J of IMAB. 2018 Apr-Jun;24(2) https://www.journal-imab-bg.org 2065

Case reports

GINGIVAL CYST OF ADULTS- TWO CASEREPORTS AND LITERATURE REVIEW

Elitsa Deliverska1, Aleksandar Stamatoski2

1) Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine,Medical University – Sofia, Bulgaria. 2) Department of maxillofacial surgery, Faculty of Dental Medicine, Ss. Cyriland Methodius University- Skopje, Macedonia.

Journal of IMAB - Annual Proceeding (Scientific Papers). 2018 Apr-Jun;24(2)Journal of IMABISSN: 1312-773Xhttps://www.journal-imab-bg.org

ABSTRACTBackground: Gingival cyst of adult is an

uncommon, small, non inflammatory, extra-osseous,developmental cyst of gingiva arising from the rests ofdental lamina.

Purpose: The aim of our paper is to present two rareclinical cases of gingival cyst of adult.

Material and methods: In the present cases, thecombined anatomic characteristics of the soft tissuepresentation and the osseous defect suggest that the lesionis a gingival cyst of adult. Two cases of gingival cyst werediagnosed and treated with exicisional biopsy followed byhistopathological confirmation and an emphasis on theclinical aspects of this lesion.

Results: The biopsy revealed histologic featuresconsistent with a gingival cyst. Clinical and radiographicexaminations 1 year post-surgery indicated uneventful softtissue healing and bone fill of the initial defect.

Conclusion: Gingival cyst most commonly occurs onthe labial side of the mandible in the canine and premolarareas. It is discrete, well-cirumscribed, painless swelling ofhe attached gingiva or gingival papilla. This is a soft tissuelesion, and if enlarged to sufficient size, it causessuperficial erosion of the cortical plate of bone. Lesionsappear to be asymptomatic and do not produce discomfort.It is a fairly rare cyst or at least it is rarely sent for biopsy.

Key words: odontogenic cyst, excisional biopsy,gingival cyst

INTRODUCTION IThe gingival cyst of the adult is an uncommon

lesion. It is an odontogenic developmental cyst of thegingival soft tissue derived from the rests of dental laminathat occurs primarily in middle aged adults. The conditionis more frequent in patients over 40 years of age. [1, 2]

Clinical and radiographic featuresGingival cysts of adults are most common in the

canine and premolar area of the mandible (60% to 75% ofcases) and usually occurs during the fifth and sixth decadesof life. They are almost invariably located on the facialgingiva or alveolar mucosa. Maxillary gingival cysts are

usually found in the incisor, canine, and premolar areas.[1, 3, 4]

Clinically, the gingival cysts may certainly occurwithout bone involvement and may appear as painless,small sessile soft tissue swellings, usually involving theinterdental area of the attached gingiva.

These lesions measure about 0.5 to 1 cm in diameter.They are often bluish or blue-gray due to thinning of theoverlying mucosa. In some instances, the cyst may causeslight erosion of the surface of the bone, which is usuallynot detected on a radiograph but is apparent during surgicalexploration.

If more bone is missing, one could argue that thelesion may be a lateral periodontal cyst that has eroded thecortical bone rather than a gingival cyst that originated inthe mucosa.

The gingival cyst of adults has no radiographicevidence of bone resorption, and only a reduced KVPpotential exposed periapical radiograph will show its softtissue density. Where the radiolucency is dark and sharplydemarcated, then communication with the periodontium isindicated, and the lesion is more likely to be a lateralperiodontal cyst that has eroded outwards. [3, 4, 5, 6]

Histopathologic featuresThe diagnosis of gingival cyst of the adult should

be restricted to lesions with the same histopathologicfeatures as those of the lateral periodontal cyst.

The lining is usually thin, resembling reducedenamel epithelium, and may have plaque-like thickenings.Small nests of these glycogen-rich clear cells may also bepresent. Sometimes the lining may be a stratified squamousepithelium without rete ridges, and occasionally it iskeratinized. [2, 3, 6]

Differential diagnosis include lateral periodontalcyst, periodontal abscess, mucocele, fibroma, peripheralossifying fibroma, neurofibroma etc.

The gingival cyst of the adult responds well to simplesurgical excision. The prognosis is excellent. Recurrenceis not seen.

