Cysts

of the Face & Jaws I-III

Common Cysts of the Jaws and Head & Neck
- Most important part of bone lesions topic.

Definition

CYSTS: A cyst is a pathological cavity containing fluid, semi-fluid
or gaseous material which is not produced by the accumulation
of pus. Cysts are frequently, but not always, lined by epithelium.

All Cysts have some Common Features:
Wall.
Lumen & Contents.
Mural Nodule(s).
Epithelial Lining.
Surrounding Tissue.
Inflammation.

For a Cyst to Develop, you require: (SMS)

A Source of Epithelium.
A Mechanism to allow it to Enlarge.
A Stimulus to make it Proliferate.

Classification Terms for Jaw Cysts

Odontogenic Cysts: Lined by an epithelium derived from Odontogenic Epithelium (arising in tissues
that give rise to teeth).
Non-Odontogenic Cysts: Lined by other epithelia.
Inflammatory: Inflammation is the stimulus causing proliferation of the epithelium and cyst
formation.
Developmental: Aetiology unknown, assumed developmental.

CLASSIFICATION OF COMMON JAW CYSTS
DEVELOPMENTAL
o Odontogenic:
! Dentigerous/Eruption Cysts.
! Odontogenic Keratocyst.
! Lateral Periodontal Cyst.
! Rare Types.
o Non-Odontogenic:
! Nasopalatine Cyst.
! Nasolabial Cyst.
! Thyroglossal and Branchial Cyst.
Inflammatory.
o Radicular (apical/lateral) & Residual.
Bone Cysts.
o Solitary Bone Cyst.
o Aneurysmal Bone Cyst.
Salivary Cysts.

Cyst which Do not exist Incorrect Terminology
Median Mandibular Cyst.
Globulomaxillary Cyst.
Old (i.e. ancient) Terminology:
o Follicular Cyst.
o Primordial Cyst.
o Keratocyst.

Relative Incidence of Cyst
Radicular Cysts " 68%.
Dentigerous Cysts " 17%.
Odontogenic Keratocysts " 3%.

Nasopalatine Cyst " 5%.

Others are rare.
Solitary Bone Cyst " 3%.

RADICULAR CYSTS (Inflammatory Dental Cysts)
Most Common (68%)

RADICULAR CYSTS: Starts as an apical granuloma in which
epithelium proliferates in response to inflammation.
Related to a non-vital tooth. (e.g. due to
caries/trauma)
Apical, lateral or residual.
Commonest in upper laterals, commoner in males.
Present in middle age (but with wide range).
Some patients are prone to cyst formation.
Very rare on deciduous teeth.

Breaks
through
the
lamina
dura

Caries

Developmental of a radicular cyst. Caries as labeled

on tooth. Breaks through the lamina dura.
Inflammation may go through stages of growth and
non-growth.

Describing/Presenting a Cyst on a Radiograph EXAMPLE KEY EXAM TECHNIQUE
SITE: Where?
SIZE: Measurements. Slow/fast growing?
SHAPE: Unilocular/Multi-locular/Pseudolocular (suggestion of multi-locularcy but it is not obvious)
OUTLINE: Well defined? Can you draw around the edge?. Corticated? Visible white margin/line
around the outside?.
RELATIVE RADIOLUCENCY: Uniform/Non-uniform?
AFFECT ON OTHER STRUCTURES:
o Radiographically
o Clinically
o E.g. expansion of jaw? How does it affect teeth displacement/resorption etc.?
Differential Dx
- Interpreting Radiographs: 1) Description of Radiograph followed by 2) Differential Dx.

