Cysts of the

Oral cavity

True cyst Pseudocyst

Definition:
True cyst is a pathological cavity lined by
epithelium & usually containing fluid or semi-fluid
material.
The epithelial lining may later degenerate under
certain conditions , but the cyst may have been
lined by epithelium at one stage of its
development.
Pseudocyst are not lined by epithelium &
may or may not contain fluid or other
material.
Origin:
True cysts of the jaw & related tissues arise
from epithelial remnants of odontogenic or
non-odontogenic origin within the maxilla
& mandible.
A. Odontogenic Epithelium:
Odontogenic epithelium may be derived
from one of the following sources:
1. Possibly from cells of the basal layer of
the oral epithelium , from which the dental
lamina develops.
2. The dental lamina.
3. The epithelial rests of Serres , which
represent remnants of the dental lamina.
4. The enamel organ.
5. The reduced enamel epithelium remaining
on the surface of the crown after
completion of enamel formation ,
representing the remains of the enamel
organ.
6. The epithelial rests of Malassez ,
remnants of the epithelial root sheath of
Hertwig.
B. Non-Odontogenic Epithelium(Surface
secretory):
1. Epithelial cells remaining entrapped
between embryonic processes at the line
of fusion of these processes (fissural
cysts).
2. Epithelium from remnants of the cervical
sinus formed by overgrowth of the second
branchial arch over the succeeding
arches(i.e. Epithelium of branchial cleft
origin).
3. Secretory glandular epithelium of minor
mucous glands & of major salivary glands.
4. Remnants of the epithelium of the
vestigial nasopalatine duct.
5. Remnants of epithelium of thyroglossal
tract.
I. Odontogenic cysts:
A- Inflammatory:
1. Apical inflammatory periodontal cyst.
2. Lateral inflammatory periodontal cyst.
3. Residual inflammatory periodontal cyst.
B- Developmental:
1. Follicular:
i. Dentigerous cyst.
ii. Primordial cyst(Odontogenic keratocyst).
Basal cell nevus-bifid rib syndrome.
2. Extra-Follicular:
i. Lateral developmental periodontal cyst.
ii. Gingival cyst:
a. Gingival cyst of the newborn.
b. Gingival cyst of the adult.
iii. Keratinizing & Calcifying Odontogenic
cyst (Gorlin cyst, Cystic keratinizing
tumor).
iv. Cystic degeneration of odontogenic
tumors ( Cystic ameloblastoma, Cystic
odontome).
II. Non-Odontogenic:
A. Fissural Cysts:
1. Nasoalveolar ( nasolabial cyst) (soft
tissue cyst related to the maxilla).
2. Median maxillary cysts
i. Median alveolar cyst.
ii. Median palatine cyst.
3. Median mandibular cyst.
4. Nasopalatine duct cyst:
i. Incisive canal cyst.
ii. Cyst of palatine papilla.
5. Globulomaxillary cyst.
B. Other developmental Cysts:
1. Branchial cleft cyst (Benign lympho-
epithelial cyst of the neck).
2. Thyroglossal tract cyst.
3. Dermoid & Epidermoid cysts.
4. Heterotopic oral gastro-intestinal cyst.
III. Cysts of the salivary glands:
1. Mucous retention & extravasation cysts:
i. Mucocele.
ii. Ranula.
IV. Pseudocysts:
1. Traumatic bone cyst (haemorrhagic bone
cyst; solitary bone cyst).
2. Aneurysmal bone cyst.
3. Static bone cyst (developmental salivary
gland inclusion cyst; latent bone cyst;
Stafne’s idiopathic bone cavity).
Cyst-like lesions:
I. Normal anatomical landmarks:
The following normal anatomical structures
produce a radiolucent picture that may
resemble the picture produced by a cystic
lesion:
1. Maxillary sinus.
2. Mental foramen.
3. Hemopoietic bone marrow defect &
physiologic osteoporosis.
4. Nasopalatine foramen & incisive canal.
II. Neoplastic & dysplastic lesions:
1. Odontogenic tumors such as simple
ameloblastoma, adenomatoid
odontogenic tumor, Pindborg’s tumor.
2. Pleomorphic adenoma of salivary glands.
3. Odontogenic myxoma & fibroma.
4. Giant cell lesions & tumors.
5. Fibrous dysplasia of bone & cherubism.
6. Central non-ossifying fibromas of the
jaws.
7. Early stage of cementifying fibroma.
8. Metastatic & invasive carcinomas to the
jaws.
9. Osteolytic osteogenic sarcoma.
10. Central hemangioma of the jaws.
III. Metabolic & Systemic Dysfunction:
1. Osteitis fibrosa cystica (hyperpara-
thyroidism, von Recklinghausen’s
disease of bone).
2. Langerhan’s Cell Reticulo-endothelioses:
a. Eosinophilic granuloma.
b. Hand-Schuller-Christan’s disease.
c. Leterrer-Siwe’s disease.
3. Lysosomal storage diseases:
a. Gaucher’s disease.
b. Nieman-Pick disease.
IV. Destruction of bone caused by micro-
organisms:
1. Chronic dentoalveolar abscess.
2. Osteomylitis:
a. Acute non-specific suppurative
osteomylitis.
b. Septic osteomylitis:
1) Tuberculous osteomylitis.
2) Actinomycotic osteomylitis.
3) Syphilitic osteomylitis & periostitis.
V. Periapical lesions:
1. Chronic periapical abscess.
2. Periapical granuloma.
