Odontogenic cysts Prof. Dr.

Dena Nadhim Mohammad

Subject : Oral pathology-4th stage

Date : 23-4-2024

Inflammatory Developmental
Radicular cyst: apical and lateral, residual Dentigerous (follicular) cyst
Paradental (inflammatory collateral, Eruption cyst
mandibular infected buccal) cyst Lateral periodontal cyst
Gingival cysts" of infants (Epstein pearls)
Gingival cyst of adults
Glandular odontogenic cyst; sialo-odontogenic cyst

Odontogenic cysts: are those cysts in which the lining of their lumen is derived from epithelium produced
during tooth development. They are derived from:
1- Rest of Malassez:
Remnants of Hertwig's epithelial root sheath persist in PDL after complete root formation.
2- Reduced Enamel Epithelium:
Residual epithelium surrounds the crown after complete enamel formation.
3- Remnants of dental lamina:
Epithelium originates from oral epithelium in tissue after inducing tooth development.

Histological Classification of Odontogenic Cysts according to origin:

1- Cysts derived from Rest of Malassez:
- Periapical cysts.
- Residual cysts.
2- Cysts derived from reduced enamel epithelium:
- Dentigerous cyst.
- Eruption cyst.

3- Cysts derived from dental lamina:

- Odontogenic keratocyst and orthokeratinized cyst.
- Lateral periodontal cyst.
- Gingival cyst of the adult.
- Dental lamina cyst of the newborn.
- Glandular odontogenic cyst.

A-Odontogenic developmental cysts

1-Dentigerous Cyst (Follicular cyst): K09.03
It is a cyst that originates from the separation of the follicle from around the crown of an unerupted tooth. It is
the most common type of developmental odontogenic cysts, making about 20% of all epithelium-lined cysts of
the jaws. The dentigerous cyst encloses the crown of an unerupted tooth and is attached to the tooth at the CEJ.
Pathogenesis is uncertain, but apparently, it develops by the accumulation of fluid between the reduced
enamel epithelium and the tooth crown.
Clinical Features:
 Most often, it involves the mandibular third molar. Other frequent sites include maxillary
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 canines, maxillary third molars, and mandibular second premolars.
 They are discovered most frequently in patients between 10-30 years of age.
 Slight male predilection.
 Small cysts are completely asymptomatic and are discovered only on a routine radiographic
examination or to determine the reason for the failure of a tooth to erupt.
 Large cysts may be
associated with a painless
expansion of the bone
and facial asymmetry.
 When the cyst becomes
secondarily infected and
may be associated with
pain and swelling.
Radiographically:
Characterized by a unilocular radiolucent area associated with the crown of an unerupted tooth. The
radiolucency has a well-defined and sclerotic border. The cyst may displace the involved tooth to a
considerable distance. Root resorption of adjacent erupted teeth can occur.

The cyst-crown relationship shows several radiographic relations:

The Central relation, which is the most common, the cyst surrounds the crown of the tooth, and the crown
projects into the cyst.
The Lateral relation is usually associated with a mesioangular impacted mandibular third molar that is partially
erupted. The cyst grows laterally along the root surface and partially surrounds the crown.
In the circumferential relation, the cyst surrounds the crown and extends for some distance along the root so
that a significant portion of the root appears to lie within the cyst.
Histopathological:
It varies depending on whether the cyst is inflamed or not. In the non-inflamed dentigerous cyst, the cyst is
lined by the epithelium of 2-4 layers thickness of flattened non keratinized cells. The fibrous connective tissue
wall is loosely arranged. Small islands or cords of inactive appearing odontogenic epithelial rests may be
present in the fibrous wall. While in the inflamed cyst, the fibrous wall is more collagenized with a variable
infiltration of chronic inflammatory cells. The epithelial lining shows a variable amount of hyperplasia, rete
ridges formation, and more definite squamous features.
Focal areas of mucous cells may be found in the epithelial lining of dentigerous cysts.
Treatment: is careful enucleation with the removal of the unerupted tooth. If an eruption of the involved tooth
is considered feasible, the tooth may be left in place after partial removal of the cyst wall. The patient may
need orthodontic treatment to assist eruption.
Prognosis: is excellent and recurrence is seldom after complete removal. However, a possibility that the lining
of the dentigerous cyst may undergo a neoplastic transformation into:
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 Ameloblastoma.
 Squamous cell carcinoma rarely arises in the lining of dentigerous cysts.
 Intraosseous mucoepidermoid carcinoma likely develops from the mucous cells in the lining of the cyst.

