Cysts

Odontogenic & Nonodontogenic
Cysts
Definition of cyst
• “ cyst is pathological cavity having fluid , semi
fluid, or gases that are not created by the
accumulation of pus ; frequently but not
always it is lined by epithelium” Kramer 1974
• This is an area where radiology plays an
important role in assisting with the diagnosis,
determining the size of the lesion and the
relationship to adjacent structure. Cysts occur
more commonly in the jaws than in any other
bone.
Commonly used radiographs
• 1. Occlusal view
• 2. Panorama view
• 3. Peri apical , Occiptomental, lateral oblique
• 4. CT - for bony lesions.
• 5. MRI - for soft tissue lesions
ETIOLOGY.
• Developmental
• Inflammatory
• Traumatic
• Neoplastic
Classification
Characteristics of Cysts
• Most cysts form from
epithelial remnants during
development
• Shape: round/hydraulic (like
water balloon)
• Appearance: very radiolucent
• Border: well defined,
corticated
• Expansile, non-destructive,
can diverge roots of teeth *
Cystic lesion
• Lets talk about cyst and features :
• They are mostly uniform in shape round or oval like water
balloon radiolucent in 2D imaging
• Slow growing expansile well defined means we can easily
trace the boundaries of the lesion
• They are located in maxilla and mandible usually in teeth
bearing areas
• And above mandibular canal
• They can expland into the antrum
Early stage Tooth Crypts
• May resemble cyst
• May be seen from birth
to late adolescence
• Another example is
Tooth crypts can be
suspecious and fool us
for a pathology in
younger patients in 3rd
molars
Radiographic features
• Uncalcified crypt: bilateral well-corticated solitary
radiolucency of same size as crown of tooth which is
developing
• May resemble primordial cyst if located at crest of ridge (We
are going to talk about primordial later)
• Uncalcified crypts of permanent teeth may resemble abcess
between roots of primary teeth
• May mimic solitary lesion with radiopaque foci if cusp tips are
just forming. (AOT, Gorlin, CEOT)
Tooth crypts
Forming follicular sac patient is young in mixed dentition around 7 to 8 years

Tooth crypt
Fibrous Healing Defect
• Bone usually heals normally if cortical plates with intact
periosteum are present
• If plates and periosteum are destroyed by pathological or
surgical trauma, then source of osteoblasts is lost and
fibrous healing defect results
• May occur with
• Apicoectomy
• Difficult extractions
• Orthognathic surgery
• Jaw fracture
• Excision of large lesions
Fibrous Healing Defect
Usually after extractions of upper 2nd premolars and 1st molars speccially where
there is a peraipical lesion and dentists are afraid to curettage to prevent from
going into the sinus
Apical Scar
• Residual periapical radiolucency
after successful apicoectomy
• Asymptomatic, do not change in
size or appearance
• Well circumscribed radiolucency
at site of previous surgery
• Characteristic “punched out” or
“see through” appearance
• May resemble residual cyst in
edentulous areas *
After surgery bone and soft tissue start to heal and soft tissue is always faster to heal
this will gives a fibrous healing Specially in larger lesions Important to defrientate is
comparing with previous radiographs to make sure entity is not expanding
Radicular cyst (most common)
• Nonvital tooth
• Corticated border, large size- differentiate from apical granuloma
Radicular cyst
Residual cyst
Dentigerous cyst
(follicular cyst)
• Most common developmental odontogenic cyst (34%)
• Epithelium-lined sac that develops about the crowns of
an unerupted tooth
• Most common mand 3rd molars, max canines, mand
premolars and max 3rd molars in that order
• Panoramic radiograph ideal for discovering
• Greatest incidence 20-30 years of age
• Associated with delayed eruption, swelling, asymmetry, no
pain
Types
• Central
– Crown of
unerupted
tooth is
completely
surrounded
by cyst
radiolucency
Centrally when tooth is completely surounded by the lesion