3. Early stage(osteolytic stage) of periapical
cemental dysplasia.
4. Apical scar.
VI. Soft tissue benign tumors which may
appear clinically as cysts:
1. Soft fibroma.
2. Lipoma.
3. Myoma.
4. hemangioma,.
5. Lymphangioma.
 DIAGNOSIS OF THE CYST
1. Physical signs.
2. Symptoms.
3. Radiographic examination.
4. Other radiological diagnostic techniques
5. Aspiration.
6. Biopsy.
 Treatment of the cysts
Aim of treatment:
1- To remove the pathological epithelium
that forms the lining or to enable the
patient’s body to rearrange the position of
the abnormal tissue so that it’s eliminated
from within the jaw.
2- To do so with the minimum of trauma to
the patient, consistent with a successful
outcome to the operation.
3- To preserve adjacent important structures
such as nerves & healthy teeth.
4- To achieve rapid healing of the operation
site.
5- To restore the part to normal or near
normal form & to restore normal function.
 Surgical Techniques
1- Enucleation or complete removal of the cyst
capsule & lining with its contents.
2- Marsupialization (Partch operation) by which the
cyst is uncovered or de-roofed by creating a
large opening in the bone & the cystic lining so
that the lining of the floor & walls becomes
continuous with the oral cavity epithelium & the
surrounding structures.
N.B:
Sometimes the lesion is initially treated by
marsupialization to decompress the intra-cystic
pressure until the cyst is reduced in size & then
a second operation is performed to enucleate
the cystic membrane.
 Enucleation
Indications:
1- Accessible cysts.
2- Small to moderate sized cysts that don’t
extensively involve vital teeth or important
anatomical structures such as the maxillary
sinus & inferior alveolar bundle.
3- Cysts that don’t involve soft tissues.
Advantages:
1- Removal of the entire pathological tissue.
2- Rapid healing than that which occurs with
marsupialization.
3- Decreased need for post-operative care.
Disadvantages:
1- Large cysts may be technically difficult to
remove.
2- Possibility of damage to vital teeth.
3- Possibility of fracture of the mandible in large
cysts involving the lower jaw, also injury to
important anatomical structures could occur e.g.
inferior alveolar nerve & vessels.In large
maxillary cysts enucleation may lead to the
creation of an oro-antral communication with
subsequent effects on the maxillary
antrum;involvement of the floor of the nose may
also occur.
4- If the cyst extends to the soft tissues complete
removal may not be possible sometimes, with a
great possibility of recurrence.
 The steps of the technique
• Enucleation can be done under general or local anaesthesia. In any case, before the
incision is demarcated, the area should be infiltrated with a local anaesthetic solution
with a vasoconstrictor. This helps in easy separation of cystic lining from the
periosteum. Whenever possible, a buccal or labial approach is preferable because of
superior visibility and accessibility. However, a cyst causing palatal expansion alone
should be approached through this direction the associated pulpless teeth should be
extracted or root-filled.
• A wide mucoperiosteal flap with margins on intact bone should be reflected. If the
bone is intact, a window cut is made with chisel or bur without perforating the cystic
wall. If the bone is thin, it can be peeled off with a periosteal elevator. Further
clearance is done using bone roungers till adequate access is obtained.
• The cyst lining is gently separated from the cavity with the broad end of
periosteal elevator. Depending upon the size of the cyst and its position, other
instruments such as spoon escavator and Mitchell’s trimmer can be used. Edge of the
instrument is applied on cavity wall with the concave surface facing the lining.
• Careful dissection should be done to separate the lining from the structures like periosteum,
nasal cavity wall, maxillary sinus, neurovascular bundles etc. Undue pressure should not be used
while doing this.
• After removing the cyst lining, the cavity is irrigated and well debrided and inspected for
any remnants of cyst lining. Hemostasis should be achieved before closing. In large cysts,
immediate control of bleeding may not be enough and further oozing is managed by placing a
gauze pack in the cavity till complete hemostasis occurs. This pack is removed after 24 hours.
• An alternate way is to pack the cavity loosely with iodoform gauze and to keep the pack for 7-10
days. A low-pressure suction drainage system may be used.
• Voorsmit, Stoelinga and van Haelst (1981) advised devitalising any fragments of lining left in the
cavity after enucleation, either by swabbing the cavity with Carnoy’s solution or by freezing the
