Pseudocysts

Contents
Introduction
Aneurysmal bone cyst
Simple bone cyst
Static bone cyst
Mucus extravasation cyst
Antral pseudocyst
Aneurysmal bone cyst

Long bones
Jaffe & Lichtenstein 1942-
blow out (radiographically)
Aneurysmal bone cyst
Intraosseous accumulation of variable sized,
blood filled spaces surrounded by cellular
fibrous connective tissue that often is
admixed with trabeculae of reactive woven
bone

Aneurysmal Bone Cyst
First three decades;
Most common in second decade
Female predilection
Mandible > maxilla (molar region >angle
> ramus)

Aneurysmal Bone Cyst
Painful swelling
Malocclusion
Rate of enlargement is progressively rapid
Recent displacement of teeth ; which are vital
Perforates the cortex and; covered by
periosteum
Thin shell of bone
Springiness or egg shell crackling, BUT IS
NOT PULSATILE


Radiographic appearance
Well defined expansile
osteolytic unilocular
radiolucency

Changes as it matures
Soap bubble
Honey bomb
Moth-eaten
Radiopaque
Etiology & Pathogenesis
Traumatic event,
Vascular malformation or
Neoplasm that disrupts the normal
osseous hemodynamics & lead to an
enlarging hemorrhage extravasation

Preexisting bone lesion- secondary
phenomenon
Ewing (1940)
Benign giant cell lesion tumor modified by
communication with large blood vessels
Jaffe (1950)
Modification of some other lesion which has
been destroyed by hemorrhage
Clough & Price (1968)
Fibrous dysplasia & chondromyxoid fibroma
Etiology & Pathogenesis
Solitary bone cysts, giant cell tumors &
osteosarcomas
More commonly with Fibro osseous lesions
What changes could have caused the
formation of ABC in these lesions???

Etiology & Pathogenesis
Formation of microcysts
(Fibrous dysplasia, Central giant cell granuloma)

Enlargement of the microcyst
(stromal break down, giant cells)

Connection with vascular compartment causes
further expansion
Etiology & Pathogenesis
Pressure on the bony wall
(endosteal resorption)

Thinning of cortex
Etiology & Pathogenesis
Struthers &Shear
Malignant lesion-breaking the bone
Telangiectatic form of osteosarcoma
To conclude many think that it is NOT a
secondary phenomenon as they did not find
any precursor lesion.
However both groups agreed that some
areas similar to those of ABC were seen.

Etiology & Pathogenesis
At operation an intact periosteum and a thin
shell of bone
Profuse bleeding
Cyst contains number of blood filled locules
and friable vascular tissue
No direct communication with any vessels can be
demonstrated at operation
Etiology & Pathogenesis
Capillaries, blood
filled spaces, lined
by flat spindle
shaped cells

Loosely textured
fibrous tissue

HISTOPATHOLOGY
Large number of
multinucleate
giant cells


Fibroblasts,
hemorrhage,
hemosiderin

Looks similar to
giant cell
granuloma


Differential diagnosis
Giant cell lesions
Osteosarcoma
Rule out any lesion primarily associated
Treatment
Depend on the nature of the associated
lesion
Curettage
Bone grafting
Can recur-
if recur evaluate the case carefully to see any
associated lesion

Simple bone cyst
(Traumatic bone cyst; hemorrhagic bone cyst,
idiopathic bone cavity; unicameral bone cyst)

Benign , empty or fluid containing cavity
within bone that is devoid of an epithelial
lining
Common in jaws
First described by Lucas (1929)

Rushton defined : A vacant or fluid
containing cystic lesion surrounded by a
hard bony wall with no epithelial lining
and no evidence of infection
Simple bone cyst
Further Donkar and Punnia-Moorthy
subclassified as:
Idiopathic-Empty
Fibrous or granulation solid matter
Extravasation cysts (containing biochemical
profile similar to serum)

Simple bone cyst
Younger patient; though (7-75 years)
More in males
Mandible mostly
Body and symphysis (ramus also
reported)
Anterior region in maxilla
Trauma prone areas

Simple bone cyst
Asymptomatic; Diagnosed on Routine
examination
Sometimes may be associated with
Pain
Swelling
Paraesthesia
History of trauma (not always)
Simple bone cyst
Smooth outlined radiolucent
with thin sclerotic border ,Root
involved - lobulated
Lamina dura may or may not
be lost

Radiographic appearance
Differential Diagnosis
Periapical cemental dysplasia
OKC
Stafne cyst (Below canal)
Pathogenesis
Olech, Sicher & Weinmann -
Trauma - hemorrhage theory

