Braz J Oral Sci. January/March 2005 - Vol.

4 - Number 12

Odontogenic cysts - A descriptive

clinicopathological study
Lus Monteiro 1
Jesus de la Pea 2
Liliana Fonseca 1
Antnio Paiva 3
Barbas do Amaral 2
Instituto Superior de Cincias da Sade - Norte
Hospital Geral Santo Antnio Porto
3
South Manchester University Hospitals, U.K.
1
2

Received for publication: August 10, 2004

Accepted: October 10, 2004

Abstract
Odontogenic cysts are lesions that deserve every attention, mainly
because of all complications they can cause. To study their
characteristics, the authors did a retrospective clinicopathological
analysis of 124 oral biopsies that were diagnosed as odontogenic
cysts, in Hospital Geral de Santo Antnio Porto. Clinical variables
such as age, sex, location, clinical diagnosis and histological diagnosis
were studied. Inflammatory radicular cysts were the most commons
(48.4%) followed by dentigerous cysts (21.0%), residual cysts (17.7%)
and keratocysts (12.1%). The most frequent clinical manifestation
was swelling (62.9%). Age appears to be related to the type of cyst,
expressing the etiopathologic characteristics of each one. It is concluded
that a definitive diagnosis is based on a triad of radiology, clinics and
histology, which presupposes a tight cooperation between the clinician
and the histopathologist.
Key Words:
oral pathology, developmental cysts, inflammatory cysts, jaw cysts,
Gorlin syndrome.

Correspondence to:
Lus Monteiro
Rua Antnio Moreira da Silva, 175
4475-457 Maia Portugal
E-mail: [email protected]

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Braz J Oral Sci. 4(12): 670-675

Introduction
Cystic pathology owes a lot of its particular characteristics
to the presence of teeth and its associated tissues. Its
special nature tends to be related with the embryologic
development of teeth and the dynamic interactions of
epithelial elements with mesenquimatous elements.
A cyst is a pathological fluid, semi-fluid or gaseous-filled
cavity lined by epithelium that, in turn, is lined by a capsule
of connective tissue. They deserve ones attention, mainly
because of all the complications they can originate, such
as facial aesthetic changes, jaw fractures, infections, and
occasional neoplasia of its epithelium 1-4.
Many classifications of jaw cysts have been proposed
and used, according to different criteria such as its
embryologic origin, aetiology, pathology, or its clinicalmorphological manifestations. The World Health
Organization (WHO) more recently, classifies epithelial
cysts (or true cysts), as odontogenic cysts and nonodontogenic cysts. The first type includes two categories:
inflammatory and developmental. Non-odontogenic cysts
are also developmental cysts and include nasopalatine
and nasoalveolar cysts, amongst others. Cysts without
epithelial lining, also called pseudo-cysts, are nowadays
considered to be non-neoplasic bone lesions and include
solitary bone cysts and aneurysmal bone cysts 5.
The purpose of this paper was to study the frequency of
several types of odontogenic cysts and some of its
clinical-pathological characteristics.
Material and Methods
It was performed a descriptive study. All histopathological
reports (n=153) of oral cavity lesions with histological
diagnosis of odontogenic cyst were reviewed. These
diagnoses were made by the Anatomic Pathology Service
of the Hospital Geral de Santo Antnio (Porto), in the
course of a three-year period, between January 1999 and
December 2001. In all cases, histological preparations were
reviewed and clinical reports were analysed, along with
the complementary means of diagnosis (plain
radiographs, orthopantomograms and computer
tomography).
Twenty-nine cases were excluded due to lack of clinical
information or non-concordance of data. Therefore, 124
patients with odontogenic cysts established the final
sample.
Variables such as, age, sex, occupation, location, clinical
manifestations, radiographic appearance, clinical and
histological diagnosis, were studied. Recurrences were
analysed over a follow-up period of 1 to 3 years.
Classification of these lesions was made according to the
WHO (Kramer and Pindborg, 1992)5. Classification of the
social-professional groups was based on the British
Registrar-General6. The location of the cystic lesions was

