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Dentigerous cyst over maxillary sinus a case report and literature review


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Dentigerous cyst over maxillary sinus a case report and literature review

  1. 1. Taiwan J Oral Maxillofac Surg20: 116-124, MaxillofacTaiwan J OralJune 2009 Surg 台灣口外誌 Dentigerous Cyst Over Maxillary Sinus : A Case Report and Literature Review Chih-Jen Wang*, Po-Hsien Huang, Yin-Lai Wang, Yih-Chung Shyng, Wen-Bin Kao# * Division of Oral and Maxillofacial Surgery, Department of Dentistry, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan # School of Dentistry, National Defense Medical Center Abstract Dentigerous cyst (DC) is a common odontogenic cyst developed abnormally around unerupted maxillary or mandibular teeth. It is often asymptomatic and can be found incidentally on dental radiography with delayed eruption of teeth. However, it can be large and cause symptoms related to expansion and impingement on contiguous structures. Pain and swelling may be the major complains of patients. However, DC seldom caused head and neck inflammation or infection. Here, we described a 20-year-old male, who was found of a DC arising from right maxillary third molar involved the maxillary sinus and with sinusitis. We also reviewed articles to discuss the differential diagnosis of DC from other odontogenic cysts or odontogenic tumors. Key words: entigerous cyst, sinusitis, maxilla. d Introduction associated with any unerupted teeth, usually attached to the tooth at the cemento-enamel Dentigerous cyst (DC) is a common oral junction. But rarely involves unerupted deciduouslesion formed by fluid accumulation between the teeth1.fully formed tooth crown and the reduced enamel Radiographically, the DC typically shows aepithelium. It is considered a developmental unilocular radiolucent shadow with a well-definedabnormality arising from the reduced enamel sclerotic border associated with the crown of anepithelium around the crown of an unerupted unerupted tooth, but an infected cyst will showtooth. The predilection site of DC is the ill-defined borders2. Here, we will describe a casemandibular third molar. Other frequent sites of DC arising from right maxillary third molar andinclude maxillary canines, maxillary third molars, involving the maxillary sinus with sinusitis.and mandibular second premolar. It is always - 116 -
  2. 2. 台灣口外誌 Dentigerous Cyst over Maxillary Sinus : A Case Report and Literature Review Case report closure of the wound was done. The opening was packed with sterilized petrolatum gauze. Oozy A 20-year-old young male soldier was discharges were found on the following 2 days.referred to the Division of Oral and Maxillofacial On the third day, the mucoperiostum was suturedSurgery, Kaohsiung Armed Force General with 4-0 silk. Postoperative antibiotics wereHospital with a history of painful sensation and prescribed for 7 days.swelling over right maxilla. He was also suffered Microscopically, the epithelium was composedwith yellow-green pus discharges from nasal of non-keratinizing stratified squamous epitheliumcavity. On physical examination, pus discharged with plenty chronic inflammatory cells infiltrationfrom right maxillary second molar distal gingival (Fig 4, 5). There is no evidence of malignantcrevice area was noted. The right maxillary third change or other odontogenic cysts differentiation.molar cannot be seen. The patient had recurrent A dentigerous cyst was confirmed.sinusitis for six years with medical treatment but One month latter, the patient was free fromin vain. He had no systemic disease or drug and sinusitis after receiving cyst enucleation. No cystfood allergy history. Family history did not show recurrence was noted after an 18-months followany contribution. up. The panoramic radiography showed a well-defined radiolucent lesion with sclerotic margin. DiscussionThe lesion pushed the impacted maxillary