LEC.

21 Dental radiology
Cysts of the jaws
Cysts are pathologic cavities in bone, and true cysts display a thin epithelial cell
lining derived from either odontogenic or nonodontogenic
1‐Odontogenic sources include the dental lamina, the reduced enamel
epithelium, and the epithelial rests of Malassez, or remnants of Hertwig
epithelial root sheath
2‐nonodontogenic sources may include respiratory epithelium or remnant
epithelial rests within areas of tissue fusion.
‐A thin connective tissue layer separates the base of the epithelium from the
adjacent bone.
‐Pseudocysts are a group of cysts that may not be lined by epithelium or they
may not be cavities in the bone at all. Rather, pseudocysts may have some but
not all of the radiologic features of a true cyst.
Odontogenic cysts are classified into two types:
1‐Inflammatory: include:‐
‐Periapical (radicular) cyst
‐Residual periapical (radicular) cyst
‐Buccal bifurcation cyst
2‐Developmental: include:‐
‐Dentigerous cyst
‐Eruption cyst
‐Odontogenic keratocyst
‐Orthokeratinized odontogenic cyst
‐Globulomaxillary cysts
‐Gingival (alveolar) cyst of the newborn
‐Gingival cyst of the adult
‐Lateral periodontal cyst
‐Calcifying odontogenic cyst
‐Glandular odontogenic cyst
1‐Odontogenic Cysts
1‐Radicular Cyst
‐The radiologic features of an abscess, granuloma, or cyst that arises in the
radicular or periradicular areas cannot be used to differentiate one of these
lesions from any of the others
‐rarefying osteitis is used in oral and maxillofacial radiology to describe a
localized inflammatory condition arising within the jaws.
‐biopsy is needed to identify the lesion as a radicular cyst.
‐the epithelial lining is derived from the epithelial cell rests of Malassez
‐Associated with nonvital pulp.
‐is an inflammatory type of odontogenic cysts
 Radiographic features
In most cases the epicenter of a radicular cyst is located approximately at the apex of a nonvital
tooth. Occasionally it appears on the mesial or distal surface of a tooth root, at the opening of an
accessory canal, or infrequently in a deep periodontal pocket. Most radicular cysts (60%) are found
in the maxilla, especially around incisors and canines. Because of the distal inclination of the root,
cysts that arise from the maxillary lateral incisor invaginate the antrum. Radicular cysts may also
form in relation to a nonvital deciduous molar and be positioned buccal to the developing bicuspid.
The periphery usually has a well‐defined cortical border. In most cases the internal structure of
radicular cysts is radiolucent. Occasionally, dystrophic calcification may develop in long‐standing
cysts, appearing as distributed, small particulate radiopacities.
2‐Residual Cyst
Disease Mechanism
A residual cyst is a cyst that develops after incomplete removal of epithelium associated with a previous cyst.
Clinical Features
A residual cyst is usually asymptomatic and is often identified in a radiologic examination of an edentulous area.
‐is an inflammatory type of odontogenic cysts

Imaging Features
Location.
Residual cysts can occur in both jaws, although they are found slightly more often in the mandible than the maxilla.
The epicenter of a residual cyst is located in the former periapical region of the involved and/or missing tooth and in
the mandible; it is always superior to the inferior alveolar canal . A residual cyst has a well‐defined and corticated
border unless it has become secondarily infected.
‐The internal aspect of a residual cyst typically is radiolucent, although dystrophic calcifications may be present in
long‐standing cysts.
‐Residual cysts can displace teeth or resorb tooth roots.
Differential Interpretation
‐OKCs. A residual cyst has,however, greater potential for expansion of bone than
an OKC.
‐The Stafne defect is located more inferiorly in the mandible, away from the
tooth‐bearing areas of the jaws, and the cortex of the Stafne defect is usually
very thick.
Management
The treatment of residual cysts is surgical removal, marsupialization, or both if
the cyst is large.
3‐Buccal Bifurcation Cyst
Disease Mechanism
‐is probably derived from the epithelial cell rests of Malassez in bifurcation of
multirooted teeth.
‐The etiology of the BBC is not certainly known, although thought that breaking oral
mucosa during eruption causes inflammation that leads to cystic formation.
Clinical Features
‐ Commonly associated with mandibular molars; they can also arise in association
with maxillary molar teeth.
‐ ‐On clinical examination, the molar may be unerupted or the tooth may be partially
erupted with its lingual cusp tips abnormally protruding through the mucosa, higher
than the position of the buccal cusps.
‐A hard swelling may be palpable buccal to the involved molar
‐The age of detection is younger, within the first two decades of life .
Imaging Features
The epicenter of the cyst is always in the buccal furcation of the affected molar.
Differential Interpretation
The major differential interpretations of the BBC include rarefying osteitis and
dentigerous cyst.
Management
A BBC is managed by conservative curettage, although some cases have
resolved without intervention. The involved molar need not be removed, and
BBCs do not recur.
2‐ Developmental odontogenic cysts
1‐Dentigerous Cyst
Disease Mechanism
‐The dentigerous or follicular cyst develops from the proliferation of the reduced enamel epithelium.
Consequently the cyst is associated with the crown of an unerupted tooth or supernumerary tooth.
‐The eruption cyst is the soft tissue counterpart of a dentigerous cyst.
‐is a developmental type of odontogenic cysts