2-Eruption Cyst (Eruption Hematoma): K09.00

It is the soft tissue analog of the dentigerous cyst. It develops as a result of the separation of the dental follicle
from around the crown of an erupting tooth that is within the soft tissue overlying the alveolar bone.
Clinical features:
 It is as a soft, often translucent swelling in the gingival mucosa
overlying the crown of an erupting tooth deciduous or permanent
tooth.
 Mostly affecting children younger than age 10 years.
 Most commonly associated with the first permanent molars and the
maxillary incisors.
 Surface trauma may result in a considerable amount of blood in the cystic fluid, which renders the cyst
a blue to purplish-brown color. Such lesions sometimes are referred to as Eruption Hematomas
Histopathological features:
Intact eruption cysts seldom are submitted to histopathological examination,
and most specimens consist of the excised roof of the cyst, which has been
removed to facilitate tooth eruption.
These show surface oral epithelium on the superior aspect. The underlying
lamina propria shows inflammatory cells infiltration. The deep portion of the
specimen, which represents the roof of the cyst, shows a thin layer of non keratinizing squamous epithelium.
Treatment and Prognosis:
Not required because the cyst usually ruptures spontaneously, permitting the tooth to erupt. If this does not
occur, simple excision of the roof of the cyst generally permits speedy eruption of the tooth.

3-Odontogenic keratocyst -- K09.02

It is a distinctive form of developmental odontogenic cyst that deserves special consideration because

of its specific histopathological features and clinical behavior. It arises from the cell rest of the dental lamina. It

shows a different growth mechanism and biological behavior from more common dentigerous and radicular

cysts. It enlarges predominantly in anteroposterior direction and can reach large size without causing gross

bone expansion.The growth may be related to activated markers in the epithelium itself or enzymatic activity in

the fibrous wall.

Pathogenesis:

1. Epithelial cells have a high proliferation rate(increased expression of ki67 and PCNA) and
overexpression of anti-apoptotic proteins causing folding in the cyst lining and projection of the cyst

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 along with cancellous spaces.

2. Production of bone-resorbing factors with overexpression of matrix

metalloproteinases results in expansion.

3. Mutations in the PTCH tumor suppressor gene of some sporadic

keratocyst and most of the keratocyst associated with nevoid basal cell
carcinoma syndrome.

Clinical:

 Most commonly affect people between 10-40 years, with a slight male predilection.

 The mandible is involved more than the maxilla, with a marked tendency to occur in the posterior body
of the mandible and ascending ramus.

 Small cysts are usually asymptomatic and are discovered only during radiographic examination. Large
cysts may be associated with pain, swelling, or drainage.

 It can occur as a single (5-15%) or multiple (5%) or syndrome-associated (5%). Nevoid Basal Cell
Carcinoma (Gorlin Syndrome) the patient complains of numerous basal cell carcinomas, multiple
Keratocyst, epidermal cysts of the skin, in addition to many other manifestations.

Radiograph:
It appears as a well-defined radiolucent area with smooth and corticated margins.

Large lesions at the posterior body and ascending ramus of the mandible appear

as multilocular. An unerupted tooth is involved in some keratocyst (25-40%).

Resorption of roots of erupted teeth adjacent to keratocyst is less common than

that noted in dentigerous and radicular cysts.

The diagnosis is based on histopathology because although the radiographic findings are often highly

suggestive, but not diagnostic. The radiographic features of keratocyst could be similar to radiographic

findings of a dentigerous cyst, a radicular cyst, a lateral periodontal cyst, a residual cyst, or a globulomaxillary

cyst.

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Histopathology:

 Grossly it has a thin, friable wall, difficult to enucleate in one piece. Moreover, the lumen may contain a
clear fluid or cheesy material (keratin).

