaOdontogenic Myxoma
HistopathologyHistopathology
Background fibromyxoid stroma
Rather acellular, with few...
OdontogenicOdontogenic
MyxofibromaMyxofibroma
Teenagers
Around crown of impacted tooth
Much less aggressive than routine m...
Odontogenic MyxomaOdontogenic Myxoma
Treatment & PrognosisTreatment & Prognosis
May be locally aggressive
-- Does not meta...
OdontogenicOdontogenic
FibromaFibroma
Odontogenic FibromaOdontogenic Fibroma
Benign neoplasm
-- Odontogenic mesenchymal cells
GALP:
-- Females
-- Second - fourt...
Odontogenic FibromaOdontogenic Fibroma
Well-demarcated radiolucency
Usually unilocular
-- Larger: often multilocular
Often...
Odontogenic FibromaOdontogenic Fibroma
HistopathologyHistopathology
Background stroma:
-- Mature fibrous tissue
Stellate a...
Odontogenic FibromaOdontogenic Fibroma
Treatment and Special VariantsTreatment and Special Variants
Enucleation or curetta...
CementoblastomaCementoblastoma
CementoblastomaCementoblastoma
Benign CementoblastomaBenign Cementoblastoma
Benign neoplasm of cementum
Attached to tooth
...
CementoblastomaCementoblastoma
Benign CementoblastomaBenign Cementoblastoma
Enlargement of root apex
Rounded or irregular ...
CementoblastomaCementoblastoma
HistopathologyHistopathology
Cementoid or osseous calcified masses
Background stroma of fib...
CementoblastomaCementoblastoma
Treatment; PathophysiologyTreatment; Pathophysiology
May become 7 cm across
Destroys root; ...
Central CementifyingCentral Cementifying
FibromaFibroma
Central Cementifying FibromaCentral Cementifying Fibroma
Odontogenic or bone tumor?
Benign tumor of alveolus
Teens to 35 y...
CentralCentral
Cementifying FibromaCementifying Fibroma
Early lesionEarly lesion
Late lesionLate lesion
Classification ofClassification of
Odontogenic CystsOdontogenic Cysts
Odontogenic CystsOdontogenic Cysts
Dentigerous Cyst
-- Eruption Cyst
Primordial Cyst
Lateral Periodontal Cyst
Buccal Bifur...
Dentigerous CystDentigerous Cyst
Dentigerous CystDentigerous Cyst
Usually developmental
Maybe: from inflammation
Cleft in reduced enamel epithelium
Separat...
Dentigerous CystDentigerous Cyst
Clinical FeaturesClinical Features
Well-demarcated radiolucency
Usually: unilocular
Often...
Dentigerous Cyst or Not?Dentigerous Cyst or Not?
The 1.5 mm. ruleThe 1.5 mm. rule
Dentigerous CystDentigerous Cyst
Once Called Cystic CarcinomaOnce Called Cystic Carcinoma
Multiple Dentigerous CystsMultiple Dentigerous Cysts
Worry About Gorlin SyndromeWorry About Gorlin Syndrome
Dentigerous CystDentigerous Cyst
HistopathologyHistopathology
Atrophic stratified squamous epithelial lining
-- Usually pa...
Dentigerous CystDentigerous Cyst
HistopathologyHistopathology
Cholesterol granuloma:
-- Cholesterol clefts
-- Foreign body...
Dentigerous CystDentigerous Cyst
Treatment; PathophysiologyTreatment; Pathophysiology
Enucleation
-- Maybe: extraction
-- ...
OrthokeratinizingOrthokeratinizing
Odontogenic CystOdontogenic Cyst
OrthokeratinizingOrthokeratinizing
Odontogenic CystOdontogenic Cyst
Parakeratinizing OdontogenicParakeratinizing Odontogen...
Eruption CystEruption Cyst
Eruption CystEruption Cyst
Eruption Hematoma; Dentigerous CystEruption Hematoma; Dentigerous Cyst
Dentigerous cyst of erup...
Eruption CystEruption Cyst
Eruption Hematoma; Dentigerous CystEruption Hematoma; Dentigerous Cyst
Cortex completely missin...
Eruption CystEruption Cyst
Dentigerous CystDentigerous Cyst
OdontogenicOdontogenic
KeratocystKeratocyst
Odontogenic KeratocystOdontogenic Keratocyst
Developmental cystic degeneration
-- Of odontogenic epithelial rests
-- Somet...
Odontogenic KeratocystOdontogenic Keratocyst
Clinical FeaturesClinical Features
Well-demarcated radiolucency
Multilocular ...
Odontogenic KeratocystOdontogenic Keratocyst
Odontogenic KeratocystOdontogenic Keratocyst
May be hazy opacity if in sinus; May become inflamedMay be hazy opacity if in...
Odontogenic KeratocystOdontogenic Keratocyst
Clinical SubtypesClinical Subtypes
Dentigerous cyst type
Primordial cyst type...
Odontogenic KeratocystOdontogenic Keratocyst
HistopathologyHistopathology
Uniform 4-7 cell thickness
Loss of rete ridges/p...
Odontogenic KeratocystOdontogenic Keratocyst
Histopathology
Fibrous/fibromyxomatous stroma
Often: islands of benign
odonto...
