Orofacial cysts

Adama science and Technology University

Lecture for C-II Medical students

Instructor: Dr. Assefa Abera

March,2014

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Orofacial cysts
Definition
 A cyst is a pathological cavity or sac
with in hard or soft tissues that may
contain fluids, semi fluids or gas.
 It may be lined by epithelium, fibrous
tissue or occasionally even by
neoplastic tissues.

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Cysts

 pathological cavity

 often fluid filled lined by

epithelium

 in many instances, exact

pathogenesis of these lesions is
still uncertain

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Cysts

 regardless of origin, once

cysts develop in oral +
maxillofacial region,

 tend to slowly increase

in size
possibly in response to
a slightly elevated
hydrostatic luminal
pressure
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Classification
- Classifications of cysts of oral & Para-
oral region is usually based on origin,
location and pathogenesis.
1.Cysts of the jaws
2.Cysts associated with maxillary sinus
3.Cysts of the soft tissues

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 1.Cysts of the jaws
 It can be either non epithelized or
epithelized.
I. Non epithelized(pseudo cysts)
a. traumatic solitary or simple bone cyst
b. aneurysmal bone cyst
c. static bone cyst
II. Epithelized(true cysts) jaw cysts is
further classified as non odontogenic(10%)
and odotogenic(90%).
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 Cont.
 Non odotogenic cysts include:-
 Nasopalatine cyst
 nasolabial cyst
 Median palatal cyst
 median mandibular cyst
 Globulmaxillary cyst

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 Cont.
 Odontogenic cyst
-It can be inflammatory or developmental
 Developmental
 Dentigerous cyst
 Eruption cyst
 Odontogenic keratocyst
 Gingival cyst of infants
 Gingival cyst of adults

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Cont.
 Lateral periodontal cyst
 Calcifying odontogenic cyst
 Inflammatory
 Radicular cyst
 Residual cyst

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Dentigerous cyst/follicular cyst/
 Results from the enlargement of the follicular
space of whole or a part of crown of an
impacted or un erupted tooth & is attached to
the neck of the tooth.
 It develops by the accumulation of fluid b/n
tooth & the REE(reduced enamel epithelium).
 Increase in the size of this cyst depends on
the increased intracystic osmotic pressure.

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 CONT.
Clinical features
 It commonly occurs in mandible
 greater incidence in males
 Large cysts may cause painless
expansion of bone that results in
facial asymmetry.
 More common in younger age group
(2nd and 3rd decades).

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 Cont.
Clinical Features

 commonly seen in
association most
with 3rd molars commonly
impacted
 maxillary canines teeth

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 Cont.
Radiologic features
 They have a well defined radiolucent area more than 3-4 mm
associated with a crown of un erupted tooth and is surrounded
by radiopaque margin.
 Usually the radiolucency is unilocular ,but sometimes it appears
as multilocular

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Cont.
 It has a tendency to cause root
resorption of adjacent teeth
 Central variety - cyst surrounds the
crown of tooth
 Lateral variety - cyst grows laterally
around the crown
 Circumferential - cyst surrounds the
crown & some portion of root also

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Cont.
Histopathologic features
Epithelial lining consists of 2 layers of
nonkeratinizing cells
Epithelial connective tissue interface is
flat
If infected connective tissue wall has
inflammatory cell infiltrate

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Cont.
Treatment
Marsupilization - in children ,if the cyst
is very large in size,or if the involved
tooth to be remained
Enucleation- in adults

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 Eruption cyst

 Soft tissue analogue of the follicular cyst;

 A “cyst arising within the oral mucosa by the
separation of the follicle from around the anatomical
crown of an erupting tooth”
 May be associated with natal teeth, deciduous or
permanent tooth.
 Bluish gray swelling of the mucosa over an erupting
tooth
 Bleed intermittently if traumatized
 Disappears when the tooth erupts

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 Cont.

Histopathologic features
 Lined by thin layer of non keratinized squamous epithelium
 Lamina propria shows inflammatory infiltrate

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Cont.
Treatment –
 Excision of a wedge of the mucosa to
expose the tooth crown

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 Odontogenic keratocyst
 Arise from the remnants of dental lamina
Clinical features
 Commonly seen at the angle of mandible
 Slight male predilection
 Larger cysts are associated with pain, swelling
 Grows in an anterioposterior direction
 Has significant recurrent rate

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Cont.)

Clinical Features

 common jaw cysts

 occur in any age

 peak incidence within

2nd-3rd decades of life

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Cont.
Clinical Features

 mandible

posterior portion of
body commonly
affected
ramus region

 maxilla -3rd molar area

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 Cont.
Radiologic features
 It may appear as unilocular or multilocular
radiolucency
 Majority of unilocular radiolucency have a
smooth periphery, some of them have a
scalloped margins
 Multilocular cysts will have one large & other
smaller cysts.
 Buccal & lingual cortical expansion may be
seen.
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Cont.

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Cont.
Histopathologic features
 The cystic fluid is similar to serum ,or
with cheesy material
 Epithelial lining consists of stratified
squamous epithelium
 Small cysts may be found in fibrous wall

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Cont.