bony wall. Carnoy’s solution is a powerful histological fixative made by mixing chloroform (3
parts), absolute alcohol (6 parts) and glacial acetic acid (1 part).
• An approach that recently has gained popularity in the management of keratocysts is a
combination of methods. The first step is to decompress the cyst. A plastic (or other suitable
material) drain is secured in place to ensure that the opening remains patent. After 6 to 8 weeks,
the lining of the cyst becomes generally thick and tough. The second step is to carefully
enucleate the cyst. At this time, the thickened cyst wall is much more easily removed than is the
usual OKC. The next step is to perform a peripheral ostectomy with a large bone bur. A margin of
2 to 3 mm is taken, depending on adjacent vital structures involved. The final step is to treat the
residual bone bed with chemical cautery (Carnoy’s solution
• This systematically thorough method, although time consuming and demanding much
patient co-operation, has achieved good results.
• To obliterate the cavity after cyst enucleation, various filling materials have been
recommended for packing into the defect prior to closure of the wound. Primarily,
these are forms of haemostatic resorbable sponge, some of which may be soaked in
a solution containing an antibiotic or thrombin. These materials are inserted to
prevent excessive bleeding and to form a scaffold into which granulation tissue can
migrate.
• It is now recognised that grafting with autogenous cancellous bone can be performed
successfully within oral wounds. In case of large defects, when pathologic fractures
are possible or there would be considerable loss of contour in a future denture-
bearing area, this procedure can be used to obliterate the cavity and stimulate
osteogenesis. Should grafting be indicated, autogenous bone provides the best
results if a second wound is not a major consideration (Boyne-1970; Flint-1964;
Mowlem-1944; Scott, Peterson and Grant-1949).
• A risk of bone grafting cyst cavities is the possibility of bone fragments becoming
infected if wound breakdown occurs. The risk of failure in these cases is greater than
when grafts are introduced after resection of a segment of mandible, because of the
greater difficulty in ensuring watertight wound closure.
• Enucleation and package
• This is an improvised method devised to combine the advantages of the two main
techniques, but in fact it combines the disadvantages of both enucleation and
marsupialisation, yet the advantages of primary closure are not achieved.
 Marsupialization
Indications:
1- Large cysts that are weakening the jaw.
2- Soft tissue cysts.
3- Cysts approximating vital teeth.
4- Cysts related to maxillary sinus or inferior
alveolar canal.
5- Dentigerous or eruption cysts to allow teeth to
erupt.
6- In elderly patients.
Advantages:
1- Preservation of vital structures from surgical
damage (teeth, maxillary sinus, inferior alveolar
nerve).
2- Minimizes bone removal ,thus the potential
danger of surgical fracture of the mandible is
avoided.
3- Bare bone is not exposed to infection.
4- Less traumatic procedure than enucleation,
hence less risky for poor surgical risk patients.
5- Needs less surgical skill than enucleation.
6- Preserves the normal contour of the mouth.
Disadvantages:
1- Leaves behind pathologic tissue with the
possible potentiality of change into malignant
neoplasm.
2- Slow healing.
3- Requires considerable post-operative care.
a. The defect is sometimes difficult for the patient
to keep clean during the healing period.
b. The defect doesn’t always fill completely with
bone.
 The steps of the techinque
• 1-The incision should be practiced according to the limits of the
• projection of cysts on the vestibular surface, therefore, a circular incision, and
• place it halfway between the sulcus and the free edge of the gums. It is
preferable
• to incision is started at a point distal to the cyst, taking her to the medial. For
• these cases the bone has been completely destroyed, with no need for
ostectomy,
• moving immediately to the incision of cystic membrane, following the same
size
• circular incision of the vestibular mucosa. Should wherever possible be
slightly
• larger than the horizontal diameter of the cyst in any depth to which the
presence
• of bone.
• 2. In cases where the cyst has externalized due to its large size,
• having already destroyed the external bony plate, with a cystic pouch in
close
• contact with the periosteum, one must take care not to accidentally open the
cyst
• and early, as this going to maneuver the detachment of the periosteum of
the bag
• is not so simple, the difficulty to be individualized to the cystic wall. For
