CYSTS OF THE JAWS AND

THE ORAL CAVITY

BY

Dr. Sahar Riad

 Cysts of the Jaws and Oral Soft

tissues
Definition:

A cyst is a Pathological cavity having fluid or

semi-fluid contents, which has not been

created by pus. Majority of these cysts are

lined wholly or in part by epithelium.

These cysts are divided into two main groups depending on the

suspected origin of the lining epithelium.

I-Odontogenic:

Ø The epithelial lining is derived from the epithelial residues of

the tooth forming organ.

Ø They can be subdivided into inflammatory and

developmental types depending on their etiology.

II-Non-Odontogenic cysts:

Ø They epithelial lining is derived from sources other than the

tooth-forming organ.
 Classification of cysts of the Jows

Epithelial cysts:

I. Odontogenic cysts:

A.Inflammatory:

1. Radicular( Apical )cyst.

2. Lateral

3. Residual

4. Paradental cyst.
B. Developmental:
1. Dentigerous (Follicular cyst)

2. Eruption cyst.

3. Odontogenic keratocyst.

4. Gingival cyst

5. Lateral Periodontal cyst.

6. Glandular odontogenic cyst.

7. Calcifying odontogenic cyst. (Gorlin)

II. Non odontogenic cysts
1. Noso palatine duct (incisive canal) cyst.
2. Naso labial (Naso alveolar) cyst
3. Globulomaxillary cyst.
4. Median cysts.
III. Non-epithelialized primary bone cyst:
1. Solitary bone cyst (Simple, traumatic, haemorrhagic
bone cyst).
2. Aneurysmal bone cyst.
3. Stafne’s idiopathic bone cavity.
IV. Soft tissue cysts:

1. Branchial (Lymphoepithelial cyst).

2. Dermoid cyst.

3. Thyroglossal duct cyst.

4. Salivary gland cysts.

Definition:
The epithelial lining of these cysts originates from
residues of the tooth-forming organ
1.The Epithelial Rests of Serres:
Persisting after dissolution of the dental lamina,they give
rise to;
ØOdontogenic Keratocyst.
ØDevelopmental lateral periodontal cyst
Ø gingival cyst.
2-The Reduced Enamel Epithelium:
Which is derived from the enamel organ and covers the

fully-formed crown of the unerupted tooth gives rise to :

Ø The dentigerous cyst.

Ø Eruption cyst.

Ø Inflammatory Paradental cyst.

3-The Rests of Malassez:

Formed by fragmentation of the epithelial root sheath of

Hertwig. All radicular cysts originate from these residus.

A-Inflammatory Odontogenic cysts
1-Radicular Apical Cysts :
Apical radicular cysts are the most common cystic lesions in
the jaws apices and are usually associated with the non-vital
teeth.
Clinical and radiographic features:
usually small.
Symptomless discovered during routine radiographic
examination.
As they enlarge may cause expansion of Alveolar bone.
Pain is seldom a feature unless there is acute exacerbation.
Any age usually rare in decidous teeth.
May be related to any tooth in the arch 60% in maxillary
anterior teeth. In mandible cysts are usually posterior to the
canine.
Clinical picture
Radiographically:
Radicular cyst present as a round or ovoid

radiolucency at the root apex.

The lesion is often well circumscribed and may

be surrounded by a peripheral radiopoque

margin continuous with the lamina dura of the

involved tooth.
Apical Cyst
This photograph displays a good
example of the apical cyst, a cavity
filled with necrotic debris and lined
by epithelium. There is a well-
demarcated sclerotic border
surrounding a radiolucency
extending from the root tip.
Although one may be suspicious
that the lesion represents an apical
cyst, there is no way to precisely
diagnose the radiolucency on the
basis of radiographs alone since
chronic apical periodontitis may
feature the exact same features.
Apical Cyst
This and the following group of
images will illustrate variations in
radiographic features of apical
cysts. All cases represent biopsy-
proven examples, the only method
by which a definitive diagnosis
can be made. This image shows a
central incisor, with root canal
therapy, featuring a small
radiolucency at the apex.
Apical Cyst

Apical cysts can become

large and quite destructive.