Examples
SITE: Radiolucency at apex of a non-vital tooth.
SIZE: Around 2mm in diameter.
SHAPE: Unilocular.
OUTLINE: Well defined. Corticated.
RELATIVE RADIOLUCENCY: Uniform radiolucency.
AFFECT ON OTHER STRUCTURES: Radiographically none, but
clinically an expansion/enlargement in the buccal sulcus.
Differential Dx: Radicular Dental Cyst. (You dont have to
reach a Differential Diagnosis this is a helpful example of how

it would present).
- Refer to Eric Whaites Dental Radiology Textbook for diagrams.
Important to know how to describe

lesions.
Important to be able to describe
SITE: Apex of non-vital lateral incisor.
radiographs.
SIZE: Around 2mm in diameter.
Interpreting radiographs 1st
SHAPE: Unilocular.
determine the presence of disease.
OUTLINE: Well defined. Corticated.
Should be able to identify
RELATIVE RADIOLUCENCY: Uniform radiolucency.
abnormal radiolucencies.
AFFECT ON OTHER STRUCTURES:
Learn the typical features of cysts.
o Radiographically displacement of the 3.
o Clinically an expansion/enlargement in the buccal sulcus.

- Should the cyst become infected, you will lose the corticated structure.

RESIDUAL CYST (cyst left behind)

A radicular cyst from which the non-vital tooth has been removed.
This removes a major diagnostic feature.

Histology of Residual Cysts
Similar/Identical to Radicular Cysts except that:
Inflammation subsides as the cause has been removed.
The epithelium is less hyperplastic, thinner and better organized.
Mural nodules appear.

Radicular cysts and residual cysts look very similar. Residual cysts may be less inflamed and the epithelium may be
less hyperplastic.
Radiographically it is hard to determine between granulation tissue/radicular cyst. Need to ensure you remove it
to prevent a Residual cyst.

PARADENTAL CYST
Inflammatory cyst arising
from epithelium near the
furcation of molars.
Some called Mandibular
Infected Buccal Cysts

Occur in vital teeth, recently
erupting.







TO SUMMARISE Histology of all Inflammatory Cells
Non-Keratinised Stratified Epithelial Lining.
Thick Fibrous Wall/Capsule usually packed with inflammatory cells.
Inflammation.
Cholesterol cysts.
Hyaline (Rushton) bodies (10% of all Odontogenic Cysts).

Why do Inflammatory Cells Enlarge?
Radicular Cysts have an internal hydrostatic pressure of 60-100cm water.
This is partly osmotic lining excludes albumin if intact but there is leakage.
Much high molecular weight protein is secreted into cysts, (e.g. immunoglobulin).
Proteins in cysts are degraded and there is poor lymphatic drainage.
Internal pressure probably fluctuates with inflammation.

How do Cysts resorb bone?
Pressure from contents can induce bone resorption.
Inflammatory mediators from the wall can induce resorption.
Bone is only removed by osteoclasts.

How fast do they grow?

Slowly.
To 2cm diameter in 10 years.
In children, to 5cm diameter in 2 years.
Once in the antrum, nose or mouth, expansion is rapid.
Structures around may be displaced radiological evidence.

The Growth Pattern of a Cyst can give Indication of the Cyst Type
All inflammatory cysts enlarge under pressure and tend to be spherical.
But shape is constrained by resistant tissues: cortical bone, teeth and mucoperiosteum.

DENTIGEROUS CYST
Second most common (17%)

Developmental.
Odontogenic.

Definition

DENTIGEROUS CYST: A Cyst which:

o
o
o
o

1) Contains the crown of an unerupted/partially erupted tooth

AND
2) Has its epithelial lining attached at the CEJ.

Commonest on Lower 8, upper 3, upper 8.

Present 10-30 years, equal sex incidence.
Reduced enamel epithelium separates from enamel to form the
cyst cavity.
Beware false dentigerous relationships.
- Especially lower 8s.
- Lower PMs.
- Any teeth that struggle to erupt into the oral cavity.

REE would be sitting around the tooth. Fluid

collects between the crown of the tooth and the

REE ! continues to expand to form a cyst.

Growth continues as more fluid accumulates.

