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MANDIBULAR INFECTED BUCCAL CYST
The mandibular infected buccal cyst (MIBC) also called buccal bifurcation cyst, is another inflammatory cyst which in many ways is similar to the paradental cyst. MIBC is seen almost exclusively associated to the buccal aspect of the first mandibular molar in children. The reason for being considered a unique entity is based on its particular location and age preference. The pathogenesis of this cyst may be associated to inflammatory pathology at the level of the root furcation. The treatment of MIBC is surgical enuclation without tooth extraction.
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The lateral periodontal cyst, as the name implies, occurs on a lateral periodontal location and it is of developmental origin arising from cystic degeneration of clear cells of the dental lamina. In order to establish the proper diagnosis, an inflammatory origin as well as exclusion of a possible odontogenic keratocyst must be ruled out clinically and histologically. This cyst's most frequent location is at the level of the mandibular premolars but it has been reported occurring in other areas. This cyst is generally an accidental radiographic finding and it characterized by being located mid distance between the apex and the cervical area of the affected tooth. Radiographically, the majority of the cases are seen as a well delineated, round, small (generally not exceeding 1 cm in diameter), radiolucency with a radiopaque rim. They are generally asymptomatic. The periodontal ligament space as a rule is not enlarged and there must not be a communication between the cyst's cavity and the oral environment. The root of the affected tooth is intact, the pulpal tissue is not necrotic and the tooth is vital. A multilocular variety has been described.
The cystic wall is lined by a thin layer of an odontogenic epithelium presenting clear cells and resembling the reduced enamel epithelium. Some areas of cellular condensation have been described as epithelial plaques, which may protrude into the cystic lumen. A different histologic appearance has been described with the name of BOTRYOID ODONTOGENIC CYST. This name reflects the histologic similarity of the cystic cavities to that of a bunch of grapes.
The treatment of the lateral periodontal cyst is surgical ablation and if at all possible the affected tooth should be preserved, which some times it is difficult. The multilocular variety including the botryoid type require a more careful surgical elimination because of their higher tendency to recur.
This a lateral periodontal cysts. Both adjacent teeth were vital and clinically there was no communication between the cystic cavity and the oral cavity. Histologically it was proven to be lined by a thin layer of clear odontogenic epithelial cells and epithelial plaque formation. Note well delineated oval radiolucency.
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The glandular odontogenic cyst (GOC), also known as sialo-odontogenic cyst has many similarities to the lateral periodontal cyst of which it is considered a variant by some authors. GOC occurs in the same location as the lateral periodontal cyst but as a rule it has a multilocular radiographic appearance. Histologically it is characterized by being lined, in areas, by a stratified squamous epithelium, within the epithelium, goblet mucous producing cells can be seen as well as crypts containing mucus. Some cells may also be ciliated. Occasional small microcysts can also be seen within the epithelium. The diagnosis of GOC should be considered when observing a lateral periodontal multilocular radiolucency. The diagnosis is essentially microscopic. The treatment should be conservative but with a careful dissection of the margins in order to avoid recurrences. Patients diagnosed with either multilocular lateral periodontal cyst, botryoid odontogenic cyst and glandular odontogenic cyst should be followed-up periodically in order to assess early recurrences.
The radiograph shows the typical multilocular appearance of the glandular odontogenic cyst. The microscopy demonstrates on A an odontogenic epithelium with microcyst formation. B shows the tendency to epithelial plaque formation similar to that seen in lateral periodontal cysts and C shows pools and crypts containing mucus.
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The odontogenic keratocyst (OKC) derives from the dental lamina and its most frequent location is the 3rd mandibular molar area (80%) with a ratio of 2 to 1, mandible to maxilla. OKC has a marked tendency to recur, the recurrence rate has been estimated to be around 60%. They can be single or multiple, if multiple. they most likely are part of the nevoid basal cell carcinoma syndrome (Gorlin syndrome). Based on various reported series the OKC represents between 1.5 and 11% of all jaw cysts. They can be found at any age but with a peak incidence in the 3rd and 4th decade of life. OKC is more prevalent in males than in females with a ratio of 2:1.
The clinical appearance of OKC varies from a symptomless incidental radiographic finding to painful cystic lesions. Paresthesia may also be present in some patients as well as secondary fractures when the cyst is large. The maxillary OKC tends to be secondarily infected with greater frequency than the mandibular ones. That may be due to its vicinity to the maxillary sinus.
Radiographically most OKCs are unilocular presenting a well defined peripheral rim. Scalloping of the border is also a frequent finding and this represents variations in the growth pattern of the cyst. Multilocular radiolucent OKC is also observed, generally representing a central cavity having satellite cysts. When it is multilocular and especially if located in the third mandibular molar area, it may be confused radiographically with an ameloblastoma. Occasionally OKC may mimic a dentigerous cyst and contain the crown of a retained tooth within its lumen. The final diagnosis of any cystic cavity within the jaw bones will be achieved only after biopsy of the surgical specimen.
