BENIGN CYSTIC LESIONS OF JAWS

DEFINITION OF A CYST OF JAW

Killey and Kay (1966)
Abnormal cavity in hard or soft tissues which
contains fluid, semifluid or gas and is often
encapsulated and lined by epithelium.

Kramer (1974)
A cyst is a pathological cavity having
fluid,semifluid or gaseous contents and which is not
created by accumulation of pus and frequently but
not always lined by epithelium.
INTRODUCTION

Most cysts, but not all, are lined by epithelium.

Cysts of the oral and maxillofacial tissues that
are not lined by epithelium are the mucous
extravasation cyst of the salivary glands, the
aneurysmal bone cyst and the solitary bone
cyst.
 Despite these examples, most pathologists
prefer to describe those pathological cavities
not lined by epithelium as pseudocysts.
Reichart and Philipsen (2004) prefer to
describen these as cavities rather than cysts;
hence, for example, aneurysmal bone cavity.
Cysts historically named globulomaxillary ,
median palatine and median mandibular cysts
have been convincingly shown by numbers of
studies to be other odontogenic or
developmental cysts.
This terminology is no longer used in diagnostic
oral pathology departments in most parts of the
world.
OVERVIEW

Definition

Classification

Pathogenesis

Signs and symptoms (general)

DIAGNOSIS

Clinical

Radiology

Aspiration

Biopsy
TREATMENT (GENERAL)

Reasons to treat

Principals of management

Goals of treatment

Factors considered
CYSTS OF HEAD & NECK REGION

I Cysts of the jaws

II Cysts associated with the maxillary antrum

III Cysts of the soft tissues of the mouth, face,

neck and salivary glands
CLASSIFICATION WHO- 1992
Epithelial cysts of the jaws
Developmental
Inflammatory

Nonepithelial cysts of the jaws (Pseudocysts)

Aneurysmal bone cyst
Solitary bone cyst (simple, traumatic, hemorrhagic,
idiopathic bone cavity)
Other cysts in the Head & Neck region
Softtissue cysts
Pseudocysts
Miscellaneous
CLASSIFICATION WHO- 1992
Epithelial cysts of the jaws
Developmental
Gingival cyst of infant ( Epstein pearls)
Gingival cyst of Adult

Eruption cyst

Odontogenic Keratocyst

Dentigerous cyst

Lateral periodontal cyst/ Botryoid odontogenic cyst

Glandular odontogenic cyst (Sialo-odontogenic cyst)

Calcifying odontogenic cyst (Gorlins cyst)

Nasolabial cyst (Nasoalveolar cyst)

Nasopalatine duct cyst (Incisive canal cyst)

CLASSIFICATION WHO- 1992
Inflammatory
Radicular cyst (Periapical /
Periradicular)
Apical
Lateral
Residual
Paradental cyst

(Mandibular infected buccal

bifurcation cyst, inflammatory
collateral cyst)
 Other cysts in the Head & Neck region
Soft tissue cysts
Epidermoid cyst
Thymic cyst
Bronchial cyst
Thyroglossal cyst
Gastric Heterotrophic cyst
Salivary duct cyst
Ciliated cyst of the maxillary antrum
Lymphoepithelial: oral cervical
Pseudocysts
Mucus retention cyst
Mucocele of the sinus
Cystic hygroma
Miscellaneous
Dermoid cyst
Polcystic disease of parotid
HIV associated lymphoepithelial lesion
LASKINS CLASSIFICATION
Odontogenic epithelial origin.. Non odontogenic epithelial
origin
1. keratinizing
nasopalatine
primordial cyst
nasoalveolar
extrafollicular dentigerous cyst
median palatine
2.non-keratinising
Bone cyst
periodontal
solitary bone cyst
1.periapical
aneurysmal bone cyst
2.lateral
3.residual
dentigerous
1.pericoronal
2.lateral
3. erruption
 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
 COMMON SITES OF OCCURENCE
Anywhere in oral cavity with vital tooth.periodontal
Impacted 3rd molars, canines and
premolars.dentigerous
Edentulous areas..residual
Mandibular 3rd molar.premordial
Below inferior alveolar canal.static bone cavity
Confined to maxilla.fissural
Infants or childrenerruption
mandiblesolitary bone cyst
SOURCE OF CYST OF JAWS : EPITHELIAL
ORIGIN
PATHOGENESIS OF A CYST

In general there are 2 phases in a cyst

pathogenesis:

Initiation or cyst formation

Enlargement or expansion of cystic cavity

FACTORS RESPONSIBLE FOR CYST
FORMATION

Proliferation of epithelial lining

Intra cystic fluid accumulation

Resorption of bone as fluid accumulates

and epithelial lining proliferates
EXPANSION OF CYST DUE TO

Increased hydrostatic Increase in surface area

pressure of lining mural factor

Displacement of
Increased osmotic surrounding soft tissues
pressure ..Lytic products or resorption
of the epithelial and
inflammatory cells
DEVELOPMENT OF CYST
THEORIES OF CYST EXPANSION
( HARRIS 1974)
Mural growth.
1. peripheral cell division
2. accumulation of cellular contents
Hydrostatic pressure theory.

Bone resorbing factor.epithelial growth

induces capsule formation which in turn
releases Bone resorbing factor which consists
of prostaglandins and leukotriens.
PERIPHERAL CELL DIVISION
ACCUMULATION OF CELLULAR CONTENTS
INCREASE IN SURFACE AREA AND LINING:

In few cysts like OKC, keratin formation is

more than hydrostatic and osmotic factors. In
such cases, instead of uniform expansion,
there are finger like projections into the
surrounding bone. This factor might determine
the recurrence and aggressiveness of a cyst.
HYDROSTATIC PRESSURE THEORY
BONE RESORBING FACTOR
GENERAL CONSIDERATION IN DIAGNOSIS OF
CYST
h/o trauma
Discoloured tooth
Missing tooth with circumscribed swelling
Pain & swelling in infected and enlarged cysts
Displacement of adjacent teeth
Consistancy
1.Smooth, hard
2. Cortex depressible like tennis ball
3. Egg shell cracking sound
4. Fluctuent swelling
 Discharge
Paresthesia , anaesthesia

Denture instabity
SIGNS
Physical signs depend on the size of a
cyst. If the cyst is small with no alveolar
expansion, there is absence of signs. As
the cyst becomes larger expansion of
alveolar bone occurs.

