Solitary cyst like radiolucencies not contacting teeth/ dental courses

Solitary cyst like radiolucencies
not contacting teeth
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
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introduction
• The termcyst likeradiolucency-a dark radiographic image
that is approximatelycircular in outline .And smoothly
contoured withwell defined borders .
• Occasionally they may be elliptical
• A thinhyperostotic border of bone may be present.

Solitary cyst like radiolucencies not necessarly contacting teeth
 Anatomic patterns
Marrow spaces
Maxillary sinus
Early stage of tooth crypt
Median sigmoid depression
 Post extraction socket
 Residual cyst
 Traumatic bone cyst

• Lingual mandibular bone cyst
• Odontogenickeratocyst
• Primordial cyst
• Ameloblastoma-unicystic
• Focal osteoporotic defect of the
jaws
• Surgical cyst
• Giant cell granuloma
• Giant cell lesion
• Focal cementoosseous
dysplasia
• Incisive canal cyst
• Mid palatine cyst
• Cementyfying and ossifying
fibroma (earlystage)
• Benign non odontogenic
tumors
• Rarities

Anatomic patterns
marrow spaces
• The patterns of marrow spaces vary fromperson to person and one
jaw to other of same person
• When marrowspaces are larger than normal ,rounded
radiolucencieswith hyperostotic borders andnot contacting teeth
they may be mistaken as cyst likeradiolucencies.
• These defectsare termed as osteoporotic bone marrowdefects.
• They occur frequently inmandibular molar area.
• M=f
• They are asymptomatic and similar patterns arepresent
contralaterally

Cyst like marrow spaces or focal
osteoporoticbone defect

Maxillary sinus
• Cyst like out pouching of maxillary sinus occurs on radiograph
of an edentulous upper jaw.
• This normal variation presents a difficulty in differentiation
frompathologic process.
• Radiographs fromdifferent angles shouldbe taken and
presence of large nutrient canals in the walls of the sinus aids
in its identification.

• The shape of the sinus may alter due to changes in patterns of
marrow spaces in response to altered function such as loss of
posterior teeth.
• Periodic radiographs and aspiration of air fromthe cavity
identifies it maxillary sinus.

A.Cyst like outpouching b.Cyst like
max.Sinus c.Large naso lacrimal duct

Early stage of tooth crypt
• The radiographic picture of tooth crypt in the earlystages of development
before calcification is round, smoothand well defined andthecrypt has
radiopaquerimas that of cyst.
• Thiscan be differentiated by periodic radiographs for approx. 6months.
• If radiolucent areais retarded developing teeththe initiationof
mineralisation atthecusp tips are soonfound.
• If no calcificationis detected within 6months to 1yr , the discontinuityin
the bone is mostlikelyprimordial cyst that began within theodontogenic
epithelium of the toothbud before calcification.

median sigmoid notch
• The radiolucent foramen like shadow is produced by an
osseous depression in some mandibles in the median portion
of the ramus just belowthe sigmiod notch area.
• The radiolucency may be unilateral or bilateral.

Post extraction socket
• The socket resembles a cyst likeradiolucency after an
extraction
• A recent extraction may be verified clinically by a depressed
area on the ridge .
• Periodic radiographic examination and surgical exploration of
the area and biopsy is indicated.
•

Extraction site 3yrs after tooth removal

Residual cyst
• A residual cyst is a radicular , lateral,dentigerous or another
cyst that has remained after its associated toothhas lost .
• Radiographs determines whether the cyst is present before
extraction or later developed in residual rests ofmalassez .
• Low grade inflammation of patent cyst might predispose it to
the formation of residual cyst..

RADIOGRAPHIC FEATURES
• location:Apical regions of the
tooth-bearing portion of the
jaws.
• Size: Variable, usually 2-3 cm in
diameter.
• Shape:— Round
— Monolocular.
• Outline:— Smooth
Well defined
—Usually well corticated
Radiodensity: radiolucent

• Effects on surrounding structures. Residual cysts can cause
tooth displacement orresorption. The outer cortical plates of
the jaws may expand.
The cyst mayinvaginate the maxillary antrumor depress the
inferior alveolar nerve canal.

