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Oral Pathology (1) 8th lecture Dr. Rima Safadi <<< Wed. 2.11.2011 >>>

Just a quick advice before we start, make sure to read the slides when you are studying as not all information in the slides were mentioned in the lecture. The doctor started this lecture by telling us that she reviewed the absent lists manually by her own to solve the problems that occurred due to the old and new seating numbers lists, and everything is ok now, and the absents are corrected according to the last seating numbers list, and that the absents are on the E-learning now, so you should not have any further complains!!!, another point the doctor emphasized was that she dont use her office which is on the 10Hs and her office is on the deanship, and she will be there every Sunday and Wednesday afternoon from 1:30 pm to 4:30 pm in the dean assistance office which located in the D1 the floor level, another thing about the absents excuses is that whatever your excuse was you should get it signed from the dean even if it was just simple as I had overslept, you should write it and get it signed from the dean!!! And if it was a medical excuse you should get it signed by the medical committees and by the dean, in order to accept it. Now lets start our lecture, the slides for this lecture are under the title Cysts Of The Jaws 2, as the doctor explain the first few slides in the last lecture she went over them in a bit of hurry. Slides No. (1-16) >>> Overall of OKC Last time we stopped with the OKC, I will continue calling it OKC because it was its name Odontogenic Keratocyst, but now it is called Keratinizing cystic odontogenic tumor as the WHO want to call it now, they changed its classification from the cysts to the tumors, as it is now worse than before, why the OKC is worse than others? The Odontogenic Keratocyst is characterized by several features not present in other cysts, the cyst has high recurrence rate; from 30% to 60% of all OKCs show recurrence, it is possible that the recurrence occurs even after 5 years or 10 years, and it is not necessarily to happen after the first year of treatment, so because of that the diagnosis of OKC is important, when I diagnose a cyst as OKC this is
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significant to the patient, because the patient has to follow us closely and yearly, not only for one year, but for years because it may show recurrence, we said that there is histopathologic features that are Daughter characteristic to the OKC like the cyst columnar basal cell layer, uniform thickness, ribbon like epithelium, sometimes separation between the epithelium and the underlying Bud connective tissue, and most of the times Para-keratenization, and we said all of this in the last lecture. In addition to that we have daughter cysts, the epithelium has a high proliferative potential, so it will proliferate giving buds inside the connective tissue capsule and later on daughter cysts will start forming, so that if the surgeon treated the cyst incompletely, there will be a cyst after that, it will return, because there is a daughter cyst here that will proliferate and come back again. Now what are the features of the epithelium that makes it highly proliferative? First of all it is mitotically active, that means there is a lot of proliferation or a lot of mitotic cells, that means the number of cells increased quickly, in addition to loss of some of the factors that control the cell cycle, do you know what does the cell cycle control mean? It means that the cell cant proliferate forever, we have controls on the rate of the proliferation, here there is a problem with the controlling factors over the cell cycles in addition to the high mitotic rate, and this makes the epithelium mitotically active, that means if the surgeon leave a small piece of epithelium it will proliferate and introduce a cyst later on in addition to the cysts here, now another feature of the epithelium is that it proliferates not uniformly, not all the epithelium proliferate at the same rate, it proliferates focally; that means it is focally active and for this reason the expansion of the cyst is multi-focal, it goes within the marrow of the cancillous bone, where ever there is a proliferation in different spots, sometimes it give us a multi-locular appearance because it has a multi-focal proliferative potential or locations of the epithelium itself, and this is what relates to epithelium, now what about what relates to the connective tissue? The connective tissue capsule is
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different than the other cysts, it is usually lacking the tensile strength, it does not stretch, it rapidly get ruptured, so as it lacks the tensile potential, it may rupture easily, and if it ruptured easily then the total removal of the cyst will be difficult, so we have features of OKC in the epithelium and in the connective tissue itself that increase the recurrence potential rate of this type of the cyst including daughter cysts formation. The best location of the OKC is the posterior part of the mandible angle (photo.1) see the next page - and ramus of the mandible (photo.2), it can be uni-locular or it can be associated with impacted tooth (photo.3), it can be between tow roots (photo.4) like the lateral periodontal cyst, it can be multilocular, it can be located like the naso-palatine duct cyst which we will talk about in a few minutes, between the roots of the maxillary incisors (photo.5), because here we have the naso-palatine duct or the naso-palatine canal, and in the naso-palatine canal there was the naso-palatine duct, later on in the development the naso-palatine duct disintegrated and it gives a remnants of epithelium and these remnants later on may give us a naso-palatine duct cyst, but this finally turned to be OKC, how did we make sure that it was an OKC? By the histopathologic diagnosis, because it has a characteristic features, and here (photo.3) it looks like the dentigerous cyst but it is big.

