Year : 2007 | Volume
: 25 | Issue : 1 | Page : 56--59
Dentigerous cyst associated with multiple mesiodens: A case report
AD Dinkar, AA Dawasaz, S Shenoy
Department of Oral Medicine, Diagnosis and Radiology, Goa Dental College and Hospital, Goa, India
A A Dawasaz
Oral Medicine, Diagnosis and Radiology Department, Goa Dental College and Hospital, Bambolim, Goa - 403 202
Dentigerous cyst is a developmental odontogenic cyst, which apparently develops by accumulation of fluid between reduced enamel epithelium and the tooth crown of an unerupted tooth. When observed with erupted and complete dentition the diagnosis is a surprise; as about 95% of dentigerous cysts involve the permanent dentition and only 5% are associated with supernumerary teeth. The usual age of clinical presentation of dentigerous cyst due to supernumerary tooth is during the first four decades.
Mesiodens is a supernumerary tooth situated between the maxillary central incisors. More frequently the mesiodens occurs unilaterally, but it may also be bilateral, while three or more supernumerary teeth in the median region of the palate are more rarely found. We report a rare case of dentigerous cyst in association with multiple mesiodens in a 14-year-old female patient.
|How to cite this article:|
Dinkar A D, Dawasaz A A, Shenoy S. Dentigerous cyst associated with multiple mesiodens: A case report.J Indian Soc Pedod Prev Dent 2007;25:56-59
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Dinkar A D, Dawasaz A A, Shenoy S. Dentigerous cyst associated with multiple mesiodens: A case report. J Indian Soc Pedod Prev Dent [serial online] 2007 [cited 2020 Apr 9 ];25:56-59
Available from: http://www.jisppd.com/text.asp?2007/25/1/56/31994
Dentigerous cyst is defined as a cyst that originates by the separation of the follicle from around the crown of an unerupted tooth. Dentigerous cysts around supernumerary teeth account for 5% of all dentigerous cysts, most developing around a mesiodens in the anterior maxilla. Because the histopathologic appearance of the lining epithelium is not specific, the diagnosis relies on the radiographic and surgical observation of the attachment of the cyst to the cemento-enamel junction. 
A 14-year-old female patient presented with a progressively enlarging painful central palatal swelling in the maxillary anterior region gradually increasing over the past one month. Clinical examination revealed a firm swelling fixed to the alveolar process of the maxilla [Figure 1]. Routine laboratory parameters were normal. Diagnostic maxillary occlusal radiograph [Figure 2],[Figure 3] and an orthopantomograph [Figure 4] showed a radiolucent lesion in the alveolar process of the anterior maxilla. The lesion was well-defined lying apical to the central incisors, measuring approximately 4.5x4 cm. Two supernumerary teeth were observed to be lying vertically and inverted within the lesion; having cone shaped crowns and one short root each. There was no evidence of resorption of the roots of associated permanent teeth. Radiographic findings, surgical resection and histopathological examination [Figure 5] confirmed the diagnosis of dentigerous cyst associated with the mesiodens. The patient remained under follow up for six months and no complications were observed [Figure 6],[Figure 7],[Figure 8],[Figure 9].
A cystic swelling of the hard palate may be the result of different kinds of odontogenic or non-odontogenic cysts. In our patient a dentigerous cyst associated with multiple mesiodens caused the swelling in the anterior palate.
The etiology of supernumerary teeth is unknown.  One school of thought is of the view that they develop from a third tooth bud arising from the dental lamina near the permanent tooth bud or probably from splitting of the permanent bud itself. This view is supported by the fact that a supernumerary tooth usually closely resembles the teeth of the group to which it belongs. The most common supernumerary tooth is the 'Mesiodens' a tooth situated between the maxillary central incisors. ,
Mesiodens may usually be diagnosed because of delayed eruption of central incisors. Unilateral persistence of deciduous incisor, wide diastema or rotation of erupted permanent incisors is other common presentations. Mesiodens may be single or multiple, erupted or impacted and are rarely seen associated with a dentigerous cyst.  The direction of the crown of the mesiodens may be normal, inverted or horizontal. Mesiodens are known to have a cone shaped crown and a short root as seen in our patient. It is a rare entity with a reported incidence of 0.15 to 1.9% and has a slight male predominance. ,
The radiological examinations indicated for the diagnosis of supernumerary teeth or mesiodens and their complications are: periapical, occlusal, and panoramic radiographs.  In case the supernumerary tooth/mesiodens is seen, their location and number should be documented by the radiologist. In addition the direction of the crown, location against dental arch, influence on adjacent teeth, resorption of adjacent roots and formation of dentigerous cyst should be carefully evaluated. ,
Most mesiodens are located palatal to the permanent incisors. Only a few lie in the dental arch or labial to the permanent incisors.  Resorption of the adjacent roots by mesiodens or its cyst is a rare complication.  In our patient, resorption of the roots was not observed.