Apical Cyst
Other apical cysts

remain small and

limited.
Multiple Apical Cysts
This patient presented with multiple apical cysts, some of which were
quite large. There were at least four in the mandible and a number of
smaller ones in the maxilla.
Apical Cyst
This gross specimen shows the typical attachment of two sac-like
structures to the apices of a molar tooth. Sometimes these cysts come
out when the tooth is extracted while in other instances the lesion may
remain in the bony crypt to become a residual cyst.
Pathogenesis:
Epithelial proliferation:

Infection from the pulp chamber induces

inflammation and proliferation of the epithelial rests

of malassez. The mechanism of formation of an

epithelial-lined cyst cavity within a granuloma is

unclear
Two mechanisms have been proposed:
1. Degeneration and death of central cells within
a prolifrating mass of epithelium, since the
epithelium is avascular.

2. Degeneration a liquefactive necrosis of

granulation tissue, due to enclavement by
proliferating strands of epithelium or due to
release of toxic products from the infected
pulp or from organisms.
Cyst expansion and bone resorption:
Radicular and many other cysts expand in a

balloon like fashion, it expands in all

directions.

This is governed by the rate of local bone

resorption.
Cyst expansion:
ØBecause of large number of osmotically-active
molecules in cyst fluid, the contents are hypertonic
compared with serum. Cyst wall acts as a
Semipermeable membrane , as a result osmotically –
active molecules are retained in Cyst lumen.
ØThis result in the movement of fluid from the tissues into
the lumen, increasing the hydrostatic pressure within the
cyst causing it to expand in a uncentric ballooning
pattern.
Histopathology:
Radicular cysts are lined wholly or in part by non-Keratinized

stratified squamous epithelium, supported by a fibrous tissue

capsule.

In newly formed cysts, the epithelial lining is irregular and may vary

in thickness i.e. hyperplastic. The fibrous capsule is richly vascular

and diffusely infiltrated by inflammatory cells.

In established cysts the epithelial lining is more regular in

appearance and of fairly uniform thickness and the capsule tends to

become more fibrous and less vascular with less inflammatory cells.

Breaks in the lining is common.

Cyst contents:
Ø Varies from watery, straw colored fluid to semi-solid
brownish material of paste-like consistency.
1. Break down products of degenerating epithelial and
inflammatory cells, and connective tissue components.
2. Serum proteins: produced by plasma cells due to
inflammation. (immunoglobulin).
3. Water and electrolytes.
4. Cholesterol crystals.
 2. Residual Radicular cyst:
It is a radicular cyst which persists after
extraction of the causative tooth.
They are a common cause of swelling of
endontulous jaw in older age.
May interfere with the fit of dentures.
The liming is of thinner epithelium and shows
mild degree of inflammation.
Residual Apical Cyst
This illustrates the typical example of a residual
cyst remaining following extraction of a non-vital
tooth. It is a well-demarcated lesion with a
sclerotic border indicative of slow growth.
Residual Apical Cyst
Residual apical cysts are often small.
It is important to know if a tooth had
been extracted. If not, the
possibilities of lateral periodontal
cyst, primordial cyst, odontogenic
keratocyst and odontogenic tumors
of various types would be likely
considerations in the differential
diagnosis before biopsy.
Residual Apical Cyst
On first glance, this might appear to be an apical cyst associated
with the bicuspid. But the bicuspid is vital, and during surgical
exploration the cyst was found not to be associated with the
bicuspid apex. It represents a residual cyst from a non-vital tooth
extracted years previously.
Residual Apical Cyst
Although biopsy revealed residual
cyst, the radiographic pattern is
atypical and unusual for this
disease. The two ovoid
radiolucencies above a cluster of
small lucencies is a pattern more
suggestive of odontogenic
keratocyst or of ameloblastoma.
 3-Lateral inflammatory periodontal cyst:

Forms on the side of a nonvital tooth as a result

of the opening of a lateral branch of the root

canal. Must be distinguished from the lateral

developmental periodontal cyst.

