CYSTS

1.
2.
3.
4.
5.
6.
7.

outline
definition
aetiology
pathogenesis
Characters
Classification
Frequency
Diagnosis
a. Clinical examination:
1.
Chief complain
2.
extra oral examination
3.
Teeth examination
4.
Vitality tests
5.
The site
6.
Aspiration
7.
Histopathology

b. x-ray
8.
Treatment
9.
Notes
10. Cysts
1. Radicular cyst
2. Residual cyst
3. Dentigerous cyst (follicular)
4. Eruption cyst (eruption hematoma)
5. Keratocyst (primordial cyst)
6. gorlin syndrome

7. lateral PERIODONTAL CYST

8. Batryoid odontogenic cyst
9. Gingival cyst of adult
10.
glandular odontogenic cyst
11.
Calcifying odontogenic cyst
12.
Globulomaxillary cyst
13.
Nasolabial cyst
14.
Nasopalatine cyst
15.
Median palatine
16.
Traumatic bone cyst
17.
Static bone cyst
18.
Aneurysmal bone cyst
19.
Dermoid &epidermoid
20.
Branchial cleft cyst
21.
Thyroglossal duct cyst
11.
12. TTT techniques
1. Enucleation
2. Marsuplization (partsch
technique)
3. Combination bt
marsupialization then
enucleation

13.
14.
15.
1.Definition of cyst :
a pathological cavity containing fluid semi fluid or gaseous material &
surrounded by a definite wall that is lined e epithelium
16.

17.

2.Aetiology

18.
for many cysts its unknown
19.
- Grow by expansion due to pressure of the cystic fluid " cystic pressure "
2- their expansion does not cause any resorption or destruction to bone or roots

20.

3.Pathogenesis

21.
requirements of cyst formation
1. Source of epithelium in odontogenic cysts:
2. stimulus for proliferation
3. mechanism for growth
22. hydrostatic pressure resorption of surrounding bone
23.
24.
4.Characters:

1. discovered during routine x-ray examination

2. slow in size (takes long time to develop )
1. weeks inflammatory abscess
2. months malignancy
3. 1 : 2 years benign
4. 3:4 years cyst
3. The cyst mainly grows by mono-cortical expansion (buccal or lingual) While
tumour undergoes bicortical expansion (both)
25.

26.

5.Classification

27.
1)Odontogenic cyst
28. -related to tooth
29. -its always intrabony (remaining odontogenic epithelium)
-arise from proliferation or cystic degeneration of the odontogenic epith. present
in the bone marrow of jaw
30. -Source of epithelium:
31. 1- Tooth germ:
32. - If liquefaction occurs before tooth formation- primordial
- If liquefaction occurs after tooth formation dentigerous cyst
33. 2- Reduced enamel epithelium
3- Epith. rests of serre's ( remnants of dental lamina )
4- Epithelial rests of molasses ( remnants of hertwig root sheath )
5- Basal layer of oral epithelium
34. ADevelopmental
1. Dentigerous cyst
5. Gingival (adult & new born)
2. Odontogenic keratocyst
6. Eruption cyst
3. Calcifying odontogenic cyst
7. Glandular odontogenic cyst
(gorlin cyst
8.
4. Primordial
9.
10.
11. BInflammatory
1. Radicular cyst (most common cyst/inflammatory cyst)
2. Lateral inflammatory periodontal
12.
13.
2)Non-Odontogenic cyst
a. Fissural cyst (derived from entrapped epithelium bt the embryonic
processes of bone at union line)
1.
Nasopalatine
4. Median mandibular
2.
Median palatine
5. globulomaxillary
3.
Nasolabial
6.
b. Pseudo-cyst (no epithelial lining)
1. Traumatic bone cyst
3.
Static bone cyst
2. Aneurysmal bone cyst
4.
Osteoporotic bone defect
5.
c. Soft tissue cyst
1.
Salivary gland cyst (mucocele and ranula)
2.
Dermoid/epidermoid
3.
Thyroglossal duct cyst
6.
7.
Recent classification (shear)

a. Cysts of maxillary antrum

1.
Mucocele
2.
Retention cyst
3.
Pseudocyst

5.
6.

