BDJ Oral Surgery Series | VERIFIABLE CPD PAPER PRACTICE

Oral surgery II:

Part 3. Cysts of the mouth and jaws and their
management
C. M. Hill1 and T. Renton*2

In brief
Cysts of the oral region occur commonly owing The classification of cysts has been amended several Presents simple strategies to optimise the
to the mouth’s complex embryonic origins and times and some of the terminology can appear management of oral cysts.
frequency of inflammation. confusing.

A cyst may be defined as a pathological (or abnormal) body cavity, usually lined by epithelium, which contains fluid (gas or liquid)
or semi-solid substances other than (primarily) pus. Even this definition is contentious, as some pathologists prefer the term
pseudocyst or cavity1 when there is no epithelial lining. However, the above definition, based on that of Kramer,2 is as inclusive as
possible. Cysts of the mouth and jaws are fairly common and their management is an essential component of oral surgery. This
third article in the series deals with the classification, diagnosis and management of the common cysts of the head and neck.

It is helpful for the surgeon to have a working In practical terms, the site of origin of a cyst
Table 1 Working classification of cysts
classification of the cystic lesions of the oral is generally self-evident. Correct diagnosis is
of the jaws
cavity. There are, however, several systems of essential as it will directly affect patient man-
classifying such cysts, some of which overlap. agement and planned surgery. Intraosseous cysts
Within the jaws, cysts can most usefully be Inflammatory
classified according to their site – hard or soft Intraosseous cysts – Apical periodontal cyst
tissue – and their tissue of origin – odontogenic – Residual cyst
when related to the teeth and non-odontogenic Three major subdivisions of intraosseous cysts – Paradental cyst
in all other cases (Table 1). were originally proposed by the World Health – Collateral cyst
Odontogenic
Organization (WHO) (Table 1), but the most
Developmental
recent editions of the classification have been
1
Honorary Senior Lecturer in Oral and Maxillofacial Surgery, – Dentigerous cyst
Cardiff Dental School; 2Professor and Honorary Consultant in contentious and more focused on neoplastic
– Odontogenic keratocyst
Oral Surgery, King’s College London; lesions.3 The original categories were:
*Correspondence to the BDJ Clinical Guide Editor: – Calcifying odontogenic cyst
Professor Tara Renton • Odontogenic cysts (eg radicular cysts, den-
Email: [email protected] tigerous cysts and odontogenic keratocysts) Developmental
Accepted 9 August 2017 • Non-odontogenic cysts Non-odontogenic – Nasopalatine duct cyst
DOI: 10.1038/sj.bdj.2017.916 • (eg incisive canal (nasopalatine duct) cysts) – Nasolabial cyst*
• Non-epithelial cysts (eg traumatic (solitary) Solitary bone cyst
Non-epithelially
ORAL SURGERY II*
bone cysts). lined bone cysts Aneurysmal bone cyst
Part 1. Acute management of dentoalveolar trauma Soft tissue cysts
Histological findings remain the corner-
Part 2. The maxillary sinus (antrum) and oral surgery
stone of diagnosis, and the original paper by Salivary gland cyst
Part 3. Cysts of the mouth and jaws and their
management Pindborg et al. summarises these.4 Dermoid cyst
Part 4. Common oral lesions Intraosseous cysts are commonly asympto- Epidermoid cyst
Part 5. Chronic orofacial pain matic at presentation and are often noted as Thyroglossal duct cyst
Part 6. Oral and maxillofacial trauma
incidental radiographic findings. Moreover, Cystic hygroma
*This series represents chapters 1, 2, 3, 4, 9 and 10 from because of their position and slow growth
the BDJ book A clinical guide to oral surgery - Book 2,
Anterior midline lingual cyst
edited by Tara Renton and C. Michael Hill. All other chapters rates, they may go unnoticed for many years Nasolabial cyst*
are published in the complete clinical guide available from and reach a considerable size before any
the BDJ Books online shop: https://shop.bda.org *Can be classified as either intraosseous or soft tissue.
symptoms develop. When they do become

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Fig. 1 (a) Sectional DPT illustrating a double or multilocular radiolucency associated with a root-canal-treated lower right canine and the
crowned, vital lower right 4. Histopathology after enucleation confirmed a radicular cyst on lower right 3 and a keratocyst on lower right 4.
The patient remains under review; (b) Large anterior mandibular cyst presenting with bluish discoloration of overlying mucosa confirming
that the cyst has breached the underlying bone or is within soft tissue