Radiologically, well-defined radiolucent lesions with sharp margins occurring in the maxilla and mandible may be odontogenic or non-odontogenic in origin: such as radicular cyst, dentigerous cyst, odontogenic keratocyst, non-odontogenic cysts like simple bone cyst, aneurysmal bone cyst, Stafne cyst or even tumors such as ameloblastoma.
Radicular cyst is the most common odontogenic cyst of the maxilla and mandible. Radiologically, it arises from the apex of the root of a carious tooth and is bounded by a thin rim of cortical bone. A large radicular cyst may expand the cortex, cause root resorption in adjoining teeth or even extend into the maxillary sinus. The close differential diagnosis of a radicular cyst is periapical granuloma. A round shape, well-defined cortical border and a size greater than 2 cm are characteristics of a cyst. The differentiating feature of this entity is its relation to the root of a carious tooth. 
Odontogenic keratocyst results from cystic degeneration of the enamel organ before the tooth is formed so that the cyst replaces the tooth. It is commonly noted in the mandible. Radiologically it is seen as a multilocular radiolucent lesion with smooth or scalloped borders. It does not expand the alveolar bone to the same degree as dentigerous cyst and may attach farther apically on the root. The classical feature of this cyst is the absence of the related tooth. 
Non-odontogenic cysts are observed in the region of incisive canal or nasolabial regions. The incisive canal cyst is in the midline located between the roots of central incisors of maxilla and is characteristically heart shaped. It may cause roots of the central incisors to be divergent. The nasolabial cyst occurs in the soft tissues of the lateral aspect of the nose and upper lip. These cysts are therefore diagnosed by their classical anatomical location.  Simple bone cyst is a unilocular cyst and is usually noted in the posterior aspect of the body of mandible. Radiologically, it is seen as a well-defined radiolucent lesion with sclerotic margins. The margin of a simple bone cyst may be scalloped. Stafne bone cyst is usually located at the angle of the mandible. It is detected incidentally and is seen as a radiolucent lesion having well-defined margins and minimal sclerosis. Most aneurysmal bone cysts occur in tubular bones or in spine, only 2% occur in the maxilla and mandible. Aneurysmal bone cyst is seen as expansible multilocular radiolucent lesion. CT/MRI may reveal presence of blood or fluid contents in the cyst.
Ameloblastoma is a uni/multilocular radiolucent lesion associated with cortical expansion and is more common in the mandible than in the maxilla. It shows scalloped margins, resorption of roots of adjacent teeth and a tendency to penetrate the cortex of jaw to present as an extra osseous soft tissue mass. In our patient all other differential diagnoses of dentigerous cyst were ruled out on the basis of characteristic radiographic features. 
Dentigerous cyst is the second most common odontogenic cyst and is characteristically related to the crown of an unerupted tooth. The diagnostic feature of this cyst is the presence of the unerupted tooth in its cavity.  It arises by accumulation of fluid between the reduced enamel epithelium and the enamel. It has been suggested that the pressure exerted by a potentially erupting tooth on an impacted follicle obstructs the venous outflow and thereby induces rapid transudation of serum across the capillary walls. The increased hydrostatic pressure of this pooling fluid separates the follicle from the crown, with or without the reduced enamel epithelium. It usually occurs in the mandible and is known to be both unilocular and multilocular and causes apical resorption of the adjacent teeth.
In conclusion, supernumerary teeth usually present with orthodontic problems in children and young adults. Dentigerous cysts in adults are usually due to unerupted teeth. Our report documents an unusually early presentation of multiple mesiodens with associated dentigerous cyst and also highlights the relevant differential diagnoses.
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