thirdmolar upward to the roof of the maxillary sinus. The DC is the second most commonThe right maxillary sinus was not clear in the odontogenic cyst, with periapical cyst beingradiography. Root resorption of upper right found more commonly. It presents mostly in thesecond molar was also noted (Fig. 1). Computed second or third decade of life in the maxillaryTomography revealed an expansive mass in or mandibular third molar or maxillary caninethe right maxillary sinus associated with the regions 3 . It can originate from any tooth,radioactive intensity similar to soft tissue. There including supernumerary tooth4. The DCs areis no bone destruction (Fig. 2). mostly asymptomatic and may be found on The patient was arranged to receive opera- routine dental radiographic check-up. They maytion under general anesthesia. Cyst enucleation also cause symptoms like pain or swelling with thewas done with Caldwell-Luc’s procedure. Full enlargement of the cyst size1. Several researchersthickness mucoperiosteal flap was reflected at reported the pathologic fracture of the mandiblethe right mucobuccal fold from right fist premolar caused by the huge of DC 4,5. The outgrowthto second molar. A bony window was made to of the cyst may also cause the resorption ofapproach the maxillary sinus (Fig. 3). The cyst adjacent tooth. According to Eliasson’s report,was totally removed and the surrounding bony roughly 1% of impacted maxillary third molars willstructures about 1 to 2 mm thickness were subsequently become involved with a DC6.also shaved by Stryker. The lesion was about Radiographically, the typical DC showed a4 × 3 × 2 cm in size with firm in consistency. well-defined radiolucency with sclerotic borderThe impacted tooth was also removed. Delayed associated with the crown of an unerupted - 117 -
  3. 3. Taiwan J Oral Maxillofac Surg 台灣口外誌Fig. 1. Unclear sinus image with distal root resorption of upper right 2nd molar were seen. The impacted tooth was pushed to the roof of maxillary sinus by the cyst. The cyst extended from upper right premolar to retromolar area and maxillary sinus roof. Fig. 2. A cystic lesion associated with an impacted teeth was seen at right maxillary sinus. There was no bony destruction at sinus wall. - 118 -
  4. 4. 台灣口外誌 Dentigerous Cyst over Maxillary Sinus : A Case Report and Literature Review Fig. 3. The lesion was removed. Fig. 4. HE staining showed non-keratinizing stratified squamous epithelium lining with plenty of chronic inflammatory cell infiltration (X100). - 119 -
  5. 5. Taiwan J Oral Maxillofac Surg 台灣口外誌 Fig. 5. Same picture from Fig.4 HE staining showed plenty of inflammatory cells infiltration with hemorrhage (X200).tooth 1. Three varieties of the cyst-to-crown panoramic radiology was sufficient for evaluation.relationships can be seen on radiographic The computed tomography may be useful forexamination. They are central variety, lateral evaluating the extent of bony involvement. Sincevariety and circumferential variety1. In the case DCs may contain fluid, in the magnetic resonancepresented here, the cyst-to- crown relationship imaging (MRI), the cyst fluid may be seen as lowwas classified to a circumferential variety. The intensity on T1-weighted and high intensity onexpansion of the cyst caused the resorption T2-weighted images8.of the distal root over upper right second Patients with DCs over maxillary sinusmolar. The cyst growth in this case was quite might present nasal symptoms such as sinusitis.extensive. The tumor extended from the mesial In addition, ophthalmologic symptoms mightaspect of upper first and second premolar, to be present such as proptosis, diplopia, ptosis,the retromolar area, and superiorly to the roof epiphora but rarely affected visual acuity.of the maxillary sinus. This large cyst made Fractured of the orbital bone caused by DC havepatient had symptoms such as pain, swelling and been reported 9. Spontaneous remission of thesinusitis. In the mandible, the DC may grow up lesion without surgical removal may happen, butin to the ramus and caused mandible expension7. cases are few10.In our case, antral obliteration was seen from The differential diagnosis of DC includescomputed tomography. Generally speaking, a odontogenic keratocyst (OKC), adenomatoid - 120 -
