A cyst is a pathological cavity, with fluid or

semi-fluid contents, not formed by the

accumulation of pus.
Several mechanisms are described for cyst
growth, including:
epithelial proliferation
internal hydraulic pressure
bone resorption
Cysts can be classified on the basis of
location
jaw
maxillary antrum
soft tissues of face and neck
cell type
epithelial
non-epithelial
pathogenesis
developmental
inflammatory
Other cysts
Cysts associated with the maxillary antrum
Benign mucosal cyst of the maxillary antrum
Postoperative maxillary cyst (surgical ciliated
cyst of the maxilla).
Cysts of the soft tissues of the mouth, face and
neck
Dermoid and epidermoid cysts
Lymphoepithelial (branchial cleft) cyst
Thyroglossal duct cyst
Cysts of the salivary glands: mucous
extravasation cyst, mucous retention cyst,
ranula.
Classification of cysts of the orofacial region based on the
WHO classification.
Epithelial cysts
Developmental odontogenic cysts
Odontogenic keratocyst

Dentigerous cyst (follicular cyst)

Eruption cyst

Lateral periodontal cyst

Gingival cyst of adults

Glandular odontogenic cyst (sialo-odontogenic)

Inflammatory odontogenic cysts
Radicular cyst (apical and lateral)
Residual cyst
Paradental cyst

Non-odontogenic cysts
Nasopalatine cyst
Nasolabial cyst

Non-epithelial cysts (not true cysts)

Solitary bone cyst
Aneurysmal bone cyst
Odontogenic cysts are lined with epithelium
derived from the following tooth development
structures:
rests of Malassez: radicular cyst, residual cyst
reduced enamel epithelium: dentigerous cyst,
eruption cyst
remnants of the dental lamina: odontogenic
keratocyst, lateral periodontal cyst, gingival
cyst of
adult, glandular odontogenic cyst
Unclassified: paradental cyst.
Cysts may be detected because of clinical
symptoms or signs. Occasionally an
asymptomatic cyst may be discovered on a
radiograph taken for another purpose.
Symptoms may include:
swelling
displacement or loosening of teeth
pain (if infected).
 The most important clinical sign is
expansion of bone. In some instances, this
may result in an eggshell-like layer of
periosteal new bone overlying the cyst. This
can break on palpation, giving rise to the
clinical sign of 'eggshell cracking'. If the
cyst lies within soft tissue or has perforated
the overlying bone, then the sign of
fluctuance may be elicited.
If a cyst becomes infected, the clinical
presentation may be that of an abscess, the
underlying cystic lesion only becoming
apparent on radiographic examination.
As a basic principle, radiological examination
should commence with intra-oral films of the
affected region; for small cystic lesions, intra-
oral films may be all that is needed for
diagnosis, while for all cysts the fine detail of
intra-oral radiography will help to clarify the
relationship between lesion and teeth. For
larger lesions, more extensive radiography is
appropriate.
Maxilla. Suitable views are:
periapicals and oblique occlusals
panoramic radiograph or lateral oblique
occipitomental (OM)
true lateral (anterior maxilla)
Mandible. Suitable views are:
periapicals and true occlusals
panoramic radiograph or lateral oblique
postero-anterior (PA) of mandible.
Computed tomography (CT) may be useful in
planning surgery of large cysts, particularly
in the posterior maxilla.
 Classically, cysts appear as well-defined round or
ovoid radiolucencies, surrounded by a well-defined
margin.
Margins. Peripheral cortication (radio-opaque margin)
is usual except in solitary bone cysts. 'Scalloped
margins are seen in larger lesions, particularly
keratocysts.
Infection of a cyst tends to cause loss of the
welldefined margin.
Shape. Most cysts grow by hydrostatic mechanisms,
resulting in the round shape. Odontogenic keratocysts
and solitary bone cysts do not grow in this manner and
have a tendency to grow through the medullary bone
rather than to expand the jaw.
 Effects upon adjacent structures. Where a
lesion abuts another structure, such as a
tooth or the inferior dental canal, it may
cause displacement. Roots of teeth may be
resorbed. When a cyst reaches a certain size,
the cortex of the bone often becomes thinned
and expanded. In posterior maxillary lesions
the antral floor may be raised. Perforation of
the cortical plates may be recognised as a
localised area of greater radiolucency
overlying the lesion.
 Effect on unerupted teeth. Unerupted teeth
may become enveloped by any cyst, a
feature which may lead to erroneous
diagnosis as a dentigerous cyst.
Locularity. True locularity (multiple cavities) is
seen occasionally in odontogenic keratocysts.
However, larger cysts of most types may
have a multilocular appearance because of
ridges in the bony wall.
Radiology
A well-defined, round or ovoid radiolucency
is associated with the root apex or, less
commonly in the lateral position, of a
heavily restored or grossly carious tooth. A
corticated margin is continuous with the
lamina dura of the root of the affected
tooth. The appearances are similar to those
of an apical granuloma, but lesions with a
diameter exceeding 10 mm are more likely
to be cystic.
Pathology
The cyst lumen is lined by a layer of simple
squamous epithelium, which may display areas
of discontinuity where it is replaced by
granulation tissue. Arcades and strands of
epithelium may extend into the cyst capsule,
which is composed of granulation tissue
infiltrated by a mixture of acute and chronic
inflammatory cells. Several features associated
with inflammatory odontogenic cysts may be
present in the cyst lumen, lining and capsule:
cholesterol clefts, foamy macrophages,
haemosiderin and Rushton's bodies.
Radiology
The residual cyst has a well-defined,
round/ovoid radiolucency in an edentulous
area. Occasionally flecks of calcification may
be seen.
Pathology
The lining and capsule are similar to the
radicular cyst; however, both appear more
mature, with the former lacking the arcades
and strands of epithelium extending into the
capsule.
 This cyst may be multiple! It is recognized
as being more aggressive than other
odontogenic cysts and has a higher rate of
recurrence. It has higher association with
nevoid basal cell carcinoma, which requires
examination of a patient with multiple cysts
of the jaws.
Radiology
There is a well-defined radiolucency in

