J Orat I'lilhot Meil tW4: 2,<: I It Copyright J* Munksgaard 1994

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JOURNAL OF

ISSN 0904-2512

Review article

Developmental odontogenic Mervyn Shear

Department of Oral Pathology,
University of the Witwatersrand,
Johannesburg, South Atrtca
cysts. An update^
Shear M; Developmental odontogenic cysts. An update, J Oral Pathol Med 1994;
23; I 11, ( Munksgaard, 1994,

This review paper reports recent advances in the subject of developmental odonto-
genic cysts, essentially those of the past decade, starting with reference to the new
WHO classification (1), On keratocysts, the latest reported recurrence rates are
assessed as are their mode of growth, immunocytochetnistry, immunology,
genetic studies, and work on specific keratocyst antigens. There is a critical
account of the group of lesions which includes the gingival cyst of adults, lateral
periodontal cysl, boUyoid odontogenic cyst and glandular odontogenic cyst, and Key words; cysts; odontogenic cysts
ihcir possible relalioiiship to one another. On dentigerous cysts, reference is made
to the relationship between them and deciduous teeth, as well as to their itnmuno- Mervyn Shear, Department of Oral Pathology,
cytocheniistry and immunology. Recent work on the unicystic ameloblastomas, University of the Western Cape, Private Bag
X08, 7785 Mitchells' Plain, South Africa
their classification and prognosis, is assessed, as is the calcifying odontogenic
cyst and its relationship with solid odontogenic tumours. Accepted for publication July 23. 1993

Classification (primordial cyst), and numerous papers with Carnoy's solution. The recurrence
on the subject have been published since rate in their first group was 13,5 per
The World Health Organization has re- an earlier review (2), cent in a I 21 year follow-up, while the
cently ptiblished ihe second edition of The frequency in our material has re- recurrence rate in their second group
Ilistological typing of odontogenic tu- mained constant at about 11 per cent of has been 2,5 per cent in a i-10 year
nwtir,s (I) which includes ihe proposed jaw cysts but is lower in some reported follow-up. Similarly. FORSSHLL ct al, (4)
cla,ssification of jaw cysts. The cpitheli- series. have pointed out that in their series of
al-lincd cysts may be of dcxclopmcntal keratocytes treated before 1975. the re-
origin, either odontogenic or non-odon- currence rate was 50 per cent, whereas
togenic; or they may be of innammatory Recurrence rates in the group treated duritig the period
origin (Kig, I), It is the recent advances, Reported recurrence rates continue to 1975 1980, the recurrence rate had
essentially those in the past decade, be high in most studies, although some dropped to 22 per cent,
which have been reported on the devel- reports indicate a declining frequency NII;MEYHR ct al, (5) reported that their
opnicnlal odontogenic cysts that are of recurrences with better understand- experience of recurrences in a series of
dealt with in this review, albeit selective- ing of the behaviour of this lesion and 62 patients with keratocysts was related
ly. The calcifying odoniogenic cysl. consequent modifications in their treat- to the operative procedure employed.
which in the WHO classification is listed ment. This view is borne out by the Thirty-three of their patients were fol-
as a benign neoplasm, will be included experience of VOORSMIT ct til, (3) who lowed for at least 6 years. The highest
ill this review. The order in which the reported the results of a follow-up study frequency of recurrences occurred in
different lesions are presenteil does not of two groups of patients treated for their patients treated by cystostomy. On
follow thai in the WHO classification, keratocysts. In the ftrst group of 52 the contrary. BRONDUM & Ji-NStN (6)
cases treated between 1959 and 1980. reported that in a 7 to i7 year follow-
the cysts were treated conservatively by up, there were no recurrences in 12 of
Odontogenic keratocyst (primordial
careful enuclealion of the entire wall, in their cases treated by cystoslomy to re-
cyst) duce the size of the lesions before cystec-
the second group of 40 cases treated
There continues lo be considerable in- between 1970 and 1980. the cysts were toiny. whereas there were recurrences in
terest in the odontogenic keratocyst removed by enucleation, along with ex- 8 of their 32 cases treated by primary
eysteciomy.
' Based on a lecture delivered al the 6th Bien- cision of the mucosa overlying any per-
nial Congress of the International Associa- foration of the cortical bone which was The considerable variation in recur-
tion of Oral Pathologisis, ,Iuly 1992, in Ham- determined at operation. Before remov- rence rate reported by different workers
burg, (iermany. al, all cysts in this group were treated may be ascribed partly to the variability
2 SHBAR
Fig. / World Health O r g a n i z a t i o n classification of epithelial cysts of the j a w s ( I ) .
Rpithelial cysts
Developmental
I 'Gingival cysts" of infants (Hpstein's pearls)
.2.Odontogenic keratocyst (primordial cyst)
.3 Dentigerous (follicular) cyst
.4 Eruption cyst
.5 Lateral periodontal cyst
,6 Gingival cyst of adults
.7 Glandular odontogenic cyst; sialo-odontogcnic cyst
.2 Nnn-Oiiimtogenic
.2.1 Nasopalatine duct (inciisive canal) cyst
.2.2 NasoJabial (nasoalveolar) cyst
3.2 Inllammatory
3.2. Radicular cyst
3.2. . I Apical and lateral
3.2. .2 Residual
3.2.2 Paradental (inflammatory collateral, mandibular infected buccal) cyst
Morphology code of the International Classiftcation of Diseases lor Oncology (ICD-O)
and the Systematized Nomenclature of Medicine (SNOMfiD).
in the follow-up period, VKDTOKTF; &
PR/ETORIUS (7). FoR,s,sELL (8) and FOR.S-
.SRI.I. ct al. (4) have shown quite clearly
that in their own material the recurrence
rate increased with extension ofthe fol-
low-up period to 5 years or more. The
latter authors (4) found that of 75 cases
in 63 patients followed for periods rang-
ing from 5 to 17 years (mean S.3). 32
(43"^) recurred. The cumulative recur-
rence rate of 67 of these cysts in patients
examined annually increased from T/n
after the first year to'STA.after the third
year. Thereafter, no new recurrences
were noted.
Age
Further studies reported over the past
few years confirm the bimodal age dis-
tribution of patients with keratocysts
(9 13), The explanation for this is prob-
ably that some keratocysts remain un-
diagnosed for many years, extending
slowly either in the maxilla or along the
mandible and into the a.scending ramus,
rather than that there are two different
varieties of the lesion,
W(K)LC;AR et al. (14) have pointed out
that the mean age of patients with multi-
ple keratocysts. with or without the
naevoid ba.sal cell carcinoma syndrome,
is considerably lower than the mean age
of patients with single non-recurrent
keratocysts and that pooling patients
Irom the three groups will account for
differences in age distribution reported
in different studies.
