Odontogenic & Developmental Cysts

Odontogenic Cysts

• Most common cyst of the jaw

• Treatments include RCT and apicoectomy

• Any age but typically occurs in 20-50 year olds

• Non-vital

• Occurs after previous extraction

• Epithelium remains behind to make a cyst

• Inflammatory cells continue to proliferate

• Located RL distal to the 3rd molar

• Buccal aspect of the MD 1st molar

• Generally found in kids

• Treatment includes enucleation

Developmental Cysts

• Most common developmental, odontogenic cysts

• Occurs in 10-30 year olds

• Often has sclerotic borders

• Unilocular

• Large cysts can extrude the tooth

• Small cysts do not

• Treatment involves enucleation

• Occurs in the 1st decade of life

• Appears as a nodule on the gingiva

• Typically located on the 1st molar, MX incisors

• No treatment is required

• Palatal cysts include Bohn's nodule (HP/SP) and Epstein pearls, found on the median palatal raphe

• Gingival cysts appear on the alveolar ridge mucosa as 1-3 mm white, creamy papules

• Occurs in adults aged 40-50 years

• Presents as a painless, dome-like swelling

• Bluish/grayish in color

• Located on the MD K9/premolar

• Treatment is excision

• Occurs after age 30

• MD K9/premolar location

• Unilocular

• Located lateral to the root or between teeth

• Does not usually go past the apex

• Vital

• Treatment is enucleation

• Uncommon

• Occurs around 49 years old

• Unilocular or multilocular

• MD anterior is more common

• Can cross the midline

• Well-defined

• Corticated

• Treatment is enucleation

• Can occur from 10-40 years of age, but can occur at any age

• MD location (60-80%)