Odontogenic KeratocystOdontogenic Keratocyst
Loss of Classical Microscopic Features in Inflamed Area
Odontogenic KeratocystOdontogenic Keratocyst
Treatment; Special ProblemsTreatment; Special Problems
Enucleation and curett...
Gorlin SyndromeGorlin Syndrome
Gorlin SyndromeGorlin Syndrome
Nevoid Basal Cell Carcinoma SyndromeNevoid Basal Cell Carcinoma Syndrome
Mutation of PATCH ...
Gorlin SyndromeGorlin Syndrome
Nevoid Basal Cell Carcinoma SyndromeNevoid Basal Cell Carcinoma Syndrome
Frontal bossing
Pa...
Gorlin CystGorlin Cyst
Calcifying Odontogenic Cyst
Gorlin Cyst; COC
Cross between:
-- Developmental cyst
-- Benign neoplasm
GAL:
-- None
-- Anter...
Calcifying Odontogenic Cyst
Clinical Features
Unilocular radiolucency
-- May be multilocular
Well-demarcated borders
-- Of...
The Original Gorlin CystThe Original Gorlin Cyst
Calcifying Odontogenic CystCalcifying Odontogenic Cyst
©Photos: Dr. R. J....
Calcifying Odontogenic
Cyst
Histopathology
Stratified squamous epithelium
lining
Fibrous stroma
Abundant keratin productio...
Calcifying Odontogenic Cyst
Special Cases
Peripheral Gorlin cyst
-- Attached gingiva
-- Not aggressive
-- May represent 30...
Calcifying Odontogenic
Cyst
Treatment & PrognosisTreatment & Prognosis
Enucleation for smaller lesions
Some recurrences
Mo...
Gingival Cyst ofGingival Cyst of
NewbornNewborn
Gingival Cyst of NewbornGingival Cyst of Newborn
Epstein Pearls; Bohn NodulesEpstein Pearls; Bohn Nodules
Developmental cy...
Gingival Cyst ofGingival Cyst of
NewbornNewborn
Clinical FeaturesClinical Features
Small, superficial whitish blebs
Single...
Gingival Cyst of NewbornGingival Cyst of Newborn
Histopathology and TreatmentHistopathology and Treatment
Cyst lining of s...
Gingival Cyst of AdultGingival Cyst of Adult
Gingival Cyst of AdultGingival Cyst of Adult
Developmental, degenerative cyst
-- Rests of Serres in gingival stroma
GAL:
-...
Gingival Cyst of AdultGingival Cyst of Adult
Clinical FeaturesClinical Features
Painless mass of attached gingiva
Dome-sha...
Gingival Cyst of AdultGingival Cyst of Adult
Histopathology; TreatmentHistopathology; Treatment
Stratified squamous epithe...
Lateral PeriodontalLateral Periodontal
CystCyst
Lateral Periodontal CystLateral Periodontal Cyst
Developmental
-- Cystic degeneration of
odontogenic epithelial rests
GALP...
Lateral Periodontal CystLateral Periodontal Cyst
Clinical FeaturesClinical Features
Asymptomatic
Teeth are viable
Center: ...
Lateral Periodontal CystLateral Periodontal Cyst
HistopathologyHistopathology
Cyst with clear fluid in lumen
-- Lumen is e...
Lateral Periodontal CystLateral Periodontal Cyst
TreatmentTreatment
Enucleation
Small recurrence rate
Caution! Make sure i...
Botryoid Lateral Periodontal CystBotryoid Lateral Periodontal Cyst
Clinical FeaturesClinical Features
Multilocular radiolu...
Buccal BifurcationBuccal Bifurcation
CystCyst
Buccal Bifurcation CystBuccal Bifurcation Cyst
Inflammatory stimulation of
epithelial rests
Always: in furcation region of...
Buccal Bifurcation CystBuccal Bifurcation Cyst
Asymptomatic or tender
Poorly demarcated
furcation radiolucency
Without per...
Buccal Bifurcation CystBuccal Bifurcation Cyst
Degenerated stratified squam. epithelium
Focally edematous fibrous stroma
N...
