Cyst Of Jaw

Cysts Of The Oral And
Maxillofacial Region

• Defination
• Types Of Cysts
• Parts Of A Cyst
• Classification Of Jaw Cysts
• Clinical, Radiological, Histological Features And
Differential Diagnosis Of Important Jaw Cysts.
OVERVIEW

• A Cyst is a pathological cavity having fluid,
semifluid or gaseous contents and which is
not created by the accumulation of pus.
Most cysts, but not all, are lined by
epithelium. (KRAMER 1974).
DEFINATION OF CYST

• TRUE CYSTS: that which is lined by
epithelium e.g dentigerous cyst, radicular
cyst etc.
• PSEUDO CYSTS: not lined by epithelium, e.g.
Solitary bone cyst, Aneurismal bone cyst etc
TYPES OF CYSTS

Cyst has following parts:
• WALL (made of connective
tissue)
• EPITHELIAL LINING
• LUMEN OF CYST
PARTS OF A CYST

1 Developmental Origin
(a) Odontogenic
i. Gingival cyst of infants
ii. Odontogenic keratocyst
iii. Dentigerous cyst
iv. Eruption cyst
v. Gingival cyst of adults
vi. Developmental lateral periodontal
cyst
vii. Botryoid odontogenic cyst
viii. Glandular odontogenic cyst
ix. Calcifying odontogenic cyst
I. CYSTS OF THE JAWS
A. EPITHELIAL-LINED CYSTS
b) Non-odontogenic
i. Midpalatal raphé cyst of infants
ii. Nasopalatine duct cyst
iii. Nasolabial cyst

2 INFLAMMATORY ORIGIN
i. Radicular cyst, apical and lateral
ii. Residual cyst
iii. Paradental cyst and juvenile paradental cyst
iv. Inflammatory collateral cyst
B. NON-EPITHELIAL-LINED CYSTS
1. Solitary bone cyst
2. Aneurysmal bone cyst
I. CYSTS OF THE JAWS

1. Mucocele
2. Retention cyst
3. Pseudocyst
4. Postoperative maxillary cyst
II. CYSTS ASSOCIATED WITH THE
MAXILLARY ANTRUM

1. Dermoid and epidermoid cysts
2. Lymphoepithelial (branchial) cyst
3. Thyroglossal duct cyst
4. Anterior median lingual cyst (intralingual cyst of foregut origin)
5. Oral cysts with gastric or intestinal epithelium (oral alimentary tract cyst)
6. Cystic hygroma
7. Nasopharyngeal cyst
8. Thymic cyst
9. Cysts of the salivary glands: mucous extravasation cyst; mucous retention cyst;
ranula; polycystic (dysgenetic) disease of the parotid
10. Parasitic cysts: hydatid cyst; Cysticercus cellulosae; trichinosis
III. CYSTS OF THE SOFT TISSUES OF THE
MOUTH, FACE AND NECK

TWO STAGES
1. Cyst initiation
2. Cyst enlargement or expansion
PATHOGENESIS
a. Initiation
b. Formation
c. Enlargement

• Initiation results in the proliferation of the epithelial cells and the
formation of small cavity.
a. Cell Rests of Malassez :
Remanants of Hertwigs epithelial root sheath in the PDL after the
root formation is completed.
b. Reduced Enamel Epithelium :
Residual epithelial cells surrounds the crown of the tooth after
enamel formation is complete.
c. Cell Rests of Serres (Dental Lamina) :
Islands of epithelial cells that originate from the oral epithelium and
remain in the tissue after inducing tooth development.
CYST INITIATION

THEORY
Harris (1974) Postulated the theories
1) Mural growth
a) Peripheral cell division
b) Accumulated contents
2) Hydrostatic
a) Secretion
b) Transuduation & exudation
c) Dialysis
CYST ENLARGEMENT

1. Increase in the volume of its contents.
2. Increase in the surface area of the sac or epithelial
proliferation.
3. Resorption of surrounding bones.
MECHANISM REGARDING
ENLARGEMENT

FACTORS
1. Secretions:
Mucus secreting cyst – Lining secretes mucus – accumulation of mucus – increase in volume
2. Transudation & exudation: Inflammatory cyst or Presence of infection.
a. Inflammatory cells release cofactors
b. Lymphocytes release lymphokine
c. Osteoclast activating factor (OAF) &
d. Monocytes release interleukin- I
3. Increased osmolarity:
a. Raises internal hydrostatic pressure.
b. Attracts fluid into the cavity.
c. Retention of fluid within the cavity
INCREASE IN THE VOLUME

• Toller suggested the role of osmolarity by the cyst fluid in
enlargement of cyst. The Mean Osmolarity was 296 mosmol
compared with Serum Osmolarity of 282 mosmol.
• The increase in the osmotic pressure is related to proteins
present in the cyst fluid such as large molecules of albumin,
globulin, fibrinogen.
• Desquamated epithelial cells of cyst lining undergo autolysis &
produce a larger number of molecules of lower molecular weight,
raising the osmolarity of the fluid.
RAISED INTERNAL
HYDROSTATIC PRESSURE

• DIALYSIS :
It results from the higher osmolarity of cyst fluid than serum.
• OSMOTIC PRESSURE :
It’s related to the number of dissolved particles in a solution.
• OSMOLARITY :
It’s the number of these dissolved particles.
• Fluid is attracted into the cyst cavity by products of epithelial cell
autolysis.
• Water from the tissue fluid (surrounding tissue) is attracted into the
cyst to raise the internal pressure.
• This hydrostatic pressure is transmitted to the adjacent bone.
ATTRACTION OF FLUID INTO
THE CAVITY

• Semi permeable membrane –
governs access into the cyst prevents the escape of certain
substances from the contents.
• Attracted fluid are unable to diffuse out of the cavity.
• The products of epithelial autolysis could effect both osmotic
attraction and retention within the cavity.
RETENTION OF FLUID WITHIN
THE CAVITY

