RADICULAR CYST

Dr. ARUNGANI.N.S
2nd year PG
Dept. of Oral and
Maxillofacial Pathology
and Oral Microbiology
CYST - DEFINITION
• Kramer (1974) has defined a cyst as ‘a pathological cavity having fluid,
semifluid or gaseous contents and which is not created by the
accumulation of pus’.
Classification of Odontogenic cysts – WHO 2005, 2017
Inflammatory cysts
• Inflammatory jaw cysts - arise as a result of epithelial proliferation within an inflammatory focus
due to a number of causes.
• Residual cyst - A radicular cyst remains in the jaw after removal of the offending tooth

• Inflammatory periodontal cyst or inflammatory collateral cyst - inflammatory cysts that may
occur towards the cervical margin of the lateral aspect of a root as a consequence of an
inflammatory process in a periodontal pocket.

• Paradental cyst- cysts of inflammatory origin occurring on the lateral aspects of the roots of
partially erupted mandibular third molars with an associated history of pericoronitis.

• A similar lesion, usually occurring on the buccal surfaces of the mandibular molars in young
children, mandibular infected buccal cyst.
Radicular cysts
Definition: Radicular cyst is an odontogenic cyst of inflammatory origin associated
with nonvital teeth. (WHO 2017)

• Most common inflammatory cysts

• Arise from the epithelial residues in the periodontal ligament as a result necrosis
of the pulp.

• Most commonly occur at the apices of the involved teeth, but on lateral aspects of
the roots as well (accessory root canals)
Clinical features – Frequency, Age
• Radicular cysts are the most common cystic lesions in the jaws, comprising (52.2%) jaw cysts.

• Jones et al. (2006) - represent 60.3% of all odontogenic cysts.

• Peak frequency occurs in the third decade and large numbers of cases in the fourth and fifth
decades, with a low frequency in the first decade. The mean age 37.3years (Jones et al., 2006).

• Although dental caries is very common in children, radicular cysts are not often associated
with deciduous teeth.
 Clinical features – Gender, Site

• They occur in all tooth-bearing areas of the jaws, 60% - maxilla and 40% -mandible.

• The lower frequency in women, which may be because they are less likely to
neglect their teeth, particularly the maxillary anterior incisors, where most radicular
cysts occur. There is the high prevalence of palatal invaginations in the maxillary
lateral incisors.

• Men, moreover, may be more likely to sustain trauma to their maxillary anterior
teeth
Clinical presentation
• Usually symptomless unless infected secondarily and are discovered
during periapical radiographs of teeth with non-vital pulps.

• The enlargement is bony hard but as the cyst increases in size, the
covering bone becomes very thin despite subperiosteal bone
deposition and the swelling then exhibits ‘springiness’ or ‘egg shell
crackling’.

• When the cyst has completely eroded the bone will the lesion be
fluctuant.
Clinical presentation
• Maxilla - buccal or palatal enlargement noticed

• Mandible - usually labial and rarely lingual enlargement noticed

• Occasionally, a sinus may lead from the cyst cavity to the oral
mucosa.

• Shear, 1961a; Stoelinga, 1973 stated that prone individuals show a

particular susceptibility to develop radicular cysts (Oehlers, 1970).

• Thus radicular cysts are relatively rare in vast numbers of grossly

carious teeth with dead pulps.
Clinical presentation
• Cyst-prone subjects have a defective immunological surveillance and suppression mechanism
(Toller, 1970a).

• It is also possible that some individuals have a genetic tendency to develop radicular cysts.

• Multiple radicular cysts may also be seen in patients with hereditary dental defects (e.g. multiple
dens-in-dente or dentinogenesis imperfecta), but in these cases this is because of morphological
defects resulting in early exposure and death of the pulp.
Clinical presentation – deciduous teeth
• Radicular cysts arising from deciduous teeth appear to be very rare (0.5%).

• Pulpal and periapical infections in deciduous teeth tend to drain more readily than those of
permanent teeth

• Periapical granulomas associated with deciduous teeth have not been subjected to the same
extensive investigations that have been carried out on periapical granulomas of permanent teeth.
Clinical differential diagnosis

• Periapical granuloma – asymptomatic, associated with non vital teeth,

incidental finding.
• Dentigerous cyst - usually asymptomatic, discovered on routine
radiographic examination, maxillary canine region.
• Periapical cementoma - periapical region of the anterior mandible,
nonexpansile with self-limiting growth.
• Traumatic bone cyst – second decade, painless incidental finding,
mandibular predominance.
Radiological features
• The classic description - round or ovoid radiolucencies surrounded by a narrow radiopaque margin
which extends from the lamina dura of the involved tooth.