Oral and Maxillofacial Pathology , Radiology
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Oral and Maxillofacial Pathology , Radiology

  1. 1. BouquotBouquot’’s Desks Desk Circa 1971Circa 1971
  2. 2. The BouquotsThe Bouquots 19811981
  3. 3. Oral & Maxillofacial Pathology IIOral & Maxillofacial Pathology II DB 3702DB 3702 Thursdays, 10:00 – 11:50 am Room DB 132 Course Director: Dr. J. E. BouquotCourse Director: Dr. J. E. Bouquot Room 3.094b; 713Room 3.094b; 713--500500--44204420 Jerry.Bouquot@uth.tmc.eduJerry.Bouquot@uth.tmc.edu Topic: Odontogenic Tumors and CystsTopic: Odontogenic Tumors and Cysts
  4. 4. Cells & TissuesCells & Tissues of Originof Origin
  5. 5. Ameloblasts v. PreameloblastsAmeloblasts v. Preameloblasts Preameloblasts Preameloblasts EnamelEnamel AmeloblastsAmeloblasts OdontoblastsOdontoblasts Stellate ReticulumStellate Reticulum Dental PapillaDental Papilla
  6. 6. Classification ofClassification of Odontogenic TumorsOdontogenic Tumors
  7. 7. Odontogenic TumorsOdontogenic Tumors Epithelial TypesEpithelial Types Ameloblastoma -- Conventional ameloblastoma -- Unicystic ameloblastoma -- Peripheral ameloblastoma Malignant ameloblastoma Ameloblastic carcinoma Clear cell odontogenic carcinoma Adenomatoid odontogenic tumor Calcifying epithelial odontogenic tumor Squamous odontogenic tumor AmeloblastomaAmeloblastoma AmeloblastomaAmeloblastoma
  8. 8. Odontogenic TumorsOdontogenic Tumors Mixed Epithelial/Mesenchymal TypesMixed Epithelial/Mesenchymal Types Ameloblastic fibroma Ameloblastic fibro-odontoma Ameloblastic fibrosarcoma Odontoameloblastoma Odontoma Ameloblastic FibromaAmeloblastic Fibroma Ameloblastic FibromaAmeloblastic Fibroma Compound OdontomaCompound Odontoma
  9. 9. Odontogenic TumorsOdontogenic Tumors Ectomesenchymal TypesEctomesenchymal Types Central Odontogenic Fibroma Peripheral Odontogenic Fibroma Granular Cell Odontogenic Tumor Odontogenic Myxoma Cementoblastoma CementoblastomaCementoblastoma Odontogenic MyxomaOdontogenic Myxoma
  10. 10. AmeloblastomaAmeloblastoma
  11. 11. AmeloblastomaAmeloblastoma Benign neoplasm of preameloblasts -- Epithelial rests of dental lamina -- Basal cells of alveolar mucosa -- Cyst lining epithelium GALP: -- None -- Any age, usually 30-50 years -- Posterior mandible -- Most common of “aggressive” odontogenic tumors PreameloblastsPreameloblasts
  12. 12. AmeloblastomaAmeloblastoma Radiographic/Clinical FeaturesRadiographic/Clinical Features Multilocular (soap bubble) radiolucency -- May be unilocular Well demarcated borders Expands, thins cortex Asymptomatic
  13. 13. AmeloblastomaAmeloblastoma Radiographic FeaturesRadiographic Features May extend far into ramus May fill maxillary sinus May be huge
  14. 14. AmeloblastomaAmeloblastoma
  15. 15. AmeloblastomaAmeloblastoma Radiographic FeaturesRadiographic Features Often associated with crown of unerupted tooth Often resorbs adjacent roots May push roots aside May push whole tooth
  16. 16. AmeloblastomaAmeloblastoma HistopathologyHistopathology Islands of odontogenic epithelium Peripheral palisading cells -- Vacuoles toward basement membrane --Preameloblasts Center: stellate reticulum Mature fibrous stroma Often cystic degeneration
  17. 17. AmeloblastomaAmeloblastoma Histopathologic SubtypesHistopathologic Subtypes Follicular type -- Most common type -- Islands resemble tooth buds Plexiform type -- Intertwining strands of epithelial cells
  18. 18. AmeloblastomaAmeloblastoma Histopathologic SubtypesHistopathologic Subtypes Acanthomatous type -- Squamous epithelium in center Granular cell type -- Histiocyte-like cells -- Granular cytoplasm Basal cell type -- Like basal cell carcinoma
  19. 19. AmeloblastomaAmeloblastoma Treatment & PrognosisTreatment & Prognosis Enucleation: >50% recurrence rate En bloc resection: <15% recurrence rate ↑ Cystic > ↑ prognosis Main problem: local destruction -- May invade through base of skull -- May wrap around neck structures Rarely: piece breaks off @ surgery: aspirated -- Ameloblastoma grows in bronchial tree
  20. 20. AmeloblastomaAmeloblastoma VariantsVariants Unicystic ameloblastoma -- Intraluminal ameloblastoma -- Mural ameloblastoma Peripheral ameloblastoma -- Extraosseous ameloblastoma Desmoplastic ameloblastoma Ameloblastic carcinoma Malignant ameloblastoma
  21. 21. AmeloblastomaAmeloblastoma VariantsVariants Unicystic ameloblastoma -- Intraluminal ameloblastoma -- Mural ameloblastoma Peripheral ameloblastoma -- Extraosseous ameloblastoma Desmoplastic ameloblastoma Ameloblastic carcinoma Malignant ameloblastoma
  22. 22. Unicystic AmeloblastomaUnicystic Ameloblastoma 15% of all ameloblastomas Degenerated “ basket weave” cyst lining Unilocular radiolucency only Resembles dentigerous cyst Younger persons -- Avg. age = 23 years Much less aggressive than regular ameloblastoma
  23. 23. Peripheral AmeloblastomaPeripheral Ameloblastoma Extraosseous AmeloblastomaExtraosseous Ameloblastoma 1% of all ameloblastomas Same histology as internal ameloblastoma Mass on gingiva -- Sessile -- Asymptomatic Minimal growth potential -- < 1 cm. diameter May cup out underlying cortex -- Saucerization Conservative surgical removal Almost no recurrence rate
  24. 24. DesmoplasticDesmoplastic AmeloblastomaAmeloblastoma Dense fibrous stroma -- Transforming growth factor ß “Squished” epithelial islands Mixed radiolucent/radiopaque -- From bone stimulation Moth-eaten radiolucency Usually not multilocular Maybe less aggressive than regular ameloblastoma
  25. 25. AmeloblastomaAmeloblastoma Malignant VariantsMalignant Variants
  26. 26. AmeloblasticAmeloblastic CarcinomaCarcinoma Cells are dysplastic Metastizes May look like salivary adenocarcinoma
  27. 27. Malignant AmeloblastomaMalignant Ameloblastoma Cells look benign Metastasizes Caution: this is not same as aspiration of ameloblastoma cells!