Periosteum
is stimulated to form new
bone producing a curved enlargement.
 Initially
lateral bone expansion turns to thinning of
cortex and can be depressed like a tennis ball or
egg shell crackling to palpation

Later fragmented outer shell disappear and the

cyst lining is beneath oral mucosa

Fluctuation can be elicited

Greater distension of cystic wall leads to eventual

discharge of fluid into mouth, which is frequently
followed by secondary infection and abscess
SYMPTOMS
Small cysts are usually asymptomatic and only if
infected, discharge from the cyst into the
mouth and produce a nasty taste.
Ex: Fissural cyst salty taste when a sinus
is present.
Edentulous patient Complains of displacement
of denture; denture ulcer
Non vital tooth associated with periapical cyst
Discoloration or lose tooth / teeth.
If there is a tooth missing- pathology can be
suspected.
Ex: Dentigerous cyst.
INVESTIGATIONS

Radiography Aspiration

Plain Radiography It is a valuable diagnostic

various intraoral and aid
extraoral views
A wide bore needle should
CT scans be inserted into the
suspected cystic lesion
under L.A and cavity then
aspirated
OTHER INVESTIGATION

Electrophoresis
keratocyst protein less than 4 gm/100ml
other dental cysts protein content more
than 5 gm/100 ml
Vitality test

biopsy
RADIOGRAPH
A well defined round or oval area of
radiolucency circumscribed by sharp
radioopaque margin of condensed bone.
Radiographic variation depends on

.type of cyst
.location of cyst
.degree of bone destruction and expansion
.infection
RADIOGRAPHY
Intraoral
standard IOPA
occlusal
Extraoral

lateral oblique view

PA view of mandible
OPG
waters view
Using radioopaque contrast media
NEEDLE ASPIRATION
 ASPIRATION
Helps in distinguishing sinus and cyst
Light straw coloured liquid with
choesterol.benign cyst
Failure to obtain fluid or air.solid lesion

Blood..hemangioma

Golden yellow with chich clots.solitary bone

cyst
Pale yellow cheesy odourless .OKC

Pus with cystic fluid.infected cyst

Thick semisolid brown mass.long standing cyst

TREATMENT GENERAL CONSIDERATION
 WHY TO TREAT ?
Increase in size leads to destruction and
subsequent fracture of bone
to remove pathologic lesion to restore integrity of
jaw bones
To differentiate it from neoplasm
histopathologically
May become infected
To make way for errupting teeth and prevent
malposition of teeth
To prevent encroaching on vital structures
PRINCIPLES OF MANAGEMENT

Decompression of intracystic pressure

Eliminate cystic lumen

Preservation of teeth

Preservation of arch size, maxillary sinus, nasal

cavity
Prevention of recurrence

Monitor vitality of adjacent teeth till

regeneration completes
AIMS OF TREATMENT
Removal of lining or enable the body to rearrange
position of abnormal tissue to eliminate from within,
and prevention of recurrence.
Minimum trauma to patient and maximum
conservation of tissue mainly of dental components.
Preserve adjacent important structures
Achieve rapid healing; to minimize number of visits
Restore the part to near normal and normal function
Prevention of pathologic fracture
Facial esthetics.
OBJECTIVES

Elimination of pathology and provide way to

tissue for rearrangement
To restore area to normal to near normal form
& function
Conserve teeth & adjacent vital structures

To achieve rapid healing

Keratocyst always require second thought

TREATMENT DEPENDS ON

Nature of lesion
Degree of destruction

Presence of infection

Conservation of involved teeth & vital

structures
FACTORS TO BE CONSIDERED IN CHOICE OF
OPERATION
Age and physical state of the patient
Young patient prompt healing

Children because of rapid cyst growth

Prompt treatment and accessibility to be

considered
Poor accessibility max tuberosity, lingual
aspect of mandible, ramus of mandible
TREATMENT

Marsupialisation

Enucleation
MARSUPIALIZATION
( DECOMPRESSION PARSCH 1 )
Incomplete removel of lining..
to open it in mouth
to open it in maxillary sinus
Secondary closure after primary
decompresssion
MARSUPIALISATION FOLLOWED BY
ENUCLEATION:

Also called Waldrons operation

A 2 stage procedure.

In the 1st stage marsupialisation is performed

and cavity allowed to shrink in size.
In the 2nd stage cyst lining is totally eliminated
ENUCLEATION WITH PRIMARY CLOSURE

Without bone grafting

With bone grafting

With decortication

Use of cauterizing solution

Use of cryosurgery.
ENUCLEATION WITH PACKED OPEN

1. With extraction
2. Without extraction (RCT conservative)
3. Combined with caldwel luc operation
4. Combined with fixation of pathologic fracture
COMBINED WITH FIXATION IN PATHOLOGIC
FRACTURE
INCISION DESIGN
SEMILUNAR INCISION
 MARSUPIALIZATION
Reflecting mucoperiosteum and removing
adequate bone followed by cutting of adequate
window in cystic lining .
The contents are evacuated to releive tension.

The remaining border of cystic lining is sutured to

oral mucosal lining.
Gradual obliteration of cystic cavity by
regeneration beneath the lining.
INDICATION OF MARSUPIALIZATION
Large cyst which has weaken jaw
Cyst involving apices of one or more teeth
Dentigerous cyst involving teeth in erruptive
stage or favourable position
Age & general condition of patients
Infected large cyst with friable margin
Erruption cyst
Inadequate access or techniques which
prevents enucleation
LINING DIFFICULT TO ENUCLEATE

If cyst erroded cortex, and lining in contact with

periosteum
Lining attached to PDL membrane of adjacent
teeth
Lining is friable if grossly infected and very thin
MARSUPIAILIZATION
ADVANTAGES

Simplicity and conservatism

Less trauma to vital structures

Less time

Great surgical skills not required

No risk of creating oroantral oronasal fistula

Can be done under L.A.

Alveolar ridge preserved

Little raw area exposed

 Minimal postop pain & swelling
No bone exposed for contamination

Ideal for patients not willing for long procedures

Wound breakdown and oozing less

DISADVANTAGES
Pathologic tissue left behind
Small tissue available for biopsy

Takes long time to obliterate after first rapid

healing.
Risk of invagination and new cyst formation

Slit like cleft harbour bacteria

Frequent visits to dentist required

Difficult to keep cavity clean

TECHNIQUE

Incision is made deep involving

mucoperiosteum, bone and cystic lining thereby
cutting a window in the roof of cyst
If the intervening bone is thick, it can be
removed with chisel, rongeurs and bur
Fluid content is evacuated with suction
The cystic lining is sutured with oral mucosa
around opening
 Cystic cavity is packed with iodoform gauze/
acriflavin/ povidone iodine/ L.A. jelly / Metrohex
gel loosely
Cavity is irrigated and pack is changed every
4th-5th day, every time using a small pack than
earlier.
Cystic epithelial lining is transformed into
normal mucus membrane. Slowly cavity fills up
because of fluid pressure in bone. Regeneration
occurs beneath defect. If a tooth is embedded in
cavity, it stands a chance of eruption into oral
cavity or can be orthodontically treated.
CASE 1 MARSUPIALIZATION
( DECOMPRESSION PARSCH 1 )
CASE 2
MARSUPIALAZATION WITH MAINTAINANCE OF
CONTINUITY
WALDRONS OPERATION
 ENUCLEATION

Complete removel
of cystic lining with
reflection of
mucoperiosteal flap and
closure of wound by
primary approximation.
ENUCLEATION AND PRIMARY CLOSURE (E & P)

Enucleation is the shelling out of an entire

cystic cavity without rupture.
A layer of fibrous connective tissue exists
between wall and bone which forms a cleavage
plane for stripping a cyst from its bony cavity
INDICATIONS OF ENUCLEATION

Cyst in upper anterior teeth

Small cyst

Periapical cyst

Dentigerous cyst in adults associated with

unfavourable tooth
Fissural cyst
ADVANTAGES

Satisfactory results for small cysts

As soon as incision heals patient no longer in
trouble
Adequate tissue for histopathologic exam.

