Oral and facial soft tissue
CYST
 A cyst is a cavity occurring in either hard or soft tissue
with a liquid ,semi liquid or air content .It is
surrounded by a definitive connective tissue wall or
capsule and usually has an epithelial lining.
WHO histologic typing of jaw cyst
(1992)
 CYST OF THE JAWS
 Epithelial lined cysts
A. Developmental origin
Odontogenic
 Gingival cyst of new born
 Odontogenic keratocyst
 Dentigerous cyst
 Gingival cyst of adult
 Developmental lateral periodontal cyst
 Botryoid odontogenic cyst
Cont
 Glandidular odontogenic cyst
 Calcifying odontogenic cyst
Non odontogenic cyst
 Mid palatal cyst of infants
 Nasopalatine duct cyst
 Nasolabial cyst
2.Inflammatory origin
 Radicular cyst apical or lateral
 Residual cyst
Cont
 Para dental cyst or juvenile para dental cyst
 Inflammatory co lateral cyst
 B.Non epithelial lined cyst
 Solitory bone cyst
 Anerysmal bone cyst
Classification (Shear ,1983)
Cyst of the jaw
1.Intraosseous cyst
2.Soft tissue cyst
1.Intraosseous cyst
Epithelial
Non epithelial
Cysts of the maxillary antrum
Classification
 Epithelial cyst
Odontogenic cyst
Nonodontogenic cysts(Fissural )
Odontogenic cyst
Developmental
Inflammatory
1. ODONTOGENIC CYSTS
 Primordial cyst
 Dentigerous cyst (follicular)
 Radicular cyst (periodontal, dental,periapical,




inflammatory, infected)
Lateral periodontal cyst
Residual cyst
Odontogenic keratocyst(2005 WHO classified as
keratocystic odontogenic tumor)
Calcifying odontogenic cyst (Gorlin cyst)
2. NONODONTOGENIC CYSTS
Fissural cysts:
 Globulomaxillary cyst
 Median mandibular cyst (median alveolar)
 Nasopalatine duct cyst (incisive canal cyst)
 Nasopalatine canal cyst
 Median palatal cyst
 Nasolabial cyst (nasoalveolar)
Overview:
Odontogenic cysts & tumors arise from the odontogenic apparatus.
The odontogenic apparatus consists of:
Epithelium:
• Remnants of dental lamina
• Reduced enamel epithelium
• Odontogenic rests
• Lining of odontogenic cysts
• Basal cell layer of oral mucosa
Ectomesenchyme:
• Dental papilla
An abnormal space within tissue lined by epithelium.
Aneurysmal bone cyst, Stafne bone cyst, Traumatic bone cyst,
Simple bone cyst, Eruption cyst No epithelial lining!
Cyst Enlargment
 Increase in the volume of contents .
 Increase in the surface area of the sac or epithelial
proliferation .
 Resorption of the surrounding bone and at times
displacements of the surrounding soft tissues .
 The periosteum is stimulated to form a layer of new
bone –subperiosteal deposition.
Cont Increase in the volume of the contents
 Secretions –transudation &exudation
 Increased hyperosmolarity , -further draws in the
fluid from the surrounding tissues .
 Increased osmolarity –osmotic difference between
serum and cystic fluid in related to protein .(large
molecule albumin,fibrnogen ,fibrin degradation
products )
Cont Epithelial proliferation mural growth in the form of




epithelial proliferation is one of the essential process by
which surface area of the sac increase basically by
peripheral cell division or by accumulation of cellular
contents.
Multicentric pattern of cyst growth –proliferation of local
group of epithelial cells –keratocyst
Collagenase activity –increased collagenolysis –primodial
or radicular cyst
Unremitting growth –due to high mitotic value –keratocyst
Presence of low grade infection –stimulate cells such as rest
of Malassez. .
cont
 Bone resorption by release of bone resorbing factors
from the capsules which stimulates osteoclast function
like prostanoids like PGE2and PGI2 and certain
leukotrienes.
 Difference in size –possibly depends upon the
quantity of release of protaglandins and other bone
resorbing factors.