Fig. 2 (a) Large radicular cyst in the anterior mandible associated with root-filled canines acting as abutments for the bridge; (b) Periapical
radiolucency on a non-vital carious lower right canine, missing second premolars, retained lower right deciduous molar

apparent, the most frequent signs and Odontogenic cysts Residual cysts
symptoms are swelling, facial asymmetry, Radicular cysts Residual cysts are almost certainly radicular
mobility of adjacent teeth and displacement Radicular cysts are the most common of all cysts that were present when a non-vital tooth
of dentures (Fig. 1a). odontogenic cysts, representing >50% of jaw was extracted and which did not resolve spon-
At this stage, the overlying bone becomes cysts in several studies.5-7,20 They result from taneously. While there is little good research on
considerably thinned by growth of the cyst and chronic inflammation around the apices of the subject, it appears that many radicular cysts
a characteristic ‘egg-shell’ crackling can often non-vital teeth, are lined by stratified squamous resolve without any further surgical intervention
be elicited with gentle manual pressure. If the epithelium and usually have a chronic inflamma- once the offending tooth has been removed;
enlarged cyst breeches the bone or resides in tory infiltrate in the wall. There may be a previous those that do not are often histologically indistin-
soft tissue the mucosa may appear with a bluish history of trauma or failed endodontic therapy, guishable from a radicular cyst other than having
hue (Fig. 1b). When cysts have reached this or another cause for the loss of tooth vitality. a general tendency to show less inflammation in
size another common late event is secondary These cysts occur more frequently in males in the the wall of the cyst as time elapses.5,8
infection (either acute or chronic) of the cyst anterior maxilla and present as unilocular peri-
cavity. The formation of pus within cyst cavities apical radiolucencies with well-circumscribed Dentigerous cysts
is not uncommon but, by definition, it needs to margins radiologically, and are often associ- These are the second most common odonto-
be a secondary process. In the mandible, cyst ated with root-canal-treated teeth (Fig. 2a) or genic cysts, representing ~20% of cases.20 They
expansion may be so great that a pathologi- carious non-vital teeth (Fig. 2b). Radicular cysts arise from the reduced enamel epithelium after
cal fracture occurs. While extensive cysts may usually enlarge in the direction of least resistance. amelogenesis is complete and are associated with
physically displace the inferior alveolar neu- Though buccal expansion is more common, a failure of eruption. The precise definitions dif-
rovascular bundle, it should be remembered cysts on teeth whose root apices are palatally or ferentiating enlarged dental follicles (Fig. 3a),
that paraesthesia is a more frequent indicator lingually placed (ie maxillary permanent second paradontal cysts (Fig. 3b) to dentigerous cysts
of serious conditions such as neoplasia or incisors and first molars) may present initially as (Figs 3c–e) are not clinically obvious, and patients
osteomyelitis. palatal or lingual swellings. may require review to assess lesion progression

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Fig. 3 Dentigerous cyst. (a) Enlarged dental follicle on lower right unerupted third molar; (b) Bilateral paradontal cysts on lower third molars
and radicular cyst on lower right first premolar; (c) Radiolucency associated with the crown of the mandibular right third molar, confirmed
to be a dentigerous cyst. Note the resorbed distal root of the first molar; (d) Cystic radiolucency, later confirmed to be a dentigerous cyst,
associated with maxillary bilateral supernumerary teeth; (e) Large left monolocular radiolucency associated with an unerupted lower left
third molar in an edentulous patient; (f) CBCT sections of a dentigerous cyst arising on a mandibular third molar

before surgery is prescribed. The dentigerous cyst are probably the third most common of all the However, keratocysts can often mimic other,
encloses the crown of an unerupted tooth (being odontogenic cysts. Of these, they have been more common cysts (Figs 4a–c) and as a result
attached at the cemento-enamel junction) and is the subject of the most research, debate and may not be appropriately managed. There is
lined by cuboidal or low columnar epithelium. name changes, which have included primordial no suggestion that odontogenic keratocysts
The cysts commonly arise on teeth that normally cysts, keratocystomas, ortho-keratinised/para- metastasise and so any nomenclature that
erupt last in the dental sextants as these are most keratinised odontogenic cysts and keratocystic suggests they are tumours is generally consid-
likely to be impacted. The cysts are almost always odontogenic tumours.10-14 This divergence is, at ered to be unhelpful.
unilocular. Unerupted teeth may be considerably least in part, due to the behaviour and presen- Odontogenic keratocysts arise from
displaced and if the associated teeth are high tation of odontogenic keratocysts, which varies remnants of the dental lamina (known as
risk for nerve injury, coronectomies may be considerably from other dental cysts in that rests or glands of Serres) and typically occur
considered. Dentigerous cysts are also known as they tend to be: as a multilocular radiolucency in the posterior
follicular cysts, but this terminology has never • More rapidly growing body/ramus of the mandible. Occasionally
been popular with pathologists.9 • Prone to recurrence after inadequate however, these cysts occur in a multifo-
treatment cal distribution as part of the naevoid basal
Odontogenic keratocyst • Difficult to treat cell carcinoma syndrome (Gorlin–Goltz
There is considerable variation in the reported • Commoner in younger age groups syndrome), which may include multiple basal
prevalence of odontogenic keratocysts but they • Frequently larger. cell carcinomas, cervical ribs and calcification