4.
Postoperative
Benign mucosal cyst
Surgical ciliated cyst of maxilla

b. Cyst of the jaws

i. Epithelial lined
ii. Non-epithelial lined (Pseudocyst)
1. Traumatic bone cyst
2. Aneurysmal bone cyst
3. Static bone cyst
c. Cyst of the soft tissue

7.

6.Frequency

1. Radicular cyst
2. Dentigerous cyst (most common developmental)
3. Keratocyst
8.
9.
7.Diagnosis :

Clinical examination :
10. 1.Chief complain
11. mainly painless swellings unless infected mild pain
12. 2.extra oral examination
13.
e.g. if theres obliteration of the nasolabial fold intraoral swelling
intra-bony lesion
14.
15. 3.Teeth examination
a. Abnormal position or inclination of teeth may indicate a cyst presence
16.
E.g. its present labially tooth is inclined labioversion
b. Absence of the tooth or no history of extraction may lead to confirmation
of dentigerous or primordial cyst .
17.
On x-ray examination absent tooth primordial cyst
18.
Present but unerupted dentigerous cyst

24.

29.

19.
4.Vitality tests
20. If tooth is non-vital(inflammatory cyst) RCT & apicoectomy are
indicated (labial flap is preferable in anterior teeth as its closer to the
apices even if the cyst is palatal)
21.
22. When there is resorption of roots included in cysts it indicates
malignant transformations
23.
5.The site
25. To detect whether its odontogenic or no odontogenic
26. Bony expansion (monocortical)
27.
rate of the growth & pain
28.
6.Aspiration
30. - Aspiration biopsy by a large gauge needle to ensure aspirating the
viscous materials
31. (in keratocyst we use a bigger gauge needle because the keratin is
viscous)

32.
1. Pale straw coloured fluid with few cholesterol crystals odontogenic
cyst
2. Bloodcentral haemangioma ,aneurysmal bone cyst , central giant
cell granuloma
3. Golden yellow fluid which will coagulate on standing traumatic bone
cyst

4. Mucosa retention cyst

5. Pale cheesy yellow material like puskeratin in keratocyst
6. Pus &cystic fluid infected cyst
7. Air maxillary sinus
8. ve aspiration tumour
33.
34.
-On taking biopsy you should do rubbing of the lining (inspect the
lining)
35.
Thin lining cyst
36.
Thick mutational change tumour
37.
If it has 2 thicknesses take biopsies from both of them
38.
39.
-to differentiate bt
40.
*Pusfetid odour
*Keratinodourless
41.
42. 7.Histopathology
43. Taking a biopsy from the lining after flap
44.

45. x-ray

1.

2.
3.

4.
5.
6.

7.

Radiographic examination confirms size and shape of the cyst

the intra-bony cyst is mainly well defined radiolucent &corticated (surrounded
by radiopaque margin as a defence mechanism of bone)
may be unilocular or mutilocular
may be mixed (as COC)
46.
47.
- Types of Radiographic films:
48. 1- Intraoral: - (periapical- occlusal -bitewing (used in detection of parotid
stones)
49. 2- Extra oral (Panoramic film - Posterior-Anterior - Occipto-Mental (for
examination of maxillary sinus) - Oblique lateral - C.T - Injection of radio-opaque
dyes)
50.
51.
N.B:
on examining panorama do systemic tracing first
52.
look from the left cond. Through mandible to the Right
condyle maxilla sinus impactionteeth
53.
tumours are mostly ill defined
54.
mainly, the cyst is removed without teeth as it doesnt cause root resorption
55.
(if its periapical we can remove the apical 1/3 )unless if
mutational changestumour (mainly ameloblastoma which is locally
aggressive tumour
56.
dentigerous cyst at 8(impacted) may push the tooth till the coronoid process
57.
after extraction of impacted tooth, make sure you ve removed the dental
follicle to avoid cyst formation
58.
intrabony cyst mainly grows till the surrounding bone becomes very thin with
egg shell crack sensation (except the cysts that grows intramedullary (anteriorposteriorly)
59.
differ bt dry socket and infected socket by pain