• dentigerous cysts in young patients with a scalpel blade number 5, or with
an
• electric scalpel, it eliminates a piece mucosa, the periosteum and the bone
and
• adjacent cystic membrane, cutting deeply into the thin tissue mass
• 3. For the flap displacement uses is a highlight periosteum or a
• blunt spatula and should be folded carefully, preferably with the aid of a
bandage
• until the upper limits of the cyst, which were guided by radiography. In the
case
• of the disappearance of bone tissue, the flap must be separated gently until
it
• found the cystic membrane. The bone can fracture very papyraceous or
mortify
• them out, and can act as a foreign body, causing suppuration, requiring
further
• surgery, as the goal of being eliminated sequestration
• 4. The ostectomy can be performed with the aid of various
• instruments. When the bone is very thin, can be eliminated with the aid of a
• straight chisel gently, and when it is partially destroyed, its elimination is
• completed with the forceps gouges. If the bone is still compact, practices the
• ostectomy with chisel to hand pressure or with the aid of drills for bone. This
• maneuver allows for good results and are less traumatic than the chisel and
• hammer. Are charged holes that match the diameter of the cyst to the fullest
• extent of the injury, and these holes together with their drill with a chisel or
else
• the manual pressure being eliminated this bony plate with the aid of a chisel
• straight through movements lever.
• 5. Eliminated the bone covering the cyst empties and the interior, it
• is an irrigation with saline, not to produce lesions in the cystic epithelium. Some
• authors practice touches inside the bag with cystic alcohol, iodine or with other
• medications unnecessary or harmful to the cystic epithelium. Opens widely
• followed, the full extent of the cyst, and this opening is larger or at least equal to
• the diameter of the cyst to prevent the edges from closing and give relapses or at
• least one cavity that does not disappear in a long time ago. To be avoided
• drawbacks just mentioned, some authors use buffer with which obliterate the
• cavity, a procedure not put into practice today. For the conservative method of
• Partsch, there is no need to fear for the integrity of the sinus or nasal cavity, much
• less the inferior alveolar nerve. The cystic membrane acts as a wall of security
• that defends these organs, where there is bone cyst separating these important
• 530
• DECOMPRESSION TECHNIQUE TO SURGICAL
• TREATMENT OF THE ORAL CAVITY CYSTS
• anatomical structures. Neighboring teeth displaced by excessive growth of the
• cyst should be kept for some time, in order to not fracture the alveolar portion and
• not creating invaginations in alveolar border, whose aesthetic and functional result
• 6. Suture of the buccal mucosa with the periphery of the bag cystic
• wired Dexon 3-0 or 3-0 vicryl. Some authors say there is no need for this
type of
• suture, because they think that the coaptation of both entities are produced
• whenever there are easily taken the precaution of not letting the bone tissue
• between them. However, it seems important and necessary that this suture
is
• performed in order to better repair scarring, less risk of recurrence.
Periapical Cyst
 Most common odontogenic cyst
 Probably arises due to
inflammatory stimulus for
proliferation of rests of Malassez
 Typically asymptomatic, but may
become secondarily inflamed
Periapical Cyst
 Radiographically present as a
round to ovoid radiolucency
 Apex of non-vital tooth
 Less commonly between teeth –
lateral radicular cyst
 Most are < 1.5 cm in diameter
Radicular cyst: ill-defined
lesion subjacent to carious
tooth root (arrow).
Radicular cyst: Note continuity between cyst cortex and
periodontal ligament space of grossly carious (C4) right
mandibular first molar. Cyst is a well-delineated
unilocular radiolucency. Note lower cortex expansion.
Radicular cyst on carious right
maxillary lateral incisor. The lesion
is a well-delineated unilocular
homogeneous radiolucency.
Radicular cyst on left mandibular first
permanent molar tooth. It is a well-delineated
homogeneous radiolucency.
Radicular cyst possibly of right mandibular
premolar tooth (or residual following extraction
of first molar) is a well-demarcated unilocular
homogeneous radiolucency (arrow).
Residual cyst: unilocular
homogeneous radiolucency
in edentulous right maxillary
molar region (periapical
radiograph).
zygoma
lateral wall of
nasal passage
cyst
Periapical Cyst
 Variably thick, non-keratinized
stratified squamous epithelial
lining
 Usually a significant degree of
inflammation present
PERIAPICAL CYST