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Fig. 4 (a) Keratocyst. Multilocular cyst associated with the mandibular left third molar; (b) Radiolucent monocystic area related to the
mandibular third molar that on biopsy was a confirmed keratocyst mimicking a dentigerous cyst; (c) Large left multilocular radiolucency

of the falx cerebri. The cysts are normally common presentation is in juveniles, which, Shear and Speight’s classic textbook Cysts of
thinly lined by epithelium and exhibit although similar in its mechanism of formation the Oral and Maxillofacial Regions has much
distinct para-keratinisation. (Those cysts with as an inflammatory response, is sometimes to commend it.19
ortho-keratinisation are now recognised as a categorised as a separate entity (the juvenile
separate and rarer entity). The fibrous capsule paradental cyst).16-18 Non-odontogenic cysts
of these lesions is normally thin, and satellite Nasopalatine duct cysts
or daughter cysts are often evident in the cyst Gingival cysts These are the commonest of the non-odon-
wall. They are often difficult to manage, having Gingival cysts are soft tissue cysts of which two togenic cysts and are also known as incisive
a greater propensity to recur following removal types are recognised: the relatively common canal cysts.18 They are more common in males
than other types of cyst.12 This may be due to gingival cyst of infants and the much rarer and, although seen in all age groups, are most
the presence of island cysts or it may be the gingival cyst of adults. The former appear as common between the ages of 20 and 60 years.
result of incomplete enucleation. small creamy-white lesions on the surface Their origin is somewhat controversial but
epithelium and may occur in isolation or in they probably arise from embryonic duct
Lateral periodontal cysts clusters. In any event, they regress sponta- remnants. It has been suggested that they may
Lateral periodontal cysts are developmental in neously and are rarely visible by the time be noted as incidental radiographic findings in
nature and usually arise in younger patients the primary dentition begins to erupt. The approximately 1.0–1.5% of individuals and this
with no apparent periodontal destruction. gingival cyst of adults is frequently applied has also been seen in some cadaveric studies.
These cysts present with a similar radiographic synonymously with the lateral periodontal The most frequent presentation is a swelling
appearance to apical cysts, but are associated cyst, despite the fact that the periodontium in the anterior midline of the palate. The
with the lateral aspect of a root and usually is not always involved. They are relatively adjacent teeth are vital and therefore typically
have vital pulps. The diagnosis of odontogenic rare and their pathogenesis remains unclear. of normal colouration. The lesion (which
keratocyst must be excluded in confirming the Simple excision is curative and, as long as the is situated within the incisive canal) is best
definition of lateral periodontal cyst.15 diagnosis is correct and a gingival cyst is not seen on an upper occlusal film and, although
mistaken for a true lateral periodontal cyst, round, may have a pear-shaped appearance.
Paradental cysts there is minimal tendency to recurrence.15 These cysts are best treated by enucleation via a
These enigmatic cysts are inflammatory in palatal flap from canine to canine; recurrences
nature and commonly arise in association Other odontogenic cysts are probably due to inadequate enucleation.
with buccal furcations of vital molar teeth Among the other odontogenic cysts are the The cyst is usually lined with a combination
(Fig. 3b) – most commonly lower third molars. calcifying odontogenic cyst, the botryoid cyst of stratified squamous and ciliated columnar
They are characterised by a well-circumscribed and the glandular odontogenic cyst. Although epithelia. The previous terminology of globu-
unilocular radiolucency and are more common they are rare, the clinician should be aware of lomaxillary cysts and median cysts found in
in males in their third decade. Unlike radicular their existence and arrange appropriate referral older textbooks has now been abandoned
cysts, however, the associated teeth are vital to a specialist unit for treatment. For those following their exclusion from the 1992 WHO
and occasionally bilateral. Another fairly wishing to study the subject in greater depth, classification.21

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Fig. 5 (a) Stafne’s bone cavity in the left mandible; (b) Aneurysmal bone cyst in the right mandible

Fig. 6 Ameloblastoma. (a) Impacted mandibular canine associated with multilocular radiolucency; (b) Large right mandibular angle
radiolucency with resorption of the adjacent lower right molar roots; (c) ‘Cystic’ lesion presenting on vital mandibular premolars, confirmed
to be a unicystic ameloblastoma

