CYSTS OF MAXILLOFACIAL REGION

PRESNTER: DR. SIYUM M. (OMFS-RII)

MODERATOR: DR. JORGE (OMFS CONSULTANT)
04/23/2023 1
OUTLINE
OBJECTIVES
INTRODUCTION
CYST FORMATION
CLASSIFICATION OF CYSTS OF ORAL AND MAXILLOFACIAL REGION
I. CYSTS OF JAWS
II. CYSTS OF MAXILLARY ANTRUM
III. CYSTS OF SOFT TISSUES OF THE MOUTH, FACE AND NECK
SUMMARY
REFERENCES

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 Objectives
 To discuss about cyst formation
 To discuss about classification of cysts of maxillofacial region
 To discuss about different treatment modalities for different cysts of
maxillofacial region.

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 Introduction
 A cyst is a pathologic cavity or sac within the hard/soft tissues that may
contain fluid, semifluid or gas and not always lined by epithelium &
contain pus if 20 infected.
 A cyst contains outer wall of fibrous connective tissue surrounding central
cavity, most commonly lined by stratified squamous epithelium.
 The cystic fluid either is secreted by the cells lining the cavity or derived
from the surrounding tissue fluid.
 Cysts may arise in any of the soft or hard tissues of the orofacial regions.

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 Cyst formation

 Cysts occur more in the jaw bones than any other bones in body, because
cysts originate from the numerous rests of odontogenic epithelium, which
remain after tooth formation.
 Two phases have been recognized in the pathophysiology of cystic lesions:
1. Cyst initiation—which results in the proliferation of the epithelial lining
and the formation of a small cavity.
2. Enlargement or expansion—of this cystic cavity, then occurs.

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1. Cyst initiation
 The stimulus for cyst initiation is not known,except inflammatory
odontogenic cysts(infection is stimulating factor).
 In others, it is possible that there is a predisposition in some individuals to
form cysts from developing odontogenic epithelium.
1) Remnants of dental lamina(cell
rests of serres)
2) A tooth germ—enamel organ
3) Extensions of basal cells from the
overlying oral Epithelium
4) Reduced enamel epithelium
5) Cell rests of Malassez.
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Cont…
Pathogenesis of cyst formation
 It is proposed that during cyst formation stage, the cyst cavity gets lined by
stratified squamous epithelium.
 The blood supply is rich at the periphery and the cells in the center lack
nutrition ---> leads to desquamation of cells in to the center of mass --->
formation of fluid with increased osmolarity in the center surrounded by
an epithelial lining.

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2. Enlargement or expansion
 Proliferation of the epithelial lining and fibrous capsule ---> degeneration
and liquefaction in the center---> Fluid accumulation within the cyst
cavity---> elevated hydrostatic luminal pressure(>70 cm of H2O than
capillary bed) ---> which exerts osmotic pressure on the walls of the cyst
---> this stimulate bone resorption( by Osteoclasts and release of
prostaglandins PGE2 & PGE3) ---> resulting in Cyst expansion/enlargement

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Cont…
 Harris in 1974 first postulated the theory of cyst expansion/enlargement.
1. Mural growth theory: Cyst epithelial division---> mural pressure which
leads to expansion.
2. Osmotic pressure theory: accumulation of protein (intraluminally) --->
increased osmotic pressure---> leads to increased fluid inflow into cystic
cavity ---> Hydrostatic pressure---> resulting in cystic expansion.
3. Bone resorption theory: Peripheral release of bone resorption factors
(BRFs) from cystic lining leads to bone resorption---> cyst expansion.
4. Accumulation theory: Accumulation of contents into cystic lumen leads
to expansion.
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 Classification of Cysts of the Oral and
Maxillofacial Region
 Originally, since the late 19th century, classifications were based upon
clinical and radiologic features, but newer findings and ideas regarding
origin and growth have led to some modifications.
 Cysts historically named globulomaxillary, median palatine and median
mandibular cysts have been convincingly shown by numbers of studies to
be other odontogenic or developmental cysts.
 This terminology is no longer used in diagnostic oral pathology
departments in most parts of the world.

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 Shear classified cysts under three main headings:

I. CYSTS OF THE JAWS II. CYSTS ASSOCIATED WITH

1. Epithelial lined MAXILLARY ANTRUM.
1). Developmental origin  Mucocele, Retention cyst, Pseudocyst
i. Odontogenic and Postoperative maxillary cyst
ii. Non-odontogenic III. CYSTS OF THE SOFT
2). Inflammatory origin TISSUES OF MOUTH, FACE
2. None epithelial lined AND NECK.
 Solitary bone cyst and
Aneurysmal bone cyst

