ODONTOGENIC CYSTS OF

THE JAWS
 ODONTOGENIC CYSTS OF
JAWS

DEFINITION
A cyst is a pathological cavity containing
fluid, semifluid or gaseous contents which
may or may not be lined by epithelium and
is not created by the accumulation of pus .
(Kramer :1974)
CLASSIFICATION
By Kramer, Pindborg and Shear, 1992 in WHO's
publication

ODONTOGENIC CYSTS

DEVELOPMENTAL INFLAMMATORY
Dentigerous cyst Periapical(Radicular)
Eruption cyst cyst
Odontogenic Residual periapical

keratocyst cyst
Gingival cyst of Buccal bifurcation

infants cyst
Gingival cyst of adults
ETIOPATHOGENESIS
Derived from epithelium associated with development of dental
apparatus i.e. tooth germs, reduced enamel epithelium, rests of
malassez, remnants of dental lamina, and basal layer of oral
epithelium.

3 CONCEPTS OF ORIGIN :-
A) Spontaneous origin concept -
Cyst results when epithelium proliferates and organizes to
protect exposed or irritated connective tissue elements
and in turn connective tissue supports and nourishes
epithelium. If it results in intact sac, it is called a cyst.
B) Neoplastic origin concept -
It implies that the involved tissues materially deviate from
normal in their power of proliferation and organization.

C) Pseudo neoplastic origin concept -

The epithelium, a simple cell, nest of cells, entire follicle
degenerate under stimulation to basic proliferation
resembling a neoplasia. Eventually a lumen is outlined
and stratified epithelium membrane may form with
organization of connective tissue.
ENLARGEMENT OF CYST

A) MURAL GROWTH

(i) Peripheral cell division peripheral

enlargement is attributed to active cell division
of lining epithelium in response to an irritant
stimulus.

(ii) Accumulation of cellular contents

keratocysts enlarge by accumulation of mural
squames as they are cast off the lining
epithelium.
(B) HYDROSTATIC ENLARGEMENT
Growth is attributed to distension of cyst wall
by fluid accumulation through following
processes:-

(i) Secretion
(ii) Transudation and Exudation
(iii) Dialysis

(C) BONE RESORBING FACTOR

Is mixture of PGE2 and PGE3. The source
can be capsule and leukocyte content,
including a vascular contribution in vivo.
 CLINICAL FEATURES
- Range from asymptomatic to incidental
finding in radiographs to observable
expansion of bone.
- Paresthesia, displacement of teeth.
- Egg shell crackling in large cysts.
- Infection results in increased swelling,
pain, discharge tenderness and redness.

RADIOLOGICALFEATURES
Classical appearance - well defined
round / oval radiolucent area circumscribed
by sharp radiopaque sclerotic margin.
- Ranges from unilocular eg. Radicular cyst to
multilocular radiolucency eg Aneurysmal bone
cyst.
HISTOLOGICAL FEATURES
- Lined by stratified squamous epithelium,
varying in thickness and extent of
keratinization depending on type of cyst.

- Lumen may contain keratin, cholesterol

crystals and various amount of protein
contents as per the type of cyst.

- Fibrous capsule may be present.

 Treatment Considerations:-
1) Marsupialization-
(Partsch I , Decompression) : Defined as
creating a surgical window in the wall of cyst,
evacuating contents of cyst and maintaining
continuity between cyst and oral cavity, maxillary
sinus or nasal cavity. (Peterson )
Very large cysts .
Indications
Cysts close to vital structures.
Advantages

Spares vital structures

Reduces morbidity and neurological loss.
Decreased risk of pathological fracture and
oro-antral fistula.