Treatment & Prognosis

 surgical excision with peripheral osseous
curettage
 osteotomy
follow up examinations are important due to
recurrence rate
most recurrence become clinically evident
within 5 years of treatment

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Gingival cyst of infants
 Arise from the remnants of dental
lamina
Clinical features
 They are seen in new born infants
 Bohn`s nodules are found on the buccal
or lingual aspects of dental ridges

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Cont.
 Epstien`s pearls are seen along the
midpalatine raphae
 They may be single or multiple
Histopathologic features
 Thin flattened epithelial lining with
parakeratotic surface
 Lumen contains keratinaceous debris

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Cont.
Treatment
They rupture spontaneously on
eruption of the underlying teeth

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Gingival cyst of adult
 Soft tissue counterpart of lateral
periodontal cyst
Clinical features
 It is commonly seen in canine
&premolar region of mandible
 They are seen in attached gingiva or
interdental papillae on the labial
aspect

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Cont.
 They are painless slow growing
swelling with a smooth surface
 They may have a normal or bluish
color
 They are soft & fluctuant &the
adjacent teeth are vital
 Sometimes there is a superficial
cortical erosion

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32
cont.
Histopathologic features
Thin flattened epithelial lining
Treatment
Surgical excision

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 Lateral periodontal cyst
Clinical features
They are found lateral to the roots of vital tooth
Asymptotic
More common in older individuals(20-85 years old)
male predilection

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 Cont.
Radiologic features
Well-defined round or ovoid radiolucency
with a sclerotic margin along the lateral aspect
of the root
Lamina dura of the involved tooth is
destroyed
Most of the cysts are smaller than 1cm

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36
CONT.
Histopathologic features
Epithelial lining is 1 to 3 cells thick
Epithelium consists of flattened
squamous cells
Glycogen rich clear cells may be seen
in the epithelial cells
Treatment
Enucleation
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Calcifying epithelial odontogenic cyst

 Also known as Gorlin cyst

Clinical features
 Commonly seen in anterior part of
mandible
 Usually occur in young patients
Radiologic features
 Small cyst will be seen b/n the roots
of the tooth
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Cont.
 It may be unilocular or multilocular
 Cortical perforation may be seen
 Calcifications may be seen within the
radiolucency
 Resorption of adjacent tooth root may
be there
 Cyst may be associated with complex
odontome or unerupted tooth
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40
Cont.
Histopathologic features
Cystic lesion with a fibrous capsule &
lining odontogenic epithelium of 4 to 10
cells thick
Ghost cells (epithelial cells with loss of
nuclei due to necrosis or keratinization)
Adjacent to the ghost cells calcified
dentinoid material can be seen

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Cont.
 Lumen may also contain ghost cells &
calcifications
Treatment
 Enucleation

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 Radicular cyst/periapical cyst/
• it is an inflammatory odotogenic
epithelized bony cyst
• it accounts about 60-70% of the cysts in
oral region which is the most prevalent
type of cyst in the jaws.

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 Cont.
 also known as Apical
Periodontal Cyst;
Periapical Cyst;
Root End Cyst
 common
not inevitable sequela of
periapical granuloma originating
as a result of:
 bacterial infection
 necrosis of dental pulp
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 following carious involvement of tooth
 Cont.
 Pathogenesis

 initial reaction leading

to cyst formation
proliferation of epithelial
rest in the Periapical
area involved by granuloma
 epithelial proliferation
follows an irregular pattern of
growth
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 Cont.
Clinical features
 more common in ages of 3rd – 6th decades
 affects male more than females
 The commonest site is maxilla more than
mandible and anterior region than posterior region
 Asymptomatic
 seldom painful (sensitive to percussion)
 represents chronic inflammatory process
 develops only over a long period of time

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 Cont.
Radiographic features
•Un infected radicular cyst appear as well demarcated
round or oval radiolucent area surrounded by
radiopaque border.
•Infection will make the appearance
hazy radio graphically
•The involved tooth is usually non-vital
•indicates reaction of bone to slowly
expanding mass

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Cont.
Contents of the cyst
• Cholesterol
• Serum albumin
• Globulin & nucleoprotein
• Polymorph nuclear leukocytes
• Water and electrolytes

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 Cont.
Ddx
Periapical granuloma
Periapical surgical scar
Early stage of Periapical cemental dysplasia
Traumatic bone cyst
Central giant cell granuloma

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 Cont.
Treatment
Depending on the size and site of the cyst
treatment is either marsupialization or
enucleation with RCT and apicoectomy or
removal of the involved tooth.

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 Cont.

Treatment & Prognosis

 involved tooth may be
removed
Periapical tissue carefully
curetted
under some condition;
root canal therapy with
apicoectomy

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 Nasopalatine cyst
 It I developmental non odotogenic cyst.
 It is either incisive canal cyst or cyst of
palatine papilla based on its location
Clinical features
 affects male more than females and
anterior portion than posterior.
 common in 4th -6th decades of life
Rx-surgical enucleation
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 Nasolabial Cyst

Clinical Features
 swelling of upper lip lateral to midline result in
elevation of ala of the nose
 enlargement often elevates mucosa of nasal
vestibule obliterates maxillary mucolabial fold
 cyst may rupture spontaneously and may drain in oral
or nasal cavity

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Cont.