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I. CYSTS OF THE JAWS
1. Epithelial lined cysts
1) Developmental cysts 2) Inflammatory cysts
A. Odontogenic Cysts  Radicular cyst
 Dentigerous cyst, OKC, COC, GOC,  Residual cyst
Gingival cyst of infants, Gingival cyst of
adults, Eruption cyst, Lateral periodontal  Paradental cyst
cyst or Botryoid odontogenic cys
B. Non-odontogenic
 Nasolabial cyst, Nasopalatine duct cyst,
Median palatal cyst, Median mandibular
cyst and Globulomaxillary cyst.
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1. Epithelial lined cysts
1) Developmental cysts
A. Odontogenic Cysts
1. Dentigerous Cyst
 Is the 2nd most common odontogenic cyst in the oral and maxillofacial region.
 Derived from reduced enamel epithelium
 Clinical Features
 Painless facial swelling with “eggshell-crackling” or “frog-belly” phenomenon.
 Frequently it occurs in association with an unerupted tooth( mand 3rd molars
>>> max.3rd molars >>max. canines > mand. 2nd premolars).
 Peak age is 10-30 years of age, M>F & whites > blacks.
Aspirate: Unless 2ly infected, it contains straw-colored to brown fluid.
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Cont…
 Radiographic features
 Welldefined unilocular radiolucency
often with a sclerotic border &
unerupted teeth.
 Depending on the location and
relationship of the cyst to the crown of
the associated tooth on the radiograph,
can be classified as:
a. Central
b. Lateral
c. Circumferential.
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Cont…
Histopathologic features
 Cyst is lined by stratified, non-keratinized
squamous epithelium(2-3 cell layers thick).
 If inflammed, cyst wall is thick showing
hyperplastic rete ridges and the fibrous cyst
wall with inflammatory infiltrates.
 The epithelial lining may give rise to:
Intraosseous mucoepidermoid carcinoma,
Atrophic stratified squamous
Carcinoma ex-dentigerous cyst epithelium without significant
Unicystic ameloblastoma. associated inflammation.
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Cont…
Treatment and Prognosis
 Small size: enucleation with curettage and removal of the associated tooth
 Large size: treated with marsupialization followed by enucleation and
curettage.
 The prognosis for most histopathologically diagnosed dentigerous cysts is
excellent, with recurrence being a rare finding.

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2. Odontogenic Keratocyst(OKC)
 The term ‘odontogenic keratocyst’ was introduced by Philipsen (1956).
 It is a distinctive form of developmental odontogenic cyst that deserves
special consideration(specific histopathologic features and aggressive
clinical behavior).
 Two variants of the OKC are: well known; the
1. Sporadic cyst
2. Syndromic cyst associated with the nevoid basal cell carcinoma syndrome.
 Both variants are believed to be derived from remnants of the dental
lamina(cell rest of Serres)

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Cont…
 Clinical Features
 Peak age 2nd and 3rd decades.
 Slight male predilection is usually seen.
 60% to 80% in the mandible and few in the maxilla.
 Pain, swelling, discharge and occasionally paresthesia of the lower lip.
 More aggressive with higher rate of recurrence than others.
Aspiration of a significant amount of the creamy contents

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Cont…
Radiographic features
 Appear unilocular or
multilocular
radiolucencies.
 Corticated scalloped
margins with moderate
expansion of the jaw
are highly suggestive.

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 Cont…
 Histologically
 There are 2 subtypes:
1. Parakeratotic(80-90%):
Lined by parakeratinized stratified squamous epithelium (6 to 10 cell layers thick).
Epithelium lacks rete pegs b/n epithelium and CT
Have a corrugated intraluminal surface
2. Orthokeratotic(10-20%):
Epithelium is composed of orthokeratinized stratified squamous epithelium 2 to
3 cell layers thick with abundant keratohyaline granules in superficial cells and
pronounced orthokeratin in the lumen
No intraluminal corrugation.
Lower potential for recurrence
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Cont…
 Treatment
 Debate still exists as to the most effective treatment for this lesion.
 Ghali and Connor, in 2003, reviewed the surgical management of the OKC:
1. Enucleation and curettage( most conservative with highest recurrence)
2. Enucleation with cryotherapy or chemical adjunct therapy,
3. Enucleation with peripheral ostectomy,
4. Decompression and marsupialization.
5. Complete resection( en bloc removal along with the surrounding
margin of 1 cm) and zero recurrence.
 The reported recurrence of the OKC 2.5% to 62.5% in various studies.
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3. Calcifying Odontogenic Cyst(COC) or
Gorlin’s cyst
 Is an uncommon lesion that demonstrates considerable histopathologic
diversity and variable clinical behavior.
Clinical Feature
1. Central cystic lesion: may be unilocular, multilocular, or associated with
an odontoma
2. Peripheral cystic lesion: occurs on the gingiva or alveolar mucosa
3. Peripheral or central solid growth or neoplasm.

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Cont…
 COC may be associated with other odontogenic tumors, most commonly
the odontoma, AOT and ameloblastomas.
 Occurs by equal frequency in the maxilla and mandible.
 Most commonly on incisor and canine areas.
 Diagnosed in the 2nd and 3rd decade of life
 Occurs in younger if associated with an odontoma.
 The extraosseous COC usually presents as a localized sessile or
pedunculated mass on the gingiva.

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  Mixed
Cont… radiolucent
Imaging Features and
radiopaque
 Unilocular well-defined lesion lesion on the
with radiopaque(irregular or occlusal
toothlike densities) structures radiograph.
within the lesions.
 But some are multilocular.
 Displacement of teeth is often
seen.
 Resorption of the roots of
adjacent teeth is a frequent
finding.  well-demarcated margins extending from the
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right to the left premolar regions of the 24
mandible with numerous calcifications
Cont…
Pathologic Features
 Well-defined cystic lesion with relatively
thick connective tissue wall and epithelial
lining of variable thickness and morphology.
 The basal cell layer is tall columnar or
cuboidal with the nuclei palisading away
from the basement membrane.
 Superficial to the basal cell layer is a
multilayered epithelium resembling stellate
reticulum. The cyst lining characteristically shows columnar
basal cells, microcalcification, and, above all, the
 The hallmark of the lesion is the presence of
“ghost” cells.
“ghost cells”

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Cont…
 DDX
 Odontomas, ameloblastomas, craniopharyngiomas, and pilomatricomas

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Cont…
 Treatment
 The standard treatment for the COC is enucleation and curettage
 Few recurrences have been reported.
 For associated with another odontogenic tumor(like ameloblastoma), the
treatment is the same as for the associated tumor.
 The peripheral lesions are cured by excision.
 The rare neoplastic variant of the COC should be treated with resection

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4. Glandular Odontogenic Cyst(GOC)
(sialo-odontogenic cyst)
 Is a rare and recently described cyst of the jaws that is capable of
aggressive behavior and recurrence.
 Although it is generally accepted as being of odontogenic origin, it shows
glandular or salivary features that seem to point to the pluripotentiality of
odontogenic epithelium.
 Occur most commonly in middle-aged adults( 5th decade of life).
 80% occur in the mandible (commonly on the anterior region with many
lesions crossing the midline).