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5 Growth of the OKC we talked about it and we also talked about the factors that are involved in the active epithelium growth. Slide No.17 >>> Odontogenic Keratocyst Growth Now about the connective tissue capsule we said that it has a little tensile strength, in addition to that there is active growth of the capsule according to the proliferative epithelium, and this means that the epithelium is focally proliferating, and in the focal areas of the proliferative epithelium there is active growth of the capsule, it goes with it; that means if the capsule did not do a proliferation with the epithelium then there will be rupture of the cyst, there is no growth within the bone, there is no folding within the bone, so there is focal active growth also in the connective tissue at the areas of the epithelium, the osteoclasts will start resorbing the surrounding bone just in the areas of the proliferation or in the proliferative areas, there will be focal or local production of interleukin 1, interleukin 6, prostaglandin and collagenase, do you remember these factors as we talked about them when we talked about the radicular cyst, and we said that they are stimulated by inflammation, but here we dont have inflammation, they are focally produced by the cells or the local cells, so these factors induce bone resorbtion increasing the expansion of the cyst, now what is the main direction of expansion? It is mainly anterio-posterior. The Intra cystic pressure actually has a big question mark, because there is a little fluid inside the cyst, and the contents of the cyst are mainly cheesy like material; something white color; which is keratin, the cyst mainly contains keratin and a little fluid, so the osmotic pressure actually is not a factor, it has a very little contribution compared to the other growth factors, for this reason; due to the changes in the cell cycle control factors, due to the high mitotic rate and due to the other factors this cyst now is list with the odontogenic tumors.
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Slide No.18 >>> Odontogenic Keratocyst >>> Management and Prognosis The management and prognosis, the surgical excision, the peripheral ostectomy, now we dont want to do a enucleation, the simple enucleation doesnt work in this cyst, this cyst should be aggressively treated to be sure that there will be no recurrence, or to decrease the rate of the recurrence. Here the doctor write some notes that are not in the book like; after they do a surgical removal they put a Carnoy solution inside the cavity that the cyst was in previously; to kill or minify the remnants of the epithelium, and his is not required; you will take it in surgery. Slide No.19 >>>Odontogenic Keratocyst >>>Reasons of Having High Recurrence Rate Now why does OKC show high recurrence rate? We have just said them; 1) Epithelial budding and satellite cyst formation. 2) Relatively thin fibrous capsule. 3) Thin friable epithelium, we notice that the thickness of the epithelium is thin and continuous; it is from 6 to 10 cell layers, and sometimes we notice a separation below the epithelium, so it can be slot easily. 4) Biologic quality of the cyst epithelium; which is the mitotic rate and the cell cycle control changes. Slide No.20 >>> Odontogenic Keratocyst >>> Management and Prognosis Now if your patient is having multiple Odontogenic Keratocysts you should think about a syndrome called nevoid basal cell carcinoma syndrome, what is this syndrome? It is autosomal dominant, it has a mutation in the tumor suppresser genes called PTCH, tumor suppresser gene. Slide No.21 >>> Nevoid Basal Cell Carcinoma Syndrome What do we have in this cyst? In this syndrome we have oral features including multiple OKCs, here (Slide No.22) we have two of them clearly
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seen, but the others are not clear, so we have multiple odontogenic keratocysts.

OKC

OKC

Now about the skin features, the patient has multiple basal cell carcinomas, starting at early age, you know that in basal cell carcinoma the 1 sun exposure is a factor, but here may be there is no sun exposure, may be the patient is young but he will have multiple basal cell carcinomas. Like this patient here (Slide No.23). Also they have hypertelorism which means increase in the inter-pupillary distance, and this is also one of the features. See here (Slide No.24) the basal cell carcinoma, the treatment of it is by Mohs surgery the doctor is not sure if it is written in the book or not; it is done as they remove the basal cell carcinoma; the lesion, but they dont remove a big safe margin, because we have several basal cell carcinomas, and that means the whole faces skin may be removed; so they start removing a little safe margin then they send it to the pathology lab for frozen section, and they ask for immediate response; is the margin free or not, and if it is not they remove a little bit more and ask for a response, and if it is not then they remove a little bit more again, but they cant remove a big save margin (1), so they should be careful when treat the basal cell carcinomas. Look here (Slide No.25) it may occur in areas that are not really
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exposed to the sun (2), but it happened because there is a problem in the tumor suppresser gene, and here (Slide No.26) there are bits on the skin and may be skin tumors also (3). 2