• Radiographic features
– Well-delineated
radiolucency
– Loss of the lamina dura
– Root resorption
– May become quite large
Periapical Cyst
 Enucleation, with either
extraction or endodontic therapy
of the involved tooth
 If the lesion is not removed, a
residual cyst may result
 Recurrence is unlikely
RESIDUAL PERIAPICAL CYST
 Well-defined radiolucency
within the alveolar ridge at the
site of a previous tooth
extraction
RESIDUAL PERIAPICAL CYST
 Histopathologic features
– Same as the periapical cyst
 Treatment
– Surgical excision
Lateral Periodontal Cyst
 Derived from dental lamina rests
 Middle aged adults, males (2:1)
 Asymptomatic, usually unilocular
radiolucency, mandibular
canine/premolar region, < 1 cm
Lateral periodontal cyst:
unilocular well-corticated
radiolucency distal to
right mandibular canine.
 L

Lateral periodontal cysts: bilateral lesions (rare

example) in mandible between canine and first
premolar teeth
Lateral periodontal cyst: well-delineated
multilocular (botryoid or “grape-like”)
homogeneous radiolucency between roots of left
mandibular premolar teeth.
Lateral Periodontal Cyst
 Identical to gingival cyst of the
adult
 Non-keratinized epithelium, focal
nodular thickenings, clear cells
Lateral Periodontal Cyst
 Curettage, conservative
enucleation
 Excellent prognosis
Botryoid Odontogenic
Cyst
 Probably represents variant of
lateral periodontal cyst
 Similar clinical setting; middle-
aged to older adults, mandibular
canine and premolar region
 Multilocular radiolucency, “grape-
like” (botryoid)
Botryoid Odontogenic
Cyst
 Conservative surgical excision
with curettage
 Slight recurrence potential
 Dentigerous Cyst
 Second most common odontogenic cyst
 By definition, a cyst that forms around the
crown of an impacted tooth
 This is a developmental (as opposed to an
inflammatory) cyst
 Arises from reduced enamel epithelium
Dentigerous Cyst
 Usually detected in young adults
 Most common sites – mand. 3rd
molar region and max. canine
region
 Pericoronal radiolucency,
sometimes with resorption of
adjacent tooth roots
 DENTIGEROUS CYST
• Radiographic features
– Unilocular radiolucency associated
with the crown of an unerupted
tooth
• Central variety
• Lateral variety
• Circumferential variety
– Radiolucency should be at least 3-
4 mm. in diameter
Dentigerous Cyst
 Thin, non-keratinized stratified
squamous epithelial lining
 Connective tissue wall is usually
uninflamed, although secondary
inflammation may be present
 Mucous cells may also be seen in
the cyst lining
 R

Dentigerous cyst seen as well-delineated

homogeneous radiolucency surrounding crown
of distally inclined third mandibular molar.
Dentigerous cyst: expansile unilocular
homogeneous radiolucency attached at
enamel-cemental junction of right molar.
R

Dentigerous cyst: left mandubular ramus.

well-demarcated, unilocular homogeneous
radiolucency envelopes third molar tooth.
Dentigerous cyst: well-delineated radiolucency
Surrounding and displacing in left mandibular
canine causing displacement and root resorption
of adjacent teeth.
Dentigerous cyst:
axial CT from previous
patient. Note buccal and
lingual expansion of
mandible.
 Dentigerous cyst: 0.5
Tesla,T2-weighted MRI
image of same patient.
Note high signal intensity
of cyst contents.

R
Dentigerous cyst: well-
delineated unilocular
homogeneous radiolucency
displacing left maxillary
third molar.
DENTIGEROUS CYST

• Treatment
– Enucleation with
removal of the
unerupted tooth
– Marsupialization
 ERUPTION CYST
(ERUPTION HEMATOMA)
 ERUPTION CYST

• Soft tissue analoque of the

dentigerous cyst
• Swelling of the gingival mucosa
overlying the crown of an erupting
deciduous or permanent tooth;
usually the first permanent molars
or maxillary incisors
• Children < 10 years of age
ERUPTION CYST

• Eruption hematoma: blood

accumulates in the cystic
fluid
ERUPTION CYST

• Treatment
– Excision of the roof
of the cyst to permit
eruption
Primordial Cyst
 By definition, a developmental
odontogenic cyst that arises in
place of a tooth, usually a mand.
3rd molar
 Should be no history of
extraction of a tooth in the area
 Most are OKC’s microscopically
 Primordial Cyst
 The overwhelming majority of these
cysts prove to be odontogenic
keratocysts on microscopic
examination
 Thin, uniform lining that produces
parakeratin and exhibits palisading
of the basal cell layer
Primordial Cyst
 Essentially the same treatment
that is rendered for the OKC
 Enucleation and curettage for
small, unilocular lesions
 More aggressive therapy for
larger, multilocular lesions
Odontogenic
Keratocyst
 Benign but locally aggressive
developmental odontogenic cyst
 Probably arises from dental lamina
rests
 Affects a wide age range, beginning in
the second decade of life
 Asymptomatic until swelling develops
 Odontogenic
Keratocyst
 Most commonly seen in the posterior
mandible, but any segment of the
jaws can be affected – clinically may
mimic a wide variety of jaw cysts
 Unilocular radiolucency when small
 Multilocular appearance often
develops as the lesion enlarges
 ODONTOGENIC
KERATOCYST
• Radiographic features
– Unilocular or multilocular
radiolucency
– 25-40% associated with an unerupted
tooth
– Root resorption is less common
compared to the dentigerous cyst
 Odontogenic keratocyst:
unilocular homogeneous
radiolucency in right
mandibular ramus
(detail from panoramic
radiograph).

R
 Odontogenic keratocyst:
large crenulated
homogeneous radiolucency
enveloping third molar tooth
in left mandibular ramus.