  28. 28. AmeloblasticAmeloblastic FibromaFibroma
  29. 29. Ameloblastic FibromaAmeloblastic Fibroma Juvenile AmeloblastomaJuvenile Ameloblastoma Benign neoplasm -- Epithelial & mesenchymal origin GAL: -- None -- First two decades of life -- Posterior mandible
  30. 30. Ameloblastic FibromaAmeloblastic Fibroma Asymptomatic Usually multilocular radiolucency -- No calcifications centrally Well demarcated -- Often: thin sclerotic rim Usually associated with crown of unerupted tooth May expand cortex Can move teeth
  31. 31. Ameloblastic FibromaAmeloblastic Fibroma Primitive mesenchymal tissues -- Immature stroma -- Large, stellate, spindled nuclei -- Mild/Moderate cellularity Double-layered strands of cuboidal odontogenic epithelium Ameloblastoma-like islands
  32. 32. Ameloblastic FibromaAmeloblastic Fibroma With AmeloblastomaWith Ameloblastoma--Like IslandsLike Islands Hyaline InductionHyaline Induction
  33. 33. Ameloblastic FibromaAmeloblastic Fibroma Treatment & PrognosisTreatment & Prognosis May become very large Conservative surgical removal or curettage 40% risk of recurrence
  34. 34. AmeloblasticAmeloblastic FibrosarcomaFibrosarcoma
  35. 35. AmeloblasticAmeloblastic FibrosarcomaFibrosarcoma Stroma shows malignancy Epithelial islands OK Behaves like fibrosarcoma
  36. 36. AmeloblasticAmeloblastic FibroFibro--OdontomaOdontoma
  37. 37. Enamel and dentin structures May be early stage of odontoma May become very large Radiolucent background Globular opacities centrally Perhaps: tooth-like shapes Ameloblastic FibroAmeloblastic Fibro--OdontomaOdontoma
  38. 38. Ameloblastic FibroAmeloblastic Fibro--OdontomaOdontoma ©Photo: WESTOP, Dr. Beatriz Aldape, National University of Mexico, Mexico City, Mexico
  39. 39. AmeloblasticAmeloblastic FibroFibro--OdontomaOdontoma ©Photo: WESTOP, Dr. Beatriz Aldape, National University of Mexico, Mexico City, Mexico
  40. 40. AdenomatoidAdenomatoid Odontogenic TumorOdontogenic Tumor
  41. 41. AdenomatoidAdenomatoid Odontogenic TumorOdontogenic Tumor AOT; AdenoameloblastomaAOT; Adenoameloblastoma Benign neoplasm -- Reduced enamel epithelium -- Maybe it’s a hamartoma GAL: -- Female -- Second decade -- Anterior maxilla -- 5% of all odontogenic tumors Reduced enamelReduced enamel epitheliumepithelium
  42. 42. Adenomatoid Odontogenic TumorAdenomatoid Odontogenic Tumor AOT; AdenoameloblastomaAOT; Adenoameloblastoma Unilocular radiolucency Often: thin sclerotic rim Well-demarcated periphery May expand cortex Eventually globular radiopacities -- Or small “snowflake” opacities Asymptomatic Around crown of impacted tooth Interferes with eruption 1-2 cm. in size
  43. 43. Adenomatoid Odontogenic TumorAdenomatoid Odontogenic Tumor
  44. 44. Adenomatoid OdontogenicAdenomatoid Odontogenic TumorTumor HistopathologyHistopathology Spindle-shaped epithelial cells -- Form sheets and strands Whorled masses and rosette structures Ductal structures -- Peripheral palisading -- Polarization of nuclei toward the basement membrane
  45. 45. Adenomatoid OdontogenicAdenomatoid Odontogenic TumorTumor HistopathologyHistopathology Dystrophic calcification Amyloid Thin fibrous capsule
  46. 46. Adenomatoid Odontogenic TumorAdenomatoid Odontogenic Tumor Treatment & Special VariantsTreatment & Special Variants Treat: Surgical curettage Almost no recurrence risk Variant: Peripheral AOT -- Very mild behavior -- Like fibroma -- On gingiva -- No recurrence
  47. 47. Calcifying EpithelialCalcifying Epithelial Odontogenic TumorOdontogenic Tumor
  48. 48. Calcifying EpithelialCalcifying Epithelial Odontogenic TumorOdontogenic Tumor CEOT; Pindborg TumorCEOT; Pindborg Tumor Benign, aggressive neoplasm Tooth bud cells -- Probably stellate reticulum GALP: -- None -- 30-50 years -- Posterior mandible -- < 1% of all odontogenic tumors
  49. 49. Calcifying Epithelial Odontogenic TumorCalcifying Epithelial Odontogenic Tumor CEOT; Pindborg TumorCEOT; Pindborg Tumor Well-demarcated radiolucency -- Unilocular or multilocular Often: globular calcified opacities Frequently associated with crown of impacted tooth Asymptomatic Expands cortex
  50. 50. Calcifying EpithelialCalcifying Epithelial Odontogenic TumorOdontogenic Tumor HistopathologyHistopathology Islands, clusters, strands of polyhedral epithelial cells Often: intercellular bridges Often: large and dysplastic-looking cells -- Not true dysplasia -- No mitotic activity Background fibrous stroma Globular calcifications with Liesegang rings (onion skinning)