a. dry socket more severe pain d.t bare bone

b. infected socketmild pain of inflammatory process
60.
8. a labioversion inclined tooth may be due to labially impacted canine
61.
9. when the dental lamina thickness increase around unerupted tooth it indicate
dentigerous cyst
62.
10.
C.T is useful in construction of models for pre plates for supporting the
mandible when there is insufficient remaining bone after cyst removal)
63.
11. Detect cholesterol crystal by putting the aspirating material on a cotton(to
aspirate the fluid in the light shimmering test
64.
12.
Recently, theres no central haemangioma (wrong name)
65.
13.
Bitewing film for parotid stone
66.

69.

67.

1)Radicular cyst (root end cyst/periapical

cyst)

68.

Aetiology

Odontogenic inflammatory cyst arising from non-vital single root (or vital multirooted
teeth e non vital one)
70. Pulp necrosis (trauma /caries )Periapical abscess Granuloma bacterial
endotoxins stimulate the epithelium Cyst growth(fluid into cyst) intracystic pressure(hydrostatic pressure)
71.

72.

Clinical manifestation
73. Site: tooth bearing area at the apex of non-vital tooth mainly at maxilla
(lateral incisor)
74. Gender M=F
75. Age 4th decade
Pt complained from pain (pulpitis that subside spontaneously (pulp
necrosis)
Non-vital tooth (It may be multirooted so have vital a& non-vital roots)
At 1st it forms hard swelling
76. Then it continues to grow & resorb the surrounding bone forming
egg shell cracking sensation And the associated teeth have slight mobility
It may form extraoral fistula especially lateral type
if left for long time slight mobility of teeth
77.
78.
Types
1. Periapical: at apex
2. Lateral: at the side of non-vital tooth due to
infection passing through opening in lateral branch
of root canal
3. Residual
79.
80.
X-ray:

87.

81. well defined radiolucent e sclerotic (RO) margin

82. The radiopaque (RO) margin indicates bone defence mechanismbetter
prognosis
83.
84.
Histopathology
85. Stratified squamous epithelium lining
86.
TTT
similar to periapical granuloma TTT
The associated tooth may be removed or not acc. to the affection of the root
o if the bone is healthy and tooth is well supportedpreserve the tooth +
enucleation
o if small, significantly resorbed, have been grossly displaced, lie within the
cyst or significantly inhibit access to the cyst extraction

88.
89.

Periapical radiolucency may be:

92.
R
91.
Peri
api
cal
gr
an
ulo
ma

93.

Periapical
abscess

96.
>
94.

98.

95.
<1.5
cm

99.
Well
de
fin
ed

97.

100.

1 :1.5

101.
Ill defined
(hasnt eroded
the bone yet)
102.
Less solid
than cyst

103.
104. 2)Residual cyst
105.
It results from extraction of the associated tooth & leaving
the radicular cyst behind
106.
Its sizer is often < 1cm

107.
108.
109.
110.

So you should do palpation for each swelling??

Cyst or tumourpainless while infection is painful
??????????
rare

111. 3)Dentigerous cyst (follicular)

It the 2nd most common cyst (1st developmental).

Its associated e a tooth either impacted, unerupted, supernumerary,
odontomes s (composite or complex) or primary tooth.
Its attached to the tooth cervix at CEJ.
It may behave like tumour and causes root resorption.
112.
Aetiology
Developmental odontogenic cyst
113. Accumulation of fluid within follicular space Release of bone resorbing
factors in cyst fluid
114.
115.
Follicular space variation
In Normal teeth, its about 0,1 mm: 5.6 mm
If more dentigerous cyst
116.
Clinical features
117.
Site
mainly at 8 > 3 (most impacted teeth)
118.
gender
in male
119.
Asymptomatic swelling + absent tooth (D.D DC or residual
cyst )
120.
Any Maxillary cyst may make pressure on the floor of orbit
causing exophthalmos
121.
x-ray
122.
well defied radiolucent e corticated margin
123.
may be unilocular or mutilocular (rare)
124.
associated e unerupted tooth (even
displaced)
125.
variation
1. central DC: enlarge till it displaces the molar into
the lower border of mandible, or the maxillary
sinus
2. lateral DC: enlarges in one lateral direction
3. circumferential DC: grown in an apical direction
to surround the root
126.
TTT: removal of associated tooth
Enucleation or marsipuliaztion
Prognosis
127.
The lining may ve mutational change & turn into
ameloblastoma or mucoepidermoid carcinoma
128.