L
Odontogenic keratocyst: multilocular
homogeneous radiolucency in left mandibular
body is well demarcated with little expansion.
Odontogenic keratocyst:
detail from panoramic
radiograph showing
homogeneous radiolucency
that surrounds roots of right
premolar and molar. The
definitive diagnosis awaits
histopathology in such cases.
Odontogenic keratocyst
(true occlusal radiograph):
homogeneous radiolucency
without expansion of the
buccal plate of the mandible.
Odontogenic
keratocyst: note
lack of jaw expansion
and lack of tooth
resorption by this
large well-delineated
homogeneous
radiolucency crossing
the midline of the
mandible
(topographic occlusal
view).
 R

Odontogenic keratocyst: PA radiograph

showing multilocular radiolucency in right
side of mandible. Expansion as seen in this case
is a late feature of this disease process.
Odontogenic keratocyst:
unilocular homogeneous
radiolucency lesion:

lateral topographical
occlusal of mandible.
Odontogenic keratocyst: panoramic view of
lesions in both jaws from multiple nevoid basal
cell carcinoma syndrome.
Odontogenic keratocyst:
unilocular homogeneous
radiolucency lesion that
does not cross the midline
(distinguishing it from the
nasoplaatine duct cyst) and
causes neither resorption
nor marked displacement of
adjacent teeth.
 Odontogenic keratocyst
(recurrent): well-delineated
multilocular homogeneous
radiolucency lesion (arrow)
at right mandibular angle.
Unlike most odontogenic
lesions this case did extend
below the mandibular canal.

R
Odontogenic
Keratocyst
 Uniform, thin stratified squamous
epithelial lining
 Luminal parakeratin production
 Palisaded (“picket fence”)
appearance of the basal cell nuclei
 Features altered with inflammation
 Satellite cyst formation may be seen
Odontogenic
Keratocyst
 33% recurrence rate overall
 With occurrence in the first
decade, or with multiple OKC’s,
the nevoid basal cell carcinoma
syndrome should be considered
 ODONTOGENIC
KERATOCYST
• Treatment and prognosis
– Enucleation, curettage, or
peripheral ostectomy

– Multiple recurrences are not

unusual; often 5-10 years after
the initial surgical procedure
 NEVOID BASAL CELL
CARCINOMA SYNDROME
(GORLIN SYNDROME)
 GORLIN SYNDROME
• Autosomal dominant trait
• Multiple basal cell carcinomas of the skin,
multiple OKC’s, rib and vertebral anomalies,
and intracranial calcifications
• 40% of patients have ocular hypertelorism
 GORLIN SYNDROME
• Basal cell carcinomas
– 2nd-3rd decades of life
– Occur on the midface area and on
non-sun exposed skin
• Palmar and plantar pits
– Occur in 65% of patients
– Represent a localized retardation in
the maturation of basal epithelial cells
 GORLIN SYNDROME
• Skeletal anomalies
– Occur in 60%-75% of patients
– Bifid ribs or splayed ribs
– Lamellar calcification of the falx cerebri
• Odontogenic keratocysts
– Occur in 75% of patients
– Occur at an earlier age than isolated OKC’s
– Often multiple
Facial Asymmetry-Gorlan’s
Syndrome
Nevoid BCCa Syndrome

Cutaneous features:
– Basal cell carcinomas, early
onset
– Palmar/plantar pitting
Nevoid BCCa Syndrome

Skeletal features:
– calcified falx cerebri
– increased cranial
circumference
– bifid ribs
Nevoid BCCa Syndrome
 Sun screens
 Excision of basal cell
carcinomas as needed
 Monitor for and excise OKCs
 Genetic counseling
Glandular Odontogenic Cyst
 More recently described (45 cases)
 Gardner, 1988
 Mandible (87%), usually anterior
 Very slow progressive growth (CC:
swelling, pain [40%])
 Radiographic findings
– Unilocular or multilocular radiolucency
Glandular Odontogenic Cyst
Glandular Odontogenic Cyst
 Histology
– Stratified epithelium
– Cuboidal, ciliated
surface lining cells
– Polycystic with
secretory and
epithelial elements
Treatment of GOC
 Considerable recurrence potential
 25% after enucleation or curettage
 Marginal resection suggested for larger
lesions or involvement of posterior maxilla
 Warrants close follow-up
Gingival Cyst of the
Newborn
 Derived from dental lamina rests
 1-2 mm whitish papules on
alveolar ridge mucosa in
newborns, maxilla
 No treatment needed
Gingival Cyst of the
Newborn
 Similar inclusion cysts are
found near midline palatal raphe
(Epstein’s pearls) or more
laterally along hard and soft
palate (Bohn’s nodules)
Palatal Cysts of the Newborn
(Epstein’s Pearls, Bohn’s Nodules)