Mural growth
1) Peripheral cell division
2) Accumulated contents
• Presence of low grade infection -- stimulate cells – cell rests of
Malassez – to proliferate and form arcades of epithelium.
• Collagenase activity – increased collagenolysis – in primordial &
radicular cyst.
• Proliferation of local group of epithelial cells – as in keratocysts
• Unremitting growth – epithelial lining in keratocysts due to high mitotic
value.
EPITHELIAL PROLIFERATION

• Increased internal pressure – transmitted to the adjacent bone –
bone undergoes resorption – bony cavity enlarged.
• Due to the above changes, the surface area of cyst lining is
increased by cell multiplication.
• Epithelial cells divide – cyst enlarges within bony cavity by the
release of bone resorbing factors from the capsule.
• Stimulate osteoclast function – eg: prostaglandins like PGE2 &
PGI2.
BONE RESORPTION

52.30%
18.10%
11.60%
8%
5.60%
4.20% SHEAR 2006 Radicular cyst
Dentigerous cyst
Odontogenic keratocyst
Residual cyst
Paradental cyst
Unclassified odontogenic
cysts
FREQUENCY OF EPITHELIAL
CYSTS OF JAWS

• The dentigerous cyst is defined as a cyst that originates
by the separat ion of the follicle from around the crown
of an unerupted tooth
• The dentigerous cyst encloses the crown of an
unerupted tooth and is attached to the tooth at the
cementoenamel junction
• The pathogenesis of this cyst is uncertain, but
apparently it develops by accumulation of fluid
between the reduced enamel epithelium and the tooth
crown.

Gross specimen of a dentigerous cyst.
Cyst encloses the crown of the tooth and is attached to
its neck
DENTIGEROUS CYST

AGE : 1st to 3rd decades.
GENDER : more frequently in males than in females.
SITE :
• 2/3rd of follicular cyst associated with unerupted mandibular
teeth, primarily III molar.
• Maxillary canine
• Mandibular premolar
• Maxillary 3rd Molar
• Supernumerary tooth also can be involved
CLINICAL FEATURES

• Most cysts grow to a large size before being discovered
accidentally while observing a dental x ray to detect
the cause of an unerupted tooth.
• Large lesions can cause cortical expansion, leading to
facial asymmetry, teeth displacement, root
resorption, even pain, if infected.
SIGNS & SYMPTOMS

• Manifests as unilocular, well defined, ‘lucency with
sclerotic margins, associated with crown of impacted /
unerupted tooth.
• A large DC may show persistence of boney
trabeculae, giving the appearance of multilocularity.
RADIOLOGICAL FEATURES

• CENTRAL TYPE:
• LATERAL TYPE :
• CIRCUMFERENTIAL
TYPE :

A central type of dentigerous cyst. Note resorption of
the root of the first mandibular molar
RADIOGRAPHIC FEATURES

Radiograph of two dentigerous cysts in the same
patient. The cyst on the right is a lateral type; that on
the left is a circumferential type

CT scan of a maxillary dentigerous cyst extending
to, and impinging on, the floor of the nose.

HISTOLOGICAL FEATURES
A. NON INFLAMMED TYPE:
• Lining derived from reduced dental epithelium, consists of 2-4
cell layers of non keratinized epithelium, without rete ridges.
• Wall composed of thin fibrous connective tissue appearing
immature, as it is derived from the dental papilla.

NON INFLAMED dentigerous cyst shows a thin.
nonkerat inized epithelial lining.
NON INFLAMMED TYPE

A. INFLAMED TYPE :
• Lining shows varying degrees of hyperplasia with rete ridges
and occasionally even keratinization.
• Wall is composed of mature connective tissue which shows
infiltration by chronic inflammatory cells.
• Focal areas of mucous cells can be seen in the lining. Small
odontogenic epithelial islands can be seen in the wall.

INFLAMED DENTIGEROUS CYST shows a thicker
epithelial
lining with hyperplastic rete ridges. The fibrous cyst
capsule shows a diffuse chronic inflammatory infiltrate
INFLAMED TYPE

DIFFERENTIAL DIAGNOSIS
Although it presents a unique feature, yet some lesions
must be considered in its differential diagnosis :
1. Unicystic ameloblastoma
2. Adenomatoid odontogenic tumor.

COMPLICATIONS
1. Recurrence due to incomplete surgical removal.
2. Development of ameloblastoma either from lining epithelium
or from odontogenic islands in the connective tissue wall.
3. Development of squamous cell carcinoma from same two
sources.
4. Development of mucoepidermoid carcinoma from mucus
secreting cells in the lining.

• The odontogenic keratocyst is a distinctive form of developmental
odontogenic cyst that deserves special consideration because of its
specific histopathologic features and clinical behavior.
• There is general agreement that the odontogenic keratocyst arises
from cell rests of the dental lamina.
• This cyst shows a different growt h mechanism and biologic behavior
from themore common dentigerous cyst and radicular cyst.
• odontogenic kerato cysts. and th eir growth may be related to
unknown facto rs inherent in the epit helium itself or enzym atic
activity in the fibrous wall.
• Several investigators suggest that odontogenic keratocysts be
regarded as benign cystic neoplasms rather than cysts

AGE : occur over a wide age range and cases have been
recorded as early as the first decade and as late as
the ninth.
In most series there has been a pronounced peak
frequency in the second and third decades.
GENDER : more frequently in males than in females.
SITE : The mandible is involved far more frequently than
the maxilla
50% cases occur in angle region and extend to
ascending ramus and forwards to body of
mandible.
CLINICAL FEATURES

Relative distribution of
odontogenic keratocysts in the jaws.
SITE DISTRIBUTION

• Pain, swelling or discharge.
• Occasionally, paraesthesia of the lower lip or teeth.
• Some are unaware of the lesions until they develop
pathological fractures.
• In many instances, patients are remarkably free of
symptoms until the cysts have reached a large size, involving
the maxillary sinus and the entire ascending
ramus, including the condylar and coronoid processes.
• occurs because the OKC tends to extend in the medullary
cavity and clinically observable expansion of the bone
occurs late.
CLINICAL FEATURES

GORLIN-GOLTZ syndrome, characterized by
• Multiple nevoid basal cell epitheliomas
• Odontogenic Keratocyst of the jaws
• Bifid ribs– sixth rib
• Plantar & palmar pits
• Occular hypertelorism
• Frontal bossing
• Ectopic calcifications

• OKC demonstrate a well-defined radiolucent area with
smooth and often corticated margins.
• Large lesions, particularly in the posterior body and
ascending ramus of the mandible, may appear multilocular
• An unerupted tooth is involved in the lesion in 25% to 40%
of cases; in such instances, the radiographic features
suggest the diagnosis of dentigerous cyst

Radiograph of a small odontogenic keratocyst.