Differential diagnosis
• Cyst like anatomic patterns
• Primordial cyst
• Keratocyst
• Traumatic bone cyst

management
• Completeenucleation
• Marsupilization
• Decompression with delayedenucleation

Traumatic bone cyst
• It idiopathic bone cavity, hemorrhagic bone cyst,extravastioncyst,
simple bone cyst, solitary bone cyst, progressive bone cyst, and
blood cyst
• It is classified as false cyst because it does not have an epithelial
lining.
• Cause –unknown
• Pts gives previous history of trauma
• They are asymptomatic
• It is located above themandibular canal and is usually roundto
oval with contoured well defined borders.

Radiographic features
• Site: — Mandible, particularly the
premolar/molar region.
— Rarely anterior maxilla.
• Size: Variable, up to several
centimetresin diameter
• •Shape: — Monolocular
• — Irregular, but the upper border
arches up betweenthe roots of the
teeth•
• Outline: — Smooth and
undulating
• — Moderately well defined
• — Moderately well or poorly
• corticated.
• • Radiodensity: Uniformly
radiolucent.
• • Effects: — Adjacent teeth —
minimal or no
• displacement, very rarely resorbed
• — Minimal or no expansionof the
jaw.

• Periapical cyst
• Medianmandibular cyst
• Periapical cementoosseous dysplasia
Management-
• Surgical exploration withcurretage

Lingual mandibular bone cyst or stafnebone cyst
• Other names-latent bone cyst or defect, developmental
submandibulargland defect of the mandible
• It is an invagination in the medial surface of mandibleusually
in the thirdmolar– angle area .
• The is causedby the mandible developing around the lobe of
submandibualrsalivary gland during embryonic life

• Location-inferior to the
mandibularcanal in the third
molar region
• Shape-round to oval to
semicircular
• Usuallyunilocular
• Radiodensity-The invagination
of lingualmandibular bone
defect is lined by smooth, dense
radioopaquerim

• Occasionally these defects are seen in anterior portion of the
mandible . These are also referred to as anterior lingual bone
defects
• Differentialdisgnosis
• When stafne cyst is small and situated in more superior
position in a region where the teeth are present or recently
been extracted may be mistaken asradicular or stafne cyst.

Odontogenic keratocyst
It is a cyst derived from the remnants(rests) of the dental
lamina, with a biological behaviour similar to a benign
neoplasm,
Definition:
OKC IS now designated by the WHO as akeratocystic
odontogenictumour and is defined as a “ benign uni or
multicystic, intraosseous tumour of odontogenic origin, witha
charecteristiclining of parakeratinized stratifiedsquamous
epitheliumand potential for aggressive, infiltrativebehaviour”

Clinical features
• Age: Second and thirddecades of life.
• Sex: Male to femaleratio 1.46:1.
• Site:Mandible(60 -80%).
Maxilla: third molar area- cuspid
region.
• Shape : Oval
mediolateral expansion.
• Frequency: 11%of all cysts.

• location: — Posterior
body/angle
• Anterior maxilla in canine
region.
• Size: Variable.
• Shape: — Oval, extending
along the body of the mandible
with littlemediolateral
expansion
• Outline: — Smooth
• — Well defined
• — Oftenwell corticated.
• Radiodensity. Uniformly
radiolucent.
• Effects: — Adjacent teeth—
minimal displacement, rarely
resorbed
• — Extensive expansionwithin
the cancellous bone.

• Dentigerouscyst
• Ameloblastoma
• Primordial cyst
• Residual cyst

Primordial cyst
• It is thought to develop as earlycystic degeneration in the tooth
germbeforemineralisation has been initiated.
• The radiographic picture is non specific , showing only a cyst
like radiolucenecy where the tooth hasnot developed.

features
• No genderprediliction
• Age-10 and30 yrs
• Location- mandibular molarregion especially3rd molar and the
area distal to it
• They cause cortical expansion
• On microscopic examination they are usually found to be
odontogenickerato cysts
• On aspiration a thick, yellowish , granular fluidcomposed
primarily of exfoliated cells and keratin.

Management
• Enucleation
• curettement

ameloblatoma
• Synonym: Adamantinoma
Adamantoblastoma
Multilocular cyst
“Unicentric, nonfunctional intermittent in growth,anatomicall
benign clinically persistent” ROBINSON
Second most common odontogenic neoplasm.

