Diagnosis of cysts in oral cavity


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Diagnosis of cysts in oral cavity

  1. 1. By: SASHI KUMAR MANOHAR CRI Department Of Oral Medicine & Radiology VMSDC
  2. 2.  A Cyst is a pathologic cavity having fluid, semi fluid or gaseous content and which is not created by accumulation of pus.  Most cysts, but not all, are lined by epithelium. (KRAMER 1974)
  3. 3.  TRUE CYSTS :  Cysts which are lined by epithelium, E.g. Dentigerous Cyst, Radicular Cyst, etc.  PSEUDO CYSTS :  Cysts which are not lined by epithelium, E.g. Solitary Bone Cyst, Aneurismal Bone Cyst, etc.
  4. 4.  A Cyst has the following parts:  1.Wall  2.Lumen Of Cyst  3.Epithelial Lining
  6. 6.  DEVELOPMENTALORIGIN i) Odontogenic a) Dentigerous cyst b) Odontogenic Keratocyst c) Lateral Periodontal Cyst d) Gingival cyst
  7. 7.  ii) Non-Odontogenic a) Globulomaxillary cyst b) Nasolabial cyst c) Median Palatal cyst
  8. 8.  INFLAMMATORYORIGIN a) Radicular cyst b) Residual cyst c) Paradental cyst
  9. 9. a) Solitary Bone Cyst b) Aneurysmal Bone Cyst c)Traumatic Bone Cyst
  10. 10.  (SHEAR 2006) 52.30% 18.10% 11.60% 8% 5.60% 4.20% SHEAR 2006 Radicularcyst Dentigerouscyst Odontogenickeratocyst Residual cyst Paradental cyst Unclassified odontogenic cysts
  11. 11.  Based On Clinical Features  Based On Anatomical Site Of Jaw  Based On Histological Features  Based On Aspirate Fluid  Based On Radiographic Features
  12. 12.  Small cysts are usually symptomatic  Large cysts exhibits large swelling and pain  Irregularity of teeth-missing tooth, impacted tooth, supernumerary tooth, displacement of tooth, non vital tooth, carious tooth, etc  Presence of fluctuation in the swelling upon palpation  Condition of the bone plate-bulging and thinning over the outer cortical bone plate
  13. 13.  Mandibular regions: -3rd molar regions, canine regions-common impacted tooth regions- Dentigerous Cyst -angle of mandible, ascending ramus of mandible regions- Odontogenic Keratocyst -Premolar and molar regions-Lateral Periodontal Membrane- Lateral Periodontal Cyst -solitary bone cyst and aneursymal bone cyst occurs only in the mandible
  14. 14.  Maxillary regions -canine and 3rd molar regions impacted canines and 3rd molars-Dentigerous Cyst
  15. 15.  Sample specimens stained with Eosin & Hemotoxylin stains
  16. 16. Dentigerous cysts exhibts two types with variant histologic features  InflammedType  Non-InflammedType
  17. 17. Lining shows varying degrees of hyperplasia with rete ridges and occasionally even keratinization. Wall is composed of mature connective tissue which shows infiltration by chronic inflammatory cells Focal areas of mucous cells can be seen in the lining. Small odontogenic epithelial islands can be seen in the wall.
  18. 18. Lining derived from reduced dental epithelium, consists of 2-4 cell layers of non keratinized epithelium, without rete ridges. Wall composed of thin fibrous connective tissue appearing immature, as it is derived from the dental papilla.
  19. 19. NON INFLAMED dentigerous cyst showing a thin nonkeratinized epithelial lining INFLAMED DENTIGEROUSCYST showing a thicker epithelial lining with hyperplastic rete ridges.The fibrous cyst capsule shows a diffuse chronic inflammatory infiltrate
  20. 20. Cholesterol crystals in from of clefts are often seen in the connective tissue wall, inciting a foreign body giant cell reaction Originate from disintegrating RBC’s in presence of inflammation Different types of dystrophic calcification are also seen in connective tissue wall. Mucus cell metaplasia as well as respiratory cells may be seen in the epithelial lining. Keratinization if found is due to metaplasia and must not be confused with an OKC.