Usually they confined within CEJ to CEJ of impacted tooth
Dentigerous cyst
• most common all cysts after radicular cysts
Types
• Lateral: It can occur
lateral to the affected tooth
– Cyst radiolucency appears

to project laterally from
unerupted tooth crown
Dentigerous cyst- radiographic
• Well demarcated radiolucency with distinct
corticated border
• Associated with the crown of an unerupted or
impacted tooth, Joins at neck of tooth
• Can grow quite large, displace teeth and
expand bone
Remember Important thing well demarcated rl with distinct
cortical boarder associated with crown of an uneupted or
impacted tooth
Dentigerous cyst
Normal follicular space is about

3 mm or less
Dentigerous cyst
When lesion comes bigger we suspect tumoral behavior

Dentigerous cyst
* (follicular cyst)
Example from cases that we

see her Impacted canine
Dentigerous Cyst- treatment
• Enucleation- complete removal of cyst and lining
• Decompression- keep cyst open using surgical drain
• Marsupialization- resection of cyst wall and suturing down cut
edges to adjacent mucosa keeping cyst open
• In all cases, removal of associated tooth
• And submit for biopsy to rule out other lesions

Complications of Dentigerous Cysts
• 8.5% turn out to be OKC’s
• 15 to 30% of all ameloblastomas arise from
dentigerous cysts (mural ameloblastomas)
• Squamous cell CA arising from a dentigerous cyst has
been documented
• Cases of mucoepidermoid CA have been found in
association with dentigerous cysts around impacted
mandibular third molars
Mural Ameloblastoma
• Ameloblastoma that
forms in the wall or
lining of a dentigerous
cyst
• Age < 30 years
• Posterior mandible
• Delayed eruption of
tooth, swelling,
asymmetry
Mural Ameloblastoma *
Interruption of
alveolar crest
Expansion
Knife edge resorption
on adjacent tooth
Odontogenic Keratocyst
• Multilocular or unilocular
• Epithelial lining is
keratinized
• 6-10 cells thick with
palisading polarized basal
cell layer (tombstone)
• Radiographically not unique
KCOT- radiographic findings
• Scalloped, usually well-
corticated, multi-locular
• Expansile with tendency to
perforate cortical border
• Resorption of the roots
• Cloudy, hazy interior to
lesion
KCOT
KCOT- treatment
• Average recurrence rate is 26% (parakeratinized
higher than orthokeratinized)
• Marsupialization- opening up of cyst with conversion
to pouch
• Enucleation and primary closure for smaller cysts
• Annual radiographs q5 years after surgery
Jaw cyst/Basal Cell Nevus/Bifid- rib
Syndrome
• Gorlin and Goltz syndrome
• Multiple keratocysts
• Basal cell nevi carcinomas
• Bifid (twinning) ribs
• Calcification of the falx cerebri
• Autosomal dominant with variable
expressivities
Jaw cyst/Basal Cell Nevus/Bifid rib
Syndrome
Jaw cyst/Basal Cell Nevus/Bifid rib
Syndrome
Calcification of
the falx
cerebri
Lateral Periodontal Cyst
• Developmental
odontogenic cyst
• Located along lateral
surfaces of tooth root
• Directly associated with
the periodontal ligament
• Usually small corticate RL
located in radicular areas
most commonly in
mandible from lateral
incisors to premolar areas
• Usually associated with root of a vital mandibular
bicuspid about halfway up the root
• If tooth is non-vital probably a radicular cyst instead
• Well defined or corticated margins
• Some divergence of teeth possible
• May see buccal bulging
• No pain involved
• tx is Enucleation and do not recur
Lateral Periodontal cyst
Residual Cyst
• Odontogenic cysts which remain after tooth has been lost
• Descriptive term, may actually be apical, lateral periodontal or
follicular cyst
• Both non-keratinizing and keratinizing types
Radiographic features:
• Well corticated, round radiolucency usually
about 1cm in diameter
• Frequently located in edentulous areas where
tooth was removed
• Often confused with primordial cysts, focal
osteoporotic bone marrow defects
Residual Cyst
Non-odontogenic
• Nasopalatine canal cyst
– Incisive canal cyst (nasopalatine canal)
– Median anterior
maxillary cyst
• Palatine papilla
– Soft tissue cyst
Incisive canal cyst
• May occupy one or both
canals
• Arises from epithelial
remnants of
nasopalatine ducts
• Classically heart shaped,
but may be round when
small
• Heart shape because
super impose anteior
nasal spine
Palatine Papilla
• Occurs within soft tissue
• Ordinarily not seen on radiograph
Nasoalveolar or nasolabial cyst
• Forms at junction of lateral

