Year : 2007 | Volume
: 25 | Issue : 4 | Page : 187--190
Dentigerous cysts of anterior maxilla in a young child: A case report
RR Kalaskar, A Tiku, SG Damle
Department of Pediatric Dentistry, Nair Hospital Dental College, Mumbai, India
R R Kalaskar
Department of Pediatric Dentistry, Nair Hospital Dental College, Mumbai
Dentigerous cysts are the most common bony lesions of the jaws in children. It is one of the most prevalent types of odontogenic cysts associated with an erupted or developing tooth, particularly the mandibular third molars; the other teeth that are commonly affected are, in order of frequency, the maxillary canines, the maxillary third molars and, rarely, the central incisor. Radiographically, the cyst appears as ovoid well-demarcated unilocular radiolucency with a sclerotic border. The present case report describes the surgical enucleation of a dentigerous cyst involving the permanent maxillary right central incisor; the surgery was followed by oral rehabilitation. Careful evaluation of the history and the clinical and radiographical findings help clinicians to correctly diagnose the condition, identify the etiological factors, and administer the appropriate treatment.
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Kalaskar R R, Tiku A, Damle S G. Dentigerous cysts of anterior maxilla in a young child: A case report.J Indian Soc Pedod Prev Dent 2007;25:187-190
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Kalaskar R R, Tiku A, Damle S G. Dentigerous cysts of anterior maxilla in a young child: A case report. J Indian Soc Pedod Prev Dent [serial online] 2007 [cited 2019 Nov 22 ];25:187-190
Available from: http://www.jisppd.com/text.asp?2007/25/4/187/37016
Dentigerous cysts are the most common of the developmental odontogenic cysts of the jaws and account for approximately 20-24% of all the epithelium-lined jaw cysts. It develops around the crown of an unerupted tooth by expansion of follicle when fluid collects or a space occurs between the reduced enamel epithelium and the enamel of an impacted tooth.  Dentigerous cysts are always associated with an unerupted or developing tooth bud and are found most frequently around the crown of the mandibular third molars followed, in order of frequency, by the maxillary canines, maxillary third molars and, rarely, the maxillary right central incisor.  These cysts are often asymptomatic unless there is an acute inflammatory exacerbation and, therefore, these lesions are usually diagnosed during routine radiographic examination.  Swelling, teeth displacement, tooth mobility, and sensitivity may be present if the cyst reaches a size larger than 2 cm in diameter.  Radiograph of the dentigerous cyst shows a well-defined unilocular radiolucency, often with a sclerotic border, surrounding the crown of an unerupted tooth.  Histologically, the dentigerous cyst consists of a fibrous wall lined by nonkeratinized stratified squamous epithelium consisting of myxoid tissue, odontogenic remnants and, rarely, sebaceous cells.  Complications associated with dentigerous cysts include pathologic bone fracture, loss of the permanent tooth, bone deformation, and development of squamous cell carcinoma, mucoepidermoid carcinoma, and ameloblastoma.  The treatment indicated for dentigerous cysts are surgical removal of the cyst, avoiding damage to the involved permanent tooth; enucleation of the cyst, along with removal of the involved tooth; or the use of a marsupialization technique, which removes the cyst while preserving the developing tooth.  The present case report describes the management of dentigerous cysts in children.
A 7-year-old boy reported to the Department of Pediatric Dentistry, Nair Hospital Dental College, Mumbai, with a chief complaint of a painless swelling in the maxillary right anterior region since 4 months. On general examination, the patient was apparently healthy. There was no significant past medical history. Intraoral examination revealed a bony swelling which caused a bulging of the cortical bone, extending from the buccal vestibule of the maxillary left deciduous central incisor to the maxillary right first deciduous molar. The swelling was well defined, firm in consistency, painless on palpation, and measured about 3 × 3 cm. There was no bruit or pulsation. The buccal cortical plate showed slight expansion and the overlying mucosa was slightly inflamed. There were no signs of any acute periodontal condition or carious lesions. The primary maxillary right central incisor was discolored and was associated with an intraoral sinus. There was history of trauma 1 year back while playing in school. The teeth on the affected side were mobile (51, 52, 53, 54, 61) although not sensitive to percussion.