No pathologic tissue left behind

No postop measures requires

Rapid bone healing

DISADVANTAGES

Damage to vital structures

Large cyst enucleation can lead to weakening
of jaws
Impossible to visualise cyst healing directly

Large blood clots can lead to infection

Alveolar crest defects difficult to restore

ENUCLEATION WITH REMOVEL OF TOOTH
ENUCLEATION WITH PACKED OPEN

Complete removel of cystic lining and underlying

cavity packed open, using antiseptic pack & later
with acrylic plate till cavity fills with granulation
tissue from all aspects.
ADVANTAGES

Simplicity
no pathologic tissue left behind

Cavity diminishes in size rapidly

DISADVANTAGES

Bung necessory
Combined disadvantages of both enucleation
and marsupiazation
Restoration of alveolar ridge difficult

Large defects risk of tear in sinus an nasal

lining.
TECHNIQUE
Administer L.A to site involved.
Incision is done in such a way that future suture lines
rests on normal bone so that flap heals well which also
facilitates for good retraction.
Mucoperiosteal flap is raised to gain access into cystic
cavity.
After elevation of flap, area of bony expansion is
identified.
At the thinned out bony wall a window is made to gain
entry into cyst.
 If the cyst wall is of equal thickness a series of
holes are made in oval fashion and all the
holes are joined by a fissure bur or chisel/
gouge and mallet.

Depending on need the window can be enlarged

with rongeur forceps. Thus cystic cavity is
widely exposed.
 A plane of cleavage is utilized between cystic
lining and bony wall to dissect out cystic sac in one
piece along with contents out of bony wall and
subjected to histopathologic examination.
 Cavity is cleaned and bony margins smoothened.
Once hemostasis achieved flap is repositioned.
Wound margins closed with interrupted sutures.
Cavity is now filled with blood clot. In due course
of time blood clot gets organized and helps in
regeneration of bone
Sutures are removed on 6th or 7th postoperative
day. Analgesics and antibiotics will take care of
post operative infection and pain.
ENUCLEATION WITH PACKED OPEN
ENUCLEATION WITH PRESERVATION OF
TOOTH
APICOECTOMY
Design of mucoperiosteal flap
Exposure of periapical region

Curretage of pathological tissue

Resection of apical part of root

Closure of root tip by retrograde filling

Burnishing of overfilled guttaparcha

Debridgement & toilet

Wound closure

After care & follow up

APICOECTOMY
ENUCLEATION OF RADICULAR CYST WITH
APICEOCTOMY
ENUCLEATION WITH BONE GRAFTS

Maintains bony
contour

Increase strength of
bone

Shorter follow up
period
ENUCLEATION WITH CURETTAGE
This means after enucleation a curette or bur is used to
remove 1 to 2mm of bone around entire periphery of cystic
cavity
Chemical cauterization Phenol/alcohol

- Carnoys solution
(ferric chloride, absolute alcohol,
glacial acetic acid, chloroform)

Thermal cauterization
Cryocautarization.
INDICATION (E&C)

In OKC because of high recurrence rate

In any recurrence cyst after thorough removal

Advantage
Ifenucleation leaves epithelial remnants curettage
will remove them, thereby decreasing likelihood of
recurrence
Disadvantage
May damage adjacent bone and tissues
 TECHNIQUE (E&C)
After enucleation the
bony cavity is inspected
for proximity to adjacent
structures. A sharp
curette or bone bur with
a sterile irrigation can be
used to remove 1-2mm
layer of bone around
complete periphery of
cystic cavity. Then
cleanse the cavity and
closed.
RECURRENCE OF CYST

In repeated recurrence cases, radical surgery

is indicated and excision of block of bone. If
large section of jaw is resected, reconstruction
followed by immediate bone graft is done.
GINGIVAL CYST OF
NEWBORNPATHOGENESIS
The epithelial remnants of
the dental lamina, the
socalled glands of Serres,
have the capacity, from as
early a stage in
development as 10weeks
in utero, to proliferate,
keratinise and form small
cysts
PATHOGENESIS
PATHOGENESIS
In the morphodifferentiation (late bell) stage of tooth
development, disintegration of the dental lamina Occurred
and numerous islands and strands of odontogenic epithelium
are seen in the corium between the tooth germ and the oral
epithelium, remote from the developing alveolar process.
Those dental lamina remnants, which had already evolved
into small cysts, expanded rapidly at this stage (1520 week
embryos) and there was thinning of the overlying oral
Epithelium.
HISTOLOGY
round or ovoid
thin lining of stratified squamous
epithelium
parakeratotic surface
keratin fills the cyst cavity,
usually in concentric laminations
containing flattened cell nuclei.
basal cells are flat, unlike those in
the keratocyst.
Epithelial-lined clefts may develop
between the cyst and the surface
oral
epithelium.
the oral epithelium may be atrophic
 CLINICAL FEATURES
The lesions are small and
white or cream coloured.
The frequency of gingival
cysts is high in newborn
infants but they are rarely
seen after 3months of
age.
most of them undergo
involution and disappear,
or rupture through the
surface epithelium and
exfoliate.
 MID PALATAL RAPH CYST OF INFANTS

Bohns nodules or Epsteins pearls. There is

some confusion about the two eponyms and
their relation to gingival cysts in neonates.
It would appear that Epsteins pearls are those
that occur along the midpalatine raph and are
not of odontogenic origin, whereas Bohns
nodules are found on the buccal or lingual
aspects of the dental ridges.
 The cysts along the
midpalatal raph have
a different origin.
They arise from epithelial
inclusions at the line of
fusion of the palatine
shelves and the nasal
processes.
This process usually ends
at 10 week.
WHY THEY ARE ABSENT IN SOFT PALATE ?

This was explained by Burdi (1968)

whose embryological studies indicated that
consolidation of the soft palate and uvula
took place not by fusion but by subepithelial
mesenchymal merging of bilateral primordia
without direct apposition and breakdown of
epithelium.
TREATMENT

There is no indication for any treatment of

gingival cysts or of midpalatal raph cysts in
infants. Once their contents are expelled, they
atrophy and disappear.
DENTIGEROUS CYST (DC)
It is defined as the one which encloses the crown
of an unerupted tooth by expansion of its follicle
and is attached to its neck.