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GOC Cont…  There is a large
unilocular radiolucent
area with a smooth
 Radiographic Features corticated margin.
 May appear either unilocular or These features are
multilocular radiolucency. non-specific.

 Radiograph of an extensive multilocular

glandular odontogenic cyst.

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GOC Cont…
Histologic Features
 They are lined by nonkeratinized epithelium consisting
of cuboidal cells, often with cilia at the luminal surface.
 The cyst has features that suggest a mucus-producing
lesion.
 There is a histologic similarity with cystic intraosseous  Higher-power
mucoepidermoid carcinoma and botryoid cyst. magnification shows
 But the epithelial lining is typically thinner and does not significant mucus
show evidence of the more solid or microcystic epithelial production within the
proliferations seen in mucoepidermoid carcinoma.
lesion, along with
scattered giant cells.
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GOC Cont…
 Treatment
 For unilocular: enucleation and curettage followed by periodic followup.
 For multilocular: enucleation with peripheral ostectomy in conjunction.
 If the lesion lies close to the sinus, pterygoid or nasal cavity:
marsupialisation with second-phase enucleation and curettage.

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5. Gingival cyst of infants
 Occurs in infants of a few hours to a few months old.
 Appear as multiple, firm, white gingival nodules on the edentulous ridges.
 They arise from proliferation of the dental lamina.
 They usually involute, and no treatment is required except parent
reassurance.

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 6. Gingival Cyst of Adults
 Is derived from the rests of Serres
 Clinical presentation
 Slowly growing, painless swelling, round
to oval, well circumscribed swelling,
usually <1cm in the attached gingiva or
the interdental papilla.
 Peak age is in the 6th decade and F>M
 Mandible >Maxilla ( in the premolar–
canine region of the mandible).
Clinical image of a gingival cyst
of an adult.
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Cont…
Radiological features
 There may be no radiographic change
or only a faint round shadow indicative
of superficial bone erosion.
Treatment
 Local surgical excision and no tendency
for recurrence.

 Radiograph of a gingival cyst in an adult.

 There is a faint radiographic shadow (marked with
arrows) indicative of superficial bone erosion.
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7. Eruption cyst
 An eruption cyst is in essence a dentigerous
cyst occurring in the soft tissues.
 Dentigerous cyst develops around the crown of
an unerupted tooth with in the bone, where as
the eruption cyst occurs when a tooth is
impeded in its eruption within the soft tissues.
 Found in children and occasionally in adults.
 Both 1ry and 2ry teeth may be involved in
anterior to the 1st permanent molar.

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Cont…
Radiological features
 The cyst may throw a soft-tissue shadow, but there is usually no bone
involvement except that the dilated and open crypt may be seen on the
radiograph.
Treatment
 Are most frequently treated by marsupialisation.
 The dome of the cyst is excised, exposing the crown of the tooth which is
allowed to erupt.

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8. Lateral Periodontal Cyst: Botryoid Odontogenic
Cyst (BOC)
 Is a rare lesion that is derived from remnants of the dental lamina.
 Clinical Features
 It occurs generally in the mandible b/n premolar and canine teeth.
 The botryoid odontogenic cyst is a variant of the lateral periodontal
cyst.
 The BOC differs from the LPC in being radiographically and
microscopically multilocular with numerous lobulations and thickened
epithelial tufts resembling a grape cluster or botryoid.

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Cont…
Radiological features
 Round or oval wellcircumscribed
radiolucent area, usually with a
sclerotic margin.
 The cysts lay somewhere between
the apex and the cervical margin of
the tooth.
 No resorption of the adjacent  Radiograph of a lateral periodontal cyst
tooth root. lying between the mandibular premolar
 Most of them are < 1 cm in teeth.
diameter except the botryoid  The margins are well corticated, indicative
variety. of slow enlargement.
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Cont…
Histologically
 Lined with a thin band of stratified squamous non-keratinized
epithelium.
 Treatment
 Surgical enucleation.
 It has a higher recurrence rate, probably because of the difficulty of its
excision.