• As palatal shelves fuse to form secondary

palate, small islands of epithelium may become
trapped below surface
• Or may arise from epithelial remnants from
development of minor salivary glands
• Epstein’s pearls occur along median palatal
raphe
• Bohn’s nodules are scattered over the hard
palate.
• No treatment required – self-healing
Gingival Cyst of the
Adult
 Derived from dental lamina rests
 Middle-aged adults (5th-6th
decades)
 Mandibular canine/premolar
region most common
 Bluish-translucent swelling, often
centered in attached gingiva
Gingival Cyst of the
Adult
 Thin, non-keratinized cuboidal to
stratified squamous epithelium
 Occasional clear cells
 Nodular thickenings of epithelial
lining may be seen
GINGIVAL CYST OF THE
ADULT
• Treatment and prognosis
– Surgical excision
– Prognosis is excellent
Calcifying Odontogenic
Cyst
 Also known as the Gorlin cyst
 Most common in 2nd-3rd
decades, but wide age range seen
 Anterior portions of jaws (65%)
 Usually intrabony, but peripheral
lesions make up 13-30%
Calcifying Odontogenic
Cyst
 Radiographically: defined
unilocular radiolucency +/- variable
radiopacities
 Resorption and divergence of
adjacent roots often seen
 1/3rd present with impacted tooth
 20% present with odontoma
 CALCIFYING
ODONTOGENIC CYST
• Radiographic features
– Presents as a well-defined unilocular
or multilocular radiolucency
– 1/3 to 1/2 of cases are associated
with radiodensities
– 1/3 of cases are associated with an
impacted tooth, often a canine
Calcifying odontogenic
Cyst:

“salt and
pepper”
calcifications
within an
expansile
unilocular
otherwise lucent
lesion (true occlusal)
Calcifying odontogenic
cyst:

Well-
delineated
unilocular
mixed radiolucency
and radiopacity
enveloping
unerupted tooth.
Calcifying Odontogenic
Cyst
 Cystic epithelial lining with
resemblance to ameloblastoma
(peripheral columnar cells and
stellate reticulum-like areas)
 Variable numbers of ghost cells
and dystrophic calcifications
 CALCIFYING
ODONTOGENIC CYST

• Treatment and prognosis

– Enucleation
– Prognosis is good
Developmental Cysts
Nasolabial Cyst (Nasoalveolar Cyst)
• Nonpainful swelling of upper lip lateral to midline,
resulting in elevation of ala of nose
• May result in nasal obstruction or may interfere
with denture.
• May rupture and may drain into oral cavity or
nose
• Complete surgical excision is preferred treatment
Nasolabial cyst: note displacement of
ala on right side.
Nasolabial cyst: lateral view shows antero-
posterior dimensions of contrast-enhanced cyst.
Nasolabial cyst with and without contrast
(topographical occlusal views).
Nasopalatine Duct Cyst
(Incisive Canal Cyst)

 Most common non-odontogenic cyst of oral

cavity

 Canals of Scarpa, organs of Jacobson

 Presenting symptoms include swelling of interior

palate, drainage and pain

 Well circumscribed radiolucency in or near the

midline of the anterior maxilla between and apical
to the central incisor teeth
Nasopalatine duct cyst
causing palatal expansion,
a common finding.

Nasopalatine duct cyst

less frequently causes
sublabial swelling.
Nasopalatine duct cyst: a well delineated
ovoid unilocular radiolucency in the midline of
the maxilla. The teeth are all vital. (topographic
occlusal view).
Nasopalatine duct cyst:
Well-delineated
unilocular radiolucency
in the midline of the
maxilla. Adjacent teeth
are vital.
Nasopalatine duct cyst:
large unilocular
radiolucency occupies much
of the palate and is causing
tooth displacement
(topographic occlusal view).
Incisive Canal Cyst
 Derived from epithelial remnants of the
nasopalatine duct (incisive canal)
 4th to 6th decades
 Palatal swelling common, asymptomatic
 Radiographic findings
– Well-delineated oval radiolucency between
maxillary incisors, root resorption occasional
 Histology
– Cyst lined by stratified squamous or
respiratory epithelium or both
Incisive Canal Cyst
Incisive Canal Cyst
 Treatment consists of surgical
enucleation or periodic radiographs
 Progressive enlargement requires
surgical intervention
Globulomaxillary Cyst
• Well-circumscribed unilocular radiolucency
between and apical to the teeth resembling an
inverted pear

• Some are consistent with periapical cysts, some

have features of odontogenic keratocyst, or
developmental lateral periodontal cyst

• Treatment consists of surgical enucleation,

endodontic therapy
GMC
Median Palatal Cyst
 True median palatal cyst presents as firm or
fluctuant swelling of the midline of the hard
palate posterior to the palatine papilla

 Well circumscribed radiolucency in the midline of

the hard palate

 Treatment is surgical removal

Median Mandibular Cyst
 Most of odontogenic origin

 Midline radiolucency found between or

apical to the mandibular central incisor
teeth, cortical expansion

 Treatment is surgical enucleation

Epidermoid Cyst
of the Skin
• Nodular, fluctuant, subcutaneous lesions that
may or may not be associated with inflammation

• Most common in the acne-prone areas of the

head, neck, and back

• May be associated with Gardner syndrome

• Treatment is conservative surgical excision

Dermoid Cyst
 Benign cystic form of teratoma
 Teratoma is a developmental tumor composed of
tissue from ectoderm, mesoderm, and endoderm.