It is important that this definition be applied

strictly and that the diagnosis of dentigerous cyst
is not made uncritically on radiographic evidence
alone, otherwise keratocysts (OKCs) of the
envelopmental variety, follicular OKCs and
Unilocular ameloblastomas involving adjacent
unerupted teeth, Are at risk of being misdiagnosed
as dentigerous cysts.
OCCURRENCE

Frequency 15-20%
Age 2nd and 3rd
decades of life
Sex males > females;
1.6:1
Race whites > Blacks;
4:1
DISTRIBUTION OF DENTIGEROUS CYSTS AT
DIFFERENT DECADES.
As age progresses DC
occurrence shifted to
posterior mandible from
anterior maxilla.
TOOTHWISE DISTRIBUTION OF DC
DENTIGEROUS CYST

Site Mandible > maxilla

Mandible 3rd molar
Maxillary canine
Mandibular premolars
Maxillary 3rd molar
Supernumerary
PATHOGENESIS
CLINICAL FEATURES

Usually seen on radiographs when taken

because of missing tooth, failure to erupt etc.
Patients become aware of cysts because of
slowly enlarging swellings
Dentigerous cysts may occasionally be painful,
particularly
if infected
RADIOGRAPHIC FEATURES
Radiographs show unilocular radiolucent areas associated
with the crowns of unerupted teeth attached at CEJ.
The cysts have well-defined sclerotic margins unless they
become infected. Occasionally, trabeculations may be seen
and this may give an erroneous impression of
multilocularity.
The unerupted teeth may be impacted as a result of
inadequate space in the dental arch or as a result of
malpositioning such as by a horizontally impacted
mandibular third molar or an inverted tooth
RESORPTION OF ROOTS OF ADJACENT
TEETH
potential for root
resorption may be
derived from its
origin from dental
follicle and the ability
of the latter to resorb
the roots of the
deciduous
predecessors of the
teeth, the crowns of
which they surround.
PRESSURE IS APPLIED TO THE CROWN OF THE
TOOTH AND MAY PUSH IT AWAY FROM ITS
DIRECTION OF ERUPTION
RADIOGRAPHIC TYPES OF DC

Central typeenvelop
crown symmetrically
Lateral typedilatation
of follicle on one side
Circumferential
typedue characteristic
manner of expansion of
follicle.
TYPES. CENTRAL TYPE
LATERAL DENTIGEROUS CYST
CIRCUMFERRENTIAL TYPE
CIRCUMFERRENTIAL LATERAL
PATHOGENESIS (DC)
dentigerous cysts may be of either
intrafollicular origin. accumulation of
fluid within the enamel organ itself.

extrafollicular origin. (after crown of

tooth has been completely formed ) due to
accumulation of fluid between reduced
enamel epithelium and tooth crown.
1) Acute and chronic inflammation in their walls,
in these instances exudation must play some
part in the expansion of the cyst.
2) The passage of desquamated epithelial cells
and inflammatory cells into the cyst cavity
must contribute to the increase in Intracystic
osmotic tension and thereby probably to
further Expansion of the cyst.
3) Pressure exerted by a potentially erupting tooth on
an impacted follicle obstructs the venous outflow
and thereby induces rapid transudation of serum
across the capillary walls. ..
.The increased hydrostatic pressure of this
pooling fluid separates the follicle from the crown,
with or without reduced enamel epithelium.
..Capillary permeability is altered so as to permit
the passage of greater quantities of protein above
the low concentration of the pure transudate.
HISTOLOGICAL EXAMINATION
a thin fibrous cyst wall
consists of young
fibroblasts widely
separated by stroma and
ground substance rich in
acid
mucopolysaccharide.
The epithelial lining, which
is in fact reduced enamel
epithelium, consists of 24
cell layers of flat or
cuboidal cells
DIAGNOSTIC CRITERIAS

1)Attachment of the cyst wall to the neck of the

associated tooth
2) microscopically, the cyst lining should
demonstrate a readily identifiable component
of reduced enamel epithelium
 TREATMENT (DC)
The emphasis is on conservative surgical
treatment,combined with orthodontics, in order
to retain the involved teeth and to ensure
eruption into normal occlusion.
Enucleation together with involved tooth
Marsupialisation which in case of involved tooth
might be brought to normal position in arch
Hyomoto et al. (2003) performed a retrospective
investigation into the eruption of teeth associated
with dentigerous cysts.
In one group, 81% of the mandibular premolars and
36% of the maxillary canines erupted successfully
in about 100 days.
The authors suggested that
1 period of 100 days after marsupialisation was
the critical time for deciding whether to extract or
to use traction.
2The eruption potential, they contended, was
closely related to root formation, so that teeth with
incomplete root formation had good potential to
erupt, whereas those with fully formed roots could
not.
 TREATMENT APPROACHES WERE BASED ON

patient age,
cyst site and size,

involvement of vital structures by the cyst, and

the potential for normal eruption into occlusion

of the impacted tooth involved.
DIFFERENTIAL DIAGNOSIS
Envelopmental type of OKC.
Radicular cysts arising from deciduous teeth
may mimic dentigerous cysts of permanent
successors radiologically.
 Pericoronal spaces smaller than 5.6 mm
cannot be diagnosed as dentigerous cyst
radiographically.
first radiographic diagnosis for a pericoronal
space enlargement, should be of
inflammation of the follicle
A differential diagnosis of dentigerous cyst
or paradental cyst might be considered.
 The final differential diagnosis between a
small dentigerous or a paradental cyst and a
pericoronal follicle depended on clinical and/or
surgical findings, such as the presence of
bone cavitation and cystic content.
POTENTIAL COMPLICATIONS (DC)

Ameloblastoma

Epidermoid carcinoma

Mucoepidermoid carcinoma
AMELOBLASTOMA FROM DENTIGEROUS
CYSTMISDIAGNOSIS
First, ameloblastoma, like an OKC, may involve
an unerupted tooth, particularly a third molar at
the angle of the mandible
Second, biopsies of ameloblastomas may be
taken of an expanded locule lined apparently
by a thin layer of epithelium.
Third, as Lucas (1954) has pointed out,
apparently isolated islets or follicles of
epithelium are sometimes found in the cyst
wall some distance from the epithelial lining
CASE 1
CASE 2
 BONE RESORPTION DUE TO CYSTS
capsule and its leucocyte content.
the source of the interleukin could be the monocyte
macrophage infiltrate, the stromal fibroblasts and
the epithelial cyst linings,
IL-1 released by the cysts could lead to a number of
osteolytic cell reactions:
the stimulation of osteoclasts to resorb bone,
connective tissue cells to produce prostaglandins
osteoclast activation.
stimulates connective tissue cells to produce
collagenase
Releases a potent bone-resorbing factor that is
predominantly a mixture of prostaglandins (PG) E2
and E3
ERUPTION CYST It is associated with
erupting deciduous
permanent teeth in
children. It is essentially
dilation of normal
follicular space about
crown of erupting tooth
caused by accumulation
of tissue fluid or blood.
Clinically lesion appears
as a circumscribed,
fluctuant, often
translucent swelling of
alveolar ridge over site of
erupting teeth
HISTOLOGY
The superficial aspect is covered by
the keratinised, stratified,
squamous epithelium of the
overlying gingiva.
This is separated from the cyst by a
strip of dense connective tissue of
varying thickness which usually
shows a mild chronic inflammatory
cell infiltrate due to exposed to
masticatory trauma,

TreatmentThe dome of the cyst is

excised, exposing the crown of
the tooth which is allowed to
erupt.
ODONTOGENIC KERATOCYST
The term OKC was introduced by Philipsen
(1956) based on histologic appearance of cystic
lining.

Magitot (1872) certain follicular cysts

developing prior to formation of any dental hard
tissues.