Clinical Features
Dentigerous cysts are the second most common type of cyst in the jaws. Clinical examination may
reveal a missing tooth or teeth and possibly a hard swelling that can manifest as facial asymmetry.
Imaging Features
Location.
‐The epicenter of a dentigerous cyst is located coronal to the crown of the involved tooth, most
commonly a third molar or a maxillary canine .
‐An important diagnostic point is that the cyst's periphery engages the tooth at its cementoenamel
junction.
‐Periphery.
Dentigerous cysts have a well‐defined and corticated periphery
Differential Interpretation
a hyperplastic follicle
odontogenic keratocyst (OKC),
an ameloblastic fibroma,
and a unicystic or cystic ameloblastoma.
‐An OKC does not expand the bone to the same degree as a dentigerous cyst, is
less likely to resorb teeth, and may attach further apically on the root or
coronally on the crown instead of at the cementoenamel junction.

Management
Dentigerous cysts are treated by surgical removal, which usually includes the
tooth as well. Large cysts may be treated by marsupialization before removal.
2‐Odontogenic Keratocyst
Disease Mechanism
The epithelial lining of OKCs is derived from the dental lamina .
Clinical Features
OKCs can develop in association with an unerupted tooth or as solitary entities in bone. OKCs usually cause no
symptoms, although mild swelling may occur. Pain may occur with secondary infection. Aspiration of the cavity
may reveal a thick, yellow, cheesy material (keratin). In contrast to other odontogenic cysts, OKCs have a great
propensity for recurrence, possibly because of small satellite cysts or fragments of epithelium left behind after
surgical removal.
‐is a developmental type of odontogenic cysts
Imaging Features
Location
OKCs most commonly arise in the posterior body of the mandible (90% occur distal to the canine teeth) and
mandibular ramus (>50%). The epicenter is located superior to the inferior alveolar canal. Occasionally OKCs
may develop in association with the crown of an unerupted or impacted tooth and may be difficult to
distinguish from dentigerous cysts.
Periphery.
OKCs have a well‐defined and corticated periphery. The periphery is smooth, but its border may scallop a thick
bone cortex
Differential Interpretation
‐ dentigerous cyst.
‐ ameloblastoma, but the latter has a greater propensity to expand bone.
‐ large lateral periodontal cysts, especially in the maxilla.
‐odontogenic myxoma .
‐ A simple bone cyst (SBC)
‐ Management
Surgical treatment may vary and can include resection, curettage, or
marsupialization
3‐Lateral Periodontal Cyst
Disease Mechanism
The lateral periodontal cyst is thought to arise from remnants of the epithelial cell rests of Malassez in the periodontal
ligament space adjacent to the surface of the tooth root.
‐This lesion is usually is unicystic
‐is a developmental type of odontogenic cysts

Clinical Features
The lateral periodontal cyst is often
small and usually asymptomatic .
Imaging Features
Location
The lateral periodontal cyst usually develops in the incisor and premolar areas
of the mandible. In the maxilla, it usually develops in the lateral incisor and the
canine area.
Periphery
A lateral periodontal cyst has a well‐defined and corticated border. Although it is
most often round to oval in shape.
Differential Interpretation
a small OKC, neurofibroma, ameloblastoma, and a focus of rarefying osteitis
located at the foramen of a lateral (accessory) root .
Management
Excisional biopsy or simple enucleation .
4‐Calcifying Odontogenic Cyst
Disease Mechanism
The COC is known by a number of other names, including calcifying epithelial odontogenic
cyst, dentinogenic ghost cell tumor, and Gorlin cyst. COCs are uncommon, slow‐growing,
benign lesions. They have a spectrum of appearances with the characteristics of a cyst and in
some instances a solid neoplasm. These cells within this lesion can produce a calcified matrix
identified as dysplastic dentin; in some instances, the lesion is associated with an odontoma.
‐is a developmental type of odontogenic cysts
Clinical Features
The COC has a wide age distribution. Clinically the lesion usually presents as a slow‐growing,
painless swelling in the jaw. Occasionally the patient may complain of pain. Aspiration often
yields a viscous granular yellow fluid.
Imaging Features
Location.
Most COCs occur centrally in bone, with a nearly equal distribution between the jaws. Most
(75%) occur mesial to the first molar, especially in the incisor and canine areas.
The lesion may be completely radiolucent or may show evidence of small foci of calcified
material that appear as white flecks or small smooth pebbles. In rare cases the lesion may
appear multilocular.
Management
The COC is treated with enucleation and curettage.
5-Globulomaxillary Cyst
Currently, the globulomaxillary cyst is considered to be odontogenic in origin. These
cysts occur in the globulomaxillary region and are usually detected during routine
radiographic examination. They can cause expansion of the cortical plate. There can
also be divergence of the roots of lateral incisor and canine.
‐is a developmental type of odontogenic cysts
Radiographically: it appears as a pear-shaped or tear-shaped radiolucency between
the roots of the lateral incisor and the canine. The narrow end of the cyst is directed
downward to the alveolar crest.
differential diagnosis
lateral fossa, dentigerous cyst and
adenomatoid odontogenic tumor .
2‐Nonodontogenic Cysts: include:‐
Nasopalatine cyst
Simple (Solitary) bone cyst
Aneurysmal cyst
1‐Nasopalatine Cyst
Disease Mechanism
The nasopalatine (duct) or incisive canal usually contains remnants of the
nasopalatine duct.
Clinical Features
Nasopalatine cysts account for about 10% of jaw cysts. The age distribution is broad,
with most cases being discovered in the fourth through sixth decades, and the
incidence is three times higher in males than in females.
Most cysts are asymptomatic; however, as they increase in size, the most frequent
chief complaint is a swelling just posterior to the palatine papilla.
Imaging Features
Location.
Most nasopalatine cysts are centered in the midline in the nasopalatine foramen or canal.
Periphery.
The nasopalataine cyst has a well‐defined and corticated periphery, and it is round or oval in shape .Sometimes
the image of the anterior nasal spine may be superimposed over the cyst, giving it a heart shape.

