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ODONTOGENIC CYST AND

NON ODONTOGENIC CYST


NIA KANIA MD Ph.D
PATHOLOGIST

Oral cavity cysts


Oral cavity cysts
exist in jaw bones
and soft tissue,
gingiva
Odontogenic:
arise from tissues
involved in tooth
formation
In jaw, cysts :
odontogenic or
non-odontogenic in
origin

Epidemiology
Most common odontogenic cyst is periapical /

radicular cyst (inflammatory cyst), followed by


dentigerous cyst, which is usually considered
developmental, but can arise from
inflammation

ODONTOGENIC CYST AND NON


ODONTOGENIC CYST
Odontogenic cyst,classified into three groups:
Inflammatory : periapical / radicular cyst
Developmental : lateral periodontal cyst,

dentigerus
cyst
Neoplastic : keratocystic odontogenic
tumor
Non-odontogenic cyst: nasopalatine duct cyst

site
Odontogenic cyst,
inflammatory: originate in
tooth bearing areas of
maxilla and mandible;
precise location depends on
cyst type
Odontogenic cyst,
developmental or
neoplastic: variable location
within maxilla or mandible
depending on cyst type

Odontogenic cysts are variable, depends on


cyst type
Rests of Malassez (from Hertwig's epithelial
root sheath): small spherules of 6-8 epithelial
cells with high nuclear to cytoplasmic ratio;
little or no reverse polarity of cells

1. Periapical (radicular)
cyst
Inflammatory

odontogenic cyst
Lined by epithelial
cells derived from
rests of Malassez
Also called radicular
cyst, apical
periodontal cyst, root
end cyst, or dental
cyst

Disebut juga

Periapical cyst

Radicular cyst

Terminology
Epithelial rest of Malassez:
Derived from Hertwig's epithelial root sheath
Small spherules of 6-8 epithelial cells with high nuclear to

cytoplasmic ratio
Little or no reverse polarity of cells
Periapical cyst: present at root apex
Lateral radicular cyst: present at the opening of lateral
accessory root canals
Residual cyst: remains even after extraction of offending
tooth
Periapical granuloma: chronic granulomatous inflammation
of periapical tissues

epidemiology
Most common odontogenic cyst (52% of jaw

cystic lesions)
Most common in 4th & 5th decades, but
occurs over wide age range
site
60% in maxilla (vs. mandible)
Most commonly in apex of lateral incisors, but
also along lateral accessory root canals

site
60% in maxilla (vs.

mandible)
Most commonly in
apex of lateral
incisors, but also
along lateral
accessory root canals

Radiology, clinis
appearance

microscopis
Lined by stratified squamous epithelium of variable

thickness, often with scattered ciliated cells


Exception is when epithelium is derived from maxillary
sinus and thus lined with respiratory epithelium
(pseudostratified ciliated columnar epithelium), may have
acute inflammatory cell infiltrate
Rushton's hyaline bodies: amorphic, eosinophilic, linear
to crescent shaped bodies, found in epithelium of 10% of
periapical cysts
Fibrous capsule: varying thickness with chronic
inflammatory cells, plasma cells may be particularly
prominent
Cholesterol clefts are common within cyst lining

Lined by

stratified
squamous
epithelium of
variable
thickness, often
with scattered
ciliated cells

Rushton's hyaline

bodies: amorphic,
eosinophilic, linear

Cholesterol

clefts are
common
within cyst
lining

2. Lateral periodontal
cyst
Non-keratinizing, developmental odontogenic

cyst which occurs along the lateral tooth root


surface within bone
Botryoid odontogenic cyst: Multicystic
variant of lateral periodontal cyst (LPC),
generally larger (5-45mm) with higher
recurrence rates (up to 33%) than LPC

epidemiologi
Usually 5th to 7th decade of life
Rare in patients less than 30 years of age
Favor males 2:1
Accounts for less than 2% of all jaw cysts

Most common adjacent

to roots of cuspid or
bicuspid teeth
60-80% occur in
mandibular premolarcanine-lateral incisor
area, but favors
premolar-canine region
When occur in maxilla,
usually involve this
same tooth region but
favors incisor area

Intraoral swelling
Most common adjacent

to roots of cuspid or
bicuspid teeth
60-80% occur in
mandibular premolarcanine-lateral incisor
area, but favors
premolar-canine region
When occur in maxilla,
usually involve this
same tooth region but
favors incisor area