Seward (1963) redefined odontogenic cyst

as those arising from odontogenic epithelium
which has not taken a direct part in development
of tooth
 Central OKC..present within the bone
peripheral odontogenic keratocystrelatively
rare variety present in peripheral soft tissues.
Dayan et al. (1988) have described the
occurrence of a lesion entirely within the
gingiva, which had the clinical features of a
gingival cyst of adults but the histological
characteristics of a typical OKC.
PATHOGENESIS (OKC)

It is a developmental anomaly arising from

odontogenic epithelium derived from dental
lamina or remnants

Because of high recurrence rate and soft tissue

involvement the surgical management is like
that of a tumor.
PATHOGENESIS
OCCURRENCE

Age 2nd and 3rd decade of life; bimodal age

distribution
Sex males > females; black > whites
Site Mandible > maxilla
Varying distance into ascending ramus and
body
Maxilla can occur into sinus; globulomaxillary
area
FREQUENCYAGE
 CLINICAL FEATURES (OKC)
Patient complains of pain,
swelling or discomfort
Occasionally parasthesia of
lower lip
Usually symptomless
unless infected
Displacement of adjacent
teeth
the maxillary cysts were
more likely than those in
the mandible to become
infected even when small,
and would probably
therefore be diagnosed at
an earlier stage in their
development.
 CORTICAL EXPANSION
Tends to extend in the medullary
cavity
clinically observable expansion
of the bone occurs late.
expansion of bone occurred
in about 60% of cases.
maxillary cysts
One third..buccal expansion,
palatal expansion was very rarely
mandibular cysts
50% . buccal expansion
33%.....lingual expansion.
 RADIOLOGICAL FEATURES

Appears small, avoid, or normal radioluscent areas

Unilocular / multilocular
Well demarcated with sclerotic margin
Spread along medullary spaces of bone than
buccolingullay
Downward displacement of the inferior alveolar canal
resorption of the lower cortical plate of the mandible
perforation of bone
UNILOCULAR OKC

Some of the unilocular

lesions have scalloped
margins and these
may be misinterpreted
as multilocular lesions
The scalloped margins
suggest that unequal
growth activity may be
taking place in
different parts of the
cyst lining
 MULTILOCULAR OKC
The multilocular variety is
particularly liable to be
misdiagnosed as
ameloblastoma
multilocular lesions may
involve the body and
ascending ramus of the
mandible extensively.
There may be no
expansion of bone at
all,exept at the angle or in
the ramus,expansion may
occur
 FOLLICULAR KERATOCYST

Altini and Cohen (1980,

1982)
lining was typically OKC
on histological
examination
which on macroscopic
examination had
completely surrounded
the crown of the tooth
and had been firmly
attached to the neck.
 the epithelium that lined
that part of the cyst closest
to the neck of the tooth was
typically reduced enamel
epithelium.
This epithelium formed an
attachment to the neck of
the tooth and extended for
a short but variable
distance.
Between this and the
typical OKC epithelium that
lined the remainder of the
wall, and fusing with both,
was a short segment of
non-keratinised, stratified
squamous epithelium.
 VARIETIES OF ODONTOGENIC CYST
MAIN (1970)
Envelopmental cyst embracing an adjacent
Unerupted tooth
Replacement cyst which forms in place of
normal tooth of series
Extraneous cyst seen in ascending ramus
away from teeth
Collateral cyst adjacent to roots of teeth
 HISTOPATHOLOGY (OKC)
Cyst is lined by regular keratinized
stratified squamous ep about 5-8
cell layers thick and no rete pegs:
usually parakeratotic and
orthokeratotic type can also be seen
Corrugated appearance of
parakeratotic layer
Polished basal cells may be
columnar / cuboidal
Nuclei of columnar cell in
parakeratotic lining tend to be
oriented away from basement
membrane and are basophilic. This
is a distinguishing feature from other
keratinized jaw cyst
 Yoshiura et al. (1994) found that a helpful
feature in the diagnosis of OKCs was the
presence of areas of increased attentuation in
CT scans, and that these areas resulted from
the presence of keratin in their cavities.
 They found that MRI
of the
ameloblastomas
differed from the OKC
in displaying a mixed
solid and cystic
pattern and
irregularly thick walls
, papillary
projections, and
strong enhancement
of solid components.
LABORATORY DIAGNOSIS
Toller (1970a) considered that estimation of the
soluble protein level in aspirated cyst fluid might be a
valuable aid in the preoperative diagnosis of OKCs.
He showed that fluids from keratinising cysts had
soluble protein levels below 3.5g per 100mL (mean
2.2g per 100mL),
the values for non-keratinising cysts were in the range
5.011.0g per 100mL with a mean of 7.1g per 100mL.

Toller postulated that a protein level of less than 4.0g per

100mL indicated a diagnosis of OKC.
 TREATMENT (OKC)

Small single lesions

can be completely
enucleated provided
access is good (Intra
oral approach)

Larger cyst careful

enucleation and done
by extraoral approach;
if an intraoral approach
may lead to blind
curettage
 TREATMENT (OKC)
Large multilocular lesions
excision of immediate bone
graft is treatment of choice
at first operation

Resection of involved bone

and reconstruction with
stainless steel, vitallium,
titanium

More conservative approach

enucleation / excision and
cauterization of bone defect
with carnoys solution
prevents recurrence
JOURNAL REFERRENCES OF OKC
 A REVIEW OF ODONTOGENIC KERATOCYSTS AND
THE BEHAVIOR OF RECURRENCES
Almost all of the recurrent lesions (6 out of 7) were found in
the symphysis-body region, because the surgeons tended to
treat this region conservatively leading to inadequate
treatment in some areas. In our study, recurrent lesions
were also found frequently in the mandibular area and
associated with the remaining teeth.
This was probably owing to difficult access and thus
incomplete removal of all cystic tissue.

It is suggested that if enucleation is chosen as a surgical treatment,

the clinician should give more attention on the dentate area and
remove the teeth if there is any doubt of leaving pathologic
tissue behind.
All types of treatment, except marginal
resection, gave rise to recurrence in this
study. The recurrent lesions occurred more
frequently in parakeratinized OKCs,
symphysis-body region, and patients who
had lesions associated with the remaining
teeth and were treated by enucleation and
enucleation with curettage.

Duangrudee Chirapathomsakul, DDS, a Panunn Sastravaha,

DDS, MS,b and Pornchai Jansisyanont, DDS,
OOO Vol. 101 No. 1 January 2006
 WALDRON AND MUSTOES CLASSIFICATION
OF ODONTOGENIC CARCINOMA
Type 1 - PIOC ex odontogenic cyst
Type 2A - Malignant ameloblastoma
Type 2B - Ameloblastic carcinoma arising de
novo,
ex ameloblastoma, or ex odontogenic cyst
Type 3 PIOC arising de novo
(a) Keratinizing type
(b) Nonkeratinizing type
Type 4 Intraosseous mucoepidermoid carcinoma
 Odontogenic keratocyst and uterus bicornis in nevoid
basal cell carcinoma syndrome: case report and
literature review
Luca Ramaglia, MD, DDS,a Fabio Morgese, DDS,b
Marcella Pighetti, MD, PhD, and Raffaele Saviano,
DDS,d Napoli, Italy

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

2006;102:217-9)
NEVOID BASAL CELL CARCINOMA SYNDROME
(NBCCS)

The syndrome, first delineated by Gorlin and

Goltz, is characterized by
-basal cell carcinomas, affect primarily the face
and back, followed by the chest.
-odontogenic keratocysts,
-palmar and/or plantar pits, and
-ectopic calcifications of the falx cerebri.

