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| CASE REPORT |
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| Year : 2022 | Volume
: 12
| Issue : 1 | Page : 38-41 |
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An infected case of small dentigerous cyst on intraoral radiograph and orthopantomography
Manisha Singh, Anjana Bagewadi
Department of Oral Medicine and Radiology, KLEVK Institute of Dental Sciences, Belagavi, Karnataka, India
| Date of Submission | 18-Oct-2021 |
| Date of Decision | 18-Mar-2022 |
| Date of Acceptance | 04-Apr-2022 |
| Date of Web Publication | 16-Jul-2022 |
Correspondence Address:
Dr. Manisha Singh
Department of Oral Medicine and Radiology, KLEVK Institute of Dental Sciences, Nehru Nagar, Belagavi, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijohs.ijohs_29_21
Dentigerous cyst is the second most common odontogenic cyst, which affects the jaws. It accounts for 15% of all true cysts in the jaws. This cyst is mostly associated with the crown of unerupted teeth involving crown of impacted mandibular third molars followed by maxillary canine and maxillary third molars. Dentigerous cysts can occur at any age, but the greatest incidence is in the second to fourth decades of life. Dentigerous cysts have the potential for attaining large size and tend to absorb roots of involved teeth. Dentigerous cysts have the potential to develop odontogenic tumors such as ameloblastoma and malignancies such as oral squamous cell carcinoma and mucoepidermoid carcinoma. The progressive nature of dentigerous cysts may show expansion and result in pathological fractures of jawbones. The early detection of this cyst decreases the severity of the disease. Here is a case report of an infected dentigerous cyst that was detected on intraoral radiograph and orthopantomography.
Keywords: Dentigerous cyst, impacted mandibular third molar, intraoral radiograph, orthopantomography
How to cite this article:
Singh M, Bagewadi A. An infected case of small dentigerous cyst on intraoral radiograph and orthopantomography. Int J Oral Health Sci 2022;12:38-41 |
| Introduction | |  |
Dentigerous cyst is the second most common odontogenic cyst associated with the crown of unerupted or impacted teeth. The most common tooth involved is the mandibular third molar followed by maxillary canine and maxillary third molar. The most accepted theory is intrafollicular theory which states that the developmental dentigerous cyst forms from the dental follicles.[1] They develop by accumulating fluid either between the reduced enamel epithelium and the enamel or in between layers of the enamel organ. The pressure exerted by an erupting tooth on the follicle may obstruct venous flow inducing accumulation of fluid between the reduced enamel epithelium and the enamel or in between layers of the enamel organ.[2] The increased hydrostatic pressure exerted by the pooling of fluid causes separation of the crown from the follicle with or without reduced enamel epithelium.
Most of dentigerous cysts are asymptomatic and of small size which can be diagnosed on routine dental radiograph. They are usually painless until secondary infection is present. They may grow to a larger size with bony expansion. This is a case report with infected dentigerous cyst detected on intraoral periapical (IOPA) radiograph and orthopantomography (OPG).
The dentigerous cysts can expand rapidly, and they may cause pathological fractures of jawbones. They may cause facial asymmetry, extreme displacement of teeth, and severe root resorption of teeth. The previous literature reveals development of ameloblastoma in the walls of dentigerous cysts from the lining epithelium or associated epithelial rests.[3] Occasionally, the wall of a dentigerous cyst may give rise to mucoepidermoid carcinoma[4] and oral squamous cell carcinoma.[5] Early detection of the cyst and its treatment is required to reduce morbidity.
This paper aims to interpret the radiographic presentation of dentigerous cyst including IOPA radiograph and OPG. The central variety of dentigerous cysts can be appreciated. This case also provides the radiographic differential diagnosis of jaw lesions present in the pericoronal region of the mandible with impacted third molar.
| Case Report | | |
A 42-year-old male reported to the department with a chief complaint of pain and swelling in the lower left side of the oral cavity for the past 1 week. The swelling was increasing in size due to which he visited a local doctor. There was a history of analgesics and antibiotics after which swelling subsided. There was no history of difficulty in mouth opening and pus discharge. There was no relevant medical and family history.
Extraoral examination revealed solitary lymph node which was present on the left submandibular region. The lymph node was soft in consistency, mobile, and tender. There was no facial asymmetry and extraoral swelling noted.
Intraoral examination revealed a diffuse swelling present in the left attached gingiva extending to buccal vestibule with 36 measuring about 1.5 cm × 1.5 cm. Swelling extended from distal side of 36 to 1 cm ahead of the retromolar region anteroposteriorly. Superoinferiorly, swelling extended from marginal gingiva of 36 to the buccal vestibule. The mucosa over the swelling appeared to be red and febrile. On palpation, the swelling was firm in consistency and tender. Obliteration of the buccal vestibule was seen [Figure 1]. Other findings included amalgam with restoration 37 and 47. | Figure 1: Intraoral picture showing obliteration of buccal vestibule in the region of 36 and 37
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Investigations
The patient was advised for cold vitality test, laboratory tests including bleeding and clotting test, hemoglobin, blood sugar levels, IOPA radiograph, and OPG. There was no vital response with 36 and 37, suggesting nonvital teeth with 36 and 37, and laboratory findings were within normal limits. IOPA radiograph was advised with 37 and 38. IOPA radiograph of 37 and 38 showed mesially inclined 38 [Figure 2]. The radiolucency was well defined coronal to crown of 38 involving the periapical area of 37 measuring about 1.5 cm × 1 cm in dimensions. The radiolucency was surrounded by the corticated border with 37 and 38. | Figure 2: Intraoral periapical radiograph revealing well-defined unilocular radiolucency involving crown of 38
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OPG showed well-defined radiolucency in the coronal portion of 38 measuring about 1.5 cm × 1 cm in diameter [Figure 3]. The radiolucency extended from the alveolar ridge of 38 to 2 cm above the inferior border of the mandible superoinferiorly. Mesially inclined 38 with the presence of cortication at the border of radiolucency and the internal structure was completely homogeneous (radiolucent).