  21. 21. Quiescent epithelium lining a mature, long-standing periapical cyst Mucous cells in the surface layer of the stratified squamous epithelial lining of a periapical cyst
  22. 22. Mural nodule of cholesterol-containing granulation tissue fungating into the cavity of a radicular cyst
  23. 23. The epithelial lining is composed of a uniform layer of stratified squamous epithelium,usually six to eight cells in thickness The epithelium and connective tissue interface is usually flat, and rete ridge formation is inconspicuous. The basal cell layer has columnar / cuboidal cells with reversely polarized nuclei, imparting a “picket fence” or “tombstone” appearance
  24. 24. The luminal surface shows flattened parakeratotic epithelial cells, which exhibit a wavy or corrugated appearance Small satellite cysts, cords, or islands of odontogenic epithelium may be seen within the fibrous wall
  25. 25. Epithelial lining is 6 to 8 cells thick, with a hyperchromatic and palisaded basal cell layer Note the corrugated parakeratotic surface Satellite microcysts in the wall of an odontogenic keratocyst that appear to be arising direct from an active dental lamina
  26. 26. 1.Dentigerous Cyst →Clear, pale, straw coloured fluid, rich in cholesterol crystals 2.Odontogenic Keratocyst →Creamy white, cheese like material, thick aspirate
  27. 27. 3.InfectedCyst →Yellowish, foul smelling fluid, pus discharge 4. Aneurysmal Bone Cyst →Blood on aspiration 5.SolidTumor Mass →Negative aspiration
  28. 28. Various radiographic methods that are used are:  Intra-Oral Periapical Radiography  Occlusal Radiography  Orthopantomogram  CT scan
  29. 29.  DENTIGEROUS CYST -  Unilocular or occasionally multilocular well- defined, radiolucency with sclerotic margins  3 types - CentralType - LateralType - CircumferentialType
  30. 30. CentralType LateralType CircumferentialType
  31. 31. (a) (b) Figure (a) shows two types of dentigerous cyst The one on the right is lateral type The one on the left is circumferential type Figure (b) shows central type of dentigerous cyst.Appreciate the resorption of the root of the first mandibular molar
  32. 32.  PERIAPICAL CYST  Round, ovoid radiolucency with thin sclerotic borders and usually associated with pulpally affected tooth  Loss of lamina dura at the apex of the tooth root
  33. 33. Figure shows well defined radiolucency associated with the apex of a non-vital root filled tooth.
  34. 34.  Odontogenic Keratocyst  Unilocular or multilocular well defined radiolucent area with smooth and scalloped radiopaque margins
  35. 35. (a) (b) (c) Figure (a) shows a small OKC lesion With scalloped border Figure (b) shows a larger OKC lesion With scalloped border Figure (c) shows a larger multilocular OKC lesion With scalloped border
  36. 36. Figure shows an OKC lesion that has enveloped An unerupted tooth to produce a “DENTIGEROUS” appearance
  37. 37.  Dentigerous Cyst  PeriapicalCyst  Odontogenic Keratocyst
  38. 38. The dentigerous cyst is defined as a cyst that originates by the separation of the follicle from around the crown of an unerupted tooth It develops by accumulation of fluid between the reduced enamel epithelium and the tooth crown The dentigerous cyst encloses the crown of an unerupted tooth and is attached to the tooth at the cementoenamel junction
  39. 39. Reduced Enamel Epithelium Dentigerous cyst arises from accumulation of fluid between the reduced enamel epithelium and the tooth crown
  40. 40. AGE : 1st to 3rd decades. GENDER : More frequently in males than in females. SITE : 2/3rd associated with unerupted mandibular 3rdmolar Maxillary canine Mandibular premolar Maxillary 3rd Molar Supernumerary tooth also can be involved
  41. 41. Most cysts grow to a large size before being discovered while observing a dental x ray to detect the cause of an unerupted tooth. Large lesions can cause cortical expansion, leading to facial asymmetry, teeth displacement, root resorption, even pain, if infected.
