DENTIGEROUS CYST IN MAXILLA IN A YOUNG GIRLAUTHORS1. Dr. Mausumi IqbalBDS, FCPS Trainee (OMS)Honorary Medical OfficerDept. of Oral & Maxillofacial SurgeryDhaka Dental College & Hospital, Dhaka2. Dr. A S M Shahidur RahmanBDS, MS, FCPSAssistant ProfessorDept. of Oral & Maxillofacial SurgeryDhaka Dental College & Hospital, Dhaka3. Prof. Dr. Mohiuddin AhmedBDS, FCPS, PhDProfessor & HeadDeptof Oral& Maxillofacial SurgeryDhaka Dental College & Hospital
ABSTRACTDentigerous cyst (DC) is a common odontogenic cyst developed abnormallyaround unerupted maxillary or mandibular teeth. It is often asymptomatic and canbe found incidentally on dental radiograph with delayed eruption of teeth.However, it can be large and cause symptoms related to expansion andimpingement on contiguous structures. Pain and swelling may be the majorcomplains of patients. However, DC seldom cause head and neck inflammation orinfection. In this article, we report a rare case of dentigerous cyst arising from anunerupted premolar which had invaded in right maxillary antrum in an 8 year-oldchild.Keywords:Dentigerous cyst, enucleation, marsupialization, unerupted maxillarypremolarINTRODUCTIONDentigerous cyst (DC) is a common oral lesion formed by fluid accumulationbetween the fully formed tooth crown and the reduced enamel epithelium. Thedentigerous cyst initially is always associated with the crown of an impacted,embedded, or unerupted tooth. The proportion of 6- to 7-year-old childrenaffected with dentigerous cysts is only 9.1%. Dentigerous cysts occurpredominantly in the third molar region of the mandible, followed in frequency by
maxillary canine, maxillary third molar, and rarely in relation to maxillary centralincisor.CASE REPORTAn 8 years old girl reported to the department of Oral and Maxillofacial Surgery ofDhaka Dental College and Hospital with the chief complaints of a swelling on rightsided upper jaw for 5 months which is visualized from extra orally from 1 month.She had taken antibiotic 1 month back prescribed by local doctor but her parentscould not remember the name of antibiotic, but the swelling didn’t subside. Ongeneral physical examination, patient was apparently healthy, medical history wasnot significant and routine hematological investigations were within normal limits.A clinical intra oral examination revealed a diffuse swelling extending frommaxillary right deciduous canine to the maxillary right deciduous 2ndmolar.[Figure: 1] Swelling was ill- defined, soft in consistency, tender onpalpation, measured about 3X2 cm extending into right maxillary buccal vestibule.The overlying mucosa was apparently normal with no signs of inflammation orserosanguinous discharge.An extra oral examination revealed a well-defined firm swelling present over rightside of cheek area, painful on palpation, overlying skin normal in colour with nosign of inflammation.
The patient had a pre-existing paranasal sinus view and an orthopantomograph.[Figure: 2 and 3] Both the radiographs revealed a partially formed and uneruptedtooth resembling bicuspid with a radiolucent area surrounding it. On aspiration ofthe swelling, straw coloured fluid was found which was sent for biochemicalinvestigation, the result of which was consistent with the diagnosis of a cysticlesion. [Figure: 4]. A provisional diagnosis of the dentigerous cyst was arrived atbased on clinical and radiologicalfeatures.Figure 1Intraoral viewFigure 2Paranasal sinus view
Figure 3OrthopantomogramFigure 4Aspirated cystic fluidEnucleation of the cyst was chosen as the treatment option. The treatmentconsisted of removal of cystic lining along with the tooth. The surgery was doneunder general anesthesia using Caldwell- Luc approach. The wound was closedprimarily and the specimen was sent for Histopathological examination. Woundhealing was uneventful. Microscopic examination was consisted with dentigerouscyst.The patient was asked to return for follow up after 15 days. The patient wasadvised for longer follow-up for prosthetic and orthodontic rehabilitation.