3 Slide No.27 >>> Odontogenic Keratocyst In Basal Cell Nevus Syndrome Odontogenic Keratocyst syndromic cysts have the same histopathologic features as any other odontogenic Keratocyst nonsyndromic cysts, which are uniform thickness, para-keratin on the surface, corrugated surface, separation from the under laying tissue, ribbon like appearance of the cyst, you should memorize these features as your names. Slide No.28 The falx cerebri is calcified, this white thing here; calcification in the falx cerebri. Slide No.29 >>> Basal Cell Nevus Syndrome Now we talked about the treatment before, but the lifespan is that the patient lives normally, and it does not affect the lifespan of the patient. Slides No.30+31 >>> Orthokeratinized Odontogenic Cyst Now suppose that we have these
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features which are typical of OKC and also we have an ortho-keratin not para-keratin, can we change the diagnosis? Or should we change the diagnosis? No, because ortho or para keratin it doesnt matter, what is important that we have the histopathologic features of the epithelial lining, because these cells are the cells which have a biologic activity that allows them to proliferate, and not the type of the keratin that affect. Now suppose we have ortho-keratin, but we have simple lining, like this (Slide No.45~Cysts Of The Jaws 1), a cyst that have this simple lining, no hyper chromatic columnar cells, no palisading, no ribbon like appearance, but there was keratin, will you call it OKC? No. So what should we call it? instead of calling it odontogenic keratocyst keratocyst is the important word here we should call it odontogenic cyst, but we add a descriptive term in the beginning, we say keratinizing odontogenic cyst, it is a regular odontogenic cyst, and it is not characteristic or a specific type, it is just an odontogenic cyst, but it is keratinizing, and this is how we know that it is not an OKC, but if you saw the word keratocyst it means OKC or the tumor variant of it, so keratin with normal lining or with a non-specific lining will be keratinizing odontogenic cyst, and we will see it in a few minutes. Slide No.32 >>> Orthokeratinized Odontogenic Cyst >>> Management and Prognosis Now why should I tell the clinician? Is it important to know if it is a keratinizing odontogenic cyst or an OKC? Yes, it is important, but why? Because the keratinizing odontogenic cyst has a very low recurrence rate 2% compared with 60% of the OKC, the keratinizing odontogenic cyst does not required aggressive treatment or extensive follow up, while OKC requires aggressive treatment and follow up. And this is an example (Slide No.31), this is a cyst lining, it is epithelium, and I cant see the columnar basal cell layer which is hyper chromatic, and I cant see any palisaded, but here in the lumen we have keratin the red color and this type is called ortho-keratin, because I dont see pecnotic
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nucleoli, so keratin with non-specific lining is called keratinizing odontogenic cyst or ortho-keratinized odontogenic cyst, but mainly it is called keratinizing odontogenic cyst, and we said what is its significant. Slide No.33 >>> Questions Now the question is: suppose that the OKC was secondarily inflamed, the inflammation comes from the adjacent tooth, what will happen to the histopathologic features? Will they still be characteristic? No, the inflammation affects the specific histopathologic features, because inflammation induce hyperplasia in the epithelium, so there will be no more thin lining or separation from the underlying connective tissue, even the basal layer become hyper plastic and we will lose the characteristic features of the OKC if there was inflammation. Slides No.34+35+36 >>> Lateral Periodontal Cyst Another developmental cyst, as we said the OKC is a developmental cyst and it is a non-inflammatory cyst arising from the remnants of the dental lamina, the dentigerous cyst is a developmental odontogenic cyst arising from the reduced enamel epithelium, now also from the dental lamina there is a cyst called the lateral periodontal cyst, and it is called lateral because it occurs on the lateral aspect of the root, and it is called periodontal because it occurs in the periodontal space, and it is called cyst because it has an epithelial lining and it is a cyst. Slide No.37 >>> A Radiograph Now let us look at the radiograph to understand the terminology, so it is lateral because it is lateral to both teeth in this case, and periodontal because it occurs between the teeth and some times in the periodontal space, and cyst because it is cystic, now this cyst although it originates from the dental lamina remnants like the OKC, but this is a simple, small cyst and does not show a recurrence and does not grow in big sizes and it doesnt need aggressive treatment and it enters in the differential diagnosis of the OKC and lateral radicular cyst; because it looks like both of them.
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Slide No.38 >>> Lateral Periodontal Cyst >>> Histopathologic Features Now do we need the tooth to be necrotic or non-vital to have this cyst? No, actually this cyst usually occurs with vital teeth, but it is possible for coincidence to find this cyst with a non-vital tooth, but when I take it to the histopathology examination it may turn to be lateral periodontal cyst and not lateral radicular cyst, this means that not every cyst associated with a non-vital tooth should be radicular or inflammatory, it may be lateral periodontal cyst, if we take it to the microscopic examination we see differences in the thickness of the epithelial lining. Slide No.39 Here we have very thin lining relatively thin lining 1 and then we have thick plaques 2, thick layers or thick areas of the lining, then you do back to thin lining 3, then all the sudden it is thick 4, we dont see this feature in OKC, in 4 1 2 3 OKC there is uniform thickness, so this feature distinguish the lateral periodontal cyst, and there are lots of glycogen within the epithelium, this means that in the thick areas the cytoplasm of the epithelium contains glycogen, so it looks pale, thin 1 ~ thick 2 ~ thin 3 ~ thick 4, so this is a lateral periodontal cyst. Slide No.40 >>> A Radiograph The most common location for the lateral periodontal cyst is in the mandibular premolar area, it is well defined radiolucency, small ~ less than 1 cm, and it does not need an aggressive treatment or any other thing. Slide No.41 >>> A Radiograph Another example of the lateral periodontal cyst, although there is a filling here. Slide No.42+43 >>> Lateral Periodontal Cyst >>>
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Management and prognosis, simple surgical removal, occasionally it could be multi-locular, but they call it botryoid, just like the grapes looks like, and that is why it is called occasionally multi-locular, and if it is multi-locular radio graphically, then we need some curettage of the area; to prevent the recurrence. Slide No.44 >>> Gingival Cyst of The Adult Now do you remember the dentigerous cyst? We said that it is completely present within the bone, it is central, and we said that when the tooth Gingival Normal erupts, the cyst will cyst of the epithelium be called eruption adult tissue cyst; because it is going to erupt, now the lateral periodontal cyst is also inside the bone, not outside; that means it is not in the gingiva, but we may have a similar cyst that is located in the gingiva, in the soft tissue, so now it is no longer bony, so now we call it gingival cyst of the adult, why do I say of the adult? Because there is a gingival cyst of the new born, so usually we dont say just gingival cyst and stop there, we say either gingival cyst of the adult or gingival cyst of the new born, depends where it appears or presents. Now this is the sac and here (1) is the cyst, it is presented within the soft tissue, there is no bone here, and this here (2) is a normal epithelium, surface epithelium, this whole biopsy is taken from the gingiva.

