CYSTS

OF THE ORAL AND

PARAORAL REGIONS
A cyst is a pathological cavity (sac) containing fluid or semisolid material.
This cavity could have epithelial lining (true cyst) or not (pseudo-cyst).
Cyst formation:

In the formation of a cyst, in a case of true cyst, the epithelial cells first
proliferate and later undergo degeneration and liquefaction. The cyst grows
from internal pressure generated by fluid (liquefied material) being drawn into
the cavity from osmosis (hydrostatic pressure).
Origin of epithelium of the true cysts:

1: From the epithelium associated with during the development of teeth

(odontogenesis), these called odontogenic cysts.

2: From the ectodermal tissue that may be trapped along the lines of fusion
the bones (embryologic processes). This "resting" epithelium (also termed
cell rests) is usually dormant or undergoes atrophy, but, when stimulated,
may form cysts, these called fissural developmental cysts (non-
odontogenic cysts).

3: From the adjacent epithelial lined structures (e.g. maxillary sinus, nasal
cavity).

4: From the glandular epithelium (true mucocele).

 Cyst

Radiographic feature Histological feature

Gross specimen

Cystic
cavity
Classification of a cyst
 The cysts are classified under different headings

1. According to the lining:

A: True cysts: lined with B: Pseudocysts: not lined with

epithelium epithelium (CT membrane or bone)
 True cysts can be classified According
to the origin of epithelial lining

Odontogenic cyst Non odontogenic cyst

Cysts arising from odontogenic Cysts arising from non
epithelium odontogenic epithelium
 Odontogenic cyst
Developmental
Primordial cyst.
Dentigerous cyst.
Eruption cyst.
Gingival cysts.
Odontogenic keratocyst. (Keratocystic odontogenic tumor, WHO, 2005).
Lateral periodontal cyst-
Calcifying odontogenic cyst. (Calcifying odontogenic tumor, WHO, 2005).
Odontogenic glandular cyst. Odontogenic cysts associated with
Jaw cyst-basal cell nevus- bifid rib syndrome (Naevoid basal cell carcinom
syndrome).

Inflammatory:
Radicular:
Apical periodontal cysts.
Lateral periodontal
 Non odontogenic cyst

(Covering, surface) epithelium Cysts arising from Salivary Gland

epithelium
1: Fissural Inclusion Developmental Cysts :
1:Cysts Associated with the maior
andminor salivary gland.
2: Non-Fissural Developmental Cysts:

3:Neck Cysts: Soft tissue developmental

cysts:
2: Cysts Associated with the
Maxillary Antrum (cental)
 Classification of a cyst

True cysts Pseudocysts

Non odontogenic cyst

Odontogenic cyst

Surface epithelium
Salivary Gland
epithelium
Developmental Inflammatory

Fissural cyst Non-Fissural Neck Cysts

 Cyst
True cyst Pseudocysts

Odontogenic cysts Non Odontogenic cysts

1-Inflammatory Developmental -2 1 Traumatic

• Apical Lateral periodontal1 bone cyst.
periodontal .cysts 2 Aneurysmal
.Gingival cyst of adults.2 bone cyst.
• Lateral Gingival cyst of.3 3 Static bone
periodontal newborn cyst.
Dentigerous cyst:.4 4 Cyst of
• Residual eruption cysts hyperparathy
.odontogenic keratocyst.5 roidism.
Gorlin’s cyst-6 5 Extravasation
mucoele.
 Cyst
True cyst

Odontogenic cysts
derived from odontogenic epithelium
1-Inflammatory Developmental -2
Apical Lateral periodontal1
periodontal .cysts
.Gingival cyst of adults.2
Lateral Gingival cyst of.3
periodontal newborn
Dentigerous cyst:.4
Residual eruption cysts
.odontogenic keratocyst.5
Gorlin’s cyst-6
 INFLAMMATORY DEVELOpmental

Non vital vital tooth

tooth

thin
epith
hyperplasti
c epith no
inflamm
cell in C.T
inflamm
cell in C.T
 Inflammatory cysts
Inf Apical periodontal Infl lateral periodontal residual
Most commonly occuring
cyst (65%)
 Odontogenic cysts

Odontogenic cysts could be developmental or inflammatory type. Developmental

cysts are derived from epithelium associated with the development of the dental
apparatus or its remnants. Several types of these cysts may occur, depending chiefly
upon the stage of odontogenesis during which they originate.
Histogenesis:

The odontogenic cysts are derived from one or more of the following sources:

1: Oral Epithelium (Basal Cells).

2: Tooth Germ, Enamel (Dental) Organ.