Thin, generally non-inflamed fibrous connective tissue wall


Non-keratinized epithelial lining of cuboidal to stratified

squamous cells
Epithelium is 2-5 cells thick in most areas
Foci of PAS+ glycogen rich clear cells interspersed among
lining epithelial cells
Focal nodular areas of epithelial thickening that may have
a whorled, swirling architecture, and appear in continuity
with the epithelial lining
These mural epithelial plaques extend into the fibrous
connective cyst wall, or may protrude into cyst lumen
Epithelial rests (may or may not be clear cells) can be
seen in fibrous wall
Botryoid odontogenic cyst has more pronounced mural
thickenings/protrusions, comprised of multilocular cysts
with thin fibrous septations and typically has a multilocular,
often larger radiographic appearance

Thin, generally non-

inflamed fibrous
connective tissue wall
Non-keratinized
epithelial lining of
cuboidal to stratified
squamous cells
Epithelium is 2-5 cells
thick in most areas

Focal nodular areas

of epithelial
thickening that may
have a whorled,
swirling
architecture, and
appear in continuity
with the epithelial
lining

terapy
Enucleation, curettage or excision with

preservation of adjacent teeth is adequate for


conventional LPC
Good prognosis with rare recurrence

3. Dentigerus cyst
Developmental odontogenic cyst that

originates by separation of dental follicle from


around the crown of an unerupted tooth
Diagnosis requires correlation with
radiographs or knowledge of radiographic
findings
Dentigerous cyst also called follicular cyst

Second most common

odontogenic cyst
Most common developmental
odontogenic cyst
Multiple simultaneous
dentigerous cysts uncommon
Represents 20% of epitheliumlined jaw cysts (
Usually seen in
teenagers/young adults,
although can occur over a
wide age range

In normal tooth development, tooth enamel is

produced by the enamel organ, an ectodermally


derived specialized epithelium
After enamel formation is complete, the enamel organ
epithelium atrophies
This reduced enamel epithelium eventually merges
with the overlying mucosal epithelium to form the
initial gingival crevicular epithelium of the newly
erupted tooth
Dentigerous cysts form when fluid accumulates
between the reduced enamel epithelium and the
crown of the unerupted tooth

Clinical appearances
May be small /

asymptomatic, identified
on routine radiographs
taken for unrelated reasons
or for imaging to
investigate delayed tooth
eruption
Can grow large enough to
produce a painless bony
expansion, can displace the
involved tooth, cause
resorption of adjacent teeth
If secondarily infected, may
be associated with pain

CT scan showing

lesion pushing the


inferior wall of the
sinus

Microscopic features are

influenced by presence of
inflammation Inflamed
Dentigerous Cyst: Fibrous
connective tissue
Hyperplastic non-keratinized
epithelium, sometimes elongated
interconnecting rete ridges
Chronic inflammatory cells
Cholesterol clefts, possibly
formation of cholesterol
granuloma
Rushton bodies
Scattered mucous, or ciliated or
sebaceous cells uncommon but
possible
Occasional dystrophic
calcifications
Odontogenic epithelial rests,
small, inactive appearing

Non-inflamed Dentigerous

Cyst:
Fibrous to fibromyxoid connective

tissue
No rete ridges, flat interface
Lining epithelium, 2-4 layers of
cuboidal epithelium, devoid of
superficial keratinization
Occasional mucous cells; rare
ciliated cells
Odontogenic epithelial rests,
small, inactive appearing
Some lesions submitted as
dentigerous cysts are partially
lined with a thin, fragmented
layer of eosinophilic columnar
cells/low cuboidal epithelium
representing the postfunctional
ameloblastic layer of the reduced
enamel epithelium

Prognosa
Excellent prognosis, almost never recurs with

complete enucleation, however follow-up


radiographic studies recommended
Recurrence may indicate incomplete excision
or possibly incorrect original diagnosis

Unicyst ameloblastoma
Also called cystic ameloblastoma
Uncommon; 20% of all ameloblastomas
Mean 25 years (younger than classic type), range 8-

60 years, 2/3 male


>90% in mandible, 63% at angle and ascending
ramus
Less aggressive than solid or multicystic
counterparts, although may expand or perforate jaw
cortex and may recur
Recurrence related to fibrous wall invasion: 36% with
vs. 7% without; recurrence may be long delayed

micros
Single cystic lesion lined by

ameloblastic epithelium that shows


typical features of ameloblastoma in
some areas, including columnar
basal cells in palisading arrangement
with vacuolated cytoplasm,
hyperchromatic nuclei polarized
away from basement membrane
Suprabasal cells loosely textured and
noncohesive, resembling stellate
reticulum, epithelial invagination,
epithelial edema and separation
May have intraluminal plexiform
patterns, tumor islands may invade
fibrous capsule with subepithelial
hyalinization

Single cystic lesion

lined by
ameloblastic
epithelium that
shows typical
features of
ameloblastoma in
some areas,
including columnar
basal cells in
palisading
arrangement with
vacuolated
cytoplasm,
hyperchromatic