Clinical Features

 commonly seen in adults

 peak prevalence in 4th-5th decades of life

 significant predilection for women

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Nasolabial Cyst
Clinical Features

 on occasion, expansion
may result in:

• nasal obstruction
• interfere with wearing
of denture

 pain is uncommon

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Cont.

Radiographic Features

 cyst arises in soft tissues

 most cases no radiographic changes are seen

 pressure resorption of underlying bone may occur

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 Cont.

Treatment & Prognosis

 complete surgical excision
of cyst via intraoral approach
 because lesion is often close
to floor of nose
 sometimes it is necessary
to sacrifice portion of nasal
mucosa to ensure total
removal

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Cont.

Treatment & Prognosis

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Cont.

Treatment & Prognosis

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 Median Palatal Cyst
 rare fissural cyst

 develops from epithelium

entrapped along embryonic
line of fusion of lateral
palatal shelves of maxilla

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Cont.

Clinical Features

 firm or fluctuant swelling

of midline of hard palate
posterior to palatine
papilla
most frequently in young
adults

 often asymptomatic
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Cont.

Clinical Features

 must be stressed out that a

true medial palatal cyst
should exhibit clinical
enlargement of palate
 midline radiolucency without
clinical evidence of expansion
is probably a nasopalatine
duct cyst
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 cont.

Radiographic Features

 occlusal radiographs
demonstrate well-
circumscribed radiolucency
in midline of hard palate

 occasional reported cases

have been associated with
divergence of central incisors
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 Median Palatal Cyst
Treatment

 surgical removal

 recurrence should not

be expected

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Nasopalatine Duct Cyst

 also known as Incisive

Canal Cyst

 most common non-odontogenic

cyst of oral cavity
believed to arise from remnants
of nasopalatine duct
 embryologic structure
 connects oral + nasal cavities in
area of incisive canal
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Cont.

 believed to arise from remnants

of nasopalatine duct

 normally degenerate in humans

but may leave epithelial
remnants behind in incisive
canals

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Cont.

Clinical Features

 almost any age

most common in 4th-6th decades of life
swelling of anterior palate
drainage

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Cont.

Clinical Features

 asymptomatic

 discovered on routine
radiographs

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Cont.

Clinical Features

 rare instances, a nasopalatine duct cyst may

develop in soft tissues of incisive papilla area
without any bone involvement
blue discoloration

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Cont.

Radiographic Features

 well-circumscribed
radiolucency in or near
midline of anterior
maxilla
between apical to central
incisor

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Cont.

Radiographic Features

 root resorption is rarely

noted

 lesion most often is round

or oval with a sclerotic
border

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Cont.

Radiographic Features

 some cases, a classic heart

shape

• result of superimposition
of nasal spine
• OR because they are notched
by nasal septum

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Cont.

Radiographic Features

 radiographic diameter
can range from small lesions,
less than 6 mm to destructive
lesions as large as 6 cm
 most cyst are in range
1.0- 2.5 cm, with average
diameter of 1.5-1.7 cm

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Cont.

Radiographic Features

 radiolucency that is 6 cm
or smaller in this area is
usually considered a normal
foramen

 unless other clinical signs

or symptoms are present
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Cont.

 Treatment & Prognosis

 surgical enucleation

 biopsy is recommended

• because lesion is not

diagnostic radiographically
• benign + malignant lesions
have been known to mimic
nasopalatine duct cyst
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Cont.

Treatment & Prognosis

 palatal flap reflected after incision made along

lingual gingival margin of anterior maxillary teeth

 recurrence is rare

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Globulomaxillary Cyst

 between lateral incisor

+ canine teeth
many are lined by inflamed
stratified squamous
epithelium

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Cont.

 Radiographic Features

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2.Cysts associated with maxillary sinus
 Benign mucosal cyst of maxillary sinus
 Surgical ciliated cyst of maxillary sinus

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3.Cysts of the soft tissues
 Salivary gland cyst /mucocele/
 Dermoid-Epidermoid cyst
 Lymphoepithelial cyst
 Thyroglossal duct cyst

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 Salivary gland cyst /mucocele/
 are small cysts formed in association with minor
salivary glands.
 It is more common in lower lip.
Clinical features
 appears as firm, painless smooth mass usually bluish
in color.
Ddx
 Benign connective tissue neoplasm
 salivary gland neoplasm
Rx-surgical removal together with associated mnor
salivary gland to prevent recurrence
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Ranula
 Extravasation cyst usually arises from ducts of
sublingual glands
Clinical features
 Bluish, dome shaped, fluctuant swelling in
floor of mouth
 May enlarge raise the tongue
 Usually seen lateral to midline
 May extend to the neck behind the posterior
border of mylohyoid (plunging ranula)

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Treatment
 Treated by marsupialization or removal
of the feeding sublingual gland

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Thank you!

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