Introduction Cysts of the Jaws and Oral Region

Aims;

The student should have knowledge of cysts which affect the jaws and their etiology and pathogenesis.

Objectives;
The student should be able to;
Classify cysts of the jaws.

Discuss in detail their etiology and pathogenesis.

Know the steps that lead to a jaw cyst diagnosis and to identify these lesions in their earliest stages.
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cyst is a pathological fluid /semifluid filled material enclosed cavity (Space) within bone or in soft tissues, generally formed by a connective tissue wall and lined wholly or in part by epithelium (mostly non-keratinized).
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Cyst lumen

The cyst's lumen usually contains fluids or semisolid material such as keratin, cellular debris, mucus or even gaseous contents - which is not created by accumulation of pus.

Cyst lumen

Non-keratinized squamous epithelial cyst lining

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Connective tissue wall that forms the cyst is composed of blood vessels and fibroblasts, and various types of lining epithelium which may be stratified squamous nonkeratinizing (Keratinized) epithelium, pseudostratified, columnar or cuboidal.

The cyst wall may or may not be infiltrated by chronic inflammatory cells (Inflamed).
If inflamed can change the morphology of the cyst with obscuring their identifying features. In rare instances intense inflammation can destroy the entire epithelial lining allowing the cyst to resolve completely without any treatment.

 Some

cyst-like lesions, without epithelial lining, also can be seen in the maxillo-facial regions.

Epithelial

lined spaces are sometimes known as True cysts" while those not lined with epithelium are False cysts or Pseudocyst".
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Where does the Epithelium lining the Jaw Cysts come from?????
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Two Sources: True Cysts

1.

Epithelium left behind from developing teeth (Odontogenesis).

2.

Epithelium left behind from face and mouth development.

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Typical Features of Jaw Cysts

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1.

Cysts are common lesions and cause of swellings of the jaws. More common in jaws than in any other bone. Clinically important because they are destructive. Mostly behave similarlythey grow slowly and expansively (Displacing rather than resorbing the teeth). Usually painless when small but can cause significant bone loss before presenting clinically. Produce significant signs and symptoms particularly when they become large or infected.

2.

3.

4.

5.

6.

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7.

Pain due to secondary infection. Noticeable swelling: initally smooth bony hard lump with normal overlying mucosa, but as bone thins through resorption and extends into soft tissues, cyst may show through as BLUISH FLUCTUANT SWELLING (COMPRESSIBLE). If a cyst becomes very large it may expand the jaw's outer limits making intraoral detection possible. Rarely large enough to cause pathological fracture.

8.

9.

10.

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11.

Frequently a chance radiographic finding for most of the oral-facial cysts as they are located within the jaws.
Being composed of soft tissues, jaw cysts appear as sharply-defined radiolucencies with smooth radioopaque borders. These single well-demarcated radiolucencies are "unilocular" lesions. Most unilocular lesions are small, measuring less than one centimeter in diameter.
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12.

13.

14.

15.

If, however, a cyst is undetected for some years, it may increase up to ten-fold (> 10 cm.).

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These large cysts may be unilocular; however, some may be partitioned -"multilocular radiolucencies."
Cysts arising in soft tissues are more likely to be discovered on intraoral examination where they produce a surface swelling. Small jaw cysts are removed easily & rarely recur; removal of large ones is more difficult, may recur.

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18.

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19.

They differ mainly in relationship to teeth and radiographic features; But it is often difficult to distinguish cystic appearing mandible/maxillary lesions from one another with radiography.
Careful consideration of the patient history and the location of the lesion within the jaws, its borders, its internal architecture, and its effects on adjacent structures generally makes it possible to narrow the differential diagnosis.

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Classification;

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 Most

cysts of the oral and facial regions are located within the jaws, they are either Intraosseous or Intrabony lesions. the sources of epithelium;

Given

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Some jaw cysts will be associated with teeth found in tooth-bearing areas; these are Odontogenic Cysts, develop during or after the formation of teeth.
The others will be found in places where oral-facial processes fused; these are Fissural cysts (Nonodontogenic).

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Odontogenic Cysts based on Typical Clinical & Radiographic Features;

A.
1.

Inflammatory Developmental
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2.

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Odontogenic; Inflammatory;
Result of inflammation;
1.

Radicular (Periodontal) cyst Residual cyst

2.

3.

Paradental (Inflammatory buccal, or Mandibular infected buccal) cyst

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Odontogenic; Developmental;
Unknown origin but are not the result of an inflammatory reaction;
1. 2. 3. 4. 5. 6. 7. 8.

Dentigerous cyst Eruption cyst Odontogenic keratocyst Gingival cyst of the new born Gingival cyst of the adult Lateral periodontal cyst Calcifying odontogenic cyst Glandular odontogenic cyst.

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B.

Histogenetic Classification; Based on Tissue of Origin

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Derived from Rests of Malassez;

Comprised of small groups of epithelial cells found close to the root surface and are remnants of Hertwigs epithelial root sheath. Periapical cyst (Radicular) Residual cyst
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1.

2.

Remnants of the disintegrated root sheath called epithelial rests can remain for long periods of time following eruption of the tooth. The first dentin that is formed is called mantle dentin, while the remaining dentin is called circumpulpal dentin. There is also a small layer interposed between these two dentin layers of less mineralized dentin called globular dentin.

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Derived from Reduced Enamel Epithelium;

The reduced dental/Enamel epithelium covers the crown of the tooth until it erupts. The histology of the REE varies from the occlusal surface towards the cervical region. Dentigerous cyst (Eruption cyst) Paradental cyst ???
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1.

2.