Internal structure.
Most nasopalatine duct cysts are radiolucent. Rarely, nasopalatine
cysts may develop internal dystrophic calcifications; these may appear
as ill‐defined, amorphous, scattered radiopacities.
Management
The management of a nasopalatine cyst is enucleation
1‐Simple Bone Cyst
Disease Mechanism
The SBC is not a true cyst because it lacks an epithelial lining. Rather, the SBC
is lined with connective tissue, and it may be empty or contain a small
amount of blood or serous fluid. The etiology of the SBC is not known;
therefore it has been referred to by many different names, including
hemorrhagic bone cyst, idiopathic bone cyst/cavity, traumatic bone cyst and
solitary bone cyst/cavity.
Clinical Features
Solitary SBCs are very common, with most occurring in the first 2 decades of
life; the mean age is approximately 18 years. SBCs are asymptomatic in most
cases, but occasionally pain or tenderness may be present. Expansion of the
mandible is also possible; however, tooth movement is unusual. If teeth are
involved, the pulps of these teeth remain vital.
Imaging Features
Location.
Almost all SBCs are found in the mandible; they rarely develop in the maxilla.
Periphery.
SBCs have well‐defined, delicately corticated borders.
Management
The management of SBCs may be observation with follow‐up imaging or a conservative entry into the lesion to
elicit bleeding and subsequent healing by secondary intention. Spontaneous healing has also been reported for
SBCs.
3‐Cysts Originating in Soft Tissues
1‐Nasolabial Cyst
Disease Mechanism
The origin of the nasolabial or nasoalveolar cyst is not known. The epithelial component of
these cysts may arise from remnant epithelial rests. Alternatively, the source of the
epithelium may be the embryonic nasolacrimal duct.
Clinical Features
The mean age is 44 years, and approximately 75% of these lesions occur in females.
Imaging Features
Location.
Nasolabial cysts are primarily soft tissue lesions located adjacent to the alveolar process
above the roots of the incisor teeth. Because this is a soft tissue lesion and plain radiographs
may not show any detectable changes, the investigation could include either MDCT or MRI .
Management.
The nasolabial cyst should be excised through an intraoral approach. These
cysts do not tend to recur.
2‐Thyroglossal Duct Cyst
Disease Mechanism
The thyroglossal duct cyst develops from epithelial remnants of the embryonic thyroglossal
duct. This cyst is the most common congenital cyst.
Clinical Features
The cyst manifests as a slow‐growing, painless mass, unless it is secondarily infected; it is
found in the midline of the neck and most are detected in the first and second decades of life.
Imaging Features
Many of thyroglossal duct cysts have a close proximal relationship with the hyoid bone. The
periphery of the cyst is usually well defined, and the curved outline is characteristic of a cyst.
The internal structure on MDCT images is homogeneous and of low attenuation, equivalent to
fluid.
Four Soft Tissue Cysts.
‐thyroglossal duct cyst (A).
‐branchial cleft cyst (B).
‐lymphoepithelial cyst positioned in the right parotid gland (C).
‐dermoid cyst (arrows) in the floor of the mouth (D).
3‐Branchial Cleft Cyst
Disease Mechanism
‐related to remnants of epithelium from the embryonic first to fourth branchial arches
Clinical Features
Branchial cleft cysts occur in the lateral aspect of the neck, anterior to the
sternocleidomastoid muscle, in the second and third decades of life. This cyst usually
manifests as a slow‐growing, painless, fluctuant swelling unless it is secondarily infected.
Imaging Features
The imaging appearance of the branchial cleft cyst is very similar to that of the thyroglossal
duct cyst in terms of both shape and internal image density .The lateral position of the
branchial cleft cyst in the neck differentiates it from a thyroglossal duct cyst. When it is
associated with the parotid gland, it may be difficult to differentiate from a lymphoepithelial
cyst.