129. 4)Eruption cyst (eruption hematoma)

130.

Variation of dentigerous cyst

131.
Soft tissue bluish swelling over crown that is erupted almost
(that has reached the alveolar bone but not penetrate soft tissue)
132.
Filled e blood or fluid
133.
Age: infant &young children (D, E mainly)
X-ray not seen (soft tissue cyst)

Histopathology
134.
like dentigerous cyst

TTT
135.
Upon incision or droolingthe tooth continues to erupt
normally
136.

137. 5)Keratocyst (primordial cyst)

Aetiology
138.
Origin
139. Stellate reticulum in enamel organ In the stage before calcification
(Enamel & dentin) absence of the associated tooth (Keratocyst)
140. *may be with a supernumerary tooth complete dentition (primordial cyst)
141.
142.
Developmental tooth follicle of 8 misdiagnosed as primordial
cyst
root formation x-ray .143
144.
- Primordial cyst
145. May also represent keratocyst
146. recurrence rate
147.
148. Displace teeth +swelling
149.
*Age 2nd :3rd decade
150.
*Site Mandible > maxilla
151. post portion of body of mandible, angle, ramus 8 region
152.
*Aspiration keratin (Diagnostic )
153.
154. *Clinical manifestations
155. No expansion danger GRF??
156. As epithelial lining( mitotic activity) creeps intramedullary bone
not seen clinically or in normal x-ray except if it grows vertically
157.
158.
*x-ray Can be seen in CT (axial) or occlusal
159.
May be mutilocular (worse)
160.
Swelling (not huge)
161.
162.
*recurrence rate GRF (30 :60 %)(if it recurred more
aggressive )(particularly those in the posterior body and ascending
ramus)
mitotic activity in intramedullary
Presence of daughter cyst into medulla
thin friable liningon removal remaining parts recurrence)
Heavily perforate the bone till reaching the soft tissue
163.
164.
Orthokeratin type has recurrence rate < parakeratinized
type
165.

1.
2.
3.
4.

1.
2.
3.
4.
5.
6.
7.

166. *Differential diagnosis

167.
Dentigerous cyst
168.
Ameloblastoma (mutilocular)
169.
170.
*TTT
Marsuplization & enucleation
Sarracurettage& peripheral osteotomy by large rose head after enucleation
safety margin from mucosa and periosteum
Intraluminal injecting Carnoys solution free the cyst from the bony wall,
easier removallower recurrence ratekill peripheral layer of bone ??
follow up to 5 years
in case of thin cortical bone left, we make resection and use reconstructional
plates
after removal the surrounding bone appears scalloped as the cyst has entered
the bt teeth and bone
171.

172. Gorlin syndrome

173. Basal cell nevus syndrome
174. Bifid rib syndrome
1.
2.
3.
4.
5.
6.
7.
8.

175.
Multiple OKC at jaws (bilateral) 1st sign to form early diagnosis
Multiple basal cell carcinoma (in sun-exposed & non exposed areas)
Skeletal abnormalities (frontal & parietal bossing (
Ribs may be splayed, fused, partially missing, bifid)
Intracranial calcification
Pitting in planter& Palmar surface
Mild Mandibular prognasthism
may be exotropia
176.
177.
178.
179.
180.