Other epithelially lined non-odontogenic solitary bone cyst is also known as the haemor- a cyst but needs to be distinguished clinically
cysts rhagic bone cyst, the simple bone cyst and the and radiographically from the solitary bone
Other epithelially lined non-odontogenic cysts traumatic bone cyst. Surgical exploration of cyst. The latter is almost always found above
occasionally occur. Of these, the midline (mid- the lesion and primary closure is almost always the inferior alveolar canal, whereas Stafne’s
palatal) raphé cyst of infants is probably the most curative, presumably by inducing wound healing. bone cavity is an asymptomatic area of rar-
common, but overall they are exceedingly rare Recurrence is rare but has been reported.22 efaction entirely beneath the inferior dental
and beyond the scope of this BDJ Clinical Guide. bundle. In reality, it is no more than a lingual
Importantly, non-odontogenic lesions will most Aneurysmal bone cyst (or cavity) defect in the bone – often occupied by a lobular
commonly occur below the inferior alveolar The aneurysmal bone cyst1 is an even rarer cyst, extension of the submandibular gland; indeed,
canal as odontogenic epithelium only originates which occurs in a similar age group and has a some pathologists prefer the term salivary
above the canal. similar site distribution to the solitary bone gland inclusions.
cyst although enlargement of the mandible No treatment is indicated for these cavities,
Non-epithelially lined cysts is a more typical feature. The lesion typically although Branstetter et al.23 suggest that magnetic
Solitary bone cyst contains numerous blood-filled spaces inter- resonance imaging should be undertaken if there
A solitary bone cyst may occur within any bone spersed with giant cells and fibroblasts and it is doubt about the diagnosis. There is some
of the body, but typically occurs in the lower is much more aggressive than the solitary bone evidence that the lesions are developmental
molar region of the jaws. It is the commonest cyst. Recurrence following exploration and rather than congenital, although their aetiology
non-epithelially lined cyst (pseudocyst). The enucleation is common and further curettage remains uncertain. Other salivary inclusion cysts
associated teeth are vital and the cysts are fre- of the lesion may be required. Some patholo- occasionally occur, as do various other lesions
quently asymptomatic – probably representing gists would argue that the aneurysmal bone that can radiographically mimic a cyst.
<1% of all intraosseous cysts. Their aetiology is cyst is actually neoplastic and should be treated
uncertain but they tend to occur in young adults accordingly. There is no doubt that recurrence Clinical & radiographic examination
(<20 years) with no definite gender imbalance rates following curettage are high and that the
(despite some reports of a male preponderance). lesions frequently show evidence of dysplastic Although a number of lesions may resemble
Although the cyst lacks an epithelial lining it if not frank neoplastic change. cysts in their presentation, including central
sometimes contains blood-stained serous fluid, giant cell lesions, ameloblastomas or even
but many are gas filled. Occasionally, a loose, Stafne’s idiopathic bone cavity tumours, a careful history and detailed inves-
fibrous tissue lines the inner surface of the cyst Stafne’s idiopathic bone cavity is sometimes tigation will refine the differential diagnosis in
with evidence of mild osteoclastic activity. The included in this classification (Fig. 5). It is not the majority of cases (Fig. 6).

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Fig. 8 Syringe aspiration of a fluid-filled

Fig. 7 Palatal swelling confirmed to be a dentigerous cyst associated with supernumerary dental cyst prior to surgical incision to confirm
maxillary teeth the absence of blood and non-white keratin

Signs and symptoms that are important to and any fluctuance elicited. In extensive lesions areas, within the radiolucency should be
note include: of the upper jaw it is also useful to ascertain recorded.
• Swelling (Fig. 7) whether nasal obstruction is present. Worrying
• Tenderness signs of malignancy are summarised in Shape: Is the radiolucency uni- or multilocular?
• Discharge Table 2. Some neoplastic lesions manifest as
• Displacement of teeth cysts – occasionally because they were cysts Outline: Is the lesion well circumscribed or not?
• Tooth mobility that have undergone malignant transformation
• Disturbance of nerve function but more commonly as primary or secondary Radiodensity: What is the relative density of
• Bluish discoloration of overlying mucosa neoplasms. These lesions should never be the lesion compared with the adjacent bone?
(see Fig. 1b) regarded as cysts but must be distinguished
• Absent or non-vital teeth. diagnostically and treated accordingly. Spread: It is particularly useful in planning
Radiographic examination alone cannot to determine the extent of the lesion. For
A note should be made of a history of trauma provide a definitive diagnosis of any cyst but lesions in the ascending ramus, the extent of
in the region and previous dental treatment it may provide important clues to the diagnosis lingual expansion and spread may be deter-
such as endodontics, extractions or apical and suggest further investigations and patterns mined using two radiographs taken at right-
surgery. Any evidence of displacement, caries, of treatment. The radiographs most frequently angles – the DPT and postero-anterior view of
mobility and tenderness to percussion should employed in the investigation of patients the mandible. A more accurate 3D representa-
also be recorded. If swelling is evident, its with intraosseous radiolucencies are dental tion can, however, be obtained using CBCT. A
consistency should be determined by palpation panoramic tomographs (DPT), intraoral peri- preoperative radiograph is essential in deter-
apical views and, less frequently, occlusal radi- mining the size and location of the lesion. It is
Table 2 Signs possibly indicating ographs. There is also increasing evidence that also important in planning the removal of teeth
malignancy cone beam computed tomography (CBCT) can at the time of operation, particularly those of
• Recent onset be a useful tool. poor prognosis due to resorption or those with
It is important to consider the following: inadequate bony support.
• Rapid growth

• Neuropathy Site: What is the relationship of the radiolu- Vitality testing: For periapical radiolucencies, if
cency to non-vital, unerupted teeth and other loss of vitality is suspected (because of a history
• Resorption of adjacent structures
anatomical structures such as the maxillary of trauma, extensive restoration or darkening
• Pain antrum and the inferior alveolar neurovascular of the tooth), then thermal or electric pulp
• Loss of vitality of tooth bundle? It should be remembered that in the testing should be performed.
posterior maxilla the maxillary antrum is close
• Lack of response to conventional treatments:
to the roots of the upper posterior teeth and Aspiration: Aspiration of cyst contents used to
– Antibiotics can display the classic appearance of a cystic be a common procedure but has largely been
lesion. Any evidence of tooth displacement or abandoned for diagnostic purposes other than
– Endodontic surgery
resorption, or the presence of radio-opaque confirming the diagnosis of an odontogenic

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keratocyst that contains thick keratin. It is