Treatment of inflammatory cysts:
1.Enucleation
Is usually very effective.
The affected (dead) tooth may be extracted or
root filled and preserved.
2.Marsupialisation:
Is for exceptionally large cysts where fracture is
a risk.
4-Paradental cyst:
Paradental cysts occasionally result from
inflammation round partially erupted teeth,
particularly mandibular 3rd molars.
Usually between the ages of 20-25 years.
The affected tooth is vital, but shows pericoronitis.
Histologically the cyst shows the same linning of a
radicular cysts but more intense inflammatory
infiltrate is seen in the wall.
Treatment: Enucleation is effective.
N.B. The tooth is vital.
Describe the Pathological condition this X-
ray picture.
Mention 3 possible differential diagnoses.
Give one differential diagnoses for this
pathological condition.
B. Developmental odontogenic cyst.

1.Dentigerous cyst

The dentigerous cyst surrounds the crown of an

uerupted tooth and is a dilatation of the follicle.

The cyst is attached to the neck of the tooth, prevents

its eruption and may displace it for a considerable

distance.
Gross Appearance
This gross specimen illustrates the typical relationship of the
dentigerous cyst as it surrounds the crown of a molar.
Clinical features:
Age: over a wide range, although many are detected in
adolescents and young adults, there is increase prevalence
up to the fifth decade. Uncommon in children.
Sex: More than twice as common in males as females.
Symptoms: Like other cysts, uncomplicated dentigerous
cysts cause no symptoms until the swelling becames
noticeable.
Usually found in routine-radiographic examination or when
looking for the cause of a missing tooth.
No pain, unless there is inflammation.
Site: the mandibular third molar and then
maxillary permenant canines, maxillary third
molars and mandibular premdars.

i.e. It is associated with teeth which are

commonly impacted or erupt late.
• They may also be associated with
supernumerary teeth.
X-Ray picture
The cavity is well circumscribed, rounded usually

unilocular and contains the crown of a tooth, displaced

from its normal position.

Occasionally there may pseudoloculation as a result of

trabeculation of the bony wall.

The slow growth of dentigerous cyst usually result in a

sclerotic bony outline and a well-defined cortex.

Dentigerous Cyst
This radiograph features
the typical example of a
dentigerous cyst. The
well-defined radiolucency
symmetrically surrounds
the crown of the
unerupted molar. Cysts of
this size are generally
asymptomatic and are
discovered on routine
radiographic examination
Dentigerous Cyst
This somewhat larger dentigerous cyst displays a sclerotic border
indicative of slow growth. Although suspicious for a cyst, the
radiolucency could also represent an odontogenic tumor. Biopsy is
required for precise evaluation.
Dentigerous Cyst
This is a somewhat larger dentigerous cyst extending mesially from
the incompletely developed molar. This one is slightly unusual in that
it involves the roots as well as the crown.
Dentigerous Cyst
At first glance, this radiolucency appears to be associated more
closely with the apices of the first and second molars rather than
with the crown of the horizontally impacted third molar.
Dentigerous Cyst
It is unusual for a dentigerous cyst not to encompass the crown of the
tooth. Notice the root resorption on the second molar. Certainly, pulp
vitality tests are indicated and biopsy is necessary to rule out the
possibility of tumor.
Dentigerous Cyst
As shown here, dentigerous cysts may become large. The
obvious root resorption is of no diagnostic significance.
Dentigerous Cyst
Dentigerous cysts also occur in
association with teeth other than third
molars. A patient presenting with retained
deciduous teeth should always be
thoroughly examined for markedly
displaced permanent teeth, possibly
associated with cysts. Here is a fairly
small dentigerous cyst associated with a
maxillary cuspid.
Dentigerous Cyst
This large dentigerous cyst apparently originated from the first
bicuspid. It extends from the incisor area to the first molar region.
One could speculate that the lesion was an apical cyst of the
deciduous teeth but apical cysts are rarely so aggressive. Also, the
location of the first bicuspid would indicate that it is the probable site
of origin.
Dentigerous Cyst
This large dentigerous cyst associated with the unerupted
bicuspid has involved the maxillary sinus.
Dentigerous Cyst
Occasionally, supernumerary teeth
are associated with dentigerous
cysts. This is a mesiodens of the
maxilla
Dentigerous Cyst
An impacted third molar and an apparent fourth molar are
associated with this cyst.
Dentigerous Cyst
Here you can see how a molar tooth may be forced down to involve or even
displace the mandibular canal. Treatment in this case would be quite
delicate. You might expect the patient to experience paresthesia of the lip, if
not prior to surgery, possibly after it.aa
Dentigerous Cyst
This frame illustrates why impacted teeth should be removed before bridges are
placed over "edentulous" areas. When the bridge was made no cyst was present;
however, follow-up two years later reveals a moderate sized cystic structure.
Pathogenesis:
The dentigerous cysts arise as a result of cystic change

