Cysts of the Jaw

Table of contents
Article 🔍
A comprehensive topic overview

Introduction

A cyst is a pathological cavity lined by epithelium containing
Cysts are common in the jaw bones as these bones contain epithelium left after tooth development.
Cysts of the jaw can be classi
epithelium derived from the dental lamina) and non-odontogenic cysts (cysts lined by other types of epithelium).
Table 1. The classi
1
Odontogenic cysts Non-odontogenic cysts
Radicular cyst
Dentigerous cyst
Odontogenic keratocyst
Lateral periodontal cyst
Nasolabial cyst
Nasopalatine cyst
Solitary bone cyst
Aneurysmal cyst

Radicular cysts

Radicular cysts are the most common type of jaw cyst. They are always found in association with a non-vital tooth.
Radicular can be classi
Periapical\: found at the apex
Lateral\: found alongside the tooth root
Residual\: persists in the tooth extraction socket following tooth removal
Aetiology
Many non-vital teeth exist without associated radicular cysts, however, in
The cyst initially develops following the proliferation of Rests of Malassez. These are small epithelial remnants of Hertwig's
epithelial root sheath, an important feature in tooth root development. As these cells proliferate and grow a central cavity
is formed from the autolyses of central cells. This central cavity contains tissue
hydrostatic pressure leading to cyst enlargement.
Clinical features
Initially, when the radicular cyst is small it is unlikely to have any presenting features. There is likely to be a history of
toothache from the causative tooth though this may precede cyst development by many years.
As the cyst grows there may be a noticeable swelling in the buccal sulcus adjacent to the causative tooth. This swelling is
often described as having ‘eggshell’ like features meaning if it is pressed a cracking sensation may be felt. If the swelling is
particularly large tooth displacement and/or mobility may be noticed.
2
If the cyst becomes infected, it may become painful.Investigations
Radiographic features
A radicular cyst typically presents as a unilocular, rounded radiolucency with a well-de
around the apex of a tooth or along its side. If it is a large cyst bucco-lingual expansion may be noted. Root resorption is
2
rare.
Histology
Unless the cyst is small and the diagnosis is certain from clinical
histopathological analysis following their removal.
A radicular cyst wall contains
contains cholesterol clefts and hemosiderin (a breakdown product of blood cells). The central lumen is surrounded by a
non-keratinised epithelium of varying thickness.
1
Management
Dental extraction is typically required, particularly as radicular cysts tend to develop in poor dental attendees with grossly
carious, unrestorable teeth.
There is some debate amongst the literature with regard to the success of endodontic treatment for radicular cysts. This is
a particularly di
histologically. It is generally accepted however that should the patient be willing (and informed of the risks of further
treatment) endodontic treatment is a good
3
Following extraction/endodontic treatment the cyst should be reviewed radiographically for signs of shrinkage. If the cyst
persists, further surgical treatment such as enucleation may be required.

Dentigerous cyst

Dentigerous cysts are always found around the crown of an unerupted tooth, attaching to the cemento-enamel junction.
Aetiology
Whilst they are considered developmental, in
follicle from an impacted tooth leads to a reduction in venous drainage and
enamel epithelium and the enamel of the tooth. The cyst then enlarges by internal pressure expanding the dental follicle.
4
Clinical features
Dentigerous cysts are typically seen in younger patients, aged 20-50 years old.
They are often asymptomatic and found incidentally on radiographs. Dentigerous cysts are most commonly found around
the teeth which are more likely to become impacted (lower 8’s, upper 3’s). With continued growth bony expansion may be
noted. As with all cysts, if they become infected, they may be painful.
Investigations
Radiographic features
Dentigerous cysts present as a well-de
displacement is common and root resorption of adjacent teeth is known to occur. Figure 1 shows an example dentigerous
cyst.
Figure 1. OPG radiograph showing
dentigerous cyst associated with LR8
(white arrows).Histopathology
Following removal of a suspected dentigerous cyst, it is always sent for histopathological analysis. This is particularly
important for cysts around the angle of the mandible where the di
(which will be discussed next) and ameloblastoma.
A dentigerous cyst will have a thin, non-keratinised squamous cell epithelium that is continuous with the reduced enamel
epithelium of the tooth.
4
Management
Management of dentigerous cysts usually involves extraction of the causative tooth and cyst enucleation. If a clinical need
exists to preserve the tooth, marsupialisation can be attempted. If a cyst is large, around a lower 8, the patient must be
warned about the possibility of iatrogenically fracturing the mandible during its removal.