Radiograph of an odontogenic keratocyst with scalloped
margins.

Radiograph of a multilocular odontogenic keratocyst.

Radiograph of an odontogenic keratocyst that has
enveloped an unerupted tooth to produce a
‘dentigerous’ appearance.

• The epithelial lin ing is composed of a uniform layer of stratified
squamous epithelium,usually six to eight cells in thickness.
• The epithelium and connective tissue interface is usually flat, and
rete ridge formation is inconspicuous.
• The basal cell layer has columnar / cuboidal cells with reversely
polarized nuclei, imparting a “picket fence” or “tombstone”
appearance.
• The luminal surface shows flattened parakeratotic epithelial
cells, which exhibit a wavy or corrugated appearance.
• Small satellite cysts, cords, or islands of odontogenic epithelium
may be seen within the fibrous wall .
HISTOLOGIC FEATURES

Epithelial lining is 6 to 8 cells thick, with a hyperchromatic and
palisaded basal cell layer. Note the corrugated parakeratotic
surface.
OKC

Satellite microcysts in the wall of an odontogenic keratocyst that
appear to be arising directly from an active dental lamina.
SATELLITE MICROCYSTS

• In case of unilocular ‘lucencies – Dentigerous cyst, Eruption
cyst, COC, AOT, Unicystic ameloblastoma etc.
• In case of multilocular ‘lucencies – Conventional
ameloblastoma, CEOT, Central giant cell
granuloma, Aneurysmal bone cyst etc.

• COMPLICATIONS IN OKC :
1. Malignant transformation of cyst lining rare, but has been
reported.
2. Recurrence – high rate of recurrence.
• REASONS FOR RECURRENCE :
1. Thin, fragile lining is very difficult to remove completely.
2. New cysts develop from satellite cysts left behind.
3. Some cysts may be left behind in cases of Gorlin – Gotz
syndrome.
4. New cysts can also develop from basal cells of overlying oral
epithelium, especially in ramus – 3rd molar region.

• Typical c/f of an eruption cyst. Note a
bluish colored, dome shaped swelling
over the unerupted molar.
• The dentigerous cyst develops around
the crown of an unerupted tooth
lying in the bone,
• The eruption cyst occurs when a
tooth is impeded in its eruption
within the soft tissues overlying the
bone.
ERUPTION CYST
Eruption cysts involving the maxillary permanent
incisors.

The circumscribed cavity contains blood (due
to surface trauma on biting with opposite
tooth )
It imparts purple / deep blue color
Hence known as
• ERUPTION HEMATOMA
PATHOGENESIS

CLINICAL FEATURES
AGE : found in children of different ages, and occasionally
in adults if there is delayed eruption
SITE : most commonly associated with the first permanent
molars and the maxillary incisors

• The cyst may throw a soft-tissue shadow, but there is
usually no bone involvement except that the dilated and
open crypt may be seen on the radiograph.

• Show surface oral epithelium on the
superior aspect. The underlying
lamina propria shows a variable
inflammatory cell infiltrate.
• The deep portion of the
specimen, which represents the roof
of the cyst, shows a thin layer at
nonkeratinizing squamous epithelium
A cystic epithelial cavity can be seen below
the mucosal surface.

PATHOGENESIS
• A number of suggestions have been made about
thepathogenesis of the gingival cyst in adults.
• It was originallyproposed that they may arise from
odontogenicepithelial cell rests; or by traumatic
implantation ofsurface epithelium; or by cystic
degeneration of deep projectionsof surface
epithelium

ORIGIN
• Cystic transformation of dental lamina, traumatic
implantation of surface epi
• Dome shaped soft, fluctuant swelling which is <1cm in
diameter
• Lesion is slow growing and painless
• Adjacent teeth usually vital

Signs and symptoms:
• Slowly enlarging, well
circumscribed painless swelling.
• Invariably occurs on facial
aspect of free / attached
gingiva.
• Surface of lesion is smooth and
of normal color.
• Fluctuant lesion, adjacent teeth
are vital
CLINICAL FEATURES
Clinical photograph of a gingival cyst of an adult
AGE : 5th – 6th decade of life
SITE : mand. canine and Pre Molar
area; attached gingiva or I/D papilla

Radiograph of a gingival cyst in an adult. There is a faint
radiographic shadow (marked with arrows) indicative of superficial
bone erosion.

• H/p features identical to Lateral
periodontal cyst.
• Some cysts lined by
thin, flattened stratified
squamous epithelium.
• Sometimes, focal thickenings
(Plaques) may be found within
the lining.
HISTOLOGY
The epithelial lining of a gingival cyst of
the adult (G) lying contiguous to the
junctional epithelium (J) of an adjacent
tooth.

• Uncommon, but well recognized type of odontogenic cyst.
• The designation ‘lateral periodontal cyst’ is confined to those
cysts that occur in the lateral periodontal position and in which
an inflammatory etiology and a diagnosis of collateral OKC have
been excluded on clinical and histological grounds
(Shear and Pindborg, 1975).
LATERAL PERIODONTAL CYST

• Age : 20 – 60 years, peak in 6th decade.
• Sex : Male predilection.
• Site : Lateral PDL regions of mandibular premolars,
followed by anterior maxilla
CLINICAL FEATURES

• Usually asymptomatic as it occurs on the lateral aspect of
root of tooth.
• Occasionally pain and swelling may occur.
• Associated teeth are vital, unless otherwise affected.
• Cysts rarely < 1cm in size, except for BOTRYOID VARIETY
which is larger and also a multilocular lesion.
SIGNS & SYMPTOMS

• Round to ovoid ‘lucency with
sclerotic margins.
• Cyst can be present
anywhere between cervical
margin to root apex.
• Radiographically, it can be
confused with collateral OKC.
Radiograph of a lateral periodontal cyst lying between the
mandibular premolar teeth. The margins are well
corticated, indicative of slow enlargement.