  51. 51. Calcifying EpithelialCalcifying Epithelial Odontogenic TumorOdontogenic Tumor HistopathologyHistopathology Masses of hyalinized material -- Amyloid -- Congo red -- Thioflavin T immunostaining
  52. 52. Calcifying EpithelialCalcifying Epithelial Odontogenic TumorOdontogenic Tumor TreatmentTreatment Less aggressive than ameloblastoma --But may be aggressive locally Conservative local resection -- Narrow rim of normal bone 15% recurrence rate
  53. 53. Peripheral Pindborg Tumor Peripheral CEOT Attached gingiva Anterior region May erode bone -- Saucerization Low biological behavior Tumor may be attached to surface epithelium
  54. 54. OdontomaOdontoma
  55. 55. OdontomaOdontoma Complex Odontoma; Compound OdontomaComplex Odontoma; Compound Odontoma Developmental hamartoma -- Maybe benign neoplasm GALP: -- None -- First two decades of life -- Compound variant = anterior maxilla -- Complex variant = molar regions (both jaws) -- Most common odontogenic tumor
  56. 56. OdontomaOdontoma Complex Odontoma;Complex Odontoma; Compound OdontomaCompound Odontoma Well-demarcated radiolucency -- With irregular or tooth-like opacities Thin sclerotic rimming Asymptomatic Usually associated with crown of unerupted tooth Prevents eruption
  57. 57. OdontomaOdontoma Complex Odontoma; Compound OdontomaComplex Odontoma; Compound Odontoma Complex odontoma -- Unorganized calcified tooth-related tissues Compound odontoma -- Tooth-like structures are present Combined odontoma -- Mixture of complex and compound Cystic odontoma -- In wall of dentigerous cyst
  58. 58. Compound OdontomaCompound Odontoma
  59. 59. Compound OdontomaCompound Odontoma
  60. 60. Cystic OdontomaCystic Odontoma
  61. 61. Complex OdontomaComplex Odontoma May interfere with eruptionMay interfere with eruption
  62. 62. OdontomaOdontoma HistopathologyHistopathology Mature fibrous stoma Containing irregular masses of dentin with areas of enamel matrix Cementum and pulp tissue Masses may be tooth-like Encapsulated
  63. 63. OdontomaOdontoma TreatmentTreatment Usually “burn out” May become huge Enucleation/curettage No recurrence
  64. 64. A Kick in the OlA Kick in the Ol’’ OdontomaOdontoma Is this a good way to treat an odontoma?!!Is this a good way to treat an odontoma?!!
  65. 65. OdontoOdonto-- AmeloblastomaAmeloblastoma
  66. 66. OdontoameloblastomaOdontoameloblastoma Collision Tumor: Ameloblastoma & OdontomaCollision Tumor: Ameloblastoma & Odontoma
  67. 67. OdontogenicOdontogenic MyxomaMyxoma
  68. 68. Odontogenic MyxomaOdontogenic Myxoma Benign neoplasm -- Of odontogenic ectomesenchyme GAL: -- None -- Second - fourth decades -- Rare Exclusively in the jaws -- There are soft tissue myxomas (e.g. cardiac myxoma)
  69. 69. Odontogenic MyxomaOdontogenic Myxoma Multilocular radiolucency -- Occasionally unilocular (Especially odontogenic fibromyxoma) Poorly or well-demarcated periphery Asymptomatic Expands and thins cortex Maybe: push teeth Maybe: resorb roots Often associated with crown of impacted tooth
  70. 70. OdontogenicOdontogenic MyxomaMyxoma
  71. 71. Odontogenic MyxomaOdontogenic Myxoma HistopathologyHistopathology Background fibromyxoid stroma Rather acellular, with few stellate or bipolar mesenchymal cells -- Similar to primitive pulp Not encapsulated If stroma is dysplastic: -- Odontogenic myxosarcoma
  72. 72. OdontogenicOdontogenic MyxofibromaMyxofibroma Teenagers Around crown of impacted tooth Much less aggressive than routine myxoma
  73. 73. Odontogenic MyxomaOdontogenic Myxoma Treatment & PrognosisTreatment & Prognosis May be locally aggressive -- Does not metastasize Small lesions: curettage Odontogenic myxofibroma: curettage Large lesions: resection with 0.5 cm. margins Odontogenic fibromyxosarcoma -- Radical surgery
  74. 74. OdontogenicOdontogenic FibromaFibroma
  75. 75. Odontogenic FibromaOdontogenic Fibroma Benign neoplasm -- Odontogenic mesenchymal cells GALP: -- Females -- Second - fourth decades of life -- Anterior maxilla and posterior mandible -- Rare
  76. 76. Odontogenic FibromaOdontogenic Fibroma Well-demarcated radiolucency Usually unilocular -- Larger: often multilocular Often surrounding crown of impacted tooth Asymptomatic May resorb roots May expand cortex May move teeth Caution! Must distinguish from hyperplastic dental follicle
  77. 77. Odontogenic FibromaOdontogenic Fibroma HistopathologyHistopathology Background stroma: -- Mature fibrous tissue Stellate and spindled fibroblasts Often with whorled pattern Stroma may be quite loose -- Like odontogenic myxoma Odontogenic epithelial rests Dystrophic calcifications -- Or cementum-like globules -- Or dentin-like globules Encapsulated
