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# cyst

Cysts of the maxilla and mandible are


common occurrences. Bone cysts occur more frequently in the
jawbones than any other bone because of the presence of
epithelium from odontogenic elements (eg, teeth) and
nonodontogenic epithelial remnants of embryonic structures.
A cyst is defined as an epithelial-lined pathologic
cavity that may contain fluid or a semisolid material. There are a group of
cystic lesions devoid of an epithelial lining that are classified as pseudocysts. A
jaw cyst is usually located deep within the jawbone, but it may occur on a bony
surface, producing a saucerization.

Classification

odontogenic Non-odontogenic Pseudocyst

Inflammatory Traumatic bone


Nasopalatine cyst
Periapical cyst cyst
Globulomaxillary
and granuloma Static bone cyst
Median cyst of
Developmental Hematopoietic
palate
Dentigerous cyst bone marrow
Gingival cystvof defect.
Eruption cyst new born and
Lateral adult
periodontal cyst Nasolabial cyst
Odontogenic
keratocyst
Calcifying
odontogenic cyst
Glandular
odontogenic cyst
# Dentigerous (Follicular) Cysts
Essentials of Diagnosis
Epithelial-lined, developmental, odontogenic
cysts.
Second most common type of jaw cyst
associated with the crown of an impacted,
unerupted, or developing tooth.
Well-defined, radiolucent, sometimes expansile
lesion.
Usually slow growing and benign.
Initially asymptomatic unless long standing with
significant enlargement or secondary infection.
Usually discovered on routine dental x-rays.
Requires histopathologic examination for
diagnosis.

General Considerations
Fifteen to eighteen percent of jaws cysts are
dentigerous, surround the crowns, and attach at the
cemento-enamel junction of unerupted teeth. The
lower-third molars and the upper canines are the most
commonly involved teeth.
Pathogenesis
Dentigerous cysts derive their epithelium from the
proliferation of the reduced enamel epithelium after the
tooth enamel is formed. The cyst develops subsequent
to an accumulation of fluid between the remnants of
the enamel organ and the contiguous tooth crown. The
expansion of this intrabony cyst is associated with an
increase in the osmolality of the cyst fluid secondary to
the migration of inflammatory cells into the cyst lumen.
Epithelial proliferation may also occur simultaneously.
Figure 231.

(A) The development of the dentigerous cyst around the crown of an unerupted tooth.
Prevention
Regular dental and oral examinations with appropriate
imaging can identify developing cystic jaw lesions
before any significant bony destruction can occur. The
removal of impacted teeth, when indicated, serves as a
preventive measure.
Clinical Findings
SYMPTOMS AND SIGNS
Small dentigerous cysts rarely produce clinical
symptoms. Larger cysts can produce a bony expansion,
which creates an intraoral swelling, an extraoral
swelling, or both. They also can result in facial
asymmetries or can become secondarily infected,
which results in pain.
IMAGING STUDIES
The most common radiographic appearance of a
dentigerous cyst is that of a well-delineated round-to-
oval mass that is associated with an unerupted tooth,
which may possibly be displaced. Figure 232
demonstrates a typical dentigerous cyst as observed on
a panoramic x-ray. Periapical and panoramic x-rays
can illustrate the extent of the cyst and contiguous
anatomic structures. With large lesions, CT scanning is
helpful in assessing the degree of expansion
perforation and the involvement of adjacent structures.
Figure 232.
A panoramic x-ray showing a dentigerous cyst appearing as a well-defined radiolucency around the
crown of an unerupted mandibular third molar.

SPECIAL TESTS
Needle aspiration with possible biopsy of the lumen of
a suspected cystic lesion can give confirmatory
diagnostic information and rule out the presence of a
vascular lesion. If there has not been significant
expansion of the cyst, with thinning of the bony cortex,
it will not be possible to penetrate the bone using a
needle and syringe technique. In these cases, if
aspiration is desired, a small mucosal incision, followed
by drilling a small hole through the buccal cortex, will
enable needle aspiration. Aspiration of a light, straw-
colored fluid is characteristic of a dentigerous cyst
(Figure 233). Histopathologic examination will reveal
a thin, nonkeratinized cyst lining. Inflammatory
changes may produce epithelial hyperplasia. Mural
hemorrhage can result in cholesterol clefts, giant cells,
and hemosiderin in the wall of the cyst. Hyaline bodies
(eg, Rushton or hyaline bodies) may be present in the
epithelium.
Figure 233.

Aspiration of a straw-colored fluid from the lumen of a dentigerous cyst.

Differential Diagnosis
The differential diagnosis should include odontogenic
keratocysts, ameloblastomas, cystic ameloblastomas,
ameloblastic fibromas, and nonodontogenic tumors.
Complications
Complications related to the damage created by an
expanding jaw cyst include bony destruction, infection,
oral or facial sinuses, weakening of the jaw,
displacement of teeth, resorption of adjacent tooth
roots, encroachment on the maxillary sinus floor, and
deflection of the inferior alveolar canal. The
transformation of the epithelial lining of a dentigerous
cyst into an ameloblastoma is also possible. Dysplasia
or the carcinomatous transformation of the epithelial
lining is possible, but rare. Complications related to the
surgical management of cysts include devitalization of
adjacent teeth, postoperative infection, neurosensory
deficits, oral-antral fistulas, jaw fracture, and cyst
recurrence.
Treatment
Enucleation of the cyst and removal of the associated
tooth is the treatment of choice. The surgical exposure
is observed in Figure 234. The surgical flap can be
repositioned and sutured with primary closure. Even
large, bony cavities can regenerate new bone over
several months time. If the tissue breaks down, the
cavity can be packed with one-quarter inch gauze and
gradually advanced over 710 days, followed by
frequent saline irrigations to allow healing by
secondary intention. For extremely large surgical
defects, primary bone grafting with autogenous
cancellous chips can accelerate the healing process.
Marsupialization of the cyst may be considered.
Prognosis
The prognosis after treatment of the cyst is excellent, with
the expectation that the surgical defect will heal. The
recurrence rate for the cyst is very low.