Trauma

intramedullary hemorrhage

Necrosis of bone marrow and endosteum

Osteoclastic resorption of trabeculae

Liquefaction of hematoma
(Before viable connective tissue formation)

Some simple cyst contain blood or serosanguineous fluid
Breakdown products of hematoma

Local rise in osmotic pressure
(Toller study)

Transudation into the cystic fluid

Increase the intraosseous pressure

Osteoclastic activity and swelling

Transudation progresses

Fluid gets diluted

Drop in the intracystic pressure
(Further bleed may cause progression of the lesion)
No more bleeding
Gradual absorption or fluid occurs
Empty cavity
Histologically
Walls lined by a
thin band of vascular
fibrous connective
tissue or demonstrate
a thickened
myxofibromatous
proliferation that
often is intermixed
with trabeculae of
cellular & reactive
bone

Areas of
vascularity, fibrin,
erythrocytes &
occasional giant
cells adjacent to
the bone surface
Diagnosis
Can be confused with Giant cell lesions
Surgical exploration necessary
EMPTY CAVITY
SMOOTH SHINY WALL
SEROSANGUINEOUS FLUID
Mandibular neurovascular bundle may seen lying
free in the cavity
Treatment
Induce hemorrhage
Some may resolve by itself
Stafne cyst
(Lingual Mandibular bone defect, static bone cavity,
latent bone cyst)
1942- Stafne described asymptomatic
radiolucent lesions located near the angle of
the mandible
Focal concavity of the cortical bone on the
lingual surface of the mandible, remain
stable in size , are not congenital
All major salivary gland can cause such
defect
Radiographic appearance
Ovoid radiolucency between
inferior alveolar canal and inferior
border of mand inn 2
nd
or 3
rd
molar
Distinguished
bet TBC-
superior to
inferior
alveolar canal
Pathogenesis
Pressure from the lobe of the gland

Resorption of the bone

Radiolucent defect

1.
Pathogenesis
Ischemic process in an area adjacent to the
passage of the facial artery + tensile muscle
forces + hemodynamic forces

Pulled the artery from the lingual cortex

Comprising it from nutrition

Atrophy
2.
Diagnosis
Clinical basis
CT & MRI, Sialography
Biopsy
Histopathology
Muscle, Fatty Tissue or Normal salivary gland
Treatment
No treatment required
Mucous extravasation
cyst
(Mucous escape reaction, mucous escape
phenomenon )
Two type
Retention (less common) and extravasation

Most commonly found on lower lip, can
also be seen on
Upper lip
Floor of mouth and ventral of tongue
Palate
Buccal mucosa
Retro molar area
Mucous extravasation cyst
Painless swelling (specially at meal times-on
and off swelling)
Round to oval
Blue and fluctuant/ normal color
Mistaken for lipoma, salivary gland tumor, fibro
epithelial polyp
Pathogenesis
Trauma to the salivary gland duct or the acini
duct itself (parenchymatous type)

Egress of mucous into the adjacent connective
tissue

Complete ductal obstruction Mucus extravasation cyst
Histopathology
Usually received with a associated salivary
gland and frequently a part of the superficial
mucosa
If cut-gelatinous material/ mucinous content
Three distinct pattern (Robinson & Horting-
Hansen)
1
st
and 2
nd
extravasation
3
rd
retention
Histopathology
Mucous acini
CONNECTIVE
TISSUE STROMA
MUCIN FILLED
CAVITY
Histopathology
Mucin filled cavity
with mucinophages,
neutrophils,histocyte
C.T- B.V,
inflammatory cell
infitrates,
Mucous acini
Treatment
Surgical excision tends to recur
Removal of the gland is advisable along
with the mucocele
Antral
Pseudocyst
Antral cysts:
True- secretory
Pseudo-non secretory
Dome shaped lesion of the sinus floor

SINUS
Antral Pseudocyst


Exudate (serum not mucin)

Accumulated under the maxillary sinus
mucosa causing sessile elevation
SINUS
Antral Pseudocyst

Odontogenic infection
Sinus infection
Allergies
Winter months

Kwappis and Whitten (1971)
Severe infection

Alter the integrity of the gland duct in the
sinus lining

Mucus into the connective tissue
Pathogenesis
Gardner and Gardner and Gullane
Focal accumulation of inflammatory exudate that lift
the antral mucosa
Endodontically treated teeth and periodontitis has
also been implicated
Mechanical stress during cold sharp angle tissue
gets rupture
Increased IgG, IgA, and C3 presence of
anaerobic infection


Pathogenesis
Radiographic appearance
Faintly radiopaque
Histopathology
Calcifications and cholesterol crystals may be seen
No treatment-regress by itself
If symptoms present
Drain by acnnulation
Large cyst remove by caidwell-Luc approach
Treatment