Disadvantages

Pathological lining left behind can transform

2) Enucleation :
It is process by which the total removal of cystic
lesion is achieved .By Definition,it means shelling out of
the entire cystic lesion without rupture.
(Peterson)

Small cysts
Indications

Potential for neoplastic

changes.
Advantages

No pathological lining left behind

Lesser chances of infection
No regular follow-up appointments
Uniform healing takes place

Disadvantages

Increased risk to adjacent vital

structures
Increased chances of pathological
fracture
 3) PARTSCH II
Marsupialization followed by Enucleation
(For large cysts)

First Marsupialization is done to evacuate the cystic

contents.
second stage surgery in the form of enucleation is
performed to remove entire cystic lining.

Vital structures spared

Advantages

No pathological lining left behind

 ERUPTION CYST
INTRODUCTION
It is the soft tissue analogue of dentigerous cyst which is
the result of seperation of dental follicle from around the
crown of an erupting tooth i.e. with in the soft tissues
overlying the alveolar bone.
PATHOGENESIS
It develops due to accumulation of fluid within the
follicular space of an erupting tooth.
CLINICAL FEATURES
Age - Children < 10 yrs.
Site - Deciduous and permanent teeth may be
involved, frequently anterior to first permanent molar.
.
Clinical presentation
- Appears as soft, translucent swelling in gingival
mucosa overlying erupting tooth.
- Painless unless infected
- Brief history of 3-4 wks duration during which enlarge
to approximately 1.5 cm.
- Exposure to masticatory trauma induces hemorrhage
with in the cyst giving rise to eruption hematoma

.
 HISTOPATHOLOGICAL FEATURES
- Superficial aspect covered by oral epithelium.
- Underlying lamina propria shows variable
inflammatory cell infiltrate.
- Deep portion which represents roof of cyst, shows
a thin layer of non-keratinizing squamous epithelium

Nonkeratinising squamous
epithelium

Oral epithelium
 RADIOLOGICAL FEATURES
- Cyst may throw a soft tissue shadow.
- Usually no bone involvement except that dilated
and open crypts may be seen.

TREATMENT AND PROGNOSIS

1) If cyst ruptures - no treatment .
2) If this does not occur Marsupialization.
ODONTOGENIC KERATOCYST

INTRODUCTION
Termed by philipsen (1956)
Very well defined histologic criteria
One clinical feature warranting its recognition and
separation as a distinctive entity is its high rate of
recurrence (5- 62% Neville)
 CLINICAL FEATURES:
Frequency : 1% among all types of jaw cysts
Age : 2nd and 3rd decades of life
Gender : Male > Females
Race : White > Black
Site : Mandible > Maxilla
50% cases occur at angle of mouth

PRESENTATION:
INITIAL STAGES - No signs / Symptoms
LARGER LESIONS - Swelling of jaw, facial asymmetry,
pain in jaw, mobility and
displacement of teeth.
Expansion of bone in Anteroposterior direction.
Expansion
Maxillary Lesions - Palatal Cortical plate (1/3 Cases)
Mandibular Lesions - Buccal cortical Plate (50%)
- Lingual Cortical Plate (30%)
Extraosseous lesions may develop in relation to gingiva
Discharge present if secondarily infected.
Larger cysts affecting maxillary sinuses leads to
displacement or destruction of floor of orbit and
protrusion of eyeball.
 NEVOID BASAL CELL CARCINOMA
SYNDROME
BASAL CELL NEVUS BIFIDRIB SYNROME
GORLIN AND GOLTZ SYNDROME
MULTIPLE JAW CYST SYNDROME
Given by Binkley and Johnson (1951)
Hereditary disease
Autosomal dominant trait
Mutiple Basal cell epitheliomas
Multiple Basal Cell nevi.
Multiple odontogenic keratocyst ofjaws
Bifid ribs
Ocular hypertelorism
Frontal bossing
CNS disturbances etc. hypogonadism in males
Ovarian tumours
50% cases show multiple cyst formation
Radiological features-
Multilocular Radiolucent areas
Soap Bubble appearance
Crosses mandibular midline oftenly
Smooth / scalloped border
Displacement of unerupted teeth
Expansion and distortion of cortical plates

