ORAL AND PARAORAL

CYSTS

Prepared by
Ass. prof. Dr. Maged Ali
 Developmental:
Odontogenic
1. Odontogenic keratocyst
2. Orthokeratinized
odontogenic cyst
3. Dentigerous cyst Non-Odontogenic Cysts.
4. Eruption cyst o Fissural cysts
5. Glandular odontogenic cyst  Nasoalveolar (Nasolabial).
6. Calcifying odontogenic cyst  Median palatine cyst.
7. Developmental lateral  Median mandibular cyst.
periodontal cyst and
Botryoid cyst
 Nasopalatine duct cysts:
8. Gingival cyst of adults
9. Gingival cyst of newborn
True cyst: is a pathological cavity
lined by epithelium and containing
fluid or semi fluid material.
Pseudo cyst: is a pathological cavity
not lined by epithelium containing
fluid or semi fluid material.
True cyst has 3 parts:
1-Epithelial lining.
2-Connective tissue wall.
3-Lumen of the cyst.
Histogenesis of epithelial lining:
• (A) Odontogenic: meaning arising
from epithelium involved in tooth
development, as :
Remnants of the dental lamina
(epithelial rests of Serres).
Remnants of enamel organ (reduced
enamel epithelium) .
Remnants of epithelial root sheath of
Hertwig (epithelial rests of
Malassez).
(B)Non-odontogenic epithelium:
Epithelial cells remaining entrapped
between embryonic processes at the line of
fusion of such processes.
Epithelium of branchial cleft
Secretory glandular epithelium
Remnants of the epithelium of the
nasopalatine duct.
Remnants of epithelium of the thyroglossal
tract.
General outline for formation of cysts

Initiation Cyst formation Enlargement

Initiation:
• True cysts are initiated by stimulation of epithelial
(odontogenic or nonodontogenic) rests usually for unclear
reasons.
Cyst formation:
• As the proliferation of epithelial rests continues, the cells in
the center of the mass degenerate and liquefy because they
become away from their source of nutrition (capillaries and
tissue fluids in connective tissue).
• This creates an epithelial lined cavity filled with fluid.
Enlargement of cysts:
• In response to a slightly elevated hydrostatic luminal pressure.
• This pressure causes bone resorption from the inside and
stretches the periosteum thus causing bone deposition from the
outside. (Clinically manifested as a bony swelling)
• If the rate of bone resorption from the inside is greater than the
rate of bone precipitation from the outside, bone perforation
occurs.
• The cyst may finally be covered by the oral mucosa only.
1. Periapical (Radicular )cyst:

 Inflammatory periapical lesions represents 63.24% of total cysts of

the oral cavity.
 The apical inflammatory lesions are usually a consequence of dental
caries that progression to pulp necrosis.

Origin of radicular cyst:

 Epithelial cells is from Malassez rests

Types of radicular cyst

1. Apical (related to the root apex),

2. Lateral (related to the lateral root surface and an accessory root
canal).
3. Residual after extraction of the related tooth.
Clinical Features:
 Age: Adult Sex: common in males
 Site: Maxilla is more common site especially the anterior
area.
Asymptomatic in its early stages.
Related to a non-vital tooth.
Pain may result due to increased intracystic pressure or due
to secondary infection
As the cyst enlarges, swelling of an area of the jaw is
commonly the chief complaint.
At first the swelling is bony hard but as the cyst
increases in size, the swelling will exhibit
“springiness” and later egg-shell crackling and finally
there will be fluctuation.
The enlargement is usually buccal or palatal in the
maxilla
while in the mandible it is usually labial or buccal
and only very rarely lingual Why?
• Radiographic Features: -
• Well defined round to ovoid radiolucency, with a radiopaque
margin.
• Root resorption is common.
Histopathology
1. Cyst cavity: contains colored serous
fluid and cellular debris
Cyst lining: lined by stratified
squamous epithelium of variable
thickness .
It usually shows arcades.
• When the epithelium is derived from
maxillary sinus, the cyst will be lined
with respiratory epithelium
(pseudostratified ciliated columnar
epithelium).
• Cyst wall: Varying thickness with chronic
inflammatory cells
• Rushton hyaline bodies: which are amorphous,
eosinophilic, linear or crescent shaped bodies
• Pathogenesis of Rushton bodies
odontogenic origin
exudate and transudate entrapped within the cystic
epithelium eventually undergo calcification
• Cholesterol clefts
• Degenerate plasma cells may be found in the
subepithelial connective tissue and are known as
Russel bodies.
• Dystrophic calcification: Basophilic calcific
deposits in degenerated or necrotic tissue.
Differential diagnosis:
• Inflamed developmental odontogenic cyst
• Periapical granuloma
• Periapical scar.
• Chronic periodontal disease
Treatment
• Enucleation or curettage with apicoectomy or marsupialization,
depend on the size of lesion
• RCT
• Extraction
2.Buccal bifurcation and paradental cyst
Inflammatory collateral cyst

