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We will be talking about cystic lesions in orofacial

region, this topic will be covered in 2 lectures , today will be talk about
different kinds of cyst ,their clinical presentation & how to diagnose them ,
next time enshallah we will talk about how to deal with them & how to treat
. them

Cyst: it is a pathological cavity containing fluids or semi- fluids, it is lined

.with epithelium
Pathological cavity: this is to differentiate it from any normal cavity in the
.body that is lined with epithelium such as maxillary sinus
So cyst is lined with epithelium to differentiate between true cyst (it is lined
.with epithelium) & psudocyst

Cysts commonly seen in the maxilla & mandible, then any other bone in
.the body

Generally we can classify cysts according to the tissue of origin,

: we are talking about jaw cysts ( in maxilla & mandible), they classify them to
.I) Odontogenic cyst: originate from tooth forming tissue
II) Non-odontogenic cyst: originate from other tissue, not
.related to the developing of teeth

:Odontogenic cyst: are divided into**

Developmental cyst: has no obvious cause or predisposing (1
.factor, for example; odontogenic keratocyst

Inflammatory cysts: they are formed in response to some sort of ( 2

stimulation & inflammatory process , for example ;radicular cysts : the cystic
changes in it take place in response to stimulation from toxic material,
microorganisms & root canals of non-vital tooth , that stimulate the whole
. process

How do cystic lesion seen clinically? Are they normally painful?

Normally they are not painful unless they become infected, then how they
?show up? What those patients come complain from
Swelling: this can displace teeth, but the cystic lesions will not compress **
.vital structures
Cystic lesion grow slowly, so the vital structures can adapt, shift & move
around them, they get displaced, but if the cyst comprise nerve it will not
.cause parasthesia or numbness

If the patient is edentulous & wearing a denture, then the cyst is developed,
what happened? denture doesn’t fit any more , some times the cystic lesions
perforate bone then soft tissue then it starts oozing its contents , which is salty
discharge in his mouth , so the patient may come & complain from salty
:discharge in his mouth , so most of the time cystic lesions are
.Asymptomatic, we find them on the radiograph incidentally *
.They cause jaw swelling *
.They may discharge through the sinus *
.They can displace the teeth *

Radio graphically they appear as radiolucent area, which surrounded by

a corticated white line, so they very defined on the radiograph & and this is the
.main difference between cyst & abscess

.Cystic lesion: well defined#

.Abscess: is ill defined#

Page 1,line 2,the right picture : I ( doc) remember this patient , who was
72 years old , he went to his dentist complain from his denture , it wasn’t
fitting any more , the dentist didn’t know what was the cause , he send patient
to us ( sergeants in our faculty ) & during examination , this is what I saw ,
this is the right side of upper edentulous jaw & you can see clearly this
swelling , there is expansion buccally and palatally , and this is why the
denture wasn’t fitting any more , and if you look carefully , you can see the
swelling ,maxillary sinus ,rugea area & the right side of the ridge ,also you
can see the bluish color in this area, this suggest that it is contain fluids , so
??what is the next step
We took a radiograph & there was a cystic lesion around an impacted 3rd molar
.((this radiograph in page 2 line 2 the right picture

:Let us talk about different types of cystic lesion, we will start with
 Radicular cysts
?What are the typical features of it
It is an inflammatory cyst @
The key feature of it, that it is always associated with non-vital @
tooth, so if the tooth is vital then it isn’t a radicular cyst
It is the most common type of the cystic lesion in maxilla & @
mandible
They don’t normally grow very big, its diameter 2-3 cm not more @
than that & and it could be even smaller, very occasionally we can see
.radicular cyst bigger than that
We see them mostly in the anterior region of the maxilla @
& posterior region of the mandible, why? Because teeth in
;these 2 regions are more likely to become non-vital
.a) In the anterior region of maxilla because of trauma
.b) In the posterior region of the mandible because of caries
See it in the middle age between 20 – 60 years old & sometimes @
over 60 years
Normally we don’t see them around deciduous teeth @

Radio graphically: it is very well defined circle, oval shape

.radiolucency area around apex of non-vital tooth
Now if the tooth in concern is extracted, without preoperative radiograph,
you indicate that this root or tooth to be extracted & you go & do extraction
but you left a cyst behind you & you didn’t know that the cyst was there, then
.the remaining cyst is called residual cyst