 Cyst Regression –Any process that lead to the
involution of the cyst epithelium -like extraction of
tooth ,marsupialization –may cause connective tissue
to regress the cavity –filled by tissue or bone.
Aspirates
Pathology
Aspirates
Other findings
Dentigerous cyst
Clear pale straw colored
fluid
Cholestrol crystals .
Total protein excess of 4
grams/100ml .
Odontogenic keratocyst
Dirty creamy white
viscoid suspension
Parakeratinized squames
Total protein less
than5gm/100ml
Periodontal cyst
Clear pale straw colored
fluid
Cholestrol crystals .
Total protein is between
5gm-11/100ml .
Infected cyst
Pus or brownish fluid
,seroprulent
/sanguinopurulant fluid
Polymorphonuclear
leukocytes ,foam cells ,
Cholestrol clefts
ContMucocele ,Ranula
Mucus
Gingival cyst
Clear fluid
Solitary bone cyst
Serous or sanguineous
fluid ,blood or empty
cavity
Stafne ,s bone cavity
Empty cavity with air
Dermoid cyst
Thick sebaceous material
Fissural cyst
Mucoid fluid
Vascular cyst walls
Fresh blood
Intramedullary cavernous Syringe full of venous
haemangioma
blood
Arterial or A-V
malformation
Bright red blood
,pulsatile plunger
Necrotic blood clot
Treatment
1.Marsupialization (decompression )
 Partsch I
 Partsch II(combined marsupialization+enucleation )
 Marsupialization by opening in to nose or antrum .
 2.Enucleation
 Enucleation and packing .
 Enucleation and primary closure
 Enucleation and primary closure with reconstruction
/bone grafting.
Primodial cyst
 Developing tooth
follicle of a
supernumerary tooth
with calcification
occurring in the
follicle. If calcification
had failed to occur,
then it would have
formed a primordial
cyst
Primordial cyst
 Primordial cyst arising
from the tooth bud of
the fourth molar.
Developing tooth
follicles of the third
molars may be
misdiagnosed as
primordial cysts
Radicular Cyst
 Radicular Cyst
 The radicular (periapical) cyst is the most common cyst of the
jaw .
 Age 30 and 50 years ,usually do not cause pain.
 A radicular cyst is the last step in a progression of
inflammatory events following the formation of a periapical
inflammatory lesion secondary to pulpal necrosis in a tooth.
 Over time, an inflammatory cyst can develop in the bone at the
root apex of a carious tooth due to inflammatory stimulation
and proliferation of the epithelial rests of Malassez (residual
epithelial cells in the periodontal ligament).
Periapical cyst or granuloma (chronic localized osteitis)
There are Rests of Malassez in the area of inflammation.
▪ The rest cells proliferate due to the inflammation
▪ The ball of cells gets too large, cells in the center die, center then
has a higher protein concentration, water rushes in to equalize the osmotic
pressure.
▪ Osmotic pressure can continue to grow the cyst independent of the
inflammation.
Other unilocular radiolucencies located periapically:
▪ (early) periapical cemento-osseous dysplasia – teeth are vital
▪ Dentin dysplasia type I – teeth are vital, multiple radiolucencies
With a periapical cyst or granuloma, the tooth is NON-VITAL
The dentigerous (follicular) cyst
 The dentigerous (follicular) cyst is the most common type
of noninflammatory odontogenic cyst
 The most common cause of a pericoronal area of lucency
associated with an impacted tooth.
 A dentigerous cyst forms within the lining of the dental
follicle when fluid accumulates between the follicular
epithelium and the crown of the developing or unerupted
tooth.
Dentigerous cyst
Lateral Periodontal Cyst
▪ The lateral periodontal cyst is generally quite small and well demarcated. It occurs most
frequently in the mandibular bicuspid area adjacent to vital teeth.
Radiolucencies are generally small and ovoid
Derived from remnants of the dental lamina
Tt : conservative enucleation
▪ Considered to be the intrabony counterpart to the Adult Gingival Cyst
Lateral periodontal
cyst
 Lateral periodontal
cyst in its
characteristic location
in the mandibular
premolar region.