Lateral periodontal cyst. Radiolucent lesion
between the roots of a vital mandibular canine and
first premolar.
Lateral periodontal cyst. A larger lesion causing
root divergence.

• The lateral periodontal cysts were lined by a thin, non-keratinising layer
of squamous or cuboidal epithelium usually ranging from 1 to 5 cell
layers wide, which resembled the reduced enamel epithelium
• The epithelial cells were sometimes separated by intercellular fluid.
Their nuclei were small and pyknotic.
• An interesting feature seen in many of the lateral periodontal cysts was
the presence of what appear to be localised plaques or thickenings of
the epithelial lining
• Small epithelial nests may be seen in connective tissue wall, which may
show signs of mild inflammation.

Lateral periodontal cyst which in part has a thin, nonkeratinised
stratified squamous epithelial lining resembling reduced enamel
epithelium. Two epithelial plaques are seen. The one on the right is
convoluted

Diagram illustrating the possible mode of formation of epithelial plaques by localised proliferation of cells.
(a) Cyst lined by thin epithelium resembling reduced enamel epithelium. (b) Early epithelial thickening by basal cell
proliferation. (c) Basal cells continue to proliferate. Superficial cells swell by accumulation of intracellular fluid. (d) and (e)
Basal proliferation ceases or slows down. Superficial cells are waterlogged and swollen. Plaque protrudes into cyst cavity
and cyst wall where it can undermine and raise adjacent cyst lining. (f) Epithelial plaque can form convolutions. Protrusions
into cyst wall as in (c–f) may be ‘pinched off’ and develop into daughter cysts, leading to the formation of the botryoid
variety of lateral periodontal cyst.

• Also called as Odontogenic ghost cell cyst or Gorlin cyst.
• It Has many features of odontogenic tumor, therefore it is
placed in the category of tumors in the latest WHO
classification of odontogenic cysts and tumors.
• In the latest WHO publication on odontogenic tumours
(Prætorius and Ledesma-Montes, 2005) it was classified as a
benign odontogenic tumour and was renamed calcifying
cystic odontogenic tumour (CCOT).
CALCIFYING ODONTOGENIC
CYST

• Age : Wide range, peak in 2nd decade.
• Sex : Equal.
• Site : Anterior segment of both jaws
CLINICAL FEATURES

• COC is a unicystic process and develops from the
reduced dental epithelium or remnants of dental
lamina.
• The cyst lining has the potential to induce
formation of dentinoid or even odontoma in
adjacent CT wall.
PATHOGENESIS

• Group 1 : ‘Simple’ cysts Calcifying odontogenic cyst (COC)
• Group 2 : Cysts associated with odontogenic hamartomas or benign
neoplasms: calcifying cystic odontogenic tumours (CCOT).
• Group 3 : Solid benign odontogenic neoplasms with similar cell
morphology to that in the COC, and with dentinoid Formation
• Group 4 : Malignant odontogenic neoplasms with features similar to
those of the dentinogenic ghost cell tumour Ghost cell
odontogenic carcinoma
CLASSIFICATION OF THE ODONTOGENIC GHOST
CELL LESIONS

• Swelling is the commonest complaint, seldom
associated with pain.
• Intraosseous lesions can cause hard bony expansion
and resulting facial asymmetry.
• Displacement of teeth can also occur.
SIGNS & SYMPTOMS

• Intraosseous lesions produce
well defined lucency which
is usually unilocular.
• Irregular calcified masses of
varying sizes may be seen
within the lucency.
• Displacement of root/roots
with or without root
resorption and expansion of
cortical plates also seen
Radiograph of a calcifying odontogenic cyst of the maxilla.
There is a well-demarcated margin and calcifications
suggestive of tooth material.

Radiograph of a calcifying odontogenic cyst with well-demarcated
margins extending from the right to the left premolar regions of the
mandible. Numerous calcifications are present, some suggestive of
small denticles.

• Lining is usually thin about 6 – 8 cell thick, may be thickened in other
areas.
• Lining shows characteristic odontogenic features with reversely
polarized basal cell layer.
• TYPICALLY – GHOST CELLS may be seen in thicker areas of lining.
• Ghost cells are enlarged, ballooned, ovoid, eosinophilic cells with well
defined cell boundaries.
• Some times many cells may fuse.
• They represent abnormal keratinization and frequently calcify.
• Tubular dentinoid and even complex odontome may be found in
connective tissue wall close to epithelial lining.

Histological features of a calcifying odontogenic cyst with clusters
of fusiform ghost cells and focal calcifications, lying in a stratified
squamous epithelium.

In this calcifying odontogenic cyst, there are sheets of ghost cells
and a focal area in which there has been induction of a strip of
dysplastic dentine (dentinoid).

• Based on radiographic appearance, following
lesions must be included in the provisional
diagnosis –
• Ameloblastoma
• CEOT
• AOT
• Ameloblastic fibro odontoma

NASOPALATINE DUCT
(INCISIVE CANAL) CYST

• Also classified as “FISSURAL CYSTS”.
• Believed to be derived from epithelial remnants included
during closure of embryonic facial processes.
• Controversy – actual “closure” of embryonic processes does
not occur. Grooves between processes is smoothed by
proliferation of underlying mesenchyme.
• Usually occurs within the nasopalatine canal or in soft tissue
of palate at the opening of canal.
NASOPALATINE DUCT

• Age : 4th, 5th & 6th decades.
• Sex : More in females
• Frequency: Commonest non odontogenic
developmental cyst
CLINICAL FEATURES

• In lower animals, the NP duct concerned with olfactory
sensation – in humans only vestigial remnants persist in
incisive canal in form of epithelial islands, ducts, cords etc.
• These nests can show central degenration to form cysts.
Etiology for cyst transformation is yet unclear.
• Some believe, it may arise spontaneously like an OKC.
PATHOGENESIS

• Commonest symptom is
swelling, usually in anterior
region of mid palate.
• Swelling can also occur in
midline on labial aspect of
alveolar ridge.
• If pressure on NP nerves – pain
• Exclude possibility of periapical
cyst by testing vitality of
incisors.
SIGNS & SYMPTOMS

NASOPALATINE DUCT
Small nasopalatine cyst presenting as a soft ovoid
swelling in the midline of the maxilla, posterior to
the central incisor teeth.
Large nasopalatine duct cyst extending laterally and
posteriorly to involve much of the hard palate.

