– Important –

Odontogenic Cysts (OC)

Developmental Cysts
True cyst: is a pathological cavity contains lumen & lined by epithelium
(non odontogenic) cysts
& surrounded by outer connective tissue wall (capsule).

OR • The remaining 5% of cysts within the

jaws are made up of non odontogenic
it’s a pathological fluid-filled cavities lined by epithelium.
cysts and arise from epithelium not
• The cystic cavity may contain fluid or semi fluid materials such associated with tooth development.
as cellular debris, keratin or mucous.
• Non odontogenic cysts
Pseudo cyst: are cystic cavities that have no epithelial lining e.g. trau-
– Incisive canal (nasopalatine duct) cyst
matic bone cyst.
– Surgical ciliated cyst of maxilla
Odontogenic cysts(OC): are cysts lined by epithelium that has been – Midpalatal cyst of infants
involved in the formation of teeth.
– Nasolabial cyst
• They are more common in the jaws because of the many rests of – Globulomaxillary cyst
odontogenic epithelium remaining in the tissue.
– Dermoid cyst
• Odontogenic cysts are derived from the following epithelium
structures:
• and there are some cysts arise from
– Rest of mallasses tissue other than epithelial tissue:

* (e.g. P.A.C. and residual cyst)

• Non epithelial cysts:-
– Reduced enamel epithelium
– Idiopathic bone cavity (traumatic,
* (e.g. dentigerous cyst and eruption cyst)
solitary, hemorrhagic bone) cyst
– Remnants of the dental lamina
– Aneurysmal bone cyst
* (e.g. odontogenic keratocyst, lateral periodontal cyst, gingi-
– Stafne’s mandibular lingual
val cyst and glandular odontogenic cyst).
cortical defect

• Odontogenic cysts are classified as developmental or inflammatory in origin:-

– Inflammatory OC – Developmental OC 6. gingival (alveolar) cyst of

1. dentigerous cyst the newborn

1. radicular cyst.
2. eruption cyst 7. gingival cyst of the adults
2. residual cyst. 3. odontogenic keratocyst
8. glandular OC
4. orthokeratinized odontogenic cyst
3. paradental cyst.
5. lateral periodontal cyst 9. calcifying OC
2 1 DENTIGEROUS CYST (DC) (FOLLICULAR CYST)

1 Dentigerous cyst (DC) (Follicular Cyst)

• surrounds the crown of an impacted tooth, caused by fluid

accumulation between the reduced enamel epithelium and the
enamel surface, resulting in a cyst in which the crown is located
within the lumen and roots outside. Figure 1: Dentigerous cyst.
Gross specimen of a dentiger-
• The pathogenesis of this cyst is uncertain but it develops by ous cyst involving a maxillary
accumulation of fluid between the REE & the tooth crown. canine tooth. The cyst has
been cut open to show the
• Progressive growth → dilatation of dental follicle. cyst-to-crown relationship.

1.1 Clinical features

• Asymptomatic, but it may produce enlargement of the maxilla or

mandible and displacement of teeth .

• Pain when become large or infected.

• * Although dentigerous cysts may occur in association with

any unerupted tooth, most often they involve mandibular third Figure 2: Dentigerous cyst.
molars, accounting for approximately 65% of all cases. Other Central type showing the crown
relatively frequent sites include maxillary canines, maxillary projecting into the cystic cavity.

third molars, and mandibular second premolars. Dentigerous

cysts rarely involve unerupted deciduous teeth. Occasionally,
they are associated with supernumerary teeth or odontomas. *

• Below 10 and 30 years of age with slight male predilection.

• Uncomplicated DC (small DC) causes no symptoms and discov-

ered on a routine radiographic examination

• Large DC may be associated with a painless expansion of the Figure 3: Dentigerous cyst.
Lateral variety showing a large
bone
cyst along the mesial root of
the un erupted molar.
• Infected DC causes pain and accelerated swelling.

1.2 Radiographically

• Well circumscribed radiolucency surrounding the crown of an

un erupted tooth.

