Jaw bone cyst

Jaw bone cysts Jaw bone cysts DR: Mazen Abood Bin Thabit. M.D, FRCPath

Assistant Prof Of Pathology

Senior lecturer of Oral pathology and oral histology

Copyright 2003, Elsevier Science (USA). All rights reserved.

IntroductionIntroduction

Definition :

Cyst is pathological fluid , simi-fluid or gas filled cavity lined by epithelium .

Most common lesion .

Most common casus of jaw swelling .

Often destructive and produce signs and symptoms .

True cyst Vs Pseudo-cyst

Definition :

Cyst is pathological fluid , simi-fluid or gas filled cavity lined by epithelium .

Most common lesion .

Most common casus of jaw swelling .

Often destructive and produce signs and symptoms .

True cyst Vs Pseudo-cyst


General feature of cyst General feature of cyst Sharpe radiolucent with well defined margin . Fluid may be aspirated . Tran-illuminated . Grow slowly Displacing rather than resorbing . Symptomless . Rarely cause pathological fracture Forms compressible and fluctuant swelling . Appears plush close to the mucosa . Cystic epithelium some time undergo neoplastic

transformation.

Sharpe radiolucent with well defined margin . Fluid may be aspirated . Tran-illuminated . Grow slowly Displacing rather than resorbing . Symptomless . Rarely cause pathological fracture Forms compressible and fluctuant swelling . Appears plush close to the mucosa . Cystic epithelium some time undergo neoplastic

transformation.


Approach of diagnosis Approach of diagnosis

Complete history:

Pain , duration , tooth mobility or loss ,

occlusion ,swelling , delay eruption Physical examination : Inspection , palpation , percussion .

Radiology: Plan X-ray ,panoramic, dental radiograph, CT.

FNAC: Biopsy:

Complete history:

Pain , duration , tooth mobility or loss ,

occlusion ,swelling , delay eruption Physical examination : Inspection , palpation , percussion .

Radiology: Plan X-ray ,panoramic, dental radiograph, CT.

FNAC: Biopsy:


Classification Classification

I. Odontogenic cysts :

Developmental cysts

1. Dntigerous cyst .

2. Eruption cyst .

3. Odontogenic keratocyst

4. Gingival cyst

5. Lateral periodontal cyst

6. Botryoid odontogenic cyst .

7. Gandular Odontogenic cyst

8. Calcifying odontognic cyst

I. Odontogenic cysts :

Developmental cysts

1. Dntigerous cyst .

2. Eruption cyst .

3. Odontogenic keratocyst

4. Gingival cyst

5. Lateral periodontal cyst

6. Botryoid odontogenic cyst .

7. Gandular Odontogenic cyst

8. Calcifying odontognic cyst



Inflammatory cysts

1. Radicular cyst .

2. Paradental cyst .

3. Residual cyst

4. Inflammatory collateral cyst .

Neoplastic cyst

1. Cystic ameloblstoma

2. Calcifying odontogenic cyst

II. Non odontogenic cyst :

1. Nasopalatine cyst .

2. Nasolabial cyst

Inflammatory cysts

1. Radicular cyst .

2. Paradental cyst .

3. Residual cyst

4. Inflammatory collateral cyst .

Neoplastic cyst

1. Cystic ameloblstoma

2. Calcifying odontogenic cyst

II. Non odontogenic cyst :

1. Nasopalatine cyst .

2. Nasolabial cyst



III. Cysts without epithelial lining ( Pseudocyst) :

1. Solitary ( Simple ) bone cyst

2. Aneurysmal bone cyst

IV. Cyst of soft tissue:

1. Dermoid and epidermoid cyst

2. Lympho-epithelial cyst .

3. Thyro-glossal cyst

III. Cysts without epithelial lining ( Pseudocyst) :

1. Solitary ( Simple ) bone cyst

2. Aneurysmal bone cyst

IV. Cyst of soft tissue:

1. Dermoid and epidermoid cyst

2. Lympho-epithelial cyst .

3. Thyro-glossal cyst


Embryological origin of cyst Embryological origin of cyst Rest Of Malassez . Reduced Enamel

epithelium Remnant of dental

lamina

Rest Of Malassez . Reduced Enamel

epithelium Remnant of dental

lamina


Radicular ( Periapical ) cyst Radicular ( Periapical ) cyst The most common

odontogenic cyst of inflammatory origin.

