Cystic lesion of the Mandible

Michael Chao, MD Thursday March 11, 2004

History
26 yo male w/ 6-8 month history of left mandibular swelling Fluctuating at first, now growing for 1 month Loose molars (teeth 17-18) Intermittent bleeding, now purulent drainage from loose teeth Pain left mandible, no decreased sensation. +trismus x 2 weeks, no dysphagia/odynophagia No weight loss.

Physical Exam
Left facial swelling over mandible and buccal region TTP along swelling Teeth 17-18 loose Mandible widened along body No sensory deficits

Panorex

CT Face

Differential Diagnosis
Odontogenic cysts Nonodontogenic cysts Odontogenic tumors

Odontogenic Cysts
Periapical Cyst Dentigerous Cyst Odontogenic keratocyst Basal cell neval syndrome Primordial cyst Lateral periodontal cyst Gingival cyst of newborn/adult

Periapical cysts
Most common odontogenic cyst (65%) Secondary to infected tooth Periapical bone resorbs and granulation tissue replaces Epithelial lining forms Cyst forms when epithelium necrosis

Dentigerous cyst
2nd most common odontogenic cyst (24%) Most commonly found in 2nd-4th decades Forms around unerupted teeth Usually incidental finding on x-ray Unilocular pericoronal radiolucent on x-ray

Odontogenic keratocyst
3rd most common odontogenic cyst 5-8% Aggressive lesion, rapid growth w/ frequent recurrence Capable of local bony destruction Swelling, drainage, pain, infection frequent complaints Can mimic any cystic lesion of mandible Recurrence 25-40% lesions

Basal cell nevus syndrome

Associated with multiple OKCs Autosomal dominant, high penetrance Early development of multiple basal cell carcinomas 5% pts w/ OKC have basal cell nevus syndrome

Other odontogenic cysts

Primordial cyst
develops instead of tooth Rarest odontogenic cyst

Lateral periodontal cyst

occur along root of vital tooth

Gingival cyst of newborn/adult

Remnants of dental lamina In newborns-multiple nodules, found in bone In adults-tense vesicles, found in soft tissue

Nonodontogenic cysts
Stafne bone cyst Traumatic bone cyst Aneurysmal bone cyst

Stafne bone cyst

Aberrant salivary tissue in or adjacent to mandible Generally occur below inferior alveolar canal

Traumatic bone cyst

Despite name only ~50% have history of trauma No epithelial lining Appears as radiolucency scalloped between tooth roots Does not erode cortex or teeth Found above inferior alveolar canal

Aneurysmal bone cyst

Can occur in any bone in body, most often spine or long bones Not a true cystno epithelial lining Displaces teeth Often presents as painful localized lesion

Odotogenic tumors
Ameloblastoma Adenomatoid odontogenic tumor Keratinizing and clacifying odontogenic cyst Odontogenic myxmoma Ameloblastic fibroma Ameloblastic fibro-odontoma Complex odontoma Compound odontoma Cementoblastoma

Ameloblastoma
Most common odontogenic tumor 13.5% Slow persistent growth locally aggressive Large lesions cause thinning of cortex, pathologic fractures Radiographically uni-/multilocular, resorb teeth

Ameloblastoma

Calcifying epithelial odontogenic tumor

Benign infiltrative odontogenic tumor Most commonly in the mandibular molar/premolar region Associated with an unerupted/impacted tooth Locally destructive and expanding Slower growth, less aggressive than Ameloblastoma Radiographically snow-driven appearance

Calcifying epithelial odontogenic tumor

Keratinizing/calcifying odontogenic cyst

Tumor with cystic tendencies Very rare lesion Usually incidental finding on dental x-ray Arise from a more mature enamel epithelium On x-ray nondescript radiolucencies with radioopaque patches Histologically may appear similar to unicystic ameloblastoma

Keratinizing/calcifying odontogenic cyst

Odontogenic myxoma
Benign infiltrative lesion locally invasive and destructive Radiographically multilocular cyst Histologically distinct from ameloblastoma
stellate fibroblasts w/ copious hyaluronic acid, scant collagen no capsule

Odontogenic myxoma
Alcian blue stain of odotogenic myxoma

Radiolucent lesion w/ small multiloculated cysts

Ameloblastic fibroma
A mixed tumor arising from 2 embryonic tissues Realtively uncommon tumorsues. Benign expansile lesion Radiograhically similar to ameloblastoma Epithelial component and connective tissue components

Ameloblastic fibroma
well defined lesion associated w/ unerupted tooth displaces adjacent teeth, does not destroy

islands of ameloblastic epithelium surrounding a stellate-reticulum-like center

Ameoblastic fibro-odontoma
Most often develops before 20yrs old Extremely rare odontogenic lesion Develops from dental hard tissues (eg, dentin, enamel, cementum) Generally do not have much growth potential Radiographically well demarcated lesion, radiolucent w/ central opacity Surgical excision is curative

Ameloblastic fibro-odontoma
cystic lesion destroying and displacing teeth

narrow cords and small islands of epithelium

Complex odontoma
One step more differentiated than ameloblastic fibro-odontoma Common lesions that persist through life Usually detected in adolescence Radiographically "sunburst" radiopacities w/ uniform rim

Complex odontoma

large radioopaque lesion well encapsulated w/ radioiolucent border

Compound odontoma
Most common odontogenic tumor Appears as a cluster of multiple abortive teeth Often prevents normal tooth eruption Radiographically multiple tiny toothlike structures are contained within a fine radiolucent rim Do not recur after excision

Compound odontoma
3 small radioopaque lesion w/ radiolucent rim

well encapsulated lesions appear similar to normal teeth

Cementoblastoma
Benign neoplasm of cementum Rare and usually diagnosed by early 20's 50% lesions associated w/ apical 1st mandiblualr molar Most commonly asymptomatic Radiographically "suburst" mass attached to apex Treatment consists of surgical extraction of tooth and lesion Recurrence is rare

Cementoblastoma
sunburst lesion at apical root radiolucent rim

acellular sheets of cemetum attached to root