|Year : 2021 | Volume
| Issue : 2 | Page : 118-121
A rare case of dentigerous cyst of the maxillary incisor abutting the nasal floor
Akhilesh Kumar Pandey1, Edlyn Rodriguez2, Vikas Dhupar2
1 Department of Dentistry (Oral and Maxillofacial Surgery), All India Institute of Medical Sciences-Jodhpur, Basni Phase 2, Jodhpur, Rajasthan, India
2 Department of Oral and Maxillofacial Surgery, Goa Dental College and Hospital, Bambolim, Goa, India
|Date of Submission||01-May-2021|
|Date of Acceptance||21-Aug-2021|
|Date of Web Publication||11-Feb-2022|
Dr. Akhilesh Kumar Pandey
Senior Resident, Department of Dentistry (Oral and Maxillofacial Surgery), All India Institute of Medical Sciences-Jodhpur, Basni Phase 2, Jodhpur, Rajasthan-342005
Source of Support: None, Conflict of Interest: None
Dentigerous cyst is a developmental odontogenic cyst of the jaw most commonly associated with impacted third molars. The incidence of the cyst is rare in the maxillary anterior tooth region. Here, we present a case of dentigerous cyst in relation to permanent maxillary central incisor abutting the nasal floor and its management.
Keywords: Dentigerous cyst, enucleation, marsupialization, maxillary central incisor
|How to cite this article:|
Pandey AK, Rodriguez E, Dhupar V. A rare case of dentigerous cyst of the maxillary incisor abutting the nasal floor. Int J Oral Health Sci 2021;11:118-21
| Introduction|| |
A dentigerous cyst is a developmental odontogenic cyst of the jaw with an incidence of 17.1% as documented by the Department of Oral Pathology of the University of the Witwatersrand, Johannesburg.
The dentigerous cyst usually envelopes the cervix of the unerupted or the impacted tooth and forms by the proliferation of the reduced enamel epithelium postenamel formation. The proliferation of the reduced enamel epithelium occurs usually as a result of the agglomeration of fluid between the reduced enamel epithelium and the surface of enamel.
The lesion is incidentally discovered on routine radiographic screening examination or on evaluation of the missing tooth. The most common site for the cyst is the mandibular third molar region followed by maxillary canine, mandibular premolar, maxillary third molar, and rarely, the maxillary central incisor.
The cyst is usually seen in the second and third decade of life with a slight male predilection of 1.8:1 ratio in the study done in the Witwatersrand area of South Africa (1965–1974).
The incidence of the dentigerous cyst in maxillary permanent central incisors is rarely noticed with an incidence of 1.5% by Shear and 0.1%–0.6% by Daley and Wysockias.
The treatment modality for the dentigerous cyst depends on the size of the lesion and the eruption potential of the tooth. Enucleation, marsupialization, and decompression are the common surgical management options described in the literature.
In this case report, we have described a case of a dentigerous cyst associated with the maxillary central incisor abutting the nasal cavity.
| Case Report|| |
A 6 ½-year-old child reported to the department of oral and maxillofacial surgery with painless swelling over the maxillary anterior region for 4 weeks. History of presenting illness revealed that the patient had self-fall 6 months back, following which maxillary deciduous central and lateral incisors were avulsed. The patient was apparently alright till 5 months later, after which his mother noticed swelling in the upper lip region. The swelling was pea-size initially which gradually increased to its present size. The patient did not report of any associated pain.
The general examination revealed that the patient was healthy with normal growth and development, and no associated syndromes were reported. Extraoral examination revealed a diffuse dome-shaped swelling present in relation to philtrum region measuring ~1 cm × 1 cm with a well-defined border. The overlying skin appeared normal with obliteration of the nasolabial fold on the left side.