Teeth are vital’
cyst which
histologically had a
keratin lining,
that is,
an odontogenic
keratocyst developed
from the lateral
periodontal cyst.
Odontogenic Keratocyst
(Keratocystic Odontogenic Tumor)
• A benign uni-or multicystic, intraosseous tumor of odontogenic origin
• Lining is parakeratinized stratified squamous epithelium
• Potential aggressive, infiltrative behavior
• Solitary or multiple (multiple usually related to Gorlin syndrome)
Three important things associated with this diagnosis:
1. High recurrence rate (up to 60%)
2. Highly aggressive (now considered by W.H.O. to be an odontogenic tumor)
3. Relation to Gorlin syndrome
Arises from the dental lamina or its remnants
PTCH(patched ) gene is a significant factor in the development of KOT
Cont Odontogenic keratocysts are believed to arise from the dental
lamina and other sources of odontogenic epithelium. They
represent 5%–15% of all jaw cysts.
 Most odontogenic keratocysts are found during the 2nd to 4th
decades of life, although they can occur at any age. The lumen
of the cyst often contains “cheesy” material and has a
parakeratinized lining epithelium .
 Daughter cysts and nests of cystic epithelia are found outside
the primary lesion; as a result, odontogenic keratocysts have
the highest recurrence rate of any odontogenic cyst (50%)
when treated conservatively with curettage .
Cont A single missing tooth from normal arch –suspicion to





KCOT.
Buccal expansion commonly seen but palatal and lingual
expansion is rare.
Unilocular to multi locular,with sclerotic margin
Treatment Enucleation followed by cryosurgery
Enucleation followed by adjunctive chemical cauterization
using Cornoy,s solution along with excision of overlying
attached mucosa.
Radical excision -reserved for multiple recurrent cases.
(Vital teeth)
Nevoid Basal Cell
Carcinoma Syndrome
(Gorlin Syndrome)
• Multiple
basal cell carcinomas
• Multiple jaw cysts (odontogenic keratocysts)
• Numerous bone abnormalities including bifid ribs, intracranial
calcification,
vertebral anomalies
PTCH gene has been mapped to chromosome 9q22.3 - site of Gorlin Syndrome
Anyone with multiple KOTs should be tested for Gorlin Syndrome
Calcifying epithelial
odontogenic cyst,
 Calcifying epithelial
odontogenic cyst,
also known as Gorlin
cyst, showing
radiographic evidence
of calcified material in
\the radiolucency
Calcifying Epithelialodontogenic cyst.
 Calcifying epithelial
odontogenic cyst.
radiolucency
does not show any
radiographic
evidence of
calcified material in the present
radiograph .
Microscopically,
calcific areas were
present in the
Lesion in this case .
Unicystic Ameloblastoma
 Account for 10-15% of intraosseous ameloblastomas
 Usually occur in younger patients.
 Because all of the ameloblastoma is inside the lumen of the cyst,
 Tt. is removal of the cyst (not jaw resection)
 But… If ameloblastoma is in the wall of the cyst, treatment
must be standard for ameloblastoma = resection
 Can often resemble a dentigerous cyst around an unerupted 3rd
molar
Non-odontogenic cyst
 Also called fissural cyst or occlusion cyst, because
they arise from embryonic epithelium that become
entrapped during embryogenesis.
2. NONODONTOGENIC CYSTS
Fissural cysts:
 Globulomaxillary cyst
 Median mandibular cyst (median alveolar)
 Nasopalatine duct cyst (incisive canal cyst,nasopalatine
canal cyst)
 Median palatal cyst
 Nasolabial cyst (nasoalveolar)
Nasopalatine Canal Cyst
(Incisive Canal Cyst)
 Located within the nasopalatine canal or the
incisive papilla
 Most commonly seen in men between 40 and
60 years old
 Usually asymptomatic
 May see a small, pink bulge near the apices
and between the roots of the maxillary
central incisors on the lingual surface.
Nasopalatine Canal Cyst (cont.)
Cont- It’s the most common & most important nonodontogenic cyst arises from embryonic remnants of
the nasopalatine duct after it’s closure, it occur at any
age, but mostly discovered in the 4th or 5th decay of
life.
