‫جراحة الفم والوجه والفكين السنة الرابعة‬

Cysts of orofacial region

Definition of cyst
Kramer (1974) has defined a cyst as ‘a pathological cavity having fluid, semifluid or
gaseous contents and which is not created by the accumulation of pus’.
Cyst growth
Several mechanisms are described for cyst growth, including:
• epithelial proliferation
• internal hydraulic pressure
• bone resorption.

Classification of oral and maxillofacial cysts

I Cysts of the jaws
II Cysts associated with the maxillary antrum
III Cysts of the soft tissues of the mouth, face and neck
 Dermoid and epidermoid cysts
 Lymphoepithelial (branchial cleft) cyst
 Thyroglossal duct cyst
 Cysts of the salivary glands: mucous extravasation cyst, mucous retention cyst,
ranula.
Classification of cysts of the orofacial region

i. Epithelial cysts
A. odontogenic
1) Developmental odontogenic cysts
 Odontogenic keratocyst
 Dentigerous cyst (follicular cyst)
 Eruption cyst
 Lateral periodontal cyst
 Gingival cyst of adults
 Glandular odontogenic cyst (sialo-odontogenic)
2) Inflammatory odontogenic cysts
 Radicular cyst (apical and lateral)

1 ‫صفحة‬ Cyst 2009/10/11

 ‫جراحة الفم والوجه والفكين السنة الرابعة‬

 Residual cyst
 Paradental cyst
B. Non-odontogenic cysts
 Nasopalatine cyst
 Nasolabial cyst
ii. Non-epithelial cysts (not true cysts)
 Solitary bone cyst
 Aneurysmal bone cyst

Odontogenic cysts:

definition
By definition, the epithelial lining of these cysts originates from residues of the tooth-forming
organ.There are three kinds of residue, each primarily responsible for the origin of a
particular type of lesion.
• rests of Malassez: radicular cyst, residual cyst
• reduced enamel epithelium: dentigerous cyst,eruption cyst
• Remnants of the dental lamina: Odontogenic keratocyst, lateral periodontal cyst, gingival
cyst of adult, glandular odontogenic cyst
• Unclassified: paradental cyst.

RADICULAR CYST

Definition: is a pathological cavity lined with epithelium and which contains fluid or semi-
fluid . associated with non-vital tooth also called ( dental cyst, periapical cyst or simply
apical cyst) .
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.
Origin: A radicular cyst develops when epithelial debris of Mallassez that present in a
granuloma at the apex of a non-vital tooth is stimulated to proliferate. (?)
Incidence: Radicular and residual cysts are by far the most common cystic lesions in the
jaws, comprising (52.2%) jaw cysts and 62% of odontogenic cysts in South African (?)

2 ‫صفحة‬ Cyst 2009/10/11

 ‫جراحة الفم والوجه والفكين السنة الرابعة‬

Clinical presentation:
 It is often said that radicular cysts are painless unless infected. (?)
 slowly enlarging swellings are often complained of .
 At first the enlargement is bony hard but as the cyst increases in size, the covering
bone becomes very thin despite subperiosteal bone deposition and the swelling then
exhibits ‘springiness’ or ‘egg shell crackling’ . with completely eroded of bone the
lesion be fluctuant. it presents as a soft fluctuant (fluid-filled) swelling in the sulcus,
which often appears slightly blue in colour.
N.B : as the apices of most teeth lie closer to the buccal than the palatal or lingual
plates,(except lateral incisor) the enlargement usually appear buccally.
 If the acutely infected cyst bursts and discharges into the mouth, the continued
discharge may lead to formation of a sinus.
 Loosening or tilting of adjacent teeth is only encountered in very large cysts, and
resorption of roots usually results from repeated infection of the cyst and is relatively
uncommon.
 Unless a radicular cyst becomes infected, it will remain painless and vital structures
will be gently moved aside to accommodate it. This can be seen clearly in larger
mandibular cysts, which push the inferior dental canal downwards to the lower
border of the mandible.
Investigaton :
Radiographically:
 Radiographic features will show the classic appearance of a round or oval-shaped
radiolucency surrounded by a sharply radiopaque line of increased bone density.
 The affected tooth will show loss of its apical lamina dura.
 Very occasionally there may be evidence of resorption of adjacent teeth and this
reflects repeated acute episodes of infection within the cyst, with haziness in the
sharp radio-opaque margin of cyst.
Aspiration: may be possible in larger cysts with little or no bony covering. the fluid appears
as straw-coloured in which a shimmer may be seen due to its cholesterol content.
Biopsy: With very large cysts, especially in the mandible, it may be prudent to obtain some
lining for histopathological examination, as this may allow differentiation between a large
radicular (or residual) cyst, a keratocyst or a cystic ameloblastoma, especially when
considering the differential diagnosis of a radiolucency of the angle of the mandible.

