This document discusses cystic lesions of the jaw that can occur in children. It defines cysts and describes their classification, including true (epithelial) cysts and pseudo (non-epithelial) cysts. It focuses on odontogenic cysts, which develop from epithelial dental tissues. The two most common odontogenic cysts discussed are dentigerous cysts, which form around the crown of unerupted teeth, and eruption cysts, which occur when a tooth's eruption is impeded. The document outlines the clinical, radiographic, histological features and treatment of these cysts.

1. CYSTIC LESION OF
JAW IN CHILDREN
Presented by: ROSHNI MAURYA
DEPT. OF PEDODONTICS & PREVENTIVE
DENTISTRY

2. OVERVIEW
• Introduction
• Definition
• Types Of Cysts
• Parts Of A Cyst
• Mechanism of Cyst formation
• Classification Of Cysts
• Approach to diagnosis
• Treatment
• Clinical, Radiological, Histological Features And
Differential Diagnosis Of Important Jaw Cysts.

3. Introduction
• The jaws are unique in the skeleton in the amount
and variety of epithelial residues contained within
them and in the range of cystic lesions to which they
give rise.
• Several long term developmental processes are
taking place in the maxillofacial area during the
pediatric age group:
• 3- dimensional growth of maxillofacial skeleton
• Odontogenesis of deciduous & permanent dentition

4. • Management of such lesions is a significant proportion
of the work-load of dental professionals esp. oral and
maxillofacial surgeons and relies on good pre-operative
interpretation of radiographs and computerised
tomography (CT) scans and accurate histopathological
diagnosis of biopsy and surgical specimens.
• One of the keys to improving accuracy in diagnosing
oral lesions is forming an appropriate differential
diagnosis.

5. •This presentation will discuss the
clinical , radiographic & histological
presentation and treatment of the most
common cystic lesions occurring in
children.

6. DEFINITION OF CYST
• 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).
• Cyst can occur within bone or soft tissues
• They may be asymptomatic or associated with
swelling and pain

7. TYPES OF CYSTS
• 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

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

9. Mechanisms of cyst
formation
• The main factors responsible for cyst development
include (in varying degree):
• - proliferation of the epithelial lining and connective
tissue capsule
• - accumulation of fluid within the cyst
• - resorption of the surrounding bone and incomplete
compensatory repair.

10. CLASSIFICATION OF CYST
1. Cyst of the
jaw
Epithelial (true cyst)
Odontogenic
Based on etiology
Developmental
Inflammatory
Based on site of origin
Reduced enamel
epithelium
Cell rest of Serres
Cell rest of
Malassez
unclassified
Non odontogenic
Non Epithelial (pseudo cyst)

11. EPITHELIAL/TRUE CYST
ODONTOGENIC NON ODONTOGENIC
FISSURAL CYST
-median anterior
maxillary cyst
-nasopalatine duct cyst
-nasolabial cyst
-globulomaxillary cyst
-median mandibular
cyst
DEVELOPMENTAL CYST
-palatal cyst of neonate
-thyroglossal tract cyst
-benign cevical
lymphoepithelial cyst
-epidermoid and dermoid
cyst
Heterotopic oral
gastrointestinal cyst

12. ODONTOGENIC
BASED ON ETIOLOGY
DEVELOPMENTAL CYST
-gingival cyst of infants
-gingival cyst of adults
-odontogenic keratocyst
-dentigerous cyst
-eruption cyst
-lateral periodantal cyst
-botryoid odontogenic
cyst
-glandular odontogenic
cyst
-calcifying odontogenic
cyst
INFLAMMATORY
-periapical cyst
-residual cyst
-paradental cyst
BASED ON SITE OF ORIGIN
1)REDUCED ENAMEL EPITHELIUM
-dentigerous cyst
-eruption cyst
2)CELL REST OF SERRE
-odontogenic keratocyst
-gingival cyst of newborn
-gingival cyst of adults
-lateral periodontal cyst
-glandular odontogenic cyst
3)CELL REST OF MALASSEZ
-periapical cyst
-residual cyst
4)UNCLASSIFIED
-calcified odontogenic cyst
-paradental cyst