Residual cyst: it is a radicular cyst which is left in the jaw after the
.associated tooth was extracted
Page 1 line 3 the right picture: this is a typical appearance of a radicular
cyst, very well defined radiolucency around the apex of non-vital tooth,
.probably because of trauma

Page 2 lines 1 the left picture: is it a residual cyst or a radicular cyst

associated with a tooth? How u can know? it isn’t exactly around apex, the 1st
thing you do is vitality test, to know if the tooth in concern is vital or not,
then simply you follow the lamina dura around the tooth in concern, if it
continuous with cystic wall then it is a radicular cyst, if not it is a residual cyst,
.but it doesn’t matter whether it is radicular or residual

Page 2 line 1 the right picture: this is another case which may be a residual
cyst around an extracted root or a radicular cyst, but the most important
.feature is the radiolucency area that is very well demarcated

Dentigerous & Eruption cyst

.It is a developmental cyst #
The most important feature of it that it is associated with #
.unerupted tooth, it doesn’t have to be impacted
it can be seen at any age , but more commonly in 5th #
. decade ( 41,42,43 not 51,52,53 yeas old) & later
we see it more around mandibular 8`s or maxillary #
canines, because these teeth are more likely to be impacted & remain
.unerupted
Sometimes it may develop around supernumeraries teeth or #
.around an odontom

Radio graphically : it appear as well defined

radiolucency that surround the crown of unerupted
tooth , the relation between the crown & the cyst is variable , it could be
central in the cyst or the cyst could be circumferential ( around the tooth ) or it
could be formed around one side of the crown in this case we call it lateral
crown ,but in all cases; part of enamel within the cystic lumen , the crown of
the tooth is located either totally or partially within the cystic lumen , because
the cyst develops within the follicle of the tooth which not normally surround
. the crown
Page 2 line 2 the left picture : this is a radiograph for the patient we
mentioned earlier ;72 years old whose his denture not fitting any more , the
picture shows upper wisdom tooth , then the cyst was formed around its crown
. , this is a Dentigerous cyst

Page 2 line 3 the left picture: this is a huge dentigerous cyst which has
formed around lower 5, which is failed to erupt & if you look carefully you
will see that the cyst extend all over the way, so it is a big cyst & clinically
when we remove the tooth & the cyst you find only the crown of the tooth is
.within the cyst
 Here is an extracted mandibular molar the crown of which is surrounded by a
dentigerous cyst. Note the cyst "space" and the prominent, but thin, wall

How can you differentiate between cyst & tumor? sometimes you cant , it
depend on the type of the tumor , but the radiograph is only one element to
reach the diagnosis but you need to know the history , examine patient
clinically & if you in doubt you take a biopsy , so there is no simple answer to
. this question

Question from nesrien : how does this cyst grow to this big size ? What
?happened to the bone in this area
Answer: what happened is the cyst start small & as it grow bigger & bigger
it dissolve the bone around the wall of the cyst, it dissolve from inside & then
the periosteum try to compensate by deposit bone outside & this is why the
mandible becomes swollen like the picture in page 2 line 3 the left one;
because the rate of resorption is faster, in some points this could leads to
.perforate bone & becomes extra bony

Page 2 line 3 the right picture: this is an example of dentigerous cyst, what
we call this appearance? Compound odontom
Page 3 line 1 the left picture: it is an upper occlusal view, this is another
dentigerous cyst & there is an impacted canine, you can see a big cyst which
.has formed around it

We mentioned eruption cyst & dentigerous cyst, but what is the difference
?between them
Eruption cyst : it is an extra bony cyst ,an example : (the picture in
page 3 line 1 the right one) this is a bluish swelling color , if you perforate this
area or aspirate it with a needle , the fluid will get out , so this is an example of
eruption cyst , sometimes you cant see the eruption cyst in the radiograph
because it is totally within the soft tissue & sometimes you can see part of it
. because part of it will be in the bone & the other part within the soft tissue

Sometimes a dentigerous cyst is located around the crown of an erupting tooth.