major clinical diagnostic criteria

 ODONTOGENIC KERATOCYST
multiple and bilateral.
mainly located in the premolar area,
displace teeth with consequent malocclusion,
can be unilocular or multilocular
preference for the mandible.
often asymptomatic may present pain, swelling,
intraoral drainage, visual disturbance, or
paresthesiae.
pathologic fractures of the mandible or facial
distortion
PITTING OF THE PALMS AND SOLES

caused by a partial or complete absence of

stratum corneum;
they are permanent, not palpable,
asymptomatic,
appear as shallow depressions measuring 1 to
3 mm in depth and 2 to 3 mm in diameter
ECTOPIC CALCIFICATIONS OF THE FALX
CEREBRI.
 MINOR CRITERIAS
cardiac or ovarian fibroma,
macrocephaly,

bifid ribs,

kyphoscoliosis,

cleft palate,

Medulloblastoma

2 major and 1 minor criteria or 1 major and 3

minor criteria are necessary for the diagnosis.
BIFID RIBS (ARROW)
 bridging of the sella turcica,
mild mandibular prognathism,
lateral displacement of the inner canthi,
frontal and biparietal bossing,
imperfect segmentation of cervical vertebrae,
lymphomesenteric cysts that tend to calcify,
short fourth metacarpal,
fibrosarcoma, meningiomas, rhabdomyosarcomas,
strabismus, dystrophic canthorum, ocular hypertelorism,
congenital blindness,
spina bifida occulta,
pectus deformity,
high arched eyebrows and palates,
narrow sloping shoulders, immobile thumbs, lowpitched voice in
females, kidney anomalies, and hypogonadism in males.
frontal bossing, macrocephaly and
hypertelorism, signs of corrective surgery
for cleft lip and palate, dentoskeletal class
III malocclusion with molar crossbite due
to an underdeveloped maxilla, palmar and
plantar pits, and brown basal cell nevi
with variable diameter (2 to 4 mm) at the
dorsal region of the body.
ultrasound pelvic examination
normal ovarian apparatus but a bicornis
uterus with 2 separate uterine cavities
OKC

Recurrence
Pindborg and Hansen (1963) reported a
recurrence of 62% in 16 cysts
REASON FOR RECURRENCE (OKC)

Tendency to multiplicity
Satellite cyst

Cystic lining is very thin and fragile, portions of

which may left behind
Epithelial lining of OKC has intrinsic growth
potential
Cyst can arise from basal cells of oral mucosa
 RESIDUAL CYST
The radicular cyst that remains
behind in the jaws after removel
of an offending tooth or root.

Alternate possibilities:
1. Cyst in relation to deciduous tooth which exfoliates
or extracted without prior knowledge of cyst
2. Lateral dentigerous cyst
3. Incomplete removel of periapical cyst or granuloma
CLINICAL FEATURES

Maxilla > mandible

Elderly patients

Edentulous jaws

Treatment .same as radicular cyst

RESIDUAL CYST
CALCIFYING EPITHELIAL ODONTOGENIC CYST
(GORLIN CYST)
Development odontogenic cyst, first described
by Gorlin and associates in 1962.

Incidence: - Very few cases have been reported

- No sex predilection
- More common in children, young adults.
Site: - Common site of occurrence is Ant. Part of
mandible.
CEOC DEFINITION WHO 1992
A cystic lesion in which the epithelial lining
shows a well-
defined basal layer of columnar cells, an
overlying layer that is
Often many cells thick and that may resemble
stellate
reticulum, and masses of ghost epithelial cell
that may be in in the epithelial lining or in the
fibrous capsule .
The ghost epithelial cells may become
calcified. Dysplastic dentine may be laid down
adjacent to the basal layer of the epithelium
and in some instances the cyst is associated
with an area of more extensive dental hard
tissue formation resembling that of a complex
or compound odontoma.
CLASSIFICATION OF ODONTOGENIC GHOST CELL
LESIONS
AGE DISTIBUTION OF CEOC
PATHOGENESIS
CLINICAL FEATURES (GORLIN CYST)
Swelling is the most frequent complaint
Only rarely has there been pain.
Intra-osseous lesions may produce a hard bony expansion
and may be fairly extensive.
Lingual expansion may sometimes be observed.
Occasionally, the calcifying odontogenic cyst may perforate
the cortical plate and extend into the soft tissues.
displacement of the teeth
Extraosseous lesions tend to be pink to red, circumscribed
elevated masses measuring up to 4cm in diameter
RADIOGRAPHIC FEATURES
intraosseous lesion appears as an essentially radiolucent area.
have a regular outline with well-demarcated margins
They are usually unilocular but a few have been multilocular.
Irregular calcified bodies of varying size and opacity may be
seen in the radiolucent area
Denser opacities are likely to be present if the cyst is
associated with a complex odontome,
The extra-osseous lesions show localised superficial
bone resorption, or saucer-shaped radiolucencies
sometimes displacement of adjacent teeth
CEOC
CEOC
HISTOLOGICAL FEATURES

clusters of fusiform ghost

cells and focal
calcifications, lying in a
stratified squamous
epithelium.
 there are sheets of ghost
cells
focal area in which there
has been induction of a
strip of dysplastic
dentine (dentinoid)
RADICULAR CYST

Periapical cysts constitute approximately one

half to three fourths of all cysts in the jaws.
These inflammatory cysts derive their epithelial
lining from the proliferation of small
odontogenic epithelial residues (rests of
Malassez) within the periodontal ligament
Associated with nonvital teeth
 Most cysts are located in the maxilla, especially
the anterior region, followed by the maxillary
posterior region, the mandibular posterior region,
and finally the mandibular anterior region.
Radiological features- Well circumscribed
unilocular radiolucency at apex/lateral aspect of
root
D/D-periapical granuloma
Treatment- Enucleation with extraction/Endodontic
treatment
Prognosis- Good
AGEGENDER DISTRIBUTION
AGE-3RD TO 4TH DECADE
MALES MORE THAN FEMALES
SITE SITE-MAXILLARY ANT. TEETH MORE
COMMON
PATHOGENESIS
INITIATION EXPANSION
RADICULAR CYST FORMATION
A process by which cavity to be lined with
proliferating stratified squamous odontogenic
epithelium.
Two possibilities:
1) Epithelial cells lining the cleft due to
degeneration of central cells.
2) Epithelial cells lining bare abscess cavity or
degeneration of connective tissue by
proteolysis.
RADICULAR CYST EXPANSION

Various mechanisms:
1. Attraction of fluid in cyst cavity

2. Retention of cyst in cyst cavity

3. Increased hydrostatic pressure inside cyst

cavity
4. Bone resorption lead to increase in size
PATHOGENESIS
CLINICAL FEATURES PROGRESSION OF CYST

At first the enlargement is bony hard but as the

cyst increases in size, the covering bone becomes
very thin despit subperiosteal bone deposition and
the swelling then exhibits springiness or egg
shell crackling.
Only when the cyst has completely eroded the
bone will the lesion be fluctuant.
In the maxilla there may be buccal or palatal
enlargement, whereas in the mandible it is usually
labial or buccal and only rarely lingual.
RADIOGRAPHIC FEATURES
round or ovoid
radiolucencies
surrounded by a narrow
radiopaque margin
which extends from the
lamina dura of the
involved tooth.
In infected or rapidly
enlarging cysts, the
radiopaque margin may
not be present.
HISTOLOGICAL FEATURES
TREATMENT (RADICULAR CYST)

Enucleation
If cyst is associated with an odontogenic tumor
a wide excision is done
CASE 1
TREATMENT OF RADICULAR CYST WITH
APICOECTOMY
GINGIVAL CYST OF ADULTS AND LATERAL
PERIODONTAL CYSTS
SIMILARITIES
predilection for occurrence in the canine and
premolar area of the mandible
less frequently, in the maxilla.