65-70% Related to apex of non-vital

tooth.

The most common odontogenic cyst of inflammatory origin.

65-70% Related to apex of non-vital

tooth.

Pathogenesis


Periapical ( Radicular ) cyst:Periapical ( Radicular ) cyst: Clinical feature : 3rd -4th decades Male . More common in anterior

maxilla . Tooth is non vital Small cyst asymptomatic . Large cyst may produce slow

growing hard bony swelling Springiness . Fluctuation if bone is eroded Pain if infected with sinus Paresthesia and pathological

fracture Lateral radicular cyst .

Clinical feature : 3rd -4th decades Male . More common in anterior

maxilla . Tooth is non vital Small cyst asymptomatic . Large cyst may produce slow

growing hard bony swelling Springiness . Fluctuation if bone is eroded Pain if infected with sinus Paresthesia and pathological

fracture Lateral radicular cyst .

Radicular csyt


Radicular ( Periapical ) cyst Radicular ( Periapical ) cyst

Radicular cyst

Well defined ,unilocular radio-lucent with well defined cortical margin


Radicular ( Periapical ) cyst Radicular ( Periapical ) cyst Histopathology: Stratified squamous 6-20cell

thick . Surrounded C.T shows

chronic inflammation . Cholesterol cleft. Russel bodies . Multinucleated giant cells Epithelium may undergo

malignant transformation

Histopathology: Stratified squamous 6-20cell

thick . Surrounded C.T shows

chronic inflammation . Cholesterol cleft. Russel bodies . Multinucleated giant cells Epithelium may undergo

malignant transformation


Radicular ( Periapical ) cyst Radicular ( Periapical ) cyst Differential diagnosis: Periapical granuloma. Periapical abscess . Cementblastoma. Traumatic bone cyst .

Differential diagnosis: Periapical granuloma. Periapical abscess . Cementblastoma. Traumatic bone cyst .

Treatment: Small cyst : Root canal treatment Large cyst : Enaculation or marsupialization


Residual cyst Residual cyst Cystic lesion may present

at the site of tooth extraction

Cystic lesion may present at the site of tooth extraction

Residual cyst

Edentulous region


Dentigerous cyst Dentigerous cyst

2nd most common . Enclose part or all the

crown Caused by accumulation of

fluid between REE and Enamel

2nd most common . Enclose part or all the

crown Caused by accumulation of

fluid between REE and Enamel

CEJ


Dentigerous cyst Dentigerous cyst

Attached to CEJ Forming cyst in which the

crown located within it’s lumen and the root out side

Attached to CEJ Forming cyst in which the

crown located within it’s lumen and the root out side

CEJ


Dentigerous cyst Dentigerous cyst Clinical presentation:

1. Asymptomatic .

2. swelling or pain .

3. Common in mandible

4. Mandibular 3rd molar , maxillary permanent canine and mandibular premolar .

5. More common in adult male

6. 20-50 years .

7. Permanent dentition may be missed

8. Large cyst may cause bone expansion and tooth displacement

9. may associated with supernumerary teeth or odontomas

Clinical presentation:

1. Asymptomatic .

2. swelling or pain .

3. Common in mandible

4. Mandibular 3rd molar , maxillary permanent canine and mandibular premolar .

5. More common in adult male

6. 20-50 years .

7. Permanent dentition may be missed

8. Large cyst may cause bone expansion and tooth displacement

9. may associated with supernumerary teeth or odontomas


Dentigerous Dentigerous

Radiograph : Unilocular radiolucent area Well circumscribed Contains crown Surrounded by sclerotic bone

outline

Radiograph : Unilocular radiolucent area Well circumscribed Contains crown Surrounded by sclerotic bone

outline

Radiolucent space around the crown


Dentigerous cystDentigerous cyst Types :

The cyst attached to CEJ and the crown related to cyst in

three ways:

1.Central type .

2.Lateral type .

3.Circumferential type

Types :

The cyst attached to CEJ and the crown related to cyst in

three ways:

1.Central type .

2.Lateral type .

