This article attempts to analyze all cases of odontogenic cysts involving upper jaw who presented at Stanley Medical college during 2007 – 2012. This article analyzes the incidence of these cystsduring the above said period, age of occurence, sex prediliction if any, clinical presentations and optimal treatment modality. Common complaints with which patients presented to our Institutionwas swelling over jaw, next was loosening of dentition, paresthesia. 30 patients had presented with cysts involving upper jaw out of which 29 were females and one was male. All these patientsunderwent surgical removal of the cystic lesion.

Ramamoorthy, Geetha

Thiagarajan, Balasubramanian

English

Otolaryngology online journal

ISSN: 2250-0359                                                               Volume 3 Issue 3 2013
Odontogenic Cysts of upper jaw an analysis
Balasubramanian Thiagarajan   Geetha Ramamoorthy
Stanley Medical College
Abstract:
This article attempts to analyze all cases of odontogenic cysts involving upper jaw who presented at 
Stanley Medical college during 2007 – 2012.  This article analyzes the incidence of these cysts 
during the above said period, age of occurence, sex prediliction if any, clinical presentations and 
optimal treatment modality.  Common complaints with which patients presented to our Institution 
was swelling over jaw, next was loosening of dentition, paresthesia.  30 patients had presented with 
cysts involving upper jaw out of which 29 were females and one was male.  All these patients 
underwent surgical removal of the cystic lesion.
Introduction:
International Classification of Diseases (ICD 10) classifies odontogenic cysts involving upper jaw 
into:
1. Radicular cysts
2. Dentigerous cysts
3. Primordial cyst
4. Lateral periodontal cyst
5. Residual cyst
6. Odontogenic keratocyst
7. Calcifying odontogenic cyst  (Gorlin cyst)
8. Globulomaxillary cyst
These cysts are the most common cystic lesions involving maxillofacial area 
1.  Cystic lesions are 
common in the jaw bones than anywhere else in the body because of the presence of epithelial cell 
rests which are commonly left behind following odontogenesis
 2.Radicular cysts:
Synonyms – Periapical cyst, dental cyst
This is the commonest of all odontogenic cysts
 3.  These cysts could also be considered as an 
inflammatory cyst originating from Malassez's cell rests
 4.  These cysts are caused by root infections 
involving roots of teeth closely related to maxillary sinus antrum.  Infections / inflammation 
releases toxins at the apex of the tooth leading on to periapical inflammation.  They stimulate the 
Malassez's cell rests which can be found in the periodontal ligament resulting in periapical 
granuloma which could either be infected or sterile.  These cysts could well be sterile if the patient 
had received antibiotic therapy for dental infections.  Radiological differentiation between 
granuloma and cyst could prove to be rather difficult.  The general rule of the thumb being if the 
lesion is large in radiological imaging then it should be considered as cyst.  These cysts increase in 
size at the expense of the surrounding bony barrier.  This expansion is caused by pressure effects 
and effects of inflammatory enzymes over the surrounding bone.  These cysts are lined by stratified 
squamous epithelium without kerain formation.  Evidence of inflammation can be seen along the 
cyst wall.
Pathophysiology of radicular cysts:
1. Inflammatory mediators / enzymes
2. Bacterial toxins
These two factors have been implicated as the probable factors contributing to Radicular cysts.  
Among these two Bacterial toxins play a rather vital role.  Bacterial endotoxins have been found in 
large amounts in and around necrotic tooth.  These toxins have been shown to be mitogenic
 5.  These 
endotoxins also stimulate expression of cytokines and chemokines
 6.  Inflammatory mediators and 
proinflammatory cytokines  released by the host tissue are known to modulate the biochemical 
activity of epidermal growth factor (EGF) there by causing increased proliferation of cellular 
elements.  They also stimulate local fibroblasts into hyperactivity by expressing Keratinocyte 
growth factor.  The epithelial cell rests of Malassez are usually quiescent / stable cells.  These cells 
are in the G0 phase
