Page 22 - SPRING 2016

Non-Invasive Implant Placement

Subsequent to a Large Glandular Odontogenic Cyst

By David Forlano, DDS
INTRODUCTION CHARACTERISTICS & BEHAVIOR
Cysts of the jawbones fall into two main categories: odontogenic The glandular odontogenic cyst is certainly rare. Only fifty cases
cysts and non-odontogenic cysts. Their classification depends have been reported in the literature prior to January 2016. 5
upon their origin. Odontogenic cysts develop from the cells that Overall incidence has been estimated as 0.012% of all cysts. It
form teeth and have a distinct membrane which is derived from occurs over a wide age-range, but more commonly in the 4th and
the rests of the odontogenic epithelium. Non-odontogenic cysts 5th decades of life. It occurs in either the maxilla or the mandible.
arise from epithelial remnants of embryonic ducts left behind after It can be unilocular or multilocular. In 95% of cases, the borders
facial and jaw development. Examples of odontogenic cysts of the glandular odontogenic cyst are well-defined radiographi-
1
include the dentigerous cyst, the radicular cyst, the residual cyst, cally. 6 The concerning characteristics of the glandular odonto-
the lateral periodontal cyst, and the odontogenic keratocyst. genic cyst are its aggressiveness and its high recurrence rate. By
Examples of non-odontogenic cysts include the nasopalatine duct aggressive, the literature means that these cysts can reach very
cyst, nasolabial duct cyst, the median palatal cyst, and the epider- large sizes and have a greater tendency to expand or even perfo-
6
moid cyst. rate the cortical plate. Sizes can range from 0.5cm - 12cm with
an average size of 5cm, with most being larger than 2cm. Root
THE GLANDULAR ODONTOGENIC CYST resorption and tooth displacement occur in approximately 23% of
6
The glandular odontogenic cyst is a unique lesion. It was report- cases. The recurrence rate ranges from 25-55%. 7
ed and described by Gardner et al in 1988 as a distinct entity due
2
to its unique histopathological features and its behavior. Prior to TREATMENT
Gardner’s distinction, these cysts were melded into both odonto- Small unilocular lesions can be treated by enucleation, which is
genic and non-odontogenic categories. Gardener distinguished the the process of removing the lesion in one piece without rupture,
histopathological appearance of this cyst from those of other jaw and without involving adjacent tissue.
cysts by the following characteristic features:
In large or multilocular lesions, treatment by enucleation alone is
8
1. There is no inflammatory infiltrate present within the connec- associated with a high recurrence rate. For these lesions, an ini-
tive tissue that underlies the stratified squamous epithelium lin- tial biopsy is recommended. Then, marsupialization followed by
ing of the cyst. second phase surgery is recommended. Marsupialization is the
2. The superficial layer of the epithelium consists of eosinophilic surgical technique of cutting a slit into the cyst and suturing the
cuboidal cells that make the surface irregular and sometimes edges of the slit to form a continuous surface from the exterior to
papillary. the interior surface of the cyst. By suturing in this fashion, the site
3. Within the epithelium, there are pools of mucicarmine-positive remains open and can drain freely. This technique is used to treat
material that are often weak and lined by eosinophilic cuboidal a cyst when a simple incision and drainage would not be effective,
cells similar to those found on the surface of the epithelium. and where complete removal of the surrounding structure would
4. Mucous cells are prominent in some, not be desirable. An example would be a
but not all examples. They are usually cyst that is close to vital anatomical struc-
found on the surface, and when they tures.
are present, they replace the
eosinophilic cuboidal cells. Other options for large lesions are enu-
5. The basal cells are sometimes hyper- cleation with peripheral osectomy for
chromatic and may be vacuolated. unilocular cases and marginal resection
6. The epithelial cells in focal areas may or partial jaw resection for multilocular
be arranged into spherical structures. cases. 6,7,9
7. Irregularly shaped calcifications may
be present in the connective tissue With all glandular odontgenic cysts, fol-
beneath the epithelium. Figure 1: Panoramic image of large low-up should continue for at least three
radiolucency of the left posterior mandible. years and up to seven years in cases with
To avoid confusion and to reinforce features associated with increased risk. 10
Gardner’s distinction, the World Health
Organization (WHO) recognized the CASE REPORT
glandular odontogenic cyst as its own FINDINGS
pathological entity and has classified it as A 51-year-old Caucasian male presented
an odontogenic cyst. Although the for a routine dental checkup. Medical
histopathological appearance is distinct, history revealed a nonsmoker with high
it remains challenging for the oral pathol- blood pressure and frequent alcohol
ogist because the mucus-producing cells intake. An incidental finding on the
found in the samples resemble those of panoramic image revealed a large radi-
the mucoepidermoid carcinoma, which olucency of the left posterior mandible
requires an entirely different approach to Figure 2: Outlined close-up of the (Figures 1, 2). The lesion was asympto-
treatment. 3,4 matic, as most cysts of the jaw bones are
radiolucency.
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