 Microscopically, a thin fibrous wall without inflammatory infiltrates folded in a

snaky appearance. The interface between epithelium and connective tissue is flat and commonly shows
detachment.

 The epithelial lining is a uniform layer of stratified parakeratotic squamous epithelium. Usually, 6-8 cells in
thickness exhibit a wavy or corrugated appearance.

 The basal layer is composed of palisaded cuboidal or columnar epithelial cells with hyperchromatism.

 Small satellite cysts, cords, or islands of the odontogenic epithelium may be seen within the fibrous wall.

 The typical features of keratocyst are altered in the presence of inflammation.

Differential Diagnosis:

1. Associated with teeth: dentigerous cyst, ameloblastoma, odontogenic

myxoma, and ameloblastic fibroma.

2. Not associated with teeth in young patients: central giant cell granuloma, traumatic bone cyst, and

aneurysmal bone cyst.

Treatment and Prognosis:

Most keratocyst is treated by enucleation and curettage. Complete removal of the cyst in one piece is
often difficult because of the thin, friable nature of the cyst wall. The recurrence rate is high, and clinical
follow-up of the site of surgery is advisable. Recurrence after treatment may be due to either: 1) Fragments of
the original cyst that is not removed at the time of operation. 2) Presence of daughter cysts in the cyst wall. 3)
Focal separation of epithelial lining from underlying C.T makes surgical removal very difficult.

4-Orthokeratinized odontogenic cyst: they are clinicopathologically different from more common aggressive
keratocyst.

Clinical features: they occur predominately in young adults with male predilection. Lesions occur twice
more frequently in the mandible(posterior area of the jaw).

Radiographically : unilocular radiolucency, or occasionally multilocular, most often involved unerupted

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 mandibular third molar. They may associated with unerupted tooth

Histopathology: cyst lining is composed of thin lining of stratified squamous epithelium, which shows
orthokeratotic surface of varying thickness, palisaded basal layer, characteristic of aggressive keratocyst is not
present in this cyst
Treatment: by enucleation. Recurrence is rarely noted .

5-Gingival Cysts of Adults: K09.01

Clinical Features:
- Derived from dental lamina rests.
- Middle-aged adults (5th-6th decades).
- Mandibular canine/premolar region most common(like lateral
periodontal cyst).
- Bluish-translucent swelling, often centered in attached
gingiva(most common located in facial gingiva or alveolar
mucosa).
- painless swelling less than 0.5 cm in diameter
Radiographic features: None, sometimes superficial (cupping out) of the underlying alveolar bone.
Histopathological features:
- Thin, non-keratinized cuboidal to stratified squamous epithelium
- Occasional clear cells
- Nodular thickenings of the epithelial lining may be seen.
Treatment: Enucleation.

6-Gingival Cyst of New Born: K09.82

Clinical features : They are small, multiple , superficial, keratin filled

cyst. Uncommon soft tissue raised nodules on edentulous alveolar
ridges of the infant.
Origin : It is derived from the rests of the dental lamina and is
composed of keratin-producing epithelium.
Histopatholgy : showed thin parakeratotic epithelial lining surface. The
lumen contains keratinaceous debris.

Treatment : It is resolved spontaneously without treatment.

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7-Lateral Periodontal Cyst (Botryoid Odontogenic Cyst):
Origin - Derived from dental lamina rests.
Clinical features : Affect middle-aged adults, males/ female ratio is (2:1)
- Share gingival cyst in clinical and histopathological features.
- Asymptomatic cause boney expansion, usually in the mandibular
canine/premolar, less than 1 cm.
Radiographic features: Well-defined, round, or teardrop-shaped radiolucency along
the lateral surface of a vital tooth. The term botryoid Odontogenic cyst is
sometimes used when the lesion is multilocular.

Histopathological features:
- Identical to the gingival cyst of the adult
- Cyst lining is the flat, thin non-keratinized squamous
epithelium, focal nodular thickenings, clear cells
- Thin fibrous wall
Treatment: Enucleation with uncommon recurrence.