in the remains of the enamel organ after enamel

formation is complete.

The mechanism of expansion of the cyst is propably

similar to that of the radicular cysts, and is dependent

on bone resorption and hydrostatic pressure.

Histopathology of dentigerous cyst:
The lining of dentigerous cyst is typically a thin, regular

layer, of non-keratinized stratified squamous epithelium

(some times flattened or low cuboidal).

Mucous cells are present due to metaplasia.

Multiple discontinuities are observed.

The lining is supported by a fibrous connective tissue

capsule free from inflammatory cell infiltration, unless there

has been secondary infection.

Islands of odontogenic epithelium may be seen.

Macroscopic features
1.Central type:
Most common type, the cysts completely surrounds the
crown of the tooth.
2.Lateral type:
The cyst projects laterally from the side of the tooth.
3.Circumferential type
Cystic change occurs in a band around the
circumference of the amelocemental junction producing
a dough-nut-shaped lesion.
Management and treatment:
If the tooth is in favourable position and space
is available, it may occasionally be possible to
marsupilaise a dentigerous cyst to allow the
tooth to erupt.

Extraction of the associated tooth and careful

enucleation of the soft tissue component is
definitive therapy in most instances.
Complications of the untreated dentigerous cyst:

Transformation of the epithelial lining of the dentigerous

cyst into an ameloblastma is a familiar occurrence.

Rarely, dysplastic or carcinomatous transformation of the

lining epithelium.

Finally, in cases, in which mucous cells are present,

development of intraosseous mucoepidermoid

carcinoma.
Differential diagnosis:
Of a pericoronal radiolucency, In addition to dentigerous

cyst:

1. Unicystic ameloblastoma.

2. An odontogenic keratocyst in relation to a tooth.

3. Ameloblastic fibroma (in post-mandibular region or in

maxilla in young age).

4. AOT.
 2. Eruption cyst:

1. An eruption cyst occasionally forms over a tooth

about to erupt.

2. It is a soft tissue cyst.

3. It arises from enamel organ epithelium after enamel

formation is complete.

4. It is a superficial dentigerous cyst.

Clinical picture

Age: Children are usually affected.

Site: The cyst lies superficially in the gingival

overlying the unerupted tooth.

It appears as a soft, rounded, bluish swelling.

Histology:
The lining of the eruption cyst may be similar
to the dentigerous cyst, the fibrous capsule
shows inflammatory cells possibly as a result
of trauma.
The epithelial lining is separated from the
alveolar mucosa by a thin layer of fibrous
tissue.
Cyst contents:

May contain blood in addition to the yellowish

protein fluid, as a result of trauma.

Management:
The cyst roof may be removed to allows the

tooth to erupt, most of them burst

spontaneously.
 3-Odontogenic keratocyst
The odontogenic keratocyst is a relatively

uncommon lesion which has aroused much

interest because of its unusual growth pattern

and tendency to recur.

It arises from remnants of the dental lamina.

 Clinical features:.
Age: 2nd and 3rd decades and sometimes in 5th decade.
Sex: Males are more affected.
Site: 70% to 80% in mandible.
Posterior mandibular region (50%) of all cases.
In maxilla if affected usually posterior to first premolar.
Symptoms: No or few symptoms, unless inflamed.

Expand in an anteroposterior direction, and can reach

large size without expansion.

X-Ray Picture:
Ø Well-defined radiolucencies, with smooth margins and

thin radio-opaque margins.