  6. 6. 台灣口外誌 Dentigerous Cyst over Maxillary Sinus : A Case Report and Literature Reviewodontogenic tumor (AOT), calcifying epithelial several immunohistochemical markers enhanced,odontogenic cyst (COC), calcifying epithelial such as Bcl-2, Bcl-xL,FGF, MMPs, Ki-67 andodontogenic tumor (CEOT), and unicystic PCNA14,15. Recently, calretinin was suggested toameloblastoma (UAs). In addition to the histo- be a specific immunohistochemical biomarker forpathologic differences between the feature of neoplastic ameloblastic epithelium and may servethe epithelium of OKC and DC, the differential as a diagnostic tool for differentiating cysticdiagnosis can also include the development odontogenic lesions from ameloblastoma16.and the recurrence tendency of these cysts. The best treatment of the UAs is radicalAbout 40% unilocular OKC contain impacted though enucleation is sufficient in subtype 1tooth. The OKC is more aggressive with higher and 217,18,21-23. Considering the similarity of UAsrecurrence risk than DC and may be associated and DC clinically, we enucleated the lesion andwith nevoid basal cell carcinoma syndrome. also trimmed the surrounding bony structuresRecently, researches showed mutation of PTCH to about 1 to 2 mm in thickness. Hopefully, thegene and overactivated of Shh signaling may be histopathological report confirmed the diagnosisassociated with the clinicopathological expression of DC.of OKCs11. BMP-4 may be a useful biochemical The DC may cause head and neck infectionmarker to differentiation of OKC and DC. BMP-4 with a prevalence of 2.1%24. The cyst can undergois expressed more intensive in OKC compared carcinomatous transformation into ameloblastomawith DC, and is more intensively expressed or squamous cell carcinoma but is rare25-28. Inin the recurred cases 12. The AOT and COC cases where mucous cells are present in thegenerally are more frequently seen in maxillary epithelium, the intraosseous mucoepidermoidanterior area with some degree of calcification carcinoma may be ruled out1. Enucleation of thewithin the cyst cavity, which may be observed cyst contents with extraction of the associatedfrom radiography 7,13. Histopathologically, the tooth is sufficient for DC. For extremely largeCOC may present keratinized epithelial cell lesions, or in cases when the involved tooth isso-called ghost cells in the cavity. The AOT desired to keep in the arch, marsupialization maydifferent from the DC, its predilection in female be done. With decompression, the involved toothwith epithelial cells syncytially arranged in may erupt spontaneously by orthodontically intorosettes or duct-like structure. The CEOT may occlusion. When other odontogenic tumors arebe differentiated from DC by its honeycomb highly suspected, radical removal of the lesionspattern radiolucency with foci of radiopacity or removal of the cyst with surrounding bonyin radiographs. Microscopically, it shows large structures is suggested.polygonal epithelial cells with variation in size andshape with amyloid materials, which contained Referencesconcentric calcified deposits (Liesegan rings)13.Although the unicystic ameloblastoma is rare, 1. Neville BW, Damm DD, Allen CM, Bouquot its clinical expression and microscopic feature JE. Oral Maxillofacial Pathology. 2nd ed.can be deceptive and may be confused with DC. Philadelphia: WB Saunders. 2002: 590-3.The UAs is more locally aggressive than DC with 2. Wood NK, Goaz PW. Differential Diagnosis of - 121 -