Mode of growth of the keratocyst
et al. (15) studied the pro-
liferation patterns ofthe epithelium and
26540*
26530
26560
26550
26520
26540
26520
266(J0
26500
43X00
26520
connective tissue of a keratocyst by
means of autoradiography and DNA
cytophotometry in serial sections sam-
pled in numerous areas. These were
compared with the proliferation pat-
terns in a radicular cyst studied in the
same way. The epithelium of the kerato-
cyst showed a higher rate of prolifera-
tion than the radicular cyst. The mean
marking index was also substantially
higher in the keratocyst than in the ra-
dicular. The authors identified both
slowly and rapidly proliferating areas in
different parts ofthe keratocyst epitheli-
um and in different planes of section.
They also demonstrated that the con-
nective tissue wall of the keratocyst
showed both slowly and rapidly prolif-
erating areas, whereas the connective
tissue wall of the radicular cyst showed
a low mean marking index. They con-
cluded that exclusively passive expan-
sion of the cyst connective tissue as a
reaction to the growth ofthe keratocyst
was unlikely. They thought that the in-
vasive growth of keratocysts was likely
to he the result of active growth of the
connective tissue wall,
AiiLtoRS et al. (9) had postulated
something along similar lines when in
1984 they proposed that the keratocyst
should be regarded as a benign neo-
plasm. They drew attention to the in-
folding of the epithelial lining into the
capsule and suggested that this was the
result of active epithelial proliferation
accompanied by collagenolytic activity
within the fibrous capsule and resorp-
tion of bone.
SMrrii ('/ al. (16 18) have reported a
series of three studies on the presence
and role of glycosaminoglyeans in
odontogenic cysts, including kerato-
cysts. In all cyst types, hyaluronic acid
was the predominant glycosaminogly-
ean present, as it was in the cyst fluids.
Heparan and chondroitin-4-sulphate
were present in substantial amounts, he-
paran sulphate showing a higher inci-
dence and abundance in the keratocyst
than the other cysts, A considerable
proportion of the glycosaminoglyeans
appeared to be complexed with protein
and was released only after proteolytic
digestion. Mast cells were widespread in
the connective tissue of all cyst types,
particularly adjacent to the epithelium,
and were probably the source of the
heparin. Epithelial permeability, the au-
thors suggested, would probably allow
passage of smaller glycosaminoglycan
chains into the luminal fiuid. The larger
chains would probably pass through ep-
ithelial discontinuities. They concluded
from their series of studies that the re-
lease of these molecules into the luminal
lluid could be expected to contribute
significantly to its osmotic and hydros-
tatic pressures and hence to the expan-
sile growth of odontogenie cysts.
Radiology
While most keratocysts which appear to
be dentigerious on radiographs are in
fact envelopmental keratocysts, very oc-
casionally the lining of a cyst in a true
dentigerous relationship may be iden-
tical to that of a keratocyst. This con-
cept has been developed by Ai.riNi &
C()III;N (19) who have introduced the
term 'follicular primordial cyst" (follicu-
lar keratocyst) for this. They postulated
that follicular keratocysts might arise
following eruption ofa tooth into a pre-
existing keratocyst ciivity in the same
way as a tooth erupts into the oral eavi-
ty. In a later study (20), they were able
to support their hypothesis in a series
of animal experiments.
It is noteworthy that in the rather
extensive literature published on the
subject of keratocysts over the past 10
years by authors with considerable ex-
perience in the diagnosis and treatment
of these lesions, very little reference has
been made to the use of cotiiputerised
tomography (CT) in their assessment,
VooRSMiT (12) described two cases in
which this techniqtie was used "to ob-
tain accurate meastiremenl ofthe exient
ofthe lesion, exaet localization of areas
of perforation through the cortex and,
particularly, assessment of soft tissue in-
volvemenL" He described the important
features of the technique as lack of
image superimposition, preservation of

soft tissue detail, selective enlargement
of areas of interest, a high degree of
accuracy and the possibility of three-
dimensional interpretation. On the
other hand, tesolutioti of ftnc details is
poorer than with conventional or xero-
tomography. Ihe high expense of the
procedure is referred to, but not the
hazards of the radiation exposure,
MACKIN/II: rt al. (21) reported the
use of computerized tomography in
the diagnosis of a keratocyst and em-
phasized the considerably higher ab-
sorbed doses of radiation, particularly
to the lens of the eye. In general, these
authors stated, the absorbed radiation
from CT studies is about 1000 titiies
higher than those associated with a
patioramic study. The associated risks,
the cost of the examination, and the
limits of the CT scan must be weighed
against Ihe additional information
which can be obtained from the proee-
dure before it is used on an individual
patient.
A leport by a joint working party
ofthe National Radiological Protection
Hoard and the Royal College of Radiol-
ogists in Britain, while stressing the ben-
efits of X-rays in diagnositig di.sease.
commented nevertheless that the avoid-
able dose of radiatioti frotn tnedicine
"outweighs the combined eontributioti
of all other nian-niade sources of popu-
hilion radiation exposure by a factor o\'
three" (22). Data obtained by the Board
indicated that CT scans now account
lor at least 20'^ of the total effective
dose of diagnostic radiation to the
populatioti. and the secietary of ihe
working party has suggested lliat radiol-
ogists slioiikl be informed ofthe "high-
dose implieations" of CT scans. When-
ever possible, the report suggested, doc-
tors should use the alternatives to X-
ray. mainly ultrasotind and magnetic
resonance imaging.
Histopathology
The histological features of the kerato-
cyst ate vvell-doetnnented and reqtiiie
little elaboration. Three recent studies
have all shown that basal budding,
odonlogenie rests in the eyst wall and
satellite cysts apix'ar to be more coni-
moti it) the eysts o\' patietits with the
naevoiii basal cell carcinoma syndrome
than in cyst patients without the syn-
dtome (9. ly 25).
SMr rii ct al. (26) foutul that tnast eells
were ptesent in substantial ntinibets in
keratocyst walls, as well as in the walls
of dentigerotis and radieular eysts. The
highest eoticentration was in the sub-
epithelial zotie where the count was 5,71
(SD±3,52) per tnicroscopie field, the
latter being defined as the area encotii-
passed by a 1 em- graticule. M;tst eells
were also observed in the epithelial
linings, whieh the authors suggested im-
plies a chemotactic stimulus to mast
cells in odontogenie cysts, attracting
them to the epithelial lining or luminal
fiuid contents.