• Seen as lucency usually in incisive
canal – DIFFICULT TO
DISTINGUISH FROM A NATURALLY
LARGE INCISIVE CANAL.
• Lucency with AP dimension upto
10 mm considered as enlarged
incisive canal, but if lucency < 14
mm, then NP duct cyst.
• The lucency appears well defined
with sclerotic borders, in midline
of palate between roots of
incisors.

Radiograph of a nasopalatine duct cyst showing a pear-
shaped radiolucency in the anterior maxilla. The lamina
dura on the left is intact although the apex appears to be
in the cyst.

Shows a large round radiolucency. The roots of the
maxillary incisor teeth are displaced laterally.

• Lining epithelium extremely
variable, consisting of stratified
squamous, pseudo stratified
columnar, simple columnar or
cuboidal epithelium.
• Most commonly lining is
stratified squamous followed by
pseudo stratified columnar.
• A useful diagnostic aid –
presence of large nerve and
vascular bundles in connective
tissue wall.

Neurovascular bundle in the wall of a
nasopalatineduct cyst.

• Radicular cyst, if it is associated with a pulpally
involved tooth.
• Large incisive canal.

• The nasolabial cyst occurs outside the bone in the
nasolabial folds below the alae nasi.
• It is traditionally regarded as a jaw cyst although
strictly speaking it should be classified as a soft
tissue cyst.
NASOLABIAL CYST

• Age : Peak incidence in 4th & 5th decades.
• Sex : More in females.
• Frequency: Rare in occurrence.
CLINICAL FEATURES

• Commonest complaint – slowly
growing swelling and
occasionally, pain and difficulty
in nasal breathing.
• Extra orally – filling out of
nasolabial fold and may lift ala
nasi.
• Intra orally – bulge in labial
sulcus.
• Fluctuant lesion.
SIGNS & SYMPTOMS
Nasolabial cyst producing a swelling of the right
upper lip, forming a bulge in the labial sulcus.

• Believed to develop from lower anterior portion of nasolacrimal
duct.
• When margins of lateral and maxillary processes fuse, ectoderm
along boundary between them gives rise to solid cellular rod which
first develops as a linear surface elevation (Nasolacrimal ridge) and
then sinks into underlying mesenchyme.
• This solid rod canalizes to form NL duct.
• The NL cysts are located such that it is possible that they develop
from embryonic remnants of NL duct.
• Importantly, a mature NL duct is lined by pseudo stratified columnar
epithelium, which is also the lining of NL cyst.
PATHOGENESIS

• Difficult to interpret on
radiograph.
• May be seen as localized
increased lucency of alveolar
process above apices of incisors.
• Lucency results from pressure
resorption on labial surface of
maxilla.
Standard occlusal radiograph of a patient with a nasolabial
cyst. There is a posterior convexity of the left half of the
radiopaque line that forms the bony border of the nasal
aperture.

• Cyst lined by non ciliated
pseudo stratified columnar
epithelium.
• Goblet cells also seen in some
cases.
• Occasionally, part of lining may
be cuboidal / flat squamous.
• Conncetive tissue wall is
fibrous, relatively acellular with
fibers arranged loosely or
compactly.
Nasolabial cyst lined by a pseudostratified
columnar epithelium containing many goblet cells.
In the example illustrated here, mucous glands are
present in the wall.

• Also called APICAL PERIODONTAL CYST
• Radicular cysts are the most common inflammatory cysts
and arise from the epithelial residues in the periodontal
ligament as a result of periapical periodontitis following
death and necrosis of the pulp.
• Quite often a radicular cyst remains behind in the jaws after
removal of the offending tooth and this is referred to as a
residual cyst.
RADICULAR CYST

1. PHASE OF INITIATION:
• Accepted generally that rests of Malassez included within a
developing periapical granuloma proliferates to form the lining
of radicular cyst.
• How these cells are stimulated is not clear.
• Some product of non vital pulp can be responsible which
simultaneously evokes an inflammatory response in CT.
• Immune factors also held responsible as plenty of plasma cells
are seen in a periapical granuloma.
PATHOGENESIS

2. PHASE OF CYST FORMATION:
• Can occur in two possible ways.
• One theory states that epithelium proliferates and covers
the bare connective tissue surface of the abscess cavity.
• Another theory – cyst cavity forms within proliferating
epithelium as the cells in center move away from their
nutrient source.
PATHOGENESIS

3. PHASE OF ENLARGEMENT:
• Enlargement occurs by collection of fluid within
the lumen of the cyst.
• Osmosis plays an important role here as the cyst
wall appears to have the properties of a semi
permeable membrane.
PATHOGENESIS

• Age : peak in 3rd, 4th and 5th decades.
• Sex : Slightly more in males.
• Site : Maxillary anterior region.
• Frequency: Commonest cystic lesion of jaws.
CLINICAL FEATURES

• Primarily symptom less.
• Discovered accidentally during routine dental X ray
exam.
• Slowly enlarging hard bony swelling initially. Later, if
cysts breaks through cortical plates, lesion becomes
fluctuant.
• Diagnostic criteria – associated teeth are non vital
• Rare in deciduous teeth.
SIGNS & SYMPTOMS

• Classically presents as
round / ovoid lucency with
sclerotic borders and
associated with pulpally
affected tooth / teeth.
• If infection supervenes, the
margins become
indistinct, making it
impossible to distinguish it
from a peripaical
granuloma.
Radiograph of a radicular cyst. The lesion is a well
defined radiolucency associated with the apex of a non-
vital root filled tooth.