  7. 7. Taiwan J Oral Maxillofac Surg 台灣口外誌 Oral Lesions. 5th ed. St. Louis Mosby 1997: the odontogenic keratocyst. J Oral Pathol 283-8. Med 2005; 34: 178-83. 3. Regezi JA, Sciubba JJ, Jodan R.C.K. Oral 13. R egezi JA, Sciubba JJ, Jodan RCK. Oral pathology, clinical pathologic correlations. pathology, clinical pathologic correlations. 4th ed. St. Louis: WB Saunders. 2003: 246- 4th ed. St Louis: WB Saunders. 2003: 274- 88. 76. 4. Som PM, Shangold LM, Biller HF. A palatal 14. Kumamoto H, Ooya L. Immunohistochemical dentigerous cyst arising from a mesiodente. analysis of Bcl-2 family proteins in benign and Am H Neuroradiol 1992; 13: 212-4. malignant ameloblastomas. J Oral Pathol Med 5. M aroo SV. Clinico-radiological aspects of 1999; 28: 343-9. dentigerous cysts. East Afr Med J 1991; 68: 15. Li TJ, Brown RM, Matthews JB. Expression 249-54. of proliferating cell nuclear antigen (PCNA) 6. E liasson S, Heimdahl A, Nordenram A. and Ki-67 in unicystic ameloblastoma. Pathological changes related to long- Histopathol 1955; 26: 219-28. term impaction of third molars. Int J Oral 16. C oleman H, Altini M, Ali H, Doflioni C, Maxillofac Surg 1989: 210-25. Favia G, Maiorano E. Use of calretinin 7. oaz PW, White SC. Oral radiology, principles G in the differential diagnosis of unicystic and interpretation. 2nd ed. St. Louis: Mosby. ameloblastomas. Histopathol 2001; 38: 312- 1987: 486-9, 426-692. 7. 8. SOM PM, Shugar JMA, Cohen BA, Biller HF. 17. Gardner D. Plexiform unicystic ameloblas- The nonspecificity of the antral bowing sign toma: a diagnostic problem in dentigerous in maxillary sinus pathology. J Comput Assist cyst. Cancer 1981; 47: 1358-63. Tomogr 1981; 5: 350-2. 18. A ckermann GL, Altini M, Shear M. The 9. O mer K, Onder B. A misdiagnosed giant unicystic ameloblastoma: a clinicopathological dentigerous cyst involving the maxillary study of 57 cases. J Oral Pathol 1988; 17: antrum and affecting the orbit. Case report. 541-6. Aust Dent J 1994; 39: 165-7. 19. Philipsen HP, reichart PA. Unicystic amelo- 10. Freedman GL. A disappearing dentigerous blastoma. A review of 193 cases from the cyst:Report of a case. J Oral Maxillofac Surg literature. Oral Oncol 1998; 34: 317-25. 1988; 46: 885-6. 21. Shear M. Cysts of the Oral Regions, 3rd ed. 11. Koyama E, Yamaai T, Isseki S, Ohuchi H, Oxfort: Wright. 1992; 75-98 Nohno T, Yoshiola H, Hayash Y, Leatherman 22. Robinson L, Martinez MG. Unicystic amelo- JL, Golden EBm Noji S, Pacifici M. Polarizing blastoma: a prognostically distinct entity. activity, Sonic hedgehog, and tooth develop- Cancer 1977; 40: 2278-85. ment in embryonic and postnatal mouse. Dev 23. L i TJ, Wu YT, Yu SF, Yu GY. Unicystic Dyn 1996; 206: 59-72. ameloblastoma: a clinicopathologic study of12. Kim SG, Yang BE, Oh SH, Min SK, Hong SP, 33 Chinese patients. Am J Surg Pathol 2000; Choi JY. The differential expression pattern 24: 1385-92. of BMP-4 between the dentigerous cyst and 24. S mith JL, Kellman RM. Dentigerous cysts - 122 -
  8. 8. 台灣口外誌 Dentigerous Cyst over Maxillary Sinus : A Case Report and Literature Review presenting as head and neck infections. 1982; 27: 365-7. Otolaryngol Head Neck Surg 2005; 133: 715- 27. Rafael M: Ameloblastoma developing from a 20. dentigerous cyst. Oral Surg Oral Med Oral25. Kramer IRH, Pindborg JJ, Shear M. Histo- Pathol 1960; 13: 781-6. logical Typing of Odontogenic Tumors. 28. M cMillan MD, Millie AC. Ameloblastomas Berlin: Springer 1992: 11-4. associated with dentigerous cysts. J Oral26. Yaacob HB, Ling KC. Ameloblastomatous Pathol Med 1981; 51: 489-96. changes in dentigerous cyst. Aust Dent J - 123 -
  9. 9. Taiwan J Oral Maxillofac Surg 台灣口外誌 上顎竇之含牙囊腫:病例報告與文獻回顧 王峙仁* 黃寶賢 王銀來 邢憶春 高文斌# * 國軍高雄總醫院牙科部口腔顎面外科 # 國防醫學院牙醫學系 摘  要 含牙囊腫是一種常見於上下顎阻生齒周圍發育異常的齒源性囊腫。由於 通常並無症狀,故患者常因為牙齒延遲萌發,於接受放射檢查時而發現。然 而,此囊腫若持續擴大,侵犯擠壓到鄰近組織,便可能產生不適。腫大與疼 痛是大多數病人的主要抱怨的症狀,但含牙囊腫鮮少引起頭頸部發炎或感 染。本文提出一位20歲男性因右上顎第三大臼齒侵犯上顎竇導致鼻竇炎的個 案報告,同時藉由回顧文獻,討論對於含牙囊腫與其他齒源性囊腫的鑑別診 斷。 關鍵詞:含牙囊腫,鼻竇炎,上顎。 Received: March 28, 2009 Accepted: May 31, 2009 Reprint requests to: r. Wen-Bin Kao, Division of Oral and Maxillofacial Surgery, Department of D Dentistry, Kaohsiung Armed Forces General Hospital. - 124 -