DEPARTMENT OF ORAL MEDICINE AND RADIOLOGY

AMRITA SCHOOL OF DENTISTRY

Serial No:- Date:

RADIOLOGICAL AND HISTOLOGICAL CORRELATION

OF CYSTS OF THE JAWS PART - I

DR AARYA H NAIR

SIGNATURE OF FACULTY
CONTENTS

INTRODUCTION

ODONTOGENESIS

DEFINITION

TYPES OF CYSTS

PARTS OF A CYST

CLASSIFICATION OF CYSTS

CLINICAL,RADIOLOGICAL,HISTOLOGIC FEATURES OF VARIOUS

CYSTS

TREATMENT
INTRODUCTION

The cysts of maxilla, mandible & perioral tissue comprise several entities and these entities

vary markedly in histogenesis, frequency, behaviour & treatment. The majority occur within

the maxilla & mandible, and are mostly inflammatory in origin.

This is an area where radiology plays an important role in assisting with the diagnosis,

determining the size of the lesion and the relationship to adjacent structure.

Cysts occur more commonly in the jaws than in any other bone. Why cysts more commonly

occur in jaw bones??

The reasons could be attributed to :

 Presence of numerous embryonic odontogenic epithelial rests in these bones that

remain after tooth formation; with proliferative property

 Source of constant inflammation from periodontium

ODONTOGENESIS

Odontogenesis is a highly co-ordinated and complex process which relies upon cell to cell

interaction that results in the initiation and generation of the tooth. The gross histological

processes are well documented, the mechanisms that are involved at a molecular level are

only now beginning to be elucidated due to the revolution in molecular biological techniques

that has occurred over the last decade.

During their early development, tooth germs exhibit many morphological and molecular

similarities with other developing epithelial appendages, such as hair follicles, mammary and

salivary glands, lungs, kidneys, etc. The developing tooth germ, which is an experimentally
accessible model for organogenesis, provides a powerful tool for elucidating the molecular

mechanisms that control the development of these organs.

Initiation of tooth development occurs when the crown-rump length of the embryo is between

13 and 14mm or about 6.5 weeks of gestation. The primary epithelial band forms a

continuous horseshoe shaped sheet of epithelium around the lateral margins of the developing

oral cavity and correspond in position to future dental arches. The formation of these

thickened epithelial bands are a result of not so much of increased proliferative activity

within the epithelium as of change in the orientation of the mitotic spindle and the cleavage

plane of the dividing cell.

The free margin of this band gives rise to two processes, the vestibular lamina and the dental

lamina, which invaginate into the underlying mesenchyme. The outer process, the vestibular

lamina, will form the vestibule that demarcates the cheeks and lips from the tooth bearing

regions. The inner process is the dental lamina and it is from this ental lamina the tooth buds

form. The vestibule forms as a result of the proliferation of the vestibular lamina into the

ectomesenchyme. Its cells rapidly enlarge and degenerate to form a cleft that becomes the

vestibule between the cheek and the tooth bearing areas.

Continued and localized proliferative activity of the dental lamina leads to the formation of a

series of epithelial outgrowths into the ectomesenchyme at sites corresponding to the

positions of the future deciduous teeth. At this time the mitotic index, the labeling index and

the growth of the epithelium are significantly lower than corresponding indexes in the

underlying ectomesenchyme and ectomesenchymal cells accumulate around the outgrowths.

From this point, tooth development proceeds in three stages: the bud, cap and bell.

Interactions between epithelial and mesenchymal tissue components have particularly

important function in developing teeth, as well as in all other organs forming as ectodermal

appendages.

At certain points along the dental lamina, each representing the location of one of the 10

mandibular and 10 maxillary deciduous teeth, the ectodermal cells multiply still more rapidly

and form little knobs that grow into the underlying mesenchyme. Each of these down growth

from the dental lamina represents the beginning of the enamel organ of the tooth bud of a

deciduous tooth. Not all of these enamel organs start to develop at the same time, and the first

to appear are those of the anterior mandibular region.

As the cell proliferation continues, each enamel organ increases in size, sinks deeper into the

ectomesenchyme (dental papilla) and due to differential growth changes its shape. As it

develops it takes on the shape that resembles a cap, with the outer convex surface facing the

oral cavity and an inner concavity.

The shape of the enamel organ continues to change. The depression occupied by the dental

papilla deepens until the enamel organ assumes a shape resembling a bell. As the

development takes place the dental lamina, which had thus far connected the enamel organ to

the oral epithelium, becomes longer and thinner and finally breaks up and the tooth bud loses

its connection with the epithelium.

Parent dental laminae: In the seventh week of development, tooth anlagen for 20 primary

teeth are formed by the dental lamina. This lamina also provides tooth germs for the

permanent teeth which have no primary predecessors. Because of this, the dental laminae

providing for the formation of the first, second, and third permanent molars may be referred

to as the parent dental laminae or the laminae for permanent molars. The mechanism

involved is simply one of continued distal growth. That is, the distal ends of the dental

laminae for each arch, after having established the tooth germs for the primary molars,

continues to grow posteriorly. These segments of the dental laminae elongate progressively,

keeping pace with the lengthening of the arches.