There has been eonsiderable interest
recently in itntnunohistoehemical teeh-
tiiques that ean be used to improve the
aecuracy of histopathological diagnosis,
Immunohistochemical staining with
monoclonal antibodies was used (27) to
study and compare the cytokeratin eon-
tent of odontogenie eysts. normal gitigi-
val epithelium and atiieloblastomas.
Their results showed that keratocysts.
radicular eysts and dentigerous cysts
have distinet profiles of eytokeratin
polypeptides and that, with the exeep-
tion of some dentigerous eysts. they all
laek large eytokeratins typieal of kera-
tinizing squatnous epithelia. The au-
thors cotieluded that epithelial eells in
keratoeysts appear to undergo a gradual
tnaturation as they tnigrate to the upper
cell layers, whereas in tadicular and
dentigerous cysts, no basal to apical dif-
ferentiation was seen with these anti-
bodies, A surprising finding in their
sitidy was the absence of cytokeratin
polypeptides typieal of keratinizing epi-
thelia. namely numbers 1. 9 and 10/11.
in all keratocyst epithelia. as judged by
two monoclonal atitibodies whieh reaet
with these eytokeratins: KA5. and K^
<S,60. These keratins are typical of tna-
ture keratinoeytes and their absenee in-
dieates, the authors suggested, that no
true keratinization takes place in kera-
toeysts. 1 hey eotieluded thetefote that
the ptesence of true keratinization is not
a distinguishing feature of keratoeysts.
They suggested that a tnarker of the
keratoeyst is the presenee of aceentuat-
ed ba,sal eells together with the presenee
of eytokeratins 8 and 19. eytokeratin
IS being demonstrable in the basal and
suprabasal eells.
L'sing tnonospeeifie antibodies on 50
odontogenie eysts with an enhanced in-
diteet imniunopetoxidase tnethod.
MArriiiAvs ct al. (28). as had HoRMtA
et al. (27), detected keratin 19 in the
epithelial linings of all eyst specitnens.
This keratin was nortnally expiessed by
the majority of epithelial eells, irrespec-
tive of their level withiti the epithelium
and/or dilTerentiation. In contrast to
the findings of HORMIA ct at. (27), how-
DcYclopnwntal odontogenic cysts 3
ever, keratins assoeiated with eornified
epithelia (keratins 10/11) were detected
in the upper suprabasal layers in 17 of
their sample of 18 keratocysts. They
aseribed the eonllietitig results to difler-
enees in the techniques used, and advo-
cated the applieation of monoelonal an-
tibodies to dry eryostat seetions. They
suggested that the apparently kerato-
eyst 'speeifie" profile (keratin 19. 10/
11 positivity) is dependent on eellular
ditTerentiation rather than histogenesis
or eyst type. Keratin profiles are there-
fore unlikely to distinguish between an
infiamed keratocyst which has lost its
typical histological appearance, and
other odontogenic cysts which have
keratinized epithelial linings as a results
of metaplasia. They suggested that the
consistent expression of both keratins
13 and 19 tnay provide a useful tnarker
of odontogenie epithelium in general.
The consistent histological appear-
ance of keratocyst epithelium suggested
to Sniui.KR & SnRivi R (29) that a spe-
eifie set of genetic events might be re-
sponsible for its particular pattern of dif-
ferentiation. As the pattern of expression
of keratin geties had beeti shown to be
elosely linked to the dilTerentiation of ep-
ithelium, they exatnined the speeifie ker-
atin proteins in the lining epithelium of
keratoeysts by eleetrophoretie and im-
munologie tnethods iti order to deter-
mine whether the unique histologic ap-
pearanee is retiected iti a reproducible
pattern of keiatin proteins.
Their studies were done on three fresh
keratoeyst speeimens, Polyaerylamide
ccl electrophoresis resolved identieal
patterns of proteins in the cytoskeletal
estraets frotn the three eysts. whieh were
in the keratin tnoleeular weight range
(40 to 70 kilodaltons). The qualitative
and quantitative distribution of this
iiroup. whieh eonsisted of 7 proteins,
was identical for all three extraets, Iin-
munoblot analysis of the proteins with
the antikeratin AEl and AE3 mono-
clonal antibodies detnonstrated that the
previously identified pioteitis had kera-
tin atitigenieity. A positive reaction was
observed for all 7 proteins previously
identified, but with variable intensity.
These fitidings were consistent with
other studies whieh had linked epithelial
differentiation and keratin gene expres-
sion, and suggested a eonnnon pattern
of gene expression underlying the ehar-
acteristie histologieal pattet n of the ker-
atoeysl.
These imtnunoeytoehemical studies
are interesting and it is itnportant that
they be puisued beeause they are pro-
4 SHKAR
viding fundamental information about
the tissues being investigated. Thus far.
the diagnostic potential appears to be
limited, and the variability ofthe results
from different laboratories suggests that
there needs to be further refinement and
standardization of the methodology,
KuusELA et al. (30) demonstrated an
antigen in the fiuid of keratoeysts which
was not present in the fiuids of other
eyst types nor in plasma or saliva. A
double-antibody fiuoresence technique
localized the antigen to the epithelial
cells of the keratocyst and they called it
keratocyst antigen (KCA), A later study
from the same laboratory (31) showed
that KCA and keratin are related mole-
cules and that the relationship of keratin
and KCA would enable the use of eom-
mereially available antikeratin antibod-
ies in the detection of KCA in the cyst
fiuids, thus making it possible to distin-
guish keratocysts prior to surgery.
Working along the same lines in the
search for either a single protein, or
group of proteins, that is eharacteristie
of a particular cell type, DotJCit.AS &
CRAIG (32) used immunologieal teeh-
niques to search for eomponents of non-
serum origin in cyst fiuids. Their investi-
gation identified the presence ofa major
antigen, which was not a keratin, in the
fiuid aspirated from all the keratoeysts
whieh they assayed. This antigen was
identified in a later paper by them as
lactoferrin. a secretory substance pres-
ent in the azurophilic granules of poly-
morphonuclear leukocytes and body se-
eretions but not in serum (33). Although
infiammation is rare in keratocysts they
suggested that the polymorphonuclear
leukocytes that infiltrate the cyst wall
aet as the souree of the laetoferrin in
the fiuid and, as it is unable to diffu.se
away into the surrounding tissues be-
cause of the relative impermeability of
the keratocyst to proteins, its concentra-
tion may increase with time. This view
was reinforced in the third of their series
of papers on the subject where they
showed that the lactoferrin concentra-
tion correlated very strongly with the
numbers of neutrophils present in kera-
tocyst fiuids, assessed in smears, but not
with fiuids from dentigerous and radic-
ular cysts (33a).