odontogenic keratocysts, often with densely

corticated margins. The shape margins may
be 'scalloped' in shape. Occasionally, there
is a multilocular appearance. Expansion
typically limited, with a propensity to grow
along the medullary cavity.
Pathology
The cyst is lined by a continuous layer of
stratified squamous epithelium of even
thickness (5-10 cells) the surface of which is
corrugated. The basal cell layer is well
defined. This epithelium is most commonly
parakeratinising, although orthokeratosis
may be observed. The lumen of the cyst is
filled with shed squames. The cyst capsule
is composed of rather delicate fibrous tissue
and is, classically, free from inflammation.
However, should the cyst become infected
then an inflammatory infiltrate may be seen
and the characteristic features of the
epithelial lining will be lost.
The presence of daughter cysts within the
capsule is a well-recognised finding.
Radiology
In dentigerous cysts, there is a pericoronal

radiolucency greater than 3-4 mm in width

that is suggestive of cystformation in a dental
follicle. The well-defined, corticated
radiolucency is associated with the crown of
an unerupted tooth. Classically the associated
crown of the tooth lies centrally within the
cyst, but lateral types occur
Although dentigerous cysts occur over a wide

age range, they are most commonly seen in

10- to 30-yearolds.
Pathology
The defining feature of a dentigerous cyst is
the site of attachment of the cyst to the
involved tooth. This must be at the level of
the amelocemental junction. The lining of the
cyst is composed of a thin layer of epithelium.
The cyst capsule is, classically, free from
inflammation. However, in common with the
odontogenic keratocyst, the normal features
of the epithelial lining may be distorted when
an inflammatory infiltrate is present.
Radiology
The extra-bony position of the eruption cyst
means that the only radiological sign is likely
to be a soft tissue mass.
Pathology
An eruption cyst is basically a dentigerous
cyst in soft tissue over an erupting tooth. The
histological features are similar to those of
the dentigerous cyst, though reduced enamel
epithelium is often seen.
 Gingival cysts are commonly found in neonates
but are rarely encountered after 3 months of
age. Many appear to undergo spontaneous
resolution. White keratinous nodules are seen
on the gingivae and these are referred to as
Bohn's nodules or Epstein's pearls.
Gingival cysts arise from the dental lamina and
histologically are keratin containing.
In neonates and infants, the cysts are typically
between 2 and 5 mm in diameter. They do not
involve bone and no treatment is required.
 Gingival cysts of adults are much less
common and are found mainly in the buccal
gingivae in the mandibular premolar-canine
region. The cyst typically presents as a
solitary soft blue swelling within the
attached gingivae, seldom larger than 5
mm in diameter. Gingival cysts of adults are
lined by a thin cuboidal or flattened
epithelium resembling dental follicle. They
do not extend into bone although they may
rest in a shallow depression in the cortex.
They are usually removed by excision
biopsy for diagnosis.
Radiology
The nasopalatine cyst appears as a well-
defined, round radiolucency in the midline of
the anterior maxilla. Sometimes it appears to
be 'heart-shaped' because of super-
imposition of the anterior nasal spine.
Radiological assessment should include
examination of the lamina dura of the central
incisors (to exclude a radicular cyst) and
assessment of size (the nasopalatine foramen
may reach a width of as much as 10 mm).
Pathology
The cyst is lined by a layer of
pseudostratified ciliated columnar
epithelium and/or stratified squamous
epithelium. The capsule of the cyst is
fibrous and may include the incisive canal
neurovascular bundle.
Radiology
As the nasolabial cyst is a soft tissue lesion,
radiography may reveal nothing. However,
radiography will be performed to exclude
other causes of the swelling. 'Bowing inwards
of the anterolateral margin of the nasal cavity
has been recorded as a feature. Ultrasound
examination would be an appropriate
investigation.
Pathology
The nasolabial cyst is lined by non-ciliated
columnar epithelium, which is often rich in
mucous cells.
Radiology
The solitary bone cyst appears as a well-
defined but non-corticated radiolucency.
Typically, it has little effect on adjacent