Types Replacement

ODONTOGENI
Collater Envelopment
C
al al
KERATOCYST

Extraneous

1. Replacement type Cyst develops in place of developing normal tooth

2. Envelopmental type - Entirely enclosing impacted tooth with in the bone.
3. Extraneous type - Develops away from tooth bearing areas of jaw
4. Collateral type - Between Roots of a tooth.
 Cystic Fluid
- Straw colored fluid contains soluble protein less than 3.5 gm /
100 ml.
- Explained by Taller
- Through electrophonetic studies
- Due to altered degree of keratinisation. Increased Permeability of
lining.
- Results in mobility of soluble proteins.
Histopathology
Corrugated epithelial lining

Cystic cavity lined by keratinized

stratified odontogenic epithelium
6-8 cell 19 years thickness.

Basal layer Tall columnar cells/

cuboidal cells palisade arrangement.

Diffuse Chronic inflammatory cells

 Differential Diagnosis
- Ameloblastoma
- Dentigerous cyst
- Aneurysmal bone eyst
- Odontogenic Myxoma
- Stafne bone cyst.
- Lateral periodontal cyst

Treatment
- Surgical enucleation
- Marsupialization
- Excise overlying oral epithelium
- Repeated recurrence - Jaw resection
 Prognosis
RECURRENCE RATE IS VERY HIGH
(5% to 62% - Neville)

Possible Reasons:
- Retained fragments of thin, delicate cystic lining
- Penetration of the original cortex eventually,
also the thin shell of new subperiosteal bone.
- Spillage of its contents
- Satellite cysts arising from epithelial residues.
 DENTIGEROUS CYST
Follicular Cyst
Coined by Paget (1963)
Definition:
Cyst enclosing crown of unerupted tooth by expansion of its
follicle, attached to the neck
Clinical Features
Frequency : 20-25%
Age : Third and forth decades
Gender : Male : Female :: 1.6:1 (Brown et al)
Race : White > Black
Site : Mand 3rd Molar > Max . Canine
>Mand. Premolar > Max 3rd molar
 Presentation
May grow large before diagnosis
Slowly enlarging swelling associated with missing teeth / tooth
failed to erupt
Painful if infected.
Lesions 4-5 cms in 3-4 years .
Radiological features
Unilocular Radiolucent
Associated with crowns of unerupted teeth.
Well defined sclerotic margins unless infected

Types Central

Dentigerou Lateral
s cyst

Circumferenti
 Presentation
May grow large before diagnosis
Slowly enlarging swelling associated with missing teeth / tooth
failed to erupt
Painful if infected.
Lesions 4-5 cms in 3-4 years .
Radiological features
Unilocular Radiolucent
Associated with crowns of unerupted teeth.
Well defined sclerotic margins unless infected

Types Central

Dentigerou Lateral
s cyst

Circumferenti
Dental Lamina Cyst of newborn:
Gingival cyst of Newborn
Epstein pearls
Bohn's Nodules
Definition : Multiple, occasionally solitary nodules on alveolar
ridge of new born / very young infants, Representing cyst
originating from remnants of dental lamina.
- Epstein Pearls : Cystic Keratin filled nodules.
Along midline raphe
Derived from entrapped epithelial remnants along line of
fusion.
- Bohn's Nodules Keratin filled cysts scattered over palate
Numerous along junction of hard and soft palate
Derived from palatal salivary gland structures.
 CLINICAL FEATURES
- Obvious small discrete white swelling of alveolar ridge
- Blanched Internal pressure
- Asymptomatic
- No discomfort
Histologic Features
- True cyst with a thin epithelial lining.
- Lumen filled with desquamated keratin.
- Inflammatory cells present
- Dystrophic calcification found
- Hyaline bodies of Rushton found
Treatment
- No treatment required
- Lesions disappear By Opening into surface
Disruption by erupting teeth
 Gingival cyst of Adult
Uncommon cyst of gingiva
Etiology and pathogenesis
- Heterscopic glandular tissue.
- Degenerative changes in proliferating epithelial retepeg.
- Remnants of dental lamina, enamel organ or epithelial islands of periodontal
membrane.
- Traumatic implantation of epithelium.
Clinical features
Frequency : 0.5%
Age : adults over 40 years
Location : Bicuspidcuspid incisor area (Mandibular)
Representation : Small, well circumscribed painless swelling
of gingiva.
Color : Same as of normal mucosa
Size : Less than 1 cm in diameter may occur in
free, attached or interdental gingiva.
 Histological Features :
True cyst
Stratified squamous epithelial lining
In lumen fluid present
Glycogen rich clear cells present.
Radiological Features
Soft tissue lesion No Radiographic Manifestation
Differential Diagnosis
- Mucocele
- Local periodontal cyst
Treatment - Local surgical excision
Prognosis - Lesions do not recur.
 LATERAL PERIODONTAL CYST