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2. Epithelial lined Cysts
1) Developmental cysts
B. Nonodontogenic Cysts
1. Nasolabial Cyst
 The term was coined by Rao.
 Two theories have been proposed for the pathogenesis of nasolabial cyst.
 1st theory: lesions are inclusion cysts arising from the epithelium retained
in the mesenchyme after the fusion of the MNP and LNP.
 2nd theory: cysts arise from proliferation of epithelial remnants from the
nasolacrimal duct that extend between the lateral nasal process and the
maxillary process.
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Cont…
Clinical Features
 Is smooth, fluctuant soft tissue mass nasolabial cyst with chxc facial deformity
blunting of the nasolabial fold, elevation of
between the upper lip and nasal aperture the ala nasi, and protrusion of the upper
with obliteration of the nasolabial fold and lip.
elevation of the nasal ala, nasal obstruction
and deformity.
 May grow toward the nasolabial fold,
vestibule of the mouth, or the vestibule of
the nose and rare bilateral presentation.
 Peak frequency in the 4th and 5th decades
with Women > men
04/23/2023 41
 Rare case of bilateral nasolabial cysts.
Cont…
Radiographic Features
 The nasolabial cyst is a soft
tissue mass that is completely
extraosseous.
 May show bony rarefaction
and deformity of the lateral Occlusal radiograph showing posterior
and anterior edges of the convexity of the left half of the
radiopaque line that forms the bony
nasal floor. border of the nasal aperture.
 There is rarely erosion of the
The extraosseous position of the
maxilla. cyst is demonstrated by aspiration
of its fluid contents and injection
of a radiopaque fluid.
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Cont…
Histopathologic Features
 Usually contains mucoid and serous
fluid, and if infected the contents are
suppurative and hemorrhagic.
 The epithelial lining is
pseudostratified epithelium,
stratified squamous, and/or cuboidal  Cyst is lined by a pseudostratified
epithelium with goblet cells. columnar epithelium containing
 Has a thick connective tissue many goblet cells.
capsule.  Mucous glands are present in the
wall.
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Cont…
Treatment
 Total excision of the cyst is curative.
 The surgical removal is accomplished by a
sublabial incision in the buccal sulcus.
 If the nasal mucosa is breached, repair is
not necessary.
 Reepithelialization occurs with gentle
packing of the vestibule

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2. Nasopalatine Duct Cyst

Clinical Features
 Rare lesion but the most common non-odontogenic cyst of the maxilla.
 Occur in the 4th and 6th decades of life, with slight male predilection.
 It is originated from epithelial remnants of the nasopalatine duct.
 Stimuli is claimed to result from trauma, infection, or mucus retention.
 Mostly small and asymptomatic with labial(usually)or palatal expansion.
 Diversion of the maxillary incisors is commonly present.

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Cont…
Radiographic Features
 well-corticated lesion either round
or heart shaped.
 The radiolucency of the cyst is
superimposed on the shadow of
the periodontal membrane of the
maxillary teeth.
 Associated teeth are vital.
 Small cysts should be differentiated
from the normal radiographic
diameter of the incisive canal (6
mm).
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Cont…
Histopathologic Features
 Lined by squamous,
pseudostratified ciliated, or a
mixture of the two, majority
being squamous epithelium.
 Frequently, mucus-secreting
glands are seen.
 Varying degrees of  Nasopalatine duct cyst lined by pseudostratified ciliated
inflammatory cell infiltrate are epithelium and inflammatory cell infiltrate of the wall.
 The wall focally contained mucous glands.
present on the cyst wall

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Cont…
Treatment
 Complete enucleation of the cyst is curative; recurrences are rare.
 The design of the surgical approach varies according to the location,
labially or palatally, and the size of the lesion.
 In large cysts that are markedly expanded palatally, a wide palatal
approach may be required.

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3. Median Palatal Cyst

 Classically the lesion was described as a fissural cyst from entrapped

epithelium between the fused lateral shelves of the maxilla.
Clinical features:
 Symptomatic or asymptomatic, firm or fluctuant swelling of the palatal midline.
 Is rare and usually present in young adults
Radiographically: well-circumscribed radiolucency on an occlusal film.
Histologically: cyst may be lined by squamous or respiratory epithelium.
 Treatment: Complete excision is curative.

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4. Median Mandibular Cyst

 It is found in the midline of the mandible and is very rare.

 Neville and colleagues briefly discussed the questionable existence of this
lesion and concluded that the lesion is probably odontogenic in origin.

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5. Globulomaxillary Cyst
Clinical Features
 It is normally found in the 2nd or 3rd decade.
 Associated teeth are vital.
 Because of lack of evidence to support the theory of embryogenic epithelial
entrapment in the site, most authors dispute its presence.
Radiographically,
 A pear-shaped well-defined radiolucency in the maxilla b/n lateral incisor and
the canine.
Histologically: lined by cystic epithelium(globular or ciliated epithelia).
It is believed that most lesions previously diagnosed as globulomaxillary cysts
can now be reclassified as OKC, RC, LPC, COC, CGCG, periapical granulomas and
odontogenic myxomas.
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1. Epithelial lined cysts
2) Inflammatory cysts
 The process of odontogenesis is a unique histogenic and morphogenic
phenomenon in human embryogenesis.
 After complete formation of the two sets of dentition, deciduous and
permanent, the embryogenic soft tissue remnants are widely accepted as the
origin of both odontogenic cysts and tumors.
 The epithelial rests of Malassez of periodontal ligament and Serres of gingiva, are
widely implicated in the pathogenesis of odontogenic cysts.
 The rests of Malassez are remnants of epithelium from the involution of the
enamel organ and rests of Serres are remnants of the dental lamina.
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1. Radicular Cyst(referred as a periapical
cyst)
 Is the most common lesion encountered 2o to infection or trauma.
Clinical Features
 Is usually small, measuring 1 or 2 cm in diameter.
 In rare cases, the cyst can attain several centimeters in diameter.
 The cyst contents are brown serosanguineous fluid with glistening
cholesterol crystals commonly present.
 If the cyst has communicated with the oral cavity, the fluid may be
suppurative.