3 ‫صفحة‬ Cyst 2009/10/11

 ‫جراحة الفم والوجه والفكين السنة الرابعة‬

Histologically:
 Radicular cysts are lined wholly or in part by non-keratinized stratified squamous
epithelium supported by a chronically inflamed fibrous tissue capsule.
 In newly formed cysts the epithelial lining is irregular and may vary considerably in
thickness , while in established cysts the epithelial lining is more regular in
appearance and of fairly even thickness.
 Metaplasia of the epithelial lining may give rise to mucous cells .
 In approximately 10 per cent of cases the lining contains hyaline eosinophilic bodies
- Rushton bodies - of varying size and shape
 Deposits of cholesterol crystals are common within the capsules of many radicular
cysts
treatment
There are two main methods of treatment for cysts:
1. Enucleation and curettage .
2. Marsupialisation: (creation of a permanent opening into the cyst cavity).
Complication :
>>>>>>>>>>>>>

DENTIGEROUS CYST

Definition: this cyst is developmental odontogenic cysts, which arise when cystic
degeneration occurs in the reduced enamel epithelium. It is seen around unerupted tooth
attached to its neck.
Site: most frequently found in the third molar areas, both upper and lower, the upper canine
region and, less frequently, around lower second premolars. (?) They may also arise in
relation to supernumerary or supplemental unerupted teeth or from odontom.
Incidence:
Male affected more than female.
Commonly with 10 – 40 years old.
Clinical presentation:
 These cysts grow slowly and have the same effect as radicular cysts on
surrounding bone.

4 ‫صفحة‬ Cyst 2009/10/11

 ‫جراحة الفم والوجه والفكين السنة الرابعة‬

 As with radicular cysts, dentigerous cysts are usually asymptomatic until infected.
Radiographically:
o radiographs show unilocular radiolucent areas associated with the crowns of
unerupted teeth.
o The cysts have well-defined sclerotic margins unless they become infected.
o Occasionally, trabeculations may be seen and this may give an erroneous
impression of multilocularity.

Three radiological variations of the dentigerous cyst may be observed :

1. Central
2. Lateral
3. Circumferential
In the central variety the crown is enveloped symmetrically. In these instances, pressure is
applied to the crown of the tooth and may push it away from its direction of eruption. In this
way, mandibular third molars may be found at the lower border of the mandible or in the
ascending ramus , and a maxillary canine may be forced into the maxillary sinus as far as
the floor of the orbit , a maxillary incisor may be found below the floor of the nose .

Differential diagnosis : OKCs , ameloblastomas

(how does large dentigerous cyst can be misdiagnosed with ameloblastoma and OKCs
???? ).
A very large dentigerous cyst in the lower third molar area can displace the wisdom tooth
and may require to be differentiated from other lesions such as a keratocyst or
ameloblastoma. Although both these lesions are classically described as being multilocular
radiolucencies on radiograph, it must be remembered that unilocular lesions do exist.
Aspiration may not be sufficient to differentiate a dentigerous cyst from a keratocyst,
particularly if there has been infection. Similarly, an ameloblastoma may have within it
areas of cystic degeneration, even in the more solid tumours, and a variant of the
ameloblastoma – known as the cystic ameloblastoma – can be very similar to the
dentigerous cyst in its clinical appearance, radiographic image and
aspirated fluid content. If any doubt exists, then biopsy of a small portion of the lining will be
diagnostic in most cases, although in the cystic ameloblastoma the tumour may only be