Table 3 Radiographic and clinical investigations of jaw cysts
sometimes undertaken therapeutically to
decompress a cyst prior to or during surgery Radiological appearances
but its original use for analysing cyst contents
• Site
for substances such as cholesterol has been
abandoned, as it had virtually no bearing on • Size, shape (unilocular, multilocular )
treatment planning but can help the surgeon • Radiolucency, well-defined, diffuse
ensure that the cavity is not solid, or blood- or
• Teeth, displacement, resorption
keratin-filled (Fig. 8).
Table  3 summarises the investigation of • Involvement of other structures, eg antrum, inferior alveolar canal
lesions.
• Relation to the inferior alveolar nerve canal

Clinical investigations
Management of common oral cysts
• Vitality testing (involved teeth and adjacent teeth should all be tested)
Once the diagnosis of a cyst has been made,
there are various treatment options, including: • Aspiration of cyst (see text for indications)

• Observe and review • Incisional biopsy (only indicated if diagnosis remains completely obscure or suggestion of malignancy)
• Dental treatment:
• Excisional biopsy (definitive)
ºº Endodontics
ºº Apicectomy
• Extraction Table 4 Management strategies for common oral cysts
• Marsupialisation
Dental/radicular cysts
• Enucleation
• Enucleation plus supplementary treatment • Endodontic treatment:
• Local excision.
– For radicular cysts

Unlike for malignant lesions, there is rarely – See Royal College of Surgeons guidelines24
any place for wide excision of the lesion and • Apicectomy ± cyst enucleation
adjacent tissue, with or without adjunctive
radiotherapy or chemotherapy and reconstruc- • Retrograde root filling
tion. If a keratocyst recurs, consideration may • Extract associated tooth ± cyst enucleation
be given to excision with a margin possibly
Dentigerous cysts
with adjunctive use of Carnoy’s solution, in
an attempt to prevent recurrence. • Enucleation in addition to extraction of associated tooth
Probably the most important aspect of any
• If high risk of nerve injury, consider coronectomy
surgical intervention is to firmly establish the
diagnosis of the lesion. Wherever possible Odontogenic keratocysts
this should be achieved by fully eradicating
• Increased recurrence rate because of:
the lesion while minimising morbidity. This
should allow rapid healing, enabling function • Site
to be restored quickly and removing any doubt • Friable lining
about the nature of the cyst.
Strategies for applying these treatment options • Daughter cysts
in the management of common oral cysts are • Under-diagnosis
summarised in Table 4. Simple endodontic
• Naevoid basal cell carcinoma syndrome (Gorlin–Goltz)
treatment of radicular cysts has been a somewhat
contentious issue, mainly due to fact that a
confirmed diagnosis cannot be obtained when
Management should be enucleation plus:*
the lesion has not been fully excised. There are
several studies on the efficacy of this treatment • Cryotherapy
modality showing it is effective as a first-line
• Carnoy’s solution
treatment for a tooth with reasonable prognosis
with a small, non-infected radicular cyst.8
Despite the various histological profiles of although both may cause increased morbidity to inferior alveolar nerve
intraoral cysts, their surgical management
*A 20-year prospective study concluded that enucleation alone was satisfactory in most cases and that a minimum 10-year
consists of variations of two basic techniques: follow-up is advisable. 25
Wide excision is only indicated for malignant change within cystic lesions.
enucleation and marsupialisation.

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Fig. 9 Anterior mandible radicular cyst. (a) Preoperative dental panoramic radiograph; (b) Clinical appearance before excision; (c) Aspirate
of pus contents; (d) Bone exposure with protection of dental nerves and bone; window cuts performed using a fissure bur; (e) Clean bone
cavities after cyst removal; (f) Cyst specimen for histopathology

Enucleation of cysts try to carefully remove the overlying bone to attached to the periapical tissues, a small
Enucleation is the removal of the entire cyst expose the maximum diameter of the cyst curette is extremely useful.
lining and the primary repair of the resultant without damaging the lining. Enlargement of Occasionally, it will be necessary to remove
defect (Fig 9a–f). The cyst space becomes the access can be achieved with a large round teeth associated with the cyst. The principal
filled with blood clot that will organise and bur and rongeur bone nibblers. Aspiration of indications for this relate to poor postoperative
remodel, resulting in bony repair. Enucleation the cyst contents at operation tends to cause functional prognosis and associated disease.
is the usual method of treatment for radicular, separation of the cyst wall from the adjacent Where teeth have a poor functional prognosis
residual and dentigerous cysts, and is generally tissue. This facilitates dissection of the cyst (being displaced, resorbed or lacking bone
the preferred option for the majority of lining from the bone or mucosa and decreases support), removal together with the cystic
both intraosseous and extraosseous cysts the risk of cyst rupture. Careful separation of lesion is generally the only appropriate form
(Figs 10a–e - overleaf). It is often carried out the cyst lining from the surrounding struc- of treatment. The necessity to remove teeth
in the context of surgical endodontics. tures should ensure removal of the lesion should be explained to the patient preop-
In removing large intraosseous cysts the intact. The lining should be raised from eratively and the discussion recorded in the
incision should be well clear of the margins the underlying bone using a spoon-shaped patient’s notes.
of the lesion, the aim being to ensure that the instrument such as a Mitchell trimmer or Odontogenic keratocysts may require
suture line will lie on healthy bone. When (where the cyst cavity is large) a Ward peri- adjunctive chemical treatment along with enu-
the cyst cavity is exposed, it is important to osteal elevator. Where the cyst lining is firmly cleation to minimise the risk of recurrence.9-14

