Introduction to Third Molar Surgery: Part-2 Indications and Contraindication

Mandibular Third Molars  

According to George Dimitroulis, there are common and uncommon reasons for the removal of the mandibular third molar.   

Oral Lichen Planus

Oral Lichen Planus on left mucosa [1]

Question: What is oral lichen planus?

Answer: It is a chronic inflammatory condition that affects the skin, nails, hair, and mucous membranes, characterised by purplish, itchy, flat eruptions.

Question: How common is the condition?

Answer: It is a common condition in India. Its cases are reported more than 10 lakh per year in India. 

Question: How much time does it need for recovery?

Answer: It can last several years or remains lifelong.

Question: Is the condition treatable? 

Answer: Treatments can help manage conditions. There is no known cure present. 

 

Question: Does diagnosis require lab tests or imaging? 

Answer: Its diagnosis rarely requires lab tests or imaging. 

 

 

 

Condition Highlights 

1. It commonly occurs for ages 35-50. 
2. It is more common in females. 
3. Family history may increase likelihood to occur. 

 

Cysts of the Jaws and Neck: Classification

 

Cysts of the Jaws and Neck 

Cysts can be classified in three types.

Odontogenic Cysts  

1. Periapical (Radicular) Cyst  
2. Lateral Periodontal Cyst  
3. Gingival Cyst of the Newborn  
4. Dentigerous Cyst  
5. Eruption Cyst  
6. Glandular Odontogenic Cyst  
7. Odontogenic Keratocyst  
8. Calcifying Odontogenic Cyst  

Nonodontogenic Cysts  

1. Globulomaxillary Lesion  
2. Nasolabial Cyst  
3. Median Mandibular Cyst  
4. Nasopalatine Canal Cyst  

Pseudocysts  

1. Aneurysmal Bone Cyst  
2. Traumatic (Simple) Bone Cyst  
3. Static Bone Cyst (Stafne’s Bone Defect)  
4. Focal Osteoporotic Bone Marrow Defect  
5. Soft Tissue Cysts of the Neck  
6. Branchial Cyst/ Cervical Lymphoepithelial Cyst  

Dentigerous/Follicular Cysts

Dentigerous (Follicular) Cysts are the second most commonly occurring odontogenic cysts after periapical cyst and the most common developmental cysts of the jaws. By definition, a dentigerous cyst is attached to the tooth cervix (enamel-cementum junction) and encloses the crown of the unerupted tooth.

Photograph1: Dentigerous cyst surrounding the crown of right mandibular third molar and going upward in ascending ramus. [1]

Etiology and Pathogenesis of Dentigerous Cyst 

A dentigerous cyst originates from the enamel organ remnant or reduced enamel epithelium. The expansion of the dentigerous cyst is related to epithelial proliferation, release of bone-resorbing factors, and an increase in cyst fluid osmolality. 

Clinical Features of Dentigerous Cyst 

Dentigerous cysts are most commonly seen associated with third molars and maxillary Canines. The peak incidence of dentigerous cysts occurs between twenty to 40 years. Males have more predilection with a ratio of l.6 to 1.  

Dentigerous cysts are generally symptomless. The delayed eruption is the most common indication of dentigerous cyst formation. This cyst can achieve significant size, occasionally causes cortical bone expansion but rarely reaches a size that predisposes the patient to a pathologic fracture. 

Radiographically, a dentigerous cyst manifests as a well-defined, unilocular or sometimes multilocular radiolucency with corticated margins in attached with the crown of an unerupted tooth. The concerned unerupted tooth is mostly displaced. In the mandible the related radiolucency may extend superiorly from the third molar site into the ramus or anteriorly and inferiorly along the body of the mandible. In maxillary dentigerous cysts in the canine region, extension into the maxillary sinus or to the orbital floor may be seen.

Histopathology.

The cyst is lined by stratified squamous epithelium. In a noninflamed dentigerous cyst the epithelial lining is nonkeratinized. It remains approximately four to six cell layers thick. Sometimes, numerous mucous cells, ciliated cells, and rarely, sebaceous cells may be found in the lining of the epithelium. The epithelium-connective tissue junction is generally flat. But when secondary inflammation established, epithelial hyperplasia may be noted.

