odontogenic cysts and tumors...odontogenic cysts • inflammatory – radicular – paradental •...
TRANSCRIPT
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Odontogenic Cysts and Tumors
SRM KATTANKULATHURDental College
Dept of Oral & Maxillofacial surgery
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Introduction
• Variety of cysts and tumors
• Uniquely derived from tissues of developing teeth
• May present to otolaryngologist
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Odontogenesis
• Projections of dental lamina into ectomesenchyme
• Layered cap (inner/outer enamel epithelium, stratum intermedium, stellate reticulum)
• Odontoblasts secrete dentin ameloblasts (from IEE) enamel
• Cementoblasts cementum• Fibroblasts periodontal membrane
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Odontogenesis
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Diagnosis
• Complete history – Pain, loose teeth, occlusion, swellings, dysthesias, delayed tooth eruption
• Thorough physical examination– Inspection, palpation, percussion, auscultation
• Plain radiographs – Panorex, dental radiographs
• CT for larger, aggressive lesions
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Diagnosis
• Differential diagnosis
• Obtain tissue– FNA – r/o vascular lesions, inflammatory
– Excisional biopsy – smaller cysts, unilocular tumors
– Incisional biopsy – larger lesions prior to definitive therapy
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Odontogenic Cysts
• Inflammatory– Radicular
– Paradental
• Developmental– Dentigerous
– Developmental lateral periodontal
– Odontogenic keratocyst
– Glandular odontogenic
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Radicular (Periapical) Cyst
• Most common (65%)
• Epithelial cell rests of Malassez
• Response to inflammation
• Radiographic findings– Pulpless, nonvital tooth
– Small well‐defined periapical radiolucency
• Histology
• Treatment – extraction, root canal
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Radicular Cyst
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Radicular Cyst
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Residual Cyst
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Paradental Cyst
• Associated with partially impacted 3rd
molars
• Result of inflammation of the gingiva over an erupting molar
• 0.5 to 4% of cysts
• Radiology – radiolucency in apical portion of the root
• Treatment – enucleation
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Paradental Cyst
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Dentigerous (follicular) Cyst
• Most common developmental cyst (24%)
• Fluid between reduced enamel epithelium and tooth crown
• Radiographic findings– Unilocular radiolucency with well‐defined sclerotic margins
• Histology– Nonkeratinizing squamous epithelium
• Treatment – enucleation, decompression
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Dentigerous Cyst
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Dentigerous Cyst
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Developmental Lateral Periodontal Cyst
• From epithelial rests in periodontal ligament vs. primordial cyst – tooth bud
• Mandibular premolar region• Middle‐aged men• Radiographic findings
– Interradicular radiolucency, well‐defined margins
• Histology– Nonkeratinizing stratified squamous or cuboidal epithelium
• Treatment – enucleation, curettage with preservation of adjacent teeth
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Developmental Lateral Periodontal Cyst
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Odontogenic Keratocyst
• 11% of jaw cysts• May mimic any of the other cysts• Most often in mandibular ramus and angle• Radiographically
– Well‐marginated, radiolucency– Pericoronal, inter‐radicular, or pericoronal– Multilocular
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Odontogenic Keratocyst
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Odontogenic Keratocyst
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Odontogenic Keratocyst
• Histology– Thin epithelial lining with underlying connective tissue (collagen and epithelial nests)
– Secondary inflammation may mask features
• High frequency of recurrence (up to 62%)
• Complete removal difficult and satellite cysts can be left behind
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Odontogenic Keratocyst
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Treatment of OKC
• Depends on extent of lesion
• Small – simple enucleation, complete removal of cyst wall
• Larger – enucleation with/without peripheral ostectomy
• Bataineh,et al, promote complete resection with 1 cm bony margins (if extension through cortex, overlying soft tissues excised)
• Long term follow‐up required (5‐10 years)
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Glandular Odontogenic Cyst
• More recently described (45 cases)
• Gardner, 1988
• Mandible (87%), usually anterior
• Very slow progressive growth (CC: swelling, pain [40%])
• Radiographic findings– Unilocular or multilocular radiolucency
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Glandular Odontogenic Cyst
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Glandular Odontogenic Cyst
• Histology– Stratified epithelium
– Cuboidal, ciliated surface lining cells
– Polycystic with secretory and epithelial elements
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Treatment of GOC
• Considerable recurrence potential
• 25% after enucleation or curettage
• Marginal resection suggested for larger lesions or involvement of posterior maxilla
• Warrants close follow‐up
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Nonodontogenic Cysts
• Incisive Canal Cyst
• Stafne Bone Cyst
• Traumatic Bone Cyst
• Surgical Ciliated Cyst (of Maxilla)
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Incisive Canal Cyst
• Derived from epithelial remnants of the nasopalatine duct (incisive canal)
• 4th to 6th decades• Palatal swelling common, asymptomatic• Radiographic findings
– Well‐delineated oval radiolucency between maxillary incisors, root resorption occasional
• Histology– Cyst lined by stratified squamous or respiratory epithelium or both
