CASE REPORT

Dentigerous cyst associated with permanent maxillary central incisor: report of two cases+
Mahmut SUMER *, Elif Ozen SANDIKCI#, Filiz KARAGOZ S Dihek Fak Derg, 2010;19:237-240
Dentigerous cyst associated with permanent maxillary central incisor: report of two cases Dentigerous cysts are the second most common type of odontogenic cyst, and the most common developmental cysts of the jaws. Dentigerous cysts are attached to the neck of an unerupted tooth and enclose the crown. The clinical examination reveals a missing tooth or teeth and possibly a hard swelling, occasionally resulting in facial asymmetry. These cysts are commonly associated with unerupted mandibular third molars, maxillary cuspids and maxillary third molars respectively. This article reports two unusual cases of dentigerous csyt associated with an upper permanent central incisor. KEY WORDS odontogenic cyst, dentigerous cyst, unerupted tooth
Submitted: November 25, 2010 Accepted for publication: December 16, 2010

Most dentigerous cysts are treated by surgical enucleation(3,4,8). In cases in which cysts affect significant portions of the jaws, an acceptable early treatment approach involves marsupialization of the cyst to allow for decompression and subsequent shrinkage of the lesion(3). In this paper two cases of dentigerous cyst associated with upper permanent central incisor is presented. CASE REPORTS Case 1 A 60 year old female was referred to the Oral and Maxillofacial Surgery Clinic with the complaint of a swelling which caused pain and discomfort overlying the anterior side of the maxilla. Her medical history was significant for hypertension. Extraoral examination revealed a mild soft tissue swelling and tenderness in the maxilla. She was fully edentulous in maxilla and had worn a complete denture. On intraoral examination, a painful swelling on the anterior maxilla was present. Panoramic radiography revealed a large unilocular, well-defined radiolucent lesion from the right first maxillary molar tooth to the left canine area and a tooth like structure in the lesion (Figure 1). The lesion was treated by marsupialization under local anesthesia consisting of excision of the overlying mucosa and the opening of a 1 cm window into the cystic cavity and related permanent central incisor was removed. Hystopathologic analysis 237

Dentigerous cysts are the second most common type of cyst in the jaws(1). They represent 33% of all odontogenic cysts(2). The dentigerous cyst develops from proliferation of reduced enamel epithelium that surrounds the crown of an unerupted tooth(3,4). The majority of dentigerous cysts are associated with the mandibular third molar, followed by the maxillary cuspids(3,4), maxillary third molars and mandibular premolars(5,6). The frequency of dentigeorous cyst formation has been calculated as 1.44 in every 100 unerupted tooth(6). The highest incidence of dentigerous cysts occurs during the second and third decades(3,7). There is a greater incidence in males, with ratio of 1.6 to 1 reported(3). Clinically a dentigerous cyst remains asymptomatic when the cyst is small. If the cyst is large or inflamed, it may produce some swelling or pain(3,4,8). In radiographic examination a dentigerous cyst appears as a well-defined, unilocular or occasionally multilocular radiolucency with corticated margins in association with the crown of an unerupted tooth(3,4). The tooth in associated with is often displaced(3-5,8). Histopathologically the wall of the cyst is lined by nonkeratinized, strafied, squamous epithelium measuring four or six cells in thickness. In cases in which secondary inflamation is seen epithelial hyperplasia may be noted(3,4).
* Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Ondokuz Mayis, Samsun, Turkey # Oral and Dental Health Center, Samsun, Turkey Department of Pathology, Faculty of Medicine, University of Ondokuz Mayis, Samsun, Turkey + The study was presented as a poster presentation in the 1st International Oral&Maxillofacial Surgery Society Congress on 2007 held in Antalya, Turkey

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of the lesion showed a cyst wall composed of mucous cells, diffuse chronic inflammatory infiltrate and lined by non-keratinized stratified squamous epithelium which was consistent with dentigerous cyst (Figure 2). After the cyst was adequately resolved, the enucleation of the lesion was performed. Case 2 A 51 year old male was referred to the Oral and Maxillofacial Surgery Clinic with the complaint of a swelling overlying the right side of the maxilla. The medical history of the patient was unremarkable. The patient had a history of gun-shot injury at the age of 6. Intraoral examination revealed a painful swelling both on the anterior and right side of the maxilla and missing of right maxillary permanent central incisor and displa-

cement of right maxillary lateral incisor, canine and left central incisor. Panoramic radiography revealed a large well-defined, radiolucent, unilocular lesion from the right third molar to the left canine area and an impacted right maxillary permanent central incisor (Figure 3). Additionally, multiple shots were observed in the maxillary region. The lesion was treated by marsupialization under local anesthesia consisting of excision of the overlying mucosa and the openning of a 1 cm window into the cystic cavity and removal of impacted tooth was performed. A shot trauma was observed on the crown of the impacted tooth. The hystopathologic analysis of the lesion revealed diffuse chronic inflammatory infiltrate and a cyst wall lined by non-keratinized stratified squamous epithelium which involves mucous cells in

Figure 1. Panoramic radiograph showing radiolucency in the maxilla (case 1).