5 ‫صفحة‬ Cyst 2009/10/11

 ‫جراحة الفم والوجه والفكين السنة الرابعة‬

evident histologically in a small area of the cyst lining and the sample taken may therefore
be misleading.
Histologically :
 These cysts are attached to the unerupted tooth at the amelocemental junction .
 The lining of dentigerous cysts is typically a thin, regular layer, some two to five cells
thick, of nonkeratinized stratified squamous epithelium. It resembles the reduced
enamel epithelium from which it is derived.
 Mucous cell metaplasia is common, and epithelial discontinuities are frequently
observed.
 The lining is supported by a fibrous connective tissue capsule free from inflammatory
cell infiltration, unless there has been secondary inflammation.
 Cholesterol clefts may be present .
Treatment :
1. Enucleation and curettage .
2. Marsupialisation .
Complication :
>>>>>>>>>>>>>

KERATOCYSTS (ODONTOGENIC KERATOCYSTS)

Definition : they are developmental odontogenic cysts that arise from remnant of dental
lamina, show cystic cavitys contain keratin cheesy_ like material and their epithelium is a
keratinising stratified squamous epithelium .
They are believed to increase in size by mural division with interhydrostatic cavity pressure
of little significance.
Keratocysts are also characterised by the formation of microcysts or satellite cysts.
Site: About half of all OKCs occur at the angle of the mandible extending for varying
distances into the ascending ramus and forward into the body.
Also they can occur anywhere in the jaws, including the midline of the mandible and maxilla
and the previously designated ‘globulomaxillary area’ in the maxilla
Incidence:
Male affected more than female.
Commonly with 10 – 40 years old.

6 ‫صفحة‬ Cyst 2009/10/11

 ‫جراحة الفم والوجه والفكين السنة الرابعة‬

Clinical presentation:
 The active growth of keratocysts appears not to be evenly distributed, so the cyst
does not expand uniformly as a sphere or oval-shaped lesion. Different rates of
activity within areas of the lining probably account for the formation of locules
 They appear to grow selectively within the looser medulla of the jaw initially and
although eventually the outer cortical plates do show expansion (Lingual as well as
buccal expansion is often noted).
 In many instances, patients are remarkably free of symptoms until the cysts have
reached a large size, involving the maxillary sinus and the entire ascending ramus,
including the condylar and coronoid processes.
 As with other intraosseous jaw lesions, the enlarging cyst may lead to displacement
of the teeth
 It is important to realise that, unless infected, these sometimes very large lesions are
painless and do not exert sufficient pressure on vital structures such as the inferior
dental nerve to cause anaesthesia of the lip and chin. When infected, however, they
can become very painful, cause anaesthesia and may discharge into the mouth, with
consequent bad taste and bad breath as additional clinical features.
N.B: Gorlin-Goltz syndrome
Gorlin-Goltz syndrome, or multiple basal-cell naevi syndrome, is an inherited (autosomal
dominant) condition in which multiple keratocysts of the jaws form part of the overall
syndrome. Other aspects in these patients are the presence of many skin lesions in the
form of basal-cell naevi or carcinomas , also show :
 Fronral possing
 Prognathism
 Hyperteleorbatism
 Fissured palm and feet
Radiographic:
Classically, the appearance is of a multilocular radiolucency with marked expansion of both
buccal and lingual plates. Unerupted wisdom teeth may well be pushed into bizarre ectopic
positions such as inverted high into the ramus of the mandible.
Displacement or tilting of the teeth can be a feature, as can resorption of roots, although
this is again probably a result of infection.
Aspiration:

7 ‫صفحة‬ Cyst 2009/10/11

 ‫جراحة الفم والوجه والفكين السنة الرابعة‬

Show high viscous cheesy like material.