• Lined partly / completely by non keratinized epithelium of
varying thickness.
• Epithelium usually shows arcading around the connective
tissue.
• The connective tissue wall shows inflammatory infiltrate
mainly in the form of lymphocytes and plasma cells.
• Hyaline / Rushton bodies are found in epithelium and rarely
in connective tissue wall.
• These are curved or linear structure with eosinophilic
staining properties

• Cholesterol crystals in from of clefts are often seen in the
connective tissue wall, inciting a foreign body giant cell
reaction.
• Originate from disintegrating RBC’s in presence of
inflammation.
• Different types of dystrophic calcification are also seen in
connective tissue wall.
• Mucus cell metaplasia as well as respiratory cells may be seen
in the epithelial lining.
• Keratinization if found is due to metaplasia and must not be
confused with an OKC.

Quiescent epithelium lining a mature, long-standing
radicular cyst (H & E).
Mucous cells in the surface layer of the stratified
squamous epithelial lining of a radicular cyst (H & E).

Hyaline bodies in the epithelial lining of a radicular
cyst (H & E).
Mural nodule of cholesterol-containing granulation
tissue fungating into the cavity of a radicular cyst
(H & E).

Radiographic appearance of a large residual
cyst left behind after extraction of 1st
mandibular molar.
• The histopathological features of the
residual cyst are similar to those
described above for conventional
radicular cysts. However, because
the cause of the cyst has been
removed, residual cysts may
progressively become less inflamed
so that eventually the cyst wall is
composed of uninflamed
• The epithelial lining may be thin and
regular and indistinguishable from a
developmental cyst such as a
dentigerous cyst or lateral
periodontal cyst. collagenous fibrous
tissue.
RESIDUAL CYSTS

Following lesions must be distinguished from other periapical
radiolucencies–
1. Periapical granuloma
2. Peripaical cemento – osseous dysplasia (early lesions)
DIFFERENTIAL DIAGNOSIS:

• A cyst of inflammatory origin-
occurring on lateral aspect of root
of partially erupted mandibular
3rd molar with an associated
history of pericoronitis
• Age : 20-40 years
• Tooth is vital
• Facial swelling
• Facial sinus in some cases
PARADENTAL CYSTS

• Affected tooth is tilted Well
demarcated RadioLucency Distal
to partially erupted tooth
• Lamina Dura is intact
• New bone may be laid down
(a,b) Two cases of bilateral paradental cysts associated with erupting
mandibular third molar teeth. The cysts are distal and buccal to the
involved teeth. Note that the periodontal ligament space is not widened
and that the distal part of the cyst is separate from the distinct distal
follicular space.

• The cysts are lined by a
hyperplastic, non-
keratinised, stratified squamous
epithelium which may be spongiotic
and of varying thickness.
• An intense inflammatory cell
infiltrate was present associated
with the hyperplastic epithelium
and in the adjacent
• fibrous capsule is the seat of an
intense chronic or mixed
inflammatory cell infiltrate. fibrous
capsule
Paradental cyst adjacent to the root of an impacted
mandibular third molar. The cyst is lined by non-keratinised
stratified squamous epithelium of variable thickness and
showing areas of proliferation (H & E).

• Uncommon cyst, found mostly in long bones and spine.
• CLINICAL FEATURES: -
1. Age : First 3 decades.
2. Sex : Mainly females.
3. Site : molar regions of mandible & maxilla.
• Signs & symptoms:
Hard, rapidly growing swelling which can cause malocclusion.
If lesion perforates cortical plates, can cause “egg shell
crackling”.
ANEURYSMAL BONE CYST

• Controversy whether lesion arises de novo or from
a vascular disturbance in the form of sudden
venous occlusion or development of an AV shunt
occurring secondarily in a pre existing lesion like
central giant cell granuloma, Osteosarcoma etc.
• Due to the malformation, change in hemodynamic
forces occurs which can lead to ABC.
PATHOGENESIS

• Classically seen as a unilocular, ovoid / fusiform lucency
which balloons the cortical plates.
• Teeth displacement and root resorption also observed.
• Lesions are usually unilocular but longer-standing lesions
may show a ‘soap-bubble’ appearance and may become
progressively calcified

Radiograph of an aneurysmal bone cyst involving the angle and
ascending ramus of the mandible. There is a ballooning expansion
of the cortex.

• It consist of many capillaries and blood-filled spaces of varying size lined by
flat spindle cells and separated by delicate loose-textured fibrous tissue
• Most lesions contain small multinucleate cells and scattered trabeculae of
osteoid and woven bone.
• In some of the solid areas, sheets of vascular tissue, containing large
numbers of multinucleate giant cells, fibroblasts, haemorrhage and
haemosiderin, look very much like giant cell granuloma of the jaws
• The diagnosis is made primarily on the basis of the clinical and radiological
features because histologically such solid lesions may be indistinguishable
from giant cell granuloma.

Aneurysmal bone cyst in which the solid areas have
histological features identical to those of the central
giant cell granuloma of the jaws (H & E).
Aneurysmal bone cyst of the mandible. The solid
areas show the features of cemento-ossifying
fibroma and a portion of one of the many cystic
spaces is present at the top of the photomicrograph
(H & E).