13. II. Cysts associated with
the maxillary antrum
•
1. Mucocele
2. Retention cyst
3. Pseudocyst
4. Postoperative maxillary cyst

14. III. Cysts of the soft tissues of the
mouth, face and neck
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

15. Frequency of Epithelial Cysts of Jaws
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

16. APPROACH OF DIAGNOSIS
• Complete history:
Pain , duration , tooth mobility or loss ,
occlusion ,swelling , delay eruption
• Physical examination :
Inspection , palpation , percussion .
• Radiology:
, Periapical x-rays
panoramic, dental radiograph, CT.
• Radiopaque dyes
• Aspiration
• Biopsy:

17. TREATMENT
• 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.

18. Aims 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.

19. 1. Enucleation
• 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.

20. 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.

21. ENUCLEATION OF CYST

22. 2. Marsupialization
• 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.

23. Indication
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.

24. • 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

25. 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 complication
associated with surgery.

26. 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.

27. • 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.

28. • 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

29. Odontogenic cysts

30. DENTIGEROUS CYST
• Synonym: follicular
cyst
• Definition:
• A cyst that forms
around the crown of
UNERUPTED tooth. It
begins when fluid
accumulates in the
layers of REDUCED
ENAMEL EPITHELIUM
or between the
epithelium and the
crown of unerupted
tooth.
CEJ

31. CLINICAL FEATURES:
• -2nd most common cyst in the jaw associated with
UNERUPTED or SUPERNUMERARY TOOTH.
(mesiodens in anterior maxilla)
• -no pain or discomfort
• -clinical examination shows:
• missing tooth with hard swelling
• resulting in facial asymmetry

32. •RADIOGRAPHIC FEATURES:
•1)Location:
•-mandibular or maxillary THIRD MOLAR
•-MAXILLARY CANINE
•-this cyst attaches at CEMENTOENAMEL junction

33. RADIOLOGICAL FEATURES
• CENTRAL TYPE:
• LATERAL TYPE :
• CIRCUMFERENTIAL TYPE :

34. • 2)Periphery and shape
• -well defined cortex with a curved or circular outline
• 3)Internal structure
• -radiolucent except the crown of involved tooth
• 4)Effect of surrounding structure
• -displacement and resorption of adjacent tooth

35. • -it displaces the associated tooth in apical direction
• -maxillary third molar or cuspid may be pushed to the floor of orbit
• -mandibular third molar may be moved to condylar or coronoid region or
to the inferior border of mandible

36. • -the floor of maxillary antrum may be displaced as the cyst invaginates
the antrum
• -The cyst may displace the inferior alveolar nerve canal in an inferior
direction
• Differential Diagnosis
• 1)hyperplastic follicle
• -size of normal follicle space is 2-3mm
• -If the folicular space exceed 5mm assaciated with tooth displacement and
bone expansion,a dentigerous cyst is more likely.
• 2)odontogenic keratocyst
• -OKC does not expand the bone to the same degree as dentigerous
cyst,less likely to resorb tooth,may attach further at apically on the root
instead of CEJ.

37. • 3)ameloblastic fibroma or ameloblastoma
• -dentigerous cyst contain internal structure(tooth)
• 4)adenomatoid odontogenic tumor and calcified odontogenic cyst
• -evidence of a radiopaque internal structure in these two lesion.
• 5)radicular cyst at the apex of primary tooth
• -occasionally surrounds the crown of the developing permanent tooth
positioned apical to it,giving false impression of dentigerous cyst
associated with permanent tooth.
• -occur most often in MANDIBULAR DECIDUOUS MOLAR and the
developing BICUSPIDS
• -thus,clinician should look for extensive caries or large restoration in
primary tooth to indicate radicular cyst.

