ISSN: 2581 - 3633

International Journal of Medical Science and Advanced Clinical Research (IJMACR)

Epidermoid cyst in mandible-a rare entity: A Case Report and Review of Literature
Dr. Rushit Patel1, Dr. Shailesh Menat2 , Dr. Khushboo Changani3 , Dr. Darshal Panchal3 , Dr. Anil Managutti4
1
Reader, 2Professor, 3Postgraduate, 4Head of the Department
Department of Oral & Maxillofacial Surgery, Narsinhbhai Patel Dental College & Hospital, Sankalchand Patel University,
Visnagar, Gujarat.
Corresponding Author: Dr. Rushit Patel, Department of Oral & Maxillofacial Surgery, Narsinhbhai Patel Dental
College & Hospital, Sankalchand Patel University, Visnagar, Gujarat.
Type of Publication: Case Report
Conflicts of Interest: Nil
Abstract orthokeratinized odontogenic cyst and epidermoid cyst
Introduction: Epidermoid and dermoid cysts of the jaws which can be distinguished clearly by histopathological
are seen rarely. Usually they are presenting in the distal examination.
phalanges of fingers. The formation theories of the Conclusion: Infected epidermoid cyst in the mandibular
intraosseous epidermoid cyst (IEC) are still not ramus associated with impacted mandibular wisdom tooth
comprehensible. The radiographic appearance is similar is a rare finding. The treatment protocols remain the same
with unilocular cysts. as the lesion is a no aggressive type with less recurrence
Case Report: Here, we report a case of a 52-year-old rate.
male patient presenting with swelling in posterior Keywords: Epidermoid cyst, Odontogenic keratocyst,
mandible with trismus since 15 days and presence of Enucleation, Wisdom tooth, OKC, Keratocyst.
fever. No pathological findings in the overlying skin and Introduction
no paresthesia was noted. The orthopantomograph An epidermoid cyst is a benign cyst usually found in the
revealed a unilocular cystic lesion involving right skin and has extreme rare occurrence in the jaws The cyst
mandibular ramus measuring 4×3 cm in diameter. Cyst develops from the ectodermal tissue. The incidence rate is
enucleation with peripheral ostectomy and chemical between 1.6 to 6.9% and only 1.6% are thought to affect
cauterization with Carnoy’s solution was done with intraoral sites. These represent 0.01% of all cysts affecting
intraoral approach along with surgical removal of the oral cavity. Epidermoid cysts are rare lesions that are
impacted mandibular third molar. Histopathologic found in the oral cavity. The general intraoral localization
findings revealed the pathologic lesion was an infected of this cyst is the floor of the mouth usually located in the
intraosseous epidermoid cyst. submandibular, sublingual and submental region, the rest
Discussion: Epidermoid cysts are rare, benign lesions are found in the tongue, lips, palate, jaws and cheek. It is a
found throughout the body of which only few cases of benign lesion which is slow growing and painless
intraosseous epidermoid cysts are described in the pathology. If they appear in bone they usually appear in
Page 5

literature. Clinically it is difficult to differentiate between the skull and in the distal phalanges of the fingers.

Corresponding Author: Dr. Rushit Patel, Volume -2 Issue -2, Page No. 05 – 08
Dr. Khushboo Changani, et al. International Journal of Medical Sciences and Advanced Clinical Research (IJMACR)

