You are on page 1of 4

[Downloaded free from http://www.jisppd.com on Sunday, October 11, 2015, IP: 14.139.236.

66]

ISSN 0970 - 4388

Dentigerous cysts of anterior maxilla in a young child: A case report


KALASKAR R. R.a, TIKU A.a, DAMLE S. G.b

Abstract

Th
si is P
te D
ho F
st is
ed av
by aila
m Me ble
ed dk fo
kn no r f
ow w ree
.c Pu d
om b ow
). lica nlo
tio a
ns d f
(w rom
w
w.

Dentigerous cysts are the most common bony lesions of the jaws in children. It is one of the most prevalent types of odontogenic
cysts associated with an erupted or developing tooth, particularly the mandibular third molars; the other teeth that are commonly
affected are, in order of frequency, the maxillary canines, the maxillary third molars and, rarely, the central incisor. Radiographically,
the cyst appears as ovoid well-demarcated unilocular radiolucency with a sclerotic border. The present case report describes the
surgical enucleation of a dentigerous cyst involving the permanent maxillary right central incisor; the surgery was followed by oral
rehabilitation. Careful evaluation of the history and the clinical and radiographical ndings help clinicians to correctly diagnose
the condition, identify the etiological factors, and administer the appropriate treatment.
Keywords: Dentigerous cyst, enucleation, marsupialization, maxillary right central incisor, unerupted

Dentigerous cysts are the most common of the developmental


odontogenic cysts of the jaws and account for approximately
20-24% of all the epithelium-lined jaw cysts. It develops
around the crown of an unerupted tooth by expansion of
follicle when fluid collects or a space occurs between the
reduced enamel epithelium and the enamel of an impacted
tooth.[1] Dentigerous cysts are always associated with an
unerupted or developing tooth bud and are found most
frequently around the crown of the mandibular third molars
followed, in order of frequency, by the maxillary canines,
maxillary third molars and, rarely, the maxillary right central
incisor.[2] These cysts are often asymptomatic unless there is
an acute inflammatory exacerbation and, therefore, these
lesions are usually diagnosed during routine radiographic
examination.[1] Swelling, teeth displacement, tooth mobility,
and sensitivity may be present if the cyst reaches a size larger
than 2 cm in diameter.[3] Radiograph of the dentigerous cyst
shows a well-defined unilocular radiolucency, often with a
sclerotic border, surrounding the crown of an unerupted
tooth.[2] Histologically, the dentigerous cyst consists of a
fibrous wall lined by nonkeratinized stratified squamous
epithelium consisting of myxoid tissue, odontogenic remnants
and, rarely, sebaceous cells.[4] Complications associated with
dentigerous cysts include pathologic bone fracture, loss of
the permanent tooth, bone deformation, and development of
squamous cell carcinoma, mucoepidermoid carcinoma, and
ameloblastoma.[5] The treatment indicated for dentigerous
cysts are surgical removal of the cyst, avoiding damage to the
involved permanent tooth; enucleation of the cyst, along with
removal of the involved tooth; or the use of a marsupialization
technique, which removes the cyst while preserving the
developing tooth.[6] The present case report describes the
management of dentigerous cysts in children.

Case Report

A 7-year-old boy reported to the Department of Pediatric


Dentistry, Nair Hospital Dental College, Mumbai, with a
chief complaint of a painless swelling in the maxillary right
anterior region since 4 months. On general examination,
the patient was apparently healthy. There was no significant
past medical history. Intraoral examination revealed a
bony swelling which caused a bulging of the cortical
bone, extending from the buccal vestibule of the maxillary
left deciduous central incisor to the maxillary right first
deciduous molar. The swelling was well defined, firm in
consistency, painless on palpation, and measured about
3 3 cm. There was no bruit or pulsation. The buccal
cortical plate showed slight expansion and the overlying
mucosa was slightly inflamed. There were no signs of
any acute periodontal condition or carious lesions. The
primary maxillary right central incisor was discolored and
was associated with an intraoral sinus. There was history
of trauma 1 year back while playing in school. The teeth on
the affected side were mobile (51, 52, 53, 54, 61) although
not sensitive to percussion.

The occlusal radiological examination showed a thin sclerotic


border surrounding the well-defined unilocular radiolucent
area that was associated with the root of a nonvital primary
maxillary right central incisor and an unerupted permanent
maxillary right central incisor [Figure 1]. The permanent
maxillary right central and lateral incisors were superiorly
and laterally displaced. There was irregular root resorption
of the primary maxillary right lateral incisor and a widened
pulpal canal of the primary maxillary right central incisor
[Figure 1]. The contents of the swelling were aspirated and
sent for investigations; the result of which was consistent with
the diagnosis of a cystic lesion. After clinical and radiological
examination, a provisional diagnosis of dentigerous cyst was
made; however, large periapical cyst, odontogenic keratocyst,
central giant-cell granuloma, adenomatoid odontogenic

Lecturer, bProfessor and Head, Department of Pediatric Dentistry,


Nair Hospital Dental College, Mumbai, India
187

J Indian Soc Pedod Prevent Dent - December 2007


187 CMYK

[Downloaded free from http://www.jisppd.com on Sunday, October 11, 2015, IP: 14.139.236.66]