181.
182. 6)lateral PERIODONTAL CYST
183. Aetiology
184.
intrabony /maybe inflammatory or developmental
185.
some say it was lateral DC and the tooth has erupted (vital
tooth)
186.
187. Site
188.
mandibular canines and premolars.
189.
190. Age
191.
23-85 years
192.
193.
x-ray
194.
unilocular radiolucent tear drop (scalloping) bt roots
195.
196. D.D

197.
Lateral DCnon-vital toothRCT
198.
199. TTT
Conservative enucleation
The associated tooth may become non-vital due tom excessive removal and
injuring removing the lateral part of the tooth
200.

201. 7)Batryoid odontogenic cyst

Polycystic form of lateral periodontal cyst
X-ray: " mutilocular RL appearance, but may be unilocular
TTT enucleation and incision
202.

203. 8)Gingival cyst of adult

Soft tissue Counterpart of lateral periodontal cyst

In attached keratinized gingiva Not in non-keratinized
May cause cupping out of bone (superficial erosion of bone) not detected on a
radiograph

204. 9)Glandular odontogenic cyst

(sialodontogenic cyst)

Rare
Some say its like Batryoid cyst but the lining converted to glandular epithelium
Affect body of mandible Usually
May be unilocular or mutilocular
Aggressive cystic lesion May cause root resorption considered as tumour
205.

206. 10)Calcifying odontogenic cyst (gorlin

cyst / COC)
207.
Its now considered a tumour
208.
It may be associated with odontomes
209. X-ray
210.
1st radiolucent then becomes mixed due to ghost cells
calcification.
211.
212.
213.
214.
215.
216.
217.

218. Developmental cysts

219. 11)Globulomaxillary cyst
220.
221.

Intrabony Developmental cyst associated with vital tooth

222. Aetiology
223.
Entrapment of epithelial remnants bt Globular & maxillary
process

224.
225.
226.
227.

Or any odontogenic cyst bt max. lateral & canine

Site bt 2 &3
root divergence pear shaped

228. 12)Nasolabial cyst

229. Aetiology
1. Entrapment of epithelial remnants bt Lateral nasal process +medial nasal process +
max. process
2. Or epithelial remnants of nasolacrimal duct
230.
231.
in upper lip press the nasal mucosa intranasal swelling
232.
233.
Open in Maxillary sinus??
234.
Expansion in soft tissue
235.
diagnosis
236.
Aspiration
237.
By injecting Radiopaque material seen in x-ray
238.
239.
Extension of nasopalatine
240.

241. 13)Nasopalatine cyst

242.
243.
244.

Related to vital teeth

heart shape (superimposed by nasal spine)

245. 14)Median palatine

246.
247.

In the middle of the palate

Some say its posterior Extension of nasopalatine

248.
249.

Pseudocyst
251. 1)Traumatic bone cyst
250.

252. Intrabony haemorrhage failure of clot formation organizationdisintegration & cavity

formation
253.

254. 2)Static bone cyst

255.
Aetiology remnants of submandibular salivary gland
entrapped in mandible
256.
Site Below inferior alveolar canal
257.

258. 3)Aneurysmal bone cyst

259.
Highly vascular
260.
History of trauma Reactivation connective tissue &
cavernous
261.
Ballooning
262.

263. Soft tissue cysts

264.
265. 1)Dermoid &epidermoid
266.
Midline in floor of mouth
267.
Rubbery consistency (keratin)
268.
Sublingual (bt geniohyoid &oral mucosa) (difficult breathing
and speaking)
269.
Or submental (bt geniohyoid & skin) (double chin appearance)
270.

271. 2)Branchial cleft cyst

272.

273.

Below sternomastoid MS at the lateral aspect of neck

274. 3)Thyroglossal duct cyst

275.
Arise from remnants of Thyroglossal (from f. caecum till
thyroid ismuthus)
276.
Move e swallowing
277.
278.

279. TTT techniques

280.

1.
2.
3.
4.
5.
6.
1.

1)Enucleation

281. Def:
282.
It is the complete removal of cyst lining membrane. After
enucleation, the cavity space becomes filled with blood clot, which
eventually organizes to form normal bone.
283.
284.
285. Indication
Readily accessible cysts.
Limited size &not encroaching on vital structures
Little or no soft tissue involvement
Complete removal of cystic sac & healing the wound by 1ry intention
Treatment of odontogenic keratocyst
Recurrence of cystic lesions of any cyst type
286.
287. Advantages
Removal of the entire pathological tissue ((cyst lining), avoiding the risk of
recurrence or its malignant transformation.