Note the thin bony trabeculae in the radiograph to the right denoting multiple cavities in that lesion. The radiograph on the left also shows, in addition to the large cavity, two smaller ones. One is above and distal to the distal molar cusp and the other is in the upper margin of the large cavity.
These are biopsies from two different cases of OKC. Arrows B point to a thin layer of parakeratin formation at the epithelial surface. The epithelium is odontogenic and is formed by a few rows of palisading cells. The basal layer of cells (arrows A) shows reversed polarized nuclei with hyperchromatism. The connective tissue is generally free of inflammatory cells.
The majority of OKC (70%) presents a thin layer of parakeratin at the epithelial surface (arrows B) the remaining 30% of cases present orthokeratin. The latter examples tend to have a lower recurrence rate. The epithelium of this cyst may undergo malignant degeneration, in such cases a squamous cell carcinoma arising in a cyst will be the end result.
The treatment of OKC is a careful surgical enucleation. Multilocular cysts should be eliminated in toto, if satellite small cysts are left behind, the cyst will recur. Large cysts may be treated by marsupialization. Some authors recommend the use of freezing techniques especially in the case of multiple OKCs associated to the Gorlin syndrome.
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As mentioned earlier if a patient presents multiple OKCs the diagnosis of Gorlin syndrome should be suspected. This syndrome is inherited as an autosomal dominant and its main components are nevi and basal cell carcinomas of the facial skin as well as the chest, multiple odontogenic keratocysts and a series of bony abnormalities.
Note the multiple nevi on the facial skin of this patient with the nevoid basal cell carcinoma syndrome. These nevi eventually become basal cell carcinomas.
This panoramic radiograph is from a 39 year-old woman with the Gorlin syndrome. Note the multiple radiolucencies in the mandible as well as in the maxilla. Biopsy of one of those lesions confirmed the diagnosis of odontogenic keratocyst.
Bifid ribs are found in around 80% of patients with the Gorlin syndrome. Ameloblastomas and facial clefting are seen in around 2% of patients with the Gorlin syndrome. Additionally a large number of benign and malignant tumors can be associated to this syndrome. The gene responsible for the nevoid basal cell carcinoma syndrome has been mapped to the long arm of chromosome 9 bands 22.3 to the 31 (9q 22.3-31)
RECENT REFERENCES TO SOME ODONTOGENIC CYSTS
Carter LC et al. Lateral periodontal cyst. Multifactorial analysis of a previously unreported series. Oral Surg Oral Med Oral Pathol Oral Radiol Endodont 1996; 81:210-6.
Curran AE; Miller EJ; Murrah VA. Adenomatoid odontogenic tumor presenting as periapical disease. Oral Surg Oral Med Oral Pathol Oral Radiol Endodont 1997; 84:557-60.
Dhanrajani PJ; Abdulkarim SA. Multiple myeloma presenting as a periapical lesion in the mandible. Indian J Dent Res 1997; 8:58-61.
Gurol M; Burkes EJ Jr; Jacoway J. Botryoid odontogenic cyst: analysis of 33 cases. J Periodont 1995; 66:1069-73.
Lehrhaupt NB; Brownstein CN; Deasy MJ. Osseous repair of a lateral periodontal cyst. J Periodont 1997; 68:608-11.
Mass E; Kaplan I; Hirshberg A. A clinical and histopathological study of radicular cysts associated with primary molars. J Oral Path Med 1995; 24:458-61.
Piattelli A; Fioroni M; Rubini C. Differentiation of odontogenic keratocysts from other odontogenic cysts by the expression of bcl-2 immunoreactivity. Oral Oncol 1998; 34:404-7.
Pompura JR; Sandor GK; Stoneman DW. The buccal bifurcation cyst: a prospective study of treatment outcomes in 44 sites.
Oral Surg Oral Med Oral Pathol Oral Radiol Endodont 1997; 83:215-21.
Ramachandran Nair PN; Pajarola G; Schroeder HE. Types and incidence of human periapical lesions obtained with extracted teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endodont 1996; 81:93-102.
Rees JS. Conservative management of a large maxillary cyst. Inter Endo J 1997; 30:64-7.
Savage NW et al. The glandular odontogenic jaw cyst: report of a case. Pathol 1996; 28:370-2.
Shear M. Cysts of The Oral Regions. Wright Ed. Oxford Engl. 1992
Slabbert H; Shear M; Altini M. Vacuolated cells and mucous metaplasia in the epithelial linings of radicular and residual cysts.
J Oral Path Med 1995; 24:309-12.
Suljak JP; Bohay RN; Wysocki GP. Lateral periodontal cyst: a case report and review of the literature. J Canad Dent Ass, 1998; 64:48-51.
Tolson GE et al. Report of a lateral periodontal cyst and gingival cyst occurring in the same patient. J Periodont 1996; 67:541-4.
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