The second stage of odontogenesis is called the bud stage and occurs at the beginning of the

eighth week of prenatal development for primary dentition. This stage is named for an

extensive proliferation, or growth, of dental lamina into buds or oval masses penetrating onto

the ectomesenchyme. At the ends of the proliferation process involving the primary

dentition’s dental lamina, both the future maxillary arch and the future mandibular arch will

each have ten buds.

The components of the bud are a compactly arranged mass of similar cells. That is, except for

the core, the cell components are morphologically and cytologically similar. Cell surfacing

the bud and hence the mesenchyme are low columnar or cuboidal in shape. While the basal

lamina over most of the bud conforms faithfully to the contour of the cell bases, such is not

the case for the cells on the superior surface. The core cells range in shape from round to

stellate with prominent intercellular spaces.

The third stage of odontogenesis is called the cap stage and occurs for the primary dentition

between the ninth and tenth week of prenatal development. The physiologic process of

proliferation continues during this stage, but the tooth bud of the dental lamina does not grow

into a large sphere surrounded by ectomesenchyme. Instead, there is unequal growth in

different parts of the tooth bud, leading to the formation of a cap shape attached to the dental

lamina.
The fourth stage of odontogenesis is the bell stage. which occurs for the primary dentition

between the eleventh and twelfth week of prenatal development. It is characterized by

continuation of the ongoing process of proliferation, differentiation and morphogenesis.

However, differentiation on all levels occurs to its furthest extent, and as a result, four

different types of cells are now found within the enamel organ. These cell types form layers

and include the inner enamel epithelium, the outer enamel epithelium, the stellate reticulum,

and stratum intermedium. Thus the cap shape of enamel organ evident in the last stage

assumes a bell shape.

During this stage, the tooth crown assumes its final shape (morphodifferentiation), and the

cells that will be making the hard tissues of the crown (ameloblast and odontoblasts) acquire

their distinctive phenotype (histodifferentiation). Cysts will develop in these and prevent

eruption of teeth.

Root development is initiated through the contributions of the cells originating from the

enamel organ, dental papilla and dental follicle. The cells of the outer enamel epithelium and

inner enamel epithelium contact at the base of the enamel organ, the cervical loop. Later as

the crown is completed the cells of the cervical loop continue to grow away from the crown

and become the root sheath cells. The inner root sheath cells cause root formation by

inducing the cells of the dental papilla to form odontoblasts, which in turn will form root

dentin. The root sheath will dictate whether the root will be single or multiple. The remainder

of the cells of the dental papilla will form the pulp. The cells of the dental follicle form the

supporting structures of the teeth, the cementum and the periodontal ligament.
A. Bud Stage B. Cap Stage C. Bell Stage D and E. Dentinogenesis and amelogenesis

F.Crown formation G. Root Formation and eruption

DEFINITION OF CYSTS

Jaw cysts were first described by Scultet (1671) as Liquid tumours.

“A pathological cavity having fluid, semifluid or gaseous contents and which is not created

by the accumulation of pus. Most cysts, but not all, are lined by the epithelium.” ---------------

-----[KRAMER,1974]

The British Standards Institution' defines a cyst as 'an abnormal cavity within a tissue, the

contents of which may be fluid or semi-fluid, but not pus, at least at the onset', and

conventionally the benign cystic lesions occurring in the jaws are subdivided into

odontogenic, fissural and bone cysts.

“A cavity occurring in either hard or soft tissue with a liquid, semiliquid or air content. It is

surrounded by a definite connective tissue wall or capsule and usually has an epithelial

lining” --------[Peterson L.W ]

“An abnormal cavity in hard or soft tissues which contains fluid, semi - fluid or gas and is

often encapsulated and lined by epithelium” -------[Killey & Kay; 1966]

Odontogenic cysts are defined as “those cysts that arise from odontogenic epithelium and

occur in the tooth-bearing regions of the jaws. It is usually considered that proliferation

and/or degeneration of this epithelium leads to odontogenic cyst development. Cystic jaw

lesions may be epithelial or non-epithelial, odontogenic or non-odontogenic, developmental,

or inflammatory in origin.”----------Manor, 2012

TYPES OF CYSTS

TRUE CYSTS: Those cysts that are lined by the epithelium. Eg: Dentigerous cysts,

Radicular cysts,etc

PSEUDO CYSTS: Those cysts that are not lined by an epithelium. Eg: Solitary bone cyst,

Aneurysmal bone cyst, etc

PARTS OF A CYST

Macroscopically: The cyst consists of a lumen and a cyst membrane

On Microscopic examination, the cyst consists of an epithelial lining, a connective tissue

capsule and a lumen

PATHOGENESIS

 (1)CYST INITIATION

 (2)CYST ENLARGEMENT AND EXPANSION

CYST INITIATION : proliferation of the epithelial cells and the formation of a small

cavity

Origin of odontogenic cysts: can occur from either of these cells namely;

1.The epithelial rests of dental lamina (Cell rests of Serres)

2.Reduced enamel epithelium

3.Cell rests of Mallassez

CYST ENLARGEMENT

Harris(1974) postulated the theories:

Mural growth:

 Peripheral cell division

 Accumulation of cellular contents

Hydrostatic enlargement:

 Secretion

 Transudation & exudation

Bone resorbing factor

MURAL GROWTH

PERIPHERAL CELL DIVISION : Cell division of lining epithelium occurs in response to

an irritant stimulus. Cyst regression occurs following the removal of such stimulus

ACCUMULATION OF CELLULAR CONTENTS:Accumulation of mural squames will

cause cyst to enlarge. For eg: Keratocyst enlarges by the mural squames, which are produced

by casting off the living epithelium

HYDROSTATIC ENLARGEMENT

SECRETIONS

Mucus secreting cyst are formed by the lining (goblet cells) which secrete mucus. The

accumulation of mucus may cause an increase in volume.