Show less than 5 g in 100ml of soluble protein whereas other dental cysts will have
quantities similar to that in the patient's serum.
Differential diagnosis :
Aneurysmal bone cyst
Central giant cell granuloma
Ameloblastoma
Dentigerous cyst
Tooth follicle
Primodial cyst
Histologically:
 thin, easily torn wall.
 lined by an even layer of parakeratinized squamous epithelium.
 palisaded basal cell layer, with thin basement membrane and loose attachment to
under connective tissue.
 contains keratinous material.
 satellite cysts in capsule.
Treatment :
1. Enucleation and curettage .
2. Marsupialisation .
3. Resection and reconstruction
Complication :
>>>>>>>>>>>>>

ERUPTION CYSTS
Definition and origin :
These are cysts forming over erupting teeth.( most frequently anterior to first permanent
molar) Those over deciduous or permanent teeth with no deciduous predecessor are
believed to originate from the cells of the enamel organ. where there has been a deciduous
predecessor the epithelial rests of Malassez from this tooth could give rise to one of these
cysts.
Clinical presentation:
An eruption cyst presents as a small blue swelling in the gum over an unerupted tooth.

8 ‫صفحة‬ Cyst 2009/10/11

 ‫جراحة الفم والوجه والفكين السنة الرابعة‬

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.
Treatment:
Eruption cysts are most frequently treated by marsupialisation, The dome of the cyst is
excised, exposing the crown of the tooth which is allowed to erupt.

Non_Dentigerous cyst

NASOLABIAL CYST :
This is a fissural cyst that is thought to form by cystic degeneration of epithelium from
the lower part of the nasolacrimal duct during embryological development.
Other thought that it is arise from entrapped epithelium at the junction of fusion between
the globular,lateral and median nasal process .

Clinically:
they may present as painless swellings in the nasolabial fold under the ala of the nose
where they may be palpated either externally on the skin surface or intraorally high in
the buccal sulcus anteriorly.
Treatment: treatment would be surgical enucleation.
GLOBULOMAXILLARY CYSTS
These occur at the junction of the globular and maxillary processes .
They arise between the maxillary lateral incisor and canine, characteristically separating
the roots of these teeth which are not concerned with the formation of the cyst and
should be vital.
many authors now consider it to be a radicular cyst derived from the lateral incisor.
MEDIAN CYSTS
These very rare cysts are found in the midline where fusion of the two halves of the
palate and mandible takes place.
NASOPALATINE CYSTS
Definition:
They are represent the commonest not odontogenic fissural cysts. These cysts arise
from epithelial remnants within or near to the nasopalatine foramen.

9 ‫صفحة‬ Cyst 2009/10/11

 ‫جراحة الفم والوجه والفكين السنة الرابعة‬

Clinical features
These cysts cause swelling of the anterior aspect of the midline of the hard palate with
salty discharge.
They may become infected and cause pain and overlying tenderness .(?)
Radiographically :
Appear as radiolucent area(heart-shaped Radiolucency) at anterior midpalatal region
behind central incisor, which may confused with radiolucency of incisive foramina
A radiolucency of approximately greater than 8 mm in diameter is more likely to
represent cystic degeneration.
When they are large, they can cause separation of the central incisor roots, but the
laminae dura of the teeth remain intact.
N.B : pulp testing can be carried out to confirm diagnosis
Treatment:
These cysts should be enucleated - never marsupialised because marsupialisation in
this area can lead to a permanent cavity that will show no evidence of restoration of the
normal contour.(?)
N.B: Normally, enucleation is carried out with a palatal flap taken around the gingival
margins of the premolars on one side to the premolars of the other. After enucleation,
interdental interrupted sutures are used to replace the flap and in larger cysts. It is
sometimes useful to have constructed a palatal plate from preoperative impressions to
support the flap and prevent the formation of a painful haematoma.