04/23/2023 53
Cont…
Imaging Features
 In large cysts either plain
films(Mostly) or CT (rarely)may
be used.
 The lesion is a well-delineated
and corticated radiolucency that
is confluent with the periodontal
ligament of the associated non- Periapical radiograph of maxillary anterior teeth showing a well
vital tooth. delineated bony rarefaction at the apices of non-vital maxillary
anterior teeth.
B, An occlusal film of a radicular cyst of a traumatized maxillary
central incisor.
Differential diagnosis from incisive canal duct cyst is necessary.
04/23/2023 54
Cont…
 Histopathologic Features
 Is lined by non-keratinized stratified squamous epithelium with varying
thickness.
 In actively inflamed cysts, the epithelium is thicker.
 Frequently, the epithelial lining is focally ulcerated.
 Histiocytes and foreign body giant cells are frequently present.

04/23/2023 55
Cont…
Treatment
 If the tooth in question is salvageable, RCT with apicoectomy is
recommended.
 The progress of healing should be monitored.
 If the tooth is extracted, the lesion should be thoroughly enucleated.
 In small lesions, enucleation can be undertaken through the socket.

04/23/2023 56
2. Residual Cyst

Clinical Features
 Residual cyst is a retained radicular cyst
or periapical tissues that are left behind
after removal of an associated tooth.
 History of extraction is important to
differentiate the lesion from primordial
OKC, which arise from epithelial elements
of the enamel organ before any
calcification.

04/23/2023 57
Cont…
Imaging Features
 The cyst is usually small (1 to 3 cm in diameter) but may assume a large
size if not treated.
 The lesion is well delineated and may even be a corticated radiolucency.

04/23/2023 58
Cont…
Histopathologic Features
 The gross and microscopic features are
similar to those of the radicular cyst.
 Presence of cholesterol clefts is common.
 Examination of the specimen is necessary
not only to confirm the clinical diagnosis,
but also to ensure that the lesion is not an
aggressive OKC or other odontogenic
tumor.

 The cyst walls show significant inflammatory cell infiltrate.

04/23/2023
 Focal presence of cholesterol clefts. 59
Cont…
 Treatment
 Because ossification of the extraction socket has probably occurred, an
independent incision is required.
 Enucleation of the cyst is curative.
 Routine follow-up radiographs reveal the healing progress.

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3. Paradental Cyst: Buccal Bifurcation
Cyst
 A cyst near the cervical margin of the lateral aspect of a vital tooth (most
commonly mandibular 3rd molars) with associated pericoronitis.
 The WHO classifies a paradental cyst as an inflammatory collateral or
mandibular infected buccal cyst.
 Other authors consider the paradental cyst as a variant of the dentigerous
cyst.
Clinical Features
 Slight to moderate tenderness.
 Inflammation is prominent.

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Cont…
Histopathologic Features
 Is nonspecific with a cyst lining of non-keratinizing stratified squamous
epithelium.
 Treatment
 Extraction of associated 3rd molars and enucleation of the associated
cyst are curative.
 In the buccal bifurcation lesion, enucleation without extraction of the
associated tooth.
 Some can resolve without surgery

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04/23/2023 63
 I. CYSTS OF JAWS
1. None epithelial lined Cysts of jaws
1. Solitary bone cyst
 Solitary bone cysts are fluid-filled or empty intra-osseous lesions found
most commonly in the proximal metaphyseal region of the long bones in
children and adolescents.
 Uncertainty about the nature of these lesions is reflected by the number
of synonyms found in the literature.
 Commonly used terms include simple bone cyst, traumatic bone cyst,
haemorrhagic bone cyst and unicameral bone cyst.

04/23/2023 64
Cont…
 Clinical features
 Patients present with mandibular swelling, most frequently buccal and
labial, occasionally lingual.
 occurs in young individuals with peak age being the 2nd decade.
 Male : female ratio of 1.6 :1.
 Mandible(body and symphyseal areas) > Maxilla(anterior region).
 Some of the patients have a history of significant trauma to the area.

04/23/2023 65
Cont…
Radiological features
 Appears as a radiolucent area with
an irregular but definite edge and
slight cortication.
 Interradicular scalloping is a
prominent feature.
 Some lesions can produce a sharp
cone effect. Radiograph of a solitary bone cyst in the right
body of the mandible having a well-defined
margin with cortication and interradicular
scalloping.
04/23/2023 66
Cont…
Histological features
 It consists of a loose vascular fibrous tissue
membrane of variable thickness with no
epithelial lining.
 There is aemorrhage and haemosiderin with
scattered small multinucleate cells.
 Reports describe an association b/n solitary  The lining is composed of
bone cysts and fibro-osseous lesions. loose vascular fibrous
tissue with osteoclastic
activity on the surface of
the adjacent bone
04/23/2023 67
Cont…
Treatment
 Solitary bone cysts are usually treated as part of the diagnostic process.
 To determine the nature of the lesion, the cyst lumen is opened to
reveal an empty cavity.
 The cyst wall is then curetted but caution is needed so as not to damage
the tooth roots or inferior alveolar nerve.

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2. Aneurysmal Bone Cyst(ABC)

 The term ‘aneurysmal bone cyst’ was suggested by Jaffe and Lichtenstein
(1942) to describe the characteristic ‘blown-out’ contour of the bone seen
in radiographs of the lesion.
 The lesion is characteristically cystic and blood filled.
 Some consider it as a vascular variant of a CGCG.

04/23/2023 69
Cont…
Clinical features
 Aneurysmal bone cysts of the jaws are rare.
 Peak occurrence is in the 2nd decade
 Slightly more common in females
 Mandible(molar regions) is the most common site.
 Patients are presented with the painful and firm swellings

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Cont…
Radiological features
 It has a‘ballooning’ growth pattern
resulting in a radiolucent area with a
typical ‘blown-out’ cortical expansion.
The “soap bubble” appearance of ABC on
 Longer-standing lesions may show a right maxilla.
‘soap-bubble’ appearance and may
become progressively calcified.