Figure 3. Panoramic radiograph showing radiolucency and multiple shots in the maxilla (case2).

Figure 2. Photomicrograph of a portion of the lining of the dentigerous cyst (case 1).

Figure 4. Photomicrograph of a portion of the lining of the dentigerous cyst (case 2).

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Sumer, Sandkc, Karagoz

some places that was consistent with dentigerous cyst (Figure 4). After the cyst was adequately resolved, the enucleation of the lesion was performed. DISCUSSION The dentigerous cyst represent 33% of all odontogenic cysts(2). Batanieh et al(9) showed that in a Jordanian population dentigerous cyst was the second most common type of odontogenic cyst (24.8%). Dentigerous cyst is generally associated with an impacted tooth(2-6) and the majority of the dentigerous cysts are associated with the mandibular third molar and then, in order of decreasing frequency, the maxillary permanent cuspids(3,4), maxillary third molars and mandibular premolars(5,6). In present cases, the dentigerous cysts occurred in association with the upper permanent central incisor which is an unusual site of occurrence. Homem et al(2) reported of a dentigerous cyst associated with upper permanent incisor. That reported case related to a trauma to the face when the patient was a child. Killian et al(10) had reported a case of trauma to the upper deciduous incisor which caused the reduced epithelium to proliferate and the permanent tooth enamel to develop the cyst. In case 2 there was a history of gun shot injury associated with the upper permanent incisor when the patient was 6 years old. However, in case 1 there was no history of trauma. Desai et al(11) reported dentigerous cysts associated with upper permanent central incisor presented in a 8 year old boy. They reported that, dentigerous cyst associated with anterior teeth would result esthetic and orthodontic problems. In case 2, absence of central incisor and displacement of other anterior teeth caused esthetic problems. Most dentigerous cysts are treated by surgical enucleation(3,4,8). Scolozzi et al(12) reported a case of relatively large dentigerous cyst associated with an unerupted mesiodens in 42 year old male. They suggested that marsupialization should be limited to those particular cases in which teeth have to be conserved and brought into the dental arch or in an unhealthy or deabilitated patient. In our opinion decompression should be kept in mind in cases in which dentigerous cysts are extremely large in volume and vestibular contour of the cyst will be collapsed according to the enucleation. Using graft materials should be the treatment choice in large dentigerous cysts. In present cases because of the patientss age and the large size of cysts, it was decided to perform marsupialization initially, and then enucleation was performed. The diagnosis of dentigerous cyst is based on a combination of radiographic and histologic features. Den-

tigerous cyst associated with permanent central incisors especially in elderly patients is an extremely uncommon pathologic entity.

Maksiller santral kesici di ile ilikili dentigerz kist: iki olgu sunumu Dentigerz kistler, odontojenik kistler iinde ikinci s kl kta ve enelerin geli imsel kistleri iinde ise en sk grlen kistlerdir. Dentigerz kistler srmemi bir di in kronunu evreler. Klinik muayenede eksik bir di veya di ler grlr ve ayn zamanda fasial asimetriye neden olabilecek sert bir ilik de gzlemlenebilir. Bu kistler en sk gml mandibular nc molar di lerle, daha sonra srasyla maksiller kanin di ler ve maksiller nc molar dilerle ili kili olarak ortaya kar. Bu makalede, maksiller santral kesici di lerle ili kili iki adet dentigerz kist olgusu sunulmaktadr. Anahtar kelimeler: odontojenik kist, dentigerz kist, gml di

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Correspondence Address: Mahmut SUMER, DDS, PhD Ondokuz May s niversitesi, Di hekimli i Fakltesi A z Di ve ene Cerrahisi Anabilim Dal 55139 Kurupelit, Samsun Phone: +90 (362) 3121919-3022 Fax: +90 (362) 4576032 E-mail: msumer1970@yahoo.com

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