When that happens the lesion may be apparent clinically. Here one surrounds the
crown of an unerupted central incisor; it is, in fact, preventing eruption of that
.tooth

Summary
Most important feature of the radicular cyst is that it associated with non
.vital tooth, & usually it doesn’t grow very big
Most important feature of the dentigerous cyst that it associated with
. unerupted tooth, but it can grow very big
(Odontogenic Keratocysts (OKC

Some people call it primordial cyst & this is because they thought that this
is formed in tooth forming organ (primordial) & replaces the tooth, so the
tooth become missing, but this is not true, because you know that this happen
in people with congenitally missing wisdom teeth & occur in people who
.don’t have missing teeth at all, but still some people call it primordial cyst

: The typical feature

It happens in younger age group of patient usually 2nd or **
.3rd decades
The most common site is the posterior of the mandible, **
near the angle
it expands in anteroposterior dimension , causing little **
or no jaw expansion , so it can be reach big size before you detect
it in the mandible clinically , but the other cystic lesions grow in ballooning
. fashion , they grow in all directions

This cyst tend to grow between the 2 plates of bone, between cancellous
spaces because it is a poor bone resorber, it doesn’t resorbe cortical plate of
.bone
It is high tendency to recur, why???? because this cyst has **
thin wall with multiple daughter cysts, if you remember histopathology,
projections of endothelium within the wall we call them daughter cysts &
because the wall is thin & fragile, it get torn easily within the surgical
removed, if we are not carefully enough, we will leave parts of wall behind &
then the cyst recurs & of course there is a way of healing, we will talk about it
.next lecture
.This is an example of OKC

Gorline – Goltz syndrome ( basal cell nervosal syndrome ) :

the typical features of it : multiple odontogenic keratocyst, multiple basal cell
carcinoma , abnormal calcification in meninges , abnormalities in vertebral
column , but you need to go & read about it , we mention it here because one
. of the typical feature : multiple odontogenic keratocyst

the typical appearance of this cyst is different from other cysts, typically &**
most of the time it appears as multilocular radiolucency but sometime it
.is unilocular

Page 3 line 2 the right picture: this is an example of OKC, you can see it as
multilocular & if you examine this patient clinically, the problem be unable to
detect any swelling in mandible, but in the other cystic lesions when the cyst
.in this big size m the mandible swollen

Page 3 line 3 the left picture: this is a radiograph of the patient with Gorline
.– Goltz syndrome, we can see a radiolucent cyst OKC

Student Question (it is very important point): this cyst is around the crown
????of this tooth, so why it is OKC??? Why it isn’t dentigerous cyst
Answer: this is a coincidental finding that this patient who has an OKC &
has an impacted wisdom tooth , but clinically you can differentiate by notice
that the mandible isn’t swollen in this area but you have to aspirate the lesion
& have a look to the content , clinically when we remove this cyst we found
that this tooth is outside the cystic lumen , but in radiograph you put a
dentigerous cyst as a part of differential diagnosis, this is depend on the
symptoms that the patient have, because most of the cystic lesions are
asymptomatic , most of them are diagnosed incidentally on the radiograph
,how????? You take a radiograph for certain complaint such as patient come
complaining from facial swelling, or from displacing of teeth or salty
.discharge

Gingival cyst
.they called it Bohn`s nodules ##
.see them most of the time in neonates ##
has similar appearance to eruption cyst but the difference that they are ##
.much smaller in size
.They rupture & disappear spontaneously ##
.Very rarely seen in adults ##
. THIS one in an infant

Lateral periodontal cyst

I) It is associated with vital teeth , this is to differentiate it from a radicular

cyst , it can be associated with non-vital tooth but this is an exception & if it
associated with non-vital tooth then the loss of vitality of the pulp has nothing
. to do with the pathogenesis of the cyst , this has to be clear

Again to explain this point : lateral periodontal cyst is usually associated

with vital tooth because normally when you examine the patient you expect to
see vital tooth not non-vital tooth , so the pathogenesis of this cyst has nothing
to do with the condition of the pulp of the tooth , if what ever reason the pulp
becomes non-vital , then the cyst become associated with non-vital tooth , but
the pathological condition of the pulp has nothing to do with the pathogenesis
. ( of the cyst ( I wish you get the idea

