Odontogenic Cysts

Dr. Amin Abusallamah

 Outline

1. INTRODUCTION 6. RADIOGRAPHIC FEATURES

2. CLASSIFICATION 7. DIFFERENTIAL DIAGNOSIS

3. CAUSES 8. TREATMENT

4. HISTOPATHOLOGY 9. PRINCIPLE OF TREATMENT

A. Types of Flaps.
5. CLICAL FEATURES B. Surgical removal the of the cyst .
 INTRODUCTION

• A cyst is an epithelium-lined sac

containing fluid or semisolid material.
In the formation of a cyst, the epithelial
cells first proliferate and later undergo
degeneration and liquefaction. The
liquefied material exerts equal pressure
on the walls of the cyst from within.
 INTRODUCTION

• Cysts grow by expansion and thus

displace the adjacent teeth by pressure.
May can produce expansion of the
cortical bone. On a radiograph, the
radiolucency of a cyst is usually
bordered by a radiopaque periphery of
dense sclerotic bone. The radiolucency
may be unilocular or multilocular
 INTRODUCTION

• Odontogenic cysts are those which

arise from the epithelium associated
with the development of teeth. The
source of epithelium is from the
enamel organ, the reduced enamel
epithelium, the cell rests of Malassez or
the remnants of the dental lamina.
 CLASSIFICATION

• Radicular cyst
• Residual cyst
• Dentigerous cyst (follicular)
• Primordial cyst
• Lateral periodontal cyst
• Odontogenic keratocyst
• Calcifying odontogenic cyst (Gorlin cyst)
Radicular cyst
 Causes

• A periapical cyst develops from a preexisting

periapical granuloma, which is a focus of chronically
inflamed granulation tissue in bone located at the
apex of a nonvital tooth.

• Periapical granulomas are initiated and maintained

by the degradation products of necrotic pulp tissue
 Histopathology

• The periapical cyst is lined by non

keratinized stratified squamous
epithelium of variable.
Transmigration of inflammatory
cells through the epithelium is
common, with large numbers of
(PMNs) and fewer numbers of
lymphocytes involved.
 Histopathology

• The underlying supportive

connective tissue may be
focally or diffusely infiltrated
with a mixed inflammatory
cell population.
 Clinical features

• Frequency:It is most common cystic lesion of jaw

comprising about approximately 52% of jaw cystic lesions.

• Age: found in 4th & 5th decades of life.

• Sex: It is more common in males 58% than females.

• Race: White patients more than Black patients.

• Site: It occurs with frequency of 60% occurs in maxillary

anterior region. Most commonly at apices of teeth.
 Radiographic features

• Location: In most cases the epicenter of a radicular cyst is

located approximately at the apex of a nonvital tooth.

• Periphery and shape: The periphery usually has a well

defined cortical border. It will become ill-defined if infected.

• Internal structure: In most radicular cysts is radiolucent.

• Effects on surrounding structures: If a radicular cyst is

large, displacement and resorption of the roots of adjacent
teeth.
 Differential Diagnosis

• Periapical abscess. Ill defined margin.

• Apical granuloma. may be difficult and in some cases impossible.

A round shape, a well-defined cortical border, and a size greater
than 2 cm in diameter are more characteristic of a cyst.

• Early stage of periapical cemental dysplasia. tooth are vital.

• Apical scar.

• Periapical surgical defect.

 Treatment

Enucleation with preservation of tooth and RCT

with follow-up

Or

Extraction with curettage

Residual cyst
 Causes

• When the necrotic tooth is extracted but the cyst lining is

incompletely removed, a residual cyst may from months to
years after the develop initial extirpation If either or the a
residual cyst original periapical cyst remains
untreated, continued growth can cause significant bone
resorption and weakening of the mandible or maxilla.
 Histopathology

Same like Radicular or periapical cyst

 Clinical features

• A Residual cyst is a cyst that develops

• after incomplete removal of the original cyst.

• Usually asymptomatic.

• Unilocular, round or oval, well--defined, usually well

corticated.

• It can cause bone expansion and displacement of the adjacent

teeth.
 Radiographic features

• Location: In both jaw but more in the mandible. Found at

periapical location, in place of an extracted tooth.

• Periphery and shape: The periphery usually has a well defined

cortical border.

• Internal structure: In most cases the internal structure of

radicular cysts is radiolucent.