| Discussion | | |
Dentigerous cysts are most common in the second to fourth decades of life, and there is slight predilection for males. The main diagnostic appearance of this cyst is radiolucency is attached at the cementoenamel junction of an impacted tooth. On radiograph, the size of the normal dental follicle is 2–3 mm, which should be differentiated from the size of dentigerous cyst which is >5 mm. Radiographically, the cyst appears unilocular radiolucent lesion with well-defined margins and often sclerotic borders. Infected cysts show ill-defined margins.[6] In the present case, clinical and radiographic findings are similar to the previous literature.
Radiographically, three types of dentigerous cyst are noted. First is the central variety where the radiolucency surrounds just the crown of the tooth, with the crown projecting into the cyst lumen.[7] Second is the lateral variety where the cyst develops laterally along the tooth root and partially surrounds the crown.[7] Third is the circumferential variety where the cyst surrounds the crown and extends down along the root surface as if the entire tooth is located within the cyst.[7] The present case provides the classic presentation of the central variety.
Based on history, clinical findings, and radiographs, a differential diagnosis of dentigerous cyst, unicystic ameloblastoma, and ameloblastic fibroma was established. Dentigerous cyst forms around the crown of an impacted tooth mostly mandibular third molar. This cyst present as pericoronal radiolucency is projected over the apex of a neighboring tooth. This cyst attaches at cementoenamel junction. The internal structure is completely radiolucent except for the crown of the involved tooth with well-defined cortex. Unicystic ameloblastoma forms in the epithelial lining of a dentigerous cyst. The most common site is mandibular third molar region. Unicystic ameloblastoma grows slowly and is discovered during routine radiograph. The borders are usually well defined and surrounded by cortical border. The internal structure is radiolucent. Ameloblastic fibroma is benign mixed odontogenic tumor. The tumor was discovered on a routine dental radiograph. They are usually seen as unilocular or multilocular pericoronal radiolucency. The internal structure is radiolucent, and the borders are well defined with cortication.
Therefore, radiographic differential diagnosis is helpful in the arrangement of instruments to be used at the time of surgery and planning different procedures of surgery including excisional biopsy, incisional biopsy, and aspiration of the cyst. The case was managed by surgical excision of cyst with extraction of 38 [Figure 4]. Root canal treatment was advised for 36 and 37. Cystic lining was sent for histopathological examination. The specimen showed the stratified squamous nonkeratinized type of cystic epithelium overlying connective tissue stroma. The histopathological features were suggestive of dentigerous cyst [Figure 5]. Prognosis of this patient with histopathologically diagnosed dentigerous cyst was good, and there were no signs of recurrence after the treatment [Figure 6] and [Figure 7]. | Figure 5: Histopathological photomicrograph revealing connective tissue stroma with fibroblasts, lymphocytes, and plasma cells
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| Conclusion | | |
This case report describes the central variety of dentigerous cysts with clinical and histopathological features. Hence, early diagnosis and treatment of dentigerous cyst will be helpful in decreasing the morbidity of the patient, and to conclude, every individual should visit dentist every 6 months.
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
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Browne RM. The pathogenesis of odontogenic cysts: A review. J Oral Pathol 1975;4:31-46.  |
| 2. | Main DM. The enlargement of epithelial jaw cysts. Odontol Revy 1970;21:29-49. |
| 3. | Leider AS, Eversole LR, Barkin ME. Cystic ameloblastoma. A clinicopathologic analysis. Oral Surg Oral Med Oral Pathol 1985;60:624-30. |
| 4. | Eversole LR, Sabes WR, Rovin S. Aggressive growth and neoplastic potential of odontogenic cysts: With special reference to central epidermoid and mucoepidermoid carcinomas. Cancer 1975;35:270-82. |
| 5. | Johnson LM, Sapp JP, McIntire DN. Squamous cell carcinoma arising in a dentigerous cyst. J Oral Maxillofac Surg 1994;52:987-90. |
| 6. | Shear M, Speight P. Cysts of the Oral and Maxillofacial Regions. 4 th ed. Blackwell Publishing Ltd.; 2007. p. 5978. |
| 7. | Mohan KR, Natarajan B, Mani S, Sahuthullah YA, Kannan AV, Doraiswamy H. An infected dentigerous cyst associated with an impacted permanent maxillary canine, inverted mesiodens and impacted supernumerary teeth. J Pharm Bioallied Sci 2013;5:S135-8. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
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