cysticlesion clinical andradiological feautures treatment

1. CYSTIC LESIONS OF
OROFACIAL REGION

2. CYST….DEFINITION
Any epithelium lined pathological cavity
containing fluid or semifluid other than pus

3. CLASSIFICATION
• ODONTOGENIC CYSTS:
Periapical (radicular) cysts
Lateral periodontal cysts
Gingival cyst of newborn
Dentigerous cyst
Eruption cyst
Glandular odontogenic cyst
Odontogenic keratocyst
Calcifying odontogenic cyst
• PSEUDOCYSTS:
Aneurysmal bone cyst
Traumatic bone cyst
Static bone Cyst
Focal Osteoporotic bone
marrow defect
• NON ODONTOGENIC
CYSTS:
Globulomaxillary cyst
Nasolabial cyst
Median mandibular cyst
Nasoplatine canal cyst
• SOFT TISSUE CYSTS OF
NECK:
Branchial cyst
Dermoid cyst
Thyroglossal tract cyst

4. How will a patient present…
• Patient may present with expanding swelling
• Unerupted teeth
• Pain
• Discolored tooth
• History of trauma to teeth
• Pathological fracture of mandible

5. How will you diagnose a cyst?
• History
• Clinical examination( extraoral/ intraoral)
• Aspiration
• Radiographic: PA, OPG, occlusal view
• CT scan for extensive lesions
• Tooth vitality tests: cold, heat, Laser
doppler flowmetry
• Lab investigations:
1. Fluid cytology
2. Electrophoresis
3. Incisional/ excisional biopsy.

6. Understanding following terms
1. MARSUPILIZATION:
• Creating a small window in the cyst wall and
removal of cystic contents.
Advantages:
• Lesser amount of surgery
• Saving vital structures if involved in cyst
Disadvantages:
• second surgical procedure is required to
remove the cyst
• Cavity is present which needs to kept clean
• The whole epithelium is not available for
histopath exam

8. ENUCLEATION
• Removing the cyst lining as a whole
Advantages:
• The whole epithelial lining is available for
histopath exam
• The surgery is curative
Diasadvantages:
• Surgery may involve large portions of the jaw
leaving it weak and prone to pathological
fractures
• Vitals structures may be compromised

9. Enucleation

10. ENUCLEATION WITH
PERIPHERAL OSTECTOMY
• Used for aggressive lesions.
• Enucleation is followed removal of all possible
remnants from bony cavity by means of burs
ENUCLEATION WITH CHEMICAL
CAUTERIZATION
• Used for aggressive lesions
• Enucleation is followed by treating with
cornoys solution or liquid nitrogen

11. PERIAPICAL (RADICULAR CYST)
• Most common cyst of orofacial region
• Epithelial lining is derived from proliferation rests of
malassez within the PDL
• 60 -75%
INCIDENCE:
One third of all cysts 75% cases
AGE DISTRIBUTION:
Third to sixth decade of life
LOCATION:
Anterior maxilla, posterior maxilla , mandibular
posterior region followed by man anterior region in
descending order

12. ETIOLOGY/ PATHOGENESIS
Caries/trauma/ periodontal disease
Pulpal necrosis
Apical boneinflammation
Dental granuloma formation
Epithelial proliferation
Periapical cyst formation

13. MECHANISM OF CYST EXPANSION
• 3 mechanism by which cysts form and expand
1. Hydrostatic mechanism…fluid ingress due to
increased osmotic pressure
2. Bone resorbing factors….prostaglandins,
interleukins, proteinases
3. Mural growth of surrounding epithelium

14. mechanism
• Bacterial antigen and irritants from necrotic
pulp
• Inflammation of cyst capsule
• Chronic inflammatory cell infiltration
• Cytokines eg interleukins-1
• Either fibroblast proliferation
• Or prostaglandins collagenases osteoclast
formation pge2 pgf2 pgd

15. CLINICAL FEATURES
• They are usually
asymptomatic except
when they are secondarily
infected
• They cause painless bone
expansion .
• The involved tooth will be
non vital / discoloured or
root canal treated.
• When sufficient bone
expands, egg shell
crackling will be present.
• Cyst may range few
millimeters to a few
centimeters in size

16. RADIOGRAPHIC VIEW
• Unilocular radiolucency with
narrow opaque margins
continuous with the lamina
dura of the involved tooth
• Differential diagnosis
1. Granuloma
2. Traumatic bone cyst
3. Giant cell lesions
4. Odontogenic tumours

17. TREATMENT
• 3 Options:
1. Extraction of teeth with
periapical currettage
2. Root canal filling
followed by apicectomy
3. Perform root canal and
wait for periapical lesion
to resolve (if small)
4. If tooth is extracted
and lesion is not
removed, then residual
cyst can form.