• Effects on surrounding structures: large cyst , displacement

and resorption of the roots of adjacent teeth may occur.
 Differential Diagnosis

• Keratocyst: residual cyst has greater potential for

expansion compared with a keratocyst.

• Stafne developmental salivary gland defect is located

below the mandibular canal
 Treatment

Enucleation if the lesion is small

Or

Marsupialization if the lesion is large

Dentigerous cyst
 Causes

• Dentigerous cyst develops from proliferation of the

enamel organ remnant or reduced enamel
epithelium.
 Histopathology

• The supporting fibrous connective

tissue wall of the cyst is lined by
stratified squamous epithelium.
In an uninflamed dentigerous cyst
the epithelial lining is
nonkeratinized and tends to be
approximately four to six cell
layers thick.
 Histopathology

• On occasion, 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, although in
cases in which there is secondary
inflammation, epithelial byperplasia
may be noted.
 Clinical features

• Dentigerous cysts are most commonly

seen in association with third molars
and maxillary canines, which are the
most commonly impacted teeth. The
highest incidence of dentigerous cysts
occurs during the second and third
decades. There is a greater incidence in
males, with a ratio of 1.6 to 1 reported.
 Clinical features

• Symptoms are generally absent, with

delayed eruption being the most
common indication of dentigerous cyst
formation. This cyst is capable of
achieving significant size, occasionally
with associated cortical bone expansion
but rarely to a size that predisposes the
patient to a pathologic fracture.
 Radiographic features

• Location: most common sites are mandibular third molar, maxillary

canine, maxillary third molar. Associated with the crown of an un-
erupted and displaced tooth.

• Periphery and shape: The periphery usually has a well defined

cortical border. Attached to the CEJ.

• Internal structure: most cases is radiolucent surrounding the crown.

• Effects on surrounding structures: Large cysts tend to expand the

outer plate (usually buccally).
 Differential Diagnosis

• Hyperplastic follicle The size of the normal follicular space is 2

to 3 mm. If the follicular space exceeds 5 mm, a dentigerous
cyst is more likely.

• Odontogenic keratocyst ,does not expand the bone to the

same degree as a dentigerous cyst, is less likely to resorb
teeth, and may attach farther apically on the root instead of at
the cementoenamel junction.
 Differential Diagnosis

• Ameloblastjc fibroma

• Cystic ameloblastoma The internal structure in both of them

differentiate

• Adenomatoid odontogenic tumors

• Calcified odontogenic cysts Both can surround the crown and

root of the involved tooth. Evidence of a radiopaque internal
structure should be sought in these two lesions.
 Treatment

Marsupialization is strongly
recommended when tooth or
adjacent teeth prevented from as
or
Enucleation is an alternative treatment
with removal of tooth
Lateral periodontal
cyst
 Causes

• The origin of this cyst is believed to be related to proliferation

of rests of dental lamina.

• The lateral periodontal cyst has been pathogcnetically linked

to the gingival cyst of the adult; t the former is believed to
arise from dental lamina remnants within bone, and the latter
from dental lamina remnants in soft tissue between the oral
epithelium and the periosteum (rests of Serres).
 Histopathology

• The close relationship between the two

entities is further supported by their
similar distribution in sites containing a
higher concentration of dental lamina
rests, and their identical histology. By
contrast, periapical cysts are most
common at the apices of teeth, where
rests of Malassez are more plentiful.
 Clinical features

• Age : Adults

• Location : Lateral periodontal membrane especially

mandibular , cuspid and premolar area

• Usually asypmtomatic ; associated tooth is vital ;origin from

rests of dental lamina ;

• some keratocysts are found in a lateral root position

;gingival cyst be soft tissue of adult may counterpart
 Radiographic features

• Location: 50-75% of lateral periodontal cysts develop in the

mandible, mostly in a region extending from the lateral incisor
to the second premolar.
• Periphery and shape: well-defined radiolucency with a
prominent cortical boundary and a round or oval shape.
• Internal structure: usually is radiolucent.
• Effects on surrounding structures: Large cysts can displace
adjacent teeth and cause expansion
 Differential Diagnosis

• Small OKC

• Mental foramen

• Small neurofibroma

• Radicular cyst at the foramen of an accessory pulp canal.