 7 of their cell cycle.  These cells need to be exposed to extracellular signals to 
push them into the cell cycle proper.  These extracellular signals are collectively known as Mitogen. 
Experimentally a cell can be identified to be in the proliferative phase by their ability to express 
markers like PCNA and Ki-67.  Ki-67 marker is present in cells belonging to all phases of cell 
division except G0 phase.  Studies reveal increased levels of PCNA and Ki-67 markers in the 
epithelial lining of radicular cysts
 8.  
The actual binding of Mitogen (growth factor) to receptors present on the cell membrane surface 
initiates a series of intracellular reactions pushing the cell into mitotic phase.
Probable growth factors (Mitogen) involved in the pathogenesis of radicular cysts include:
1. EFG & KGF – released by stromal fibroblast
2. TGF-α – released by macrophages and lymphocytes
3. IGF (Insulin like growth factor) – released by stromal fibroblasts
In the pathophysiology of formation of radicular cysts mediators released by inflammatory cells (macrophages and lymphocyts) play a vital role
 9.
Enlargement of radicular cyst:
This invariably occurs at a rather slow pace.  Various factors influence the rate of expansion.  These 
factors include:
1. Mural growth
2. Hydrostatic enlargement
3. Bone resorbing factor 
10
Rapid expansion of radicular cyst is associated with increase in hydrostatic pressure within the cyst. 
The hydrostatic pressure within the cyst is higher than that of capillary pressure, causing fluid to 
enter from the capillaries into the cyst cavity.  This high hydrostatic pressure within the cyst has 
been attributed due to the amount of high molecular weight protein present in the cyst fluid.  This 
protein is released by inflammatory cells in response to inflammatory stimulus.
Role played by mast cells in radicular cyst enlargement:
Mast cells play a significant role in radicular cyst enlargement 
11.  Studies reveal that there are 
increased number of mast cells in the subepithelial zone of these cysts.  Mast cells contribute to 
increase in the size of these cysts in the following manner:
1. By directly releasing heparin into the lumen
2. By releasing hydrolyic enzymes
3. By releasing histamine which causes transudation of serum proteins 
11
Bone resorption by radicular cysts:
Radicular cysts causes resorption of alveolar process of maxilla.  Osteoclasts have been known to 
cause this bone resorption.  Osteoclasts need to be activated before it can reabsorb bone matrix.  
Osteoclasts can be activated by:
RANKL
This reaction can be blocked by:
Osteoprotegerin (OPG)
RANKL is the molecule which activates osteoclasts by binding to its receptor RANK  which is 
expressed on the surface of osteoclast precursor cells, where as OPG blocks this very reaction 
preventing activation of osteoclasts.Inflammatory mediators like cytokines and Interleukins stimulate prolilferation of osteoclasts.
In response to inflammation host cells are known to produce Matrix Metallo Proteinase (MMP).   
This molecule is capable of degrading extracellular matrix like collagen, fibronectin and 
proteoglycans.  Endotoxins released by bacteria also stimualtes release of MMP.  This substance 
helps osteoclasts in the bone resorption process.
Dentigerous cysts:
Also known as follicular cyst.  This cyst is associated with unerupted tooth.  This cyst is formed due 
to accumulation of fluid between the enamel epithelium and the completely formed tooth crown.    
This overlying cyst prevents teeth from erupting.  This cyst is almost always associated with 
permanent dentition.  In the upper jaw it is common in the canine tooth area.  This cyst has its 
highest incidence during the 2
nd and 3
rd decades of life.  
Radiologically the presence of pericoronal radiolucency is a diagnostic pointer.  This tumor should 
be differentiated from ameloblastoma, odontogenic keratocyst and calcifying odontogenic cyst.  All 
these lesions manifest with pericoronal radiolucency in routine radiographs.
Primordial cyst:
This cyst arises due to cystic changes that occur in a developing tooth bud before the actual 
formation of enamel and dentin matrix.  Since this cyst arises from developing tooth bud the tooth 
would be missing from the dental arch, or if teeth are all present then the presence of  
suprenumerary teeth should be suspected.