DISCUSSIONThe dentigerous cyst is the most frequent developmental odontogenic cystaffecting permanent teeth.  Dentigerous cysts of maxilla are commonlyassociated with the maxillary third molar  and not with a canine tooth. In thepresent case, the ectopic tooth was apermanent canine. There have been previouscase reports of a dentigerous cyst with a deciduous tooth  and with asupernumerarytooth.  A case of a large maxillary cyst involving the whole sinusand producing epiphora has been reported by Atlas et al. Dentigerous cysts are usually solitary, benign odontogenic cysts associated withthe crowns of unerupted teeth. The exact histiogenesis ofthe dentigerous cyst is notknown. It is stated that the dentigerous cyst develops by the accumulation of fluideither between the reducedenamel epithelium and the enamel or in between layersof the enamel organ. This fluid accumulation occurs as a result of thepressureexerted by an erupting tooth on an impacted follicle, which obstructs thevenous outflow and thereby induces a rapid transudation ofserum across thecapillary wall. Toller stated that the likely origin of the dentigerous cyst isthe breakdown of proliferating cells ofthe follicle after impeded eruption. Thesebreakdown products result in increased osmotic tension and hence cyst formation.These cystsusually occur in the late second and third decades, are discovered onroutine radiography, and predominantly involve mandibular third molars.
The second type is inflammatory origin and occurs in immature teeth as a result ofinflammation from a non-vital deciduous tooth.Bloch  suggested that the originof the dentigerous cyst is the overlying necrotic deciduous tooth. The resultantperiapicalinflammation will spread to involve the follicle of an uneruptedpermanent successor; inflammatory exudates ensue and result indentigerous cystformation. These cysts are diagnosed in the first and early part of the seconddecade either on routine radiographicexamination or when the patient complains ofswelling or pain. We believe that our case might be classified as the second typeofdentigerous cyst.Treatment of a dentigerous cyst depends on size, location, and disfigurement andoften requires variable bone removal to ensure a totalremoval of the cyst. Eventhough marsupialization of the cyst is the treatment of choice for dentigerous cystin children in order to give achance to the unerupted tooth to erupt, the majordisadvantage of marsupialization is that pathologic tissue is left in situ, without athorough histologic examination. [12, 13] Although the tissue taken from thewindow created can be submitted for pathologicexamination, there is a possibilityof a more aggressive lesion in the residual tissue. But, in this case, as the tooth wasalmost displaced tooth up to the roof of the developing maxillary sinus far from thealveolar arch with a questionable viability, enucleation with the removal ofthedisplaced tooth was favored.
CONCLUSIONIn summary, dentigerous cyst development associated with an uneruptedpermanent tooth is not uncommon. Dentigerous cysts ofmaxilla are usuallyassociated with the maxillary third molar and not with a premolar tooth. In thepresent case, the cyst was associated with premolar and was almost involving thedeveloping maxillary sinus of the 8-year-old child. These findings are not commonindentigerous cysts, and hence, this case is reported.REFERENCES1. Wang CJ, Huang PH, Wang YL, Shyng WC, Kao YB et al. Dentigerous Cystover Maxillary Sinus: A Case report and literature review. Taiwan J OralMaxillofacial Surgery. 2009; 20: 116-124.2. Shafer WG, Hine ML, Levy BM. A Textbook of Oral Pathology. 4th ed.Philadelphia, PA: Saunders; 1983. pp. 271–3.3. Tachibana T, Shimizu M, Shioda S. Clinical observation of the cysts of thejaws in childhood. J Oral MaxillofacSurg. 1980; 26:337.4. Ishikawa G. Oral Pathology 2. Kyoto Nagasueshoten Co; 1982. pp. 379–81.5. Kusukawa J, Iric K, Morimatsu M, Koyanagi S, Kameyama T. DentigerousCyst associated with a deciduous tooth. Oral Surgery, OralMedicine, OralPathology. 1992; 73:415–8.6. Frer AA, Friedman AL, Jarrett WJ, Brooklyn NY. Dentigerous cyst involvingthe maxillary sinus. Oral Surgery. 1972; 34:378–80.
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