• Conventional ameloblastoma
• CEOT
• Central giant cell granuloma

• Also called as Hemorrhagic bone cyst, or Traumatic
bone cyst.
• Commonly seen in mandible, rare in maxilla.
• Identical to solitary bone cyst of humerus in
children and adolescents.
SOLITARY BONE CYST

• Age : Young individuals
• Sex : Equal
• Site : Body and symphysismenti of mandible.
CLINICAL FEATURES

• None of the theories are certain about exact cause.
• First theory – cyst may follow trauma to bone which causes
intra medullary hemorrhage which fails to organize. This clot
subsequently liquefies - CYST.
• Recent theory osteogenic cells fail to differentiate locally
and thus instead of bone, the undifferentiated cells form
synovial tissue.
PATHOGENESIS

• Asymptomatic.
• Rarely, swelling and pain may be seen.
• Half of all patients give a history of trauma to the
area.
SIGNS & SYMPTOMS

• Appears as a lucency with
irregular but well defined
edges and slight
cortication.
• On occlusal view the
‘lucency is seen to extend
along cancellous bone.
Radiograph of a solitary bone cyst involving an
extensive area in the right body of the mandible. This
example has a well-defined margin with cortication.
Interradicular scalloping is a prominent feature.

• Lumen not lined by any
epithelium (Pseudo cyst).
• Wall shows loose fibro vascular
connective tissue.
• Hemorrhage and hemosiderin
pigment usually present.
• Multinucleated giant cells
scattered within the connective
tissue.
• Adjacent bone shows
osteoclastic resorption on inner
surface.
A solitary bone cyst of the jaw. The lining is
composed of loose vascular fibrous tissue with
osteoclastic activity on the surface of the adjacent
bone (H & E).

REASONS
• Cysts tend to increase in size.
• Cysts tend to get infected.
• Cysts weaken the jaw. ( pathological fracture)
• Some cysts undergo changes. Eg:
Ameloblastoma, Mucoepidermoid carcinoma ( histological study
to be done)
• Cysts prevent eruption of teeth. (dentigerous cyst)
• Involvement of neighboring structures.( maxillary
sinus, nose, adjacent tooth)
PRINCIPLES OF TREATMENT

1. To remove the lining totally or to remove a part of lining to
enable the body to rearrange the position of abnormal
tissue so that it is eliminated from within the jaws.
2. To preserve important adjacent structures such as nerves
and healthy tissues.
3. To achieve rapid healing of the operation site.
4. To restore the part to a near normal form and to restore
normal function.
1. AIMS OF TREATMENT

1. Marsupialization (Partch 1 Operation) (Cystotomy)
Combined Decompression & enucleation
Marupialization through nose or antrum
2) Enucleation (Partch 2 Operation) (Cystectomy))
a) Enucleation & packing
b) Enucleation & primary closure
c) Enucleation & primary closure with reconstruction / bone grafting
TREATMENT

• RADIOLOGY
a. Periapical x-rays
b. Occlusal view x-rays
c. Lateral oblique view x-rays
d. Panoramic x-rays
e. P.A view x-rays
f. Sinus view x-rays
• C.T.SCAN
• RADIOPAQUE DYES
• ASPIRATION
• BIOPSY
DIAGNOSIS

VARIOUS ASPIRATES
PATHOLOGY ASPIRATE Other Findings of Aspirates
Dentigerous Cyst Clear, pale straw colour
fluid
Cholesterol crystals.
Total protein in excess
4 g / 100ml. Resembles serum
Odontogenic Keratocyst Dirty, creamy white
viscoid suspension
Para keratinized squames.
Total protein less than
4 g /100ml. Mostly albumin
Periodontal Cyst Clear, pale yellow straw
colour fluid
Cholesterol crystals.
Total protein 5 — 11g / 100ml
Infected Cyst Pus, brownish fluid Polymorphonuclear leukocytes,
,Cholesterol clefts
Mucocele, Ranula Mucus -----
Gingival Cysts Clear fluid -----

VARIOUS ASPIRATES
PATHOLOGY ASPIRATE Other Findings of
Aspirates
Solitary Bone Cyst Serous fluid, blood or
empty cavity
Necrotic blood clot
Stafne’s Bone Cyst Empty cavity – yield air ---
Dermoid Cyst Thick sebaceous material ---
Fissural Cyst Mucoid fluid ----

Cysts of the jaws are treated in one of the following four basic methods:
(1) Enucleation,
(2) Marsupialization,
(3) A staged combination of the two procedures, and
(4) Enucleation with curettage.
TREATMENT

• Enucleation is the process by which the total removal of a cystic lesion
is achieved.
• By definition, it means a shelling- out of the entire cystic lesion without
rupture.
• Enucleation of cysts should be performed with care, in an attempt to
remove the cyst in one piece without frag-mentation, which reduces
the chances of recurrence by increasing the likelihood of total removal.
• However, maintenance of the cystic architecture is not always
possible, and rupture of the cystic contents may occur during
manipulation.
1. ENUCLEATION

Indications :
• Enucleation is the treatment of choice
Advantages :
• pathologic examination of the entire cyst can be undertaken
• the initial excisional biopsy (i.e., enucleation) has also appropriately treated
the lesion.
• The patient does not have to care for a marsupial cavity with constant
irrigations.
Disadvantages
• Normal tissue may be jeopardized
• Fracture of the jaw
• Devitalization of associated teeth
• Impacted teeth that the clinician may wish to save could be removed.
ENUCLEATION

TECHNIQUE :
• Aspiration Biopsy of Radiolucent Lesions
• Mucoperiosteal Flaps
• Osseous Window
• Removal of Specimen
ENUCLEATION

Aspiration Biopsy of Radiolucent Lesions :
• Any radiolucent lesion should be aspirated before surgical exploration.
• This provides the dentist with valuable diagnostic information regarding
the nature of the lesion
Mucoperiosteal Flaps :
• Several varieties of mucoperiosteal flaps are available; the choice
depends chiefly on the size and location of the lesion.
• Access may necessitate extension of the irmcoperiosteal flap. The
location of the lesion dictates where the flap incisions are to be made.
• the flap design should provide 4 to 5 mm of sound bone around the
anticipated surgical margins
• mucoperiosteal flaps for biopsies in or on the jaws she be full thickness
and incised through mucosa, submucosa, and periosteum
ENUCLEATION

Osseous Window :
• once the flap has been elevated, a rotating bur should be used to
remove an osseous window
• The size of the window depends on the size of the lesion and the
proximity of the window to normal anatomic structures such as roots
and neurovascular bundles.
ENUCLEATION