Ø It may be unilocular or multilocular.

Ø Many present in apparent dentigerious relation-ship

associated with unerupted third molars, but the

crowns are usually separated from the cyst.

Ø The roots of adjacent teeth may become displaced.

Keratocyst
Odontogenic keratocysts can be, and often are, quite large. Resorbing
the lower border of the mandible and tooth roots.
Histopathology
Ø Cyst wall usually thin, folded and lined by a regular

continuous layer of keratinized stratified squamous

epithelium, 5-10 layers.

Ø The basal layer is well defined and consists of

palisaded columnar or occasionally cuboidal cells.

Ø The suprabasal cells resemble those of the stratum

spinosum of the oral epithelium.

Ø Parakeratosis predominantes, but areas of

orthokeratinization are seen.

Ø Mitotic activity is higher than in other cysts.

Ø The fibrous C.T. capsule usually thin and generally free

from inflammatory cell infiltration.

Ø Small groups of epithelial cells are resembling dental

lamina rests are found in the capsule.( satellites)

Cyst content
Keratocyst contain thick, grey, white cheesy material
consisting of keratinous debris.
N.B

Ø Retention of these satellite cysts after enucleation of

the main cyst is one of the factors responsible for the

high recurrence rate.

Ø Odontogenic keratocyst must not be used to describe

any odontogenic cyst producing keratin.

Pathogenesis and expansion

ØDerived from remnants of dental lamina,

stimulus of cystic transformation is unknown.

ØAlthough hydrostatic forces are involved in

expansion, other possible factors are also

responsible.
1-Hydrostatic forces: due to hypertonic contents of the

cyst as in radicular cyst.

2-Active epithelial growth:

Epithelial lining exhibit greater mitotic activity.

(Proliferation of local groups may account for the

folding in the cyst lining and projections of the cyst in

the cancellous spaces).

3-Production of bone resorbing factors:

The odontogenic keratocyst releases bone resorbing

factors including.

ØProstaglandins,

ØCollagenase

ØInterleukin-1 and 6.
They are less than in radicular cysts, and so they extend

through the less dense cancellous bone.

4-Accumilation of Mural squames.

Management:
1. Diagnosis should be confirmed before

operation.

2. Treatment should be complete enucleation.

(recurrence rate up to 60%).

3. Carnoy’s fluid improves the result).

4. Resectioen provides the lowest recurrence.

 THE BASAL CELL NEAVUS SYNDROME [GORLIN-
COLTZ SYNDROME]
(Inherited as an autosomal dominant trait.)
ØMultiple odontogenic keratocyst.
ØMultiple naevoid basal cell carcinomas of the skin.
ØSkeletal abnormalities (Bifid ribs).
ØMandibular prognathism and facial dysmorphogenesis
may be seen as broad nasal bridge.
ØCalcification in cerebral meninges. [Flax cerebri] .due
to abnormalities of calcium and phosphate
metabolism.
 4-Lateral periodontal cyst
It is an uncommon lesion that must be distinguished from lateral
radicular cyst associated with a non vital tooth, and from an
odontogenic keratocyst arising along the root of a tooth.

Clinically:
§ In canine, premolar region.
§ In mandible more than maxilla
§ Middle age patients.
§ May cause expansion.
§ Cause no symptoms unless they erode through the bone and
extend in the gingiva. (may appear as a gingival cyst).
X-ray
- Not diagnositc.

- Discovered on routine x-ray.

- A well-defined radiolucent

area with sclerotic margin,

located laterally to the roots

of vital teeth.
Lateral Periodontal Cyst
This is another good example
of a lateral periodontal cyst
that often has a teardrop
appearance.
Histology

1. Lined by non-keratinized squamous or cuboidal

epithelium resembling reduced enamel

epithelium, with no inflammation

2. Focal plaque-like thickenings may be seen.

3. Clear cells and epithelial rests are some times

seen in the capsule.

Pathogenesis:
Ø It is uncertain.

Ø It was suggested that it could arise initially as a lateral

dentigerous cyst which is retained in the bone when

the tooth erupts.

Treatment
Ø Conservative enucleation.