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Fig. 10 Maxillary left quadrant radicular cyst. (a) Dental panoramic radiograph (previous extraction of first molar years before presentation);
(b) Buccal sulcus before cyst enucleation; (c) Flap elevated and bony window opened to expose cyst lining; (d) After cyst removal;
(e) Replaced buccal flap, using resorbable Vicryl sutures

Additionally, teeth associated with the lining of especially where the cysts are in the soft tissue, of exogenous material simply increases the
odontogenic keratocysts are also best removed as the solution is quite toxic – basically being risk of secondary infection. In some instances,
to minimise the risk of recurrence as a result designed to ‘pickle’ the remnant cyst island however, where the mandible is severely struc-
of incomplete removal of cyst epithelium from cells. However, it is non-discriminatory and turally weakened, bone grafting and internal
the root surface. can cause significant damage to the adjacent fixation may be essential to restore functional
Following removal of the specimen (and soft tissues and especially the inferior alveolar integrity.
associated teeth where necessary), debridement nerve if it has been exposed.
is performed. The rough edges of the cavity Where extensive bony destruction has Marsupialisation of cysts
should be smoothed using a large round bur. In resulted from the cystic expansion, attempts The marsupialisation of cysts involves the
an attempt to decrease the high rate of recur- have sometimes been made to pack the cyst creation of a surgical window in the lining of
rence of odontogenic keratocysts, treatment cavity using resorbable materials, autologous the cyst by removal of the overlying mucosa,
of the cyst cavity with cryotherapy and/or bone and even blood to facilitate the healing mucoperiosteum and bone to decompress the
Carnoy’s fluid is often employed. Extreme process. There is, however, little evidence that lumen (Figs 11a–i). This procedure involves
care should be taken in their application, this is effective and in most cases the addition minimal trauma to the adjacent structures and

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Fig. 11 Asymptomatic large dentigerous cyst of the left mandibular third molar. (a) Preoperative dental panoramic radiograph; (b) Mucosa
overlying the cyst; (c) Aspiration of cyst contents; (d) Incision for the buccal two-sided flap; (e) Elevated flap exposing bone; (f) Window
cuts in the bone using a fissure bur to expose and enucleate the cyst; (g) Radiopaque ‘spray’ of bismuth iodoform paste lining the shrinking
cyst cavity with h) bony infill of the cavity; (i) Post extraction of lower left 8 once there was sufficient bone to minimise risk of mandibular
fracture

is simple and relatively quick to perform, often mucoperiosteum and the small amount of cyst An alternative technique is to leave the
being carried out under local anaesthesia. lining removed are sent for histopathological cavity open and instruct patients on the use
It should involve incision around the cyst diagnosis. The pack should remain in situ for of irrigation using an antiseptic medicament
margin; tissue is removed for histology to at least 10 days, when it can be removed and and a blunt-ended syringe. In either case,
confirm the putative diagnosis, the mucoperi- replaced as necessary. As the cavity shrinks in regular follow-up is a necessary component
osteal flap is reflected and bone is removed to size it is repacked with smaller dressings, and of treatment.
expose as much of the cyst as possible. The even gutta-percha plugs, acrylic stoppers or There are disadvantages to marsupialisation
patency of the hole should then be secured extensions to dentures have been employed. as it offers decreased amounts of tissue for his-
by suturing the cyst lining to the mucosa This procedure not only allows decreases tological examination and protracted incon-
using sutures such as black silk or Vicryl. in the hydrostatic pressure (which is an venience and repeated visits for the patient
The cyst cavity can then be carefully packed essential component of cyst formation in most and clinician alike over months or even years
open using a non-resorbable material such as instances) but also allows the cyst lining to be until healing is complete. Nonetheless, while
ribbon gauze soaked in Whitehead’s varnish repopulated by keratinocytes migrating in enucleation is the treatment of choice for the
or bismuth iodoform paste. The overlying from the oral mucosa at the edge of the wound. surgical treatment of the majority of cysts there

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are four situations where marsupialisation is be an eosinophyllic granuloma (a form of