18. DENTIGEROUS CYSTS
• Second most common cyst of the jaw 10 15%
• It is attached to the tooth cementoenamel
junction and encloses the crown of the unerupted
tooth
ETIOLOGY / PATHOGENESIS:
It develops from proliferation of
reduced enamel epithelium
Expansion of cyst occurs from
hydrostatic mechanism and
release of bone resorbing
factors.

19. RADIOGRAPHIC FEATURES
• Lucency associated with crown
of impacted tooth
• Third molars/canine teeth
most commonly affected.
SIGNS & SYMPTOMS:
Swelling
Pain
Unerupted tooth

20. DIFFERENTIAL DIAGNOSIS
• Odontogenic keratocysts
• Ameloblastoma
• Odontogenic tumors
POSSIBLE COMPLICATION:
bone destruction
Resorption of roots
Displacement of teeth
Neoplastic transformation…
ameloblastoma…carcinoma rarely

21. TREATMENT
• Removal of adjacent tooth and enucleation of
cystic content.
• Marsuplization to shrink the lining and allow
eruption of tooth.

22. ERUPTION CYST
• Results from fluid accumulation in the
follicular space around an erupting tooth
• With trauma, blood may fill up this space
• No treatment is required , as cyst
disintegrates with eruption of tooth
• Fluctuant bluish swelling
• Pesent in both perm and decidous
• Is a true dentigerous cyst erupting on extra
alveolar location

23. ODONTOGENIC KERATOCYST
• They are different from other cyst due to
aggressive nature, high recurrence rate and
their association with basal cell nevoid
syndrome.
ETIOLOGY:
They develop from dental lamina remnants in
the maxilla and mandible
However, an origin from basal cells of the
overlying epithelium

24. PATHOGENESIS
High proliferation rate
Overexpression of antiapoptotic protein Bcl-2
Overexpression of matrix metalloproteas-es, MMP 2,9
Mutation of PTCH,overexpression of sonic hedgehog
pathway , formation of smoothened protein
SUFU gene mutation

25. CLINICAL FEATURES
• Age group involved is
second to third decade of
life.
• 5-15%of all cysts.
• Approx 5% of all OKC
patients have basal cell
nevoid syndrome.
• More common in the
mandible, posterior portion
of body and angle area
most commonly involved.
• Buccal expansion will be
present

26. BASAL CELL NEVOID SYNDROME
• Multiple odontogenic cysts
• Basal cell carcinomas on skin
• Frontal bossing, parietal bossing
• Mandibular prognathism
• Spina bifida and bifid ribs
• Kyphoscoliosis
• Calcified falx cerebri
• Palmer/planter keratosis
• Hypertelorism
• Also called gorlin goltz syndrome

28. RADIOGRAPHIC FEATURES
• Multilocular
radiolucency is present
• With smooth margins
• Resorption of roots may
be seen.

29. Diagnosis
• Two types of keratocysts:
1. orthokeratinized…. Less common, not
syndrome associated and lower recurrence
rate
2. Parakeratinized… epithelial budding and
daughter cysts, higher recurrence rate.

30. TREATMENT
• Surgical enucleation followed by peripheral osseous
currettage or ostectomy.
• Chemical cauterization can also be done with cornoys
solution/ liquid nitrogen.
• In some larger cysts marsupilization can be done to
reduce the size of the cyst.
RECURRENCE:
10-30% recurrence rate due to;
1. Daughter / satellite cysts
2. Fragile lining
3. Epithelial proliferate rate is very high
4. Production of bone resorbing factors
5. Finger like extension into cancellous bone
6. Inf standard of treatment
7. pseudooccurence

31. Lateral periodontal cyst
• Cyst present beside a tooth and tooth is vital
• Near the crest of ridge two types
 Botryoid glandular
 Most common in mandibubular premolar and canine
area and have clear glycogen containing cell and bud
like proliferation
 While glandular has pools of mucous cells and mucin
• Multilocular ,strong tendency to
recur,enucleation

32. NASOPALATINE DUCT CYST also called
median palatine, median alveolar, mid palatine
palatine pappila
• Presents as a swelling in the midline of anterior
palate
• Patient may complain of salty discharge and irritation
to the tongue
• On radiograph, heart shaped radiolucency is present
greater than 6 mm. Divergence of the roots is seen
• It is believed to arise from the remnants of
nasopalatine duct within the incisive canal.
• Stimulus for cyst formation is either bacterial
infections or trauma
• Surgical enucleation from palatal approach is the
treatment of choice

34. NASOLABIAL CYST
• It appears as a swelling
in the nasolabial fold
and upper lip,bilateral
• The swelling is painless
unless infected,distorts
nostrils
• It is a soft tissue
swelling so not visible
radiographically
• It is believed to arise
from remnants of
nasolacrimal duct.
• Surgical enucleation is
the treatment of

35. Concept of fissural cysts
• Globulomaxillary, midline mandibular cysts
were initially thought as cysts arising from
epithelial residues trapped in the line of
fusion
• However new concept has changed these
views.
• These cysts may actually be any other cyst in
the making.