TRANSUDATION AND EXUDATION

It is seen in cases of inflammatory cysts/presence of infection. Based on the protein content

within the cystic lumen, there is increased osmolarity and raised internal hydrostatic pressure.

It attracts fluid into the cavity and helps in the retention of fluid within the cavity.

RAISED INTERNAL HYDROSTATIC PRESSURE

Toller et al. had suggested that the increase in the osmotic pressure is related to proteins

present in the cyst fluid such as large molecules of albumin, globulin, fibrinogen. The

desquamated epithelial cells of cyst lining undergo autolysis and produce a larger number of

molecules of lower molecular weight, raising the osmolarity of the fluid.

ATTRACTION OF FLUID INTO THE CAVITY

Results from the higher osmolarity of cyst fluid than serum

RETENTION OF FLUID WITHIN THE CAVITY

The lining acts as a semipermeable membrane and the attracted fluid are unable to diffuse out

of the cavity. The products of epithelial autolysis could affect both osmotic attraction and

retention within the cavity.

BONE RESORPTION
Increased internal pressure is transmitted to the adjacent bone and the bone undergoes

resorption thereby causing the bone cavity to be enlarged. The surface area of cyst lining is

increased by cell multiplication. The epithelial cells divide – cyst enlarges within bony cavity

by the release of bone resorbing factors from the capsule. They also stimulate osteoclast

function. Eg:prostaglandins like PGE2 &PGI2

CLASSIFICATION (WHO) 2005
DEVELOPMENTAL

ODONTOGENIC

1.GINGIVAL CYST OF INFANTS

2.ODONTOGENIC KERATOCYST(removed in the revised classification)

3.DENTIGEROUS CYST

4.ERUPTION CYST

5.GINGIVAL CYST OF ADULTS

6.LATERAL PERIODONTAL CYST

7.BOTYROID ODONTOGENIC CYST

8.CALCIFYING ODONTOGENIC CYST(removed in the revised classification)

NON-ODONTOGENIC

1.MID-PALATINE RAPHE CYST OF INFANTS

2.NASOPALATINE DUCT CYST

3.NASOLABIAL CYST

INFLAMMATORY

RADICULAR CYST

RESIDUAL CYST

PARADENTAL CYST

INFLAMMATORY COLLATERAL CYST

ROBINSON’S CLASSIFICATION

1. FROM ODONTOGENIC TISSUE

PERIODONTAL CYST

RADICULAR TYPE

LATERAL TYPE

RESIDUAL TYPE

DENTIGEROUS CYST

PRIMORDIAL CYST

2. FROM NON-DENTAL TISSUE

MEDIAN CYST

INCISIVE CANAL CYST

GLOBULOMAXILLARY CYST
SEWARDI CLASSIFICATION

1. CYST WITH AN EPITHELIAL LINING

NON-ODONTOGENIC EPITHELIUM

MAXILLARY

NASOPALATINE

MEDIAN PALATINE

NASOLABIAL

MANDIBULAR

MEDIAN MANDIBULAR CYST

ODONTOGENIC EPITHELIUM

ASSOCIATED WITH CROWN:CYST OF ERUPTION,DENTIGEROUS CYST

ASSOCIATED WITH ROOT:RADICULAR CYST,PERIODONTAL CYST

UNASSOCIATED WITH A TOOTH: PRIMORDIAL

CYSTIC NEOPLASM

2. CYST WITHOUT EPITHELIAL LINING

BONE CYST

STROMAL CYST IN NEOPLASM

WHO CLASSIFICATION (2017)
ODONTOGENIC CYSTS

DENTIGEROUS CYST

“FOLLICULAR / PERICORONAL”

It is the second most common type of odontogenic cyst. Dentigerous cyst were first described

in France in 1778 but was not delineated until 1842 when Harris C.A published a case report

on dentigerous cyst. Dentigerous cyst can be either Intrafollicular- Accumulation of fluid

either between the reduced enamel epithelium and the enamel, or within the enamel organ

itself or dental lamina. i.e. Degeneration of stellate reticulum at an early stage of development

– associated usually with enamel hypoplasia. Or it may develop after completion of the

crown by accumulation of fluid between the layers of the reduced enamel epithelium. Or

Extrafollicular: Foci of enamel hypoplasia. It diminishes the adherence of reduced enamel

epithelium to crown. Provides starting point for the development of the cyst. Crown of

permanent tooth may erupt into a radicular cyst of it’s deciduous predecessor – exceptionally

rare – tooth may indent rather than penetrate the wall. Inflammation at the apex of the

deciduous tooth can lead to the development of an inflammatory follicular cyst – Benn (1991)
PATHOGENESIS

Developmental / inflammatory pathogenesis

Inflammatory:

Inflammatory type dentigerous cyst is found in relation to the crown of an unerupted

permanent tooth due to periapical inflammation from an overlying primary tooth. Eg:

Partially erupted mandibular third molar is usually associated with inflamed cyst like lesion

along the distal / buccal aspect.