Dentigerous cysts of anterior maxilla in a young child

si is P
te D
ho F
st is
ed av
by aila
m Me ble
ed dk fo
kn no r f
ow w ree
.c Pu d
om b ow
). lica nlo
tio a
ns d f
(w rom
w
w.

attached to the cementoenamel junction of the unerupted


tooth.[7] Dentigerous cysts account for more than 24% of jaw
cysts. The substantial majority of dentigerous cysts involve
the mandibular third molar and the maxillary permanent
canine, followed by the mandibular premolars, maxillary
third molars and rarely the central incisors.[8] Studies have
shown that the incidence rate of dentigerous cysts involving
the maxillary central incisor was 1.5% as compared to 45.7%
involving the mandibular third molar.[8] Mourshed[9] stated
that 1.44% of impacted teeth undergo dentigerous cyst
transformation, so dentigerous cysts involving the permanent
central incisor are rare. Daley et al.[10] reported an incidence
rate of 0.1-0.6%, whereas Shear found the incidence to be
1.5%.[8] Dentigerous cysts most commonly occur in the 2nd
and 3rd decades of life. These lesions can also be found in
children and adolescents and show a male predilection.[8] In
the present case report, the dentigerous cyst was associated
with the permanent maxillary right central incisor in a 7year-old male child.

Figure 1: Occlusal radiograph showing a large circular welldened unilocular radiolucent area surrounding 11

tumor, and ameloblastic fibroma were also considered in the


differential diagnoses. Prior to surgery, routine blood and urine
examination were advised; the results were within normal limits.
Surgical enucleation of the cyst was chosen as the treatment of
choice. The treatment consisted of extraction of the maxillary
right deciduous central incisor, maxillary right deciduous
lateral incisor, maxillary right deciduous canine, maxillary
left deciduous central incisor, and permanent maxillary right
canine, along with total enucleation of the dentigerous cyst.
The surgery was done using local anesthesia (Dentocaine 2%
Pharma Health Care Product, Mumbai) and under antibiotic
cover. The cyst was attached to the cementoenamel junction of
maxillary right permanent central incisor [Figures 2 and 3]. The
cyst cavity was packed with sterile iodoform gauze to achieve
hemostasis and to prevent hematoma formation [Figure 4]. The
iodoform gauze was removed on the next day and the sutures
were removed after one week. The specimen was sent for
histopathological examination. The histological examination
showed a thin fibrous cystic wall lined by a 2 to 3 layer thick
nonkeratinized stratified squamous epithelium, with islands of
odontogenic epithelium. The connective tissue showed a slight
inflammatory cell infiltrate, which confirmed the diagnosis of
dentigerous cyst [Figure 5]. After 15 days, a removable partial
denture was delivered, which served as a functional space
maintainer, improved esthetics and phonetics, and also as
a guidance for the eruption of the permanent maxillary left
central incisor. The patient was asked to return for clinical and
radiographic follow-up once a month. After 6 months, bone
neoformation was observed in the same region [Figure 6] and
the permanent maxillary left central incisor was seen erupting
in its proper place [Figure 7]. A follow-up after every 6 months
and careful monitoring of the permanent right lateral incisor
and permanent left central incisor is required.

Th

The exact histogenesis of the dentigerous cyst is not known. It


is stated that the dentigerous cyst develops around the crown
of an unerupted tooth by accumulation of fluid either between
the reduced enamel epithelium and enamel or in between the
layers of the enamel organ. This fluid accumulation occurs
as a result of the pressure exerted by an erupting tooth on
an impacted follicle, which obstructs the venous outflow
and thereby induces rapid transudation of serum across the
capillary wall.[11] Toller[12] stated that the likely origin of the
dentigerous cyst is the breakdown of proliferating cells of the
follicle after impeded eruption. These breakdown products
result in increased osmotic tension and hence cyst formation.
Bloch suggested that the origin of the dentigerous cyst is
from the overlying necrotic deciduous tooth. The resultant
periapical inflammation will spread to involve the follicle
of the unerupted permanent successor; an inflammatory
exudate ensues and results in dentigerous cyst formation.[13]
In the present case, the most likely explanation is that the
cyst originated from the discolored primary maxillary right
central incisor. Most of the authors have reported the presence
of carious or discolored deciduous teeth in relation to the
development of dentigerous cysts.[9,10] This suggests that
the periapical inflammatory exudates from the deciduous
teeth might be one of the risk factor for the occurrence of
dentigerous cysts.
A large periapical cyst, odontogenic keratocyst, central
giant-cell granuloma, and unicystic ameloblastoma can
mimic a dentigerous cyst. Odontogenic keratocyst and
unicystic ameloblastoma most frequently occur in the molar
region of the lower jaws in the 2nd and 3rd decades of life.
A radiograph will not differentiate between a radiolucency
associated with the root of a nonvital primary teeth and
the crown of unerupted teeth.[13] Unlike other odontogenic
cysts, the epithelial cells lining the lumen of the dentigerous
cyst possesses an unusual ability to undergo metaplastic

Discussion
A dentigerous cyst can be defined as a cyst that encloses
the crown of an unerupted tooth, expands the follicle and is
J Indian Soc Pedod Prevent Dent - December 2007
188 CMYK

188

[Downloaded free from http://www.jisppd.com on Sunday, October 11, 2015, IP: 14.139.236.66]

Th
si is P
te D
ho F
st is
ed av
by aila
m Me ble
ed dk fo
kn no r f
ow w ree
.c Pu d
om b ow
). lica nlo
tio a
ns d f
(w rom
w
w.