Slide No.45 >>> Questions For now we have talked about OKC, lateral periodontal cyst, gingival
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cyst of the adult and the dentigerous cyst, and these 4 cysts are developmental cysts. Now what is the most common developmental cyst between them? It is the dentigerous cyst. Which one of them has the highest recurrence rate? It is the OKC. What is the cyst that was put with the tumors now? It is the OKC. Now among all the cysts that you have heard about, what is the cyst that should be associated with a non-vital tooth? It is the radicular cyst, which is an inflammatory cyst. Now we will move to other slides with the title Odontogenic Cysts 3 and 4 Slide No.1 >>> Paradental Cyst Now we have another inflammatory cyst which is called paradental cyst, now how many inflammatory cysts we have talked about until now? This one is the second one, and all the others were developmental cysts, the paradental cyst is an inflammatory cyst that occurs on one side of a partially erupted tooth, because of that we have inflammation here, because the tooth is partially erupted, there is a communication with the oral cavity and bacteria enters between the tooth and the surrounding soft tissue, then the inflammation occurs, and then proliferation of the remnants of reduced enamel epithelium which are present at the side of the tooth and it is partially covering the unerupted tooth, as we said this is a partially erupted tooth, and its crown is covered with the reduced enamel epithelium, and the partially erupted tooth with the remnants of the reduced enamel epithelium, if it gets stimulated with an inflammation it may proliferate, now why some teeth will have a paradental cysts and others dont (not all the teeth have a paradental cyst), now some of the teeth which are completely erupted or fully erupted may have paradental cyst, why? As it is fully erupted from where the inflammation will come? The cause here is that the tooth may have a cervical enamel extension, do you remember when we talked about
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the developmental changes we said that the enamel may occur in an abnormal location; like enamel pearl and the cervical enamel extension, it goes downward from the crown to the root surface, and we said that the significance of it is that there will be lost of the PDL attachment; so a pocket will be formed, and then the bacteria will enter, and an inflammation will occur, then there will be a proliferation of the epithelium and finally a cyst formation, occurring in any root surface where a cervical enamel extension is present, the histology is just like the radicular cyst, but it is an inflammatory cyst, and there may be a rushton bodies, or cholesterol clefts, and we may see also hyperplastic epithelium due to the inflammation, and there may be a mucous metaplasia. Slides No.2+3+4 >>> Glandular Odontogenic Cyst Now we will start with another new developmental cyst which is called the glandular odontogenic cyst, and it is called glandular because it acts like a gland or a gland-like structures in the lining, and this gland-like structures are mucous cells, see this empty cells here (Slide No.3), they are mucous cells, and this thing here is a mucus material or a water-like material which is inside the cells, and these cells here are mucous cells, and when the mucous cell aggregate or accumulate, they give us a glandlike appearance, and that is why they call it a glandular cyst, but it is a glandular odontogenic cyst, because these mucous cell came from metaplasia of the odontogenic epithelium, so it is called a glandular odontogenic cyst. Now does it have specific features? Yes, it has a characteristic location and it has a special clinical behavior, the location of it is or it prefers to present in the anterior part of the mandible, it may be multi-locular, and also it has a relatively higher recurrence rate, now this cyst is the second one which has a high recurrence rate, and the first one or the main one or lets say the boss of them is the OKC, now as the glandular odontogenic cyst also may show a high recurrence rate, so it needs an aggressive surgical removal, curettage and so on.
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Also it has a strong predilection to the anterior part of the jaws, especially in the mandible, and it comes with pain or paresthesia some times; now when the paresthesia occurs? When it makes a compression or a pressure on the nerve, especially the mental nerve which is present here or its branches. And about the prognosis we said that it is potentially aggressive, locally invasive and it has a tendency to re-occur, so it needs a slightly aggressive treatment. Slide No.5 >>> Non-odontogenic Cysts of The Jaw Now we have finished the cysts which have an odontogenic lining, where its lining epithelium is from odontogenic origin, now we will start with the cysts which have a lining which is non-odontogenic. Slide No.6 >>> Naso-palatine Duct Cyst (Incisive Canal Cyst) We talked a little bit about the naso-palatine duct or the nasopalatine canal, in the embryo the naso-palatine canal were containing the naso-palatine duct, and later on the naso-palatine duct will disintegrate leaving remnants, what else do we have as you took in the anatomy course? What else does the naso-palatine canal contain? What exits from it and enters the oral cavity? The naso-palatine nerve, the naso-palatine artery, the remnants of the duct as it disintegrated and disappeared and the neurovascular bundle; that means we have a vein, nerve and an artery, that enters this canal and goes down toward the oral cavity. Now this naso-palatine canal end with the incisive papilla intra-orally, which is located between the roots of the central incisors, the naso-palatine duct cyst is possible to be anywhere along the nasopalatine canal, it may occur intra-orally in the soft tissue; like in the incisive papilla and then we will call it the cyst of the incisive papilla, or the cyst could be anywhere along the naso-palatine canal, it may be here in the bone, or it may goes a little bit above or more; like between the nose and the oral cavity. Slide No.7 >>> Naso-palatine Duct Cyst (Incisive Canal Cyst) >>> Clinical Features
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It is non-odontogenic cyst, and intra-orally it may present as a swelling and it may drain pus if it was secondarily inflamed. The naso-palatine duct cyst is a non-odontogenic cyst, it is a true cyst and it is a developmental cyst; that means it occurs by itself without a previous warning, and the cause is idiopathic, there are no predisposing factors for the developmental cysts, and no one can determine whether to have an OKC or not, or to have a noso-palatine duct cyst or not, there are no predisposing factors for this cyst. In the naso-palatine duct cyst they say that there may be a trauma or an inflammation and etc., but in general it is a non-inflammatory cyst. It may happen with a vital or a non-vital teeth; it does not matter, unlike the radicular cysts. Slide No.8 >>> Cyst of the Incisive Papilla (Cyst of Papilla Palatina) We said about the cyst of the incisive papilla that it is a soft tissue cyst. Now how many cysts we talked about and it occurs in the bone, and at the same time has a soft tissue counterpart? Go and revise it. >>> may be there are 3 of them, but Im not sure. Slide No.9 >>>Nasopalatine Duct Cyst (Incisive Canal Cyst)>>>Radiographic Features Now lets look to this radio graph (Slide No.10) photo.1, here we have a heart-shaped radio-lucency presents at the mid line of the maxilla, also here (Slide No.11) photo.2, there is an inverted heart shaped radiolucency; because we have here the nasal spine, which will be super imposed over it, so that will give us the heart shaped, and in the mid line between the roots of the central incisors it may push the central incisors roots and cause a displacement of them, and it may induce a root resorption, because it is chronic which means a continuous pressure here.