Intrafollicular-

It is formed by the fluid accumulation between the reduced enamel epithelium and the

enamel, or within the enamel organ itself or dental lamina. Later, it is characterized by the

degeneration of stellate reticulum at an early stage of development. The developing tooth is

associated with enamel hypoplasia.

Extrafollicular:

It is characterized by foci of enamel hypoplasia. It diminishes the adherence of reduced

enamel epithelium to crown and provides starting point for the development of the cyst.

Crown of permanent tooth may erupt into a radicular cyst of it’s deciduous predecessor and

in exceptionally rare cases, the tooth may indent rather than penetrate the wall. Inflammation

at the apex of the deciduous tooth can lead to the development of an inflammatory

dentigerous cyst.
The pathogenic mechanism is as follows:

Potentially – erupting tooth exerts pressure over impacted follicle → obstructs Venous out

flow → Breakdown of proliferating cells of follicle → Rapid transduction of serum across the

capillary wall →Pooling of fluid→ Increased hydrostatic pressure→ Separation of follicle

from the crown with or without reduced enamel epithelium – with time →Altered capillary

permeability→ Permit the passage of greater quantities of protein and transudate→

Dentigerous cyst
Bilateral dentigerous cysts are associated with BASAL CELL NEVUS SYNDROME

(GORLIN-GOLTZ SYNDROME),CLEIDOCRANIAL DYSPLASIA

When it contains blood, it is referred to as “BLUE DOMED CYST”

RADIOLOGICAL FEATURES

 LOCATION: Mandibular third molar, Maxillary third molar, Maxillary canine

o Epicenter : above the crown

o Attached to CEJ

 PERIPHERY & SHAPE:

o Well-defined

o Curved / circular outline

o Infected : cortex absent

 INTERNAL STRUCTURE:

o Completely radiolucent except crown

 EFFECT ON SURROUNDING STRUCTURE:

 o Displace & resorb adjacent teeth

o Apical/ramus

o Expansion of cortex

TYPES OF DENTIGEROUS CYST:

a)Central

b)Lateral

c)Circumferential

According to Mourshed:

Class I: associated with completely unerupted teeth which fail to erupt due to lack of space in

the dental arch

Due to malpositioning of the tooth germ

Unerupted supernumerary teeth

Class II: associated with partially erupted teeth

CT EVALUATION

CT and CBCT – help in determinining the relationship of the unerupted tooth with the cyst to

the mandibular canal and maxillary sinus prior to surgery, to assess cyst contents and also the

integrity of the cortical rim.

MRI EVALUATION

Classically T1 hypointense and T2 hyperintense with an enhancing rim can be seen. Presence

of Cholesterol crystals or proteinaceous material renders the lesions T1 hyperintense.

BONE SCAN

Bone scan may show a central photon defect with surrounding peripheral rim uptake of

mandibular cyst.

HISTOPATHOLOGICAL FEATURES

Non-inflamed : Will show a loosely arranged fibrous connective tissue wall. The epithelial

lining-two to four layers of Stratified squamous epithelium. The epithelium and CT interface

is flat. Small islands or cords of inactive – appearing scattered odotnogenic epithelial rests –

with glycosaminoglycan ground substance. Dystrophic calcification may be seen.

Inflamed : Epithelial lining wlli be thicker with rete pegs. The connective tissue wall will be

more densely collagenized. Focal mucin producing cells (Mucous cells) may be seen. It may

show evidence of ciliated epithelial cells, sebaceous cells,etc. Mucous, Ciliated and

Sebaceous contents are responsible for the multipotentiality of the odontogenic epithelial

lining.
CORRELATION

RADIOLOGICALLY HISTOLOGICALLY

 Sclerotic border surrounding crown  Epi. Lining surrounding the

of impacted tooth

 Lumen – Radiolucent on plain  Lumen – cystic fluid

radiography  CT shows inflammatory cell

 Hyperintense in MRI infiltrate

 INFLAMMATORY:

 Loss of cortical boundary

DIFFERENTIAL DIAGNOSIS :

• HYPERPLASTIC FOLLICLE

• AOT

• ODONTOGENIC KERATOCYST

• AMELOBLASTIC FIBROMA

• UNICYSTIC AMELOBLASTOMA
TREATMENT

Smaller lesions: Enucleation of the cyst can be done.

Larger lesions: Marsupialization with decompression by placing a small acrylic button in the

preformed surgical opening (keeps it open and facilitates drainage)

COMPLICATIONS

Recurrence due to incomplete surgical removal

Transformation to: Ameloblastoma(mural ameloblastoma), Squamous cell carcinoma or

Mucoepidermoid carcinoma
ERUPTION CYST(ERUPTION HEMATOMA)

Eruption cyst is characterized by the presence of a bluish dome-shaped swelling over the

unerupted tooth. The associated tooth is impeded within the soft tissues overlying the bone.

The etiology is not clear. Aguilo et al., has suggested the possible factors to be:

o Early caries

o Trauma

o Infection

o Deficient space for eruption

RADIOGRAPHIC FEATURES:

Sometimes associated with expansion of normal follicular space of the erupting tooth crown.