INTRODUCTION
This designation is confined to those cysts which
occur in the lateral periodontal position and in
which an inflammatory etiology and a diagnosis
of collateral keratocyst have been excluded
(Shear and Pindborg 1975).

PATHOGENESIS
Arise from reduced enamel epithelium, remnants
of dental lamina and cell rests of Malassez
CLINICAL FEATURES
- Frequency - 0.7% (Mervyn Shear 1989)
- Age - 5th to 7th decade
- Sex - Male > Female
- Site - Mandibular premolar area.

Clinical presentation
(a) Asymptomatic and discovered during radiographic
examination.
(b) When on labial surface of roots, slight mass obvious,
although mucosa is normal.
(c) Tooth is vital.
(d) If infected, it may resemble lateral periodontal abscess.

2
RADIOLOGICAL FEATURES
- Well circumscribed radiolucent area
lateral to root of vital tooth.
- Most cysts < 1 cm diameter.
-HISTOPATHOLOGICAL
When polycystic, known as botryoid
FEATURES
odontogenic cyst.
- Hollow sac with connective tissue wall lined
on inner surface by
stratified squamous epithelium which is
single to several cells thick.
- Foci of glycogen rich clear cells in epithelial
cells.
-Focal nodular thickenings of lining epithelium
composed chiefly of clear cells.
- Fibrous wall contains clear cell epithelial rests

DIFFERENTIAL DIAGNOSIS
- Lateral periodontal abscess/granuloma
- Radicular cyst
- Lateral dentigerous cyst
- Collateral type of primordial cyst

TREATMENT AND PROGNOSIS

- Conservative enucleation without damaging the
associated tooth.
- Recurrence unusual except in botryoid variant
since of polycystic nature.
 CALCIFYING ODONTOGENIC CYST
(Gorlin Cyst)
INTRODUCTION
-Uncommon epithelial lesion characterized by unusual keratin
production and dystrophic calcification.
-First described by Gorlin in 1962, who drew attention to an entity
that they described as Calcifying odontogenic cyst likening it to
the calcifying epithelioma of Malherbe.

CLASSIFICATION - by Praetorious and co-workers

Type I A Simple unicystic type
Type I B Odontome producing type
Type IC Ameloblastomatous proliferating type

II Neoplasm like lesion

PATHOGENESIS
Develops from reduced enamel epithelial cells or
remnants of odontogenic epithelium in dental
.
follicle,gingiva or bone

CLINICAL FEATURES
- Age - 2nd decade
- Sex - Male = Female
- Race - No predilection
- Site - equal frequency in maxilla and
mandible
- Common in incisor and canine
areas.
Clinical presentation
(a) Mostly asymptomatic.
(b) Swelling is the most frequent complaint.
(c) Rarely painful
(d) Intraosseous lesions may produce a hard
bony expansion, may perforate cortex and
extend into soft tissue.
RADIOLOGICAL FEATURES
(a)Intraosseous lesions appear as
radiolucent area with well defined
margins.
 (b)Irregular calcifications seen in radiolucent
area.
(c) Root resorption of adjacent teeth is seen