Odontogenic keratocyst

Odontogenic keratocysts make up about 5-10% of jaw cysts and have distinctive clinical, radiographic and histological
features.
Aetiology
Odontogenic keratocysts arise from the rests of Serres (a rest of odontogenic epithelium which remains after tooth
formation). Many are linked to a mutation of the PTCH gene.
Clinical features
Odontogenic keratocysts are usually found in the mandible, often around the angle. Like other cysts, it is often
asymptomatic until large or infected.
Swelling is possible, though less common with odontogenic keratocysts as the cyst will spread through the medullary
cavity of the bone (ie in a proximal-distal direction) before expanding in a bucco-lingual direction. Therefore, patients with
bucco-lingual swelling often have a large underlying cyst.
If the cyst contents are aspirated a white
Investigations
Radiographic features
Odontogenic keratocysts present as a well-de
As previously mentioned, there is often evidence of growth along the medulla of the bone with little cortical expansion
(Figure 2).
Figure 2. OPG radiograph showing the
radiographic appearance of a right-sided
odontogenic keratocyst.
Histopathology
As previously discussed, all cysts presenting as a radiolucency around the angle of the mandible are sent for
histopathological analysis.
An odontogenic keratocyst has distinctive histopathological features including\:
1
Uniform thickness, thin epithelial layer
Satellite cysts within the wall (important as these can lead to recurrence)
The lining epithelium is corrugated with a thin parakeratinsed surfaceManagement
Enucleation of the odontogenic keratocyst is the mainstay of treatment.
However, unlike other cysts, if treated by this alone the odontogenic keratocyst will usually recur. This is due to the
presence of Satellite cysts with the cyst wall which itself is thin and friable and likely to break during removal. To
overcome this, surgeons will typically use an intra-operative
remaining tissue.
Gorlin-Goltz syndrome
Gorlin-Goltz syndrome (also called basal cell naevus syndrome) is a rare, autosomal dominant condition. Clinical
features include\:
Multiple odontogenic keratocysts
Multiple basal cell carcinomas
Bi
Its features can all be linked to an abnormal sonic hedgehog signalling pathway which includes mutation of PTCH
genes. Thus, patients presenting with multiple odontogenic keratocysts should be tested for this condition.
5

Lateral periodontal cyst

Lateral periodontal cysts are uncommon however there is a tendency amongst dental students to misdiagnose lateral
radicular cysts as them. They are found as unilocular, round radiolucency’s on the lateral surface of tooth roots (typically a
lower canine/premolar).
Lateral periodontal cysts can be distinguished from a radicular cyst as often the associated tooth is vital.
These cysts should be enucleated and sent to histopathology however if small, asymptomatic and the associated tooth is
proven to be vital it can be left and closely monitored.
4

Nasopalatine duct cyst

A nasopalatine duct cyst is a non-odontogenic cyst, which is sometimes called an incisive canal cyst. These typically
present in 30-60-year-olds.
Aetiology
A nasopalatine duct cyst is thought to be derived from epithelial residues in the nasopalatine canal.
Clinical features
Nasopalatine duct cysts typically present as a swelling in the anterior, midline palate. There may be associated
pain/discharge or tooth mobility/displacement if particularly large. The anterior teeth are vital.
Investigations
Radiological features
When nasopalatine duct cysts are small on radiographs it can sometimes be di
appearance of a large incisive foramen.
When nasopalatine duct cysts are large, they present as a round, unilocular, corticated uniform radiolucency. They can
appear heart-shaped either due to notching by the nasal septum or superimposition of the nasal spine.
6
Histopathology
Histopathological
columnar or cuboidal. Specialised respiratory cells such as goblet cells are occasionally found. Neurovascular bundles are
found in most nasopalatine cyst walls.
1
Management
As with other cysts, the mainstay of management of nasopalatine duct cysts is surgical enucleation.