• If the width of RL around the crown is less than 2mm, it is con-

sidered a normal tooth follicle, and if 3 to 4 mm then a DC
Figure 4: Dentigerous cyst.
should be considered. Circumferential variety show-
ing cyst extension along the
mesial and distal roots of the
un erupted tooth.
1 DENTIGEROUS CYST (DC) (FOLLICULAR CYST) 3

• A large DC appear as a multilocular process because of the

persistence of bone trabeculare within the RL.

• A keratocyst or ameloblastoma may envelop the crown of the

tooth and appear radiographically similar to DC so the diagno-
sis depends on histological examination not on radiographical
Figure 5: Dentigerous
findings. cyst or enlarged follicle.
Radiolucent lesion involving the crown of an unerupted

1.3 Histopathology mandibular premolar. Distinction between a dentigerous

cyst and an enlarged follicle for a lesion of this size by

• Nodular thickening, which must examined microscopically to radiographic and even histopathologic means is difficult,

role out early neoplastic changes. if not impossible.

• The lining of a non inflamed DC composed of stratified squa-

mous epithelium, rarely showing keratinization with mucous
producing cells.

• The wall consists of loose fibrous C.T. with inactive odontogenic

epithelial rests. Small nests of sebaceous cells rarely may be
noticed with the fibrous cyst wall. Figure 6: Dentigerous cyst.
This non inflamed dentiger-
ous cyst shows a thin, non
keratinized epithelial lining.
• In inflamed DC the fibrous wall is more collagenized with the
chronic inflammatory cells and the lining show hyperplasia and
develop rete ridges.

1.4 Treatment

• Surgical enucleation, with removal of associated tooth.

• A large DC may be treated by marsupialization, which permits Figure 7: Dentigerous cyst.

This inflamed dentigerous
decompression of the cyst (canines) and then we do alignment of
cyst shows a thicker epithelial
the tooth by orthodontic appliance. lining with hyperplastic rete
ridges. The fibrous cyst cap-
• Recurrences are rare.
sule shows a diffuse chronic
inflammatory infiltrate.

Figure 8: Dentigerous cyst.

Scattered mucous cells can
be seen within the epithelial
lining.
4 2 ERUPTION CYST (ERUPTION HEMATOMA)

2 Eruption cyst (eruption hematoma)

• Forms over a tooth about to erupt.

• It’s a soft tissue analogue of the DC, results from separation of

the dental follicle from around the crown of eruption tooth.
Figure 9: Eruption cyst.
• The cysts developed because of collagen deposition in the
This soft gingival swelling
gingival C.T. contains considerable blood
and can also be designated as
2.1 Clinical features an eruption hematoma.

• Children and adult in the deciduous teeth or permanent mo-

lars.

• Its soft, fluctuant, translucent swelling in the gingival mucosa

overlying the crown of un erupting tooth and rarely painful.

• Surface trauma result in an amount of blood in the cystic fluid

which gives its blue to purple brown color and referred as
eruption hematomas.
Figure 10: Eruption cyst. A
cystic epithelial cavity can
2.2 Radiographically be seen below the mucosal
surface.
No X-ray findings appear because it occurs in soft tissue.

2.3 Histopathologically

• Surface thin layer of oral non keratinized squamous epithelium

covering the underlying lamina propria with inflammatory cells.

2.4 Treatment

• Not needed because the cyst usually ruptures spontaneously

permitting the tooth to erupt.

• Simple excision of the roof of the cyst is needed

to permits the eruption of tooth.
3 ODONTOGENIC KERATOCYST (OK) (OKC) (KERATOCYSTIC ODONTOGENIC TUMOR) 5

3 Odontogenic keratocyst (OK) (OKC) (Keratocystic Odonto-

genic Tumor)

• Arises from cell rests of the dental lamina.

• Dentigerous cyst and radicular cyst enlarged as a result of in-

Figure 11: Odontogenic kera-
creased osmatic pressure within the lumen of the cyst, while the
tocyst. Relative distribution of
growth of the keratocyst may be related to:- odontogenic keratocysts in the
jaws
– unknown factors inherent in the epithelium itself

– or enzymatic activity in the fibrous wall

• It makes up 3% to 11% of all odontogenic cysts.

3.1 Clinical features

• Ages 20 to 30 years.