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Incisive Canal Cyst
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Incisive Canal Cyst
• Treatment consists of surgical enucleation or periodic radiographs
• Progressive enlargement requires surgical intervention
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Stafne Bone Cyst
• Submandibular salivary gland depression
• Incidental finding, not a true cyst
• Radiographs – small, circular, corticated radiolucency below mandibular canal
• Histology – normal salivary tissue
• Treatment – routine follow up
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Stafne Bone Cyst
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Traumatic Bone Cyst
• Empty or fluid filled cavity associated with jaw trauma (50%)
• Radiographic findings– Radiolucency, most commonly in body or anterior portion of mandible
• Histology – thin membrane of fibrous granulation
• Treatment – exploratory surgery may expedite healing
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Traumatic Bone Cyst
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Surgical Ciliated Cyst
• May occur following Caldwell‐Luc
• Trapped fragments of sinus epithelium that undergo benign proliferation
• Radiographic findings– Unilocular radiolucency in maxilla
• Histology– Lining of pseudostratified columnar ciliated
• Treatment ‐ enucleation
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Surgical Ciliated Cyst
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Odontogenic Tumors
• Ameloblastoma
• Calcifying Epithelial Odontogenic Tumor
• Adenomatoid Odontogenic Tumor
• Squamous Odontogenic Tumor
• Calcifying Odontogenic Cyst
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Ameloblastoma
• Most common odontogenic tumor
• Benign, but locally invasive
• Clinically and histologically similar to BCCa
• 4th and 5th decades
• Occasionally arise from dentigerous cysts
• Subtypes – multicystic (86%), unicystic (13%), and peripheral (extraosseous – 1%)
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Ameloblastoma
• Radiographic findings– Classic – multilocular radiolucency of posterior mandible
– Well‐circumscribed, soap‐bubble
– Unilocular – often confused with odontogenic cysts
– Root resorption – associated with malignancy
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Ameloblastoma
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Ameloblastoma
• Histology– Two patterns – plexiform and follicular (no bearing on prognosis)
– Classic – sheets and islands of tumor cells, outer rim of ameloblasts is polarized away from basement membrane
– Center looks like stellate reticulum– Squamous differentiation (1%) – Diagnosed as ameloblastic carcinoma
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Ameloblastoma
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Treatment of Ameloblastoma
• According to growth characteristics and type• Unicystic
– Complete removal– Peripheral ostectomies if extension through cyst wall
• Classic infiltrative (aggressive)– Mandibular – adequate normal bone around margins of resection
– Maxillary – more aggressive surgery, 1.5 cm margins
• Ameloblastic carcinoma – Radical surgical resection (like SCCa)– Neck dissection for LAN
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Calcifying Epithelial Odontogenic Tumor
• a.k.a. Pindborg tumor
• Aggressive tumor of epithelial derivation
• Impacted tooth, mandible body/ramus
• Chief sign – cortical expansion
• Pain not normally a complaint
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Calcifying Epithelial Odontogenic Tumor
• Radiographic findings– Expanded cortices in all dimensions
– Radiolucent; poorly defined, noncorticated borders
– Unilocular, multilocular, or “moth‐eaten”
– “Driven‐snow” appearance from multiple radiopaque foci
– Root divergence/resorption; impacted tooth
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Calcifying Epithelial Odontogenic Tumor
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Calcifying Epithelial Odontogenic Tumor
• Histology– Islands of eosinophilic epithelial cells
– Cells infiltrate bony trabeculae
– Nuclear hyperchromatism and pleomorphism
– Psammoma‐like calcifications (Liesegang rings)
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Calcifying Epithelial Odontogenic Tumor
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Treatment of CEOT
• Behaves like ameloblastoma
• Smaller recurrence rates
• En bloc resection, hemimandibulectomy partial maxillectomy suggested
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Adenomatoid Odontogenic Tumor
• Associated with the crown of an impacted anterior tooth
• Painless expansion
• Radiographic findings– Well‐defined expansile radiolucency
– Root divergence, calcified flecks (“target”)
• Histology– Thick fibrous capsule, clusters of spindle cells, columnar cells (rosettes, ductal) throughout
• Treatment – enucleation, recurrence is rare
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Adenomatoid Odontogenic Tumor
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Squamous Odontogenic Tumor
• Hamartomatous proliferation• Maxillary incisor‐canine and mandibular molar • Tooth mobility common complaint• Radiology – triangular, localized radiolucency between contiguous teeth
• Histology – oval nest of squamous epithelium in mature collagen stroma
• Treatment – extraction of involved tooth and thorough curettage; maxillary – more extensive resection; recurrences – treat with aggressive resection
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Squamous Odontogenic Tumor
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Calcifying Odontogenic Cyst
• Tumor‐like cyst of mandibular premolar region• ¼ are peripheral – gingival swelling• Osseous lesions – expansion, vital teeth• Radiographic findings
– Radiolucency with progressive calcification– Target lesion (lucent halo); root divergence
• Histology– Stratified squamous epithelial lining– Polarized basal layer, lumen contains ghost cells
• Treatment – enucleation with curettage; rarely recur
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Mesenchymal Odontogenic Tumors