 Ballooning expansion of the cortex on angle

04/23/2023 and ascending ramus of the mandible 71
Cont…
Histological features
 Consist of many capillaries and blood-
filled spaces of varying size lined by
flat spindle cells and separated by
delicate loose-textured fibrous tissue.
 Some lesions contain small
multinucleate cells and scattered
trabeculae of osteoid and woven
 Dilated blood vessels and
bone.
microcysts in part of an
aneurysmal bone cyst.

04/23/2023 72
Cont…
Treatment
 It responds well to aggressive curettage, although hemorrhage can be a
problem.
 Recurrences are rare.

04/23/2023 73
II. CYSTS ASSOCIATED WITH
MAXILLARY ANTRUM
1. Mucocele of the maxillary antrum
 A true antral mucocoele completely fills the sinus and is caused by
blockage of the ostium, w/c may be 20 to inflammatory changes associated
with chronic rhinosinusitis.
 Is a true cyst filled with mucus and lined by the mucoperiosteum.

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Cont…
 Clinical features
 Is a gradually enlarging swelling of the cheek and lateral nasal region
with:
Obliteration of the nasolabial fold and buccal sulcus,
Ballooning expansion, destruction and perforation of the surrounding
bone,
Displacement of adjacent structures,
Pain or tenderness of the cheek or teeth,
Nasal drainage, headache and occasionally proptosis.
 Peak age is in the 5th decade with no gender predilection.
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Cont…
 Radiological features
 Early stage: no defining radiological
features on plain radiographs.
 Late stage: well-defined radiolucency with
expansion and perforation of the bone
margins.
 On CT complete opacification of the
maxillary sinus with bony expansion.
 CT of a mucocoele of the left
maxillary antrum.
 There is complete opacification of the
antrum with medial bulging into the
nose.
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Cont…
Histological features
 Cyst is filled with mucus or mucoid material, and lined by essentially
normal antral mucosa, covered by ciliated respiratory type epithelium
or flattened simple cuboidal or squamous epithelium.
 There may be chronic inflammation in the wall and if there is an
associated allergic sinusitis then acute inflammatory cells and
eosinophils may also be present.

04/23/2023 77
2. Retention cyst and Pseudocyst of the
Maxillary antrum.
 Retention cysts and pseudocysts are considered together because they
have similar behaviour and may be indisindistinguishable on clinical
examination.
Clinical features
 Localised dull pain, fullness or numbness of the cheek, nasal
obstruction, postnasal drip and a copious discharge of yellow fluid from
the nostrils.
 Peak age of occurrence is in the 3rd decade.
 Slightly M>F, the antral floor is the most common site.

04/23/2023 78
Cont…
Radiological features
 Appear as spherical, ovoid or dome-shaped radiopacities with smooth
and uniform outline and narrow or broad base.
 CT will usually reveal normally aerated segments of residual antrum.
 Unlike mucocoeles, the lesions are not destructive and they rarely
expand or resorb the bony walls of the antrum.
 Pseudocysts, which are often associated with odontogenic infections,
are located on the floor of the sinus, but retention cysts may be located
elsewhere.

04/23/2023 79
Cont…

 Radiograph of a mucosal cyst of the

maxillary antrum.
 The lesion appears as a domeshaped
radiopacity rising from the floor of the
antrum.

04/23/2023 80
Cont…
Histopathological features
 Has a smooth blue surface and thin-wall containing mucinous material.
 Pseudocyst shows pools of mucoid material lined by inflamed fibrous
connective tissue which in places may be the raised periosteum.
 Retention cysts are usually small and are found within an inflamed
antral mucosa and lined by duct-like pesudostratified columnar
epithelium
 A mucus plug may be evident.

04/23/2023 81
Cont…
Treatment
 They are not destructive and usually remain static, many appear to regress
spontaneously, and surgical intervention is unnecessary.
 If there are specific or pertinent clinical features, surgical removal through
a Caldwell–Luc approach or endoscopic approach are indicated.

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3. Postoperative maxillary cyst
(Surgically ciliated maxillary cyst)
 Is fairly commonly encountered in Japan but rare lesion in other parts of
world.
 It is a delayed complication arising years after surgery of maxillary sinus.
Clinical features
 Present with pain, discomfort & swelling in the cheek, face, palate &
alveolus.
 Pus may be discharged.
 Peak age in the 4th and 5th decades
 Male : Female (2: 1)
 Mostly occur in molar and premolar regions.
04/23/2023 83
Cont…
Radiological features
 Radiographs reveal a well-defined
radiolucent area closely related to
the maxillary sinus.
 In the early lesions no destruction
of bone is evident.
 Gradually, the cyst expands beyond
the original boundaries of the
sinus. Postoperative maxillary cyst presented
as a well-defined radiolucency at the
right maxillary sinus.
04/23/2023 84
 Cont…
Histological features
 Are lined by pseudostratified ciliated
columnar epithelium, with squamous
metaplasia in chronically inflamed areas.
 The epithelium may be ulcerated in parts.
 Cellular or fibrotic underlying connective
tissue.
 Foam cells, cholesterin clefts, haemosiderin
and foci of calcification may be present.
 Histology of the postoperative
maxillary cyst with lining
composed of pseudostratified
04/23/2023
ciliated columnar epithelium.85
Cont…
Treatment
 In most cases enucleation is the treatment of choice, but marsupialisation
for unilocular cysts with a thin wall and extensive bony perforation.