In this paper, we describe two cases of gingival cyst

https://doi.org/10.5272/jimab.2018242.2065

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of the adult, located in the alveolar mucosa on the facialaspect of the mandibular lateral incisor-canine/ canine -firstpremolar region. [7, 8, 9, 10]

CASE REPORTSCase 145-year-old female patient presented at the

Department of Oral and Maxillofacial surgery, MedicalUniversity - Sofia, with a complaint of a swelling in thegum on the left side of the lower jaw dating from six toseven months prior to presentation. The gingiva in this areawas apparently normal before the appearance of the lesionaccording to patient. She could not recall any recenttrauma, pain, or discharge from the swelling or an increasein the size of the lesion. Medical history was non-significant, and the patient was not on any medication atthat time.

During intraoral examination, a smooth roundnodule approximately 5 mm in diameter was observed. Itwas located on the attached gingiva in relation to the lowerleft canine and lateral incisor extending inferiorly up tothe mucogingival junction.

Fig. 1. Clinical presentation of the lesion in frontalregion of lower jaw gingiva.

radiographical finding suggesting of osseous involvement;peripheral fibroma was ruled since the lesion was soft andcystic in consistency and odontogenic keratocyst was ruledout since the lesion was not associated with pain orlocalized expansion of bone, and again radiographicallythere was no osseous involvement. The treatment planincluded scaling, root planning, re-evaluation, andexcisional biopsy of the lesion. Anesthesia was obtainedwith local infiltration. Excision of the lesion was performedwith scalpel. The surgical specimen measuring 5 × 5 mmwas placed in 10% neutral buffered formalin. After removalof lesion, the area was irrigated with sterile saline andIodine povidon 10 % solution. We achieved primaryclosure secured with a 3-0 black silk suture. Gentle pressurewas applied with wet gauze to achieve hemostasis, and thewound was covered with a Parodium gel. The patient wasgiven postoperative instructions and was dismissed withprescription for an analgesic (tab Ibuprofen-400 mg everyeight hours), antibiotic (Amoxicillin-1,0 g - 2x1 for fivedays) and antimicrobial rinse (Tantum verde spray- twice aday for one week). Postoperative period was without anycomplications.

Case 2A 64 years old male patient referred to our

department for multiple tooth extractions. Prior to thisvisit, the patient had not received dental care for more than10 years. During the intraoral examination, a lesion withclinical characteristic of gingival cyst was found on thevestibular mandibular gingiva between 33 and 34 teeth(fig.2).

Fig. 2 Clinical presentation of the lesion.

The nodule was non - tender, soft, and cystic inconsistency, fluctuant and non-compressible (fig.1).Probing of the adjacent teeth yielded pocket depths of 2-3mm with all sites exhibiting bleeding on probing, withoutany communication between the sulci of the adjacent teethand the lesion. Pulp testing of the canine and lateral incisorindicated that both were vital. Radiographically, there wasno finding suggestive of osseous involvement. Based onthe clinical and radiographic findings, the provisionaldiagnosis of cystic lesion of the gingiva was made. Thedifferential diagnosis included a lateral periodontal cyst,peripheral fibroma and odontogenic keratocyst. Lateralperiodontal cyst was ruled out because there was no

The lesion was nodular with a sessile base,nonulcerated, or painful; it was normal in colour andmeasured 5.0 mm in diameter. An excisional biopsy underlocal anesthesia was performed, and surgical explorationrevealed osseous surface erosion. (fig. 3, 4)

J of IMAB. 2018 Apr-Jun;24(2) https://www.journal-imab-bg.org 2067

Fig. 3. Intraoral radiological examination of thesame patient.

DISCUSSIONThe presented cases documented examples of

gingival cyst of adult treated with excisional biopsy. Theoutward appearance of a gingival cyst of adult is typicallyan oval-to-round, firm, elevated swelling located on theattached gingiva. Commonly they are <5 mm in diameter,but lesions >5 cm can also be seen.[3] The lesions oftendemonstrate little or no change in colour in the overlyingmucosa, but some appear bluish due to the cystic fluid.Eighty percent are found in the mandible, with the mostcommon site being the canine-premolar area. The gingivalcyst of adult is believed to be of odontogenic derivation,specifically from the remnants of ectodermic tissue.[11] Thegingival cyst of adult is not related to any inflammatorylesion, and the associated teeth when tested are vital. Theradiograph does not accurately depict the topography ofthis soft tissue-originating cyst, as the cyst may involve thealveolar bone surface and can often compromise the buccalor lingual plate with a shallow 2 2 saucer-like2 2 defect.[12] Root exposure associated with this lesion is anextremely rare finding. Gingival cyst of adult is routinelytreated with excisional biopsy and has a rare chance ofrecurrence. The differential diagnosis of gingival cyst ofadult includes several lesions presenting as gingivalswellings such as a lateral periodontal cyst and peripheralfibroma. The lesion that may be more difficult todifferentiate is the lateral periodontal cyst, especially inthe presence of both radiographic and gingivalinvolvement. [3, 14, 15] This is because both lateralperiodontal cyst and gingival cyst of adult are non-inflammatory cystic lesions, typically present in themandibular canine-premolar area, and share similarhistopathological characteristics.[5, 16] In the present cases,the combined anatomic characteristics of the soft tissuepresentation and the osseous destruction in second casesuggest that the lesion was gingival cyst of adult.