The occlusal radiological examination showed a thin sclerotic border surrounding the well-defined unilocular radiolucent area that was associated with the root of a nonvital primary maxillary right central incisor and an unerupted permanent maxillary right central incisor [Figure 1]. The permanent maxillary right central and lateral incisors were superiorly and laterally displaced. There was irregular root resorption of the primary maxillary right lateral incisor and a widened pulpal canal of the primary maxillary right central incisor [Figure 1]. The contents of the swelling were aspirated and sent for investigations; the result of which was consistent with the diagnosis of a cystic lesion. After clinical and radiological examination, a provisional diagnosis of dentigerous cyst was made; however, large periapical cyst, odontogenic keratocyst, central giant-cell granuloma, adenomatoid odontogenic tumor, and ameloblastic fibroma were also considered in the differential diagnoses. Prior to surgery, routine blood and urine examination were advised; the results were within normal limits. Surgical enucleation of the cyst was chosen as the treatment of choice. The treatment consisted of extraction of the maxillary right deciduous central incisor, maxillary right deciduous lateral incisor, maxillary right deciduous canine, maxillary left deciduous central incisor, and permanent maxillary right canine, along with total enucleation of the dentigerous cyst. The surgery was done using local anesthesia (Dentocaine 2% Pharma Health Care Product, Mumbai) and under antibiotic cover. The cyst was attached to the cementoenamel junction of maxillary right permanent central incisor [Figure 2],[Figure 3]. The cyst cavity was packed with sterile iodoform gauze to achieve hemostasis and to prevent hematoma formation [Figure 4]. The iodoform gauze was removed on the next day and the sutures were removed after one week. The specimen was sent for histopathological examination. The histological examination showed a thin fibrous cystic wall lined by a 2 to 3 layer thick nonkeratinized stratified squamous epithelium, with islands of odontogenic epithelium. The connective tissue showed a slight inflammatory cell infiltrate, which confirmed the diagnosis of dentigerous cyst [Figure 5]. After 15 days, a removable partial denture was delivered, which served as a functional space maintainer, improved esthetics and phonetics, and also as a guidance for the eruption of the permanent maxillary left central incisor. The patient was asked to return for clinical and radiographic follow-up once a month. After 6 months, bone neoformation was observed in the same region [Figure 6] and the permanent maxillary left central incisor was seen erupting in its proper place [Figure 7]. A follow-up after every 6 months and careful monitoring of the permanent right lateral incisor and permanent left central incisor is required.
A dentigerous cyst can be defined as a cyst that encloses the crown of an unerupted tooth, expands the follicle and is attached to the cementoenamel junction of the unerupted tooth.  Dentigerous cysts account for more than 24% of jaw cysts. The substantial majority of dentigerous cysts involve the mandibular third molar and the maxillary permanent canine, followed by the mandibular premolars, maxillary third molars and rarely the central incisors.  Studies have shown that the incidence rate of dentigerous cysts involving the maxillary central incisor was 1.5% as compared to 45.7% involving the mandibular third molar.  Mourshed  stated that 1.44% of impacted teeth undergo dentigerous cyst transformation, so dentigerous cysts involving the permanent central incisor are rare. Daley et al .  reported an incidence rate of 0.1-0.6%, whereas Shear found the incidence to be 1.5%.  Dentigerous cysts most commonly occur in the 2 nd and 3 rd decades of life. These lesions can also be found in children and adolescents and show a male predilection.  In the present case report, the dentigerous cyst was associated with the permanent maxillary right central incisor in a 7-year-old male child.
The exact histogenesis of the dentigerous cyst is not known. It is stated that the dentigerous cyst develops around the crown of an unerupted tooth by accumulation of fluid either between the reduced enamel epithelium and enamel or in between the layers of the enamel organ. This fluid accumulation occurs as a result of the pressure exerted by an erupting tooth on an impacted follicle, which obstructs the venous outflow and thereby induces rapid transudation of serum across the capillary wall.  Toller  stated that the likely origin of the dentigerous cyst is the breakdown of proliferating cells of the follicle after impeded eruption. These breakdown products result in increased osmotic tension and hence cyst formation. Bloch suggested that the origin of the dentigerous cyst is from the overlying necrotic deciduous tooth. The resultant periapical inflammation will spread to involve the follicle of the unerupted permanent successor; an inflammatory exudate ensues and results in dentigerous cyst formation.  In the present case, the most likely explanation is that the cyst originated from the discolored primary maxillary right central incisor. Most of the authors have reported the presence of carious or discolored deciduous teeth in relation to the development of dentigerous cysts. , This suggests that the periapical inflammatory exudates from the deciduous teeth might be one of the risk factor for the occurrence of dentigerous cysts.
A large periapical cyst, odontogenic keratocyst, central giant-cell granuloma, and unicystic ameloblastoma can mimic a dentigerous cyst. Odontogenic keratocyst and unicystic ameloblastoma most frequently occur in the molar region of the lower jaws in the 2 nd and 3 rd decades of life. A radiograph will not differentiate between a radiolucency associated with the root of a nonvital primary teeth and the crown of unerupted teeth.  Unlike other odontogenic cysts, the epithelial cells lining the lumen of the dentigerous cyst possesses an unusual ability to undergo metaplastic transition. On occasion, some untreated dentigerous cysts rarely develop into an odontogenic tumor (e.g., ameloblastoma) or a malignancy (e.g., oral squamous cell carcinoma).  Marsupialization and surgical enucleation of the cyst may be the treatment of choice. In the present case surgical enucleation of the cyst was done.
The present case occurring in a 7-year-old boy, supports the age and sex predilection mentioned by other authors. , Though dentigerous cysts are most common in the mandibular jaw, in the present case the maxillary jaw was involved. A dentigerous cyst associated with an anterior tooth will result in failure of eruption of the tooth and therefore lead to esthetic and orthodontic problems. Absence of a central incisor can have an impact on the psychology of child. Further esthetic management has to be considered to prevent any psychological trauma to the child. In the present case, esthetic management was done by providing the patient with a removable partial denture, which also serves as a functional space maintainer and facilitates the eruption of the permanent maxillary left central incisor.
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