 It is asymptomatic discovered by routine X-ray or it
may infected & cause pain & swelling in the incisive
papilla.
Cont- Radiographic
 A well-defined, radiolucent lesion
 May be oval or heart-shaped
 Histologic
 Lined by epithelium varying from stratified squamous to
pseudostratified ciliated columnar epithelium
 Treatment
 Surgical excision
Median Palatine Cyst
 A well-defined, unilocular radiolucency
 Located in the midline of the hard palate
 Histologic
 Lined with stratified, squamous epithelium surrounded by
dense fibrous connective tissue
 Treatment
 Surgical removal
Median Palatine Cyst (cont.)
Globulomaxillary Cyst
 A well-defined, pear-shaped radiolucency found between
the roots of the maxillary lateral incisor and cuspid
 Was thought to be a fissural cyst, now believed to be of
odontogenic epithelial origin
 Treatment
 Surgical removal
Globulomaxillary Cyst (cont.)
Median Mandibular Cyst
 A rare lesion located in the midline of the mandible
 Lined with squamous epithelium
 Radiographic
 A well-defined radiolucency below the apices of mandibular
incisors
 Treatment
 Surgical removal
Nasolabial Cyst
 A soft tissue cyst
 Thought to originate from the lower anterior
portion of the nasolacrimal duct
 Observed in adults from 40 to 50 years of
age
 4:1 ratio in favor of females
Nasolabial Cyst (cont.)
 Clinical
 An expansion or swelling in
the mucobuccal fold in the
area of the maxillary canine
and the floor of the nose
 Histologic
 Lined with pseudostratified,
ciliated columnar epithelium
and multiple goblet cells
 Treatment
 Surgical excisions
Pseudocysts
 Static Bone Cyst
 Simple Bone Cyst
 Aneurysmal Bone Cyst
Static Bone Cyst (Lingual Mandibular
Bone Cavity) (Stafne Bone Cyst)
 A pseudocyst (not a true cyst)
 A well-defined cyst like radiolucency may be
observed on radiograph in the posterior region of the
mandible inferior to the mandibular canal.
 Caused by a lingual depression in the mandible
 Treatment
 None
Static Bone Cyst (Lingual Mandibular
Bone Cavity) (Stafne Bone Cyst) (cont.)
Simple Bone Cyst,Solitary bone cyst
(Traumatic Bone Cyst)
 A pathologic cavity in bone that is not lined with
epithelium




May be associated with trauma.
10-20 yr of age
More common in male
More common in mandible above the inferior canal in the
cuspid and molar region
 Radiographic
 A well-defined unilocular or multilocular radiolucency
 Characteristically shows scalloping around roots of teeth
 Treatment
 Curettage on the wall lining, stimulates hemorrhage leads to –
healing of cavity .
Simple Bone Cyst
(Traumatic Bone Cyst) (cont.)
Aneurysmal Bone Cyst
 WHO classifies ABC as a tumor like lesion and defines
it as an expanding osteolytic lesion consisting of
blood filled spaces of variable sizes separated by
connective tissue septa containing trabeculae of
osteoid tissue and osteoclast giant cells.
Aneurysmal Bone Cyst
 A pseudocyst
 Name is misleading as it does not contain vascuar
aneurysm and it is not a true bone cyst.
 Often seen in long bone and spine.
 Consists of blood filled spaces surrounded by
multinucleated giant cells and fibrous connective
tissue
 Etiology –h/o of trauma , relation ship with giant cell
lesion
 Variation in the hemodynamic of the area
 Sudden venous occlusion
Aneurysmal Bone Cyst (cont.)
 More common in mandible posterior region .
 Usually seen in persons less than 30 years old
 Slight predilection for females
 Radiographic
 Multilocular appearance “honeycomb,” “soap
bubble”/unilocular
 Dark venous blood can be aspirated .
 Treatment
 Surgical excision
 Radiotherapy is contra indicated .
 Intralesional calcitonin in combination with
methylprednisolone
Cont
 Intra lesional fibrosing agent Ethioblocethicon .
 Arterial embolization followed by enblock resection .