Odontogenic cysts - A descriptive anatomo-clinical study

divided into maxillary or mandibular and anterior sector

(incisors and canines) or posterior sector (premolars and
molars).
Statistical analysis included the chi-square test to analyse
the categorical variables, and the t-student test and the
Kruskal-Wallis test were used to analyse the continuous
variables. For this purpose it was used the SPSS 10.0
specific computer program. The admitted level of
significance was p<0.05.
This study was approved by the Health Ethics Commission
of Hospital Geral de Santo Antnio Porto.
Results
The studied sample included 124 patients, 72 of them were
men (58.1%) and 52 were women (41.9%).
The most frequent type of cysts was the radicular cyst
with a total of 60 cases (48.4%), followed by 26 dentigerous
cysts (21.0%), 22 residual cysts (17.7%), 15 keratocysts
(12.1%), and 1 paradental cyst (0.8%).
The age interval at diagnosis with the greatest number of
cases (25.0%) was the one ranging from 30 to 39 years
old. The median age was 34 years, the youngest being 7
years old and the eldest 79 years old. When age and cyst
type were related, dentigerous cysts were more frequent
on the second and third decade, radicular cysts were more
frequent on the fourth decade, residual cysts were more
frequent on the fourth, fifth and sixth decade and
keratocysts were more frequent on the second and third
decades of life. The median distribution of each type of
cyst, displayed on table 2, shows a significant difference
(p=0.002).

Fig. 1 - Distribution of odontogenic cysts by age.

The most representative (47.0%) social-professional group

on this sample was the semi-specialised group (table 1).

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Odontogenic cysts - A descriptive anatomo-clinical study

Table 1. Distribution by social-professional activity.

Social-professional group

I (Differentiated)

4,3

II (Technical)

6,1

III (Qualified)

7,0

IV (Semi-specialised)

54

47,0

V (Non-specialised)

41

35,7

About 10.5% of all patients (n=13) had more than one cyst,
which makes a total of 144 cysts on the final sample. Thus,
89.5% had 1 cyst (n=111), 5.6% had 2 cysts (n=7), 2.4% had
3 cysts (n=3) and 2.4% had 4 cysts (n=3).
As for the location of the cysts (n=144), 53.5% (n=77) of all
cysts were on the maxilla and 46.5% (n=67) were on the
mandible. In the maxilla, the most affected sector was
the anterior (59.7%, n=43), whereas in the mandible, the
most affected sector was the posterior (81.5%, n=53)
(p<0.001). The most frequent location of inflammatory
cysts (radicular and residual cysts) was the maxilla, and for
developmental cysts (keratocysts and dentigerous cysts)
was the mandible, mainly in the posterior sector (table 2).
The most common clinical manifestation was swelling that
was present in 62.9% of cases (n=78). Other symptoms, by
decreasing order of appearance were spontaneous drainage
of fluids in 21.0% of patients (n=26), infection (20.2%, n=25),
pain (17.7%, n=22), caries (15.3%, n=19), face cellulitis (7.3%
n=9), teeth mobility (2.4%, n=3), sinusitis (1.6%, n=2),
trismus (1.6%, n=2), changes in alveolar healing (1.6%, n=2)
and paresthesia (0.8%, n=1). In a large number of patients
these complaints were associated. It is important to point
out that in 36.4% of patients, cysts were discovered by
accidental radiological finding (n=44). This situation was
more evident for keratocysts and less evident for radicular
cysts (p=0.019).
Clinical diagnosis made before histological ones, had a
positive histological confirmation in 82.9% of cases (n=92).
Patients underwent cystectomy, 86.0% (n=107) of which
were performed under general anaesthesia and 14.0% (n=17)
with local anaesthesia.
The cysts radiological image was unilocular (90.6%, n=116),
followed by unilocular with lobulated margins (6.3%, n=8)
and multilocular (3.1%, n=4).
Cysts size was between 1 to 10 centimetres. Radicular cysts
had a median size of 2 centimetres, thus smaller than
dentigerous cysts and keratocysts (median = 3cm). This
difference was significant (p=0.02).
Clinical diagnosis made before histological ones, had a
positive histological confirmation in 82.9% of cases (n=92).
Patients underwent cystectomy, 86.0% (n=107) of which were
performed under general anaesthesia and 14.0% (n=17) with
local anaesthesia.