• Odontogenic Myxoma
• Cementoblastoma
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Odontogenic Myxoma
• Originates from dental papilla or follicular mesenchyme
• Slow growing, aggressively invasive• Multilocular, expansile; impacted teeth?• Radiology – radiolucency with septae• Histology – spindle/stellate fibroblasts with basophilic ground substance
• Treatment – en bloc resection, curettage may be attempted if fibrotic
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Cementoblastoma
• True neoplasm of cementoblasts• First mandibular molars• Cortex expanded without pain• Involved tooth ankylosed, percussion• Radiology – apical mass; lucent or solid, radiolucent halo with dense lesions
• Histology – radially oriented trabeculae from cementum, rim of osteoblasts
• Treatment – complete excision and tooth sacrifice
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Cementoblastoma
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Mixed Odontogenic Tumors
• Ameloblastic fibroma, ameloblastic fibrodentinoma, ameloblastic fibro‐odontoma, odontoma
• Both epithelial and mesenchymal cells• Mimic differentiation of developing tooth• Treatment – enucleation, thorough curettage with extraction of impacted tooth
• Ameloblastic fibrosarcomas – malignant, treat with aggressive en bloc resection
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Related Jaw Lesions
• Giant Cell Lesions– Central giant cell granuloma
– Brown tumor
– Aneurysmal bone cyst
• Fibroosseous lesions– Fibrous dysplasia
– Ossifying fibroma
• Condensing Osteitis
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Central Giant Cell Granuloma
• Neoplastic‐like reactive proliferation
• Common in children and young adults
• Females > males (hormonal?)
• Mandible > maxilla
• Expansile lesions – root resorption
• Slow‐growing – asymptomatic swelling
• Rapid‐growing – pain, loose dentition (high rate of recurrence)
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Central Giant Cell Granuloma
• Radiographic findings– Unilocular, multilocular radiolucencies
– Well‐defined or irregular borders
• Histology– Multinucleated giant cells, dispersed throughout a fibrovascular stroma
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Central Giant Cell Granuloma
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Central Giant Cell Granuloma
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Central Giant Cell Granuloma
• Treatment– Curettage, segmental resection
– Radiation – out of favor (risk of sarcoma)
– Intralesional steroids – younger patients, very large lesions
– Individualized treatment depending on characteristics and location of tumor
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Brown Tumor
• Local manifestation of hyperparathyroid
• Histologically identical to CGCG
• Serum calcium and phosphorus
• More likely in older patients
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Aneurysmal Bone Cyst
• Large vascular sinusoids (no bruit)
• Not a true cyst; aggressive, reactive
• Great potential for growth, deformity
• Multilocular radiolucency with cortical expansion
• Mandible body
• Simple enucleation, rare recurrence
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Fibrous Dysplasia
• Monostotic vs. polystotic
• Monostotic – More common in jaws and cranium
• Polystotic– McCune‐Albright’s syndrome
– Cutaneous pigmentation, hyper‐functioning endocrine glands, precocious puberty
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Fibrous Dysplasia
• Painless expansile dysplastic process of osteoprogenitor connective tissue
• Maxilla most common
• Does not typically cross midline (one bone)
• Antrum obliterated, orbital floor involvement (globe displacement)
• Radiology – ground‐glass appearance
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Fibrous Dysplasia
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Fibrous Dysplasia
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Fibrous Dysplasia
• Histology – irregular osseous trabeculae in hypercellular fibrous stroma
• Treatment– Deferred, if possible until skeletal maturity– Quarterly clinical and radiographic f/u– If quiescent – contour excision (cosmesis or function)
– Accelerated growth or disabling functional impairment ‐ surgical intervention (en bloc resection, reconstruction)
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Ossifying Fibroma
• True neoplasm of medullary jaws
• Elements of periodontal ligament
• Younger patients, premolar – mandible
• Frequently grow to expand jaw bone
• Radiology – radiolucent lesion early, well‐demarcated
– Progressive calcification (radiopaque – 6 yrs)
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Ossifying Fibroma
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Ossifying Fibroma
• Histologically similar to fibrous dysplasia
• Treatment– Surgical excision – shells out
– Recurrence is uncommon
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Condensing Osteitis
• 4% to 8% of population
• Focal areas of radiodense sclerotic bone
• Mandible, apices of first molar
• Reactive bony sclerosis to pulp inflammation
• Irregular, radiopaque
• Stable, no treatment required
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Condensing Osteitis
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Conclusion
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Case Presentation
• 20 year‐old hispanic female with several month history of lesion in right maxilla, treated initially by oral surgeon with multiple curettage.
• Has experienced recent onset of rapid expansion, after pregnancy, with complaints of loose dentition and pain.
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Physical Examination
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Physical Examination
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Radiographs
• Plain films – facial series
• Computerized Tomography of facial series
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Pathology
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Treatment
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Treatment