In a study of immunoglobulin-pro-
ducing eells in human odontogenic
cysts, SMiTit ct al. (34) found that igCi-
containing plasma cells were the pre-
dominant sjjecies in all eyst types with
a much lower percentage of IgA- and
few IgM-eontaining plasma cells. There
were, however, significantly fewer IgG
and significantly more IgA plasma cells eysts reported in the literature is the
observed in the keratoeysts than in the mandibular canine-premolar area, fol-
radieular and dentigerous cysts. IgA lowed by the anterior region ofthe max-
plasma cells appear to represent a signi- illa. In our material, surprisingly, the
fieantly higher proportion of the total distribution was somewhat different.
plasma cell population in keratocysts Although all otir cases occurred anlerior
than in radicular and dentigerous cysts, to the first permanent molars, 10 of 18
although IgG cells still predominate. cases (56'^) were found in the maxilla,
Generally, IgG plasma cells predomi- all of which were clustered anterior to
nate in areas of diffuse chronic infiatn- the first premolar teeth.
mation and the rai.sed proportion of
IgA plasma eells in the keratoeyst may,
the authors speculated, refiect the focal Pathogenesis of the iaterai periodontai
cyst
nature of the infiammatory infiltrate.
They also found intense extraeellular Although there can be little doubt that
staining for IgG in the eapsule and this lateral periodontal eysts are of develop-
they thought would support the view tnental odontogenie origin, there is dis-
that the IgGs in odontogenic cyst fiuids pute about which odontogenic epitheli-
may be derived from local synthesis in um they arise from. There seem to be
the cyst capsules as well as from the three possibilities: teduced enamel epi-
infiammatory exudate, thelium, remnants of dental lamina and
cell rests of Malassez, As is well known,
the cyst is lined for the most part by a
Gingival cyst of adults, iaterai narrow non-keratinized epitheliutn
periodontai cyst, botryoid
whieh resetnbles reduced enamel epithe-
odontogenic cyst and gianduiar lium. As such, the proposal that it arises
(siaio-odontogenic) cyst
initially as a dentigerous eyst developing
This group of lesions also continues to by expansion of the folliele along the
excite interest and there has been some lateral surfaee of the crown (39, 39a) is
advance in thinking on their pathogene- an attractive one. If tooth eruption is
sis and their relationship to one another. nortnal, the expanded follicle may fin-
WYSOCKI ct al. (35) postulated, on the ally lie on the lateral aspect of the root.
basis of their clinical and morphological This hypothesis is supported by the faet
similarities, that the gingival eyst of that lateral periodontal eysts tend to oe-
adults and the lateral periodontal cyst cur in areas where dentigerous cysts are
have a comtnon histogenesis and that likely to be assoeiated with vertieally
they represent the intra-osseous and ex- impacted teeth sueh as mandibular pre-
tra-osseous manifestations of the same molars and maxillary incisors and ca-
lesion. In two recently eompleted stud- nines.
ies, we agreed (36, 37) that the two Further support lor origin of lateral
lesions probably share a common par- periodontal cysts from reduced enamel
entage, and BUCIINI:R & HAN,SI:N (38) epithelium eomes from immunoeyto-
considered that they were probably of ehemical studies. HhiKiNiiMMO et al.
the same epithelial origin. (40) investigated the cytokeratin com-
position ofthe eyst epithelium in a ea.se
of a botryoid variety of lateral perio-
Frequency dontal eyst and found that cytokeratin
There were 14 gingival eysts of adults 18 was strongly expressed; HORMIA ct
and 18 cases of lateral periodontal cyst al. (27) have reported that this eytoker-
registered in our department between atin is present in all the layers of some
1958 and 1989. representing 0,5 and dentigerous eysts but not in other types
O.TAi respectively of the 2616 eysts of the of odontogenie eyst.
jaws seen during that period. Of some WYS(KKI ct al. (35) have proposed
significance, however, is the fact that that the lateral periodontal eyst, like the
these lateral periodontal cysts were re- gingival eyst of adults, arises from elear
corded during the 17-year period eell rests of dental lamina. They suggest-
1973 89. indicating that prior to this a ed that unicystic forms arise throtigh
number of cases were probably going un- cystic ehange in a single dental latnina
recognized. rest and polycystic lesions develop if
concomitant changes oecur in several
adjaeent eell rests. In support of their
Site hypothesis, they placed a lot of empha-
The most frequent location of adult gin- sis on the faet that glyeogen-eontaining
gival eysts and of lateral periodontal elear-eell rests ofthe dental latnina may

sometimes be demonstrated, and that
similar cells also oecur in parts of the
lining of lateral periodontal eysls, as well
as in the epithelial plaques which are a
feature of their linitigs. They also pointed
to the occasional presenee of glyeogen-
rieh clear-cell rests of what they interpre-
ted as dental lamina in the wall of the
cysts. It is important to note, however,
that the epithelial plaques do not coni-
pri.se clear cells dc novo but start rather
as fusiform eells with seanty eytoplasm
arising by loealized proliferation of basal
eells. We have suggested (37) that the
strtietures deseribed as cell tests of the
dental lamina adjaeent (o the eysts are
more likely to be the "pitiehed off exten-
sions ofthe epithelial plaques referred to
above, a coneept originally postulated by
Wi;ATm:Ks& WAI.DRON (41),
I share with WYSOCKI ct al. (35) the
view that the lateral periodontal eyst
and the gingival cyst of adults have a
comtnon ancestry; the lateral periodon-
tal cyst from redueed enamel epitheliutn
before eruption of the tooth and the
gingival eyst of adults from redueed
enamel epithelium after eruption of the
tooth (36, 37, 39a).
The third po,ssibility is origin from
the cell rests of Malassez, Other than
the faet that the rests of Malassez oecur
in the periodontiutn and that they are
well-positioned for a lateral periodontal
cysL this is not a theory which has re-
ceived very much support.
Histology of the iaterai periodontai cyst
A reeent study on a series of 20 lateral
periodotital eysts (37) has cotifirmed the
presence of glyeogeti in abt)ut two-thirds
of them, either in the lining epithelium or
in the plaques, or both, II was not found
exelusively in the clear eells. niatiy of
which showed no positivity. btit also oe-
curred in the superfieial sqtiamous and
cuboidal cells of the lining epithelium. In
this study, two groups were reeognised;
unieystie (9 eases. 45'^) and nniltieystie
(11 eases. 55"/ii). Some ofthe inultieystie
lesiotis (6 of our series) eonsisted of 2 or
more cystic spaces eotUained within a
single round or oval fibrous capsule;
others (5 of our series) were larger and
less regtilat, having a distinctly botryoid
appearance, eonsisting of several cystic
spaces ol' varying size separated by fi-
brous tissue.