The pathogenesis of these cysts, particularly

with regard to the cells of origin is same.
Involvement of periodontium.

Histologically similar.
 Gregg and OBrien ..concluded that the
distinguishing clinical feature is the ability to
determine the involvement of the periodontal
ligament at surgical exploration; while
histologically is the presence in the lateral
periodontal cysts of plaquelike thickenings of
the epithelial linings.
OCCURRENCE OF
GINGIVAL CYST LAT. PERIODONTAL
 lateral periodontal cyst
PATHOGENESIS develops from reduced
enamel epithelium before
eruption of the tooth
the gingival cyst of adults
from junctional epithelium
(reduced enamel
epithelium) after eruption of
the tooth .
Origin from postfunctional
epithelium, such as reduced
enamel epithelium, would
help to explain the
unaggressive nature of the
gingival cyst of adults and the
lateral periodontal cyst
compared with the OKC
LATERAL PERIODONTAL GINGIVAL CYST
CYST OF ADULT
PATHOGENESIS OF LATERAL PERIODONTAL
CYST
 CLINICAL PRESENTATION
GINGIVAL CYST OF ADULTS LATERAL PERIODONTAL CYSTS

round to oval, wellcircumscribed may be symptomless

swellings and only discovered
usually less then 1cm in fortuitously during
diameter routine radiological
examination of the
may occur in the attached
teeth. Sometimes, a
gingiva or the interdental papilla,
gingival swelling may
invariably on the facial aspect. occur on the facial
surface is smooth aspect
colour of normal gingiva or Tender on palpation
bluish . The associated teeth will
soft and fluctuant be vital
adjacent teeth are usually vital.
 GINGIVAL CYST LATERAL PERIODONTAL CYST

RADIOGRAPHICAL
 LATERAL PERIODONTAL CYST
GINGIVAL CYST
faint radiographic a round or oval well
shadow indicative of circumscribed
superficial bone radiolucent area, usually
erosion with a sclerotic margin.
The cysts lay somewhere
between the apex and
the cervical margin of
the tooth
Treatmentsurgical
Treatment..surgical enucleation
excision
NASOPALATINE CYST
The epithelial-lined cysts of non-odontogenic origin
had been thought to be derived from embryonic
epithelial residues in the nasopalatine canal and,
from epithelium included in lines of fusion of
embryonic facial processes.
It may occur within the nasopalatine canal .
nasopalatine duct cyst is preferred to the
synonymous incisive canal cyst
in the soft tissues of the palate, at the opening of
the canal, where it is called the cyst of the
palatine papilla
LOCATION
OCCURRENCE
PATHOGENESIS
In humans, vestigial remnants of this primitive
organ of smell may be found in the incisive canals
in the form of epithelial-lined ducts, epithelial
cords, epithelial rests or combinations of these.
Epithelial rests may show central degeneration.
The vomernasal organs of Jacobson are
sometimes mentioned as a possible source of
cysts in the incisive canal but this is most unlikely.
They are bilateral structures that lie at the base of
the nasal septum just above the nasal extremity of
the incisive canals.
 CLINICAL PRESENTATION
most common symptom is
swelling, usually in the
anterior region of the midline
of palate
Swelling also occurs in the
midline on the labial aspect
of the alveolar ridge
pain through pressure on the
nasopalatine nerves
Discharge may be mucoid,
may be purulent foul taste
RADIOGRAPHIC FEATURES
a pear-shaped
radiolucency in the
anterior maxilla. The
lamina dura is intact
although the apex
appears to be in the cyst.
roots of the maxillary
incisor teeth are
displaced laterally.

Treatment: surgical
enucleation
DIFFERENTIATION FROM INCISIVE FOSSA
Roper-Hall concluded that any radiograph of the
fossa that showed a shadow less than 6mm wide
may be considered to be within normal limits,
provided the patients have no other symptoms.
Shear stated that a radiographic shadow with
anteroposterior dimensions of as much as 10mm
in the incisive fossa region may be within normal
limits. In the absence of any other symptoms
signs, such patients should be observed and re-
radiographed at intervals before proceeding to
surgery.
 NASOLABIAL CYST

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.
As the alveolus is not involved, the term nasolabial is
preferred to nasoalveolar cyst.
CLINICAL PRESENTATION

The most frequent symptom is swelling and

very often this was the only complaint.
Sometimes the patients complained of pain
and difficulty in nasal breathing, but pain is
generally present when the cysts are infected.
The cysts grow slowly, producing a swelling of
the lip.
 They fill out the nasolabial
fold and often lift the ala
nasi, distort the nostril and
produce a swelling of the
floor of the nose.
Intra-orally they form a bulge
in the labial sulcus
The cysts are fluctuant and,
on bimanual palpation,
fluctuation may be elicited
between the swelling on the
floor of the nose and that in
the labial sulcus.
RADIOGRAPHIC FEATURES
Nasolabial cyst. The
extraosseous position of the
cyst is demonstrated by
aspiration of its fluid contents
and injection of a radiopaque
fluid.

Treatment Although the

nasolabial cysts are extra-
osseous they liesubperiosteally,
and careful surgical enucleation
via atransoral sublabial
approach is the treatment of
choice.
CASE 1
GLOBULOMAXILLARY CYST
 most of the evidence currently available leads
to the conclusion that the so-called
globulomaxillary cyst is not an entity but that a
variety of cysts and tumours can occur as well
demarcated radiolucent lesions in the lateral
incisor canine region of the maxilla.
THE ANEURYSMAL BONE CYST
uncommon lesion which has been found in most
bones of the skeleton, although the majority occur
in the long bones and in the spine
The true nature of the lesion remains uncertain,
although most regard it as probably reactive.
Although the lesion is characteristically cystic and
blood filled, the term aneurysmal bone cyst was
suggested by Jaffe and Lichtenstein (1942) to
describe the characteristic blown-out contour of
the bone seen in radiographs of the lesion.
 Extremely rare in jaws
Common in children and adults

Most of the cases were located in the molar

regions of the mandible and maxilla
number of the mandibular cases extended
posteriorly to involve the angle and ascending
ramus.
CLINICAL FEATURES
Local, nonexpansile, painless swelling
malocclusion
history of recent displacement of teeth, which
remain vital.
When the lesion perforates the cortex and is
covered by periosteum or only a thin shell of bone,
it may exhibit springiness or egg-shell crackling
not pulsatile.
Bruits are not heard.
 Characteristic ballooning
growth pattern which
results in a radiolucent
area
elevation of the
periosteum to produce
an ovoid or fusiform
expansion of the bone
with the typical blown-
out cortical expansion
Presence of septa leads
to soap bubble, honey
comb appearence
PATHOGENESIS
Unknown
Trauma hematomaattempt to repair ----
maintain circulatory connections
Artero-venous fistula
Sudden venous occlusionThey postulated
that the primary lesion initiated an
arteriovenous malformation in the bone and
that its haemodynamic forces established the
aneurysmal bone cyst
TREATMENT