04/23/2023 86
04/23/2023 87
III. CYSTS OF SOFT TISSUES OF MOUTH,
FACE AND NECK.
1. Dermoid and Epidermoid Cysts
Are developmental keratinizing squamous epithelium
lined cysts.
Clinical Features
Present as a soft, mobile midline suprahyoid-growing
mass in the neck of children and young adults
Dermoid cysts have dermal appendages
Do not move on protrusion of the tongue.
Dermoid cysts commonly occur in periorbital & lateral
eyebrow followed by floor of the mouth.
Epidermoid cysts are rare and mostly occur during  Dermoid cyst of the floor of the
infancy. mouth with submental swelling.
04/23/2023 88
 Cont…
Radiographic Features
 Dermoid cysts appear as a moderately thin-walled, unilocular mass.
 On CT scan the central cavity is usually filled with homogeneous,
hypoattenuated fluid material.

 Axial, and sagittal CT- scan images showing a well-circumscribed, hypodense lesion.
04/23/2023 89
Cont…
Histopathologic Features
 Both cysts are lined with stratified squamous
epithelium with keratin and/or a sebaceous
material–filled cavity.
 In dermoid cysts contain dermal appendages
in the connective tissue walls.
 Occasionally contain respiratory epithelium.

 Dermoid cyst lined with stratified squamous

epithelium.
 Dermal appendages are seen in the cyst wall.
B, Higher magnification.
04/23/2023 90
Cont…
 Treatment
 Complete surgical excision is the treatment of choice.
 Cysts occurring above the geniohyoid muscle can be removed through
an intraoral approach.
 Cysts below geniohyoid and mylohyoid muscle require an extraoral
approach.
 Rare recurrence on follow-up.
 Malignant transformation to SCC has rarely been reported.

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2. Thyroglossal Duct Cyst(TGDC)

 The thyroid primordium originates at the level of the foramen cecum,

which in adults lies at the junction of the anterior 2/3rd and posterior 1/3rd
of the tongue.
 The primitive thyroid descends through the mesoderm of the tongue--->
floor of the mouth---> anterior to the developing hyoid bone and laryngeal
cartilage---> reaches final position in the anterior part of the neck by the
7th week of gestation.

04/23/2023 92
 During migration, the thyroid gland is connected to the tongue by a
narrow tubular structure, the thyroglossal duct w/c involutes by the 8th to
10th gestational week.
 If any portion of the thyroglossal duct persists, cystic changes may occur
as a result of secretion from the epithelial lining.

Foramen cecum Foramen

cecum
Thyroglossal
duct

Hyoid bone

Esophagus
Thyroid gland
Tongue
Trachea
04/23/2023
Thyroid gland 93
 Cont…
Clinical Features
 Common in the first 2 decades of life( 50% of cases).
 Slight female predilection(F:M ratio of 3:2).
 Present as painless fluctuant mass in the midline or
paramedian area within 2 cm of the midline, most on
the left, for unkown reasons.
 The lesion moves upward on tongue protrusion w/c
indicates the origin of the duct at the foramen cecum.

 Thyroglossal duct cyst located

below the hyoid bone(80%) and
04/23/2023 above the hyoid bone(20%)94 .
Cont…
Radiographic Features
 A TGDC appears in CT scans as a
smooth, well-circumscribed mass
anywhere along the vertical
course of the vestigial thyroglossal
duct; the mass has a thin wall and
homogeneous attenuation.
 The rim of the cyst is unenhancing
unless inflammation is present.  Axial computed tomography scan
showing a TGDC present anterior to
the thyroid cartilage, at the midline
and extending slightly to the right
side.
04/23/2023 95
Cont…
Histopathologic Features
 A TGDC contains colorless, viscous
secretions.
 Cyst is lined with pseudostratified
columnar ciliated respiratory-type
epithelium, or squamous epithelium
mucous glands may be present.
 Thyroid tissue may be found in the cyst  Thyroglossal duct cyst
showing ciliated columnar
wall.
epithelial lining.
 Thyroid follicles are present in
the cyst wall.
04/23/2023 96
Cont…
 Treatment
 The recommended surgery is called the Sistrunk procedure w/c involves
en bloc excision of the entire TGD tract to the foramen cecum, as well as
the central 1-2 cm of the hyoid bone.
 With this procedure recurrence rate is < 4% to 6%.
 I & D is not recommended.
 Malignant changes are very rare, developing in less than 1% of patients.

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3. Branchial Cleft Cyst
 Four pharyngeal clefts are
recognized in the 5-week-old
embryo.
 The 1st cleft gives rise to the
external auditory meatus.
 The 2nd , 3rd , and 4th clefts fuse and
temporarily form an ectoderm-lined
sinus, the cervical sinus w/c
disappears entirely with A, Schematic representation of the development of the
development. pharyngeal clefts and pouches from pharyngeal arches.
The 2nd arch grows over the 3rd and 4th arches.
B, Remnants of the 2nd , 3rd , and 4th pharyngeal clefts form
the cervical sinus.
04/23/2023 98
Cont…
 Branchial cleft anomalies develop as a result of incomplete obliteration of
the cervical sinus or from epithelial rests of the branchial clefts.
 Abnormalities of the branchial clefts are usually cysts, sinuses, and fistulae.
 They occur primarily on the lateral side of the neck along the anterior
border of the SCM muscle and rarely bilateral and may be familial.
 Occasionally, it may be associated with other defects(patent ductus
arteriosus, hearing abnormalities, and malformed auricles).
 About 95% of branchial cleft anomalies arise from the 2nd cleft as a cysts.