It may appear as saucer-shaped excavation of bone projecting very slightly into the cavity

with well defined margin.

Differential diagnosis

o Granuloma

o Amalgam tattoo

o Bohns nodule

HISTOPATHOLOGY

It is characterized by the presence of surface oral epithelium on the superior aspect. The

underlying lamina propria consists of variable inflammatory cell infiltrate and the deep

portion which forms the roof of the cyst shows thin layer of non- keratinizing squamous

epithelium.

CORRELATION

Since it is a soft tissue lesion, it appears as a radiolucency on conventional radiography.

Advanced modalities are usually not indicated since the lesion is self-limiting.

MANAGEMENT

Mostly do not require treatment. Surgical intervention - when they hurt, bleed, are infected,

or esthetic problems arise. Simple excision of the roof of the cyst generally permits speedy

eruption of the tooth. Er, Cr-YSGG laser for treatment of eruption cysts : doesnot require

anesthesia, no excessive operative bleeding, does not produce heat or friction, comfortable,
bactericidal and has coagulative effects, and the tissue healing is better and faster, and not

associated with postoperative pain.

ODONTOGENIC KERATOCYST

DEFINITION:

A cyst derived from the remnants of the dental lamina, with a biologic behavior similar to a

benign neoplasm ,with a distinctive lining of six to ten cells in thickness, and that exhibits a

basal cell layer of palisaded cells and a surface of corrugated parakeratin

The terminology Odontogenic Keratocyst was first suggested by PHILIPSEN(1956) and the

essential features of OKC was described by PINDBORG and HANSEN(1963).

This cysts arises from the dental lamina. Unlike other cysts which are thought to grow solely

from osmotic pressure, the epithelium in OKC appears to have an innate growth potential

similar to a benign tumor. This difference in growth mechanism gives OKC a different

radiographic appearance.

Recently terminology: “KERATOCYSTIC ODONTOGENIC TUMOR(KCOT)”according to

WHO 2005 classification. Again the terminology has been reverted to Odontogenic

Keratocyst according to the recent WHO 2017 classification.

The epithelial lining is distinctive because it is keratinized and thin. In some cases , bud like

proliferation from the basal cell layerinto adjacent connective tissue wall or proliferation of

islands of odontogenic epithelium that may be present in the wall giving rise to satellite

microcysts which support the fact that OKCs have a high recurrence rate.
CLINICAL FEATURES:

Multiple odontogenic keratocysts are found in the following syndromes:

 Gorlin-Goltz syndrome

 Marfan syndrome

 Ehlers – Danlos syndrome

 Noonan’s syndrome
RADIOGRAPHIC FEATURES

 LOCATION: Posterior body mandible & ramus. The epicentre is usually superior to

IAC. It may have a pericoronal position as that of a dentigerous cyst. Radiologically it

shows aggressive growth with undulating borders,cloudy interiors,and presence of

internal septas giving a multilocular appearance. The margins are hyperostotic.

 PERIPHERY & SHAPE: Usually it has a cortical border. If infected, the cortical

border may be absent. It usually has a smooth round or oval shape and a scalloped

outline.

 INTERNAL STRUCTURE: The internal structure is usually radiolucent. The

presence of the internal keratin usually doesnot increase radiopacity. It usually has a

curved internal septa giving it a multilocular appearance

 EFFECT ON SURROUNDING STRUCTURES: It has the potential to grow along

internal aspect and causes minimal expansion. Sometimes may cause expansion of the

ramus & coronoid process. It may displace & resorb teeth but to a lesser extent than
 dentigerous cyst. It may displace Inferior alveolar canal. When associated with

maxilla, it may invade the maxillary antrum.

RADIOLOGICAL TYPES:

ENVELOPMENTAL TYPE: this embraces an adjacent unerupted tooth

REPLACEMENT TYPE:forms in the place of normal teeth

EXTRANEOUS TYPE:in the ascending ramus away from the teeth

COLLATERAL TYPE:adjacent to the roots of teeth which are indistinguishable

radiologically from the lateral periodontal cyst

Characteristic of OKCs:

1) A distinctly corticated, often scalloped, border

2) Expansion, especially toward the lingual (medial) side, and growth along the length of

the mandibular bone

3) Displacement of developing teeth and/or separation or resorption of the roots of

erupted teeth and extrusion of erupted teeth

4) Radiolucent lumen, and occasionally a cloudy or milky appearance of the lumen on

the panoramic radiograph

5) Occasional presence of multiple or bilateral cysts, suggestive of basal cell nevus

syndrome

CT EVALUATION

CT provides additional information about the contents of the lesion. Presence of a high

attenuation may suggest high protein concentration in the dense keratin filling the lumen.
Other possibilities could include hemorrhage or Calcification. With a vascular lesion, a

change in attenuation should occur when a contrast-enhanced CT scan is compared with a

nonenhanced CT scan. High attenuation within an expansile benign lesion of the mandible on

nonenhanced CT scans, with no enhancement after contrast material injection, can indicate an

OKC. High attenuation suggests the presence of a dense proteinacious material such as

keratin.

MRI EVALUATION

OKC typically has low to intermediate signal intensity on T1-weighted images. High signal

intensity on T2-weighted images. Weak enhancement of rim can be seen, caused by fluid

containing a low concentration of protein, which results in intermediate signal intensity on

T1-weighted images while homogenous signal intensity in other odontogenic cysts can be

seen.