• The multiple (botryoid) cysts with a multilocular

appearance may resemble a small ameloblastoma.
 Treatment

Enucleation with preservation of

adjoining teeth
Odontogenic
keratocyst
 Causes

• There is general agreement that OKCs develop from dental

lamina remnants in the mandible and maxilla. However, an
origin of this cyst From extension of basal cells of the
overlying oral epithelium has also been suggested.

• Genetic
 Histopathology

• The epithelial lining is uniformly thin, generally ranging from 8

to 10 cell layers thick.

• The basal layer exhibits a characteristic palisaded pattern with

polarized and intensely stained nuclei of uniform diameter.
The luminal epithelial cells are parakeratinized and produce an
uneven or corrugated profile.
 Histopathology

• Additional histologic features that may

occasionally be encountered include
budding of the basal cells into the C.T
wall and microcyst formation.

• The fibrous connective tissue

component of the cyst wall is often free
of inflammatory cell infiltrate and is
relatively thin.
 Clinical features

• Age: Any age , especially adults

• Location : Mandibular molar ramus area favored ; may be

found dentigerous , in position of lateral root , periapical , or
primordial cyst

• OKCs are relatively common jaw cysts They occur at any age
and have a peak incidence within the second and third
decades.
 Radiographic features

• Location : The most common is the posterior body of the

mandible (90% posterior to the canines)and ramus (more
than 50%). This type of cyst occasionally has the same
pericoronal position asdentigerous cyst.

• Periphery and shape Usually : with a cortical border unless

become secondarily infected. The cyst may have a smooth
(round or oval shape), or it may have a scalloped outline.
 Radiographic features

• Internal structure

• most commonly is radiolucent.

• The cystic cavity contain keratin.

• In some cases curved internal septa may be present, giving

the lesion a multilocular Appearance.
 Radiographic features

• The effects on surrounding structures : It grow along the

internal aspect of the jaws, causing minimal expansion except
for the upper ramus and coronoid process, where
considerable expansion may occur. OKCs can displace and
resorbe teeth but to a slightly lesser degree than dentigerous
cysts. The inferior alveolar nerve canal may be displaced
inferiorly. In the maxilla this cyst can invaginate and occupy
the entire maxillary antrum
 Differential Diagnosis

• Dentigerous cyst OKC

• Ameloblastoma, AB has a greater propensity to expand.

• Odontogenic myxoma, multilocular with fine straight septa.

• A simple bone cyst often has a scalloped margin and minimal

bone expansion.

• several OKCs are found, these cysts may constitute part of a

basal cell nevus syndrome.
 Treatment

Wide (local) surgical excision for prevent the

recurrence
or
Marsupialization - the surgical opening of the
(KCOT) cavity and a creation of a marsupial-
like pouch, so that the cavity is in contact with
the outside for an extended period.
 Calcifying
odontogenic cyst
(Gorlin cyst)
 Causes

• COGs are believed to be derived from odontogenic epithelial

remnants within the gingiva or within the mandible or maxilla.
 Histopathology

• Most COCs present as well-

delineated cystic proliferations with
a fibrous connective tissue wall lined
by odontogenic epithelium.
Intraluminal epithelial proliferation
occasionally obscures the cyst
lumen, thereby producing the
impression of a solid tumor.
 Histopathology

• The basal epithelium may focally be quite prominent, with

hyperchromatic nuclei and a cuboidal to columnar pattern.
Above the basal layer are more loosely arranged epithelial
cells, sometimes resembling the stellate reticulum of the
enamel organ. The most prominent and unique microscopic
feature is the presence of ghost cell keratinization.
 Histopathology

• The ghost cells are anucleate and

retain the outline of the
cell membrane. These cells
undergo dystrophic mineralization
characterized by fine basophilic
granularity, which may eventually
result in large sheets of calcined
material On occasion.
 Clinical features

• Age: Any age

• Location : Maxilla favored ; gingiva second most common site

• No distinctive age gender, gender, or locationLucent to mixe

d radiographic patterns
 Radiographic features

• COCs may present as unilocular or multilocular radiolucencies

with discrete, welldemarcated margins. Within the
radiolucency there may be scattered, irregularly sized
calcifications. Such opacities may produce a salt-and-pepper
type of pattern, with an equal and diffuse distribution. In
some cases mineralization may develop to such an extent that
the radiographic margins of the lesion are difficult to
determine.
 Differential Diagnosis

• Dentigerous cyst,

• OKC,

• Ameloblastoma. In later stages ,

• Adenomatoid odontogenic tumor,

• Ameloblastic fibroodontoma
 Treatment

Surgical Enucleation is the preferred

therapy
 Principle of Treatment

1. local anesthesia.

