10/4/12 Dentigerous cyst Ent Scholar

Dentigerous cyst
From supernumerary teeth
October 3, 201 2 Rhinology

Authors
BalasubramanianThiagarajan

Abstract
Dentigerouscystsarethemostcommondevelopmentalodontogeniccysts.Theyareusuallyderived
fromtheepithelialremnantsoftoothformingorgans.Thesecystsincreaseinsizegradually.There
mayalsobeassociatedboneresorption.Managingtheselesionscreatesproblemsin
children.Itisalwaysbettertobeconservativeinmanagingthisprobleminchildrenbecausedentition
isyettocompleteinthem.

Introduction:

Dentigerouscystsarethemostcommondevelopmentalodontogeniccysts.Theyareusuallyderived
fromtheepithelialremnantsoftoothformingorgans1.Dentigerouscystsareclassicallydefinedas
cysticlesionsthatarecausedbyseparationoffolliclesfromaroundthecrownofuneruptedteeth.
Mostcommonlydentigerouscystinvolveslower3rdmolar(mandibular)2.Dentigerouscystswere
earliertermedasFollicularcystssinceitwasassumedthatthesecystswerederivedfromtooth
folliclewhichisamesodermalstructure.Laterthistermwasabandonedasitwasconceivedonan
erroneousperception.Dentigerouscystscanalsobecausedby:

1.Impactedteeth

2.SupernumeraryteethIsdefined8asteethinexcessofusualconfigurationof20deciduousand
32permanentteeth.Dentigerouscystsarisingfromsupernumeraryteethaccountsfornearly5%ofall
thesecysts.

3.Ectopicteeth(eruptionofateethinsitesotherthanthenaturalposition).Mostcommonlyseen
ectopicallyeruptedteethinvolves3rdmolars

4.Rarelyatooth/rootofteethmaybefoundinthesinuscavity.Thisteethmayhavedentigerous
cystassociatedwithit3.

Theoriesofdentigerouscystformation:

Usuallyalldentigerouscystsarisefromtheenamelorganaftercompletionofamelogenesis.
Dentigerouscystarisesduetoaccumulationoffluidcausingseparationofenameloftheunerupted
tooth.Thefluidpresentinsidethecystishyperosmolarduetothepresenceofalbumin,
immunoglobulinandsquamousepithelialdebris.Thishyperosmolarfluidcausesinfluxofextracellular
fluidintothecystcausinghugeexpansionofcysttooccur.Theepithelialliningofthecystsecretes
collagenaseandosteoclastactivatingfactorwhichcauseslocalboneresorptioncausingfurther
increaseinthesizeofthecyst.Thisenlargingcystenclosesthecrownoftheuneruptedteethandis

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attachedtoitscementoenameljunction.

TheoriesexplaininggenesisofDentigerouscyst:

1.Theoryofstimulation

2.Theoryofinflammation4

Incidence:

Studiesrevealthatdentigerouscystconstitutemorethanaquarterofalljawcysts.Itpredominates
duringthe2nd3rddecadesoflife5.Thereisaveryslightmalepreponderance.

Majorityofdentigerouscystsinvolvesthemandibularthirdmolarwhilemaxillarycanineisthenextin
theorderofinvolvement.Veryrarelydentigerouscystcanoccurfromectopicallyeruptedtoothwithin
themaxillarysinus6.

Symptoms:

Thesepatientsusuallypresentwithpainlessslowgrowingswellinginvolvingtheaffectedarea.This
swellingisveryfrimonpalpationindicatingcorticalexpansion.Ifitispresentintheupperjawthenthe
swellingcouldinvolvethehardpalatealso.

Thesecystsareusuallypainlessanddormant.Theremaybesomedegreeofexpansionofcortical
bone.Presenceofpainandrapidswellingdefinitlyindicatesinflammation.Fistulacanrarelyoccur
whenthedentigerouscystispresentinthemaxillarysinus.Thesepatientsusuallypresentwith
evidenceofsinusitis7.Whenthesecystsareaspiratedthenyellowishfluid9couldbeobserved.The
swellingmayalsoreduceinsizefollowingaspirationonlytoincreaseinsizelater.