Dentigerous cysts of anterior maxilla in a young child

Figure 5: Photomicrograph showing thin brous cystic wall


lined by a 2-3 layer thick stratied squamous epithelium

Figure 3: Bony cavity after excision of the dentigerous cyst

Figure 6: Follow-up occlusal radiograph at 6 months, showing


bony consolidation

Figure 2: Excised specimen showing cyst attached to the


cementoenamel junction of the maxillary right permanent
central incisor

Figure 4: Photograph showing cystic cavity packed with sterile


iodoform gauze

Figure 7: Photograph showing removable partial denture in


place and the erupting 21
189

J Indian Soc Pedod Prevent Dent - December 2007


189 CMYK

[Downloaded free from http://www.jisppd.com on Sunday, October 11, 2015, IP: 14.139.236.66]

Dentigerous cysts of anterior maxilla in a young child

transition. On occasion, some untreated dentigerous


cysts rarely develop into an odontogenic tumor (e.g.,
ameloblastoma) or a malignancy (e.g., oral squamous cell
carcinoma).[14] Marsupialization and surgical enucleation of
the cyst may be the treatment of choice. In the present case
surgical enucleation of the cyst was done.

3.
4.
5.

The present case occurring in a 7-year-old boy, supports the


age and sex predilection mentioned by other authors.[11,13]
Though dentigerous cysts are most common in the
mandibular jaw, in the present case the maxillary jaw was
involved. A dentigerous cyst associated with an anterior tooth
will result in failure of eruption of the tooth and therefore
lead to esthetic and orthodontic problems. Absence of a
central incisor can have an impact on the psychology of
child. Further esthetic management has to be considered to
prevent any psychological trauma to the child. In the present
case, esthetic management was done by providing the patient
with a removable partial denture, which also serves as a
functional space maintainer and facilitates the eruption of
the permanent maxillary left central incisor.

si is P
te D
ho F
st is
ed av
by aila
m Me ble
ed dk fo
kn no r f
ow w ree
.c Pu d
om b ow
). lica nlo
tio a
ns d f
(w rom
w
w.

6.

technique to treat a large dentigerous cyst. J Am Dent Assoc


1997;128:201-5
Bodner L, Woldenberg Y, Bar-Ziv J. Radiographic features of large
cysts lesion of jaws in children. Pediatr Radiol 2003;33:3-6
Tuzum MS. Marsupialization of a cyst lesion to allow tooth eruption:
A case report. Quintessence Int 1997;28:283-4
Chakraborty A, Sarkar S, Dutta BB. Localized disturbances
associated with primary teeth eruption. J Indian Soc Pedod Prev
Dent 1994;12:25-8
ONeil DW, Mosby EL, Love JW. Bilateral mandibular dentigerous
cyst in a five year old child: Report of 3 cases. ASDC J Dent Child
1989;56:382-4
Boyczulc MP, Berger JR. Identifying a deciduous dentigerous cyst.
J Am Dent Assoc 1995;126:643-4
Shear M. Dentigerous cyst of oral region. 2nd ed. Wright PSG:
Bristol; 1983. pp. 56-75
Mourshed F. A roentgenographic study of dentigerous cysts, II:
Role of roentgenograms in detecting dentigerous cyst in the early
stages. Oral Surg 1964;18:54-61
Daley TD, Wysock GP. The small dentigerous cyst, the diagnostic
dilemma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1995;79:77-81
Main DM. The enlargement of epithelial jaw cyst. Odontol Revy
1970;21:21-9
Toller PA. The osmolarity of fluid from the cyst of jaw. Br Dent J
1970;129:275-8
Bloch JK. Dentigerous cyst. Dent Cosm 1928;70:708-11
Slootweg DJ. Carcinoma arising from reduced enamel epithelium.
J Oral Pathol 1987;16:479-82

7.
8.

9.

10.

11.

12.

13.
14.

References

Reprint requests to:


Dr. Ritesh R. Kalaskar,
Department of Pediatric Dentistry,
Nair Hospital Dental College, Mumbai, India.
E-mail: riteshpedo@rediffmail.com

Th

1. Ikeshima A, Tamura Y. Differential diagnosis between dentigerous


cyst and benign tumor with an embedded tooth. J Oral Sci
2002;44:13-7
2. Ziccardi VB, Eggleston TE, Schnider RE. Using fenestration

J Indian Soc Pedod Prevent Dent - December 2007


190 CMYK

190