38. HISTOLOGICAL FEATURES
• Non keratinized squamous epithelium
• 2-10 cell thick .
• May be atrophic or ulcerated .
• Wall dense fibrous and no inflammation .
• Islands of odontogenic epithelium may seen.
• Cyst filled proteineous material and cholesterol cleft
• Long standing cyst may shows dysplasia
• Neoplastic tumors may arise from cyst

39. •Treatment:
Marsupialization & Enucleation
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.

40. ERUPTION CYST
• The eruption cyst occurs
when a tooth is impeded in
its eruption within the soft
tissues overlying the bone.
Eruption cysts involving the maxillary permanent
incisors.

41. PATHOGENESIS
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

42. 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

43. Radiological features
• 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.

44. HISTOLOGICAL FEATURES
• 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.

45. •Management:
•The tissue overlying the crown of the tooth may be
removed, but most eruption cysts probably burst
spontaneously as the tooth erupts.

46. GINGIVAL CYSTS
• Two types of gingival cysts are recognized, namely,
• infantile (dental lamina cyst of the newborn) and
• adult types.

47. Dental lamina cyst of the newborn (GINGIVAL
CYSTS)
• These are multiple, occasionally solitary, superficial raised nodules
on edentulous alv. ridges of infants that resolve without treatment,
derived from rests of dental lamina ,consisting of keratin producing
epi. Lining
• These may enlarge sufficiently to become clinically obvious as creamy
coloured swellings, a few millimetres in diameter, but rupture
spontaneously and heal in a matter of months.
• Microscopically, dental lamina cysts are lined by thin stratified
squamous epithelium and contain layers of desquamated keratin.

48. Gingival cyst

49. •Varient :
1. Epstein’s pearls: Mid palatine raphe.
2. Bohn’s nodules: Junction of hard and soft palate

50. Primordial cyst
arises from cystic changes in developing tooth bud
 before formation of enamel + dentin matrix
 since it arise from tooth bud, tooth will be missing from dental
arch
 unless cyst arose from supernumerary tooth
•

51. CLINICAL FEATURES:
• usually found in children & young adults between 10 years and 30
years of age
• Male predominance .
• 2/3 in the mandible in the posterior alveolar ridge
• In the maxilla , the 3rd molar region is more affected .
• Cyst have remarkable growth potentiality .
• Grow in antero-posterior direction
• Usually single , occasionally multiple ( Golin – Gottz syndrome ).
• Small cyst discovered incidentally by X-ray .
• Large cyst cause bone swelling
•

52. • Pain , mobility and displacement of teeth .
• Occasional paresthesia of lower lips and teeth .
• In some cases extraosseous extension to gingiva.
• Pus discharge and sinus.
• May attain a large destructive size.
• High recurrence rate after Enucleation 25-60%
• Recent WHO classification designate this cyst as Keratocystic
odontogenic tumor .

53.  RADIOGRAPHIC FEATURES
• circular radiolucency
• with radiopaque border with sclerotic or reactive border
• found at site where tooth failed to develop
• more in relation to 3rd molars
• unilocular or multilocular
• seen below or between roots or
• near to alveolar ridge

54. HISTOPATHOLOGY:
• The cyst lined by thin parakeratinized odontogenic
• squamous epithelium of 6-10 cell layer .
• Palisaded layer of columnar or cuboidal basal layer with
reverse polarity .
• Corrugated layer of parakeratin on it’s luminal surface .
• The junction between cyst and connective tissue is weak
• with focal separation.
• Cyst contains desquamated parakeratin , and cheesy
• material
• Inflammation absent .
• Thin fibrous wall .

55. Parakeratin layer
Basal layer

56. Causes of recurrence:
1. Thin fragile lining .
2. Budding or finger like cyst .
3. Daughter cyst .
4. Other dental lamina
5. Focal separation of the
epithelium

57. TREATMENT :
1. Small : Simple nucleation .
2. Large: Nucleation with or without peripheral ostetomy.
3. Complete resection with 1cm margin .
4. Long term follow up .