2. Healing is more rapid.

3. Obviate tedious postoperative maneuverer following marsupialization.
288.
289. Disadvantages
1. May cause damage to vital structures
2. Difficult if extends into soft tissue
3. Extensive defects will give rise to large clots and are prone to becoming
secondarily infected with subsequent wound breakdown.
4. The presence of pre-existing infection will also compromise primary healing
290.
291. Steps
1. Reflect mucoperiosteal flap. Whenever possible a buccal or labial approaches
preferable because of Superior visibility & accessibility
2. Bone removal to gain access to thee cyst (making window with surgical rose
head bur
3. Separation of cyst from bone by bone curette inspect the cavity for the presence
of remnants of the cyst, and copious irrigation with saline solution and suturing
of the flap fol
4. Reconstructed plate if bone is undermined (keratocyst) (graft is contraindicated
if infected)
292.
293.
With (out) Cavity obliteration
294. Indication
1. Rapid increase in strength of bone
2. Rapid healing
295.
296. Requirements
297. No infection
298.
299.
2)Marsuplization (partsch technique)
cutting an adequate window(opening) in the outer wall of the cyst through which
the contents are the evacuated.
The remaining part of the membrane is left in situ.
With release of intracystic pressure, the functional stresses allowed to stimulate
new bone formation beneath the cyst membrane causing gradual obliteration of
the cyst cavity and exteriorization of the lining.
At the end the cystic cavity is completely filled with bone and the lining diminish in
size until it disappears
300.
301. Indication
1. limitation due to age & general condition of p (young child, developing tooth
germs,
enucleation would damage the tooth bud).( the elderly, debilitated patient,
marsupialization,
is less stressful and a reasonable alternative)
2. Infected cyst e friable lining where primary closure of the wound isnt
possible
3. Cyst encroaching g upon vital structures such as the inferior alveolar nerve
during the enucleation of large cysts at the angle of the mandible
4. Dentigerous cyst when it is presumed that an unerupted tooth (patients below
20 years of age) involved in it v ill erupt into position
5. In very large cysts, where enucleation, could result in a pathological fracture
6. When the apices of many adjacent erupted teeth, are involved within a large
cyst, enucleation could prejudice the vitality of these teeth.

1.
2.
3.
4.

1.
2.
3.
4.
5.
6.
7.

302.
303. Advantages
Preservation of tissues
Preservation of teeth (allow eruption of unerupted teeth behind)
Preservation of vital structures
Avoid possibility of oroantral commination
304.
305.
306. Disadvantage
Leaving behind a pathological tissue with the possible potentiality for
recurrence and malignant transformation.
Slow healing process
It requires considerable post-operative care in the way of daily, irrigation and
change of dressing.
Sometimes there is difficulty to clean the defect during the healing period.
Fabrication of cyst plug
Need cooperative patient
Histologic examination of the entire cystic lining is not done .
307. 3)Combination bt marsupialization then enucleation
308.
The cystic lesion is treated. initially with marsupialization and
allowed to reduce in size,' then a second operation is performed to,
enucleate the remaining pathological cyst lining after bone is laid
down under the membrane.
309.

Postoperative complications

1. Oedema
2. Ameloblastic fibroma
3. Odontogenic myxona
4. Fracture, pathological
5. Infection prior to surgery may be acute or chronic
6. Postoperative wound dehiscence
7. Loss of vitality of teeth
8. Neuropraxia in infected cysts
9. Postoperative infection
10.
Recurrence in some cysts
11.
Dysplastic, neoplastic or even malignant changes.
310.
311.
N.B:
312.
Cysts that behave like a tumour
1) DC
2) OKC
3) Glandular odontogenic
4) COC
313.
314.
Radiolucency in a site of missed tooth may be :
a-Primordial cyst : if the related tooth is not formed from the
beginning
b-Residual cyst : if the related tooth is extracted