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Slide No.12>>>Naso-palatine Duct Cyst (Incisive Canal Cyst)>>>Microscopic Features Before we start talking about the microscopically features of the naso-palatine duct cyst, what do you expect the lining of the nasal cavity and the maxillary sinus to be? What is their type? It is ciliated pseudo stratified columnar cells, so the lining of the naso-palatine duct cyst may contain ciliated pseudo stratified columnar cells or squamous epithelial cells, or mucous metaplasia, it is like a mixture of the lining epithelium which could present there. Also as the naso-palatine canal contains a neurovascular bundle, so that we may find a prominent neurovascular bundles in the cyst wall, so when they remove it and send it to do the biopsy tests in the lab we may find a big or a prominent neurovascular bundles. Slide No.13 >>> Naso-palatine Duct Cyst Here you can see a mucous cells and a ciliated pseudo stratified columnar cells.

Slide No.14 >>> The Concept of The Median Cysts In the book they wrote a little bit about the median cysts, previously they were saying that there is a median cyst that occurs in the mid line of the palate and it is separate than the other cysts, but actually now it turned to be that the median cyst is just a descriptive term of a cyst which can be a naso-palatine duct cyst or an OKC or a radicular cyst or it can be any other odontogenic cyst, this means that we dont have a separate cyst which is called the median cyst,