HISTOPATHOLOGICAL FEATURES
Well-defined cystic lesion with
fibrous capsule and a lining of
odontogenic epithelium
1 Odontogenic
epithelium
a) 4-10 cells thick.
Basal cells may be cuboidal /
columnar.
Ghost cells
 (c) Overlying layer of loosely arranged epithelium
resembles stellate reticulum of ameloblastoma
(d) Characteristic feature - "ghost cells" within
epithelial component.
(e) Calcified tissues in epithelial cells.
2 Connective tissue -
Consist of ameloblastoma - like strands and
islands of odontogenic epithelium Infiltrating
into mature connective tissue .
3. Capsule-
- Ameloblastoma - like proliferations in connective tissue of
fibrous capsule and lumen of cyst
- Ghost cells and varying amount of dentinoid in
-
contact with odontogenic epithelium.
 TREATMENT AND PROGNOSIS

Surgical enucleation because of propensity

for continued growth.
Lack of recurrence dependent upon
completeness of excision.
Carcinomatous transformation into
squamous cell carcinoma has been recorded.
GLANDULAR ODONTOGENIC CYST
(Sialo - odontogenic cyst)
The term most descriptive of the lesion is
mucoepidermoid odontogenic cyst because of
presence of both secretory elements and stratified

squamous epithelium.

CLINICAL FEATURES
- Age - Middle aged adults with a
mean age of 49 yrs.
- Site - Mandibular anterior region.
Clinical Presentation -
(a) Small cysts asymptomatic
(b) Large cysts produce clinical
expansion, sometimes associated with
pain or paresthesia.
RADIOLOGICAL FEATURES
(a) Unilocular or commonly multilocular
radiolucency.
(b) Margins well defined with a sclerotic rim.

HISTOPATHOLOGICAL FEATURES
(a) Squamous epithelium of varying thickness.
(b) Interface between epithelium and fibrous
connective tissue wall is flat.
(c) Fibrous cyst wall devoid of inflammatory
infiltrate.
(d) Superficial epithelial cells are columnar /
cuboidal, occasionally with cilia and epithelium
has glandular/ pseudoglandular structure with
intraepithelial crypts or microcysts or pools lined by
cells similar to those on surface.
Squamous epithelium

with cilia

Microcyst

TREATMENT AND PROGNOSIS

(a) Enucleation or curettage have been
commonly done.
(b) Because of its propensity for recurrence and
aggressive nature, some authors advocate
enbloc resection.
INFLAMMATORY CYSTS
PERIAPICAL CYST (RADICULAR CYST;
APICAL PERIODONTAL CYST)
INTRODUCTION
Epithelium at apex of a non vital tooth can be
PATHOGENESIS
presumably stimulated by inflammation to form a
Occurs in several phases:
true epithelium-lined cyst or periapical cysts.
-Phase of initiation
Pulpal inflammation of nonvital tooth reaches to
periapical region and stimulates epithelial cell
rests of Malassez present there.
- Phase of proliferation
Stimulation to cell rests of Malassez leads to
excessive and exuberant proliferation of these cells,
which leads to formation of a large mass .
- Phase of cystification.
The centrally located cells become necrosed due to
lack of nutritional supply giving rise to cyst-like
structure, that contains hollow space inside and
peripheral lining of epithelial cells around it.

- Phase of enlargement
Small cyst formed enlarges by higher osmotic
and hydrostatic tension and through bone
resorbing factor
CLINICAL FEATURES
- Frequency - 60% - 70%
- Age - 3rd to 5th decades
- Sex - Males > Females
- Race - Whites > Blacks
- Site - Maxilla> Mandible
(60%) (40%)
Predilection for maxillary anterior region.
Clinical presentation
(a) Mostly asymptomatic and discovered on
roentgenographic examination of nonvital teeth.
(b) At first enlargement is bony hard but fluctuation
results from complete erosion of bone.
(c) In maxillary buccal or palatal enlargement
occurs. In mandible buccal enlargement is
common.
(d) Pain and infection may be present.