These types of cysts should be sent in for
examination.






SITE: Around a crown of an unerupted tooth (as this is where the epithelium is).
SIZE: Several cm in diameter.
SHAPE: Unilocular.
OUTLINE: Well defined & Corticated
RELATIVE RADIOLUCENCY: Uniformly Radiolucent.

- Unilocular radiolucency at apex of 2nd molar NOT a radicular cyst as this tooth is vital.

Dentigerous Cyst Histology
In early stages looks like Reduced Enamel Epithelium (REE) 2 cells thick.
Gradually thickens to form a Stratified Non-Keratinised Epithelium.
If inflamed, looks like a Radicular cyst.

- Squamous epithelium multiple layers thick

How do Dentigerous Cysts Grow?
Probably in the same way as inflammatory cysts.
They have an internal hydrostatic pressure.
Inflammation is probably important.
Growth pattern is as for radicular cysts and this aids diagnosis.

Example
SITE: Radiolucency around the crown of an unerupted tooth.
SIZE: Several cm in diameter.
SHAPE: Unilocular.

OUTLINE: Well defined. Corticated.

RELATIVE RADIOLUCENCY: Uniformly radiolucenct.
AFFECT ON OTHER STRUCTURES:
o Radiographically causes displacement to adjacent teeth.
o Clinically an expansion is visible in the buccal sulcus.
Differential Dx: most likely diagnosis is a Dentigerous cyst.

ODONTOGENIC KERATOCYST (OKC)
Third most common 3%.
kerato- produces keratin.

Commonest at angle of mandible, behind or instead of 8s.
Present at 10-30 years.
Unilocular/Multilocular.
May replace a tooth.
Arise from dental lamina rests.
Are a feature in the Basal Cell Naevus Syndrome.
They can recur.
Recognizing the growth pattern of Odontogenic Keratocysts
is useful in diagnosis.
No other cyst grows in this way (though solitary bone cysts
are similar).

Mainly anterior-posterior growth pattern.

Grow at a slow pace. Dont tend to grow mediolaterally.

Cant diagnose an Odontogenic Keratocyst

from a Radiograph alone but include in
your differential diagnoses.
SITE: Posterior part of mandible.
SIZE: Can get quite large
especially antero-posteriorly.
SHAPE: Multilocular.
OUTLINE: Well defined,
Corticated.

Multilocular nature of lesion.

If the tooth involved in the cyst is vital then it is NOT
a Radicular cyst.
Last tooth to arise ! 8s ! dental lamina then
disintegrates at end to form Cell Rests of Molasses at
back of jaw ! Odontogenic Keratocyst.
- pseudo-locularcy suggestion of
multilocularcy but it is not obvious.
- Ameloblastoma example of odontoblast
tumour.

Histopathology
Regular Stratified Squamous Epithelium.
Thin Epithelial Layer (5-8 cells thick).
Palisaded basal layer.
Corrugated surface which can be parakeratinised or
orthokeratinised.
Thin, friable fibrous capsule little inflammation.
Satellite (daughter) cells.
Flanel of Keratin dont see this with other cysts

How do Odontogenic Keratocysts Grow?

They have no internal pressure.
Enlargement is by growth of the lining.
The lining has a high mitotic activity and the wall secretes bone resorbing factors.
Growth is by burrowing along the path of least resistance.
Teeth are not displaced, cortical bone is not resorbed.
Burrow through cancellous bone, leaving cortical bone intact.
Ability to penetrate and burrow more like a tumour.

Recurrence in Odontogenic Keratocyst
Up to 40% recur if followed for 30 years.
Thin wall and piecemeal removed.
Multilocular.
Growth potential.
New lesions (below retromolar mucosa).
Or is a neoplasm?