Nasolabial cyst

Nasolabial cysts are also known as a nasoalveolar cyst. These are exceedingly rare development cysts with a limited
number of reports. Due to this, there is a wide age distribution in the literature (from 12 to 75 years).
1
Aetiology
Due to the limited number of nasolabial cyst cases, precise aetiology is di
the cyst seems to develop from epithelial remnants of the nasolacrimal duct/rod.
1
Clinical features
Swelling is often the only clinical feature, typically of the lip and nasolabial fold. If particularly large there may be a degree
of nasal obstruction.
Investigations
Radiological features
A nasolabial cyst presents as a radiolucency above the apices of the incisor teeth. If large there may be resorption of the
inferior nasal notch.
Histopathology
A nasolabial cyst has a non-ciliated pseudostrati
is relatively acellular. Nasolabial cysts are extra-osseous but lie subperiosteally.
1
Management
Careful surgical enucleation is the primary treatment for nasolabial cysts.

Solitary bone cyst

Solitary bone cysts are rare
patients though can also present in the jaw.
Clinical features
Solitary bone cysts are more common in the mandible and are often seen in the premolar region. Almost all maxillary
cases are found anteriorly.
Solitary bone cysts are typically asymptomatic and seen as an incidental
are known to cause swelling, pain or paraesthesia.
1
Investigations
Radiological features
Solitary bone cysts present as a well-de
Scalloping between the roots of the teeth is common.
4
Histopathology
Solitary bone cysts are often found to be empty. They may consist of loose
1
ManagementSurgical management of solitary bone cysts is usually only done to aid diagnosis. The cyst wall is curreted and this results
in healing in most cases.Aneurysmal bone cyst
Aneurysmal bone cysts are uncommon, blood-
within the long bones/spine.
Clinical features
In the jaw, aneurysmal bone cysts present as a
described as reasonably rapid. Aneurysmal bone cysts are often found at the angle of the mandible and depending upon
their size may cause trismus.
1
Investigations
Radiological features
An aneurysmal bone cyst presents as a multilocular radiolucency with cortical expansion. It can be di
clinically and radiographically from other similar lesions (including odontogenic keratocyst and ameloblastoma).
1
Histopathology
As the name “aneurysmal bone cysts” suggests the lesion consists of many blood vessels. There is typically cellular
tissue containing multiple blood lakes. Small multinucleate cells (giant cells) and osteoid/woven bone are also commonly
found.
1
Management
It is
demonstrate blood. This is vital as approaching the cyst surgically without this knowledge could lead to a catastrophic
bleed.
The most frequent treatment of an aneurysmal bone cyst is curettage of the lesion. There is a need for close follow up as
the recurrence rates are high.
1

Summary table

Table 1. A summary of the three most encountered cysts of the jaw.
Most likely
location
Radicular cyst Dentigerous cyst
Around the crown of
an unerupted tooth
(typically a lower 8)
Odontogenic
keratocyst
Angle of the
mandible
Clinical
features
Associated with a
non-vital tooth
(typically the apex)
Often preceding
toothache
The cyst can be
asymptomatic if
small
Can have facial
swelling/pain if
large or infected
Often asymptomatic
if small
If infected can get
pain/facial swelling
Radiographic
features
Well de
unilocular
radiolucency
associated with a
non vital tooth
Well de
unilocular
radiolucency around
the crown of an
unerupted tooth
Often asymptomatic
initially.
Spreads through the
medullary cavity
so bucco-lingual
expansion of the
mandible is often a
late sign
Well de
multilocular (though
can be unilocular)
radiolucency around
the angle of the
mandibleHistopathologi
cal features
Management
Cyst wall contains