Most of the lesions were small, vary-
ing frotn 5 15 tnni in dianielet. whereas
the botryoid variety were substantially
larger, one of the ea,ses having measuted
50 tnm.
While the unieystie and tnultieystie va-
rieties shared similar histologieal fea-
tures, the botryoid type may oeeasional-
ly show sotnewhat different charaeteris-
ties. Two examples of the botryoid
variety in our study were linked pre-
dominantly by non-keratinizing strati-
fied squamous epithelium with a lesser
redueed enatnel epithelium-like cotnpo-
nent.
Clear eells were unusual both in the
lining epithelium and in the plaques, the
majority of which consisted only of stra-
tified squamous epitheliutn. Moreover,
iti two of our cases there was an increase
in the nueleo-cytoplasmic ratio in tnuch
ofthe epitheliutn, with resultant crowd-
ing ofthe eells. The nuelei were pyknot-
ie. One of our eases showed surfaee epi-
thelial infolding with erypt formation
and superfieial palisaded euboidal-eo-
lutnnar eells. All varieties of lateral
periodontal eyst may have small epithe-
lial nests or follieles in the fibrotts wall
and 1 have already referred to evidence
whieh suggests that they arise frotn ex-
tensions of the epithelial plaques.
The fonnation of the epithelial
plaques, their budding olT to form epi-
thelial islands whieh in turn beeoine eys-
tic. the repetition of this process
through a number of generations, and
the pre.senee of epithelial dysplasia in
the botryoid varieties, are indicative of
an active process of proliferation ofthe
odontogenic epithelium involved in
their genesis.
Sinee their original description, bot-
lyoid odontogenie eysts have been wide-
ly regarded as variants of the lateral
periodontal eyst, and generally publica-
tions on the subjeets have not distin-
guished them from the smaller multicys-
tic lateral periodontal eysts. In tny opin-
ion these two varieties are not entirely
synonytnous. Some ofthe bottyoid vari-
ety dilTer in inorphology and radio-
graphie appeatanee, histology, behav-
iour and prognosis, showing a distinet
propetisity for recurretiee. It may be
useful to distinguish between the clearly
botryoid variety and other multieystie
lateial periodontal cysts in prospective
elinieopathological studies, as this will
help to elueidate whether there is a dif-
feretiee in biologieal behavior between
the two. It tnust be regarded as a distinet
possibility, however, that the multieystie
variety can develop into a botryoid type
by eontinued expansion of individual
cysts. In a very teeetit papet\ VAN 1)I;R
WAAI (42) has argued th;\t the bottyoid
odontogenie eyst should tiot be tegard-
ed as a variant ofthe lateial periodontal
Developmental odontogenic cysts 5
eyst when it extends well beyond the
lateral area ofa tooth. He suggested the
terms "multieystie odontogenie lesions
with features of a lateral periodontal
eyst" or "lateral periodontal eystlike
lesions" rather than botryoid odonto-
genie eyst.
Three of our cases of the botryoid
variety also share some features of the
glandular odontogenic cyst, in that they
have epithelial erypts and supxirficial
low columnar cells, although no mucous
cells are demonstrable, a feature also
deseribed in a ease reported by LINDH &
LARSSON (42a), This raises the question
of whether the glandular odontogenie
cyst forms part of the clinieopathologi-
cal speetrum of the lateral periodontal
eyst, a point which must be given seri-
ous consideration.
Treatment
Provided that the lesion is unilocular
on radiological examination, the lateral
periodontal eyst is treated by surgical
enucleation. Attempts should be made
to avoid sacrificing the associated tooth,
but this may not always be possible, A
number of reports have been published
which indicate that the botryoid variety
has a predileetion for reeurrenee (40,
43^5) and must be earefully exeised. It
is not yet elear from the literature
whether the encapsulated inultieystie
lateral periodontal eyst has the same
tendeney to recur following simple enu-
cleation. Eight of 10 recurrent cases re-
ported by GRKER & JOHNSON (44) were
unilocular radiologically but multilocu-
lar histologically. Lititil we have further
infonnation about the behaviour ofthe
encapsulated inultiloeular variety, elini-
eians are advised to follow these cases
for a nutnber of years.
Glandular odontogenic cyst (sialo-
odontogenic cyst;
mucoepidermoid odontogenic cyst)
A eyst with fairly typieal histologieal
features whieh has sotne eharaeteristies
in common with the lateral periodontal
cyst and the botryoid odontogenic eyst,
has reeently been reported (46 47) and
discussed at the tneeting of the Interna-
tional Assoeiation of Oral Pathologists
in 1984, WALDRON & Koii (48) have
discussed it in eonnection with the cen-
tral mticoepidemioid tumour of the
jaws and Fu ARRA ct al. (49) reported a
ease in which a diagnosis of low-grade
mucoepidennoid eareinotna had been
made.
6 SHEAR
The name of the cyst is not yet estab-
lished. The term most descriptive ofthe
lesion is probably 'mucoepidermoid
odontogenie cyst" because of the pres-
ence of both secretory elements and
stratified squamous epithelium (50),
The u,se of this name might, however,
lead to confusion with the mueoepider-
moid eareinoma, and is therefore un-
likely to find favour,
PADAYACHEE & VAN WYK (46), who
u.sed the term 'sialo-odontogenie cyst",
reported two eases whieh resetnbled
both the botryoid odontogenie eyst and
the central mucoepidermoid tumour of
the jaws, but after a careful analysis
concluded that they differed suffieiently
to warrant separation as an entity.
GARDNHR ('/ al. (47), who favoured the
name 'glandular odontogenic cyst', sug-
gested also that its histological features
and biological behaviour are sufficiently
distinct for it to be regarded as an entity.
PATRON ct al. (51) reported 3 new
eases and summarized the data from 13
eases. The age range was 19 to 85 years.
9 of the 13 cases were in men and 10
oecurred in the mandible. Radiologieal-
ly the lesions have been well-defined
with a unilocular or multiloeular
pattern but without specific diagnostic
features, TTiree of 10 eases that have
been followed up have recurred.
Radiographs may show a unilocular
radiolueent area with a smooth eortieat-
ed margin or may be more extensive
and multiloeular, T"he roots of adjaeent
teeth may be displaced.
The microscopie features are vari-
able. The cyst may be lined in parts by
a non-keratinized stratified squamous
epithelium with a chronic inflammatory
infiltration of the connective tissue wall,
the same as is found in a radicular eyst.