• Mandible usually affected (jaw angle and ramus).

• It grows in anterioposterior direction within modularly cavity of

the bone without causing obvious bone expansion but DC &
RC produce bone expansion. Figure 12: Odontogenic kera-
tocyst. Relative distribution of
• Multiple OK is seen in nevoid basal cell carcinoma syndrome odontogenic keratocysts in the
jaws
(gorlin syndrome) which characterized by:-

– multiple KC,

– basal cell nevi of the skin

– and bifid ribs.

Figure 13: Nevoid basal call

3.2 Radiographically
carcinoma syndrome. An ul-
• Well defined RL with smooth corticated margin. cerating basal cell carcinoma is
present on the upper face.
• Large lesion in posterior body and ascending ramus of the
mandible may appear multilocular.

• An un erupted tooth is involved in the lesion in 25% to 40% of

cases.

Figure 14: Nevoid basal

cell carcinoma syndrome.
This 52-year-old man had more than 100

basal cell carcinomas removed from his face

over a 30-year period. Several basal cell

carcinomas are present in this photograph.

The lesion at the inner canthus of the left

eye was deeply invasive and was eventually

fatal as a result of brain invasion.

6 3 ODONTOGENIC KERATOCYST (OK) (OKC) (KERATOCYSTIC ODONTOGENIC TUMOR)

3.3 Differential diagnosis

• DC (radiographic findings are highly suggestive but not diag-

nostic)

• Large RC and residual C which are near impacted tooth.

• Lateral periodontal cyst or globulomaxillary cyst if the KC is

small and between teeth.

3.4 Histopathology
Figure 15: Nevoid basal cell
• Thin uniform lining of parakeratinized squamous epithelia carcinoma syndrome. Facial
deformity secondary to mul-
6-10 cells thickness.
tiple surgical procedures to
remove basal cell carcinomas.
• Palisaded layer of columnar or cuboidal basal cells.

• Corrugated layer of parakeratin.

• Lack of rete ridges, and focal separation of epithelium C.T.

wall.

• The C.T. wall is often loose and fibrillar and free of inflamma- Figure 16: Odontogenic kera-
tion. tocyst. Large, multilocular cyst
involving the ramus.
• Dental lamina rests and micro cysts (daughter or satellite) may
present in the capsule wall.

• The capsule wall is folded.

• The lumen contains desquamated parakeratin.

Figure 17: Odontogenic kera-

3.5 Treatment tocyst. This cyst involves the
crown of an un erupted pre-
• Complete removal by enucleation and curettage. molar. Radiographically, this
lesion cannot be differentiated
• Recurred 5–62% because of:- from a dentigerous cyst.

– the thin, friable nature of the cyst wall that result in fragments

– or due to formation of new cyst from dental lamina rest or

daughter cysts.

3.6 Prognosis

Good. (Exclude nevoid basal cell carcinoma syndrome).

Figure 18: Nevoid basal cell

carcinoma syndrome. Chest
film showing presence of bifid
ribs (arrows).
 3 ODONTOGENIC KERATOCYST (OK) (OKC) (KERATOCYSTIC ODONTOGENIC TUMOR) 7

Nevoid basal cell carcinoma syndrome.

Anteroposterior skull film showing Large cysts are present in the right and left mandibular molar re-
calcification of the falx cerebri. (Left) gions, together with a smaller cyst involving the right maxillary
canine. (Right)

Computed tomography (CT)
scan showing a large cyst in-
volving the crown of an un
erupted maxillary third mo-
lar. The cyst largely fills the
maxillary sinus. (Left)
Odontogenic keratocyst.
This cyst cannot be radiograph-
ically differentiated from a
lateral periodontal cyst. (Cen-
ter)
A, Large unilocular radiolucency
associated with right mandibu-
lar third molar. B, Six months
after insertion of a polyethylene
drainage tube to allow decom-
pression, the cyst has shrunk
and the third molar has migrated
downward and forward. (right)
8 3 ODONTOGENIC KERATOCYST (OK) (OKC) (KERATOCYSTIC ODONTOGENIC TUMOR)

Odontogenic keratocyst.
The epithelial lining is 6 to 8 cells thick, with a The characteristic microscopic features have been
hyperchromatic and palisaded basal cell layer. lost in the central area of this portion of the cystic
Note the corrugated parakeratotic surface. lining because of the heavy chronic inflammatory
cell infiltrate.

