Odontogenic Cysts and Related Jaw Tumors

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Odontogenic Cysts and Related Jaw Tumors

Head and Neck Surgery
Author Credentials 

James Cohen MD, PhD
Professor Otolaryngology/Head and Neck Surgery
Oregon Health Sciences University
3710 SW US Veteran’s Hospital Road, P3-OC
Portland, Oregon, 97210
email: James.Cohen2@va.gov

Module Summary

Although the primary area of expertise of the otolaryngologist is not is not in the dental sciences, odontogenic tumors and cysts can present as swellings in the mouth or maxillary sinuses. It is therefore important that the otolaryngologist has a working knowledge of the common types of these lesions and a logical approach to their diagnosis, especially in terms of the need for and proper approach to biopsy where indicated.  Recent changes in the understanding of their classification and pathogenesis have helped in understanding the need for management and how aggressive the approach should be.

Module Learning Objectives 

The vast majority of odontogenic cysts and related jaw tumors are diagnosed and managed by dentists and oral/maxillofacial surgeons. However, a patient with a swelling or mass in their mouth is often initially referred to an otolaryngologists/head and neck surgeon. It is therefore important to have a fundamental understanding of the typical presentation of these lesions and an appropriate diagnostic approach to ensure that other pathologies are not missed. In addition, otolaryngologists may be asked to be involved in situations where the extent of resection and/or the need for reconstruction are such that the operations are more like typical oncologic head and neck operations.
Rather than deal with each possible type of odontogenic cyst/tumor this module will use the more common and prototypical pathologies to illustrate the principles of diagnosis and management. References can be read with a focus on the following histologies.

  1. Keratocystic Odontogenic Tumor/Odontogenic Keratocyst
  2. Dentigerous Cyst
  3. Periapical Cyst
  4. Nasopalatine Cyst
  5. Aneurysmal Bone Cyst
  6. Ameloblastoma

After completing this module the physician will be able to:

  1. Describe the basis for the classification and pathogenesis of the different types of jaw cysts/tumors seen.
  2. Discuss appropriate imaging techniques for the diagnosis of these lesions and the typical radiologic findings that may help establish the diagnosis.
  3. Explain the principles that guide when a biopsy is indicated and the appropriate method(s) of performing this.
  4. Explain the principles of management for the different cysts/tumors types.

Pathogenesis

Learning Objectives 
  • Understand the basis for the classification of jaw cysts in the context of the following broad categories
    1. Epithelial Lined Cysts
      1. Developmental
        1. Odontogenic
        2. Non Odontogenic
      2. Inflammatory
    2. Non Epithelial Lined Cysts
  • Explain the role of the three groups of epithelial rests that provide the epithelium for odontogenic cysts
    1. The rests of Malassez
    2. Reduced enamel epithelium
    3. Remnants of dental lamina
  • Understand the controversy that surrounds the possible origin of non-odontogenic epithelial cysts in terms of the theory of trapped epithelial rests.
References 
  1. Regezi JA, Courtney RM, Batsakis JG. The pathology of head and neck tumors: cysts of the jaws, part 12. Head Neck Surg. 1981 Sep-Oct;4(1):48-57. EBM Level 5
  2. Daley TE, Wysocki GP. New developments in selected cysts of the jaws. J Can Dent Assoc. 1997 Jul-Aug;63(7):526-7, 530-2. EBM Level 5
  3. Madras J, Lapointe H. Keratocystic odontogenic tumour: reclassification of the odontogenic keratocyst from cyst to tumour. J Can Dent Assoc. 2008 Mar;74(2):165-165h. EBM Level 5
  4. Wright JM, Vered M.  Update from the 4th Edition of the World Health Organization Classification of Head and Neck Tumours: Odontogenic and Maxillofacial Bone Tumors. Head Neck Pathol. 2017 Mar;11(1):68-77. EBM Level 5

Incidence

Learning Objectives 

Know the relative incidence of the six histologies listed above—the most common types.