nasal and maxillary
processes
• Swelling at wing of nose
• Exclusively in soft tissue
• Normally not visible on
radiograph
Nasal labial cleft cyst
Pseudo cysts
• Resemble cysts, but have no cystic lining
• Not as destructive as cysts
– Traumatic bone cyst
– Aneurysmal bone cyst
– Developmental salivary gland defect
Traumatic Bone Cyst (simple bone cyst, solitary bone
cyst, unicameral cyst, hemorrhagic bone cyst)
• Large ‘cyst like’ lesions with no epithelial lining
• Etiology unknown, atypical bone remodeling or
trauma or both
• mostly adolescents, males 3:2
• Radiolucency sometimes with a thin faint sclerotic
border (less than true cyst)
• Will scallop between the roots of teeth
• Ratio of man to max lesions is 6.5 to 1 *
• Usually posterior mandible above canal
• Does not resorb teeth, diverge roots, or destroy
lamina dura
Traumatic bone cyst
Traumatic Bone “Cyst”
• Radiographic Features: Well-demarcated radiolucency below

and around the roots of vital teeth
– No effect on teeth
Traumatic Bone “Cyst”
• Radiographic Features: Well-demarcated radiolucency below

and around the roots of vital teeth
– Can expend and/or erode the bone
Aneurysmal Bone “Cyst” (ABC)
• Trauma or a tumor induced process ??? CGCG
• Pain and/or swelling
• Most typically under the age of 20
• Long Bones
Aneurysmal Bone “Cyst”
• Ramus area posterior to 1st molar here in left ramus very
• Expansible, multilocular radiolucent lesion
• Root resorption
• Treatment: surgical removal of the entire lesion
Developmental Lingual Mandibular
Salivary Gland Depression *
• Stafne’s “cyst”, Static bone cyst, Latent bone
cyst
• Inclusion of salivary gland tissue within or
adjacent to lingual surface of body of mandible
• Most common posterior (angle) mandible
below canal
• Well circumscribed lucency with thick cortical
outline
• Also anterior in cuspid-lateral incisor area
• Teeth vital/unrelated
• More common in adult males
• Asymptomatic- no treatment
• Tissue may or may not be present in defect
Salivary Gland Depression
Salivary Gland Depression
Developmental Salivary Gland Defect (Stafne’s)
• Microscopic Features: Normal salivary gland tissue
• Pathogenesis: Unknown
• Radiographic Features: Radiolucencies (often bilateral)

Cysts

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Cysts

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Odontogenic & Nonodontogenic

Forming follicular sac patient is young in mixed dentition around 7 to 8 years

Centrally when tooth is completely surounded by the lesion

– Cyst radiolucency appears

Normal follicular space is about

When lesion comes bigger we suspect tumoral behavior

Example from cases that we

• And submit for biopsy to rule out other lesions

• Forms at junction of lateral

• Radiographic Features: Well-demarcated radiolucency below

• Radiographic Features: Well-demarcated radiolucency below

• Trauma or a tumor induced process ??? CGCG

• Pain and/or swelling

• Most typically under the age of 20

• Microscopic Features: Normal salivary gland tissue

• Radiographic Features: Radiolucencies (often bilateral)

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