Lateral periodontal cyst:
This cyst develops from the periodontal ligament close to the lateral surface of erupted / unerupted 
teeth.  This cyst is asymptomatic.  The involved teeth is vital.
Residual cyst:
This cyst arises from remnants of epithelial cell rests left behind after extraction.  This can also 
occur when  a radicular cyst at the apex of the teeth is extracted.  This cyst is commonly seen in the 
elderly.
Odontogenic Keratocyst:
This cyst has a keratinized epithelial lining.  Major draw back of this condition is its propensity to recur even after complete removal.  This cyst can mimic any of the cysts described above.  It needs 
to be identified radiologically and pathologically.  This cyst is seen between wide age groups.
Calcifying odontogenic cyst (Gorlin's cyst):
This is a very rare slow growing benign tumor like cyst.  This condition manifests the features of 
solid mass while displaying features of tumor and cystic lesion.  This cyst has equal incidence in 
both maxilla and mandible.
Globulomaxillary cyst:
This is actually a fissural cyst arising from epithelial inclusions trapped at the line of fusion between 
the globular portion of the median  nasal process and the maxillary process.  Pathologists consider 
this cyst to be odontogenic rather than developmental.  Radiographs show these cysts as pear 
shaped / circular shaped between the roots of maxillary lateral incisor and canine.  Both these teeth 
are vital in these patients.
Results:
No of patients presented with cystic lesions involving upper jaw during study period – 30
Females – 29
Male – 1
Age of occurence:
60-70 years – 22
40-50 years - 8
Type of cystic lesions:
Radicular cyst – 18
Dentigerous cyst – 6
Lateral periodontal cyst - 3
Residual cyst – 1
Globulomaxillary cyst – 2Chart showing the number of male and female patients who presented with cystic lesions of upper 
jaw
Male
FemaleChart showing the different types of cystic lesions encountered in our study
Radicular
Dentigerous
Lateral periodontal
Residual
Globulomaxillary
0
2
4
6
8
10
12
14
16
18Chart showing the complaints with which these patients presented with
Clinical photograph of patient with swelling left upper jaw due to cystic expansion
Swelling Loosening of teeth Parasthesia Pain
0
5
10
15
20
25
30
Row 2Clinical photograph showing radicular cyst maxilla being exposed via sublabial incision
Coronal CT of nose and sinuses showing radicular cyst of upper jawCT scan axial cut of nose and sinuses showing globulomaxillary cyst
CT scan showing dentigerous cyst with unerupted teethPicture showing dentigerous cyst exposed via sublabial incision
Picture showing unerupted tooth within dentigerous cystDiscussion:
All patients who reported to our hospital with cystic lesions of upper jaw were managed surgically.  
These cysts were accessed via sublabial approach.
Specimen of radicular cyst after removal
One patient in our study had a rapidly enlarging lesion involving the maxillary bone.  The whole 
enlargement took place within a span of 3 weeks.  This cyst was found to be filled with pus when 
aspirated.  Acute infections of the cyst can lead to rapid enlargement of the cyst.
All specimen surgically removed from our patients were submitted for histopathological 
examination for final diagnosis.  
As is the case in our study too radicular cysts of upper jaw constituted the majority.
Since majority of cystic lesions involving the maxilla are benign in nature, removal via sublabial 
approach would suffice.
Conclusion:
This retrospective study shows that the commonest cystic lesion of upper jaw happens to be 
radicular cyst.  Considering the benign nature of the lesion complete extirpation of the cyst would 
suffice.  In one patient the cyst was so large it had to be ruptured to ensure complete removal of the 
cyst wall.  CT scan is virtually diagnostic.  Histopathology remained the final say in the diagnosis.
Age of presentation of our patients happens to be between 40-60.  Almost all of them were females 
except for one patient (dentigerous cyst) who happend to be a male.References:
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Odontogenic Cysts of upper jaw an analysis

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Odontogenic Cysts of upper jaw an analysis

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