• It is an inflammatory odontogenic cyst arising on the buccal

(buccal bifurcation) or distobuccal (paradental) aspects of
the roots of partially or recently erupted teeth.
Pathogenesis:
• Inflammation in the pericoronal tissue.
• Tooth eruption may initiate an inflammatory response in
the surrounding tooth follicle that can stimulate cyst
formation.
Clinical Features:
Age: 7 to 20 years.
Site buccal root surface of  Affected tooth is vital (differentiate
partially erupted between buccal bifurcation cyst and
mandibular first permanent radicular cyst)
molar
 Recurring pericoronitis
 deep pocket formation.
 Asymptomatic or shows swelling,
tenderness or pain, foul tasting
discharge
Radiographs
Cupped-out unilocular radiolucent lesion
surrounding the roots of the involved tooth
Histopathologic Features:
• Grossly: A cyst-like soft tissue attached to
the CET, or along the root of the tooth
Microscopically:
• Non specific picture of an inflamed cyst
wall (identical to radicular cyst)
• Treatment: by enucleation
Developmental cysts of the
jaw
1-Dentigerous cyst (follicular cyst):
• It is a developmental odontogenic cyst that surrounds
the crown of an impacted tooth and is attached to the
tooth at the cementoenamel junction.
• It is the most common developmental cyst of
odontogenic origin, comprising 17% to 20% of cysts in
the jaws.
Histogenesis:
• It derived from reduced enamel epithelium.
• There is accumulation of fluid between the reduced
enamel epithelium and the tooth crown.
Clinical Features:
Permanent mandibular third molars
Complications:
followed by maxillary third molar and
maxillary canines. 1. Jaw fracture
2. Neoplasms can arise from
Painless bony expansion (Painful if
secondarily infected) dentigerous cyst lining, most
commonly:
Can displace the involved tooth
 Ameloblastoma
Cause resorption of adjacent teeth  Squamous cell carcinoma
Multiple simultaneous dentigerous  Intraosseous
cysts are uncommon but may appear mucoepidermoid carcinoma
in some syndromes such as
cleidocranial dysplasia
Radiographic
Well defined radiolucency having
radiopaque margin and associated with the Central
crown of an unerupted tooth.
The cyst may pushes the impacted tooth
downward to the inferior border of mandible
or upward to the ramus.
Three cyst crown relations are present: Lateral

Central: crown lies in center of the cavity

Circumferential
 Lateral: crown lies lateral to the cavity
 Circumferential: tooth are surrounded by
cavity and seems to be pushed inside it.
Histopathology
• The cyst wall consists of a connective tissue
capsule free from inflammatory cells unless
the cyst had become infected.
• It is lined by a thin layer of flat stratified
squamous epithelium.
• The epithelial lining frequently contains
mucous secreting cells.
• It treated by enucleation of the cyst in
conjunction with removal of the associated
tooth.
2. Eruption cyst
• It is the soft tissue counterpart to dentigerous cyst;
involving an erupting tooth.
If blood accumulates in the cystic cavity it is
termed (Eruption hematoma
Clinical Features:
• Dome-shaped swelling of the alveolar mucosa
overlying an erupting tooth.
• It is translucent with a bluish hue due to the
collection of cystic fluid and hemorrhage within
the follicular sac.
• Most cases occur in children with erupting
deciduous first molars .
Histopathology
• The surface of the specimen is covered
by normal alveolar mucosa
• The deep margin is lined with a thin
layer of nonkeratinizing stratified
squamous epithelium, which
represents the roof of the cyst.
• Inflammatory cells may be present.
3. Glandular odontogenic cyst
• Glandular odontogenic cyst (sialo-odontogenic cyst) (GOC)
is an uncommon developmental odontogenic cyst that can
show aggressive behavior
• It represent a cystic neoplasm because of its locally
aggressive behaviour and high recurrence rate, but at this
time, it is still classified as a cyst.
• Origin: Dental lamina rests.
Clinical Features:
Commonly in mandible (75%) at anterior
region.
Slowly expanding painless swelling.
Recurrence is common.
Radiographic Features:
Unilocular or multilocular with well-defined
margins.
Root resorption, cortical bone thinning and
perforation, and tooth displacement may
occur.
In mandible it may cross the midline.
Histopathology
• The GOC is lined by squamous epithelium of varying thickness.
• In some areas, the squamous epithelial cells may for swirling
spherical aggregates.
• The superficial epithelial cells that line the cyst cavity are eosinophilic
cuboidal cells, resulting in an uneven hobnail appearance.
• Intraepithelial microcysts, duct-like spaces which may contain
mucous pools, or appear empty.
• Papillary projections or "tufting" of epithelium.
• Clear cells in basal or parabasal layers
• Mucous goblet cells within the surface layer
GOC
• Treatment:
• 1. Complete removal with curettage.
• 2. En bloc resection for large aggressive lesions
 4. Calcifying odontogenic cyst: (Gorlin cyst)