2. Types of Flaps.

3. Surgical removal the of the cyst .

Local anesthesia
 Types of Flaps
1. Trapezoidal flap.
• Advantage : Provides excellent
access, allows surgery to be performed
on more than two teeth, produces no
tension in the tissues allows easy
reapproximation of the flap to its original
position.

• Disadvantages: Produces a defect in the

attachedgingiva
 Types of Flaps
2. Triangular Flap.
• Advantage : Ensures an adequate blood
supply, satisfactory visualization, very
good stability .

• Disadvantages: Limited access to long

roots, tension is created when the flap is
held with a retractor, and it causes a
defect in the attached gingiva.
 Types of Flaps
3. Envelope Flap.
• Advantage : Avoidance of vertical
incision and easy reapproximation to
original position

• Disadvantages: Difficult reflection

(mainly palatally), great tension with a risk
of the ends tearing, limited visualization
in apicoectomies, limited
access, possibility of injury of palatal
vessels and nerves, defect of attached
gingiva
 Types of Flaps
4. Semilunar Flap.
• Advantage : Small incision and easy
reflection, no recession of gingivae
around the prosthetic restoration.

• Disadvantages: The incision being

performed right over the bone lesion due to
miscalculation, scarring in the anterior
area, difficulty of reapproximation , limited
access and visualization, tendency to tear.
 Surgical removal the of the cyst
• Enucleation: This technique involves complete removal of
the cystic sac and healing of the wound by primary intention.
This is the most satisfactory method of treatment of a cyst
and is indicated in all cases where cysts are involved, whose
wall may be removed without damaging adjacent teeth and
other anatomic structures.
 Surgical removal the of the cyst
• The surgical procedure for treatment of a cyst with
enucleation includes the following steps:

1. Reflection of a mucoperiosteal flap.

2. Removal of bone and exposure of part of the cyst.

3. Enucleation of the cystic sac.

4. Care of the wound and suturing.

 Surgical removal the of the cyst

Panoramic radiograph showing an

Clinical photograph of case
extensive radicularlesion at the region
of teeth 22, 23, 24
 Surgical removal the of the cyst

Removal of maxillary cyst, with labial access. Incision for creating a trapezoidal flap.

Reflection of flap and exposure of surgical field.

Surgical removal the of the cyst

Removal of bone at the labial aspect respective to the lesion.

Osseous window created to expose part of the lesion.

Surgical removal the of the cyst

Removal of cyst from bony cavity, using hemostat and curette.

Surgical field after removal of lesion.

 Surgical removal the of the cyst

Operation site after placement of sutures.

Panoramic radiograph and clinical photograph taken 2 months after the surgical procedure.
 Surgical removal the of the cyst
• Marsupialization This method is usually employed for the
removal of large cysts and entails opening a surgical window
at an appropriate site above the lesion. In order to create the
surgical window, initially a circular incision is made, which
includes the mucoperiosteum, the underlying perforated
(usually) bone, and the respective wall of the cystic sac
 Surgical removal the of the cyst
• Marsupialization: After this procedure, the contents of the cyst
are evacuated, and interrupted sutures are placed around the
periphery of the cyst, suturing the mucoperiosteum and the cystic
wall together . Afterwards, the cystic cavity is irrigated with saline
solution and packed with iodoform gauze ,which is removed a week
later together with the sutures. During that period, the wound
margins will have healed, establishing permanent communication.
Irrigation of the cystic cavity is performed several times
daily, keeping it clean of food debris and avertinga potential
infection.
 Surgical removal the of the cyst

Marsupialization method. Circular incision includes mucosa and periosteum.

Enlargement
of osseous
window with
rongeur

Exposure of buccal cortical plate and removal of portion of bone with round bur
Surgical removal the of the cyst

Exposure of cyst Suturing of wound

after removal of margins with
bone cystic wall
Surgical removal the of the cyst

Packing of cystic Cystic cavity after

cavity with insertion of
iodoform gauz gauze
Thank
you