Technique :
• A dental curette is used to peel the connective tissues wall of the
specimen from surrounding bone.
• The concave surface of the instrument should always be kept in contact
with the osseous surfaces of the bone cavity
• The bony cavity is inspected after irrigation with sterile saline
• Any residual fragments of soft tissue within the cavity should be
removed with curettes.
• Once the cavity is devoid of residual pathologic tissue, it is irrigated and
the flap is replaced and sutured in its proper location.
ENUCLEATION

• Marsupialization, decompression, and the Partsch operation all refer to
creating a surgical window in the wall of the cyst, evacuating the
contents of the cyst, and maintaining continuity between the cyst and
the oral cavity, maxillary sinus, or nasal cavity.
• The only portion of the cyst that is removed is the piece removed to
produce the window. The remaining cystic lining is left in situ.
• This process decreases intracystic pressure and promotes shrinkage of
the cyst and bone fill. Marsupialtzatron can be used as the sole therapy
for a cyst or as a preliminary step in management, with enucleation
deferred until later.
2. MARSUPIAIIZATION

1. Amount of tissue injury : Proximity of a cyst to vital structures can mean
unnecessary sacrifice of tissue if enucleation is used.
2. Surgical access : If access to all portions of the cyst is difficult, portions of the
cystic wall may be left behind, which could result in recurrence.
3. Assistance in eruption of teeth : If an unerupted tooth that is needed in the
dental arch is involved with the cyst (i.e., a dentigerous cyst), marsupialization
may allow its continued eruption into the oral cavity
4. Extent of surgery : Marsupialization is a reasonable alternative to
enucleation, because it is simple and may be less stressful for the patient
5. Size of cyst : In very large cysts, a risk of jaw fracture during enucleation is
possible. It may be better to marsupialize the cyst and defer enucleation until
after considerable bone fill has occurred.
INDICATION

Advantages :
• It is a simple procedure to perform. Marsupiaiization also spare vital
structures from damage should immediate enucleation be attempted.
Disadvantages :
• Pathologic tissue is left in situ, without thorough histologic
examination.
• Patient is inconvenienced in several respects
• The cystic cavity must be kept clean to prevent infection, because the
cavity frequently traps food debris.
• In most instances this means that the patient must irrigate the cavity
several times every day with a syringe
MARSUPIAIIZATION

1) Anaesthesia
2) Aspiration
3) Incision
Circular, oval or elliptic. Inverted U shaped incision with broad base
to the buccal sulcus. Mucoperioteum is reflected in this case.
4) Removal of bone
5) Removal of cystic lining specimen
6) Visual examination of residual cystic lining
7) Irrigation of cystic cavity
8) Suturing
Cystic lining sutured with the edge of oral mucosa.
In U shaped incision the mucoperiosteal flap can be turned into cystic
cavity covering the margin. The remaining is sutured to oral mucosa.
TECHNIQUE OF MARSUPIAIIZATION

9) Packing-- Prevents food contamination & covers wound margins.
Done with ribbon gauze soaked with WHITEHEAD VARNISH.
COMPOSTION:
Benzoin – 10g
Iodoform – 10g
Storax - 7.5g
Balsam of Tolu – 5g
Solvent ether to 100ml
Pack removed after 2 weeks.
10) Maintenance of cystic cavity
Instruct the patient to clean and irrigate the cavity regularly with oral
antiseptic rinse with a disposable syringe.
CONTINUE…

11) Use of plug
Prevents contamination. Preserves patency of cyst orifice.
Plug should be stable, retentive and safe design.
Should be made of resilient material ( avoid irritation) like acrylic.
12) Healing
Cavity may or may not obliterate totally. Depression remains in the
alveolar process.
CONTINUE…

3. ENUCLEATION AFTER
MARSUPIALIZATION
INDICATIONS
• When bone has covered the adjacent vital structures.
• Adequate bone fill. Prevents fracture during enucleation.
• When patients find it difficult to cleanse the cavity.
• To detect any occult pathological condition.
ADVANTAGES
• Spares adjacent vital structures
• Accelerates healing process
• Development of thick cystic lining – enucleation easier
• Allows histopathological examination of residual tissue.
• Combined approach reduces morbidity
DISADVANTAGES
• Patient has under go second surgery and any possible complicatton
associated with surgery.

4. ENUCLEATION WITH
CURETTAGE
• Enucleation with curettage means that after enucleation a curette or
bur is used to remove 1 to 2 mm of bone around the entire periphery of
the cystic cavity
• Any remaining epithelial cells that may be present in the periphery of
the cystic wall or bony cavity must be removed.
• These cells could proliferate into a recurrence of the cyst.

Indications :
• In this case the more aggressive approach of enucleation with curettage
should be used.
• Daughter, or satellite, cysts found in the periphery of the main cystic
lesion may be incompletely removed
• The second instance in which enucleation with curettage is indicated is
with any cyst that recurs after what was deemed a thorough removal.
Advantages :
• If enucleation leaves epithelial remnants, curettage may remove
them, thereby decreasing the likelihood of recurrence.
ENUCLEATION WITH
CURETTAGE

Disadvantages :
• Curettage is more destructive of adjacent bone and other tissues
• The dental pulps may be stripped of their neurovascular supply when
curettage is performed close to the root tips
• Adjacent neurovascular bundles can be similarly damaged
ENUCLEATION WITH
CURETTAGE

ENUCLEATION OF OKC
CONSERVATIVE TREATMENT

SURGICAL MANAGEMENT OF OKC
RADICAL TREATMENT

• Large cystic lesion involving left
ramus of Mandible and
extending up.
• There are areas of cortical
break.
Transverse View

Post operative after 1 month Healed incision area

Post operative Ortho Pantomogram

PREPARED AND SUBMITTED BY :
• RAVIRAJ PATEL
• YASIN VAJA
GUIDED BY :
• DR. TARNJEET KAUR
(HEAD OF THE DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY,
GOV. DENTAL COLLEGE AND HOSPITAL, JAMNAGAR)

Cyst Of Jaw

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