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the median cyst is now a description of any cyst that occurs in the mid line of the palate. Slide No.15 >>> Extra-osseous Developmental Cysts >>> The Naso-labial Cyst Now we almost finished the bony cysts; there is a one more bony cyst. Any way lets now talk about the soft tissue cysts, which are cysts that occurs in the soft tissue, as we talked about canals, and we talked about the naso-palatine duct remnants, we also have a nasolacrimal duct remnants, when the person gets tears inside his eyes, where will some of the tears go? To the nasal cavity; as you took in the anatomy we have an opening of the naso-lacrimal duct within the nasal cavity, and the theory here is that there may be a displacement of this naso-lacrimal duct during the development or during the embryogenesis, so it goes out of the nose or a remnants of this duct remained outside the nasal cavity, so later on a developmental cyst may occur and develop from the remnants of the naso-lacrimal duct, and this swelling in the soft tissue here between the nose and the lip and on the lateral aspect of the nose is called a naso-labial cyst. Is it true cyst or pseudo cyst? Do you know what is the difference between the true and the pseudo cysts? IT is that the true cyst has an epithelial lining, and the pseudo cyst does not have an epithelial lining. So the naso-labial cyst is a true cyst; because it has an epithelial lining which comes from the naso-lacrimal duct remnants. Now every duct is lined be epithelium, the ducts of the minor salivary glands, the naso-lacrimal and the naso-palatine ducts. Any duct is lined be epithelium, so when we say remnants of the naso-palatine or the naso-lacrimal this means that we have an epithelial lining.

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Slide No.16 >>> Non-epithelial (Pseudo cysts) of The Jaws The pseudo cysts that occurs in the jaws, we have more than one cyst named pseudo cyst that is occurring within the jaws bone. Slide No.18 >>> The Trauma-hemorrhage Theory Now before we talk about these pseudo cysts we have the traumahemorrhage theory, some times when the patient or a child get a trauma to the mandible a box for example, what will happen? May be there will be a bleeding and a hemorrhage within the bone inside the bone, now if there is a clot formation or coagulation of the hemorrhage after the clot formation there will be an organization of the clot and bone may form again and then the cavity will be closed or the bleeding will disappeare, and this is the normal situation or how the healing occurs in any organ, like if you have a skin cut or an injury, then there will be clots on the surface and then the clot later on will go on an organization and it will transform to other type of tissues, so if hemorrhage occurs within the bone and a clot was form and organization of the thrombus or the clot occurs, this may end up without a cavity. Now if hemorrhage occur and disintegration of the thrombus occurs and the clot is gone, we will end up with a cavity an empty cavity, and this is one end, the best is to have organization of the thrombus and bone formation, then we may have a cavity and the other extreme is that the hemorrhage will be accumulated within the cavity, and the blood gets accumulated within the cavity without an endothelial lining not like blood vessels it just get accumulated and it is surrounded by a connective tissue. Slide No.17 >>> Solitary Bone Cyst Now if the cavity is empty we call it solitary bone cyst, which is also called traumatic bone cyst, simple bone cyst and idiopathic bone cyst, it is an empty cavity containing nothing or very little amount of a connective tissue, and it occurs more in children; because they say that it is following the trauma-hemorrhage theory which is more in children and adolescence, and it may cause a bone expansion. There was only one case interesting that Dr.Rima faced before, it was very obvious case of solitary bone cyst occurring in the ramus of the mandible causing bone expansion for a teenager, which has a significant expansion, but the other solitary bone cysts were without expansion.
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So 25% of the solitary bone cyst causes bone expansion, and it is mostly in the molar region. Slides No.19+20 >>> Radiographic Features + Treatment and Prognosis Also it has a characteristic feature which is the scalloping between the roots, it goes up and down between the roots, and as we said it follows the trauma-hemorrhage theory, it is rarely multi-locular, and sometimes we need a surgical intervention, but why? Why some times this will not heal unless we perforate the cyst? To induce another hemorrhage so that a thrombus may form and organization may occur and the cyst may close. And also to establish the diagnosis; if we were suspecting with another thing. Slide No.21 >>> Aneurysmal Bone Cyst The aneurysmal bone cyst is what? What we have just said about it? The aneurysmal bone cyst is the cyst which is on the other extreme of the trauma-hemorrhage theory; as we said its either we have a closure or an empty cavity or a collection of hemorrhage or blood within the cavity or within the connective tissue, and this is called the aneurysmal bone cyst, it may be rapidly expanding, and it may cause a gross disfigurement of the patient as it cause an expansion rapidly and it contains a lot of blood, so if it is perforated it may bleed heavily, it occurs mostly in the posterior part of the mandible, it may be occur alone by itself due to a trauma or it may occur in an association with other lesions, this means that it could be a primary or a secondary, the other lesions are like the giant cell granuloma or like the fibro-osseous lesions, and you will take these things later on when we talk about the bone lesions. Slide No.22 >>> Aneurysmal Bone Cyst >>> The Pathogenesis The pathogenesis for it is controversial or uncertain, the traumahemorrhage theory again, or the haemodynamic disturbance.
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Slide No.23 >>> A Radiograph See how it looks multi-locular, and the bone is expanding (see the arrows), and the pressure is too much; as it causes some times an external root resorbtion associated with it, other than the displacement of the teeth. So when the lesion is rapidly growing it will resorb the teeth, and there is no time for the teeth to be displaced, when the lesion is chronic, or over a long periods of time the roots may be displaced and it may be resorbed. Slide No.24 >>> Aneurysmal Bone Cyst >>> Microscopic Features Microscopically we have pools of blood surrounded by multinucleated giant cells, and I did not say surrounded by endothelial lining, because if you go back to the definition of the blood vessels or the capillaries you will find that the capillaries and the blood vessels are lined by endothelial cells, but here we dont have an endothelial lining, so these are not true blood vessels, they are just accumulation. Slides No.25+26+27 >>> Lingual Bone Defect Do you remember the lingual bone defect? That one we have taken before, it is called the Stafne bone defect, it occurs below the ID canal, and also we talked about the lingual bone defect that is possible to occur in the anterior part of the mandible, so go back to the developmental changes for these two lesions, but here because of the cysts we will say that these are not true cysts, these are concavities in the lingual aspect of the bone. Slide No.28>Cysts of the Soft Tissue>The Salivary Mucocele>Extravasation mucocele We still have a little things to talk about, we have what is called the