Non-epithelial cysts (not true cysts)

SOLITARY BONE CYST
This used to be known as a traumatic bone cyst or a haemorrhagic bone cyst. It is
usually found in the mandibular body
Radiology
The solitary bone cyst appears as a well-defined but non-corticated radiolucency.
Typically, it has little effect on adjacent structures and 'arches' up between the roots of
teeth. The inferior dental canal may not be displaced, but the cortical margins of the
canal may be lost where it overlies the lesion. Expansion is rare.
Pathology

10 ‫صفحة‬ Cyst 2009/10/11

 ‫جراحة الفم والوجه والفكين السنة الرابعة‬

The cyst is lined by fibrovascular tissue that often includes haemosiderin and
multinucleate giant cells.
Treatment :???????????????

ANEURYSMAL BONE CYST

This very rare condition of unknown cause affects the mandible rather than the maxilla.
Radiology The aneurysmal bone cyst typically presents as a fairly well-defined
radiolucency. Sometimes it has a multilocular appearance(soapbubble type of appearance)
because of the occurrence of internal bony septa and opacification. Marked expansion is a
feature.
Pathology
The predominant feature of an aneurysmal bone cyst is the presence of blood-filled spaces
of variable size lying in a stroma rich in fibroblasts, multinucleate giant cells and
haemosiderin. Deposits of osteoid are also seen.
Treatment :???????????????

Surgical management of cysts

Enucleation
Enucleation of a cyst involves the removal of the whole cyst, including the epithelial and
capsular layers from the bony walls of the cavity. This permits histopathological
examination and ensures that no pathological tissue remains.
A large mucoperiosteal flap, usually buccal, is raised to ensure that closure will be over
adjacent sound tissues and not the bony cavity. Primary closure is nearly always
undertaken unless the cyst is very infected, in which case this may be delayed and the
cavity initially dressed with antiseptic on ribbon gauze.
Enucleation of a nasopalatine cyst will require the nraising of a palatal flap to provide
surgical access and cyst removal. This inevitably damages the nasopalatine
nerves and vessels and results in a small area of paraesthesia, which usually does not
cause concern to the patient.

11 ‫صفحة‬ Cyst 2009/10/11

 ‫جراحة الفم والوجه والفكين السنة الرابعة‬

Marsupialisation
Marsupialisation is a simple operation that may be performed under local anaesthesia in
which a window is cut and removed from the cyst lining. This allows decompression of the
cyst, which then slowly heals by bone deposition in the base of the cavity. However, this
technique permits histopathological examination of only a small and possibly non-
representative sample of tissue.
Primary closure is not undertaken but rather the cyst lining is sutured to the oral mucosa to
keep the cavity open . The cavity must be filled with a dressing, which must be frequently
replaced, to prevent food debris trapping during the many months the cavity may take to
heal. Alternatively,an extension may be added to a denture to protect the cavity, which
becomes reduced in size as the cavity heals.
Marsupialisation is advocated when the cyst is so large that jaw fracture is the likely
outcome of enucleation, although enucleation and simultaneous bone grafting may be
preferable. The technique may also be useful if there are associated structures, such as the
inferior alveolar nerve, maxillary antrum or nose, that are at risk of damage during
enucleation. Similarly, marsupialisation of an eruption cyst will allow the eruption of a
tooth without it being damaged by enucleation.

REFERENCES
1) TEXTBOOK OF GENERAL AND ORAL SURGERY – BY D AVID WRAY, D AVID STENHOUSE ,
DAVID LEE AND AJ CLARK .
2) MASTER DENTISTRY ORAL AND MAXILLOFACIAL SURGERY, RADIOLOGY , PATHOLOGY AND
ORAL MEDICINE – BY DR P AUL COULTHARD, PROFESSOR KEITH H ORNER , PROFESSOR PHILIP
SLOAN AND MS ELIZABETH D. THEAKER .
3) FRAGISKOS D. FRAGISKOS _ORAL SURGERY .
4) PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERY , FIFTH EDITION , EDITED BY U. J. MOORE
FDSRCS (ENG), PHD (NCLE ) LECTURER IN ORAL AND MAXILLOFACIAL SURGERY UNIVERSITY OF
NEWCASTLE -UPON-TYNE .

2009 10 11

12 ‫صفحة‬ Cyst 2009/10/11