• It characterized by odontogenic epithelium containing “ghost

cells,” which then may undergo calcification.
• The current WHO classification system, these lesions have
been categorized as odontogenic tumors under three categories
(based on the cystic, solid, or malignant nature of the lesion):
• 1. Calcifying cystic odontogenic tumor
• 2. Dentinogenic ghost cell tumor
• 3. Ghost cell odontogenic carcinoma
Origin: rests of dental lamina.
Clinical features:
Asymptomatic
Commonly in incisors and canines’ areas.
Associated with unerupted teeth.
75% is central within the bone and 25% are
peripheral as growths on the gingiva
 If the cyst becomes infected, the swelling
becomes painful.
Radiology description: unilocular, well-defined radiolucency, although
the lesion occasionally may appear multilocular
scattered some irregularly-sized radiopacities of variable density giving
a characteristic “Salt & Pepper appearance”
Histopathology
• A well-defined cystic lesion with a fibrous
capsule
 A lining of odontogenic epithelium of four to
ten cells in thickness.
 The basal cells of the epithelial lining may be
cuboidal or columnar and are similar to
ameloblasts.
 The overlying layer of loosely arranged
epithelium may resemble the stellate reticulum
of an ameloblastoma.
 The most characteristic histopathologic feature is
the presence of variable numbers of “ghost cells”
within the epithelial component.
 These eosinophilic ghost cells are altered epithelial
cells that are characterized by the loss of nuclei
with preservation of the basic cell outline
 Calcification within the ghost cells is common and
result in basophilic bodies
 Dysplastic dentin (dentinoid) also may be present
5. ODONTOGENIC KERATOCYST (OKC)
• It is a distinctive form of developmental odontogenic cyst
that deserves special consideration because:
Its biological activities is different from other odontogenic
cysts; it may exhibit clinically aggressive behavior, high
growth potential and higher recurrence rate.
Possible association with the nevoid basal cell carcinoma
syndrome
• So that several investigators have suggested that the OKC be
regarded as a benign cystic neoplasm rather than a cyst
• Thus it has been given the name keratocystic odontogenic
tumor.
Origin: - arises from rests of the dental lamina.
- or from enamel organ before amelogenesis.
Clinical
• Site: posterior body of the mandible and ramus.
• It grows anteroposterior direction within the medullary cavity
of the bone without causing obvious bone expansion so it
may grow to a large size before it manifests clinically.
• OKC does not grow due to elevated hydrostatic luminal
pressure, but due to genetic mutation that causes increase in
the mitotic index of its epithelium.
• If multiple OKCs are present, the patient should be evaluated
for other manifestations of the Nevoid basal cell carcinoma
syndrome.
Radiographic Features:
• Well-defined radiolucent area.
• Large lesions may be multilocular (Soap
bubble appearance)
• An unerupted tooth may be seen within the
lesion; in this case it resembles a
dentigerous cyst radiographically.
• This happens when the OKC arises from
dental lamina rests near an unerupted tooth
and grows to envelop the unerupted tooth.
Histopathology
Cyst lumen: filled with a cheesy material
(keratin debris)
The luminal surface shows parakeratotic
epithelial cells, which show a wavy or
corrugated appearance.
Cyst lining: Uniform thin epithelial lining
that is friable, thus difficult to enucleate
from the bone in one piece.
The basal epithelial layer is composed of a
palisaded layer of cuboidal or columnar
epithelial cells, which are often
hyperchromatic.
Artifactual clef may be seen between
epithelium and underlying connective
tissue.
Connective tissue wall: thin fibrous wall
devoid of significant inflammation.
Budding of the epithelium and small
satellite cysts or islands of odontogenic
epithelium
Treatment:
• 1. Enucleation and curettage.
• 2. Occasionally, resection is indicated in cases of:
• ➢ a locally aggressive OKC with frequent recurrences
• ➢ in the case of large multilocular keratocysts in which
enucleation and curettage would result extensive loss of bone
by itself.
• 3. Complete removal of the cyst in one piece is often difficult
because of thin, friable cyst wall
Prognosis:
OKC tends to recur due to:
1. Fragmentation of the friable cyst lining where it remains in the
bone.
2. Satellite cysts may be left behind in the bone after operation.
3. Seeding of viable epithelial cells into the tissues.
Nevoid Basal Cell Carcinoma Syndrome (Gorlin
syndrome)
Pathogenesis : abnormalities in the PTCH gene
Major Criteria
• 1. Multiple basal cell carcinomas (before age of 30)
• 2. Odontogenic keratocysts (with more satellite cysts)
• 3. Epidermal cysts of the skin
• 4. Enlarged head circumference
• 5. Rib anomalies (fused, partially missing, and/or bifid)
• 6. Ocular hypertelorism
• 7. Plantar pits
Multiple basal cell
Multiple bifid ribs Ocular hypertelorism more satellite cysts
carcinomas