 In most complex form, teratomatous

malformations produce multiple types of tissue
arranged in a disorganized fashion
Dermoid Cyst, cont.

• Teratoid cyst – cystic form of teratoma that

contains a variety of germ layer derivatives (skin
appendages, connective tissue elements, and
endodermal structures)

• Dermoid cysts are simpler in structure

than complex teratomas or teratoid cysts
Dermoid Cyst, cont.

• Occur in midline of floor of mouth.

• Usually slow growing and painless, presenting as
a doughy or rubbery mass that retains pitting
after application of pressure
• Secondary infection may occur, treatment is
surgical removal
Dermoid cyst
Neck: dermoid cyst
Thyroglossal Duct Cyst
(Thyroglossal Tract Cyst)

• 60%-80% of cysts develop below hyoid bone

• Usually presents as painless, fluctuant, movable
swelling unless complicated by secondary
infection
• Best treated by removal of cyst, midline section
of hyoid bone, and muscular tissue
 Thyroglossal Cyst
• Midline mass
• Age 10 – 20yrs
• Most common cystic embryological
remnant in head/neck
• 65% infrahyoid
• Elevate on protrusion of tongue
Cervical Lymphoepithelial Cyst
(Branchial Cleft Cyst)

• Developmental cyst that occurs in upper lateral

neck along anterior border of the
sternocleidomastoid muscle
• Soft fluctuant mass ranging from 1-10 cm
• Increased numbers reported in persons with HIV
infection
• Treatment is surgical removal
 Lumps
What can you describe?
• Site • Consistency
• Size • Colour
• Shape • Transillumination
• Surface Fixation / tethering
• Edge • Pulsation
 Thyroid Lumps
• Goitre
• Single nodule
• Multiple nodules
• Elevate on swallowing
• May have features of hyper / hypothyroidism
• Eye signs
• Rarely midline
 Carotid Body Tumour
• Slow growing
• Carotid bifurcation
• Transmits carotid pulse
• May be pulsatile itself
• Moves side – side, not up – down
 Branchial Cleft Cyst
• Junction of upper 1/3 – lower 2/3 SCM

• Painless

• Contain cholesterol crystals

 Parotid Tumours
• Pre and post auricular

• May elevate earlobe

• May involve facial nerve

 Summary list of lumps
• Thyroglossal cyst • Elevates when tongue out
• Dermoid cyst • Midline, fixed to skin
• Thyroid lump • Elevates on swallowing
• Carotid body tumour • Pulsatile, side – side mvmt
• Lymph node
• Parotid tumour • Lifts earlobe
Oral Lymphoepithelial Cyst

• Waldeyer’s ring – palatine tonsils, lingual

tonsils and pharyngeal adenoids
• Small asymptomatic submucosal mass,
firm or soft, white or yellow, on floor of the
mouth
• Treatment is surgical excision
Pseudocysts
Stafne Bone Cyst
 Submandibular salivary gland depression
 Incidental finding, not a true cyst
 Radiographs – small, circular, corticated
radiolucency below mandibular canal
 Histology – normal salivary tissue
 Treatment – routine follow up
Stafne Bone Cyst
Traumatic Bone Cyst
 Empty or fluid filled cavity associated
with jaw trauma (50%)
 Radiographic findings
– Radiolucency, most commonly in body or
anterior portion of mandible
 Histology – thin membrane of fibrous
granulation
 Treatment – exploratory surgery may
expedite healing
Traumatic Bone Cyst
Traumatic bone cyst extending from right
premolar to left canine (mandibular true occlusal
view). Note lack of expansion.
Traumatic bone cyst: axial CT shows only minor
expansion of mandible in molar region (arrow).
Traumatic bone cyst

Normal follicle
space.

Lesion.
Traumatic bone cyst showing
typical scalloped appearance
from extension between tooth
roots. Note partial loss of
lamina dura.
Traumatic bone cyst in
mandibular premolar
region (detail from
panoramic radiograph).
This is a well-delineated
noncorticated lucency.
Aneurysmal Bone Cyst
 etiology is unknown it may be due
to failure of attempted repair of a
haematoma in bone in which a
circulatory connection with the
damaged vessels persists leading to
a slow flow of blood through the
lesion
 Aneurysmal bone cyst:
PA view
showing buccal
expansion in left
mandibular angle.

R
R

Aneurysmal bone cyst: PA view of lesion in right

mandibular ramus, the most common site for this
condition in the jaws (more than 99% of this lesion
are found elsewhere in the skeleton).
Surgical Ciliated Cyst
 May occur following Caldwell-Luc
 Trapped fragments of sinus epithelium
that undergo benign proliferation
 Radiographic findings
 Unilocular radiolucency in maxilla
 Histology
 Lining of pseudostratified columnar ciliated
 Treatment - enucleation
Surgical Ciliated Cyst