• Often corticated

• Antero-posterior growth before lateral

• Treatment is enucleation with peripheral ostectomy

• Mutation in PTCH

• Multiple basal cell carcinomas of the skin

• Calcified falx cerebri

• Rib anomalies

• Epidermal cysts of skin

• Palmar/plantar pitting

• Increased risk of medulloblastoma

• Treatment is enucleation with peripheral ostectomy

• Usually unilocular, but can be mixed

• Occurs around age 30

• Anterior to molars, incisor/K9 area

• May cause blunt root resorption or displacement of roots

Non-Odontogenic Cysts

Developmental Cysts

• Occurs in females aged 30-40 years old

• Located on the upper lip, lateral to the midline

• Swelling in the lateral MX vestibule

• Causes elevation of ala of nose

• Surgical excision that uses the intraoral approach

• Also known as Median palatal

• Occurs in 30-50 year olds, but can occur at any age

• Swelling of anterior palate

• RL is sclerotic

• Border superimposition within the nasal septum

• Can appear as a heart shape

• Treatment includes surgical excision and enucleation

Pseudocysts

• Occurs around 20 years old in the 1st-2nd decade

• Rapid swelling or pain/paresthesia

• Unilocular or multilocular

• Teeth may be displaced along with cortical expansion/thinning

• Spikey root resorption may also occur

• Accumulation of inflammatory exudate in the sinus

• Appears as a RO, dome-shaped elevation of the sinus floor

Simple Bone Cyst/Traumatic Bone Cyst

• Reactive

• Occurs in younger patients undergoing ortho, male more likely

• MD, premolar/molar location

• Painless swelling

• Scalloping appearance

• Vital

• Associated with Florid COD

• Treatment is biopsy with exploration and curettage

• Occurs in the female, posterior MD

• Often an area where extraction happened, appears irregular

• Shaped RL

• Occurs in adult males

• Focal concavity of cortical bone on lingual MD

• Angle of MD below IAN

• Well corticated

• No treatment required

Soft Tissue Cysts

• Occurs in the 1st-2nd decade

• Doughy or rubbery

• Usually anterior floor of the midline

• Swelling that elevates the tongue or appears under the chin

• Treatment is surgical excision

• After inflammation of the hair follicle, typically in males

• Unusual before puberty, but associated with Gardners

• Subcutaneous nodule that is a firm-fluctuant papule on the skin

• Treatment is excision

• Differentiated from salivary gland tumor/pleomorphic adenoma

• Occurs prior to 20 years old in 30% of cases

• Forms at the midline

• 1/3 have fistula tract

• Treatment is surgical incision

• Lateral aspect of the neck

• Anterior to SCM, 20-40 years old

• Soft fluctuant swelling

• Multiple lympoepithelial cysts bilaterally in HIV + pts

• Treatment is surgical excision

• FOM (50%), also on the lateral posterior tongue, tonsillar pillar, soft palate

• Soft and firm, painless

• Creamy-yellow color in young adults

• Treatment is excision

Benign Odontogenic Tumors

• Most likely to occur around 40 years old, at any age with a gender bias

• 80% MD location

• BRAF mutation

• B/L cortical expansion

• Sclerotic borders

• Blunt root resorption

• Possible displacement of teeth

• Treatment is resection

• Occurs in the 2nd decade

• Treatment includes enucleation and curettage

• Occurs around 30-50 years old

• 2/3 posterior MD location with either unilocular/multilocular pattern

• Mixed with calcifications

• MD 3rd molar is most common

• Can have swellings of the gingiva/alveolus

• Treatment = conservative local resection with a rim of normal bone

• 2/3 Anterior jaws, female, MX

• Impacted K9, 2nd decade (10-19)

• 75% uniloc involving the crown and interrupted tooth

• Less often between teeth

• Can be mixed ("snowflake" calcifications)

• If so, can have divergence of roots

• Treatment is enucleation

• Rare

• Arise from rests of Malassez

• Mean age is 40

• Anterior alveolar ridge

• May have tooth mobility and slight pain

• Semilunar RL of alveolar ridge

• Mimics periodontal disease, can be ill-defined

• Treatment is conservative local excision

• Mean age is 40

• Unilocular/multilocular

• Fibromas tend to expand in circular/oval fashion

• 1/3 withunerupted tooth, sclerotic/corticated borders

• Treatment is enucleation and curettage

• MX posterior lesions should be treated more aggressively due to proximity to MX sinus and base of skull

• Average onset is 25-30 years old

• MD > MX

• Large lesions and painless expansion of bone

• "Soap bubble" RL, scalloping of borders and around roots of teeth; can displace teeth and resorb roots

• Treatment is surgical excision or resection

• Occurs in the 2nd-3rd decade

• 75% prior to 30 years old

• Attached to VITAL ROOT

• Can see loss of PDL space

• 75% MD, ~90% molar/premolar region

• 2/3 cases have pain and swelling

• RO mass fused to root, usually thin RL RIM

• Treatment= surgical extraction of tooth with tumor, if smaller root amputation with the attached tumor and endo

• Get to a certain size and stops growing with masses of enamel and dentin

• Mean age = 14 yo, may prevent eruption of teeth

• RO w/RL rim

-Compound location- Anterior jaws, MX, small tooth-like structures -Complex location- posterior jaws MD, poorly developed mass of calcified deposits surrounded by Narrow RL rim -Treatment= excision or enucleation

• Occurs in the 1st 2 decades, mean age = 12yo

• Treatment =surgical excision or curettage

• Large can cause bone expansion

• ~70% posterior MD, -75% unerupted teeth

• Smaller = unilocular, larger = multilocular

• Well-defined, sclerotic, circular/oval growth

• Posterior jaw, mixed lesion, well-circum unilocular, rarely multilocular

• Some can have largely calcified mass w/ narrow rim of RL

• Arise in site of previous AF/AFO or arise de novo, 80% MD

• Pain, swelling, rapid growth, ill-defined destructive RL

• Treatment is surgical excision

• In older adults >40

• Bone pain common, jaws enlarged

• Progressive bone enlargement, hypercementosis, tooth separation causing malocclusion, ↑ serum alkaline phosphatase

• MX > MD, entire MD or MX affected (bilateral)

• "Hat or denture not fitting", RL in skull, cotton wool, Florid X-rays may resemble COD

• Management = bisphosphonates

• Mutation in APC, children/adolescents, ↑ risk thyroid carcinoma, asymptomatic until 20's

• Premalignant colon & rectal polyps, multiple osteomas, odontomas, impacted /supernumerary teeth

• By age 30, 50% pts will develop colorectal carcinoma

• Increase bone density

• Infantile type- marrow failure, frequent fractures, initial sign- normocytic anemia w/ hepatosplenomegaly, facial deformity= broad face and frontal bossing, tooth eruption delayed

• Adult type-in a symptomatic pt- bone pain, 40% asymptomatic, when MD involved- fracture and osteomyelitis of the jaw after EXT is a complication

• Increased RO of bone, symmetric, thick lamina dura and cortical borders , roots difficult to visualize

• Occurs in children

• Painless, bilateral expansion of posterior MD

• Enlargements can cause tooth displacement or failure of eruption , impair mastication