672

Recurrence occurred in 4.4% of all cases.

In patients with keratocysts, it were found 3 cases of
Gorlins syndrome, in individuals with multiple keratocysts.
They also showed the typical alterations of this syndrome
such as several basal cell naevi, hydrocephaly, calcification
of the falx cerebri, broad nasal root, hypertelorism, history
of basal cell carcinoma, mild mental retardation and family
history of jaw cysts and brain calcifications. Other variables
connected to keratocysts and other odontogenic cysts are
shown on table 2.
About 47.8% (n=11) of all keratocysts were associated to
impacted teeth (p<0.001).
Histologically, about 86.7% of keratocysts were
parakeratotic (n=13).
It is important to mention that 18.2% (n=4) of keratocysts
recurred, while other types of cysts rarely recur.

Fig. 2 Ortopantomography with a multiple keratocysts on firth,

third and fourth quadrants.

Fig. 3 Histology of a parakeratotic keratocyst 200x (HE).

The paradental cyst (n=1) occurred in a 30-year-old woman,

located on the mandible in the posterior sector. It was an
occasional radiological finding and the histological
diagnosis confirmed the clinical diagnosis.

Braz J Oral Sci. 4(12): 670-675

Odontogenic cysts - A descriptive anatomo-clinical study

Table 2. Clinical-radiological characteristics distribution according to odontogenic cysts type.

Radicular cysts
n (%)

Discussion
Inflammatory odontogenic cysts were 65.9% (n=83) of the
total sample and 32.5% (n=41) were developmental
odontogenic cysts. The most frequent inflammatory cysts
were radicular (47.6%, n=60) followed by residual cysts. In
the group of developmental odontogenic cysts,
dentigerous cysts were the most common (20.6%, n=26).
Many studies, support these results. Daley et al.7 in a study
of 40000 oral biopsies made on the Diagnosis and Oral
Pathology Service of the Western Ontario University
(Canada), found a percentage of 64.9% for radicular cysts,
24.1% for dentigerous cysts and only 4.8% for keratocysts.
On the other hand, Mosqueta-Taylor et al.8 analysed 856
cases of odontogenic cysts in Mexico and found a
percentage of 21.5% for keratocysts. The frequency of
keratocysts is, therefore, variable from study to study,

Dentigerous cysts
n (%)

Residual cysts
n (%)

Keratocysts
n (%)

maybe because of the different criteria used in the

histological diagnosis, because of the lack of
communication between physician and pathologists or
because of the heterogeneity of the studied populations.
Shear et al.9 mention a study of 2616 cysts diagnosed in the
Department of Oral Pathology of the WitWatesrand
University in South Africa, where a frequency of 52.3% for
radicular cysts and 11.2% for keratocysts was found, which
are very close to those obtained in this study.
The studied sample showed a slightly higher frequency in
men. Men were also more affected by the several types of
jaw cysts, except for keratocysts. Most studies also show a
higher frequency in men8,10-11. Unlike other studies8,12-13, in
this study, the keratocysts slightly affected women more
frequently than man. Taylor et al.8, in their sample, also
found that women were more affected but only by radicular