Histology:

Histopathologicalexaminationofthecystwallshowedthecysttobelinedbyreducedenamel
epithelium.Connectivetissuestromawillshowfeaturesofprimitivetypeofectomesenchyme.Findings
woulddependonwhetherthereisinflammatorycomponenttothecystispresentornot.Innon
infectedcyststheliningepitheliumis24layersthickformedbyprimitiveectomesenchyme.These
liningcellsarelowcuboidaltocolumnar.Retepegscouldbeseenonlyincystswhichareinfected.The
connectivetissuestromaislooseandisrichinacidmucopolysaccharides.Whenthedentigerouscyst
isinflamedthenitischaracterisedbythepresenceofhyperplasticreteridgesandthecystwall
demonstratesinflammatoryinfiltrate.

Theoriesofdentigerouscystformation:

Intrafolliculartheory:

Accordingtothistheorycystformationoccursduetofluidaccumulationbetweenthelayersofinner
andouterenamelepitheliumaftercrownformation.

Enamelhypoplasiatheory:

Thistheorysuggeststhatdentigerouscystformationoccursduetodegenerationofstellatereticulum
ataveryearlystageoftoothdevelopment.Thereisalsoassociatedenamelhypoplasia.

Mainstheory:

Thistheorysuggeststhatimpactedtoothexertspressureonthefolliclewithresultingobstructionof
venousoutflow.Thisinducesrapidtransudationoffluidacrossthecapillarywalls.Thiscausesan

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increaseinthehydrostaticpressureexertedcausingseparationofcrownfromthefollicle.Thismaybe
associatedwithreducedenamelepithelium.

Radiographicfeatures:

Inplainradiographsthesecystspresentasawelldefinedunilocularradiolucency.Oftenthereisa
demarcatingscleroticborder.Sincethecystliningisderivedfromreducedenamelepitheliumthis

radiolucencypreferentiallysurroundsthecrownoftheteeth.Alargedentigerouscystmayprovidean
impressionasifitismultilocular.Thisappearanceisduetothepersistenceofbonytrabeculaewithin
theradiolucency.Thesecystsareparticularyunilocularinnature.

Radiographictypesofdentigerouscysts:

1.Centralvariety:Inthisvarietytheradiolucencysurroundsthecrownoftheuneruptedteeth.The
crowncanclearlybeseenprojectingintothecystlumen.

2.Lateralvariety:Inthisvarietythecystdevelopslaterallyalongthetoothroot,partiallyencirclingthe
crown

3.Circumferentialvariety:Thecystentirelysurroundstheuneruptedteeth.Radiologicallythe
uneruptedteethcouldbeseenwithinthecystcavity.

Dentigerouscystshowinguneruptedteeth

CTscanshowingdentigerouscyst

Treatment:

Theusualtreatmentofdentigerouscystiscarefulenucleationofthecystintoto.Uneruptedtoothif
presentshouldusuallyberemovedalongwiththecyst.Sometimesiferuptionofthisteethis
Sometimesorthodontictreatmentmaybeadvocatedtoassisteruptionofuneruptedteeth.

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Dentigerouscyst

Marsupialization:

Thisismoreconservativemethodthanenucleationoftheentirecyst.Thisshouldbeconsideredas
thefirstlineofmanagementinchildrenwithdentigerouscyst.Majoradvantageofthisprocedureis
lossofviablepermanenttoothbudscanbeprevented.Thesepatientsshouldbefollowedupcarefully
byperformingradiologicalimagingevery6monthsinordertokeepaneyeonpotentialrecurrence.
Thisfollowupshouldbecontinuedatleastforaperiodof2yearsfollowingmarsupialization.

Uneruptedteethseeninsidedentigerouscyst

Whydentigerouscystsshouldbetreated?

1.Theyblockeruptionofnormalteeth

2.Theyincreaseinsizeandcausedisplacementofteeth

3.Theycancausebonedestruction

4.Theycancausedisplacementofvitalstructureslikeinferioralveolarnerve

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Abouttheseads

References
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