Thorough curretage
Excision and bone grafting

Radiotherapy not indicated

SOLITARY BONE CYST

Hemorrhagic traumatic, simple ,progressive

bone cyst
No microscopically detectable epithelial lining

Devoid of liquid contents

HOWES CRITERIA FOR DIAGNOSIS

Cyst should be single

Should not be infected

Should not be lined by epithelium

Should contains fluid and not soft tissue

Should be covered by bone

CLINICAL FEATURES

1st or 2nd decade never after 30 yrs of age

Male > females

Mandible > maxilla

History of trauma

Symptomless

Bony expansion less than other cysts

RADIOGRAPHIC FEATURES

Unilocular cavity with ridges on its internal

surface
Envelop roots of adjacent teeth

Scalloping is prominent and occurs in between

roots of teeth
Distension of outer & inner cortical plates
uncommon
PATHOGENESIS

h/o trauma --- hematoma ----hemolysis--- failure

to organise ----transudation ----- increase
hydrostatic pressure ---- osteoclastic activity -----
bone resorption
CONTENTS

Empty
Golden yellow coloured fluid

Blood stained fluid

Serosanguinous fluid

Presence of hemosiderin
TREATMENT

Heamorrhage encourages healing

Surgical exploration evacuating contents and
creating bleeding to fill the space
STAFNES BONE CYST ,STATIC BONE CAVITY,
LATENT BONE CYST, LINGUAL MANDIBULAR BONE
DEFECT
The lingual mandibular
bone defect (Fig. 14.4) is
not a cyst. However, it
does produce a cystic
appearance on
radiographs, and as it is
occasionally confused
with the solitary bone
cyst.
A description of 35 cases
was first reported by
Stafne (1942)
DIFFERENTIAL DIAGNOSIS

The solitary bone cyst

almost invariably lies
above the inferior
alveolar canal while the
lingual mandibular bone
defect lies below the
canal
 The cavities are usually
discovered fortuitously
during radiographic
examination.
They appear as round or
ovoid radiolucencies
varying from 1 to 3cm
diameter below the inferior
alveolar canal
approximately in line with
the position of the third
molar tooth.
 Surgical exploration of these cavities has
indicated that they represent developmental
defects on the lingual aspect of the mandible
which are occupied by a lobe of normal salivary
gland, suggesting that the salivary gland has an
aetiological role in the development of the defect.
Magnetic resonance imaging (MRI) of a typical
case clearly demonstrated that the cavity was
filled by a lobular extension of normal
submandibular gland
PATHOGENESIS

1..With regard to pathogenesis, the evidence

tends to suggest that in some individuals,
particularly middle-aged or elderly males, a
lobe of the submandibular salivary gland may
produce a localised pressure atrophy of the
lingual surface of the mandible
2. . Lello and Makek (1985), who reported an
extensive review of the literature, suggested
that the bone defect was the result of an
ischaemic process in an area adjacent to the
passage of the facial artery. Tensile muscle
forces together with haemodynamic forces,
they proposed, pulled the artery from the
lingual cortex,thus compromising its nutrition
SALIVARY GLAND CYSTS
 MUCOCOELES
Mucous extravasation cysts and mucous
retention cysts are often referred to collectively
as mucocoeles.
the term mucous extravasation cyst for those
lesions in which mucus has extravasated into the
connective tissues and in which there is no
epithelial lining.
The term mucous retention cyst is employed to
describe mucocoeles that result from dilatation
of the ducts and which are lined by epithelium.
OCCURENCE
 Patients with mucocoeles
usually complain of a
painless swelling which is
frequently recurrent.
The swelling may develop
suddenly at mealtimes
and many drain
spontaneously at
intervals.
The mucocoele may be
only 12mm in diameter
but it is usually larger, the
majority being between 5
and 10mm in diameter.
PATHOGENESIS

trauma to a duct which is either pinched or

severed;
trauma to the secretory acini, leading to the
extravasation of mucus.
complete ductal obstruction lead to the
development of a mucous retention cyst.
MUCOCOELES OF THE GLANDS OF BLANDIN AND
NUHN
on the anterior ventral
aspect of the tongue
appear as polypoid or
pedunculated swellings
they may reach a large
size and cases of 3cm or
greater have been
reported.
interfere with normal
feeding or may
compromise the airway
PATHOLOGY.. A MUCOUS EXTRAVASATION CYST

lined by inflamed fibrous

connective tissue with
many muciphages which
are also seen in the
lumen
MUCOUS RETENTION CYST

lined by two layers of

cuboidal epithelium
TREATMENT

Larger lesions require surgical removal, usually

through a small vertical incision. The cyst and
its associated lobules of salivary gland should,
whenever possible, be removed together and
intact.
RANULA

ranula is used to describe those mucocoeles

occurring on the floor of the mouth.
They are usually unilateral and because they
produce a translucent blue swelling were
likened to a frogs belly; from this the term
ranula was derived.
 classified as either superficial or plunging.
The superficial variety may develop as a
retention or extravasation phenomenon
associated with trauma to one or more of the
numerous excretory ducts of the sublingual
salivary gland.
Its pathogenesis and pathology are no
different from those of the mucocoeles
elsewhere in the mouth.
no epithelial lining
 CLINICAL FEATURES
invariably larger than
mucocoecele.
The swellings are round or
oval and smooth
The superficial lesions
are blue and fluctuant
the deeper lesions are the
colour of normal mucosa
and are firmer.
PLUNGING RANULACLINICAL FEATURES

Present in the deeper submandibular tissues

without evidence of an intra-oral swelling.
peak age of presentation in the second
decade .
Females > males

23 cm in diameter.
PATHOGENESIS OF PLUNGING RANULA
A deficiency or hiatus between the anterior and
posterior parts of the mylohyoid muscle
herniated projections of the sublingual gland
through these perforations
permit mucus extravasation into the
submandibular space and the tissues of the
neck.
mucus may extend deep into the cervical
tissues and occasionally into the thorax
TREATMENT
surgical removal of the sublingual gland
through the mouth without any cervical
approach is the initial form of treatment.
This removes the secreting source, thereby
preventing recurrences, and also avoids the
problem of a difficult neck dissection.
plunging ranulas have been treated with the

sclerosing agent OK-432.sclerosing and

immune system stimulating agent derived from
lyophilised Streptococcus pyogenes.
CYSTS OF MAXILLARY SINUS
 Cloudy radiopacity may be
noticeable but in the early MUCOCOCELE
lesion the bony walls of the
antrum appear normal.
well-defined radiolucency
with expansion and
perforation of the bone
margins.
lesion is spherical in
outline except inferiorly
where it embraces the roots
of the teeth.
medial expansion and the
lesion may also raise the
orbital floor or the anterior
 CLINICAL FEATURES
Gradually enlarging swelling of the cheek and
lateral nasal region
obliteration of the nasolabial fold or of the buccal
sulcus
lesion is expansile there is bulging of the medial
wall of the antrum causing partial obliteration of
the nasal cavity
pain or tenderness of the cheek or teeth, nasal
drainage, headache, proptosis.