Clinical feature:
True neoplasmof Odontogenic epitheliumwhichis locallyinvasive ;it is
aggressive but has benign characteristics.
Age: between20 and 50 yrs
Sex: males
Location: Mandible molar-ramusregion
Maxilla: third molar area
Clinical presentation:
Slowgrowing mass, facial asymmetry
Teethmaybe displaced and become mobile.
Bonyexpansion
On palpation it may elicit a bony hard sensation or crepitus

It is a radiolucent lesionwhichis usuallywell-circumscribed; it may be unilocularor
multilocular(soapbubble , honeycomb) occasionallyan Ameloblastoma may be illdefined
Location: Molar ramusregionof the mandible
Thirdmolar areain maxilla
Periphery: Usuallywell defined
InternalStructure:Radiolucent to mixed with the presenceof bony septacreatinginternal
compartment.
These septaare oftenremodeled intocurvedshapesproviding a honeycomb or soapbubble
EffectsOn SurroundingStructures:
Root resorption .
Toothdisplacement.
Thinningof corticalplateleaving a thineggshell of bone.

Unilocular variety of ameloblastoma
Cropped image

Multilocular(honey-comb
appereance)
Multilocular (soap bubble
appeareance)

DIFFERENTIAL DIAGNOSIS
• Dentigerouscyst
• Odontogenickeratocyst
• Giant cell granuloma
• Odontogenicmyxoma
• Ossifyingfibroma

• Unicysticameloblastoma V/S okc & dentigerous cyst
Unicystic Ameloblastoma
Marked expansion along the
border
OKC: minimal expansion
Unicystic Ameloblastoma:
Larger the lesion more chances of a
tumor
Dentigerous Cyst: cannot be
differentiated without histologic
examination

Odontogenic myxoma:
Presence of one or two thin
stright septa(tennisracquet )
Giant Cell Granuloma:
Internal septa are very thin
and irregularly arranged
Ant to 1st molar
Ossifying Fibroma: internal
septa is granular n ill defined
with small irregular
trabeculae

Hyperparathyroidism
• It is an endocrine abnormality in whichthere is an excess of
PTH
• As a result it mobilizes calciumfromskeleton and increases
renal tubularreabsorption of calcium,the net result is increase
in the serumcalciumlevels
• Two types :
• Primary and secondary

PRIMARY HYPER PARATHYRIODISM
• Result froma benigntumor of one of the parathyroid gland.
• Hyperparathyroidism jawtumor syndrome
Involves the tumorsof parathyroid gland, jaws, and kidneys
the elevation of serumcalciumlevels and elevatedserumlevels of
PTH is a diagnostic of hyperparathyroism
Incidence is about 0.1%

SECONDARY
• Resultsfromcompensatoryincrease in output of PTHin responseto
hypocalcemia.
• Underlyinghypocalcemia may be resultfrominadequatedietaryintake,or
poorintestinal absorption.
• TERITIARY
• Parathyroid tumours develops after long standing secondary
hyperparathyroidism.

CLINICAL FINDINGS
• female predilection
• 30-60 age group
• Renal calculi, peptic ulcers ,bones and joint pains
• Gradual loosening and drifting of the teeth
• Serumalkalinephosphatase levels may also increase .

RADIOGRAPHIC FEATUERS
• Metastatic calcifications:
• ectopic calcifications is most common feature.
• Subperiosteal erosions:
• Erosions of bonephalanges .
• Lossof laminadura is a typeof subperiosteal erosion,
• osteitisfibrosa generalisata(cystica):
• refers to pattern of generalised rarefactionof bone.
• Bones may appear quite r/l withthin cortices and hazyindistinct
trabeculae.
• Some may lesshomogenous producemoth eaten appearance.

• Thinning of the cortical boundaries
• Density of the jaws is decreased
• The teeth stand out in contrast to theradolucent jaws
• The change in the normaltrabecular pattern that is
groundglassappereance
• Trabeculaeare numoerous small randomlyoriented
• Loss of laminadura
• May be partial or complete

Brown gaint cell lesions:
More common in sec hyperparathyroidism
Most common in mandibularmolar area.
 Develops in 10%of patients.
• Most common in jaws may cause r/l s that are central or peripheral
and unilocularor multilocular.
• Unilocular: cyst likeborders
borders indistinct
• Multi locular soap bubble appearance.
• the lesions may develop multiple with in a single bone.

R/G Picture of hyperparathyroidism-ground glass appearance

Loss of lamina dura and granular bone pattern

Granular bone pattern

Brown tumour in hyperparathyroidism

r/g of brown tumour

DIFFERENTIAL DIAGNOSIS OF BROWN
TUMOURS
• Unilocular:
post extraction socket
Primordial bone cyst, traumatic bone cyst, odontogenic cyst-
Serumchemistry is normal
Multilocular:
Paget's disease , ameloblastoma , CGCG, Cherubism,
Fibrous dysplasia, multiple myeloma.