invaluable: Langerhans cell histiocytosis) which requires
1. Where the patient is unfit because relatively medical management, not surgery and
large cysts can be treated quickly under long-term review.
local anaesthesia.
2. Where a high rate of recurrence is antici- Cysts involving the maxillary antrum
pated – for example in the treatment of
odontogenic keratocysts. In such cases Surgical pathology of the maxillary antrum is
proponents argue that any recurrence is covered in Part 2 of this series (BDJ 2017; 223:
directly visible, but marsupialisation of such 483–493) or Chapter 2 in the associated BDJ
cysts remains controversial and primary Clinical Guide).
enucleation is usually the preferred option Many cysts that arise within the maxilla will
unless there are overriding factors concern- expand upwards, pushing the antral lining
ing the patient’s general health. superiorly and leaving the antral airspace
3. Where it is desirable that the teeth within separate from the cyst cavity. However, in
the cyst are allowed to erupt. In these cases, some cases (especially as a result of secondary
ie eruption and dentigerous cysts (where infection), the very thin antral lining may
the operator wishes to retain the tooth/ break down, allowing the cyst to expand into
teeth), most of the cystic lesion is excised, the maxillary antrum itself. In determining
and the crown of the tooth is surgically the extent of the cyst and destruction of the Fig. 12 Long cone periapical radiograph of
exposed. thin antral wall, conventional and 3D refor- lower anterior incisors where root canal
treatment of a non-vital tooth did not
4. Where the cyst is associated with the roots matted CT scans may be useful. In situations
resolve a presumed radicular cyst; on biopsy,
of many vital teeth, the inferior alveolar where the maxillary antrum is in continuity
eosinophyllic granuloma was confirmed
nerve or a risk of fracture. with the lining of the cystic lesion, enucleation
can be performed safely so long as the antral
Postoperative care floor remains intact, the defect becoming the floor of the mouth, in the sublingual and
Patients are usually initially reviewed 5-7 days re-epithelialised from the residual antral submandibular region. Patients may present
post-operatively regardless of the treatment lining. Enucleation is therefore the principal with an enlarging swelling under the tongue
modality. The prescription of antibiotics is treatment of choice, with a few notable excep- that is affecting speech and eating. Both types
contentious but still commonly employed tions (see ‘Enucleation of cysts’ in this chapter). of cyst are developmental, the dermoid cyst
along with postoperative analgesia. The use of Where a cyst involves the maxillary antrum, being lined with ectodermal tissue and the
intraoperative steroids to reduce postoperative inhalation and sympathomimetic agents may epidermoid cyst with epidermis-like cells.
swelling also remains controversial. be of some additional benefit. The epidermoid cyst is found more commonly
Clinical and radiographic follow-up of the on the external skin whereas the dermoid
treated cyst will depend largely on the histo- Soft tissue cysts cyst may present either above or below the
pathological diagnosis. Clinical examination mylohyoid muscle, but is bimanually palpable
accompanied by intermittent radiographic Mucocoeles in the submental region and in the floor of the
examination to observe new bone formation By far the most frequently encountered soft mouth. King et al. review 195 cases of dermoid
is usually sufficient to assess the degree of tissue cysts of the oral cavity are the minor and epidermoid cysts in their paper.27
healing. In large cysts that have been marsu- salivary gland cysts. These can be formed by Aspiration, which is often not possible,
pialised, it may be 18 months before there is mucous extravasation (into the adjacent tissues) produces keratin. These lesions can grow
any appreciable diminution in size on radio- or mucous retention (within the small ducts) to several centimetres in diameter and
graphs. However, enucleated cysts usually heal and are seen most frequently in the lower lip are generally better treated in the hospital
uneventfully and show rapid bony repair such and floor of the mouth (although they can occur setting under general anaesthesia. They are
that patients can often be discharged at the anywhere there are mucous glands. Collectively, enucleated via intraoral, extraoral or occa-
6-monthly review. these tend to be referred to as mucocoeles as they sionally combined approaches. An intraoral
In the case of odontogenic keratocysts, are clinically indistinguishable.26 Mucocoeles approach involves an incision being made in
follow-up is essential over a long period of time are normally treated by excising an ellipse of soft the depth of the lingual sulcus in the floor of
(at least 5 years) due to the high frequency with tissue and enucleating the lesion. A proportion the mouth. Blunt dissection is carried out to
which they recur and the rate of growth they of these recur but this can almost certainly be avoid damage to the submandibular ducts. The
can exhibit. reduced by excising the tiny adjacent mucous lesion has a thick lining, which aids enuclea-
It should be noted that if resolution does glands along the incision line. tion. A sublingual drain may be required for
not take place when root canal treatment 24 hours to reduce the size of any sublingual
is performed for what is presumed to be Dermoid and epidermoid cysts haematoma and steroids should be adminis-
a radicular cyst (Fig.  12) associated with These cysts are uncommon in the mouth tered. Ultrasound is of use when investigating
a non-vital tooth, then biopsy may be although both can occur. Usually asympto- such soft tissue lesions of the neck to determine
necessary. The lesion in Fig.  12 proved to matic, they typically occur in young adults in their distribution.