04/23/2023 99
 Cont…
Clinical Features
 Painless fluctuant mass in the lateral portion of
the neck adjacent to the anteromedial border
of the SCM muscle, at the mandibular angle.
 In a young patient, a hx of recurrent
inflammation in the region of the mandibular
angle is highly suggestive of a branchial cleft  Branchial cleft cyst
cyst. presenting as a mass in the
submandibular area,
adjacent to the anterior and
medial borders of the
sternocleidomastoid muscle.
04/23/2023 100
Cont…
Radiographic Features
 CT scan shows typically well-circumscribed,
homogeneous, hypoattenuated masses
surrounded by a uniformly thin wall.
 Mural thickness may increase after
infection.
 Located at anterior medial border of the
SCM muscle lateral to the carotid space and Axial CT scan showing a large
at the posterior margin of the branchial cleft cyst that
submandibular gland. appears as a well-defined
ovoid fluid-filled lesion in the
left neck.
04/23/2023 101
 Cont…
Histopathologic Features
 Usually filled with turbid yellowish fluid
that may contain cholesterol crystals.
 Walls are usually thin and lined with
stratified squamous epithelium.
 With repeated infection the wall
become fibrotic and the epithelium may
be replaced by granulation tissue or
fibrous tissue.  Branchial cleft cyst showing thin
stratified squamous epithelium
lining.

04/23/2023 102
Cont…
Treatment
 Complete surgical excision is indicated because of the frequency of 20
infections.
 During inflammation, surgery may be delayed until it is resolved.
 Higher recurrence rates were found in cases with a history of infection.
 Malignant change in branchial cleft cysts (branchial cleft carcinoma) is
extremely rare.

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4. CYSTIC HYGROMA

 Is a developmental abnormality in which there is progressive dilatation of

the lymphatic channels.
 The lesion is more correctly designated as a cavernous type of
lymphangioma but cystic hygroma is a commonly used clinical term.
Clinical Features
 Involves the face and neck and are diagnosed before the age of 2 yrs.
 Present as a painless and usually compressible swelling, usually
unilateral.
 The overlying skin may be blue and the swelling transilluminates.

04/23/2023 104
Cont…
Histologically,
 Consists of dilated cystic spaces lined by endothelial cells.
Treatment
 Treatment choice is complete surgical removal of the mass.
 The use of intralesional injections may be a promising alternative to
surgery.

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5. NASOPHARYNGEAL CYSTS

 Nasopharyngeal cysts are rare clinical entities including the following:

 Retention cysts
 Are the most frequent and are usually attributed to coalescence of the
median recess of the pharyngeal tonsil.
 Lined by ciliated or non-ciliated columnar epithelium.
 Lymphoid follicles are present in the wall.
 The cyst cavity is packed with epithelial debris.

04/23/2023 106
Cont…
Congenital midline cysts
 May arise either from the pharyngeal bursa (Tornwaldt’s bursa) or from
Rathke’s pouch.
 Clinically and histologically similar to those of the retention cysts.
 They are lined by stratified squamous epithelium(ectodermal origin).
Lateral nasopharyngeal cysts are usually of branchial cleft origin.

04/23/2023 107
6. THYMIC CYSTS

 Are rare clinical entities which arise in persistent thymic tissue which may
occur in any location between the angle of the mandible and the midline
of the upper neck to the sternal notch.
 Are most often encountered on the left side of the neck & M:F is 2:1
 70% occur in 1st decade and the remainder are before the age of 30 years.
Histologically, the cyst is lined by squamous and cuboidal epithelium with
thymic tissue in the cystic wall.

04/23/2023 108
7. Parasitic Cysts
 Parasitic cysts occur in the mouth although they are rare.
 Most of the reported cases in the mouth have been caused by the class
Cestoidea (flatworms and tapeworms), which include the genera
Echinococcus and Taenia.
 Examples include:
1. Hydatid cyst
2. Cysticercus cellulosae
3. Trichinosis

04/23/2023 109
Cont…
1. HYDATID CYST
 Hydatid cysts occur in hydatid disease or echinococcosis.
 Caused by the larvae of E. granulosus (dog tapeworm).
 The mostly affects the salivary glands and the pterygopalatine or
infratemporal fossa areas.
 Treatment choice is enucleation.

04/23/2023 110
Cont…
2. CYSTICERCUS CELLULOSAE
 Humans develop cysticercosis from pork
tapeworm Taenia solium.
 The most common sites are tongue, buccal
mucosa and lips.
 In the lab. Exam shows intact cystic masses
which, when cut, contained clear watery fluid
and a coiled white structure apparently
attached to the inner aspect of the cyst.  Gross specimen of Cysticercus
cellulosae removed from tongue.
 Treatment: Enucleation
04/23/2023 111
Cont…
3. TRICHINOSIS
 Trichinosis is caused by T. spiralis, a roundworm parasite of rats and pigs.
 Microscopic examination showed an encysted form of T. spiralis.

04/23/2023 112
 Summary
 The type and the biologic nature of the epithelium have a significant
impact on the lesion prognosis and recurrence rate.
 The major classifications have been based on the origin of the epithelium.
 The initial surgical treatment and the subsequent follow-up of cysts of the
oral and maxillofacial region depend on several factors:
1. The patient’s age and overall health condition
2. Size and location of the cyst
3. Histologic diagnosis of the lesion gained by excisional, incisional, or FNA biopsies
 After surgical removal of the cysts, it is critical to submit any tissue for
microscopic examination regardless of the size.
04/23/2023 113
 . References

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 THANK YOU!!!

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