• Primary hyperparathyroidism:
• inc level of serumcalcium.
• Serumphosphatase dec
• Serumalkalinephosphatase inc.
• Secondaryhyperparathyroidism:
• Serumcalciumlevels normal-
decrease
• Serumphosphatase-inc
• Serumalkaline phosphatase-inc

CENTRAL GIANT CELL GRANULOMA
• Synonyms
• Giant cell reparativegranuloma, giant cell lesion, and giant cell
tumor
• Definition:
• central giant cellgranuloma(CGCG) is thought to be a reactive
lesion to an as yet unknown stimulus and not aneoplastic
lesion.
• However, radiographically the characteristicsof the lesion are
similar to those of a benign tumor. .

• The histologic appearance consists primarilyof fibroblasts,
numerous vascular channels, multinucleated giant cells, and
macrophages.
• Clinical features:
• Age:
• Adolescents and young adults
• Painless swelling
• Palpation;
• Tenderness
• Usually grow slowly

• Location-
• Mandible anterior to 1st molar
• Maxilla-anterior to cuspid
• Lesions can cross the midline
• Periphery:
• Mandible-well defined
corticated
• Maxilla-illdefined
• Internal structure-granular
pattern of calcifications
• Occ. Thisgranular bone-
illdefined
• Wipsysepta if present, these
granular septa are characteristic
of this lesion, especiallyif they
emanate at right angles fromthe
periphery of the lesion

• In some instances the septa are better defined and divide the
internal aspect into compartments, creatingamultilocular
appearance
• Effect on surrounding structures:
• Displacement andresorption of teeth

Various internal patterns seen in giant cell granulomas. A, A lesion in the
anterior maxilla with a very fine granular pattern (arrow). B A portion of a
panoramic
fil m showing wispy, ill-defined

DIFFERENTIAL DIAGNOSIS
• Ameloblastoma
• Odontogenic myxoma
• Aneurysmal bone cyst
• Cherubism
• Brown tumours of hyperparathyriodism

Focal osteoporotic bone marrow defect of the jaws
• Location–mandible premolar and molar area
• F>m
• Radiographic appearance varies fromcyst like tomultilocular
to irregular and borders arewelldefined .
• Laminadura is intact
• Tooth is vital
• microscopically the defect is filled withhemopoetic marrow
withvariable fat component

• Dental granulomas
• Rareifyingosteitis
• Odontogeniccysts
• Traumatic bone cysts
• Osteomyelitis
• Odontogenictumors
• Benign and malignant tumors of bone
• Manifestations of leukemia
• Langerhanscell disease
• Advancedanemias

MANAGEMENT
• if malignancy is suspected surgical exploration and biopsy
should be carried out.

Surgical defect
• Defects of a transitory or permanent nature result frombone
surgery
• These possess well definedborders ; when they are round or
oviod,they have cyst like appearance on radiograph.
• Occasionally a surgical defect is permanent because large
areas of cortical bone along withperiosteumand marrowhas
been lost there is deficiency of bone forming elements.

• Periodic radiographs should be taken whether the area is
decreasing ,remaining constant or increasing.
• If the area has remained constant ,is decreasing slightly or is
increasing in radiodensity – surgical defect
• If it is increasing in size–recurrence of the original defect or
new lesion
• Palpation of the jaw bone reveal adepressiononmedial or
lateral surface in a position corresponding to the location of
radiolucency–diagnosis of defect

Focal cemento osseous defect
• It occurs in edentulous tooth bearing areasposteriorly in the
mandible
• The lesion is asymptomatic focal and either radiolucent
,radioopaqueor mixed .
• These lesions are referred to ascementomas.

Incisive canal cyst
• This cyst develops fromepithelial remnants of thenasopalatine
duct or incisive canal.
• Clinical features:
• Age: Variable, but most frequently detected in middleage (40-60
year-olds).
• Frequency:Most common of all non odontogenic cysts, affecting
about 1 % of total population.