  78. 78. Odontogenic FibromaOdontogenic Fibroma Treatment and Special VariantsTreatment and Special Variants Enucleation or curettage Recurrence is rare Simple odontogenic fibroma -- Almost all fibrous -- Small epithelial islands -- Small dystrophic calcification WHO type of odontogenic fibroma -- Many epithelial islands -- Calcified globules Peripheral odontogenic fibroma -- Innocuous gingiva mass
  79. 79. CementoblastomaCementoblastoma
  80. 80. CementoblastomaCementoblastoma Benign CementoblastomaBenign Cementoblastoma Benign neoplasm of cementum Attached to tooth Bone counterpart: -- Osteoblastoma GALP: -- Female -- Second-fourth decades -- Mandibular molar -- Rare
  81. 81. CementoblastomaCementoblastoma Benign CementoblastomaBenign Cementoblastoma Enlargement of root apex Rounded or irregular radiopacity -- May be some radiolucency Well-demarcated Thin capsule, may be irregular -- Continuous with PDL Often: tender/painful May expand cortex
  82. 82. CementoblastomaCementoblastoma HistopathologyHistopathology Cementoid or osseous calcified masses Background stroma of fibrous tissue Cementoblasts/cementoclasts Encapsulated (PLD?)
  83. 83. CementoblastomaCementoblastoma Treatment; PathophysiologyTreatment; Pathophysiology May become 7 cm across Destroys root; tooth remains viable Maybe: pressure resorption of adjacent root Extraction Recurrences are rare
  84. 84. Central CementifyingCentral Cementifying FibromaFibroma
  85. 85. Central Cementifying FibromaCentral Cementifying Fibroma Odontogenic or bone tumor? Benign tumor of alveolus Teens to 35 years of age Asymptomatic Radiolucent background, globular radiopacities in center Gets more opaque over time Capsule around it Usually <3 cm. in size May expand cortex Histopathology: --Like cementoblastoma
  86. 86. CentralCentral Cementifying FibromaCementifying Fibroma Early lesionEarly lesion Late lesionLate lesion
  87. 87. Classification ofClassification of Odontogenic CystsOdontogenic Cysts
  88. 88. Odontogenic CystsOdontogenic Cysts Dentigerous Cyst -- Eruption Cyst Primordial Cyst Lateral Periodontal Cyst Buccal Bifurcation Cyst Odontogenic Keratocyst -- Gorlin Syndrome Orthokeratinized Odontogenic Cyst Gingival Cyst of the Newborn Gingival Cyst of the Adult Calcifying Odontogenic Cyst Glandular Odontogenic Cyst Odontogenic KeratocystOdontogenic Keratocyst Dentigerous CystDentigerous Cyst With rare exceptions, epithelium-lined cysts in bone are seen only in the jaws
  89. 89. Dentigerous CystDentigerous Cyst
  90. 90. Dentigerous CystDentigerous Cyst Usually developmental Maybe: from inflammation Cleft in reduced enamel epithelium Separation from crown Degenerated stellate reticulum GAL: -- None -- 10-30 years of age -- Third molar areas -- Especially mandible
  91. 91. Dentigerous CystDentigerous Cyst Clinical FeaturesClinical Features Well-demarcated radiolucency Usually: unilocular Often: thin sclerotic rimming Around crown, by definition Teeth can be pushed May: resorb roots Often: prevents eruption Three types -- Central -- Lateral -- Circumferential
  92. 92. Dentigerous Cyst or Not?Dentigerous Cyst or Not? The 1.5 mm. ruleThe 1.5 mm. rule
  93. 93. Dentigerous CystDentigerous Cyst Once Called Cystic CarcinomaOnce Called Cystic Carcinoma
  94. 94. Multiple Dentigerous CystsMultiple Dentigerous Cysts Worry About Gorlin SyndromeWorry About Gorlin Syndrome
  95. 95. Dentigerous CystDentigerous Cyst HistopathologyHistopathology Atrophic stratified squamous epithelial lining -- Usually parakeratin -- Maybe: mucus metaplasia Fibrous/fibromyxomatous stroma -- Often hyperplastic -- Maybe inflamed Attached at cervical region Maybe: ulcerated epithelial lining
  96. 96. Dentigerous CystDentigerous Cyst HistopathologyHistopathology Cholesterol granuloma: -- Cholesterol clefts -- Foreign body reaction -- Multinucleated giant cells Waldron type dentigerous cyst -- If reduced enamel epithelium -- If no epithelium Orthokeratinized odontogenic cyst
  97. 97. Dentigerous CystDentigerous Cyst Treatment; PathophysiologyTreatment; Pathophysiology Enucleation -- Maybe: extraction -- Maybe: orthodontic guidance Marsupialized (large lesions) Special Problems: -- Odontogenic keratocyst -- Carcinoma in epithelial lining -- Eruption cyst
  98. 98. OrthokeratinizingOrthokeratinizing Odontogenic CystOdontogenic Cyst