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cysts, while men were more affected by keratocysts and

dentigerous cysts. These results are thought to be more
related to the type of populations studied than to the
specific characteristics of these cysts.
The present study revealed that this pathology might
appear at any age. However, certain types of cysts seem to
appear mostly at certain ages, which can be seen when
analysing the median of ages. Dentigerous cysts were more
frequent in young individuals, whereas radicular and
residual cysts were commoner in adults and elder
individuals. Such results, partially confirmed by other
studies, express the etiopathogenic characteristics of each
type of cyst 12.
The most frequent location for inflammatory cysts (radicular
and residual cysts) was the maxilla, whereas for
developmental cysts (keratocysts and dentigerous cysts)
was the mandible, mainly in the posterior sector.
The most frequent radiological feature of these lesions was
unilocular as the multilocular appearance was only seen in
keratocysts, which seems to be a characteristic of such
lesions. In a study of odontogenic keratocysts performed
by Zhao et al.11 in the Wuhan University, in China, it was
found that 16% of keratocysts were multilocular. It should
be pointed out that the radiological feature unilocular
lobulated and multilocular are distinct, although they can
be confused in conventional radiology. Thats why CT scan
images should be used in its classification, as it was done
in this study. It was also keratocysts that had the highest
recurrence rate (18.2%, n=4) after a follow up period of three
years. Radiological features showed no relationship with
recurrence. Their recurring nature is a typical characteristic
for this type of cysts, mostly in the first 10 years after their
first presentation 4,10,12.
In this study, it was found three Gorlin syndromes (in 20%
of the cases with keratocysts) associated to multiple
keratocysts of the parakeratotic type. Not all published
papers present identical results. Oda et al. 10, in a study
made in the USA with 393 patients with keratocysts, found
that 5% had Gorlins syndrome. Of the 87 cases reported
by Kakarantza-Angelopoulou and Nicolatou 14, in a study
made in Athens, 8.8% had the syndrome. In a paper
published by Cabral et al.12, in a sample with 238 epithelial
maxillary cysts, no Gorlins syndromes were found. When
the diagnosis of a keratocyst is made, especially if there
are multiple recurrent lesions, it is essential to search for a
possible Gorlins syndrome.
If cysts are slow growing, expansive and usually
symptomless lesions, it is understandable why, in this
study, the most frequent clinical manifestation was swelling,
which represents an advanced stage.
It was also established that cysts frequently were accidental
radiological findings. Thus, 36.0% (n=44) of cases in the
total sample were radiological findings. That demonstrates

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Odontogenic cysts - A descriptive anatomo-clinical study

the value of periodical x-ray examinations for the screening

of such pathology. Keratocysts corresponded to the largest
number of radiological findings (60.0%, n=9). They were the
ones with the least clinical manifestations, but when they
were present, the lesion was usually in an advanced stage. It
should be mentioned that in some cases, other signs and
symptoms were identified after the radiological finding.
In several cases, the clinical diagnosis did not match the
histological one, which demonstrates the importance of
having a histopathological examination done. The clinical
concordance was highest for dentigerous cysts, followed
by radicular cysts, which means that these types of cysts
have more obvious clinical-radiological features than other
types of cysts such as keratocysts. The latter were the ones
with the least clinical concordance in this sample, which
shows that for the diagnosis of this type of cyst, the
histological examination is extremely important. Its thought
that the presence of impacted teeth makes the clinical
diagnosis easier for dentigerous cysts, but it can be an
element of error for the assumption diagnosis of keratocysts.
In fact, almost half of the keratocysts in this sample were
associated to an impacted tooth, which may cause its mistake
for a dentigerous cyst. Thats why, in such cases, histological
examinations allows confirmation of dentigerous cysts or
might diagnose the presence of keratocysts or even neoplasic
lesions.
In the same way, there were several cases where the
histopathologist was only able to tell the type of cyst after
receiving clinical and radiological information, which
demonstrates its importance. It should be pointed out that
its very important to send all surgically removed specimens
for histological examination, in appropriate conditioning,
along with all clinical and radiological information, thus
allowing an adequate, complete and conclusive diagnosis.
One might say that the definitive diagnosis is based on a
triad composed by clinical observations, radiological
features and histological examining, which requires an open
dialogue and a close cooperation between the dentist/
surgeon and the histopathologist.
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