Swelling
RADIOLOGICAL FEATURES
(a) Round ./ ovoid
radiolucency surrounded
by a narrow radiopaque
margin which extends
from lamina dura of
involved tooth is seen at
apex.
(b) Root resorption is
common
HISTOPATHOLOGICAL FEATURES
(a) Stratified squamous epithelium which may
demonstrate Rushton bodies.
(b) Lumen filled with fluid and cellular debris.
Dystrophic calcification, cholesterol clefts with
multinucleated giant cells, RBCs and areas of
hemosiderin pigmentation may be present in
lumen wall or both.
(c) Wall consists of dense fibrous connective
tissue, often with inflammatory infiltrate
containing lymphocytes, neutrophils. plasma
cells, histiocytes and (rarely) mast cells and
eosinophils.
DIFFERENTIALDIAGNOSIS
Periapical granuloma
Periapical abscess
Cementoma (stageI)
Traumatic bone cyst
Bony artifact
TREATMENT AND PROGNOSIS
(a) Extraction and curettage.
(b) Root canal therapy with apicoectomy of
involved tooth.
(c) Residual cysts may develop later.
(d) Epidermoid carcinoma develops from lining
epithelium.
 RESIDUAL PERIAPICAL CYST

INTRODUCTION
When a radicular cyst remains behind in the jaws after
removal of offending tooth , it is referred to as residual
cyst.

ETIOLOGY
- Develops upon either a deciduous tooth / retained root
that later exfoliates or is extracted.
- Tooth associated with dentigerous cyst is removed but
cyst is unrecognized, the residual cyst will persist and
increase in size.
- Incomplete removal of periapical cyst /
granuloma
CLINICAL FEATURES
Incidence - less common than radicular cyst.

(Daniel E. Waite)
Age - middle aged / elderly
Sex - Equal
Site - Maxilla > Mandible
Clinical presentation
- Present in edentulous area.
- Majority asymptomatic .
- Found on routine radiographic
examination.
- Pathologic fracture or encroachment on
associated structures.
RADIOLOGICAL FEATURES
- Round to oval radiolucency of variable
size within alveolar ridge at site of a
previous tooth extraction.
- As the cyst ages, dystrophic
calcification and central luminal
radiopacity results from degeneration
of luminal cellular contents.

TREATMENT
- Same as for apical cyst but preserve
contour of edentulous ridge.
BUCCAL BIFURCATION CYST
INTRODUCTION
It is an uncommon inflammatory cyst that
characteristically develops on buccal aspect of
PATHOGENESIS
mandibular first permanent molar.
When tooth erupts, an inflammatory response
may occur in surrounding follicular tissues
that stimulate cyst formation.

CLINICAL FEATURES
Age - Children from 5-11 yrs
 Clinical presentation
(a) Slight to moderate tenderness on buccal
aspect of erupting mandibular first molar.
(b) Clinical swelling and a foul tasting discharge
present.
(c) Periodontal probing reveals pocket formation
on buccal aspect.

RADIOLOGICAL FEATURES
Well circumscribed unilocular radiolucency
involving buccal bifurcation and root area of
involved tooth.
- 1.2 2.5 cm in diameter.
- Occlusal radiograph is helpful.
- Root apices of molar are tipped towards the
lingual mandibular cortex.
- Many cases associated with proliferative
periosteitis of overlying buccal cortex.
HISTOPATHOLOGICAL FEATURES
- Non-specific
- Lined by nonkeratinizing stratified
squamous epithelium with areas of
hyperplasia.
- A prominent chronic inflammatory cell
infiltrate in connective tissue wall.

TREATMENT AND PROGNOSIS

(a) Usually enucleation ; extraction
unnecessary.
(b) Complete healing with in 1 year.