58. ODONTOGENIC KERATOCYST
Synonyms:
-KERATOCYSTIC ODONTOGENIC TUMOR(KOT)
-primordial cyst
Definition:
The WHO has reclassified this cystic lesion into a unicystic or multicystic
odontogenic tumor on the basis of TUMORLIKE CHARACTERISTIC of the
lining epithelium. The epithelium in the KOT appear to have innate
growth potential, consistent with benign tumor. The epithelial lining is
DISTINCTIVE because it is KERATINIZED (hence the name)and thin (4-8
cells thick).Occasionally,budlike proliferations of epithelium grow from
the basal layer into the adjacent connective tissue wall.Islands of
epithelium in the wall may give rise to SATELLITE MICROCYST.Inside the
cyst contain a viscous or cheesy material derived from epithelial lining.

59. CLINICAL FEATURES:
-KOT account for about one tenth (1/10) of all cystic lesion in jaws
-age:20-30
-sex:male predominance
-may associated with UNERUPTED tooth
-asymptomatic
-aspiration reveal a thick yellow cheesy material(KERATIN)
Have high properties of RECCURENCE ,because of small satellite cyst or
epithelium fragments left behind after surgical removal of epithelium.
RADIOGRAPHIC FEATURES:
1)Location
-most common:POSTERIOR BODY OF MANDIBLE
(90% occur posterior to canine)
:RAMUS (more than 50%)
-the epicenter located superior to inferior alveolar nerve canal

60. -has same pericoronal position as dentigerous cyst.
2)Periphery and shape
-well-defined cortical border
-smooth round or oval shape
-or might have scalloped outline

61. 3)Internal Structure:
-radiolucent
-in some case curved internal septa may be present giving a multilocular
apppearance.

62. 4)Effect on surrounding structure:
-a very characteristic feature that its PROPENSITY TO GROW ALONG THE
INTERNAL ASPECT OF THE JAW CAUSING MINIMAL EXPANSION.
-this occur throughout the mandible except for the upper ramus and
coronoid process.

63. • -the relatively slight expansion contributes to their late
detection,which allow them to reach a large size.
• -KOT can displace and resorb teeth but to a slightly degree
than dentigerous cyst.
• -the inferior alveolar nerve canal may be displaced inferiorly.
• -this may invaginate and occupy the maxillary antrum.

64. RADIOGRAPHIC VARIETIES
1. REPLACEMENTAL –
Cyst forms in place of normal tooth by
degeneration of dental lamina.
2. EXTRANEOUS –
OKC occurs in ascending ramus, away
from tooth bearing areas

65. • Differential Diagnosis:
1)dentigerous cyst
-it is KOT if the cystic outline is connected to the tooth at the point apical to
CEJ,and if no expansion of the cortical plate.
• -although KOT can develop occlusal to developing tooth ,the follicle of involved
tooth is not enlarged as dentigerous cyst.
2)Ameloblastoma
-scalloped margin and multilocular appearance of KOT may resemble
ameloblastoma but ameloblastoma has greater propensity to expand.
3)Odontogenic myxoma
-have similar characteristic of mild expansion and multilocular appearance.
4)Simple bone cyst
-have similar characteristic of scalloped margin and minimal bone expansion
-however the margins of simple bone cyst are more delicate and difficult to detect.
5)4-5% of KOT cases may constitute part of BASAL CELL NEVUS SYNDROME.

66. MANAGEMENT:
• -referral to radiologist for a complete radiologic examination is advisable.
• -resection,curretage,or marsupialization to reduce the size of large lesion
before surgical excision.
• -complete removal of the cystic walls to reduce the chance of recurrence
• -after surgical treatment,it is important to make periodic posttreatment
clinical and radiographic examination to detect any recurrence.
• -recurrent lesion usually develop within the first 5 years but may delayed
as long as 10 years.