• Radiation therapy is contraindicated

• Multilocular expansile RL's in jaw

• Can become active during pregnancy or with use of oral contraceptives

• Clinically: unilateral swelling, can affect multiple bones

• Jaffe type: FD + café au lait spots

• Macune- Albright Syndrome: FD + café au lait spots + endocrine abnormalities

• Radiographically :MX > MD, posterior area, early-> more RL, mature-> more RO, abnormal trabeculae, ground-glass, expansion and intact thinned cortex, lamina dura disappears+ narrowed PDL space, can displace IAN superiorly

• Management= Monitoring, w/most lesions, growth is complete at skeletal maturation

• (In MX -> K9 fossa, zygomatic arch area)

• Young adults, F > M, MD, inferior to premolars/molars, superior to IAC

• Well-defined, unilocular, mixed lesion or almost totally RO w/RL rim (sclerotic border), cortical expansion, No perforation

• Can cause tooth or IAN canal displacement and tooth resorption

• Large can cause downward bowing of inferior cortex of MD Tx= enucleation or resection

• Very aggressive form, first 2 decades, MX

• Grows rapidly, lacks continuity w/ adj normal bone

• Well-circum RL, may have central RO,"ground-glass" opacifications

• Middle age, > F, African Americans (EXCEPT FOCAL COD)

• Involved teeth-vital, no history of pain or sensitivity, well defined, often RL border of varying width, lamina dura lost, tooth structure unaffected

• Treatment = not normally required, complication of biopsy = secondary infection

• Single site, mostly posterior jaw, mean age = 38 yo, caucasian woman

• Anterior MD, 30-40 yo, black, teeth vital, circumscribed RL apical area of the tooth, PDL intact

• Multifocal, middle age-older, black, bilateral, often symmetric, pts may complain of dull pain

Benign Non-Odontogenic Tumors of Bone:

• Most are reactive, 60% prior to 30 yo, MD, anterior to 1st molar

• Frequently crosses midline, may perforate cortical plate, not commonly corticated, frequently displaces teeth

• Pear/tear drop RL between teeth-con mimic lateral perio cyst, but CGCG goes past apices, hyperparathyroidism should be ruled out

• Treatment= curettage or intralesional injections of corticosteroids

• MX, 10-20 YO, BLEEDING RISK, always aspirate prior to biopsy for multilocular RL, commonly root resorption

• Slowly expanding swelling, may have pain, mobility of teeth or bleeding from gingiva in area,

• Serpentine/snake-like shape of an entire canal

• widening of the canal and foramen w/ intact bone

• MD, larger than osteoid osteomas, >2 cm, 85% before 30 yo, mild pain (dull ache)

• NOT relieved by aspirin

• Well-circum mixed lesion w/ RL halo

• Treatment = surgical excision/curettage

• 4-25 years old, rare in jaw, smaller than 2 cm, a tumor produces prostaglandins that can cause pain RELIEVED BY ASPIRIN

• Body of MD/condyle (difficulty opening), posterior to premolars on lingual surface

• Periostal- arise on surface of bone as a polypoid or sessile mass

• Endosteal- located in medullary bone

• Uniform radiopacities, no RL rim, mushroom-like ovoid growth

Malignant Non-Odontogenic Tumors of Bone:

• Occurs around 40 years old

• Painless swelling/tooth mobility

• MX, symmetric widening of PDL, poorly defined RL w/ scattered RO foci, "moth-eaten" look

• Treatment: surgical excision (initial treatment), doesn't respond well to radiation/chemo

• Most common primary malignant tumor

• Less than 40 years old, mean age= 33

• Swelling, pain, 25% have toothache, can have loose teeth, paresthesia of the lip and nasal obstruction, MD>MX

• ill-defined, spiking resorption of teeth, sunburst pattern, symmetric widening of PDL early on Treatment-pre-op multi-agent chemo followed by surgery

• Patients may develop a progressive CNS neurodegenerative syndrome

• Males>, ½ cases under 10 years old, classic triad-> exophthalmos, diabetes insipidus, lytic defects of bone, mobility of teeth, TEETH FLOATING IN AIR, punched out RL lesions, scooped out RL at mid-root level

• Treatment is curettage if the lesion is accessible

DDX of Alveolar Bone Loss in Children -> "teeth floating in air"

1. Aggressive periodontitis
2. Langerhans cell histiocytosis
3. Papillon-Lefevre syndrome
4. Cyclic Neutropenia/agranulocytosis
5. Burkitt's Lymphoma

• Occurs between 5-30 years old and is mostly in kids/adolescents, caucasians > black/asian
• Patients present with pain/swelling, fever, elevated ESR
• Paresthesia/loosening of teeth/ perforate cortex/involve soft tissue/ irregular lytic lesion will ill-defined margins
• Treatment is multi-agent chemo, radiation therapy, and surgery