Photomicrography 2: showed a thin non-keratinized epithelial lining composed of 2–3 layers of cuboidal epithelial cells and a fibrous connective-tissue wall loosely arranged. The arrow indicates an occasional mucous cell (bar = 0.2 mm) [1]

Differential diagnosis

When it is small, it is difficult to differentiate a dentigerous cyst from a large but normal dental follicle. When larger, the differential is essential that of lytic lesions of the jaw and includes:

1. periapical cyst
2. aneurysmal bone cyst
3. ameloblastoma
4. odontogenic keratocyst
5. fibrous dysplasia
6. Stafne cyst

Treatment

Removal of the associated tooth and enucleation of the soft tissue part is definitive therapy in most cases. When cysts affect significant portions of the mandible, exteriorization or marsupialization of the cyst is done to allow for decompression and subsequent shrinkage of the lesion followed by surgical enucleation. 

Ref:

1. https://jcda.ca/article/c59
2. https://radiopaedia.org/cases/dentigerous-cyst-9
3. https://www.pathologyoutlines.com/topic/mandiblemaxilladentigerous.html
4. https://www.nature.com/articles/modpathol2016191

Odontogenic Keratocyst 

 

Odontogenic keratocyst (OKC) is a parakeratin lined cyst like lesion within bone.

OKCs mostly occur in the 2nd and 3rd decades of life; although can occur over a wide age range with male predilection. Odontogenic keratocyst comprises of 4 to 12 percent of all odontogenic cysts. Ninety percent of odontogenic keratocysts are solitary. Multiple cysts are found in Nevoid Basal Cell Carcinoma Syndrome / Gorlin Syndrome[1]. 

The most commonly involved body part in mandible, 65-85%; mostly posterior mandible. Normally, they are associated with third molars but may be present without associating with third molars; rarely occur in soft tissues.

They are considered to arise from dental lamina. 

Clinical Features 

Odontogenic keratocysts are often asymptomatic. They are incidentally discovered on radiographs. They can cause symptomatic swelling. They can cause parasthesia of lip and teeth. Symptoms of pain and drainage are found if secondarily infected. They can cause local bone and soft tissue destruction, but usually spare teeth and roots.

Swelling observed at the right buccal mucosa (dotted area) posterior to the orifice of Stensen’s duct-arrow head [3].

Odontogenic keratocyst-exposed anterior to the masseter muscle.

Radiographic features 

Mostly, they are seen as small unilocular radiolucent lesions with variable sclerotic margins. Larger lesions are often seen multilocular with variable scalloped margins. Therefore, They may resemble radicular cyst, dentigerous cyst, lateral periodontal cyst, and ameloblastoma.

Keratocystic Odontogenic tumer in orthopantomograph being shown as  multiple radiolucencies associated with mandibular anterior region, maxillary right and left as well as mandibular left impacted third molar tooth [5].

Classic look to a keratocyctic odontogenic tumor in the right mandible in the place of a former wisdom tooth. Unicystic lesion growing along the bone. Lesion was seen by oral surgeon on routine panoramic radiography without any symptoms [2].

Histology

Histological findings in the above slides are
a: The cyst wall is lined with parakeratinized squamous cells with a corrugated surface.
b: Nuclei of the cells in the basal layer are palisaded. The rete ridge of the epithelium is not evident [3]. 

Differential Diagnosis

1. Ameloblastoma
2. Dentigerous cyst
3. Peri-apical cyst
4. Lateral periodontal cyst

Prognosis

Recurrence rates of OKC are from 20% to 56% with enucleation alone. Resection have been reported to have no recurrences, but it may be considered excessive for a benign cyst.

Multiple lesions can occur when OKCs are associated with Nevoid Basal Cell Carcinoma Syndrome (NBCCS)/Gorlin Syndrome Therefore, early diagnosis and follow-up of the patient with OKC is important as there is always a possibility of developing other features of NBCCS in the future.

Treatment

Treatment is given taking into consideration of recurrence and morbidity. Following are the treatments given alone or in combination to a patient of odontogenic Keratocyst. 

1. Decompression.
2. Enucleation with possible curettage.
3. Chemical curettage with Carnoy’s solution.
4. Marsupialization.
5. Resection.

Case Studies

For further studies on case reports, you can consult the reference number 4 and 5.

Ref:

1. Morrison A. Odontogenic keratocyst. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/mandiblemaxillakeratocyst.html. Accessed September 11th, 2022.
2. https://en.wikipedia.org/wiki/File:Classic_keratocystic_odontogenic_tumour.jpg
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3837368/figure/F1/
4. https://www.pathologyoutlines.com/caseofweek/case503.htm
5. K. M. Veena, Rekha Rao, H. Jagadishchandra, Prasanna Kumar Rao, "Odontogenic Keratocyst Looks Can Be Deceptive, Causing Endodontic Misdiagnosis", Case Reports in Pathology, vol. 2011, Article ID 159501, 3 pages, 2011. https://doi.org/10.1155/2011/159501