Ø The cyst should be enucleated and the related tooth

can be retained if healthy.

 [Botryoid odontogenic cyst]
§ A variant and even more rare than the lateral periodontal

cyst.

§ It affects the mandibular premolar to canine region.

§ Adults over 50 years.

Microscopically:
§ It is typically multilocular with fine septa of fibrous tissue.

§ Lining consists of flattened non=Keratinised epithelium.

Treatments

It should be enucleated or conservatively

excised as it has strong tendency to recur.

Botryoid, because of their resemblance to a

bunch of grapes.
 5. Gingival cysts
These cysts are of little significance

They are due to proliferation of epithelial rest of

serres.

Gingival cyst of Newborn (alveolar cyst):

They are common in neonates, referred to as

“Bonhn’s Nodules” or “Epstein’s pearsl”.

Fairly common lesions.
Found on the maxillary alveolus, midline of the

palate and on the hard and soft palate.

Small usually multiple whitish papules.
Lining is formed of thin flattened epithelial lining of
parakeratotic surface.
Most resolve spontaneously by 3 months of age.
Epstein Pearl
Similar lesions occurring on the edentulous gingiva of infants are termed Epstein's
pearls. These are common lesions but generally undergo spontaneous involution.
Remnants of dental lamina epithelium are apparently the basis for these cysts.
 Gingival cyst of adult
ØVery rare
ØSoft tissue counterpart of the lateral periodontal
cyst.
ØAfter age of 40
§Occur in the mandibular canine premolar area.
§Located on the facial gingiva of the alveolar mucosa.
§Often bluish or bluish grey n color.
§May cause cupping-out of the alveolar bone.
ØForms a painless dome like swelling less than 1 cm
in diameter.
ØLined by thin, flat stratified squamous epithelium
with focal plaques and clear cells.
ØExcision, unlikely recur.
Gingival Cyst
This is a good illustration of a small slightly bluish gingival cyst on the mandibular
gingiva between the lateral incisor and cuspid. Gingival cysts differ from lateral
periodontal cysts only by the fact that no significant radiographic findings are
present in association with the gingival variety.
Gingival Cyst
This is a somewhat larger gingival cyst located in an area
typical for this lesion. The lesions are generally asymptomatic.
 6-Glandular Odontogenic cyst
ØIs very rare.

ØSlowly growing painless, unilocular or multilocular

radiolucency.

Histologically:
ØThe cyst is lined by epithelium of varying thickness,

superficial layer of columnar or cuboidal cells.

ØOccasional mucous cells and pools of mucin.

ØCrypts or small cyst-like spaces are present with

the thickness of epithelium.

ØThe lining has a glandular structure.

ØThis cyst has a potentially aggressive, locally

invasive nature and tendency to reccur.

ØShould be conservatively excised.

 7. Calcifying odontogenic cyst

Gorlin

It is a rare type of cyst, usually grouped

with the odontogenic tumours.

Clinically:

Age: Usually below the age of 40.

Site: 75% of the cases are intra-osseous.

ØAnterior to the first molar tooth.

ØBoth jaws are affected.

Symptoms: Slowly growing but symptomless.

X-Ray Picture

Appears as a well-defined unilocular or

multilocular radiolucent area, containing varying

amounts of radioopaque calcified material.

May be associated with the crown of an

unerupted tooth.
Calcifying Odontogenic Cyst
You can easily see the calcification in this larger, more destructive example of
the calcifying odontogenic cyst. Radiographic findings are neither consistent nor
diagnostic. This radiograph would also suggest fibro-osseous disease,
osteomyelitis and certain odontogenic tumors.
Histologically
ØThe cyst is lined by squamous epithelium with cuboidal
or ameloblast-like basal cells.
ØThe overlying layers are more loosely arranged cells
resemble stellate reticulum.
ØThe diagnostic feature is (ghost cells). [Swollen,
eospinophilic cells , keratinized epithelial cells.]
ØThey may later calcify.
ØBreakdown of the epithelium may release keratinous
debries in the C.T. resulting in foreign body gaint-cell
reaction.
Treatment
Behaviour is similar to that of non-neoplastic cyst,
and enucleation is effective.