Chapter 15: Odontogenic cysts and tumors

Overview: Odontogenic cysts & tumors arise from the odontogenic apparatus. The odontogenic apparatus consists of: Epithelium: • Remnants of dental lamina • Reduced enamel epithelium • Odontogenic rests • Lining of odontogenic cysts • Basal cell layer of oral mucosa Ectomesenchyme: • Dental papilla Q: What is a cyst? A: An abnormal space within tissue lined by epithelium. Q: Name some “cysts” that are not really cysts: A: Aneurysmal bone cyst, Stafne bone cyst, Traumatic bone cyst, Simple bone cyst, Eruption cyst Q: Why are they not cysts? A: No epithelial lining!

The Cysts and Tumors of Chapter 15: Odontogenic cysts: Inflammatory: •Periapical (radicular) cyst •Residual periapical (radicular) cyst •Buccal bifurcation cyst (usually first molars) –Paradental cysts (partially erupted third molars Developmental: •Dentigerous cyst •Odontogenic keratocyst (KOT) •Orthokeratinized odontogenic cyst •Gingival (alveolar) cyst of the newborn •Gingival cyst of the adult •Lateral periodontal cyst •Calcifying odontogenic (Gorlin) cyst •Glandular odontogenic cyst •Eruption cyst Odontogenic Tumors: Epithelial Tumors: •Ameloblastoma •Adenomatoid odontogenic tumor •Calcifying epithelial odontogenic tumor (Pindborg tumor) •Squamous odontogenic tumor •Clear cell odontogenic carcinoma Ectomesenchymal Tumors: •Odontogenic myxoma •Granular cell odontogenic tumor •Central odontogenic fibroma •Cementoblastoma Mixed Odontogenic Tumors: • Odontoma –Compound –Complex • Ameloblastic fibroma • Ameloblastic fibro-odontoma • Ameloblastic fibrosarcoma • Odontoameloblastoma

Periapical cyst or granuloma (chronic localized osteitis) ▪ Impossible to tell radiographically which one it is – only histologically, so you must include both in your differential diagnosis. Q: Why does a periapical cyst form instead of just a granuloma? A: If by chance there are Rests of Malassez in the area of inflammation. ▪ The rest cells proliferate due to the inflammation ▪ The ball of cells gets too large, cells in the center die, center then has a higher protein concentration, water rushes in to equalize the osmotic pressure. ▪ Osmotic pressure can continue to grow the cyst independent of the inflammation. Other unilocular radiolucencies located periapically: ▪ (early) periapical cemento-osseous dysplasia – teeth are vital ▪ Dentin dysplasia type I – teeth are vital, multiple radiolucencies With a periapical cyst or granuloma, the tooth is NON-VITAL Take a vitality test!! ▪ Tx for a non-vital tooth is root canal. ▪ Must biopsy a radiolucent lesion beneath a vital tooth.

Dentigerous cyst ▪ Radiolucency associated with an unerupted tooth ▪ encloses the crown of the unerupted tooth and is attached at the CEJ ▪ Most common developmental odontogenic cyst ▪ Should be the first differential diagnosis for any radiolucency associated with an unerupted tooth Others: Odontogenic Keratocyst (KOT), Ameloblastoma

(Vital teeth)

Odontogenic Keratocyst (Keratocystic Odontogenic Tumor) Can be in the location of ANY other type of odontogenic cyst or can be isolated in the jaws! • a benign uni-or multicystic, intraosseous tumor of odontogenic origin • lining is parakeratinized stratified squamous epithelium • potential aggressive, infiltrative behavior • solitary or multiple (multiple usually related to Gorlin syndrome) Three important things associated with this diagnosis: 1. High recurrence rate (up to 60%) 2. Highly aggressive (now considered by W.H.O. to be an odontogenic tumor) 3. Relation to Gorlin syndrome Arises from the dental lamina or its remnants PTCH gene is a significant factor in the development of KOT

Nevoid Basal Cell Carcinoma Syndrome (Gorlin Syndrome) • Multiple basal cell carcinomas • Multiple jaw cysts (odontogenic keratocysts) • Numerous bone abnormalities including bifid ribs, intracranial calcification, vertebral anomalies PTCH gene has been mapped to chromosome 9q22.3 - site of Gorlin Syndrome Anyone with multiple KOTs should be tested for Gorlin Syndrome

Lateral Periodontal Cyst ▪ The lateral periodontal cyst is generally quite small and well demarcated. It occurs most frequently in the mandibular bicuspid area adjacent to vital teeth. Radiolucencies are generally small and ovoid ▪ Derived from remnants of the dental lamina Tx: conservative enucleation ▪ Considered to be the intrabony counterpart to the Adult Gingival Cyst

Biopsy:

Calcifying Cystic Odontogenic Tumor (Gorlin’s cyst) • Uncommon lesion that demonstrates considerable histopathologic diversity and variable clinical behavior • Can be unilocular or multilocular, can be associated with an unerupted tooth Tx: simple surgical excision, prognosis is usually good “Ghost” cells calcify

Biopsy:

Ameloblastoma • Slow growing, non-painful, multilocular, radiolucent lesion • Most common clinically significant odontogenic tumor • Epithelial origin • Average age = 33 Tx: resection beyond the margins (tumor is to difficult to remove, and tends to recur) Peripheral, palisaded cells with nuclei polarized away from the basement membrane

Unicystic Ameloblastoma • Account for 10-15% of intraosseous ameloblastomas • Usually occur in younger patients •Because all of the ameloblastoma is inside the lumen of the cyst, Tx. is removal of the cyst (not jaw resection) But… If ameloblastoma is in the wall of the cyst, treatment must be standard for ameloblastoma = resection Can often resemble a dentigerous cyst around an unerupted 3rd molar

Biopsy:

Adenomatoid Odontogenic Tumor “A.O.T” •Young patients •Anterior jaws •Usually associated with impacted teeth •Easily removed, therefore small chance of recurrence Tx: curettage “Gland-like” structures in a solid tumor of odontogenic cells

Biopsy:

Calcifying Epithelial Odontogenic Tumor (Pindborg Tumor) • Uncommon (less than 200 cases reported to date) Radiolucent lesion with calcified radiopacities inside (calcifications are most often seen in association with an impacted tooth) Tx: local resection Protein in the “amyloid” areas is a new, recently discovered protein *With Congo Red stain the lesion will exhibit apple-green bifringence when viewed with polarized light

Ameloblastic Fibroma Tumor of both ectodermal and epithelial layers • Younger patients • Not generally aggressive, easily removed if discovered and treated early If the lesion contains calcifications, then it is an Ameloblastic Fibro-odontoma

A. B.

Odontoma “Tooth tumor” – mixed odontogenic tumor A.) Compound: look like little teeth, tooth material is in correct relation B.) Complex: everything mixed together, no normal relation of tooth material Tx: simple local excision – prognosis is excellent

Biopsy:

Odontogenic Myxoma • “soap bubble” appearance • aggressive- may displace or cause resorption of teeth • Derived from odontogenic ectomesenchyme Tx: small lesions can be treated by curattage, but since the lesion is not encapsulated, the site should be closely monitored, and large lesions may require more extensive resection. Hisologically odontogenic myxomas look just like dental papilla