There is a great deal of confusion about therelationship between the gingival cyst of adults and thelateral periodontal cyst, much of which appears to havearisen because both types of cyst have a predilection foroccurrence in the canine and premolar area of the mandibleand, less frequently, in the maxilla. The pathogenesis ofthese cysts, particularly with regard to the cells of origin,is also far from clear.

On the basis of the clinical and morphologicalsimilarities between the two cysts, it is believed that theyhave a common histogenesis and probably the sameepithelial origin and that they represent the intra-osseousand extra-osseous manifestations of the same lesion. [14,15, 17, 18, 19]

It is considered to represent the soft tissue (the extra-osseous) counterpart of the intra-osseous lateralperiodontal cyst. Gingival cysts of the adult are thoughtto arise from dental lamina rests or from entrapment ofsurface epithelium. [5,13]

Fig. 4. Osseous surface resorption under the lesion

Histopathological analysis confirmed the clinicalhypothesis of gingival cyst. Postoperative period wasuneventful with primary healing of the defect (Fig. 5).

Fig. 5. Postoperative status 7 days after surgery.

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12. Bhaskar SN, Laskin DM.Gingival cysts; Report of three cases.Oral Surg Oral Med Oral Pathol. 1955Aug;8(8):803-7. [PubMed]

13. Sato H, Kobayashi W, Sakaki H,Kimura H. Huge Gingival Cyst of theAdult: A Case Report and Review ofthe Literature. Asian J OralMaxillofac Surg. 2007 Sep;19(3):176-8. [CrossRef]

14. Nxumalo TN, Shear M.Gingival cyst in adults. J Oral PatholMed. 1992 Aug;21(7):309-13.[PubMed] [CrossRef]

CONCLUSIONThe gingival cyst of adult is a unique pathologic

lesion of the oral cavity, typically localized in themandibular canine and premolar region, appearing in adultsin their fourth to fifth decades of life. Associated osseousinvolvement occurs <50% of cases and is oftenundetectable radiographically. Treatment by excisional

REFERENCES:15. Hegde U, Reddy R. Gingival

cyst of adult—a case report with unu-sual findings. Indian J Dent Res. 2004Apr-Jun;15(2):78-80. [PubMed]

16. Giunta JL. Gingival cysts inthe adult . J Periodontol. 2002Jul;73(7): 827-31. [PubMed][CrossRef]

17. Schulz MK, Teixeira LR,Fernandes D, Bufalino A, Leon JE. Al-veolar cyst of the adult: Counterpartof gingival cyst of the adult in eden-tulous ridge. J Oral Maxillofac SurgMed Pathol. Available online 10 April2018. [CrossRef]

18. Wagner VP, Martins MD, CurraM, Martins MA, Munerato MC.Gingival Cysts of Adults: Retrospec-tive Analysis from Two Centers inSouth Brazil and a Review of the Lit-erature. J Int Acad Periodontol. 2015Jan;17(1): 14-9. [PubMed]

19. Kelsey WP 5th, Kalmar JR,Tatakis DN. Gingival cyst of the adult:regenerative therapy of associated rootexposure. A case report and literaturereview. J Periodontol. 2009 Dec;80(12):2073-81. [PubMed] [CrossRef]

Address for correspondence: Elitsa Georgieva Deliverska, Associate Professor,Department of Oral and Maxillofacial surgery, Faculty of Dental Medicine,Medical University Sofia,1, Georgi Sofiiski Blvd., 1431 Sofia, Bulgaria.E-mail: elitsadeliverska@yahoo.com

biopsy is definitive. Exposure of the tooth root is anextremely rare feature of the gingival cyst of adult; in suchcases, as in the present report, a combined regenerativetreatment approach may be used to achieve resolution ofthe lesion-associated osseous defect and the excisionalbiopsy-associated soft tissue defect.

Please cite this article as: Deliverska EG, Stamatoski A. Gingival cyst of adults- two case reports and literature review. Jof IMAB. 2018 Apr-Jun;24(2):2065-2068. DOI: https://doi.org/10.5272/jimab.2018242.2065

Received: 28/02/2018; Published online: 21/06/2018