  99. 99. OrthokeratinizingOrthokeratinizing Odontogenic CystOdontogenic Cyst Parakeratinizing OdontogenicParakeratinizing Odontogenic KeratocystKeratocyst Usually dentigerous cyst Once thought to be a variant of odontogenic keratocyst -- But histology is different! Same biological behavior as dentigerous cyst
  100. 100. Eruption CystEruption Cyst
  101. 101. Eruption CystEruption Cyst Eruption Hematoma; Dentigerous CystEruption Hematoma; Dentigerous Cyst Dentigerous cyst of erupting tooth Blue or bluish-red color Cortex completely missing Fibrous stroma between epithelia No treatment needed -- Unless infected -- Tooth erupts normally May erupt into pericoronitis: -- Paradental cyst
  102. 102. Eruption CystEruption Cyst Eruption Hematoma; Dentigerous CystEruption Hematoma; Dentigerous Cyst Cortex completely missing -- Fibrous stroma between epithelia Blue or bluish-red color -- Maybe: clear fluid inside
  103. 103. Eruption CystEruption Cyst Dentigerous CystDentigerous Cyst
  104. 104. OdontogenicOdontogenic KeratocystKeratocyst
  105. 105. Odontogenic KeratocystOdontogenic Keratocyst Developmental cystic degeneration -- Of odontogenic epithelial rests -- Sometimes triggered by inflammation? GAL: -- None -- 10-40 years -- Posterior mandible -- Ramus
  106. 106. Odontogenic KeratocystOdontogenic Keratocyst Clinical FeaturesClinical Features Well-demarcated radiolucency Multilocular or unilocular Asymptomatic Often associated with crown of impacted tooth Seldom expands cortex, may thin it --Except: superior-inferior May become very large May push teeth May resorb roots, perforate cortex
  107. 107. Odontogenic KeratocystOdontogenic Keratocyst
  108. 108. Odontogenic KeratocystOdontogenic Keratocyst May be hazy opacity if in sinus; May become inflamedMay be hazy opacity if in sinus; May become inflamed
  109. 109. Odontogenic KeratocystOdontogenic Keratocyst Clinical SubtypesClinical Subtypes Dentigerous cyst type Primordial cyst type Lateral periodontal cyst type Periapical cyst type
  110. 110. Odontogenic KeratocystOdontogenic Keratocyst HistopathologyHistopathology Uniform 4-7 cell thickness Loss of rete ridges/processes Thin corrugated parakeratin layer Polarized basal cell nuclei Hyperchromatic basal cell nuclei Pulling away from basement membrane Orthokeratizing odontogenic cyst looks different!
  111. 111. Odontogenic KeratocystOdontogenic Keratocyst Histopathology Fibrous/fibromyxomatous stroma Often: islands of benign odontogenic epithelium Maybe: daughter cysts
  112. 112. Odontogenic KeratocystOdontogenic Keratocyst Loss of Classical Microscopic Features in Inflamed Area
  113. 113. Odontogenic KeratocystOdontogenic Keratocyst Treatment; Special ProblemsTreatment; Special Problems Enucleation and curettage -- Up to 62% recurrence -- Usually within 5 years Ostectomy/En bloc resection Hemimandibulectomy Chemical cauterization -- Carnoy’s solution Marsupialization (large lesions) Rare: carcinoma develops Problem: Gorlin syndrome
  114. 114. Gorlin SyndromeGorlin Syndrome
  115. 115. Gorlin SyndromeGorlin Syndrome Nevoid Basal Cell Carcinoma SyndromeNevoid Basal Cell Carcinoma Syndrome Mutation of PATCH (PTCH, patched) -- Tumor suppressor gene -- Chromosome 9q22.3-q31 Multiple keratocysts -- Often dentigerous cyst type -- May be huge Multiple basal cell carcinomas and nevi
  116. 116. Gorlin SyndromeGorlin Syndrome Nevoid Basal Cell Carcinoma SyndromeNevoid Basal Cell Carcinoma Syndrome Frontal bossing Palmar/plantar pits Bifid ribs Splayed ribs Fused ribs Missing ribs Calcified falx cerebri Spina bifida occulta
  117. 117. Gorlin CystGorlin Cyst
  118. 118. Calcifying Odontogenic Cyst Gorlin Cyst; COC Cross between: -- Developmental cyst -- Benign neoplasm GAL: -- None -- Anterior maxilla/mandible (65% of cases)
  119. 119. Calcifying Odontogenic Cyst Clinical Features Unilocular radiolucency -- May be multilocular Well-demarcated borders -- Often: thin sclerotic rimming Eventually: irregular radiopacities -- Or tooth-like structures Around crown of tooth -- 1/3 of cases Usually 2-4 cm. -- Maybe: much larger
  120. 120. The Original Gorlin CystThe Original Gorlin Cyst Calcifying Odontogenic CystCalcifying Odontogenic Cyst ©Photos: Dr. R. J. Gorlin, University of Minnesota, Minneapolis, Minnesota
  121. 121. Calcifying Odontogenic Cyst Histopathology Stratified squamous epithelium lining Fibrous stroma Abundant keratin production -- Eosinophilic ghost cells --Dystrophic calcification Basal cells might be cuboidal -- Look like preameloblasts Epithelium may proliferate -- Into lumen -- Into fibrous stroma
