|Year : 2016 | Volume
| Issue : 2 | Page : 114-117
Nonsyndromic multiple dentigerous cyst: A rare clinical presentation
U Punitha Gnanaselvi, D Kamatchi, Keerthana Sekar, Soorya Narayanan
Department of Dental Surgery, KAPV Government Medical College and Hospitals, Trichy, Tamil Nadu, India
|Date of Web Publication||19-May-2016|
B4, 172, BHEL Township, Kailasapuram, Trichy - 620 014, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Odontogenic developmental cysts of jaws usually present as asymptomatic lesions. Dentigerous cyst is one variety of these cysts, which may grow to a large size within the jaws before it manifests clinically. This aggressive behavior can be attributed to its potential to transform to ameloblastoma and squamous cell carcinoma. We present a case of nonsyndromic multiple dentigerous cysts associated with multiple impacted maxillary and mandibular teeth manifesting as diffuse swelling of the mid-face and lower face region.
Keywords: Dental follicle, dentigerous cyst, enucleation, impacted teeth
|How to cite this article:|
Gnanaselvi U P, Kamatchi D, Sekar K, Narayanan S. Nonsyndromic multiple dentigerous cyst: A rare clinical presentation. SRM J Res Dent Sci 2016;7:114-7
|How to cite this URL:|
Gnanaselvi U P, Kamatchi D, Sekar K, Narayanan S. Nonsyndromic multiple dentigerous cyst: A rare clinical presentation. SRM J Res Dent Sci [serial online] 2016 [cited 2022 May 23];7:114-7. Available from: https://www.srmjrds.in/text.asp?2016/7/2/114/182661
| Introduction|| |
Cysts of the jaws usually present as asymptomatic swellings of the mandible and mid-face region. Most dentigerous cysts are asymptomatic, and their discovery is usually an incidental finding on radiography. The cyst being asymptomatic may attain a large size with resorption of the roots of teeth until they manifest clinically or become evident radiographically. Usually, dentigerous cysts occur around the crown of an impacted tooth, and multiple dentigerous cysts are rare and occur concurrently with syndromes. This case presentation is unique while considering the age of the patient and the massive bone destruction associated with the lesion, the multiple locations of the cyst, and unassociation with any syndrome.
| Case Report|| |
A 14-year-old patient presented to the Department of Dental Surgery, KAPV Government Medical College and Hospitals with a chief complaint of pain and swelling in the lower front tooth region for the past 2 months. Past medical history revealed that patient had a history of frontoparietal abscess for which craniotomy was performed before 1 year. History revealed a progressive increase in the swelling for past 3 months, painful for past 2 weeks. Pain was dull, continuous, nonradiating in character, and gets aggravated on chewing. Extraoral examination revealed a swelling involving the bilateral parasymphysis region, tender on palpation, soft, and fluctuant in nature. Intraorally multiple retained deciduous teeth 52, 53, 54, 55, 62, 63, 64, 65,73, 74, 83, 84 were seen and clinically missing multiple teeth 12, 13, 14, 15, 22, 23, 24, 25, 33, 34, 43, 44, 45 were seen. Diffuse swelling obliterating the buccal sulcus extending from 35 to 45 regions in the mandible was evident. On further intraoral examination, pus discharge is seen from the gingival sulcus with tenderness on palpation in relation to 44 region [Figure 1]. Distally tilted 32 and 42, mesially tilted 35, and Grade II mobility in relation to 31, 32, 41, 42 and Grade I mobility with 35 were observed. Diagnostic orthopantomograph [Figure 2] showed a multiple unilocular radiolucency associated with 33, 34 and 43, 44 was seen impacted and enclosed within the lesion. Computed tomography scan of facial skeleton [Figure 3] revealed the presence of unilocular osteolytic lesion present in both sides of mandible in parasymphsis region and bilateral maxilla with the evidence of eccentrically placed tooth inside.
|Figure 1: (a) Intraoral preoperative view (b) extraoral preoperative view|
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Routine laboratory parameters were normal. Aspiration of the lesion was performed, and purulent fluid was obtained. An incisional biopsy was taken from both right and left mandibular lesions for histopathological examination (HPE). HPE showed cyst lined by hyperplastic benign squamous lining and congested inflamed fibrous stroma with inflammatory cell infiltrate [Figure 4].