36. PSEUDOCYSTS
ANEURYSMAL BONE CYST
• Appear like cysts but not lined by epithelium
• 40 % are in mandible, 25% in maxilla
Etiology: appear to be a reactive lesion, in
association with primary bone lesions like
fibrous dysplasia, CGCG etc
Clinical Features: young patients(<30 yr) with
female predilection 10 20yrs of age
The posterior regions are involved mostly
No bruit on auscultation

37. Radiographic features
• Presence of a destructive , osteolytic lesion
with slightly irregular margins.
• Multilocular pattern ,soap bubble appearance,
• Teeth may be displaced with/ without
external root resorption
Differential Diagnosis: OKC, Giant cell lesions,
odontogenic tumors
Histopathology: Giant cell lesions, with blood
filled sinusoids
Treatment: excision with cryotherapy is the
treatment of choice

39. TRAUMATIC BONE CYSTS
• Traumatic bone cyst is pseudocyst that is actually an
empty bony cavity
Etiology: usually associated with trauma.
• Hypothesis is that hematoma develops..clot
breaks down…empty bone cavity
• Other theories are cystic degeneration of tumors,
disorders of calcium metabolism
Clinical Features:
Teenagers females are usually involved
Mandible is the commonest site. Rarely
bilateral lesions are present.
Uncommon after age of 25
Also called hemmeraghic solitary r simple bone cyst

40. Radiographic Features
• Radiolucency with
irregular margins.
Interradicular
scalloping is present
 Cyst expands b/w roots
of teeth
 Much larger
radiolucency than size
of swelling
Treatment:
Surgical entry to initiate
bleeding and
stimulate healing
Some heal spontaneously

41. STATIC BONE CYST
• This is anatomic indentation of the posterior
lingual mandible that appears as a cyst on
radiograph
• It may also be due to entrapment of the
salivary gland tissue during development
• It may also be due to hyperplastic salivary
gland tissue
Location:
• Located bilaterally in the mandible
• Oval radiolucency below the inferior alveolar
canal
Clinical Features: No symptoms, no treatment

43. FOCAL OSTEOPOROTIC BONE
MARROW DEFECT
• Uncommon asymptomatic radiolucencies where
hematopoiesis is see normally(angle of
mandible,maxillary tuberosity)
• Pathogenesis is unknown,
1. one theory states that abnormal healing
following tooth extraction
2. Another theory states that residual remnants
of fetal marrow may persist
3. It may be a focus of extramedullary
hematopoiesis that becomes hyperplasticc in
life
No treatment is required

44. SOFT TISSUE CYSTS OF
OROFACIAL/NECK REGION
DERMOID CYST
• It is a developmental cyst. In the orofacial
region, it occurs in the midline of the floor of
mouth
• If it occurs below the mylohyoid, it becomes
swelling in the neck
• All lesions are soft and doughy because of
keratin and sebum.
• Contains all dermal appendages.
• Most common location is the midline of the floor
of mouth (may cause respiratory obstruction
when large).
• Enucleation solves the problem.

46. THYROGLOSSAL DUCT CYST

47. • Most common developmental cyst of the neck
• The basis for this pathology is thyroid gland
development.
• Derivatives of first and second branchial arches
form the posterior portion of tongue. Thyroid
tissue grows downwards from the foreman
caecum to its permanent location in the neck
• It occur anywhere along the thyroglossal duct
tract.
• Moves with swallowing and protrusion of tongue ,
if attached to the hyoid bone or tongue.
• Surgical excision is the treatment, but before
this it is must to determine that this is not the
only functioning thyroid tissue.

49. BRANCHIAL CYST

50. • These are developmental cysts located in the
lateral portions of the neck, anterior to the
sternomastoid.
• Floor of mouth is also a common site
• Current theory states that they are formed
of epithelial entrapment within lymph nodes
• Soft fluctuant in nature. May have a draining
sinus
• Excision is the treatment of choice.

51. D/D of floor of mouth lesions
• Ranula
• Dermoid cyst
• Lymphangioma
• Salivary gland tumor
• Sialadenitis/sialolith
• Mesenchymal tumors
• lymphomas

52. D/D of Palatal Swellings
• Tori
• Palatal abscess
• Radicular cyst
• Dentigerous cyst
• Mucous retention
cyst
• Salivary gland tumor
• Tumors from the
max sinus
• lymphoma

53. Patient presents with swelling of left
buccal sulcus. OPG shows radiolucent
lesion in angle ramus area. D/D
• Radicular cyst?
• Dentigerous cyst
• Odontogenic keratocyst
• Static bone cyst
• Aneurysmal cyst
• Traumatic cyst
• Ameloblastoma
• Odontogenic myxoma
• Ameloblastic fibroma
• Early ossifying fibroma
• Giant cell tumor if
anterior to 1st molar
• Brown’s tumor
• Osteosarcoma very
uncommon