67. LATERAL PERIODONTAL CYST
• 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).
• It’s derived from rest of dental lamina

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

69. Signs & symptoms
• 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.

70. RADIOLOGICAL FEATURES
• 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.

71. Radiological features
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.

72. X-ray: Tear or drop shape
radiolucency

73. HISTOLOGICAL FEATURES
• Thin non keratinized squamous
epithelium
• One or two cell thick .
• Some cells are of clear cytoplasm
• The cyst separate from PDL.
Clear cells
Surgical excision of cyst along
with the tooth
MANAGEMENT

74. CALCIFYING ODONTOGENIC CYST
Synonyms:, Calcifying epithelial odontogenic cyst, Gorlin cyst
Definition :
-uncommon slow growing, benign lesions . occupy a spectrum ranging
from a cyst to an odontogenic tumor . It may manufacture calcified tissue
(dysplastic dentin) or associated with an odontoma. when it contains a
more solid component ,it gives appearance resembling ameloblastoma
although it does not behave like one.

75. • CLINICAL FEATURES:
• Mean age:36 years
• first peak:10-19 years
• second peak:seventh decade
• Appearance:slow –growing,painless swelling in jaw
• RADIOGRAPHIC FEATURES:
• 1) location:
• - 75% occur in bone anterior to first molar especially associated with
cuspids and incisors

76. • 2) periphery and shape:
• -vary from well-defined and corticated with a curved, cystlike shape to ill-
defined and regular
• 3) Internal structure:
• -a)completely radiolucent
• -b)evidence of small foci or calcified material that appear as white flecks or
small smooth pebbles
• -c)larger,solid,amorphous masses
• -d)multilocular

77. • 4) effect on surrounding structure:
• -20-50% of cases is associated with tooth(cuspid) and impedes it eruption
• -displacement of teeth and root resorptions
• -perforation of cortical plate may be seen with enlarging lesion.
• MANAGEMENT:
• Enucleation and curettage.

78. RADICULAR CYST
• SYNONYMS:PERIAPICAL CYST,APICAL PERIODONTAL CYST,DENTAL CYST
• Definition:
• Cyst that results when cell rest of Malassez in periodontal ligament are
stimulated to proliferate and undergo cystic degeneration by
inflammatory products from NON VITAL tooth.
• 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.

79. CLINICAL FEATURES:
• The most common type of cyst in the jaw
• Age:3rd-6th decade
• Sex:MALE predominance
• Arise from NON VITAL TOOTH ;
• -due to extensive caries,large restorations,
• trauma
• Asymptomatic
• Larger cyst may cause swelling
• On palpation,the swelling may feel
• A)bony and hard if cortex is intact
• B)crepitant as the bone thins
• C)rubbery and fluctuant if the outer cortex
is lost

80. • Primarily symptom less.
• Discovered accidentally during routine dental X ray
exam.
•Diagnostic criteria – associated teeth are non vital
• Rare in deciduous teeth.

81. • RADIOGRAPHIC FEATURES;
• 1)location:
• -approximately at the apex of a non vital tooth,
• -60% are found in MAXILLA
• -Especially around INCISORS
• and CANINES
• -(mesial/distal surface of tooth root
at the opening of accessory canal
or in deep periodontal pocket)
• -because of distal inclination of the root,cyst that arise from the maxillary lateral
incisor may invaginate the antrum
• -may associated with NONVITAL DECIDUOS MOLAR which is situated buccal to
developing bicuspid.
•

82. • Periphery and Shape:
• -well-defined cortical border
• -if the cyst is secondarily infected,the
• inflammatory reaction surrounding the
• bone may result in loss of this cortex or
• alteration lead to sclerotic border.
• -outline:curved or circular

83. • Internal Structure:
• -radiolucent
• -in long standing cyst,dystrophic calcification may developed,appearing as
sparsely distributed small particulate radiopacities.
• Effects on surrounding structures:
• -large cyst lead to displacement and resorption of adjacent teeth.
• -resorption patern have curved outline
• -the cyst may invaginate the antrum,but there should be evidence of
cortical boundaries between the contents of the cyst and the internal
structure of antrum.
• -cyst may displace mandibular alveolar canal
• in an inferior direction.