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Pools of saliva

2*

salivary mucoceles, now as you took previously in the anatomy and the histology; the salivary glands are lobules and ducts that exits from it, and in the oral cavity there are a lot of minor salivary glands with ducts that open in the inside of the oral cavity, the labial mucosa, the lower labial or the whole labial mucosa. Now where there are no salivary glands or minor salivary glands in the oral cavity? In the anterior part of the hard palate, on the gingiva, the anterior tow thirds of the dorsum of the tongue; because posteriorly there are the Von Ebners glands. But any other location like the lateral border of the tongue or the ventral surface of the tongue, the floor of the mouth, the upper and the lower labial mucosa, the buccal mucosa and the soft palate, it contains minor salivary glands. A trauma to the minor salivary glands, the lower lip which is supposed to trauma very much like box for example, what will happen to the lower lip? One of the complications is to have a leakage of saliva from the minor salivary glands, we have two cases either we may have a leakage out of the duct or we may have accumulation of the saliva 1 2 within the duct, now look to this photo (Slide No.29), here we have a duct photo.1, and we said that the ducts are lined with epithelium, and suppose that we have saliva accumulation here, so we have fluid, and now we will have a fluid lined in a cavity that is lined by epithelium, so this is a cyst; there is a fluid and a cavity lined by epithelium, so here we have a cyst, and in this case we will call it a retention mucocele, the retention mucocele is a true cyst; it has a lining epithelium, but when the saliva goes out of the duct photo.2, a rupture of the duct or the salivary gland lobules occur, here in the center we have a cavity, and we have a wall, but we dont have an epithelial lining, because all the saliva goes out of the duct see the 2* arrow, and we dont have an epithelial lining, so we call it pseudo cyst. So we have pseudo cysts and we have a true cysts in the mucoceles, the true cyst is called the retention mucocele, where the saliva is retained inside the duct, and the extravasation mucocele is a pseudo cyst, where there is no epithelium, and the saliva leaked out of the duct and it is
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accumulating within the connective tissue, and as the saliva is a foreign body; the body will try to localize it by granulation tissue, so here we have a granulation tissues surrounding the pools of saliva; the saliva appears as a pools or accumulations, so the pools of saliva are surrounded by granulation tissues without epithelial lining. What do we see in this wall? We see fibroblasts, blood vessels and a lot of inflammatory cells; mainly macrophages, the macrophages here are coming to engulf the saliva, to induce a healing of the area, so we have here macrophages which are engulfing the saliva. So the extravasation mucocele is not lined by epithelium, and the retention type is lined by epithelium, most of the mucoceles occurs in the lower lip, and most of the mucoceles are extravasation type. Now how do they appear clinically? They appear bluish; because they contain fluid, so they give us a bluish translucent submucosal swelling, and usually the patient gives us a history of a trauma, and they fluctuate in size, sometimes the saliva leaks and increase the size of the mucoceles, and sometimes there is decreased, maybe we can say that the lower lip is swollen, but it may be increased or decreased inside, and this is the fluctuant size. Slide No.30>>>Cysts of the Soft Tissues>>Salivary Mucocele>>>Retention Mucocele The retention we said that it is lined by ductal epithelium. Why there is no inflammatory reaction in the retention mucocele? Because the saliva is still inside the duct, it does not go out of the *** As you may be confused now, the salivary mucoceles which we talked about till now are of two types: Type 1 is the extravasation mucocele which 70% of its cases occur in the lower lip. And Type 2 is the retention mucocele which is rare in the lower lip. duct or the saliva did not leak to induce an inflammatory reaction, it is still contained within the duct.