tissue, cholesterol
clefts and
hemosiderin
The central lumen
is surrounded by a
non-keratinised
epithelium of
varying thickness
Extraction of
causative tooth (or
endodontic
treatment of tooth
if clinically
appropriate)
Enucleation of cyst
if large/persistent
after extraction/
endodontics
Thin, non-
keratinised
squamous cell
epithelium that is
continuous with the
reduced enamel
epithelium of the
tooth
Uniform thickness,
thin epithelial layer
Satellite cysts within
the wall
The lining epithelium
is corrugated with a
thin parakeratinsed
surface
Enucleation of the
cyst with extraction
of the associated
tooth
Enucleation of the
cyst followed by use
of a
solution)

Key points

A cyst is a pathological cavity lined by epithelium and
The bones of the jaw contain odontogenic epithelium. Therefore cysts are more commonly found in the jaw than any
other bone of the body.
Cysts of the jaw can be categorised according to their epithelium as either odontogenic or non-odontogenic.
Jaw cysts have a variable clinical presentation ranging from asymptomatic to jaw pain/facial swelling.
A radicular cyst is by far the most common jaw cyst. These are always associated with a non-vital tooth.
There are numerous possibilities for a cyst presenting as a radiolucency at the angle of the mandible which include
dentigerous cyst and odontogenic keratocyst.
Due to the often overlapping clinical and radiographic features, the majority of cysts are sent to histopathology
following removal.
Aspirating a cyst prior to removing it may give an indication of the diagnosis. This is especially important when an
aneurysmal bone cyst is being considered (where blood would be aspirated).
The surgical management of jaw cysts typically involves cyst enucleation and removal of any causative teeth.

References

Shear M and Speight P. Cysts of the Oral and Maxillofacial Regions. Fourth Edition. 2007. Blackwell Munksgaard.
Mortensen H, Winther J, Bein H. 1970. Periapical granulomas and cysts. An investigation of 1600 cases. S c a n d i n a v i a n
J o u r n a l o f D e n t a l R e s e a r c h . 7 8 \: 2 4 1-2 5 0 .
Nair P. 1998. New perspectives on Radicular Cysts\: do they heal? I n t e r n a t i o n a l E n d o d o n t i c J o u r n a l . 3 1 1 5 5-1 6 0 .
Odell E. 2017. Cawsons Essentials of Oral Pathology and Oral Medicine. Ninth Edition. Elsevier.
Athar M, Li C, Kim A, Speigelman V, Bickers D. 2014. Sonic Hedgehig Signalling in Basal Cell Nevus Syndrome. C a n c e r R e s .
7 4 ( 1 8 ) \: 1-9 .
Elliott, KA, et al. 2004. Diagnosis and surgical management of nasopalatine duct cysts. L a r y n g o s c o p e 1 1 4 \: 1 3 3 6-1 3 4 0Image references
BY]
Figure 1. Coronation Dental Specialty Group. O P G r a d i o g r a p h s h o w i n g d e n t i g e r o u s c y s t a s s o c i a t e d w i t h L R 8 . License\: [CC
Figure 2. Coronation Dental o d o n t o g e n i c k e r a t o c y s t . Specialty License\: [CC Group. BY]
O P G r a d i o g r a p h s h o w i n g t h e r a d i o gr a p h i c a p p e a r a n c e a r i gh t-s i d e d

Reviewer

Mr R JJ Pilkington
StR OMFS

Related notes

Temporomandibular Dysfunction (TMD)

Test yourself

Contents

Introduction
Radicular cysts
Source\: geekymedics.com