• Site: Midline, anterior maxilla just
posterior to the upper central
incisors.
• Size:Variable, but usually from6
mm to several centimetres in
diameter
• Shape:— Roundor oval
(superimpositionof the nasal
septumor anterior nasal spine may
cause the cyst to appear heart-
shapedor resemble an inverted
tear drop)
• — Monolocular
• Outline: — Smooth
—Well defined
—Well corticated(unless
infected).
• Radiodensity: Uniformly radiolucent
but radiopaque shadowsometimes
superimposed
• • Effects: — Adjacent teeth
— distal displacement, rarely
resorption
• — Palatal expansion(only
identifiable if extensive

• Large incisive foramen
• Radicularcyst associated with central incisors
Treatment
• Enucleation

midpalatinecyst
• It is the bony cyst that develops in the midline of palate
posterior to palatine papilla.
• It originates in residualembronic epithelial nests in the fusion
line of lateral palatine shelves.
• Large cysts may destroy the bony palate.

• Radiographic features:
• Location : palatal area opposite the bicuspid and molar region
• Shape and outline:
A well circumscribed radiolucent area borderedby sclerotic
layer of bone
• Internal structure:
radiolucent

• Incisive canal cyst
• radicular cyst
• Palatine space abscess
• Lipoma
• Plexiformneurofibroma
• Mucocele
• Papillary cyst adenoma
• Mucoepidermiodtumour(lowgrade)

management
• Enucleation and curettement .

Early stage of cemento ossifying fibroma
• Cementoossifyingfibromas are classifiedas neoplastc fibro
osseous lesions that arise from elements of the periodontal
ligament .
• The early stage is osteolytic, in whichthe surrounding bone is
resorbed and replacedby a fibro vascular type of soft tissue
containing osteoblasts and cementoblasts
• At this stage , these lesions may appear as solitary cyst like
radiolucenciesnot in contact with teeth
• The margins are contoured and distinct.

features
• Small-asymptomatic
• Large-expand the jawbone
• Location-mandibular premolar and molarregion
• Age-30yrs
• F>m
• During the initial radiolucent stage the lesion is usually
changes progressively from apredominanatly fibroblatic lesion
to a increasingly calcified structure.

• During maturation a number of small droplets of
cementum,spiculesof bone, cementoblasts and osteoblasts in a
fibrous vascularstroma.
• In mature stage ,most of the lesion consists of calcified tissue
and appears on radiograph as well definedradioopacity
usually surrounded by a radiolucent zone that represents as a
non calcified area of fibrous tissue at the periphery.

• Cementoossifyingfibroma
• Differ fromperiapical and focal cementoosseus dysplasia in
that they occur in younger patients , most often in the
premolar and molar region of the mandible.
• If left untreated attain larger size causing expansion of the
jaws.
• Management-
• Surgical excision andcurretement.

Benign non odontogenic tumours
• Tumours have occurred withsome frequency within the jaws
as cyst likeradiolucencies not necessarilyin contact withthe
teeth are lipoma
• Salivary glandadenoma
• Amputationneuroma
• Neurofibroma
• Schwannoma
• leiomyoma

• Because their growth is slow,they present as well defined
radiolucenciesof varyingshape.
• Features-
• Most of themare asymptomatic except for peripheral nerve
tumors that develop with major sensory nerves.
• Patent reports pain , paraesthesia , or anesthesia in the region.
• The patient withan amputationneuroma describes a previous
traumatic incident ,a tooth extraction ,jawfracture or major
jaw surgery

• If untreated they grow slowly and expand the cortical plates .
• Aspiration is non productive for the benign nonodontgenic
tumors.
• Differential diagnosis-
• Neurofibromainvolving mandibular canal foundas elangated
broadening of canal.
• It represents peripheral nervous tissuetumour or
arteriovenouspathosis alsobe considered

• When pt gives h/o major surgery or fracture in a region that
has painful cyst like radiolucency-amputationneuroma is
considered.
• Management-
• Conservative excision including enucleation and curettement.

Neurilemoma showing cyst like radiolucencey
between mand.canine and premolar

Cyst like metastatic branchogenic carcinoma

Rarities
• Aot
• Aneurysmal bone cyst
• Av malformation
• Coc
• Ceot
• Central hemangioma
• Central salivary glandtumour
• Dentinoma
• Hydatid cyst
• Lipoma
• Metastatic carcinoma
• Odontogenic fibroma
• Odontoma
• Squamous odontogenictumour

Aneurysmal bone cyst and langerhan cell
histocytsis

References
• 1.Differentialdignosis of oral and maxilofacial lesions-paul
w.Goaz-5th edition
• 2.Oral radiology–whiteand pharoah -5th edition
• 3.Oralpathology-shafers- 6th edition

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