structures and 'arches' up between the roots
of teeth. The mandibular canal may not be
displaced, but the cortical margins of the
canal may be lost where it overlies the lesion.
Expansion is rare.
Pathology
The cyst is lined by fibrovascular tissue that
often includes haemosiderin and
multinucleate giant cells.
Radiology
The aneurysmal bone cyst may appear after
traumatic injury. It typically presents as a fairly
well-defined radiolucency. Sometimes it has a
multilocular appearance because of the
occurrence of internal bony septa and
opacification.
Pathology
The predominant feature of an aneurysmal bone
cyst is the presence of blood-filled spaces of
variable size lying in a stroma rich in fibroblasts,
multinucleate giant cells and haemosiderin.
Deposits of osteoid are also seen.
 Surgical management of cysts generally
implies enucleation, but occasionally
marsupialisation is the technique of choice.
Some small radicular cysts do not require
surgery and regress once the root canal of
the associated tooth has been effectively
cleaned and filled.
Antibiotic therapy may be required if a cyst
has become infected.
Aspiration of fluid from a pathological cavity
may be helpful in confirming the presence of
cyst rather than maxillary sinus (air) or
tumour (solid).
 Enucleation of a cyst is removal of the whole
cyst, including the epithelial and capsular
layers from the bony walls of the cavity. This
permits histopathological examination and
ensures that no pathological tissue remains.
A large mucoperiosteal flap, usually buccal, is
raised to ensure that closure will be over
adjacent sound tissues and not the bony cavity.
Primary closure is nearly always undertaken
unless the cyst is very infected.
Enucleation of a nasopalatine cyst will require
the raising of a palatal flap to provide surgical
access and cyst removal. This inevitably
damages the nasopalatine nerves and vessels
and results in a small area of paraesthesia,
which usually does not cause concern to the
patient.
 Marsupialisation is a simple operation in
which a window is cut and removed from
the cyst lining. This allows decompression of
the cyst, which then slowly heals by bone
deposition in the base of the cavity.
However, this technique permits
histopathological examination of only a
small and possibly non-representative
sample of tissue. Primary closure is not
undertaken but rather the cyst lining is
sutured to the oral mucosa to keep the
cavity open.
 Marsupialisation is advocated when the cyst
is so large that jaw fracture is the likely
outcome of enucleation, although enucleation
and simultaneous bone grafting may be
preferable. The technique may also be useful
if there are associated structures, such as the
inferior alveolar nerve, maxillary antrum or
nose, that are at risk of damage during
enucleation. Similarly, marsupialisation of an
eruption cyst will allow the eruption of a tooth
without it being damaged by enucleation.
 Radicular cysts of single-rooted teeth that do
not resolve following conventional endodontic
treatment, require enucleation and surgical
endodontic management to seal the root
canal of the associated tooth.
Bone is removed with a rosehead bur over
the tooth root apex, which is then divided
with a fissure bur and removed so that the
root face may be readily visualised from the
buccal aspect
 High recurrence rates are reported (up to
60%) because of technical difficulty in
removing all of the cyst lining, including
projections into cancellous bone. Enucleation
must be thorough.
Some advocate irrigating the cyst cavity with
chemical fixatives to cause necrosis of any
remaining remnants, and others suggest
excision to include a bone margin about the
cyst.
Annual radiographic review is recommended.
 Reassurance of the parents is usually the only
management required as these cysts
frequently fenestrate spontaneously and
require no surgical intervention.
Occasionally, however, they may require
marsupialisation to expose the tooth.
 These bone cysts are often incidental findings
on radiographs.
Aspiration may reveal clear fluid or air
indicating that no further intervention is
necessary.
 These cysts benefit from curretage. However,
they may be associated with a second
pathological lesion such as a vascular
malformation which may lead to profound
haemorrhage. Patients with this cyst need to
be managed in hospital.