84. • -the outer cortical plates of maxilla or mandible may expand in curved or
circular shape

85. • Differential Diagnosis:
• 1)Apical granuloma
• -cyst characterized by round shape,well-defined cortical border,and size greater
than 2cm in diameter.
• 2)early stage of periapical cemental dysplasia,an apical scar or surgical defect
• -patient’s history helps with the differentiation
• 3)Odontogenic keratocyst or Lateral Periodontal cyst
• -vitality of involved tooth should be test.
• -non vital tooth have large pulp chamber due to lack of secondary dentin.
• 4)Benign fibro-osseous lesion
• -a larger radicular cyst that invaginated maxillary antrum may collapse and start
filling in with the new bone.with biopsy,the histologic analysis may result in
ossifying fibroma or benign fibro-osseous lesion.Radiographically,the new bone
will form first at the periphery of the cyst as the cyst shrinks and not in the
center of cyst.(this is different pattern from benign lesion)

87. HISTOLOGICAL FEATURES
• 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

88. HISTOLOGICAL FEATURES
• 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.

89. HISTOLOGICAL FEATURES
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).

90. HISTOLOGICAL FEATURES
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).

91. • MANAGEMENT:
• -extraction
• -endodontic therapy
• -Apical surgery
• Larger cyst
• -surgical removal
• -marsupialization

92. PARADENTAL CYSTS(BUCCAL
BIFURCATION CYSTS)
• A cyst of inflammatory
origin- occurring on lateral
aspect of root of partially
erupted mandibular 1st
molar with an associated
history of pericoronitis

93. CLINICAL FEATURES
• Most common in the 6- to 11-year-old age group.
• Usually associated with the mandibular first molar,
• occasionally the mandibular second molar.
• The associated tooth has an altered eruption pattern with
• buccal tilting of the crown.
• The associated tooth is vital.
• Deep periodontal pockets on the buccal aspect of the tooth.
• +/- swelling
• +/- pain or tenderness
• +/- infection.

94. RADIOGRAPHIC FEATURES
• 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.

95. HISTOLOGICAL FEATURES
• 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).

96. Non-odontogenic
Cysts

97. Fissural cysts

98. • Most common of the so called fissural cyst.
• Earlier 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.
• Now believed to arise from vestigial elements of the
embryologic nasopalatine duct located in the incisive canal.
this aspect has been thoroughly studied by Abrams et al
Nasopalatine Duct (Incisive Canal)
Cyst

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

100. • 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.

101. • Occasionally, they arise in the lower end of incisive canal and
expand by elevating the periosteum distally , appearing as
cysts of the midline of the hard palate.
• In some cases the patient gives a history of variation in size
and of periodic drainage.

102. Large nasopalatine duct cyst extending
laterally and posteriorly to involve much of the
hard palate.

103. • 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.
RADIOLOGICAL FEATURES

104.  Radiographic Features
 some cases, a classic heart
shape

105. 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.
RADIOLOGICAL
FEATURES

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

107. • 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.
HISTOLOGICAL FEATURES

108. Histological features
Neurovascular bundle in the wall of a
nasopalatineduct cyst.

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

110. TREATMENT
• Lesion is treated by reflection of an anterior flap, severing
the neurovascular bundle to expose the cyst for Enucleation.
• When located high in canal ,overlying bone may have to be
removed .

111. • 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

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

113. • 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.
Nasolabial cyst producing a swelling of the right
upper lip, forming a bulge in the labial sulcus.

114. • 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

115. • 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.
RADIOLOGICAL FEATURES
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.

116. • 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.
HISTOLOGICAL FEATURES
Nasolabial cyst lined by a pseudostratified
columnar epithelium containing many goblet cells.
In the example illustrated here, mucous glands are
present in the wall.