8- Calcifying odontogenic cyst; Calcifying ghost cell odontogenic cyst

Clinical: is an uncommon lesion, that occurs predominantly as intraosseous lesion. The mean age is 33 years.
It happened with equal frequency in the mandible and maxilla. Most commonly detected in the incisor and
canine region.
Radiographic features: unilocular, with well-defined radiolucency, and may appear multilocular. Radiopaque
structures within the lesion ( irregular calcification or teeth like ) are present. These cysts could be associated
with unerupted teeth.Root resorption of adjacent teeth may be seen.

Histopathological features: the lining of 4- 10 cells thickness, the basal cells may be cuboidal or columnar
and are similar to ameloblast, the overlying layer of the epithelium may resemble the stellate reticulum. The
most characteristic feature is the presence of a variable number of ghost cells within the epithelium ( these are
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altered eosinophilic epithelial cells with loss of nucleus and preservation of cell outline). These cells may fuse
to form large sheets of amorphous, acellular material. Calcification with in these ghost cells is common, that
first appeared as basophilic granules. Furthermore , area of eosinophilic matrix ( dysplastic dentin ) may be
present adjacent to the epithelia. In certain reports, the calcifying odontogenic cysts may be associated with
odontomas.

Treatment : the prognosis is good for non -neoplastic cyst, with simple enucleation and few recurrence
cases.

9-Glandular Odontogenic Cyst / sial-odontogenic cyst :

Suggest a mucus-producing salivary gland tumor
Clinically:
- More recently described as a rare developmental cyst,
locally aggressive lesion.
- Middle-aged adults.
- Either jaw ( anterior > posterior) Mandible (80%)
- Very slow progressive growth
- This cyst is ranged from small (less than 1 cm in
diameter) to large destructive lesion that may involve
most of the jaw.
Radiographic findings
- Unilocular or multilocular radiolucency, well or ill-
defined, small or large size.
Histopathologic features:
- Uniform thickness of squamous epithelia with focal
thickening.
- The superficial epithelial cells that line the cyst is columnar or cuboidal cells with papillary surfaces.
- Occasionally, goblet-like mucous-secreting cells are present in the surface layer .
- Glandular, ductlike spaces are seen within the epithelial lining , these spaces are lined by cuboidal cells
and often contain mucicarmine-positive fluid..
- The fibrous cyst wall is usually free of any inflammatory cell infiltrate.

Treatment : This cyst is treated by enucleation or curettage. Recurrence is reported in some cases
(approximately 30%). Recurrence appears to be more common among the lesions that present in a
multilocular pattern.

B-Odontogenic inflammatory cyst

Paradental Cyst:
It could arise from the rest of the malassez , reduced enamel epithelium, or dental lamina.
Clinically: it is located on the distal surface of a vital partially erupted mandibular third molar involving
pericoronitis or deep pocket, or on the buccal aspect of an erupted vital mandibular molar (buccal
bifurcation cyst) that exhibits cervical enamel projection. Occur in children, with slight tenderness on the
buccal aspect of associated teeth
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Radiographically, on buccal aspect is not visible unless by occlusal radiograph, while the distal aspect shows
well-circumscribed radiolucency.
Histologically similar to periapical cyst lined by non keratinized stratified squamous epithelium, with
significant inflammation in the wall of the cyst.
Treatment surgical removal.

Carcinoma in odontogenic cysts ;

Most intraosseous carcinomas arise in odontogenic cysts

origin: the lining of odontogenic cysts histopathologically demonstrates varying degrees of epithelial dysplasia
and later changed to carcinoma.

Clinical : They are seen in older patients. The mean age is 60 years., more frequently detected in men . Pain
and swelling are the most common complaints. The diagnosis of carcinoma is made with a microscopic
examination of a presumed odontogenic cyst.

Raiographic features: like any odontogenic cyst, although the margins of the radiolucent defect are usually
irregular and ill-defined. . CT scans of the lesion may demonstrate a destructive pattern.

Associated cysts; residual periapical cyst is the most common type associated with carcinomatous
transformation (60% ). Dentigerous cyst (16%), less frequently lateral periodontal cyst , and orthokeratinized
odontogenic cysts.

Histopathologic features; They showed well-differentiated or moderately well-differentiated squamous cell

carcinomas.

Treatment: it varied from local excision to radical resection.