References 
  1. Regezi JA, Courtney RM, Batsakis JG. The pathology of head and neck tumors: cysts of the jaws, part 12. Head Neck Surg. 1981 Sep-Oct;4(1):48-57.  EBM Level 5
  2. Weber AL  Cystic lesions of the mandible and maxilla--radiological evaluation and differentiation. Isr J Med Sci. 1992 Mar-Apr;28(3-4):198-205.  EBM Level 5
  3. Johnson NR, Gannon OM, Savage NW, Batstone MD. Frequency of odontogenic cysts and tumors: a systematic review. J Investig Clin Dent. 2014 Feb;5(1):9-14. EBM Level 5

Genetics

Learning Objectives 

Be familiar with the evolving role of genetics in the understanding of these cysts / tumors.

References 
  1. Wright JM, Vered M.  Update from the 4th Edition of the World Health Organization Classification of Head and Neck Tumours: Odontogenic and Maxillofacial Bone Tumors. Head Neck Pathol. 2017 Mar;11(1):68-77. EBM Level 5

Patient Evaluation

Learning Objectives 

Beyond the presence of a submucosal swelling in the mandible or maxilla evaluation is almost entirely dependent on imaging (see below) and where indicated biopsy.

Imaging

Learning Objectives 

Understand the role of different types of imaging modalities that are used in the work up of these lesions.

References 
  1. Weber AL. Cystic lesions of the mandible and maxilla--radiological evaluation and differentiation. Isr J Med Sci. 1992 Mar-Apr;28(3-4):198-205. EBM Level 5
  2. Scarfe WC, Toghyani S, Azevedo B. Imaging of Benign Odontogenic Lesions. Radiol Clin North Am. 2018 Jan;56(1):45-62. EBM Level 5
  3. Devenney-Cakir B, Subramaniam RM, Reddy SM, Imsande H, Gohel A, Sakai O. Cystic and cystic-appearing lesions of the mandible: review. AJR Am J Roentgenol. 2011 Jun;196(6 Suppl):WS66-77. EBM Level 5

Pathology

Learning Objectives 
  1. Discuss the importance of correlation of both imaging and histology in the diagnosis of these lesions
  2. Describe the importance of adequate sampling of the cyst lining for accurate diagnosis and therefore the limited role of needle biopsy in the diagnosis of these lesions.
  3. Understand the importance of planning the surgical approach for the biopsy in such a way that it does not compromise subsequent management.
References 
  1. Robinson RA. Diagnosing the most common odontogenic cystic and osseous lesions of the jaws for the practicing pathologist. Mod Pathol. 2017 Jan;30(s1):S96-S103. EBM Level 5

Treatment

Learning Objectives 

Understand the concepts of enucleation/curettage vs. resection in the surgical management of these cysts/tumors and the basis for the controversy that surround them according to cyst/tumor type.

References 

Case Studies

  1. A 46 year old women presents with a submucosal swelling in the left retromolar trigone that has been present for an in determinant period of time. Examination reveal expansion of the lingual cortex of the mandible. There is no associated mucosal change and the posterior molars (#17-19) are missing in that area. What imaging studies would be most valuable in the diagnosis of this lesion? How would you establish the diagnosis? How would you decide whether curettage vs. wide local resection would be appropriate management?
  2. A 50 year old man presents with a recurring area of granulation on the buccal cortex of the mandible adjacent to tooth #28. Biopsy has shown granulation only and the lesion has recurred after excision. The tooth has a crown on it. What would be your next step in management?
  3. A 75 year old female presents after a CT done for evaluation of sinusitis has revealed a bone covered lesion in the floor of her left maxillary sinus. The sinus above it is without evidence of mucosal inflammation. The teeth in the adjacent maxillary ridge are vital on exam and without evidence of looseness or periodontitis?. CT reveals that the roots of the adjacent teeth # 8,9 seem to extend into the lesion. How would you proceed?
     

Review

Review Questions 
  1. Explain how our understanding of maxillary cysts has evolved such that the concept of “fissural cysts” no longer seem valid.
  2. Why has there been so much controversy over the classification of odontogenic keratocyst vs. keratocystic odontogenic tumor and how is it reflected in the management of these lesions?
  3. What are the concepts that guide the management of periapical cysts?
  4. Why is curettage alone not sufficient management for amelobastomas?
  5. What are the two most essential elements in the diagnosis of any mandibular cystic lesion?
  6. In a patient with multiple mandibular cysts what other physical exam findings should be looked for?