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Following the formation of the crown , the enamel organ collapses to form the reduced enamel epithelium which covers the tooth through eruption. The reduced enamel epithelium consists of the mature/protective ameloblasts and remnants of the outer layers of the enamel organ. Numerous capillaries, which had formed to supply oxygen and nutrients to the ameloblasts following dentin formation, surround the reduced enamel epithelium.

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Derived from Dental Lamina (Rests of Serres);

1.

Odontogenic Keratocyst Lateral periodontal cyst

2.

3.

Glandular odontogenic cyst.

Gingival cyst of the new born Gingival cyst of the adult.
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4.

5.

During the fifth week of embryonic development, the oral epithelium thickens along the future dental arches to form the dental lamina. The dental lamina appears as an epithelial thickening of the oral epithelium adjacent to a condensation of ectomesenchyme.

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Unclassified;
1.

Paradental cyst The cystic epithelium may be derived from the cell rests of Serres, the cell rests of Malassez, apical migration of cells of the dental lamina or reduced enamel epithelium. Calcifying odontogenic cyst.??
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2.

Non- Odontogenic;
1.

Fissure Bone Soft tissue

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2.

3.

A. Fissural;
1.

Nasopalatine
Nasolabial Median palatine Globulomaxillary
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2.

3.

4.

B. Bone;
1.

Simple bone cyst;

Solitary, Haemorrhagic, Traumatic Aneurysmal bone cyst.
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a.

b.
c.

2.

C. Soft Tissue;
1.

Mucous Extravasation and Retention cyst. Dermoid/Epidermoid Lymphoepithelial (Branchial) Thyroglassal duct cyst
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2.

3.

4.

Incidence of Jaw Cysts;

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Odontogenic;
1.

90%
65 70 15 20 5 10 35 % % % %

Radicular Dentigerous OKC Paradental

2.

3.

4.

5.

Gingival
Lateral periodontal

<1
<1

%
%
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6.

Non- Odontogenic;
1.

10%
5 10 % 0.5 5 % %

Nasopalatine Nasolabial Others (Combined)

2.

3.

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Etiology & Pathogenesis;

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The etiology and pathogenesis of jaw cysts simply is not known. There is very little experimental evidence that sheds light on their origin.
This lack of hard evidence doesn't prevent speculation, however..
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There are two long-standing theories regarding the formation of the cyst cavity;
The nutritional deficiency theory.

1.

2.

The abscess theory postulates that the proliferating epithelium surrounds an abscess formed by tissue necrosis and lysis, because of the innate nature of epithelial cells to cover exposed connective tissue surfaces.
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Nutritional Deficiency Theory

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1.

Jaw cysts arise from epithelium (Main source) associated with formation of the teeth, oral cavity, and face.

2.

If this epithelium is somehow stimulated (Possible links to genetic defects in a tumor suppressor gene) by inflammation, for example, they proliferate forming an ever-larger mass.
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The genesis of true cysts has been discussed as occurring in three stages;
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During the first phase;

1.

Proliferation [hyperplasia] of dormant epithelial cells, probably under the influence of growth factors (Epidermal growth factor & Transforming growth factor) that are released by various cells residing in the lesion. As a result the cells in the center of the mass, being at some distance from their blood supply, die (their source of nutrition is being removed).
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2.

During the second phase;

Central cell death (necrosis and degeneration) produces an epitheliumlined central cavity surrounded by viable epithelial cells -- a true cyst is formed.

a)

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During the third phase; The cyst grows, but the exact mechanism has not yet been adequately clarified..??

a.

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 In the

early and intermediate stages of cystic growth, osmotic pressure differences play an important role; however, for very large cysts, this role becomes negligible and cell birth in the lining dominates growth.

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Suggested Mechanisms for continued cyst growth and accompanying bone resorption.
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1.

Hydrostatic mechanisms

2.

Bone resorption.

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Hydrostatic Mechanisms

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1.

All cysts expand in balloon like fashion indicating that Internal pressure plays a major role in their growth.
The degradation of the central cells in the cyst results in an increased osmotic pressure in comparison to the osmotic pressure of the surrounding stroma. This gradient draws water into the cavity (to balance the osmotic pressure), resulting in an increase in hydrostatic pressure inside the cyst in comparison to the stroma.
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1.

2.

4.

The volume expansion stretches the epithelial layer inducing division of the epithelial cells in order to maintain the intact epithelial lining.
The osmotic pressure difference is therefore maintained through the constant shedding of cells into the lumen. The surrounding stroma reacts by producing varying amounts of collagen fibers and reorganizing them into the so-called cystic capsule.
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5.

6.

Bone Resorption

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Pro-inflammatory Cytokines;

Cyst expansion depends upon osteoclastic resorption of bone Osteoclasts recruited by the mediators that stimulate bone resorption; Mediators generated locally by macrophages, lymphocytes, epithelial cells and fibroblasts IL-1/ IL-6

1.

2.

PGE2 (Fibroblasts)

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IL-1 & IL-6 stimulate epithelial proliferation. interleukin 1 may play an important role in cyst expansion by its direct effects on fibroblast proliferation and bone resorption and by stimulating prostaglandin synthesis in stromal fibroblasts of the cyst capsule. PEG2 a potent stimulator of bone resorption and its presence in the cyst walls have been demonstrated to have considerable bone resorptive activity which facilitates intraosseous cyst expansion.
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 Cyst

expansion and bone resorption occur together as the lesion enlarges is not clear whether cyst growth promotes the bone resorption or the bone resorption allows the cyst growth events
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It

Or indeed they are coincidental

unrelated to each other

Some cysts can become large and affect nearby healthy teeth. A cyst will not go away by itself. If it starts to Some cysts can become large and affect nearby healthy teeth. A cyst will not go away by itself. If it starts to cause problems, it it is usually best to treat the cyst beforesymptoms get worse. cause problems, is usually best to treat the cyst before symptoms get worse.

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