II) It can cause expansion of the jaw over the root of the tooth , but most of
the time it is small & diagnosed incidentally on the radiograph , the most
common sites are lower canine & premolar regions , & sometimes it is
multilocular in appearance & this is called botryoid odontogenic cyst, they
. are not common
Paradental cyst
Are more commonly seen , you can see them at the distal aspect of a
crown of partially erupted lower wisdom tooth , if the tooth of concern is
extracted , a buccal enamel spur ( projections ) are normally seen ,but we don’t
. know if this spur is associated with the pathogenesis of the cyst or not
It is inflammatory in origin & the inflammatory process which stimulate the
.cyst changes in this case; it is the pericoronitis around the tooth of concern

Nasopalatine duct cyst

.I) It is the commonest non-odontogenic cyst
.II) Seen in the middle age or the elderly people
III) Most of the time it is incidentally finding or sometimes patients come
.complaining from a swelling in the palate or from salty discharge
IV) This cyst develop from the remnants of nasopalatine duct (which the
duct that connect the nose with the anterior part of the palate through which
nasopalatine nerve or bundle exits, just behind the two upper central incisors
.(& we have foramina in that area

Radio graphically : if you have a radiolucency that is bigger than 6

mm in diameter then this is no likely to be foramina it is more likely to be cyst
. ; because foramina is normally 6mm or less in diameter
Page 4 line 2 the right picture : this is an example of nasopalatine duct cyst ,
this swelling in the area & if you look carefully it is bluish here , this suggest
fluid content so this is nasopalatine duct cyst ,( doc use this photograph in his
. ( viva exam , so remember it

.Page 4line 3 the left picture: this is a radiograph of the cyst

Globulomaxillary cysts

It used to be thought as separate clinical entity, but nowadays we think it

may be not a separate clinical entity, it may be a variation of a radicular cyst or
.a residual cyst or some other types of cysts

The typical appearance: it is between the roots of the maxillary lateral

incisor & canine, usually the canine has an inverted pear shape, the narrow
part of pear is downward & the wide side upward, it causes displacement of
.the roots of the teeth

Page 5 line 1 the left picture: this is a radiolucency which displacing the
.roots of lateral & canine

Nasolabial cyst
Another non-odontogenic cyst , it is a soft tissue cyst ,I ( doc ) saw a **
case of nasolabial cyst few months ago I took some photograph but I didn’t
have enough time to put them here, it is purely soft tissue cyst
.hasn’t any radiographic appearance **
It develops within the upper lip below ala of the nose, it is usually **
.causing obliteration of the nasolabial fold, it causes swelling in that area
Its origin from the remnants of the epithelium of different phases during **
.(development (u can read it a lone

There is a swelling of this boy's right mid-face.

 Median cysts

.Are very rare @

They appear in the midline of the maxilla or the mandible & @
.sometimes in the palate
.Their origin is unknown; I (doc) have never seen a single case @

All cystic lesions we have mentioned so far are true cystic lesions, which
mean that they are surrounded with epithelium, now we will talk about another
.cystic lesion which is not typically surrounded with epithelium

Solitary bone cysts

 Other people call it traumatic bone cyst

.it is from unknown origin
. It develops in adolescent
. It is not surrounded with epithelium
. Most common location is the body of the mandible
 It is usually asymptomatic
. usually need no intervention, it heals spontaneously

The proposed pathogenesis is that some types of trauma causes bleeding

within the body of the mandible , a clot forms there & then instead of
organizing & forming bone in that area ,the clot fails to organize to bone &
. leaves a cavity behind
.Typical appearance: is radiolucency area with scalloped upper margins

Aneurysmal bone cyst

(They are not very common, just focus on main parts)

. It is mainly unilocular or multilocular in appearance

 Histopathology it appears as non-endothelial lined blood filled spaces,
.because it contains blood

Stafne`s idiopathic bone cavity

Is simply the impression of submandibular gland of the inner aspect of

the body of the mandible & sometimes it leaves a very deep impression where
the bone becomes thin , so relatively it appears radiolucent & if you do
sialograph of submandibular gland you see that salivary gland is located in this
. radiolucency

Picture in page 6 : this is stafne`s below ID canal , well defined

radiolucency & actually it is an impression in the inner aspect of mandible
. because of submandibular salivary gland
. Plz forgive me if there is any mistake