DIFFERENTIAL DIAGNOSIS:

 Dentigerous cyst: in OKC, the cyst is connected to the tooth at a point apical to the

CEJ.

 Ameloblastoma: usually seen in the older age group, usually multilocular, causes

paresthesia, resorption of adjacent teeth, no amber or straw colored fluidon aspiration.

 Traumatic cyst: unilocular with scalloped margins, rarely shows cortical expansion, if

it does occur, then buccal only, positive history of trauma. Needle aspiration is usually

non-productive, but may sometimes yield a few millimetre of straw-coloured or

serosanguinous fluid.

 Giant cell granuloma: usually found in the anterior region of the jaw.

 Odontogenic myxoma: usually rare, may be considered if the tooth has failed to

develop and may be seen as a cyst like radiolucency.

HISTOLOGIC FEATURES

OKC has a thin friable wall with cystic lumen containing clear liquid similar to transudate of

serm or cheesy material with keratinaceous debris. The thin fibrous wall is devoid of

inflammation. The epithelial lining is composed of stratified squamous epithelium,6-8 cells in

thickness. The epithelium – connective tissue interface is usually flat and rete ridge formation

is inconspicuous, so detachment can be seen commonly. The basal cell layer has cuboidal /

columnar cells with reversly polarized nuclei giving a picket fence /tombstone appearance.

Luminal surface shows flattened parakeratotic epithelial cells,which exhibit a wavy/

corrugated appearance. Small satellite cysts,cords,or islands of odontogenic epithelium may

be seen in the connective tissue. The basal epithelial layer will be palisaded cuboidal /

columnar epithelium with a hyperchromatic nuclei. Rarely, cartilage can be seen within the

lesion. The presence of inflammation may alter the typical features such that the

parakeratinized luminal surface may disappear and the epithelium proliferate to form rete

ridges with loss of characteristic palisaded basal layer.

CORRELATION

RADIOLOGICAL HISTOLOGICAL

 Difference in attenuation - unlikely to  Cystic lumen – cheesy , keratin

help in the distinction between the material

typical parakeratotic OKCs and the  Inflammation – loss of characteristic

less aggressive orthokeratotic subtype typical features.

of odontogenic cysts

 Most parakeratotic keratocysts have

low CT attenuation within the lesion

 Cloudy interior - OPG

 Inaflammation- loss of cortication

TREATMENT:

Enucleation with peripheral ostectomy(using vital staining technique) - Methylene blue is

used for staining and 1-2mm of bone is removed.

Physicochemical treatment with Carnoys solution: Carnoys solution:placed for 5minutes.

Some practitioners leave this bone in place, whereas others remove it with a drill to get down

to normal bone. This technique generally involves a removal of 1 to 2 mm of bone. Carnoy

solution is neurotoxic and chemically fixes the inferior alveolar or lingual nerves if it comes

in contact with them for up to 2 minutes. The nerve should therefore be protected; bone wax

can be used for protection of the inferior alveolar nerve. The other issue with Carnoy

solution, as originally formulated, is that it contains chloroform, now classified as a

borderline carcinogen by the US Environmental Protection Agency (EPA).

Physical treatment with cryotherapy using liquid nitrogen

COMPLICATIONS IN OKC

Malignant transformation of cyst lining to squamous cell carcinoma.

Recurrence(With simple enucleation, it seems that the recurrence rate may be from 25% to

60%)

REASONS FOR RECURRENCE:

 Thin fragile lining :very difficult to remove completely

 New cysts develop from satellite cysts

 Some cysts may be left behind in cases of GORLIN-GOLTZ SYNDROME

 New cysts may develop from basal cells of overlying epithelium, especially in ramus-

third molar region

ORTHOKERATINISED ODONTOGENIC CYST

This entity was first reported by Wright in 1981. Thin layer of luminal orthokeratin ( without

cell nuclei). Usually appears as a pericoronal Radiolucency (72% cases)

RADIOLOGY

o LOCATION: mandible ; poserior to second molar region

o RADIOLOGIC FEATURES : Size – 1- 7cm

o Mostly solitary Radiolucencies

o 72% : pericoronal RL about an impacted tooth

o Expansion – 5% cases

o Displacement of the involved tooth & resorption of adjacent teeth

HISTOPATHOLOGICALLY:

The cyst lining consists of stratified squamous epithelium with orthokeratotic surface of

varying thickness. Keratohyaline granules may be present in the superficial epithelial layer.

The epithelial lining is relatively thin and the prominent palisaded basal layer will be absent.

GINGIVAL CYST OF ADULTS

Definition:

It is an uncommon cyst occurring either on a free or attached gingival margin, from the

degenerative changes in the epithelium or from the remnants of dental lamina, enamel organ

or epithelial islands of periodontal membrane, traumatic implantation of epithelium or from

postfunctional rests of dental lamina.

Origin:

Cystic transformation of the dental lamina,traumatic implantation of the surface epithelium

CLINICAL FINDINGS:

RADIOGRAPHIC FINDINGS:

No radiological changes

Sometimes a faint round shadow which is indicative of superficial bone erosion with

extension into the periodontium may be seen

HISTOPATHOLOGY

The histopathological appearance is similar to lateral periodontal cyst. The epithelium will be

lined by thin, flattened stratified squamous epithelium with focal thickenings(plaques)may be

found within the lining.