Basal Cell Naevus Syndrome (BCNS)
BCNS, Gorlins or jaw cyst bifid rib syndrome.
Multiple Odontogenic Keratocysts in jaw in 3rd decade.
Multiple basal cell carcinomas start to appear in
adolescence but often seen in 3rd decade.
Bifid, fused and supernumerary ribs.
Frontal Bossing (large, prominent forehead), mild skeletal
class 3, skin pitting + more.
Autosomal dominant or sporadic.
Cause is mutation of patched gene active in developmental
patterning.
Is also a tumour suppressor gene controlling the cell cycle via
the hedgehog signaling pathway.
Inheriting one mutant allele causes many skeletal features.
A second mutant allele causes basal cell carcinomas (BCCs)
and Odontogenic Keratocysts Develop.

Hedgehog Pathway
Responsible for developmental positioning.
Highly conserved.
Named after larval appearance of Cuticular Denticles.
Hh inhibits Ptch.
Smoothened accumulates.
Ci is not cleaved.
Genes including growth factors transcribed.
A tumour suppressor.

Histology of Cysts in BCNS Syndrome

Is exactly the same as in non-syndrome Odontogenic Keratocysts.
- BCC ulcerated tumours with rolled margins, malignant but not much ability to
metastasize.

Are OKC Benign Neoplasms?

YES:
# Recur.
# Frequently described as aggressive.
# Soft tissue spread.
# May develop dysplasia/malignancy.
# Association with Patched gene mutation.

NO:
$
$
$
$

Over rated aggressive.

Can remove effectively but not conservatively.
Recurrence rates low in best centres, with Carnoys.
Resolve on marsupialization.

The WHO has decided that the Odontogenic Keratocyst should be called: Keratocystic Odontogenic
Tumour.



INCISIVE CANAL CYST or NASOPALATINE DUCT CYST

Developmental
Non-Odontogenic

INCISIVE CANAL CYST
Commonest non-odontogenic cyst.
Arises from epithelium in the incisve canal (nasopalatine duct remnant).
Age ranges 30-60 but wide.
Presents as swelling over incisive canal or mucoid or salty discharge into the nose or mouth.
Teeth are vital.
Incisive Canal is otherwise known as Nasopalatine canal hence the name.
The foramen/opening is palatal and therefore the swelling is usually in the palate.

- Non-odontogenic cyst
- Painless
- Not related to vitality here.
- SITE: Anterior midline of maxilla (same place always)
- SIZE: Usually a couple of mm in diameter (depends on time of discovery)
- SHAPE: Unilocular. Slow-growing.
- OUTLINE: Well defined. Corticated.
- RELATIVE RADIOLUCENCY: Uniformly radiolucenct.
- AFFECT ON OTHER STRUCTURES:
o Radiographically Can get displacement of the adjacent teeth
o Clinically an expansion is visible in the palate anteriorly.
- Differential Dx: Incisive Canal/Nasopalatine Duct Cyst.

Incisive Canal Cyst
Lined by Respiratory Epithelium OR Stratified Squamous Epithelium.
Blood vessels and nerves in wall.


RARER CYSTS

Use the additional resources (recommended reading) to cover
these in greater detail.

Nasolabial Cyst
In nasiolabial fold, upper buccal sulcus and lip.
10% bilateral.

May be partial nasal obstruction.
May erode bone of anterior nasal aperture.
Probably developmental disturbance of nasolacrimal duct.
Lined by respiratory epithelium.

Lateral Periodontal Cyst

Developmental Odontogenic Cyst.
Canine/premolar area in the mandible.
Mid age.
Adjacent teeth vital.
Thin epithelial lining with plaque like thickenings.

Botryoid Odontogenic Cyst
Rare
Multilocular lateral periodontal cyst.
High risk of recurrence.
Require excision.
More pronounced growth potential.

Gingival Cysts of Infants and Adults

Infants Bohns nodules/Epsteins pearls keratinized.
Adults Possibly a relative of Lateral Periodontal Cyst.
o 5-6th decades.
o No great significance.
o Simple epithelium or with plaques.
o Often mangled on removal.