|Figure 4: Incisional biopsy showing cyst lined by stratified squamous epithelium admixed with fibrous tissue (H and E, ×10)|
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Under general anesthesia, an intraoral vestibular incision was given, and cyst enucleation was performed with the extraction of involved teeth [Figure 5]. The enucleacted cyst contents were sent for HPE. It revealed cystic lining with hyperplastic benign squamous lining, irregular rete pegs and congested inflamed stroma with mixed inflammatory cell infiltration [Figure 6]. Radiographic findings, surgical resection, and HPE confirmed the diagnosis of multiple infected dentigerous cysts. The patient was kept under observation for periodic clinical reviews and follow-up.
|Figure 6: Excisional biopsy showing cystic lining with hyperplastic benign squamous lining, irregular rete pegs, and congested inflamed stroma with mixed inflammatory cell infiltration picture (H and E, ×10)|
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| Discussion|| |
Dentigerous cyst is one that encloses the crown of an unerupted tooth by the expansion of the follicle and is attached to its neck. The term “dentigerous” is preferred, the literal meaning being “tooth bearing.” Dentigerous cyst was earlier termed as “follicular cyst” but as the latter implies to be derived from the tooth follicle which is mesodermal structure, the term was discontinued.
In order of its frequency, they are associated with third molars, maxillary canines, mandibular second premolars, and maxillary third molars. They may also occur around supernumerary teeth; however, they are only rarely associated with primary teeth., Our case was related to permanent maxillary canine. These cysts can grow to very large size and can cause displacement of teeth or in few cases, it may remain relatively small although some may grow to considerable size causing bony expansion that is usually painless until secondary infection occurs. The age range varies widely from 5 years to 57 years. Radiographically, the dentigerous cyst presents as a well-defined unilocular radiolucency, often with a sclerotic border. Since the epithelial lining is derived from the reduced enamel epithelium, this radiolucency typically and preferentially surrounds the crown of the tooth. A large dentigerous cyst may give the impression of a multilocular process because of the persistence of bone trabeculae within the radiolucency. However, dentigerous cysts are grossly, and histopathologically, unilocular processes and probably are never truly multilocular lesions. The histological features of dentigerous cysts may vary greatly depending mainly on whether or not the cyst is inflamed. In the noninflamed dentigerous cyst, a thin epithelial lining may be present with the fibrous connective tissue wall loosely arranged with inflammatory cells. As the lining is derived from reduced enamel epithelium, it is 2–4 cell layer thick primitive type. The cells are cuboidal or low columnar, and rete pegs formation is absent except in cases that are secondarily infected. As the connective tissue wall is derived from the dental follicle of developing enamel organ, it is a loose connective tissue stroma, which is rich in acid mucopolysaccharides. In the inflamed dentigerous cyst, the epithelium commonly demonstrates hyperplastic rete ridges and the fibrous cyst wall shows an inflammatory infiltrate. Rarely, sebaceous glands in the walls are observed. The content of the cystic lumen is usually thin watery yellow fluid and is occasionally blood tinged. The osmolality of the cyst fluid is modified by increased permeability to glycosaminoglycans such as hyaluronic acid, heparin and chondroitin sulfate, which causes expansile growth rapid. Edamatsu et al. examined the expression of Fas, bcl-2, and single-stranded deoxyribonucleic acid in dental follicles to classify the possible role of these apopstosis-related factors in the pathogenesis of dentigerous cyst. Fas is a cell surface glycoprotein that transmits apoptotic signals from the cell surface to the cytoplasm while bcl-2 proto-oncogene encodes a protein that inhibits apoptosis. Most dentigerous cysts are treated with enucleation of the cyst and removal of the associated tooth. Large dentigerous cysts may be treated with marsupialization when enucleation and curettage might otherwise result in neurosensory dysfunction or predispose the patient to an increased chance of pathological fracture. Occasionally, it transforms to squamous cell carcinoma, mucoepidermoid carcinoma or ameloblastoma from or in association with a dentigerous cyst.,, The prognosis for most histopathologically diagnosed dentigerous cysts is excellent, recurrence being a rare finding.,
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]