MANAGEMENT:

The gingival cyst is removed by local surgical excision and in the majority of cases there is

no tendency for recurrence. However, caution must be observed if the pathologist reports a

multicystic or botryoid variety of cyst. This may signal that one is dealing with a lateral

periodontal rather than an adult gingival cyst

LATERAL PERIODONTAL CYST

The designation ‘lateral periodontal cyst’ is confined to those cysts that occur in the lateral

periodontal position and in which an inflammatory aetiology and a diagnosis of collateral

OKC have been excluded on clinical and histological grounds (Shear and Pindborg, 1975).

The first five well-documented cases were reported by Standish and Shafer (1958).

CLINICAL FEATURES:

It is asymptomatic and less than 1cm in diameter occurs chiefly in adults between the age of

22 to 85 years. It shows a male predilection. The Site commonly involved is the lateral PDL

regions of mandibular premolars, followed by anterior maxilla

SIGNS & SYMPTOMS: Usually asymptomatic as it occurs on the lateral aspect of the root

of the tooth. When observed on the labial surface it appears as a slight onvious mass. It

appears as a dome-shaped fluctuant swelling of the interdental papilla. If the cyst becomes

infected, it resembles a periodontal abscess. The associated teeth are vital. Cysts are usually

less than 1cm in size,except for BOTYROID variety which is larger and also a multilocular

type.
RADIOLOGICAL APPEARANCE OF LATERAL PERIODONTAL CYST
RADIOGRAPHIC FEATURES OF BOTYROID CYST

One of the locules occupies the same location as the LPC. With respect to the teeth present,

the lesion cause resorption of the lamina dura in areas where it extends to the roots of

adjacent teeth. It usually appears high on the alveolar crest. When the lesion extends beyond

apical region, this extension appears to be limited to approx. 1cm. The periphery of locules

shows continuous cortication with well-defined, intact borders and the internal loculations are

mostly absent, with scalloped outline. When present, loculations are circular & well –

corticated with lack of linear striations

HISTOLOGICAL FEATURES

The epithelium is lined by a thin,non inflamed, fibrous wall with layer of stratified squamous

or cuboidal epithelium-1-5 layers wide. The cells consist of flattened squamous cells,

sometimes cuboidal. Foci of glycogen-rich clear cells among epithelial lining are present.

Also presence of localized plaque /thickenings of the epithelial lining are characteristic.
CORRELATION
RADIOGRAPHICALLY HISTOLOGICALLY

Multilocular ( Botyroid ) Multilocular

DIFFERENTIAL DIAGNOSIS

Lateral radicular cyst – associated with a non-vital tooth, pulpal infection and a discontinuous

lamina dura.

Lateral periodontal abscess – if the size is less than 1.5cm

Lateral dentigerous cyst – usually associated with an impacted tooth

Primordial cyst – more common in the younger age. If the primordial cyst arising from a

supernumerary tooth is superimposed on the adjacent tooth surface, then it may be considered

in differential diagnosis.

MANAGEMENT:

Provided that the lesion is unilocular on radiological examination, the lateral periodontal cyst

is treated by surgical enucleation. Attempts should be made to avoid sacrificing the

associated tooth, but this may not always be possible.It is not yet clear from the literature

whether the encapsulated multicystic lateral periodontal cyst has the same tendency to recur

following simple enucleation. Eight of 10 recurrent cases reported by Greer and Johnson

(1988) were unilocular radiologically but multicystic histologically.

CALCIFYING ODONTOGENIC CYST

This is an unusual lesion with features suggestive of a cyst and characteristics of a solid

neoplasm. It is also known as “ODONTOGENIC GHOST CELL CYST or GORLIN CYST.

It has many features of odontogenic tumor, hence placed in the category of benign tumors

and has been renamed as “CALCIFYING CYSTIC ODONTOGENIC TUMOR”(CCOT)in

the WHO 2005 classification. It usually arises centrally within the bone, but it may occur

peripherally in the soft tissue. It is also known as intraosseous odontogenic cyst.

As defined in the WHO classification of 1992, it is:

‘A cystic lesion in which the epithelial lining shows a well-defined basal layer of columnar

cells, an overlying layer that is often many cells thick and that may resemble stellate

reticulum, and masses of “ghost” epithelial cell that may be in in the epithelial lining or in the

fibrous capsule. The “ghost” epithelial cells may become calcified. Dysplastic dentine may be

laid down adjacent to the basal layer of the epithelium, and in some instances the cyst is

associated with an area of more extensive dental hard tissue formation resembling that of a

complex or compound odontoma.’

DIFFERENT TERMINOLOGIES USED
CLASSIFICATION

BY REICHART

1) Non-neoplastic (simple cystic variant):

1) With non-proliferative epithelial lining

2) Non-proliferative epithelial lining with odontomas

3) Proliferative epithelial lining

4) Unicystic , plexiform ameloblastomatous proliferation Of epithelial lining

2) Neoplastic variant

1) Benign type

1) Cystic subtype

2) Solid subtype

2) Malignant type

1) Cystic

2) Solid
CLINICAL FEATURES

Age: affects a wide age range that peaks at 10-19 years, with mean age of 36 years and the

second peak occurs during the 7th decade

Site: 3/4th lesion occurs centrally, 75% occurring anterior to the first molar. It is equally

affecting both the jaws.