Glandular Odontogenic Cyst
Mucoepidermoid Odontogenic Cyst.
Wide age range.
Mostly in mandible.
Multilocular or unilocular.
May grow very large or recur.
Not be confused with central mucoepidermoid carcinoma of jaws.


Differential Diagnosis of Cysts

Clinical Features:
About 1/3 rd are asymptomatic chance findings.
About 1/3 rd are infected.
Expansion, change of denture fit.
Asymmetry.
Loose displaced or non-erupted teeth.
Fluid discharge, spontaneous, on extraction or RCT.
Pathological fracture.

Examination:
Bluish colour when beyond bone.
Eggshell crackling.
Fluctuation.

Investigations:
Vitality tests.
Radiographs.
Biopsy.
Aspiration.
Family History.

Role of Biopsy in Cyst Diagnosis
Odontogenic Keratocyst and some rarer entities have diagnostic appearances unless inflamed.
Other cysts, biopsy is comfirmatory.
Excludes solid tumours and cyst-like lesions.

Role of Cyst Aspiration

Rarely performed.
Microscopy may show keratin or signs of inflammation.
Culture and sensitivity for infected cysts.
Soluble protein level:
o <3g/100ml in odontogenic keratocysts,
o >4g/100ml in inflammatory cysts/others.
Bilirubin level raised in solitary bone cyst.


How do you tell a Cyst from the Antrum?
They are both epithelial-lined cavities.
They may both be associated with non-vital teeth.
Both may have a narrow cortical bone layer.
They may both give rise to similar symptoms.
Vitality of teeth.
Symmetry
o Y-shaped line of Ennis.
Wall of cyst is not concave.
Needle aspiration/fluid injection.

How do you Treat Cysts?
Enucleation (The process of completely removing an
organ, tumour, or cystic lesion)

Marsupialisation (An operative technique for the
removal of a cyst in which an incision is made into the cyst and the cyst lining is sutured to the oral
mucosa, thus creating a pouch which is open to the oral environment. The wound is kept open with either a
pack or a stent until healing is complete).
Combination.
Excision.
Carnoys solution and enucleation.

Malignancy developing in Odontogenic Cysts
It is most frequently associated with odontogenic keratocysts.
Is sometimes preceeded by dysplasia.
Dysplasia can be identified using criteria for any squamous epithelium.
A rare occurrence and often diagnosed after malignancy supervenes.


Supplementary Notes

The difference between a cyst and an abscess

By definition, a cyst is not FORMED by the accumulation of pus.

It is a cavity usually with an epithelial lining but it can become infected and will then contain pus.

The old term for this was a cyst abscess but this seems to have fallen into disuse, despite being a good
description.

The important thing to remember about a cyst abscess is that it needs to be treated by antibiotics and
usually drainage (as the total volume of pass in a cyst can be very large and cause significant systemic
symptoms) and then the cyst will still need to be treated.

It cannot resolve by treating the infection alone because the underlying cyst lining will still be present.

Thus if a cyst becomes infected the question is not whether it then becomes an abscess or is a cyst, it is both
an abscess in a cyst.

The difference between a periapical granuloma, abscess and a radicular cyst.

All three are inflamed, but the development of pus defines an abscess.

Most small periapical radiolucencies will be granulomas and they will have a chronic course of
intermittent flare-up with a low risk of developing an abscess.
If an abscess forms it will usually drain through a sinus after a short period. Prolonged inflammation can
give rise to a cyst, and as noted above, that cyst can become infected and become a cyst abscess.
Whether there is acute or chronic inflammation in a periapical granuloma or a cyst will vary over time.
Chronic inflammation is by definition frustrated healing and a cyclical series of chronic inflammation and
subacute flare-up is usual, explaining why most patients periapical granulomas are asymptomatic.
Conversely, abscesses are always acutely inflamed.