3.Circumferential type


Histopathology

Non keratinized squamous epithelium 2-10 cell thick . May be atrophic or ulcerated . Wall dense fibrous and no inflammation . Islands of odontogenic epithelium may

seen. Cyst filled proteineous material and

cholisterol cleft Long standing cyst may shows dysplasia Neoplastic tumors may arise from cyst

Histopathology

Non keratinized squamous epithelium 2-10 cell thick . May be atrophic or ulcerated . Wall dense fibrous and no inflammation . Islands of odontogenic epithelium may

seen. Cyst filled proteineous material and

cholisterol cleft Long standing cyst may shows dysplasia Neoplastic tumors may arise from cyst


Dentigerous cyst Dentigerous cyst Treatment:

Marsupialization .

Enaculation Differential diagnosis:

1.Adenomatoid odontogenic tumor .

2. Unilocular cystic ameloblastoma.

3. primordial cyst .

4. Ameloblastic fibroma

5. CEOC

Treatment:

Marsupialization .

Enaculation Differential diagnosis:

1.Adenomatoid odontogenic tumor .

2. Unilocular cystic ameloblastoma.

3. primordial cyst .

4. Ameloblastic fibroma

5. CEOC


Eruption cyst Eruption cyst Odontogenic cyst

similar to dentigerous cyst with teeth about to erupt.

Odontogenic cyst similar to dentigerous cyst with teeth about to erupt.

Tooth crown has erupt through the jaw bone


Eruption cyst Eruption cyst Clinical feature : 1. Affect children in both

dentition

2. Superficial appears as soft , bluish fluctuant swelling on the alveolar ridge .

3. Repetitive trauma may induce hemorrhage with the cyst ( Eruption hematoma) .

Clinical feature : 1. Affect children in both

dentition

2. Superficial appears as soft , bluish fluctuant swelling on the alveolar ridge .

3. Repetitive trauma may induce hemorrhage with the cyst ( Eruption hematoma) .

No treatmentOccasionally surgical removal of cyst roof


Odontogenic keratocyst Odontogenic keratocyst Also called Primordial

cyst and arises mainly from remnant of dental lamina

Also called Primordial cyst and arises mainly from remnant of dental lamina

Jaw bone

Cyst cavity


Primordial cyst Primordial cyst Clinical feature: 1. 1st peak 20- 30 years and

the 2nd peak 50-70 years .

2. Male predominance .

3. 2/3 in the mandible in the posterior alveolar ridge .

4. In the maxilla , the 3rd molar region is more affected .

5. Cyst have remarkable growth potentiality .

6. Grow in antero-posterior direction

Clinical feature: 1. 1st peak 20- 30 years and

the 2nd peak 50-70 years .

2. Male predominance .

3. 2/3 in the mandible in the posterior alveolar ridge .

4. In the maxilla , the 3rd molar region is more affected .

5. Cyst have remarkable growth potentiality .

6. Grow in antero-posterior direction


Primordial cyst Primordial cyst Clinical feature: 7. Usually single , occasionally

multiple ( Golin –Gottz syndrome ).

8. Small cyst discovered incidentally by X-ray .

9. Large cyst cause bone swelling

10 . Pain , mobility and displacement of teeth .

11. Occasional paresthesia of lower lips and teeth .

12. In some cases extraosseous extension to gingiva.

13. Pus discharge and sinus

Clinical feature: 7. Usually single , occasionally

multiple ( Golin –Gottz syndrome ).

8. Small cyst discovered incidentally by X-ray .

9. Large cyst cause bone swelling

10 . Pain , mobility and displacement of teeth .

11. Occasional paresthesia of lower lips and teeth .

12. In some cases extraosseous extension to gingiva.

13. Pus discharge and sinus


Primordial cyst Primordial cyst Radiography : 1. High and remarkable growth

potential .

2. May attain a large destructive size.

3. High recurrence rate after enaculation 25-60%

4 . Recent WHO classification designate this cyst as Keratocystic adontogenic tumor .

Radiography : 1. High and remarkable growth

potential .





Primordial cyst Primordial cyst Clinical behavior : 1. High and remarkable growth

potential .




Clinical behavior : 1. High and remarkable growth

potential .





Histopathology: The cyst lined by thin

parakeratinized odontogenic squamous epithelium of 6-10 cell layer .

Palisaded layer of columnar or cuboidal basal layer with reverse polarity .

Corrugated layer of parakeratin on it’s luminal surface .

The junction between cyst and connective tissue is weak with focal separation.

Cyst contains desquamated parakeratin , and cheesy material

Inflammation absent .

Thin fibrous wall .