• Several studies have indicated that it is not possible to rely on the radiographic size of a periapical
radiolucency to establish the diagnosis of either cyst or granuloma unless the lesion is larger than
2 cm in diameter.

• Rarely radicular cysts will induce resorption of the root of the affected tooth.
Radiological features
• It is difficult to differentiate radiologically between radicular
cysts and apical granulomas.

• Mortensen et al. (1970) that because of infection many cysts

had a diffuse radiographic margin and therefore lacked the
circumscribed appearance usually ascribed to radicular cysts.

• Shrout et al. (1993) stated that it may be feasible to

differentiate between radicular cysts and periapical
granulomas on the basis of radiographic density.
Biochemical procedures
• To differentiate between periapical cysts and granulomas, Aspirates of root canal fluids from patients with
cysts showed an intense albumin pattern and definite patterns in the globulin zones, on gel electrophoresis.

• Fluids associated with periapical granulomas, had a faint to moderate pattern in the albumin zone.
PATHOGENESIS - The phase of initiation
Pulp necrosis

Periapical spread

Bacterial endotoxin (P. gingivalis, A. actinomycetemcomitans, E. coli)

Inflammatory reaction

Epithelial proliferation
Phase of cyst formation

Hypothesis 1 Hypothesis 2
The epithelium proliferates and A cyst cavity forms within a
covers the bare connective tissue proliferating epithelial mass in an
surface of an abscess cavity or a apical granuloma by degeneration
cavity which may occur as a result and death of cells in the centre.
of connective tissue breakdown
by proteolytic enzyme activity Widely supported theory
(Summers, 1974).
Phase of cyst formation
Proliferating epithelial cells – intercellular edema

The intercellular fluids coalesce to form microcyst (epithelial and inflammatory cells)

Increased acid phosphatase and proteolyitic activity (central area within the proliferating epithelium)

Bone resorption and Autolysis

Cavity formation within the proliferating epithelial cell

Growth and enlargement – Osmotic pressure

Lytic products - epithelial and inflammatory cells

Raised the osmotic pressure of the cyst fluid

Upper limit of permeability - close to size of albumin, particles of larger size

finds difficulty in diffusing across a cyst lining.

Cyst walls have the properties of a semi-permeable membrane.

Growth and enlargement – Osmotic pressure
• Toller (1966b) - the contents of cyst cavities are subjected to an
osmotic imbalance with the surrounding tissues because of the
absence of lymphatic drainage.
• Ylipaavalniemi (1977) - that when the inflammation ceased, a balance
was probably established between the protein concentrations in cyst
fluid and in serum.
Growth and enlargement-hydrostatic pressure
• Toller (1948) - the internal hydrostatic pressures in radicular cysts
ranged from 56.6 to 95.0cm water with a mean of 70.0cm which is
higher than capillary blood pressure
• Hydrostatic pressure is considered to be of primary importance in the
growth of all cyst types.
• Kubota et al. (2004) measured the intracystic fluid pressure of
odontogenic keratocysts, dentigerous cysts and radicular cysts and
stated that greater than the local blood pressure in all the cyst types.
Growth and enlargement
• Growth of the cyst must also be accompanied by degradation of
adjacent connective tissues and bone resorption.
• Harris and Goldhaber (1973) postulated that intra-osseous cyst
expansion is facilitated by local enzyme or hormone-induced bone
resorption and suggested that the active principle is a prostaglandin.
• Cyst walls did release prostaglandin-like material in tissue culture.
• IL – 1, 1L – 6, MMPs are involved in degrading the connective tissue
favoring enlargement.
Pathological features:
• GROSS EXAMINATION: An intact specimen may be a spherical or ovoid intact cystic mass, but
often they are irregular and collapsed. Lesions are usually 1.0–1.5 cm in diameter and rarely
exceed 3cm. The walls vary from extremely thin to a thickness of about 5mm. The inner surface
may be smooth or corrugated. Yellow nodules of cholesterol may project into the cavity.