Nevoid basal cell carcinoma syndrome.

Odontogenic keratocyst showing numerous odontogenic epithelial rests in the cyst wall.
4 ORTHOKERATINIZED OC 9

4 Orthokeratinized OC

• Microscopically shows an orthokeratinized epithelial lining.

• Variant of OK.

• Represents 7% to 17% of all keratinizing jaw cyst.

Figure 19: Orthokeratinized
• Clinically and radio graphically like dentigerous cyst. odontogenic cyst. Small uniloc-
ular radiolucency associated
• Involve un erupted mandibular 3rd molar. with the impacted mandibular
left third molar.
• Show 2:1 male to female ratio

• Mandible more than the maxilla

• Appear as a unilocular RL but may appear as multilocular.

Figure 20: Orthokeratinized

4.1 Histopathology odontogenic cyst. A large
cyst involving a horizontally
• The cyst lining composed of stratified squamous epithelia, impacted lower third molar.
which shows an orthokeratotic surface of various thicknesses.

• The epithelial lining thin and the prominent palisaded basal

cell layers of OKC not present.

4.2 Treatment Figure 21: Orthokeratinized

odontogenic cyst. Microscopic
• Enucleation with curettage. features showing a thin epithe-
lial lining. The basal epithelial
• No recurrence but may be associated with greater risk of malig- layer does not demonstrate
nant transformationepithelial . palisading. Keratohyaline
granules are present, and a
thick layer of orthokeratin is
seen on the luminal surface.
10 5 LATERAL PERIODONTAL C.

5 Lateral periodontal C.

• Occur along the root surface of a tooth.

• Arise from rests of dental lamina. Figure 22: Lateral periodon-

tal cyst. Relative distribution of lateral
• Asymptomatic lesion.
periodontal cysts in the jaws.

• Occur in mandibular canine premolar region and between

maxillary lateral and canine.

5.1 Radiographically

• Well circumscribed RL laterally to the root(s) of vital tooth.

• Appears multilocular(poly cystic) and termed botryoid OC.

5.2 Differential diagnosis

• An odontogenic KC that develop between the roots of adjacent

teeth may show identical radiographic findings
Figure 23: Lateral periodontal
• An inflammatory RC that occurs laterally to a root in relation to cyst. Radiolucent lesion between the
roots of a vital mandibular canine and first
an accessory foramen
premolar.

• A cyst that arises from periodontal inflammation.

5.3 Histopathology

• Lining of non keratinized epithelia 1-2 cell layers thick with

foci of glycogen rich clear cells.

• Focal epithelial thickening (plaque) of clear cells.

• Clear cell epithelial rests sometimes are seen within the fibrous
wall.

5.4 Treatment
Figure 24: Lateral periodon-
• Enucleation. tal cyst. A larger lesion causing root
divergence.

• No recurrence.

Figure 25: Lateral periodontal

cyst. Gross specimen of a botryoid vari-
ant. Microscopically, this grapelike cluster

revealed three separate cavities.

5 LATERAL PERIODONTAL C. 11

Figure 26: Lateral periodontal

cyst.
A, This photomicrograph
shows a thin epithelial lining
with focal nodular thickenings.
B, These thickenings often
show a swirling appearance of
the cells.
12 7 GINGIVAL CYST OF NEWBORN (ALVEOLAR)

6 Gingival cyst of the adult

• Extra osseous form of lateral periodontal cyst.

• Mandibular canine and premolar area 60-75(facial gingival or

Figure 27: Gingival cyst of the
alveolar mucosa). adult. Low-power photomicro-
graph showing a thin walled
• The fifth and sixth decades of life. cyst in the gingival soft tissue.

• Small painless bluish gray swelling.

6.1 Histopathologic

• Resemble lateral periodontal cyst.