Unicyst ameloblastoma

May have intraluminal plexiform patterns,

tumor islands may invade fibrous capsule with


subepithelial hyalinization

Therapy
Enucleation or curettage
More aggressive if invasion of fibrous wall

4. Keratocystic odontogenic tumor


Parakeratin lined cyst-like lesion/tumor within

bone
Formerly called odontogenic keratocyst (OKC),
but re-classified as keratocystic odontogenic
tumor (KCOT) due to its potential for
aggressive behavior, recurrence and genetic
abnormalities

Keratocyst

EPIDEMIOLOGY
4-12% of all odontogenic cysts (often

compared to odontogenic cysts even though


WHO classifies as tumor)
Peaks in second and third decade of life, but
can occur over wide age range
90% are solitary
Multiple tumors seen in Nevoid Basal Cell
Carcinoma Syndrome / Gorlins Syndrome

SITE
Mandible most
commonly involved
(65-85% of KCOT)
Most common site:
posterior mandible
Not uncommonly,
but not exclusively
associated with
impacted teeth
Rarely occurs in soft
tissue

PATHOLOGY
Thought to arise from dental lamina
Two-hit mechanism results in bi-allelic loss of

PTCH (patched) tumor suppressor on


9q22.3-q31 causing dysregulation of p53 and
cyclin D1 oncoproteins
Can occur sporadically or associated with
Nevoid Basal Cell Carcinoma Syndrome /
Gorlins Syndrome

RADIOLOGY
Small lesions often
unilocular
radiolucent lesion,
variable sclerotic
margins
Larger lesions often
multilocular, variable
scalloped margins

MICROSCOPIS
Uniform epithelial lining 6-8 cells thick lacking rete ridges
May have artifactual clefting between epithelium and

underlying fibroconnective tissue


Epithelium characterized by palisaded hyperchromatic
basal cell layer comprised of cuboidal to columnar cells
May have areas of budding growth from the basal cells
Luminal surface has wavy (corrugated) parakeratotic
epithelial cells
Lumen may contain keratinaceous debris
Orthokeratinized variant: orthokeratosis (anuclear
keratin), granular layer and poorly organized basal layer;
not syndrome associated, less aggressive behavior

Uniform epithelial lining

6-8 cells thick lacking


rete ridges
May have artifactual
clefting between
epithelium and
underlying
fibroconnective tissue
Epithelium characterized
by palisaded
hyperchromatic basal
cell layer comprised of
cuboidal to columnar
cells

Lumen may

contain
keratinaceous
debris

Epithelium

characterized by
palisaded
hyperchromatic basal
cell layer comprised of
cuboidal to columnar
cells May have areas
of budding growth
from the basal cells

TERAPY

Decompression alone
Enucleation with possible curettage
Chemical curettage with Carnoys solution
Marsupialization
Resection
Treatment must balance minimizing
recurrence rate with morbidity associated with
an extensive resection

4. Nasopalatine cyst
Most common intraosseous, non-odontogenic

cyst of jaw (maxilla)


TERMINOLOGY
Median anterior cyst
Midline maxillary cyst
Anterior median palatine cyst
Incisive canal cyst
Incisor duct cyst

Occurs in ~1% of population


Represents 1.7-11.9% of all jaw cysts
Usually adults, peak prevalence in fourth and

fifth decades
More common in males (ranges in literature
from slightly more common to up to 3x more
common in males than females)

ETIOLOGY
Two main theories: First: originates from

spontaneous proliferation of remnants of


nasopalatine duct within incisive canal
Exact trigger that stimulates development is

unknown, but factors proposed include trauma


and infection

Second: theory now out of favor; originates

from trapping of epithelial remnants during


embryologic fusion between nasal cavity and
anterior maxilla

GENERAL
FEATURE
Usually asymptomatic,
may have swelling of
palate in relation to
maxillary central
incisors
Occasionally produces a
midline anterior
maxillary swelling if
cyst erodes bone of the
anterior maxilla
Can present with painful
swelling or drainage, or
tooth root displacement

Well defined round

radiolucent area

Lined by stratified squamous epithelium alone

or with pseudostratified columnar epithelium


(variable cilia and goblet cells), simple
columnar epithelium or simple cuboidal
epithelium
Cyst wall is composed of fibrous tissue with
nerves, cartilaginous rests, arteries and veins
The nasopalatine duct contains the
nasopalatine nerve and the terminal branch of
the descending palatine artery

Lined by stratified

squamous epithelium
alone or with
pseudostratified
columnar epithelium
(variable cilia and
goblet cells), simple
columnar epithelium
or simple cuboidal
epithelium

Cyst wall is composed

of fibrous tissue with


nerves, cartilaginous
rests, arteries and
veins

THERAPY
Surgical excision is most common, but

marsupialization has also been performed

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