Diffuse intraoral swelling was noted in relation to the edentulous region of 61.62 extending from incisive foramen till unattached gingiva apical to 63 measuring ~1 cm × 1 cm. The swelling was dome shaped with an ill-defined border, tender to palpation, firm in consistency, with a breach in the continuity of the buccal cortical plate, and the overlying mucosa was normal [Figure 1]. On aspiration, a straw-colored fluid was seen.
|Figure 1: Intraoral view showing swelling in relation to maxillary anterior region|
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The cone beam computed tomography showed large well-defined unilocular radiolucency involving the unerupted permanent maxillary left central incisor. A breach in the continuity of the buccal cortex was noted; however, the palatal cortical plate was intact. The floor of the nasal cavity of the left side was seen to be displaced superiorly [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d.
|Figure 2: (a) Axial, (b) Coronal, (c) Sagittal, (d) 3 Dimensional reconstruction section of the Cone Beam Computed Tomography Scan showing dentigerous cyst in relation to 21|
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Based on the clinical and radiographic evaluation, a provisional diagnosis of the dentigerous cyst was made.
With the informed consent of the parents, general anesthesia was induced to the patient. An envelope incision with two vertical release incisions was made, and a mucoperiosteal flap was raised. The cyst and the impacted tooth were exposed, the cystic lining was enucleated, and 51, 21 were extracted as permanent maxillary left central incisor's further eruption was unlikely [Figure 3], [Figure 4], [Figure 5], [Figure 6]. Hemostasis was achieved and closure was done with 3-0 vicryl interrupted suturing technique, and the specimen was sent for further histopathological evaluation.
The microscopic analysis demonstrated cystic lining resembling the reduced enamel epithelium which was stratified squamous nonkeratinized (2–3 layers thick cells) with arcading pattern. The stroma was composed of collagen fibers, fibroblasts, an aggregate of foam cells with blood vessels, trabeculae of vital bone with few dystrophic hematoxyphillic calcifications along with inactive odontogenic cell rests, confirming the diagnosis of dentigerous cyst.
| Discussion|| |
The dentigerous cyst – “tooth bearing” cyst encloses an unerupted/impacted tooth by the expansion of its follicle and is attached to its cervical part. Two theories are supporting the formation of dentigerous cyst: developmental and inflammatory.
The developmental theory states that the cyst develops either by an accumulation of fluid between reduced enamel epithelium and enamel or between layers of the enamel organ. This fluid accumulation occurs as a result of pressure exerted by the erupting teeth on the follicle which impairs the venous outflow inducing transudation of serum across the capillary wall. The other school of thought states that the DC forms as a result of the breakdown of proliferating cells of the follicle after the impacted tooth has failed to erupt. The breakdown products cause an increase in osmotic pressure ensuing in cyst formation.
The inflammatory theory states that the overlying inflammation from the nonvital deciduous tooth spreads to involve the follicle of the underlying permanent tooth, resulting in an inflammatory exudate that forms the dentigerous cyst per se.
It is most commonly associated with impacted mandibular third molar 45.7% followed by maxillary canines, i.e. 19.6% with maxillary central incisor's incidence being a mere 1.6%. Shear reported an incidence of 1.5% while Daley and Wysockias reported it to be 0.1%–0.6% (Brown et al., 1982).
Most of the time, the dentigerous cysts are accidentally discovered during the radiographic examination to investigate the etiology of the missing teeth. Orthopantomogram is the routine radiograph taken by dental professionals to find the cause of missing teeth. However, to fully understand the nature of the cystic lesion, cone beam computed tomography remains the scan of choice to evaluate the origin, site, size, locules (unilocular/multilocular), the extension of the lesion, and also to evaluate if the cortical plates are intact.
The treatment of the cystic lesion depends on the type of the cyst (histopathologic evaluation), size, and location of the lesion.