Figure 28: Gingival cyst of the

6.2 Treatment adult. Low-power photomicro-
graph showing a thin walled
• Enucleation.
cyst in the gingival soft tissue.

7 Gingival cyst of newborn (alveolar)

• Arises from remnants of the dental lamina.

• Small, superficial and keratin filled cysts that are found on the
Figure 29: Gingival cyst of the
alveolar mucosa of infants. newborn. Multiple whitish
papules on the alveolar ridge
• Small, multiple whitish papules on the mucosa overlying the of a newborn infant.
alveolar processes of neonates.

7.1 Histopathology

• Thin, flattened epithelia lining with parakeratin.

• The lumen contain keratinaceous debris.

Figure 30: Gingival cyst of the

adult. Tense and fluid filled
swelling on facial gingiva.
8 GLANDULAR ODONTOGENIC CYST 13

8 Glandular odontogenic cyst

• Aggressive behavior.

• Resemble polycystic variant of lateral periodontal Figure 31: Glandular odonto-

cyst . genic cyst. A, Expansile lesion
of the anterior mandible. B,
• Tendency to recur. The panoramic radiograph
shows a large multilocular
radiolucency.
8.1 Clinical feature

• Middle aged adult

• More in mandible (anterior region of the jaws).

• Small lesion less than 1cm to large destructive lesions that

involve most of the jaw

8.2 Radiographically
Figure 32: Glandular odonto-
Well defined unilocualr or multilocuallr RL. genic cyst. The cyst is lined by
stratified squamous epithelium
8.3 Histopathology that exhibits surface columnar
cells with cilia. Small micro-
• Lining by squamous epithelia of varying thickness. cysts and clusters of mucous
cells are present.
• The interface between the epithlia and the fibrous C.T. wall in
flat.

• The fibrous wall is usually devoid of any inflammatory cell

infiltrate.

• Glandular structures of microcysts within epithelia.

• Glandular structure lined by cuboidal cells.

• The lumen contain secretory products.

8.4 Treatment

• Enucleation and curettage.

• Recurrence present in a multilocualr fashion.

14 9 CALCIFYING OC (CALCIFYING CHOST CELL OC) GORLIN CYST

9 Calcifying OC (calcifying chost cell OC) Gorlin cyst

• Regards a cyst, some investigators prefer to classify it as a neo-

plasm.

• WHO classification of OT groups, consider the calcifying OC

Figure 33: Calcifying odonto-
with all its variants as an OT rather than an OC. genic cyst. Relative distribu-
tion of calcifying odontogenic
9.1 Clinical features cysts in the jaws.

• Intra osscous and 13-30% of cases reported as peripheral (extra

osseous) lesion.

• Maxilla.

• Mean age is 33 years.

Figure 34: Calcifying odonto-
• Associated with odontoma in younger patients. genic cyst. Relative distribu-
tion of calcifying odontogenic
cysts in the jaws.
9.2 Radiographically

• RL.

• Multilocualr RL.

• RO structures in one third to one half of cases.

9.3 Histopathology

• Epithelium lining with palisading of the basal cells which re-

semble ameloblasts and the overlying layer of loosely arranged Figure 35: Calcifying odonto-
genic cyst. Maxillary radiolu-
epithelium may resemble stellate reticulum.
cent lesion containing calcified
• Abnormal keratinization producing swollen cells whose outlines structures.

and nuclei become progressively polar (ghost cell).

• The nature of the ghost cell represent:

1. Coagulative necrosis or accumulation of enamel protein.

2. Normal or aberrant keratinization of oral epithelium. Figure 36: Calcifying odon-

togenic cyst. A, Expansion
of the posterior maxillary
alveolus caused by a large
calcifying odontogenic cyst.
B, Panoramic radiograph of
the same patient showing a
large radiolucency in the pos-
terior maxilla. A small calcified
structure is seen in the lower
portion of the cyst.
9 CALCIFYING OC (CALCIFYING CHOST CELL OC) GORLIN CYST 15

Calcifying odontogenic cyst. The cyst lining shows ameloblastoma

like epithelial cells, with a columnar basal layer. Eosinophilic ghost
cells present within epithelial lining.

Calcifying odontogenic cyst. Eosinophilic dentinoid material is

present adjacent to a sheet of ghost cells.