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There were a question by a student which I couldnt hear, but here is the doctors answer: the retention mucocele has more than one cause, it could be traumatic and it could be due to a stone in the duct; may be a stone will close the duct, so all the saliva will be accumulating in the other part or the posterior part of the duct, so it will cause the retention mucocele. Slide No.31 >>> Ranula Ranula is a mucocele that occurs in the floor of the mouth, maybe it is mainly from the sublingual salivary gland, a trauma to the sublingual salivary gland may leak saliva in the floor of the mouth inducing an extravasation type of mucocele. What is the plunging ranula? It is a ranula occurring in the floor of the mouth that goes through the mylohyoid muscle and present extra orally, and you know we dont like these things to be in the floor of the mouth; because it will cause an elevation to the tongue, it may have an effect vocally or it may affect the larynx, or it may affect the are ways; and that is why it is called the plunging ranula. Slide No.32 >>> Ranula >>> Clinical Photo And here is an example, it didnt leak through the mylohyoid muscle, it presents intra orally as a ranula, which is a swelling, bluish translucent in the floor of the mouth, from the sublingual salivary gland, and actually it is from the extravasation type. The same appearance of it may be seen in another cyst which is called the dermoid cyst. Slide No.33 >>> Dermoid and Epidermoid Cysts The mucoceles when subjected to pressure or palpation it has fluidcells, while when doing a palpation for the dermoid cyst it does not have fluid-cells, so what does the dermoid cyst contain? It contains epithelial cells, but before that lets answer this question; what is the different between the dermoid cyst and teratoma? What is teratoma? Teratoma is a tumor which has two aspects a benign and a malignant. Do you hear before about someone with a hair cyst? And where does
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it occur most of the times? It occurs mainly in the mid line of the back; because the mid line of the body is the area where the three layers of the embryo; the ectoderm, the mesoderm and the endoderm meet and fuse, now the floor of the mouth is a mid line, so we may have dermoid cysts and we may have teratoma in the floor of the mouth. The dermoid cyst does not contain all products of the three germ layers; it may have two of them, where the teratoma contains products of the three germ layers. In the teratoma we may find teeth, but in the dermoid cyst we may find epithelium and hair and may be other contents or components, but not teeth and other products like the intestine, but we may have it in the teratoma. So the dermoid cyst is a developmental lesion, which occurs usually in the mid line of the oral cavity or in the mid line of the back, and maybe there is entrapment of the epithelium in the mid line, it is lined by ortho-keratinized epithelium, it contains keratin, and it also contains a skin appendages; which means the things that appears or emerges from the skin; like the hair and the sebaceous glands which are associated with the hair. Now suppose that we dont have hair, but we have only a squamous epithelial lining of this cyst, so what should we call it? In this case we call it epidermoid cyst, where the cyst is lined only by epithelium and it is not containing hair appendages, but when it is containing hair appendages we call it dermoid cysts. You should know how to distinguish between the dermoid cyst and the epidermoid cyst. Slides No.34+35+36 >>> Lymphoepithelial Cyst The last soft tissue cysts we will take about today are the lymphoepithelial cyst, we talked about these cyst in the developmental changes, as we said that we have oral lymphoepithelial cyst; because we have a lot of lymphoid tissue in the oral cavity, and again the locations that contains a lot of lymphoid tissue are the lateral border of the tongue, the soft plate, the floor of the mouth, in addition to other locations. Here the lymphoid tissue may have entrapped epithelium, the
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epithelium may enters these lymphoid tissue, and this epithelium may proliferate later on, and it may form a cavity lined by epithelium and surrounded by a wall of lymphoid tissue, it is called lympho because the wall is lymphoid, epithelial because the lining is epithelium, and cyst because it is a cyst. Now what does it contain? It contains sloughed epithelium +/- keratin and products of the lining epithelium. What are the locations? The soft palate and the lateral tongue. How does it look clinically? It looks as a small soft swelling which is yellowish in color. What is these black dots here (Slide No.36)? They are lymphocytes, this is a lymphoid tissue, it seems like the same structure as the lymph node, and also we have germinal centers here. If this cyst occurs extra orally; in the neck, we call it cervical lymphoepithelial cyst, which has a characteristic location; anterior to the sterno-cleiodo-mastoid muscle, but here we dont have a mucosa. So here from where dose the lymphoid tissue come from? It comes from the lymph nodes. And from where the epithelium came? May be it is a remnants of the branchial arches or traumatic displacement of the epithelium, because of a trauma the patient had during the development, the epithelium may enter the lymph nodes causing a developmental cyst called the lymphoepithelial cyst. So the lymphoepithelial cyst either it is cervical or intra orally it has the same histopathologic appearance, the lymphoid tissue, there is a cavity lined by epithelium and containing sloughed epithelium or keratin. But the pathogenesis is different, here in the cervical lymphoepithelial cyst it could be from branchial arches remnants and there in the intra orally lymphoepithelial cyst it is just displacement of the epithelium in the underlying lymphoid tissue. Slide No.37 >>> Thyroglossal Cyst The thyroglossal cyst, we talked about it before in the developmental changes, so read it from the developmental changes.
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The End

.Im really sorry for being late, but it is Eid .I wish you all get high marks in your exams

.Done by : Raja Amin El-haddad - ... ... ... ...

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