It is a slow growing, painless, non-tender swelling, which may cause expansion and/or

destruction of the cortical plates. The cystic mass may become palpable and discharging.

Adjacent teeth may be displaced.

It may be associated with an odontoma, and may have calcified material identified as

dysplastic dentine. Aspiration yields a viscous, granular, yellow fluid.

PATHOGENESIS:

The pathogenesis of calcifying odontogenic cyst is a unicystic process and develops from the

REE or remnants of dental lamina. The cyst lining has the potential to induce the formation

of dentinoid or even odontoma in adjacent CT wall. However, elucidation of the pathogenesis

is considerably complicated by the fact that the epithelial lining of a calcifying odontogenic

cyst appears to have the ability to induce the formation of dental tissues in the adjacent

connective tissue wall; and that other odontogenic tumours such as the ameloblastoma, the

odontoameloblastoma, the ameloblastic fibroma and the ameloblastic fibro-odontome may

sometimes be associated with it. Prætorius believes that the dentinogenic ghost cell tumour is

a neoplasm de novo, but the COC plus benign neoplasm or hamartoma is a cyst from the

beginning.

RADIOGRAPHIC FEATURES

The central lesion may appear as a cyst like radiolucency with variable margins which may

be smooth well defined or irregular in shape with poorly defined borders. It may be

unilocular or multilocular. The expanded bone appears perforated. Inspite of these features,

the radiopaque foci may show various features such as:

  R/O foci are often clustered around the occlusal or incisal surface of an impacted

tooth

 May appear clustered toward an edge of the lesion

 May resemble a compound / complex odontoma

Additional imaging:

The desquamated keratin creates an increased attenuation area in a cyst. By varying the

window setting, both keratin and calcifications can be identified on the CT. By widening the

window settings, desquamated keratin with a CT value of 100-200 HU becomes less distinct

due to less of soft tissue details, whereas calcifications with HU value of 800-1600 HU

remains detectable on the CT.

HISTOLOGIC FEATURES

The epithelial lining thin usually about 6-8 cell thick; and may be thickened in other areas. It

may show characteristic odontogenic features with reversely polarized basal layer. Typically

GHOST CELLS may be seen in thicker areas of lining. The ghost cells are enlarged,

ballooned, ovoid or elongated elliptoid epithelial cells. They are eosinophilic and although

the cell outlines are usually well-defined, they may sometimes be blurred so that groups of

them appear fused. A few ghost cells may contain nuclear remnants but these are in various

stages of degeneration and in the majority all traces of chromatin have disappeared leaving

only a faint outline of the original nucleus. The ghost cells represent an abnormal type of

keratinisation and have an affinity for calcification. They have the same histological reactions

as keratin, giving a yellow fluorescence with rhodamine B.

An atubular dentinoid is often found in the wall close to the epithelial lining and often in

relation to the epithelial proliferations. Sometimes many cells may fuse which represent

abnormal keratinization and frequently calcify.

DIFFERENTIAL DIAGNOSIS

FIBROUS DYSPLASIA: mottled / smoky defined border,more common in maxilla

PARTIALLY CALCIFIED ODONTOMA: appears within the capsule

AOT : intermediate stage of development AOT appears like a CEOT

OSSIFYING FIBROMA: more inferior position in the mandible, “CHINESE LETTER”

shaped islands of calcification in Connective tissue

ODONTOGENIC FIBROMA: Histologically, it shows odontogenic tissue, like cementum

CEMENTOBLASTOMA: well defined & attached to the root of the tooth

MANAGEMENT:

The COC is treated by surgical enucleation unless it is associated with another odontogenic

tumour, in which case wider excision may be required. In the presence of a complex

odontome, conservative removal will still be adequate. An ameloblastoma or one of its

variants with foci of ghost cells must be treated as would be an ameloblastoma without ghost

cells. Although classic uncomplicated cases of COCs may grow to a large size, reported

recurrences are rare.

CORRELATIVE FINDINGS

RADIOLOGY PATHOLOGY

Small foci of calcified material - white flecks Tubular dentine / odontome - connective

or smooth pebbles tissue wall close to epithelial lining.

Calcification seen twice commonly

CONCLUSION:

Thus the knowledge of odontogenic cysts are required for accurate diagnosis and

management. Also the correlation between the radiological and histopathological entities will

help in diagnosing these lesions more effectively in the clinics. Also, the classification of

odontogenic cysts has been widely debated and there has been much debate and controversy

about the true nature of some of the lesions. Although cysts are common in the jaws, most are

radicular cysts of inflammatory origin or simple dentigerous cysts. Others are less frequently

encountered and may present diagnostic difficulties because of their varied features. The

previous WHO classification, in 2005, redesignated a number of these lesions as true

neoplasms, but this was controversial and was not based on sound evidence. For the latest

WHO classification (2017), an international consensus group reappraised these lesions and

agreed a terminology and new classification.

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• NEVILLE,ORAL AND MAXILLOFACIAL PATHOLOGY

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• TEXTBOOK OF ORAL SURGERY-NEELIMA ANIL MALIK

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