• FLUID: The fluid contents are usually brown from the breakdown of blood and when cholesterol
crystals are present they impart a shimmering gold or straw colour.
HISTOPATHOLOGY
The nature of the lining:

• Almost all radicular cysts are lined wholly or in part by stratified squamous epithelium. These linings may be
discontinuous in part and range in thickness from 1 to 50 cell layers. The majority are 6–20 cell layers thick.

• May depend on the age or stage of development of the cyst, or on the intensity of the inflammation.

• In early cysts, the epithelial lining may be proliferative and show arcading with an intense associated
inflammatory process but as the cyst enlarges the lining becomes quiescent and fairly regular with a certain
degree of differentiation to resemble a simple stratified squamous epithelium.
HISTOPATHOLOGY
• Keratin formation:

• Seen in about 2% of radicular cysts and when present it affects only part of the cyst wall. Orthokeratinisation
is most common, with evidence of a granular cell layer, but parakeratinisation may also be seen.

• The inflammatory cell infiltrate:

• In the proliferating epithelial linings consists predominantly of polymorphonuclear leucocytes whereas the
adjacent fibrous capsule is infiltrated mainly by chronic inflammatory cells. These proliferating epithelial
linings show a considerable degree of spongiosis.
HISTOPATHOLOGY
• Spongiosis: In the SEM the spongiotic spaces represent channels running between the epithelial cells and
extending from the basal layer to the cyst lumen (Cohen, 1979). The polymorphonuclear leucocytes
migrate along these channels and into the cyst cavity through interepithelial spaces on the luminal surface.
Interepithelial spaces and channels in the cyst linings have also been demonstrated by means TEM (Frithiof
and Hägglund, 1966).

• As the cyst enlarges, the wall may become less inflamed and fibrous. This is most noticeable distant from
the apex of the tooth.

• Adjacent to the apex, where the cyst is constantly exposed to the infected root canal, inflammation may
persist and polymorphonuclear leucocytes are invariably present even in long-standing lesions.
HISTOPATHOLOGY
• Metaplasia: Mucous, ciliated cells.
• Mucous cells - may be present in the surface layer of the stratified squamous
epithelial lining, either as a continuous row or as scattered cells, and they may be
found associated with ciliated epithelium. They are found in cysts occurring in all
parts of the mandible and maxilla.

• Browne - increasing frequency of mucous cells with age, at the rate of 7% per
decade.