117. TREATMENT
•Surgical excision

118.  between lateral incisor
+ canine teeth
 many are lined by inflamed
stratified squamous
epithelium
Globulomaxillary Cyst

119. 
Treatment : surgical excision

120. Epidermoid, dermoid and teratomatous cysts
• Developmental cysts involving the ventral tongue & FOM
may be classifies as above mentioned cysts.
• Epidermoid cysts are lined by a layer of squamous
epithelium.
• Dermoid cysts are similar, with the addition of adnexal
structures (sebaceous glands, sweat glands , hair follicles).
• Teratomatous cysts contains elements from all the 3 germ
layers .
• Dermoid cysts is the clinical term for all the 3 types of cysts.

121. Clinical features:
• First symptom is usually a gradually enlarging intraoral
swelling, occasionally interfering with the phonation and
deglutition.
• In cysts that occur below the mylohyoid or extend through
it,an extraoral swelling may appear, giving the patient a
double chin appearance.

122. •Differential diagnosis:
• Ranula;thyroglossal duct cyst,cystic hygroma,tumours and infections
of the salivary glands,& normal submental fat.
•Management:
• Surgical excision is the treatment of choice

123. Branchial cleft cyst
• It is usually noticed during late adolescence or early
adulthood along the anterior border of the
sternocleidomastoid muscle.
• Size ranges from 2-10 cm (avg.3-4 cm)
• Mass is not attached to surrounding structures and is often
fluctuant.
• Arises from epithelium enclaved within lymph nodes along
the cervical chain.
• Lining epithelium is usually stratified squamous in type
surrounded by lymphoid tissue with germinal centers.
• Lesion are inappropriately considered synonymous with
branchial fistulae.

125. Lymphoepithelial Cyst
• This cyst is an intramucosal cyst and appears as an asymptomatic,
small yellow to white Submucosal mound as seen in the illustrations.
• The floor of the mouth is a common site for this cyst as is the
posterior lateral tongue, oropharynx and soft palate.
• Their origin is unclear and is of insufficient interest to pursue here.
• On microscopic examination, a lymphoepithelial cyst is found to
consist of a small, keratin-filled cyst lined by flattened squamous
epithelium.

126. Small lymphoepithelial cyst
in the floor of the mouth.
Lymphoepithelial cyst, right
oropharynx.

127. • A mantle of lymphoid tissue partially or completely surrounds the
cyst,thus the name lymphoepithelial. They are harmless but usually
removed to confirm the diagnosis.
• This cyst is thought to be a miniature variety of the larger branchial
cleft cyst (cervical lymphoepithelial cyst) that occurs in the neck
anterior to the sternocleidomastoid muscle from the ear to the
clavicle.

128. Thyroglossal tract cyst
•It is an uncommon developmental cyst that may
form anywhere along the embryonic thyroglossal
tract between the foramen cecum of the tongue
and the thyroid glands.
•It apparently arises from remnants of this tract that
do not become obliterated.

129. • The cyst usually occurs in young persons but can develop at
any age.
• It appears clinically as a firm cystic midline mass, varying in
size from a few mms to several cms.
• The swelling generally develops slowly and is asymptomatic
unless occupying a position high in the tract , near the
tongue.
•Treatment:
• Complete surgical excision

130. CONCLUSION
Cystic jaw lesions may be epithelial or non-epithelial, odontogenic
or non-odontogenic, developmental, or inflammatory in origin.
The distribution of jaw cysts according to diagnosis in a general
population is: radicular cysts (RC) 56%, dentigerous cysts (DC)
17%, nasopalatine duct cysts (NPDC) 13%, odontogenic
keratocysts (OKC) 11%, globulomaxillary cysts 2.3%, traumatic
bone cysts (TBC) 1.0%, and eruption cysts (EC) 0.7% [
• The DC is most common in the pediatric age group, whereas the
RC is most common in the adult age group. The treatment
modalities in both groups are: marsupialization &
enucleation{[International Journal of Medical Sciences 2012;
9(1):20-26 ] [Cystic Lesions of the Jaws – A
Clinicopathological Study of 322 Cases and Review of
the Literature ]

131. PICTORIAL CONCLUSION

133. THANK U !