  42. 42. Multiple gross specimens of Dentigerous Cyst Notice the cystic lesion encloses the crown of the tooth and is attached to its cementoenamel junction
  43. 43. Although dentigerous cysts present a unique feature, but some lesions must be considered in its differential diagnosis : 1. Unicystic ameloblastoma 2. Adenomatoid odontogenic tumor.
  44. 44. Recurrence due to incomplete surgical removal. Development of ameloblastoma either from lining epithelium or from odontogenic islands in the connective tissue wall. Development of squamous cell carcinoma either from lining epithelium or from odontogenic islands in the connective tissue wall. Development of mucoepidermoid carcinoma from mucus secreting cells in the lining.
  45. 45. Synonyms : Radicular cyst Apical Periodontal cyst Periapical cysts are the most common inflammatory cysts They arise from the epithelial residues in the periodontal ligament as a result of periapical periodontitis following death and necrosis of the pulp.
  46. 46.  Periapical cysts usually arises at the apical end of a carious tooth, they arise from the epithelial residues in the periodontal ligament  Carious infection followed by slow necrosis of the pulpal tissues of the tooth  Death of pulpal tissues results in formation of granulation tissue at the apical end of the tooth root  Lession develops to cyst following periapical periodontitis
  47. 47. Age: 3rd, 4th and 5th decades Sex: Slightly frequent more in males Site: Maxillary anterior region and mandibular anterior regions Frequency: Most common inflammatory cystic lesion of the oral region
  48. 48. Primarily asymptomatic Usually associated carious tooth and non vital tooth Discovered during routine dental X ray exam while examining a carious tooth Slowly enlarging hard bony swelling initially. Later, if cysts breaks through cortical plates, lesion becomes fluctuant Rare in deciduous teeth
  49. 49. OKC’s arises from cell rests of the dental lamina. They exhibit a different growth mechanism and biologic behavior from the more common dentigerous cyst and radicular cyst. Several investigations suggest that odontogenic keratocysts can be regarded as benign cystic neoplasms rather than cysts
  50. 50. cell rests of serres (dental lamina) OKC arises from Islands of epithelial cells that originate from the oral epithelium and remain in the tissue after inducing tooth development.
  51. 51. AGE: Occurs over a wide age range and cases have been recorded as early as the first decade and as late as the ninth In most series there has been a pronounced peak frequency in the second and third decades GENDER: More frequently in males than in females SITE:The mandible is involved far more frequently than the maxilla 50% cases occur in angle region and extending to the ascending ramus and forwards to body of mandible
  52. 52. Pain, swelling or discharge seen Occasionally, paraesthesia of the lower lip or teeth. Some are unaware of the lesions until they develop pathological fractures In many instances, patients are remarkably free of symptoms until the cysts have reached a large size, involving the maxillary sinus and the entire ascending ramus, including the condylar and coronoid processes occurs because the OKC tends to extend in the medullary cavity and clinically observable expansion of the bone occurs late.
  53. 53. Gross specimens of eneucleated Odontogenic Keratocyst (OKC)
  54. 54. In case of unilocular radiolucency– Dentigerous cyst, Eruption cyst,Unicystic ameloblastoma etc. In case of multilocular radiolucencies – Conventional ameloblastoma, Central giant cell granuloma,Aneurysmal bone cyst etc.
  55. 55. Malignant transformation of cyst lining rare, but has been reported. High rate of recurrence Reasons for recurrence : 1. Thin, fragile lining is very difficult to remove completely. 2. New cysts develop from satellite cysts left behind. 3. New cysts can also develop from basal cells of overlying oral epithelium, especially in ramus – 3rd molar region.