• Takeda et al. - mostly arranged along the surface epithelium, but occasional intra-
epithelial gland-like structures were also noted, especially in areas of hyperplasia.
HISTOPATHOLOGY
• Mucous cells – maxilla (21%)
mandibule (14%).
• Slabbert et al. - mucous cells were
associated with vacuolated cells, many
of which were empty, but some
contained fine granules or networks of
periodic acid–Schiff (PAS) positive
material.
• He suggested that the vacuolated cells
represent an intermediate stage in the
process of mucous metaplasia.
HISTOPATHOLOGY
• Ciliated epithelium - occasionally found in
radicular cysts and most often occurs in maxillary
lesions as a result of involvement of antral lining
(Nair et al., 2002).
• Ciliated epithelium has been found in cysts in the
anterior and posterior regions of the mandible.
• Takeda et al. (2005), ciliated cells were found in
11% of radicular cysts and in 12% and 9% of
maxillary and mandibular lesions.
• The presence of secretory and ciliated epithelium
in mandibular radicular cysts further confirms that
these processes may arise as a result of metaplasia.
HISTOPATHOLOGY- Rushton Bodies
• Dewey in 1918 - hyaline bodies, in the
epithelial linings, rare in the fibrous
capsule.
• The bodies measure up to about 0.1 mm
and are linear, straight or curved or of
hairpin shape and sometimes they are
concentrically laminated. They are brittle
and frequently fracture.
HISTOPATHOLOGY- Rushton Bodies
• Special stains and histochemical studies – the bodies contain cystine
and suggested that they were of odontogenic epithelial origin,
probably a form of keratin.
• Bouyssou (1965) and Sedano (1968) suggested their haematogenous
origin, and were derived from thrombi in venules of the connective
tissue and strangled by epithelium that encircled them, and that they
reacted histochemically as haemoglobin.
• They suggested that the thrombi shrank centrifugally and underwent
splitting, or they may calcify.
HISTOPATHOLOGY- Rushton Bodies
• Dent and Wertheimer (1967) stated that although hyaline bodies
reacted to several haemoglobin and iron stains, the histochemical
reactions for haemoglobin were not specific.
• Browne and Matthews (1985) stained cysts containing hyaline bodies,
fibrinogen was detected in the cores of some circular and polycyclic
forms.
• Hence fibrinogen in the cores of some hyaline bodies could support
the notion of a haematogenous origin of the granular bodies.
HISTOPATHOLOGY- Rushton Bodies
• Lam and Chan (2000) - hyaline bodies in 7% of a series of 69
odontogenic keratocysts
• Ide et al. (1996) - unusual glandular odontogenic cyst with hyaline
bodies.
• Takeda et al. (1985) - presence in a plexiform ameloblastoma.
• Though unusual, they appear to be restricted to odontogenic lesions.
HISTOPATHOLOGY- Cholesterol crystal
• Deposits of cholesterol crystals are found in many radicular cysts, but
by no means in all.
• Browne - demonstrated a significant correlation between the
presence of cholesterol and haemosiderin.
• Disintegrating RBCs readily crystallises in the tissues.
• Cholesterol from this source and also from serum accumulates in the
tissues because of the relative inaccessibility of normal lymphatic
drainage.
 HISTOPATHOLOGY- Cholesterol crystal
• Arwill (1973) confirmed the origin from red
blood cells. They showed that the crystals
may form in congested capillaries in the
inflamed areas as they appear to be
enveloped by endothelial cells.
• Trott et al. (1973) - slow but considerable
accumulation of cholesterol could occur
through degeneration and disintegration of
lymphocytes, plasma cells and
macrophages taking part in the
inflammatory process, with consequent
release of cholesterol from their walls.
 HISTOPATHOLOGY- Cholesterol crystal
• Cholesterol crystals in fibrous
capsules, behave as foreign
bodies and excite a foreign body,
giant cell reaction.
• In histological sections, the
cholesterol crystals are dissolved
out.
HISTOPATHOLOGY- Differential Diagnosis
• Periapical granuloma - Epithelial rests of Malassez may be identified
within the granulation tissue. Cholesterol clefts, associated with
multinucleated giant cells and areas of red blood cell extravasation
with hemosiderin pigmentation, may be present.
• Dentigerous cyst - In inflamed dentigerous cyst, the fibrous wall is
more collagenized, with a variable infiltration of chronic inflammatory
cells.
• The epithelial lining may show varying amounts of hyperplasia with
the development of rete ridges.
• Mucous, ciliated and sebaceous elements are present.
Carcinomatous change
• Squamous carcinoma may occasionally arise from the epithelial lining
of radicular cysts.
• Eversole et al. (1975) reviewed series of cases of central epidermoid
carcinoma and central muco-epidermoid carcinoma of the jaws and
found that 75% of the former were associated with a cyst lining and
48% of the latter were associated with either a cyst or an impacted
tooth.
Carcinomatous change
• It is possible that cyst and neoplasm may have developed
independently adjacent to one another and ultimately fused in some
parts.
• Careful questioning of the patient and clinical examination are
necessary to exclude the possibility that the neoplasm arose primarily
from the oral mucosa, or that it is a metastatic deposit in the jaw.
• A further possibility is that the lesion was initially an epithelial
neoplasm which underwent secondary cystic change.
Carcinomatous change
• Histological evidence of transition from a cyst lining through epithelial
dysplasia to infiltrating squamous carcinoma has also been suggested.
• Browne and Gough (1972) - suggested that keratin metaplasia in long-
standing radicular and dentigerous cysts may precede malignant
change.
Treatment
• It is not intended to give surgical treatment for the radicular cysts.
• Oehlers (1970) believed that many periapical lesions left in situ,
including cysts, are eliminated by the body once the causative agents
are removed.
• Bhaskar (1972), who suggested that the vast majority of radicular
cysts underwent resolution following conservative endodontic
therapy.
• His hypothesis was based on endodontists’ claims that 85–90% of
apical lesions disappeared or become markedly reduced in size
following conservative endodontic procedures.
• He suggested that during the endodontic procedure, instrumentation
should be performed slightly beyond the apical foramen.
• This produced a transitory acute inflammation which may destroy the
epithelial linings of the radicular cysts and convert them into
granulomas, thus leading to their resolution.
References

• Rajendran R. Shafer's textbook of oral pathology. Elsevier India;

2009.

• Neville BW, Damm DD, Allen CM, Chi AC. Oral and maxillofacial
pathology. Elsevier Health Sciences; 2015 May 13.
• Shear. Cysts of oral and maxillofacial region. 4th edition.
Thank you!