The diagno.sis is made when the superfi-
eial layer ofthe epithelial lining consists
of columnar or euboidal eells. occasion-
ally with cilia, and the epithelium has a
glandular or pseudoglandular strueture.
with intraepithelial crypts or mierocysts
or pools lined by cells similar to those
on the surface. In certain planes of sec-
tion these mierocysts may be seen to
open onto the surfaee of the epithelium
through openings or crypts, giving the
epithelium a papillary or corrugated
surface. They are sometimes empty and
sometimes contain a structureless eosin-
ophilie material whieh gives a positive
mucicarmine reaction. Numerous gob-
let eells may be present, mainly in the
superficial part ofthe epithelium. Occa-
sionally the epithelium is thinner, sim-
ilar to redueed enamel epithelium. Epi-
thelial thiekenings or plaques may be the radieular eyst and this sould be ap-
present in either this thin epithelium or parent histologically, if not macro,scopi-
in the stratified squamous epithelium. cally (58, 59),
The plaques, whieh are idetitieal to A variation of this coneept is that
those in the gingival cyst of adults, the infiammation at the apex ofa deeiduous
lateral periodontal cyst and the botry- tooth can lead to the development of an
oid odontogenic cyst, may either pro- infiammatory follicular cyst around the
trude into the cyst cavity or extend into permanent sueees.sor (61, 62). BI:NN'S
the connective tissue wall. Islands of 1991 study (62) ineltided 15 patients
odontogenic epithelium and even miero- ranging in age from 5 to 12 years. In
cysts may be pre.sent in the connective 12 cases the infiammation arose from a
ti,ssue wall of the cyst. Irregular calcifi- non-vital deciduous predecessor, while
cations may be present in the connective two patients had Garre's osteomyelitis.
tissue wall. The mandible was involved in 10 cases
and the maxilla in 5, The premolar teeth
were associated with the eysts in 9 eases,
Treatment the eanines in 3 and the second molars
Despite the paueity of documented ex- in 2 cases, presumably in the patients
amples of this eyst. the available infor- with Garrc's osteomyelitis. Maeroseopi-
mation suggests that, like the botryoid cally, all the eysts were attached to the
odontogenic cyst, it should be carefully necks of teeth showing virttially no root
excised rather than enucleated in order formation, Histologieally. the most
commonly occurring feature was the
to obviate recurrence,
presence of non-keralinied stratified
sqtiamous epithelium of varying thiek-
Dentigerous cyst ness with focal areas of arcading. All
Frequency cases showed some degree of infiamma-
tion.
In the 32-year period 1958-89. 433 of
2616 jaw cysts recorded in our depart- There would appear thus to be some
ment have been dentigerous eysts evidenee of an infiammatory etiology in
(16.6%). This means that we are seeing the pathogenesis of some denligerous
about 14 cases a year and, as our mate- eysts. Nevertheless, individual cases
rial is drawn from a number of sourees. need to be assessed critically. The eyst
individual surgeons and departments wall must surround the crown of the
are apparently dealing with far fewer associated tooth and be attached to the
than this number eaeh year, neck; and microseopieally, the cyst
lining should demonstrate a readily
identifiable component of reduced
Pathogenesis enamel epitheliutn befote a diagnosis of
Some further work has been done re- dentigerous cyst is made. Most of the
cently to elucidate the pathogenesis of eases reported by SHAW ct at. (60) were
the dentigerous cyst but we are no eloser resolved after extraction ofthe involved
to knowing what triggers the process. primary tooth and curellage of the
Despite the faet that in mouse molar socket.
tooth transplant experiments (52 56) The experimental work of AI.TINI &
cysts fortn within the enamel organ of COIII:N (19, 20) demonstrated that
the developing tooth, it seems that in erupting teeth may penetrate epithelial
humans the cyst develops between the lined-eysts and in (his way give rise to
redueed enamel epithelium and the follicular keratoeysts.
erown of an unerupted tooth in certain Reeent work has developed earlier
cyst-prone individuals; and it is likely studies whieh showed that vital eyst
that a genetie faetor contributes to the tissue in eulture releases a potent bone-
process, although this has yet to be dem- re.sorbing faetor that is predominantly
onstrated at a molecular level. a mixture of prostaglandins B, and E,
Another tnode of origin which has (63 66), The source of this resorbing
been proposed is that the crown of a factor was thought to be the capsule
permanent tooth may erupt into a radic- and its leucocyte content.
ular cyst of its deciduous predecessor. MA nuKA ('/ al. (bl) have made some
This phenomenon probably does oecur, observations on dentigerous eysts. The
but only exceptionally rarely, beeause two dentigerous cysts they investigated
radieular cysts involving the deciduous were the only two in their sample of 12
dentition are so uncommon (57), In in which they found prostaglandin F,,,.
sueh a ease the erupting tooth may in- Using radicular and dentigerous
dent rather than penetrate the wall of cysts. MiXiiiJi ('/ al. (68) demonstrated

the synthesis in vitro ofa inaerotnolecu-
lar faetor with osteolytic aetivity which
has the eharaeteristies of interleukin I,
They believed that the souree of the in-
terleukin eoukl be the monoeyte/mae-
rophage infiltrate, the strotnal fibro-
blasts and the epithelial eyst linings; and
that the interleukin 1 released by the
cysts eould lead to a nutnber of osteolyt-
ic cell reactions; the stimulation of os-
teoelasts to tesorb botie. and the eon-
neetive tissue cells to produee prosta-
glandins which will be responsible for
further osteoelast activation. It also
stimulates eonneetive tissue cells to pro-
duce collagenase whieh is involved in
the destruelion of bone matrix.
Histoiogy
Iinnuinohistochemieal studies have
been done on dentigerous eysts by a
number of workers in the field, Undif-
ferentiated epithelium lining dentiger-
ous eysts. like redueed enamel epitheli-
um of dental follicles, yielded eonsis-
tently negative results for blood group
antigens A and B in the hatids of
WRIGHT (69), However, VHOTOI ii: ct al.
(70) were able to demonstrate the A. B
and H type 2 antigens in dentigerous
as well as in radicular and keratoeysts.
They aseribed the variation between
their findings and those of WRKiiir (69)
to technical and sampling differences,
GARDNIR & O'Niiii (71) also found
that 5 of 7 dentigerous eysts whieh they
studied were markedly positive lor
blood group antigens A. B and H type
2. Two exhibited only a few positive
cells.
HoKMiA Ct <d. (27) and MArriiivvs
('/ al. (28) used iinnnrnohistoehernieal
staining with monoclonal antibodies to
study and eornpare the eytokeratin eon-
tenl of odontogenic cysts. Results on
dentigerous eysts in the two studies that
coincided, were the demonstration of
cytokeratin 19 in all speeimens and in
cells at all levels; and cytokeratins 13
and 16 (although there was variation
in staining intensity between samples).