Histopathology: The cyst lined by thin

parakeratinized odontogenic squamous epithelium of 6-10 cell layer .

Palisaded layer of columnar or cuboidal basal layer with reverse polarity .

Corrugated layer of parakeratin on it’s luminal surface .

The junction between cyst and connective tissue is weak with focal separation.

Cyst contains desquamated parakeratin , and cheesy material

Inflammation absent .

Thin fibrous wall .

Basal layer

Parakeratin layer


Primordial cyst Primordial cyst

Causes of recurrence:1. Thin fragile lining .

2. Budding or finger like cyst .

3. Daughter cyst .

4. Other dental lamina

5. Focal separation of the epithelium

Causes of recurrence:1. Thin fragile lining .

2. Budding or finger like cyst .

3. Daughter cyst .

4. Other dental lamina

5. Focal separation of the epithelium



Daughter cyst



Treatment :1. Small : Simple enaculation

.

2. Large: Enaculation with or without peripheral osteomy.

3. Complete resection with 1cm margin .

4. Long term follow up .

Treatment :1. Small : Simple enaculation

.

2. Large: Enaculation with or without peripheral osteomy.

3. Complete resection with 1cm margin .

4. Long term follow up .


Lateral periodontal cyst Lateral periodontal cyst

Uncommon intra-osseous odontogenic cyst similar to gingival cyst of adult

Uncommon intra-osseous odontogenic cyst similar to gingival cyst of adult

It’s derived from rest of dental lamina

Lateral to the root surface of erupted tooth


Lateral periodontal cyst Lateral periodontal cyst Clinical feature: 0.7% of jaw bone cyst .

Middle age patient .

Both mandible and maxilla

Canine and premolar of mandible .

Near the crest of ridge

Asymptomatic.

May produce bone expansion and pain

Tooth is vital .

Cyst less than 1 cm .

Clinical feature: 0.7% of jaw bone cyst .

Middle age patient .

Both mandible and maxilla

Canine and premolar of mandible .

Near the crest of ridge

Asymptomatic.

May produce bone expansion and pain

Tooth is vital .

Cyst less than 1 cm .

X-ray: Tear or drop shape radiolucency

Differential diagosis


Lateral periodontal cyst :Lateral periodontal cyst :

Histopathology: Thin non keratinized

squamous epithelium

One or two cell thick .

Some cells are of clear cystoplasm

The cyst separate from PDL.

Histopathology: Thin non keratinized

squamous epithelium

One or two cell thick .

Some cells are of clear cystoplasm

The cyst separate from PDL.

Clear cells

Surgical excsion of cyst along with the tooth


Gingival cyst of adult Gingival cyst of adult

An extra-osseous odontogenic cyst of the gingival tissue

Arise from rest of dental lamina

An extra-osseous odontogenic cyst of the gingival tissue

Arise from rest of dental lamina

Gingival cyst


Gingival cyst of adult Gingival cyst of adult

Clinical feature: Rare

4o years

Firm , compressible and dome shape swelling less than 1cm

Facial gingiva of incisor or premolar

Clinical feature: Rare

4o years

Firm , compressible and dome shape swelling less than 1cm

Facial gingiva of incisor or premolar

Gingival cyst

Histopathology :Very thin flat non keratinized squamous epithelium


Gingival cyst of newbornGingival cyst of newbornCalled Dental lamina cyst of

newborn

Uncommon .

Multiple superficial nodules .

Resolve without treatment .

Thin keratinized squamous epithelium

Called Dental lamina cyst of newborn

Uncommon .

Multiple superficial nodules .

Resolve without treatment .

Thin keratinized squamous epithelium

Gingival cyst

Varient :1. Epstein’s pearls: Mid palatine

raphe.2. Bohn’s nodules: Junction of hard

and soft palate


Botryoid odontogenic cyst Botryoid odontogenic cyst Rare odontogenic cyst

resembles the cluster of grapes .

Cystic changes of multiple adjacent dental lamina

Polycystic variant . Expensile , painless central

swelling . Multilocular cysts with fine

septa. Flat nonkeratinized

epithelium with clear cells Strong tendency to

recurrence

Rare odontogenic cyst resembles the cluster of grapes .