Marsupialization and decompression are the earliest advocated procedures suggested by Partsch in German literature for the treatment of cysts of jaws. There exists ambiguity in using these terms interchangeably in the literature. Decompression means measures taken to reduce the pressure from the cyst, whereas marsupialization means the conversion of a cyst into a pouch by the creation of a stoma or an opening that has a self-maintaining ability. Marsupialization is often used in common cystic lesions such as a dentigerous cyst, radicular cyst, keratocystic odontogenic tumor, cystic ameloblastomas. It is the preferred conservative management technique for large lesions involving the maxilla or mandible with a close approximation to the maxillary sinus or vital structures like the inferior alveolar canal. Often, this is accompanied by tooth extraction, traction, enucleation, curettage, or surgical resection at a later stage.
The aim of using conservative techniques such as marsupialization and decompression is to minimize the size of the cyst, preserve the adjacent vital structures, and promote osteogenesis.
Enucleation with primary closure is the preferred treatment modality in the cyst of small size.
DC is known to recur and has neoplastic potential and it also shows associated pathologies such as ameloblastoma, squamous cell carcinoma, mucoepidermoid carcinoma, adenomatoid odontogenic tumor, and odontoma. With enucleation, the entire lining is removed along with the extraction of the impacted tooth compared to marsupialization which leaves pathological tissue in situ leading to recurrence and neoplastic transformation.
It offers distinct advantages such as removal of cystic lining in toto, a thorough examination of the lining, and rapid recovery. Enucleation along with the extraction of central incisor was treatment preferred in this case, as the cyst was of small size and also because of severe displacement and incomplete root formation of the unerupted permanent central incisor.
| Conclusion|| |
Dentigerous cyst is rare to occur during the first decade of life and is more commonly associated with impacted third molars. Its association with central incisors has been well documented; however, it is quite rare an occurrence. It becomes exceedingly important to diagnose the cyst at an early stage for its better prognosis and decrease the associated morbidity.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shear M, Speight P. Cysts of the Oral and Maxillofacial Regions. 4th
ed. Oxford U.K: Blackwell Munksgaard; 2007. p. 59.
Picciotti M, Di Vece L, Parrini S, Pettini M, Lorenzini G. Replantation of tooth involved in dentigerous cyst: A case report. Eur J Paediatr Dent 2012;13:349-51.
Park C, Park K. Surgical management of dentigerous cyst for preserving permanent tooth buds. J Korean Acad Pedtatric Dent 2014;41:85-92.
dos Santos Pinheiro R, Castro GF, Roter M, Netto R, Meirelles V Jr., Janini ME, et al
. An unusual dentigerous cyst in a young child. Gen Dent 2013;61:62-4.
Cakarer S, Selvi F, Isler SC, Keskin C. Decompression, enucleation, and implant placement in the management of a large dentigerous cyst. J Craniofac Surg 2011;22:922-4.
Kirtaniya BC, Sachdev V, Singla A, Sharma AK. Marsupialization: A conservative approach for treating dentigerous cyst in children in the mixed dentition. J Indian Soc Pedod Prev Dent 2010;28:203-8.
] [Full text]
Hou R, Zhou H. Articles of marsupialization and decompression on cystic lesions of the jaws: A literature review. J Oral Maxillofac Surg Med Pathol 2013;25:299-304.
Demiriz L, Misir AF, Gorur DI. Dentigerous cyst in a young child. Eur J Dent 2015;9:599-602.
] [Full text]
Parul B, Purv P. Recurrent dentigerous cyst with malignant transformation of cyst lining a case report. J Pierre Fauchard Acad (India Sect) 2012;26:59-63.
Motamedi MH, Talesh KT. Management of extensive dentigerous cysts. Br Dent J 2005;198:203-6.
Kalburge J, Latti B, Kalburge V, Kulkarni M. Neoplasms associated with dentigerous cyst: An insight into pathogenesis and clinicopathologic features. Arch Med Health Sci 2015;3:309-13. [Full text]
Jain N, Gaur G, Chaturvedy V, Verma A. A rare site occurrence and a rare coincidence. Int J Clin Pediatr Dent 2018;11:50-2.
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