 Soft tissue cysts
Gingival Cyst: is located in the gingival soft tissues outside of the bone, & is
derived from the rests of the dental lamina .
2 types of gingival cyst
:
 1-Gingival cyst of the adult:
 Occurs as a firm but compressible, swelling on the mand. or max. facial
gingiva in the premolar, canine, incisor region.
 The cyst not appear on radiograph because it confined to the gingival soft
tissue.
 Histopathologically, include a thin lining of non-keratinized epith. about 13 cells in thickness with a number of clear cells.
 Treatment: by conservative surgical enucleation.
 2- Gingival cyst of the newborn:
 Generally seen on the alveolar ridges of newborn infants as small, often
multiple swelling, & appear whitish in color.
 Microscopically, consist of a thin walled cystic lesion lined by a thin,
stratified squamous epith., & containing compact desquamated keratin.
 The lesion resolved spontaneously in response to normal function, therefore
no treatment required.
Gingival Cyst: is located in the gingival soft tissues outside of the bone, & is
derived from the rests of the dental lamina .
Thyroglossal Tract Cyst
 Forms along the tract the thyroid gland follows in
development
 Most often found in young individuals under 20
years of age
 No sex predilection
 Treatment
 Excision of the cyst and tract
1- Thyroglossal tract cyst: it’s an uncommon developmental cyst that formed
any were along the embryonic thyroglossal tract between the foramen caecum of
the tongue & the thyroid gland.
Clinically:
 Occur in young person, but may occur at any age.
 Forming a mobile cystic mass which may lie on one side of the
midline, but mostly in midline
 It is asymptomatic, but when occur high near the tongue it may cause
dysphagia, sometime infected causing abscess with fistula.
 Histopathology:
 The cyst lined by stratified squamous epith., ciliated columnar epith.,
transitional epith, or a mixture of epith. Types.
 The capsule include lymphoid aggregation, thyroid tissue, mucus
gland.
 Treatment: complete surgical excision.
Thyroglossal cyst
Thyroglossal Tract Cyst (cont.)
Lymphoepithelial cyst
 It develop either from epithelial invaginations that detached from the
surface mucosa & entrapped within the lymphoid tissue, or from
epithelium of minor salivary gland ducts that traverse oral lymphoid
tissue.
 Clinically:
 Most commonly found on the anterior floor of the mouth & posterior
lateral borders of the tongue.
 It’s an asymptomatic, yellowish, superficial submucosal mass,
usually less than 1cm in diameter.
 Histopathology:
 The cyst lined by a thin layer of parakeratinized squamous epith.
Surrounded by a well defined mass of normal lymphoid tissue
showing variable numbers of germinal centers.
Branchial Cleft Cyst (Lymphoepithelial
Cyst)
 Most commonly found in major salivary glands
 A stratified squamous epithelial lining surrounded by a wellcircumscribed component of lymphoid tissue
 Appears to arise from epithelium trapped in a lymph node
during development
Branchial Cleft Cyst (Lymphoepithelial
Cyst) (cont.)
Branchial Cleft Cyst (Lymphoepithelial
Cyst) (cont.)
 Most commonly found intraorally on the floor of the
mouth and the lateral borders of the tongue
 Appears as a pinkish, yellow raised nodule
 Treatment
 Surgical excision
Dermoid & Epidermoid cyst
 These represents a simple form of cystic teratoma derived from skin epith.
entrapped during embryonic development.
 Most of these cysts occur in the head & neck region, primarily in the skin
around the eyes & the anterior upper neck, extending superiorly into the floor
of the mouth.
 Clinically:
 Mostly occur in young adults, present as painless swelling exhibiting a doughy
consistency on palpation,& may cause elevation of the tongue & can interfere
with eating & speaking.
 Histopathology:
 The cyst lined by a layer of orthokeratinized squamous epith., surrounding by
C.T. capsule.
 In dermoid cyst in addition to these the lesion exhibiting variable numbers of
dermal appendages including hair follicles, sebaceous glands.
 Treatment: this is best treated by surgical excision.