MAIHIIWS ct al. (28) found cytoker-
atins 8 and 18 poorly expressed, where-
as HORMIA ct al. (27) reported vari-
ability in their staining reaetion. Both
groups agreed on the absence of kera-
lins 10 and II. MAIIHIAVS ct al. (28)
detected careino-einbryonic antigen
(CEA) and epithelial membrane antigen
(EMA), partietrlarly the latter, in the
majority of epithelial cells lining dentig-
erous eysts; rat liver antigen (RLA) was
expressed by the majority of suprabasal
cells in all linings and oeeasionally in all
layers,
HORMIA ct al. (27) pointed out that
their results indicated that dentigerous
eysts. but not other eyst types, may
shate with sotne eases of atneloblastoma
the expression of eytokeratin 18, The
cytokeratin 18-positive eells eould have
a speeifie histogenetie origin and eould
eonsequently have distinet functional
eharaeteristies. Another possibility, they
suggested, is that the expression of eyto-
keratin 18 in dentigerous cysts is a sign
of oncofetal transformation in these
lesions. Further studies are required to
determine whether the presenee of eyto-
keratin 18 in dentigerotts eyst epitheli-
um might be associated with aineloblas-
toinatous ehanges in the eyst.
Unicystic ameiobiastoma
A nurnber of workers have referred to
the oecurrenee, in part ofa dentigerous
eyst lining, ofa mural nodule of prolif-
erating epithelium which elosely resem-
bles a plexiform ameloblastoma
(72 76), The nodule protrudes into the
eyst eavity and varies in size but gen-
erally shows either no. or only limited,
infiltration into the eonneetive tissue
eapsule, GARDNIIR (74) regarded these
lesions as ameloblastomas, although he
suggested that they require only eon,ser-
valivc trealineiit and propo,sed the term
plexiform unicystic ameloblastoma. The
use of this term has been regarded as
unfortunate (39) because of its similari-
ty to the tenn 'plexiform ameloblasto-
ma' and beeause the eysts do not exhibit
the criteria in the epithelium deseribed
by VicKr Rs & GoRi.rN (77) as itulieative
of ameloblastoma, I have also been crit-
ical of the reference to this lesion as an
ameloblastoma. as it was not infiltra-
live. and suggested that it might be
termed 'odontogenie papilloma" (2) and
PHM IPSI-N (pers eornrn) refers to it as
ameloblastoniatous hyperplasia. Never-
theless the pathologist should examine
numerous parts of sueh a eyst wall in
order to exelude the possibility of infil-
trating plexiform ameloblastoma else-
where,
GARONI-R & CoRio (75. 76) have
eotinter-ed this eritieisin by reporting
cases of unieystie ameloblastoma that
exhibit both patterns, namely a plexi-
form nodule and plexiform ameloblas-
toma in the same lesion. In their 1984
study, they reported their findings in a
.series of 35 ca,ses. Of 28 examples treat-
ed by enueleation or etirettage. only 3
reeurred (10,7"'..). which is a rntieh lower
Developmental odontogenic cysts 7
reeurrenee rate than that reported for
typieal solid or tnultieystie ameloblasto-
mas. They eautioned that cases should
nevertheless be followed for at least 10
years after treatment beeause of the
small proportion that do recur. They
believed that the plexiform unieystie
ameloblastoma should be regarded as a
histologic variant of unieystie amel-
oblastoma as its biologieal behaviour
was no difierent frorn the others.
Another point of interest in their se-
eond paper (76) is that they identifed 4
eases of plexiform unieystie ameloblas-
totna whieh were not in a dentigerous
relationship with a tooth.
We have undertaken a detailed study
of the unicystic ameloblastomas in our
department (78), In a series of 380 amel-
oblastomas reeorded during the 30-year
period 1958-1987. 57 (15%") were classi-
fied as unieystie,
Mieroseopieally, three distinet pat-
terns eould be identified, on the basis
of whieh the sample was divided into 3
groups.
Group I eoinprises uniloeular eystic
lesions whieh are lined to a greater or
lesser extent by epithelium whieh shows
eriteria defined by VKKI-.RS & GORLIN
(77) for the diagnosis of ameloblasto-
matous epitheliutn. These are eolurnnar
basal eells with hyperehromatie nuclei,
nuelear palisading with polarization,
and cytoplasmic vacuoles with intercel-
lular spaeing.
Group 2 comprises uniloeular eystie
lesions in which a mural nodule arises
from the epithelial lining and projects
into the lumen of the eyst. The nodule
consists of odontogenic epithelium with
a plexifortii pattern whieh elosely resetn-
bles that seen in the plexiform amel-
oblastoma. Part of the cyst lining may
demonstrate the Viekers-Gorlin eriteria,
but there is no evidence of infiltration
of the fibrous eyst wall by odontogenie
epithelium.
Group S comprises unilocular cystic
lesions in whieh invasive islands of ei-
ther follieular or plexiform ameloblasto-
ma. w hieh may or may not be eonnected
to the epithelial lining of the eyst. are
found in the fibrous wall.
Substantial portions ofthe cyst lining
in all 3 groups may laek the cytologieal
features which are typieal of atneloblas-
toma. and may instead be lined by a
non-specifie epitheliutn ranging from
one with only 1-2 cell layers to an acan-
thotie stratified squamous epithelium,
Stieh cases will pose problems in histo-
logieal diagnosis and eognizance must
be taken of clinical and radiological de-
8 SHEAR
tails. It is also essential to sample multi-
ple areas from the specimen before mak-
ing a definitive diagnosis. SAKU et al.
(79) reported that staining for the lectins
Ulex europaeus agglutinin I (UEA-l)
and Bandeirea simplicifolia agglutinin I
(BSA-I) assisted in the differentiation
between eystic ameloblastoma and
odontogenie cysts. Using a substantial
sample of ameloblastomas, keratocysts,
dentigerous cysts and radicular cysts,
they found that in the simple cysts most
of their specimens showed positive bind-
ing with UEA-I and BSA-I in the epi-
thelial linings. No positive reactions
were obtained for these two lectins in
the epithelium of the ameloblastomas,
except for limited UEA-I binding to
keratinized cells in 4 cases.
With regard to the question of wheth-
er these lesions develop dc novo or arise
in existing odontogenic cysts, partic-
ularly dentigerous cysts, ACKERMANN ct
al. (78) pointed out that only a small
number of their series were associated
with the crowns of unerupted teeth in a
true follicular relationship and there
was no evidence at all that any other
odontogenic eyst existed prior to the
development of the lesions. As far as
treatment is concerned, ACKERMANN ct
al. proposed that Groups I and 2 may
be treated conservatively, while Group
3 must be treated aggressively in the
same manner as solid and multieystie
ameloblastomas.