Epidermoid cysts derived from squamous epithelial cells from distal portion of the right first molar to 1mm below
that have penetrated deep into the dermis layer. For e.g. sigmoid notch. Horizontally placed right third molar is
after skin surgery, trauma or congenital. The content of seen in the radiolucency [Figure 2].
the cyst is mainly keratin as only the cysts do not contain Aspiration was negative. So, based on clinical and
dermal structures such as hair follicle or sebaceous glands. radiographical examination the provisional diagnosis was
Here we report a case of a rare cyst present in jaw. Orthokeratinized Odontogenic Cyst.
Case Report Marsupialization followed by enucleation of cyst was
A 52 year old male patient came to the department of oral done under general anesthesia, along with the extraction
and maxillofacial surgery, NPDCH with the chief of 47, 48 teeth, peripheral osteotomy involving 1cm of
complaint of painless swelling in lower right back teeth fresh bony margins and chemical cauterization (carnoy’s
region and reduced mouth opening since 15 days which solution) by preserving the inferior alveolar neve [Figure
was associated with fever. Patient was a known case of 3]. The histopathological examination of the specimen
hypertension since 6 months and was taking amlodipine was carried out.
5mg once daily. Extraorally, swelling was present over the Histopathological examination showed epidermal cyst
lower border of the mandible on right side of the face, filled with keratin lined by squamous epithelium with a
which was approximately 4x3 cm in size, which was prominent granular cell layer supported by bone. There
diffused, soft in consistency, tender on palpation, were no features to suggest this is an odontogenic
extending anteroposteriorly 1 cm away from the right keratocyst, radicular or dentigerous cyst or a dermoid cyst
corner of the mouth to the posterior border of ramus of [Figure 4].
mandible and superoinferiorly 3 cm below the ala-tragus On basis of clinical features and confirmatory
line to 3 cm below lower border of mandible. Intraorally, histopathological findings, we conclude our final
tenderness on percussion was present i.r.t. 47, 48 teeth. A diagnosis as ‘Epidermoid cyst’ in mandibular angle region
firm, non-fluctuant hard swelling was present on the lower associated with right mandibular third molar.
right vestibule irt 46, 47 region and gingiva was Follow up: Post-operative Orthopantomogram after 6
edematous with no obvious pus discharge. month shows well defined radiopacity in the defect
Radiographically, OPG showed a unilocular radiolucency suggestive of good healing progress [Figure 5].
extending anteroposteriorly from distal of 46 tooth upto
the posterior border of the mandible and superioinferiorly
3mm below the sigmoid notch upto the inferior border of
mandible [Figure 1]. On thorough careful examination
there were no pathological findings in the skin, no inferior
alveolar nerve anesthesia, no lymphadenopathy. Vitality
test showed delayed response in 47. CBCT Scan shows
well defined oval shaped radiolucent lesion in right body
Figure 1: Pre-operative Orthopantomogram
of the mandible and ramus, which was well demarcated,
having internal septas, with corticated boundaries. Extent
6
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Discussion
Epidermal cysts are mostly associated with areas of
[1]
embryonic fusion . The causes of both epidermoids and
dermoids include failure of surface ectoderm to separate
from underlying structures, sequestration and implantation
of surface ectoderm. Most congenital dermoid and
Figure 2: CBCT Scan shows well defined oval shaped epidermoid cysts possibly arise because of an embryologic
radiolucent lesion in right body of the mandible and accident during the early phases of development, between
ramus, which was well demarcated, having internal septas, 3 and 5 weeks of gestation. Enclosed ectodermal cysts can
with corticated boundaries. begin when the surface ectoderm fails to separate entirely
from the underlying neural tube. Consecutively, they may
result from abnormal sequestration or invagination of
surface ectoderm along the embryologic sites of dermal
[3]
fusion which form the eyes, ears, and face .Epidermoid
and dermoid cysts are rare, benign lesions found
Figure 3: Enucleation of cyst followed by chemical
cauterization with Carnoy’s solution throughout the body, with 7% occurring in the head and
neck area, 1.6% of which occur in the oral cavity. In the
head and neck area they usually appear in the submental
region. Only a few cases in literature describe intraosseous
epidermoid cysts. Orbit is the most common location of
epidermoid cyst at the head and neck (47%), followed by
the mouth floor (23%) and the cervical area (9~24%), but
[2]
in the jaw bone it is considered very infrequent .
According to the literature, etiologic factors of epidermoid
cysts are congenital, but there are reports from many
Figure 4: Photomicrograph shows epidermal cyst lining
authors that trauma was the possible cause of this lesion.
along with keratin lined by squamous epithelium with a
Perhaps, in our case it was associated with lower right
prominent granular cell layer supported by bone (HxE
impacted third molar, of which a similar case was reported
Stain, x4).
by orcun topas et.al[3] Although clinical behavior of
epidermoid cysts and keratocystic cysts is hard to
distinguish, the characteristics features of
histopathological elements of epidermoid cysts which
distinguish them from keratocystic odontogenic cyst is
laminated keratin in the cyst lined by stratified squamous

Figure 5: Post-operative Orthopantomogram after 6 month epithelium, while keratocysts have keratinizing lining
epithelium with corrugated parakeratin layer and satellite
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follow-up.
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cysts in cystic capsule [2]. Histopathologically, epidermoid 4. Ertem et al. An unusual presentation of an
cyst wall shows stratified squamous epithelial lining with intraosseous epidermoid cyst of the anterior maxilla: a
orthokeratotic production which is similar to epidermis. case report Journal of Medical Case Reports 2014,
Still, keratocystic odontogenic tumours have high level 8:262.
keratinising epithelial layer which is detached from basal 5. Alimoğlu et al Mandibular Ramus Epidermal
cell layer and epidermoid cysts have mild keratinising Inclusion Cyst. The Journal of Craniofacial Surgery &
epidermis. The absence of skin appendages eliminated the Volume 21, Number 5, September 2010.
[3]
dermoid cyst in diagnosis . The researchers suggests the 6. Sunil et al. Epidermoid cysts of head and neck region
diagnostic work up for IEC including ultrasonography, – case series and review of literature. Int J
computed tomography or magnetic resonance imaging to Odontostomat 2014; 8:165–9.
evaluate the adjacent anatomical structures, determine the 7. Ohn BH, Koh SW, Park SJ, Chee YD, Epidermoid
exact location of lesion and decide the appropriate surgical Cyst of the Mandible: Case Report, J Korean Assoc
[3]
approach . Maxillofac Plast Reconstr Surg. 2011; 33: 535-9
Conclusion 8. Janarthanam J, Mahadevan S. Epidermoid cyst of
Epidermoid cyst located in the mandibular ramus submandibular region, Oral Maxillofac Pathol. 2012
associated with impacted tooth is rare. These lesions Sep-Dec; 16(3): 435-7., doi: 10.4103/0973-
should be considered in the differential diagnosis of 029X.102511
radiolucent lesions of the jaws, therefore during
9. Jayade BV, Upadya VH, Goplakrishnan K, Shirganvi
examination we should consider aspiration biopsy,
MS. Epidermal inclusion cyst of the mandible after
ultrasonography and other advanced imaging techniques
extraction of a third molar: case report. Br J Oral
since conventional radiographs are not enough for
Maxillofac Surg 2012; 50:e72–4.
differential diagnosis of cystic similar bone lesions.
10. Debaize S, Gebhart M, Fourrez T, Rahier I, Baillon
Surgically they have a very good prognosis, they are non-
JM. Squamous cell carcinoma arising in a giant
aggressive lesions.
epidermal cyst: a case report. Acta Chir Belg 2002;
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