Glandular odontogenic cyst

The performance of radiographic imaging i.e. computed tomography, at the affected area is considered essential.[13] Radiographic imaging of the GOC can display a defined unilocular or multilocular appearance that may be "rounded or oval" shaped upon clinical observation.[5][4] Scans may present a distribution of the GOC at the upper jaw as it presents a 71.8% prevalence in cases.[2] The margin surrounding the GOC is usually occupied with a scalloped definition.[2] A bilateral presentation of the GOC is possible but is not common at either the maxilla or mandible sites.[13] The GOC has an average size of 4.9 cm that can develop over the midline when positioned at the mandible or maxilla region.[3][14] Analysis of scans allow for the differentiation of GOC from other parallel lesions, i.e. "ameloblastoma, odontogenic myxoma, or dentigerous cyst" in order to minimise the chance of a misdiagnosis.[5] These scans can display the severity of cortical plate, root, and tooth complications, which is observed to determine the necessary action for reconstruction.[5]

Histological features related to the GOC differ in each scenario; however, there is a general criterion to identify the cyst.[14] The GOC usually features a "stratified squamous epithelium" attached to connective tissue that is filled with active immune cells.[2][7] The lining of the epithelium features a very small diameter that is usually non-keratinised.[8][13] In contrast, the lining of the GOC has rather an inconsistent diameter.[2] The basal cells of the GOC usually has no association to a cancerous origin.[12] Tissue cells can be faced with an abnormal increase in the concentration of calcium, which can cause the region to calcify.[7] The transformation of the epithelium is associated with a focal luminal development.[2] Eosinophilic organelles such as columnar and cuboidal cells can be observed during microscopy.[11] Intra-epithelial crypts may be identified in the internal framework of the epithelium or at the external space where it presents itself as papillae protrusions.[8][13] Mucin is observable after the application of "alcian blue dye" on the tissue specimen.[8] The histological observation of goblet cells is a common feature with the "odontogenic dentigerous cyst".[11] In some circumstances, the epithelium can have variable plaque structures that appear as swirls in the tissue layers.[8] Interestingly, histologists were able to identify hyaline bodies within the tissue framework of the GOC.[7] It is encouraged that the histological identification of at least seven of these biological characteristics is required to accurately distinguish the presence of the GOC.[11]

Pathologists have identified hemosiderin pigments that are considered unique to the GOC.[12] The discovery of this pigment can be pivotal to the differentiation of the GOC from other lesions.[12] The staining at the epithelium is due to the haemorrhaging of the lining.[12] The cause of the haemorrhaging can be triggered by the type of treatment, cellular degradation, or structural deformation inflicted during GOC expansion.[12] Examination of the GOC tissue section indicated that red blood cells from the intraluminal space had combined with the extracellular constituents.[12] This process is carried out through transepithelial elimination.[12] This clinical procedure is beneficial to confirm the benign or malignant nature of the GOC.[12]

The examination of cytokeratin profiles is deemed useful when observing the differences between the GOC and the central MEC.[14] These two lesions show individualised expression for cytokeratin 18 and 19.[7] Past studies observed Ki-67, p53, and PCNA expression in common jaw cysts that shared similar characteristics.[7] There was a lack of p53 expression found in radicular cysts.[7] Similarly, Ki-67 was seen less in the central MEC compared to the other lesions, though this discovery is not essential to the process of differential diagnosis.[7][14] Proliferating cell nuclear antigen readings were established to have no role in the differentiation process.[14] The TGF-beta marker is present in the GOC and can explain the limited concentration of normal functioning cells.[15]

The observation of a MAML2 rearrangement is described as a procedure useful in the differential diagnosis of the GOC and its closely related lesion, the central MEC.[11] A second cystic development displayed the presence of CRTC3-MAML2 fusion after an in-vitro application.[11] The MAML2 rearrangement represents the developmental growth of the central MEC from the GOC.[11] The use of fusion-gene transcript may be helpful towards the differentiation of the GOC from the central MEC of the jaw and salivary glands.[11]

Panoramic radiography used to provide visualisations of the maxilla and mandible. X-rays will display the degree of impact on case, caused by the GOC.

A computed tomography and panoramic x-ray must be undertaken in order to observe the severity of internal complications.[5] These scans allow for the observation of the GOC size, radiolucency, cortical bone, dentition, root, and vestibular zone.[5] In some cases, the dentition may be embedded into the cavity walls of the lesion, depending on the position of expansion at the odontogenic tissue.[13] The diagnosis of a smaller sized GOC is related to the attachment of only two teeth.[6] While, a greater sized GOC develops over two teeth.[6] Presentation of a greater sized lesion usually requires a biopsy for a differential diagnosis and a precise treatment plan.[6]

The unilocular and multilocular nature is imperative to the determination of treatment style.[6] Local anesthesia is regularly provided as the GOC is embedded within the tissue structure of the jaw and requires an invasive procedure for a safe and accurate extraction.[2] For unilocular GOCs with minimal tissue deterioration, "enucleation, curettage, and marsupialization" is a suitable treatment plan.[6] Notably, the performance of enucleation or curettage as the primary action is linked to an incomplete extraction of the GOC and is only recommended to the less invasive lesions.[6] Multilocular GOCs require a more invasive procedure such as "peripheral ostectomy, marginal resection, or partial jaw resection".[6] GOCs associated with a more severe structural damage are encouraged to undergo marsupialization as either an initial or supplementary surgery.[6] The frequency of reappearance is likely due to the lingering cystic tissue structures that remain after the performance of curettage.[13] The incorporation of a "dredging method i.e. repetition of enucleation and curettage" is also suggested until the remnants of the GOC diminishes for certain.[9] The treatment ensures scar tissue is removed to promote the successful reconstruction of osseous material for jaw preservation.[9] Alongside the main treatments, bone allograft application, cryosurgery, and apicoectomy are available but have not been consistently recommended.[9][13][5] Though Carnoy's solution, the chloroform-free version, is recommended with the treatment as it degenerates the majority of the damaged dental lamina.[13] The most effective type of treatment remains unknown due to the lack of detailed data from reported cases.[3]

Follow-up appointments are necessary after the removal of the GOC as there is a high chance of remission, which may be exacerbated in cases dealing with "cortical plate perforation".[13][5] The GOC has a significant remission rate of 21 to 55% that can potentially develop during the period of 0.5 to 7 years post-surgery.[7][6] Cases occupied with a lower risk lesion are expected to continue appointments with physicians for up to 3 years post-surgery.[6] A higher risk lesion is encouraged to consistently consult with physicians during a 7 year period after treatment.[13] Remission events require immediate attention and appropriate procedures such as enucleation or curettage.[6] In more damaging cases of remission, tissue resection, and marsupialization may have to be performed.[7]