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Thyroglossal cysts thymic cyst, cystic hygroma, lingual cysts and 12. Shear M. Developmental odontogenic keratocysts. An
update. J Oral Pathol Med 1994; 23: 1–11.
Thyroglossal cysts may present anywhere along various intrasalivary gland cysts. This list is 13. Stoelinga P J W, Peters J H. A note on the origin of
the tract resulting from the migration of the not exhaustive and readers are again directed keratocysts of the jaws. Int J Oral Surg 1973; 2: 37–44.
14. Pitak-Arnnop P, Chaine A, Oprean N, Dhanuthai K, Bertrand
thyroid gland from the foramen caecum, at the to Shear and Speight’s textbook for a more J C, Bertolus C. Management of odontogenic keratocysts
junction of the anterior two-thirds and posterior detailed treatise on the subject.19 of the jaws: a ten-year experience with 120 consecutive
lesions. J Craniomaxillofac Surg 2010; 38: 358–364.
third of the tongue. Pathognomonically, and in 15. Shear M, Pindborg J J. Microscopic features of the lateral
1. Reichart P A, Philipsen H P. Aneurysmal bone cavity
contrast to the dermoid cyst, the cyst moves (cyst). In: Odontogenic tumours and allied lesions. Lon- periodontal cyst. Scand J Dent Res 1975; 83: 103–110.
don: Quintessence, 2004. 16. Main D M. Epithelial jaw cysts: a clinicopathological
with the larynx when swallowing or protrud- reappraisal. Br J Oral Surg 1970; 8: 114–125.
2. Kramer I R. Changing views on oral disease. Proc R Soc
ing the tongue. These cysts should be treated in Med 1974; 67: 271–276. 17. Craig G T. The paradental cyst. A specific inflammatory
3. Barnes L, Eveson J W, Reichart P, Sidransky D. World odontogenic cyst. Br Dent J 1976; 141: 9–14.
the hospital setting under general anaesthesia. 18. Main D M G. Epithelial jaw cysts: 10 years of the WHO
Health Organization classification of tumors. Pathology
and genetics of head and neck tumours. Lyon: IARC Press, Classification. J Oral Pathol 1985; 41: 1–7.
19. Shear M, Speight P M. Cysts of the oral and maxillofacial
Nasolabial cysts 2005.
regions. 4th ed. Oxford: Blackwell Munksgaard, 2007.
4. Pindborg J J, Kramer I R H, Torloni H. Histological typing
Nasolabial cysts arise as a swelling between of odontogenic tumours, jaw cysts, and allied lesions. 20. Daley T D, Wysocki G P, Pringle G A. Relative incidence
Geneva: World Health Organization, 1971. of odontogenic tumours and oral and jaw cysts in a
the upper lip and lateral aspect of the alar Canadian population. Oral Surg Oral Med Oral Pathol
5. Soames J V, Southam J C. Oral pathology. Oxford Univer-
cartilage of the nose. Occurring most fre- sity Press, 2005, p. 69. 1994; 77: 276–280.
21. Kramer I R H, Pindborg J J, Shear M. Histological typing
quently in females in the 20- to 40-year age 6. Hjørting-Hansen E, Andreasen J O, Robinson L H. A
of odontogenic tumours. Berlin: Springer, 1992.
study of odontogenic cysts, with special reference to
group, the cysts are superficially placed and location of keratocysts. Br J Oral Surg 1969; 7: 15–23.
22. Horner K, Forman G H, Smith N J. Atypical simple bone
cysts of the jaws. I: Recurrent lesions. Clin Radiol 1985;
not visible radiographically unless they resorb 7. Meningaud J P, Oprean N, Pitak-Arnnop P, Bertrand J C.
39: 53–57.
Odontogenic cysts: a clinical study of 695 cases. J Oral
the underlying bone. Lined with stratified Sci 2006; 48: 59–62.
23. Brandsetter B F, Weissman J L, Kaplan S B. Imaging of a
Stafne bone cavity: what MR adds and why a new name
squamous or respiratory epithelia, these cysts 8. Lin L M, Ricucci D, Lin J, Rosenberg P A. Nonsurgical root
is needed. Am J Neuroradiol 1999; 20: 587–589.
canal therapy of large cyst-like inflammatory periapical
are best removed via an intraoral approach and lesions and inflammatory apical cysts. J Endod 2009; 35:
24. Evans G E, Bishop K, Renton T. Guidelines for surgical
endodontics. London: Royal College of Surgeons of
enucleation is curative. 607–615.
England, 2012. http://www.rcseng.ac.uk/fds/publica-
9. Browne R M, Smith A J. Pathogenesis of odontogenic tions-clinicalguidelines/ clinical_guidelines/documents/
cysts. In: Browne R M (ed), Investigative pathology of surgical_endodontics_2012.pdf
Other soft tissue cysts odontogenic cysts. Boca Raton, FL: CRC Press, 1991. 25. Stoelinga P J W. Long-term follow-up on keratocysts
10. Avelar R L, Antunes A A, Carvalho R W, Bezerra P G,
Other soft tissue cysts occur infrequently and treated according to a defined protocol. Int J Oral Maxil-
Oliveira Neto P J, Andrade E S. Odontogenic cysts: a lofac Surg 2001; 30: 14–21.
may involve the face, the mouth or the neck. clinicopathological study of 507 cases. J Oral Sci 2009; 26. Bhaskar S N, Bolden T E, Weinmann J P. Pathogenesis of
Of these the branchial cleft cyst (cervical 51: 581–586. mucoceles. J Dent Res 1956; 35: 863–874.
11. Mosqueda Taylor A, Irigoyen Camacho M E, Diaz Franco 27. King R C, Smith B R, Burk J L. Dermoid cyst in the floor
lympho-epithelial cyst) is probably the most M A, Torres Tejero M A. Odontogenic cysts. Analysis of of the mouth. Review of the literature and case reports.
common, with rarer examples including the 856 cases. Med Oral 2002; 7: 89–96. Oral Surg Oral Med Oral Pathol 1994; 78: 567–576.

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