  122. 122. Calcifying Odontogenic Cyst Special Cases Peripheral Gorlin cyst -- Attached gingiva -- Not aggressive -- May represent 30% of total Epithelial odontogenic ghost cell tumor -- No cyst formation; solid tumor -- 2-14% of all “Gorlin cysts” -- More aggressive Gorlin cyst phenomenon Odontogenic ghost cell carcinoma -- Very rare -- 73% 5-year survival
  123. 123. Calcifying Odontogenic Cyst Treatment & PrognosisTreatment & Prognosis Enucleation for smaller lesions Some recurrences More solid = more aggressive Large/aggressive lesion: -- Resection
  124. 124. Gingival Cyst ofGingival Cyst of NewbornNewborn
  125. 125. Gingival Cyst of NewbornGingival Cyst of Newborn Epstein Pearls; Bohn NodulesEpstein Pearls; Bohn Nodules Developmental cyst -- Remnants of dental lamina 100+ tooth buds to create 32 teeth Prevalence: up to 50% of newborns GAL: -- None -- Congenital -- Alveolus -- Palate
  126. 126. Gingival Cyst ofGingival Cyst of NewbornNewborn Clinical FeaturesClinical Features Small, superficial whitish blebs Single or maybe dozens On posterior hard/soft palate: -- Epstein pearls -- Bohn nodules
  127. 127. Gingival Cyst of NewbornGingival Cyst of Newborn Histopathology and TreatmentHistopathology and Treatment Cyst lining of stratified squamous epithelium Lumen filled with sloughed keratin No treatment required -- Cysts rupture spontaneously within days -- May last until teeth erupt -- Cysts do not interfere with eruption
  128. 128. Gingival Cyst of AdultGingival Cyst of Adult
  129. 129. Gingival Cyst of AdultGingival Cyst of Adult Developmental, degenerative cyst -- Rests of Serres in gingival stroma GAL: -- None -- 40-60 years -- Attached gingiva (facial) -- Mandibular cuspid/premolar area (70% of cases)
  130. 130. Gingival Cyst of AdultGingival Cyst of Adult Clinical FeaturesClinical Features Painless mass of attached gingiva Dome-shaped (sessile) Fluctuant <.5 cm diameter Maybe: blue color Maybe: saucerization Round radiolucency -- Well demarcated
  131. 131. Gingival Cyst of AdultGingival Cyst of Adult Histopathology; TreatmentHistopathology; Treatment Stratified squamous epithelial cyst lining Dense fibrous stroma Lumen: filled with fluid or keratin Enucleation -- No recurrence
  132. 132. Lateral PeriodontalLateral Periodontal CystCyst
  133. 133. Lateral Periodontal CystLateral Periodontal Cyst Developmental -- Cystic degeneration of odontogenic epithelial rests GALP: -- None -- 40-70 years -- Mandibular premolar area (80% of all cases) -- <2% of all odontogenic cysts
  134. 134. Lateral Periodontal CystLateral Periodontal Cyst Clinical FeaturesClinical Features Asymptomatic Teeth are viable Center: inter-radicular bone -- Not periodontal ligament -- Midpoint halfway between premolars Well-demarcated radiolucency -- Unilocular Usually < 5 mm. diameter May push roots out of way Does not resorb roots
  135. 135. Lateral Periodontal CystLateral Periodontal Cyst HistopathologyHistopathology Cyst with clear fluid in lumen -- Lumen is empty on H&E slide Thin stratified squamous epithelium Focal epithelial nodules (unique!) -- Extend into lumen Seldom inflamed
  136. 136. Lateral Periodontal CystLateral Periodontal Cyst TreatmentTreatment Enucleation Small recurrence rate Caution! Make sure it’s not mental foramen! Caution! Must send for biopsy diagnosis -- Odontogenic keratocyst can have similar x-ray presentation
  137. 137. Botryoid Lateral Periodontal CystBotryoid Lateral Periodontal Cyst Clinical FeaturesClinical Features Multilocular radiolucency -- Like a grape cluster (”botryoid”) May be very large May be more aggressive Higher recurrence rate May require block resection
  138. 138. Buccal BifurcationBuccal Bifurcation CystCyst
  139. 139. Buccal Bifurcation CystBuccal Bifurcation Cyst Inflammatory stimulation of epithelial rests Always: in furcation region of mandibular molar GALP: -- None -- Middle-aged -- First mandibular molar area -- Rare
  140. 140. Buccal Bifurcation CystBuccal Bifurcation Cyst Asymptomatic or tender Poorly demarcated furcation radiolucency Without periodontal pocket Tooth is viable Sessile, moderately firm gingival mass -- Facing toward the facial -- < 8 mm. diameter
  141. 141. Buccal Bifurcation CystBuccal Bifurcation Cyst Degenerated stratified squam. epithelium Focally edematous fibrous stroma Numerous chronic inflammatory cells PMNs in and beneath epithelium Treat: Enucleation -- May have to extract tooth Caution! Check vitality of the tooth Caution Probe for periodontal pockets

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