3: Remnants of Enamel (Dental) Organ:

Remnants of dental lamina (Epithelial Rests of Serres).
Remnants of sheath of Hertwigvs (Epithelial Rests of Malassez).
Remnants of enamel (dental) organ (Reduced Enamel Epithelium).
Common clinical features of jaw cysts

Asymptomatic, slowly growing painless swelling unless secondarily

infected. It may cause displacement of teeth. With variable sizes, few mm to
several cm in diameter. Rarely large enough to cause pathological fracture.
Overlying mucosa appears normal color or bluish when it near to the
surface.
 Radiographic features:
Well circumscribed radiolucent area.
Unilocular or multilocular,
Surrounded by thin rim of radioopacity.
Sometimes, it may cause displacement of teeth and/or Root resorption in
advanced cases, (depond up on the nature and the behavior of the lesion).
 Radiographic features:

Unilocular Multilocular
Common histological features: include the following: Cystic space content,
Epithelial lining and Connective tissue wall pattern and contents.
Cavity or cystic space content:
It could contain: fluid, semifluid, semisolid or gaseous materials, even keratin or
calcifications.
Epithelial lining: To describe the following:
Its type (simple, stratified & others).
Its thickness (how many layers).
Its base (rete ridges: present or not).
Its surface (most superficial layer) and
Other interesting findings, if any, the epithelial is always: a-
Stratified squamous epithelium or respiratory epithelium.
Thin Thickness (4-6 or 8) layers.
The lining showing cuboidal or columnar basal cells with dark
oval nuclei forming a palisade.
Absence of rete pegs unless secondarily infected.
The surface may be nonkeratinzed or keratinized (corrugated
and covered by para or ortho- keratin).
Connective tissue wall:
a- Parallel compactness of connective tissue fibers, b- Interspersed by
fibroblasts and blood vessels, c- Chronic inflammatory cells may be present.
Cysts are formed either in soft tissue or in bone, when found in bone, they are
called central cysts. Most cysts do not cause any symptoms, and are
discovered on routine dental radiographs. As the cyst grows, it may cause the
following:

1: Resorption of the bone around the cyst.

2: Displacement of teeth due to pressure.
3: Compression of other vital structures such as nerves and blood vessels.
4: Resorption of the roots of teeth.
5: Expansion of the cortical bone, when the cysts are large.
On a radiograph, the radiolucency of a cyst is usually bordered by a
radiopaque periphery of dense sclerotic (reactive) bone. The radiolucency
may be unilocular or multilocular.
Treatment

Some cysts may not require any treatment, but if treatment is required, it usually
involves some minor surgery to partially or completely remove the cyst in a one or two-
stage procedure. When treatment is required, this is usually by surgical removal of the
cyst. There are four wavs in which cysts are managed.

1: Enucleation; removal of the entire cyst.

2: Marsupialization: the creation of a window into the wall of a cyst, allowing the
contents to be drained. The window is left open, and the lack of pressure within the cyst
causes the lesion to shrink, as the surrounding bone starts to fill in again.
3 :Enucleation following marsupialization: Marsupialization usually is followed by a
second procedure to remove the cyst, in a case of very large cysts are and their removal
would leave a significant surgical defect.
4: Enucleation with curettage: this is removal of the cyst and some of the surrounding
bone, which may contain some of the lining of the cyst.
Enucleation
Enucleation
Marsupialization
 1: Primordial cyst:
Origin: It arises from cystic degeneration or liquefaction in a developing tooth
bud or the stellate reticulum of enamel organ before any hard calcified tissue
(enamel and dentin) matrix has been formed.
:Clinical Features
In addition to the common features, Missing tooth from the dental arch
unless the cyst arose from the tooth bud of a supernumerary tooth
X ray:
it found at the site where the tooth failed to develop
Histopathological Features:
In addition to the common features most primordial cysts have the same
characteristic features as those of odontogenic keratocysts
 DENTIGEROUS CYST (Follicular cyst)

:Origin Accumulation of fluid between the reduced enamel epithelium and the
tooth crown
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CD
CO
:Clinical Features
In addition to the common features,

It commonly leads to displacement, caries or resorption of roots of adjacent

teeth.

Hallowing out of the ramus may be present with facial deformity, neuralgia
and trismus.

The tooth remains unerupted.

Most common site: in association with impacted

X ray:
In addition to the common features it surrounds the crown of impacted tooth.
Types:
Central,
Lateral or
Circumferential

Central Lateral Circumferential

Histopathological Features:
In addition to the common features *

proliferation of the lining into:

1: Ameloblastoma (mural form).
2: Sauamous cell carcinoma.
3- Mucoepidermoid carcinoma.
Scattered mucous secreting cells
Complications

1. Ameloblastoma.

2. Squamous cell carcinoma.

3. Intraosseous mucoepidermoid carcinomas develop from

mucous cells in the lining of a dentigerous cyst.
 ERUPTION CYST (eruption hematoma)
Origin: Due to an accumulation of fluid or blood in a dilated follicular space.
Clinical Features:
It is associated with the eruption of deciduous or permanent teeth.
A circumscribed, fluctuant, often translucent painless swelling of the
alveolar ridge over the site of the erupting tooth.
X ray:
It is difficult to distinguish the cystic space because both the cyst and tooth are
directly in the soft tissue of the alveolar crest and no bone involvement is seen.
Histopathological Features:
In addition to the common features *
The epithelial lining of the cyst is separated from the alveolar mucosa by a
thin layer of fibrous tissue with the epithelial tags of cystic epithelium facing
those of the alveolar mucosa.
 GLANDULAR ODNTOGENIC CYST
(Sialo-Odontogenic Cyst)

Origin: mucous cell metaplasia.

:Clinical Features
In addition to the common features . It is likely to show aggressive growth
X ray:
Always, a multilocular radiolucency and thinning of buccal and lingual cortex
Histopathological Features:
In addition to the common features . cyst wall lining of non­keratinized
epithelium, with papillary projections, nodular thickenings, mucous filled
clefts, and ‘mucous lakes’