Cystic changes of multiple adjacent dental lamina

Polycystic variant . Expensile , painless central

swelling . Multilocular cysts with fine

septa. Flat nonkeratinized

epithelium with clear cells Strong tendency to

recurrence


Glandular cyst Glandular cyst Also called sialo-odontogenic

cyst . Intra osseous from dental

lamina . Rare . Large single unilocular or multi Anterior mandible . Uni or multilocular radio-luncent

. Thin stratified squamous with

small glandular or microcyst ( Pseudo-duct like )

High tendency to recurrence

Also called sialo-odontogenic cyst .

Intra osseous from dental lamina .

Rare . Large single unilocular or multi Anterior mandible . Uni or multilocular radio-luncent

. Thin stratified squamous with

small glandular or microcyst ( Pseudo-duct like )

High tendency to recurrence


Solitary bone cyst Solitary bone cyst Traumatic bone cyst ,

unicameral bone cyst or hemorrhagic bone cyst.

Children and adolescent. Mandibular premolar and

molar Painless swelling . Round radio-lucent and less

sharply defined . Bony wall lined by thin loose

C.T , RBCs or hemosedrin laden macrophages

Unknown

Traumatic bone cyst , unicameral bone cyst or hemorrhagic bone cyst.

Children and adolescent. Mandibular premolar and

molar Painless swelling . Round radio-lucent and less

sharply defined . Bony wall lined by thin loose

C.T , RBCs or hemosedrin laden macrophages

Unknown

Unicameral cyst

X-Ray

C.T.Scan


Aneurysmal bone cyst Aneurysmal bone cyst Rare in the jaw . Posterior part of body or

angle of the mandible 10-20 years Firm and painless swelling

. Numerous non endothelial

lining spaces , filled with blood , fibrous septa with giant cells

Rare in the jaw . Posterior part of body or

angle of the mandible 10-20 years Firm and painless swelling

. Numerous non endothelial

lining spaces , filled with blood , fibrous septa with giant cells


Aneurysmal bone cyst Aneurysmal bone cyst Uni or multilocular radio-

lucent Balloon like

Uni or multilocular radio-lucent

Balloon like

Aneurysmal bone cyst


Nasopalatine ( Incisive canal ) cyst Nasopalatine ( Incisive canal ) cyst The most common

nonodntogenic Remnant of nasopalatine duct. Slow growing swelling in the

anterior region of midline palate .

Intermittent salty discharge . Should differentiated from

palatine fossa Incisive papillae

The most common nonodntogenic

Remnant of nasopalatine duct. Slow growing swelling in the

anterior region of midline palate .

Intermittent salty discharge . Should differentiated from

palatine fossa Incisive papillae

Well defined ovoid or heart shape radio-lucent

Pathology:1. Pseudo-stratified columnar .2. Stratified squamous The wall has nerve and small macular arteries

and veins


Globulomaxillay cystGlobulomaxillay cyst Common . Bone fusion between

maxilla and premaxilla Cyst between maxillary

lateral incisor and canine Asymptomatic unless

infected. Pseudo- stratifeid

columnar or squamous Pathogenesis .

Common . Bone fusion between

maxilla and premaxilla Cyst between maxillary

lateral incisor and canine Asymptomatic unless

infected. Pseudo- stratifeid

columnar or squamous Pathogenesis .

Inverted pear shaped radiolucent cyst .


Naso-labial cyst :Naso-labial cyst : Uncommon . Female of 4th decade Upper lip Remnant of nasolacrimal

duct Swelling obliterate the

naso-labial fold and nostrils .

Pseudo-s stratified columnar

Uncommon . Female of 4th decade Upper lip Remnant of nasolacrimal

duct Swelling obliterate the

naso-labial fold and nostrils .

Pseudo-s stratified columnar

Pseudo-startified columnar with mucus cells

1. Median cyst :2. Median mandibular cyst


Lympho-epithelial cyst :Lympho-epithelial cyst : Deep to sternomatoid

muscles or at the level of mandibular angle

Rarely intra-oral . Remnant of brachial arches

. Stratied squamous and the

wall coantins lymphoid follicles

Deep to sternomatoid muscles or at the level of mandibular angle

Rarely intra-oral . Remnant of brachial arches

. Stratied squamous and the

wall coantins lymphoid follicles

Thyro -glossal duct cyst

In the region of hyoid bone .Rarely intra-oral at the midline of tongue or floor


Residual cyst Residual cyst


Glandular odontoGlandular odonto


Trumatic bone cyst Trumatic bone cyst

Jaw bone cyst

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