Epidermal Cyst
 A raised nodule on the skin of the face or neck
 May be noted intraorally on occasion
 Histologic
 Lined by keratinizing epithelium the resembles the
epithelium of the skin
 The lumen is usually filled with keratin scales
 Treatment
 Surgical excision
Dermoid Cyst and Benign Cystic Teratoma
 A developmental cyst often present at birth or noted in
young children
 It is usually found on the floor of the mouth when it is
located in the oral cavity.
 May have a doughy consistency when palpated
Dermoid Cyst
 Histologic
 Lined by orthokeratinized, stratified squamous
epithelium surrounded by a connective tissue wall
 The lumen is usually filled with keratin
 Hair follicles, sebaceous glands, and sweat glands
may be seen in the cyst wall
 Benign cystic teratoma

Resembles a dermoid cyst
 Treatment
 Surgical excision
Illusion of a cyst
 The radiolucency
between the radiopaque
external and internal
oblique lines produces
the illusion of a cyst
Illusions of Cysts
 Osteoporotic bone
marrow defect in the
edentulous region. It
is an area of
hematopoietic or fatty
marrow and is seen
usually in sites of
abnormal healing
following extraction,
trauma or local
inflammation
Maxillary sinus may
be misdiagnosed
 Maxillary sinus may
be misdiagnosed as a
cyst.
On a radiograph
of the maxillary
canine region, the
maxillary sinus may
be misinterpreted as
a radicular cyst. The
periodontal ligament
space is normal and
the tooth is vital
Parasitic cysts
 Rarely may involve oral tissues .
 Hydatid cyst –occurs in hydatid disease or
echinococcosis caused by the larvae of E granulosus
(dog tape worm).
 Cysticercosis -develop because of the pork tape worm
(Taenia solium ).
The spread to the oral tissue occurs when larvae
penetrate the intestinal mucosa and –blood and
lymphatics –may localized in the orofacial tissues .
Heterotopic Cysts
 Oral cyst with gastric or intestinal epithelium
 Infants and young children .
 Sublingual ,apex and dorsum of tongue.
Complications
 Fracture (Pathological ).
 Infection
 Post operative wound dehiscence .
 Loss of vitality of teeth.
 Neuropaxia in infected cyst.
 Recurrence
 Dysplastic ,neoplastic,or even malignant changes.
 ADVISE –LONG TERM FOLLOW UP
1
 Not a cyst it was
ossifying fibroma
2
3
4
5
6
7
8
9
MCQ.1
 1.Factors responsible for cyst formations are
 A.Proliferation of the epithelial lining .
 B.fluid accumulation with in the cyst cavity .
 Bone resortpion .
 All of the above
2
 2.Follicular or dentigerous cyst results
 A.because of enlargment of the follicular space of the
whole or part of the crown of an impacted or
unerupted tooth and its attachment to the neck of the
tooth .
 The above statement
 True
 False
3
 Stafne,s idiopathic bone cavity
 A.is mandibular salivary gland depression
 B.true cyst
 Psedudocyst
 Filled with dark venous blood.
4
 Aneurysmal bone cyst commonly present
 A.posterior mandible region
 Anterior mandible
 Anterior maxilla .
 Posterior maxilla
5
 Hydaytid cyst
 Parasitic cyst
 Caused by E Granulosus
 Tape worm worm
 All of the above are correct
6
 Cysticercosis is
 Parasitic cyst
 Caused by pork tape worm
 Taenia solium
 All of the
7
 In keratocystic odontogenic
 Total protein content
 Less than 5 gm /100 ml
 More than 5 gm /100 ml
 More than 15 gm / 100ml
 More than 20 gm/100.ml
8
 In dentigerous cyst total protein content is
 More than 4.0 gm /100 ml
 Less than 2 gm /100 ml
 More than 10 gm /100 ml
 More than 14 gm /100 ml
9
 The incidence of dentigerous cyst is
 More common than primodial cyst but less common
than apical cyst .
 Less common than primodial cyst bot more common
than periapical cyst .
 More common than primodial and periapical cyst
 Less common than primodial and periapical cyst
10
 Residual cyst is one
 Present after extraction of causative root /tooth
 In relation to impacted tooth
 In presence of supernumerary toot
 Not a true cyst