Plantar pits
6. Orthokeratinized odontogenic cyst
Clinical Features:
Mostly asymptomatic and discovered only on routine
radiographic examination.
Site: most cases occur in posterior mandible Sex: 3:1 male
predilection
No association with nevoid basal cell carcinoma syndrome
Radiographically:
 Unilocular radiolucency one half of cases are associated
with impacted tooth .
Histopathology
 Uniformly 5 to 15 cells thickness with
flattened or cuboidal no palisading of
basal cell nuclei
 Prominent granular cell layer
 keratinaceous material in lumen
 No satellite cysts in wall
Treatment:
• Simple enucleation
Odontogenic keratocyst Orthokeratinized odontogenic cyst
 Usually multilocular  Usually unilocular
 Palisaded basal layer  Flattened or cuboidal basal
 Corrugated parakeratinized cells
surface  Prominent granular cell layer
 Daughter cysts and budding  No daughter cysts or budding
 Less keratin production  Abundant keratin may fill the
 Higher recurrence rate cavity
 Maybe associated with nevoid  No recurrence
basal cell carcinoma syndrome.  Not associated with nevoid
basal cell carcinoma syndrome.
7. Developmental lateral periodontal cyst

Pathogenesis
Rests of dental lamina.
Clinical
• Site: between the premolars, followed by
the canine-lateral area , along the lateral
root surface of a vital tooth
• Asymptomatic and can be detected during a
radiographic examination.
• Unilocular radiolucency is evident
between two teeth that are vital
• Multiloculated radiolucency in the same
locations may represent botryoid
odontogenic cyst
• Histopathologic Features

• Thin stratified squamous

epithelium, composed of 1 to 3
cells in thickness.
• Clusters of glycogen-rich, clear
epithelial cells may be noted in
nodular thickenings of the cyst
lining.
• Non inflamed, fibrous wall.
Treatment and Prognosis:
Conservative enucleation.
 Excellent prognosis
For Botryoid cyst, recurrence is common so it might need
good curettage or more extensive treatment.
 8.GINGIVAL (ALVEOLAR) CYST OF THE NEWBORN
Gingival cysts of the newborn are small, superficial,
keratin-filled that are found on the alveolar mucosa
of infants.
• Origin: remnants of the dental lamina
Clinical Features:
In half of all newborns.
More common in maxillary alveolus than in
mandibular alveolus.
Appear as small, multiple whitish papules on the
mucosa overlying the alveolar processes of
neonates.
Disappear spontaneously by rupture into the oral
cavity.
• Histopathologic Features
 Thin, flattened epithelial lining with a
parakeratotic luminal surface.
 The lumen contains keratinaceous
debris.
• Treatment and Prognosis
• No treatment because the lesions
spontaneously involute as a result of the
rupture of the cysts
 9.GINGIVAL CYST OF THE ADULT
• The gingival cyst of the adult is an uncommon lesion.
• It is considered to represent the soft tissue counterpart of the lateral
periodontal cyst
• Origin: derived from rests of the dental lamina
• Clinically: Closely resembles that of the lateral periodontal cyst.
 painless, domelike swellings, commonly in the mandibular canine and
premolar area
 less than 0.5 cm in diameter.
 They are often bluish or blue-gray.
• Histopathologic Features
• Similar to lateral periodontal cyst
• Treatment and Prognosis
• simple surgical excision.
• The prognosis is excellent.