Eruption cyst
There have been no new papers on the
subject of eruption cyst in recent years,
Caicifying odontogenic cyst
There have been some noteworthy pub-
lications on this subject during the past
decade (80-88).
Frequency
Despite the fact that the calcifying odon-
togenic cyst is now a well-recognized
lesion, it is not very commonly encoun-
tered. We see only one or two ca.ses a year
in our department and regard the lesion
as extremely rare. During the 32-year
period 1958 89. 25 examples were re-
corded in our archives, representing V'Ai
of 2616 jaw cysts doeumented during
that period. In his literature review of
215 cases, Bw HNER (86) pointed out that
there have been about five times as many
central lesions reported in the literature
as peripheral lesions.
an odontome, may be found in the cyst
Age
wall, induced by the lining epithelium.
The observation that there is a distinct They classified these as Type I, whieh
peak in the second decade has been eon- may have 3 different patterns; Type I A,
firtned in the extensive literature review the simple unieystie type; Type 1 B, the
of 215 lesions reported by BUC"HNI:R odontome-producing type; and Type
(86), PR/ETORIUS et al. (80) have drawn IC, the ameloblastomatous proliferat-
attention to the bimodal age distribu- ing type. The neoplasm which pos,sesses
tion in support of their contention that some of the histological features of the
two different entities may be involved, calcifying odontogenic cyst should, in
SHAMA.SKIN ct al. (82) found that of the opinion of PR/f;T()RitJS ct al. be re-
5 extraosseous lesions, 4 were in patients garded as a .separate entity, and they
over 50 years, while in their literature have classified it as Type 2. It occurs in
review of 29 extraosseous eases, KAIJG- older patients and consists of amel-
ARS ct al. (88) found that 16 patients obla,stomatous epithelium in whieh the
were in their sixth decade or older. development of cysts is a secondary fea-
However, in their study of the peripher- ture. Areas of ghost cell formation and
al calcifying odontogenic cyst, BUCHNER varying amounts of dentinoid are in-
et al. (85) observed a bimodal age distri- dueed by the odontogenie epithelium.
bution with peaks in the second and They have suggested the term 'dentino-
sixth decades. genie ghost cell tumour' for this neo-
plasm, I have seen a ease of this type in
which enamel as well as dentine was
Site found.
Again referring mainly to the peripheral HiR.snBER(; ct ai (89) reviewed the
lesions of the .series of 29 extraosseous literature and identified 6 eases reported
ca,ses documented by KAUCJARS ct al. as calcifying odontogenie cysts which
(88), about one-half developed between were solid masses with or without amel-
the canines and none was posterior to oblastomatous proliferation and with-
the first molar; in the study of BUCHNER out any association with other odonto-
ct al. (85), most ofthe peripheral lesions genic tumours. In their review of'odon-
were located in the maxillary or man- togenic ghost cell tumours'. COI,MI:NI:RO
dibular gingiva or alveolar mucosa an- ct al. (90) observed two different enti-
terior to the first molar. ties; one with infiltrating odontogenic
epithelium and ghost cells which was
locally aggressive like the ameloblasto-
Pathogenesis and pathology ma; and the other which was malignant
The histologieal features of a classic with potential to metastasize. The latter
calcifying odontogenic cyst are eharac- entity is best deseribed as an 'odonto-
teristic and present few diagnostic prob- genic ghost cell carcinoma' (91).
lems. Elueidation ofthe pathogenesis is, S(OIT & WooiJ (92) reported a case with
however, considerably complicated by ameloblastomatous and basaloid fea-
the fact that the epithelial lining of a tures which behaved aggressively, and
calcifying odontogenie eyst appears to believed that as sueh a tumour has rnore
have the ability to induce the formation in eommon with an ameloblastoma
of dental tissues in the adjacent connec- than a caleifying odontogenie eyst, its
tive tissue wall; and that other odonto- diagnostie designation should adequate-
genic tumours sueh as the ameloblasto- ly refiect this. They propo.sed the term
ma, the odontoameloblastoma. the 'dentinogenic ghost-eell ameloblasto-
ameloblastie fibroma and the amelo- ma,' I concur with this view and would
blastie fibro-odontome may sometimes suggest that the rare cases with enamel
be associated with it. It is widely accept- deposition as well as dentine, should be
ed that those calcifying odontogenie termed 'odontogenic ghost eell amel-
cysts which have other features of odon- oblastoma' in keeping with the pattern
togenic tumours develop these second- used in the World health Organization
arily, rather than that they are them- classification of odontogenic tumours
selves secondary phenomena in pre-ex- (1).
isting odontogenic tumours (80. 83).
The caleifying odontogenic cyst is
pR/T'TORius ct al. (80) suggested that the
most frequently a uniloeular lesion but
calcifying odontogenic cyst is a unicystic
multieystie lesions have been reported
process which develops from reduced
enamel epithelium or remnants of odon- (86. 87), Satellite cysts may develop
togenie epithelium in the follicle, gingi- from odontogenie epithelial islands in
val tissue or bone. Dentinoid alone, or the wall (83), In the sttidy of the periph-
eral lesions by BUCHNER et al. (85), two-

thirds were eystie and one-third were
solid.
The satellite cyst described by
TAKI-PA ('/ al. (83) could be grouped into
the same 3 histologieal types deseribed
by PR/ITORKIS ct at. (1981), but these
did not always eoineide with the typing
of the mother cyst.
Treatment
The calcifying odontogenic eyst is treat-
ed by surgical enucleation unless it is
assoeiated with another odontogenie tu-
mour such as an ameloblastic fibrotna,
in which case wider excision will be re-
quired. In the presenee of a complex
odontome, conservative removal will
still be adequate. An ameloblastoma or
one of its variants with foei of ghost
cells must be treated radieally. Although
classic uncomplicated cases of calcifying
odontogenic cyst may grow to a large
size, reported recurrences are rare,
Acknowledgement I am most grateful to D R
J. J. Hir.i.i:, Head ofthe Department of Oral
Pathology. University of ihe Western Cape,
who kindly tiiadc available the facilities of
his department.
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///.•itotiiginil ty/'ini; of oilontogcnie tu-
mours ik-rliti: Spritiger Vcrlag. 1^92.
2. Sill AR M. Cysts of the jaws: recent ad-
vances. J (hat Pathot ms,*;; 14: 4,^ 59.
3. VooRSMir RAC'A. Sioii iN(iA PJW. VAN
ilAi i.si U,ICiM. Tin; matiitgetnent ol'ker-
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