Dentigerous Cyst: a review of 37 Cases

Dr. Ali H. Murad  B.D.S.,M.Sc.

Assistant Prof. Head of Oral Pathology, College of Dentistry, University of Thamar

Abstract

A retrospective  study  looked at the  features  of  dentigerous cyst  clinically,   radiographically   and   histopathologically   in   thirty-seven    Iraqi    patients    from    the   archives   of    the Oral    Pathology  Department,  College   of   Dentistry,  University   of     Baghdad,  for the  period  1990-2000.  The  results  showed  that  the  mean  age was (22.2)years,  males   were    affected    more   than    females in a ratio of 1.5:1. The maxillary   canine  area  was   the   most   specific    site  involved,   followed  by mandibular  third  molar. The most common clinical  features  were  alveolar  bone  swelling,  while   pain  is   not a prominent    feature.    Radiographic        appearance       revealed    a radiolucency   associated    with   an    unerupted     tooth,     in    one   case    the    cyst    was    associated    with  a supernumerary  tooth  in  upper   incisor    area.   Histologically,   the   cyst   shows ameloblastic variation in only two cases.

Introduction

Odontogenic epithelium within the jaws act as the wellspring for a  multiplicity   of   odontogenic   cysts   of    varied   clinical    feature, histogenisis   and  biological   behavior.  Some  of  these   lesions   are relatively innocuous whereas others which originate by the  separation of the follicle from around the crown of unerupted tooth (dentigerous cyst)  can  behave  in  extremely aggressive  manner (1) . It  is  worth  of mention   that    dentigerous   cyst    can  not   be   diagnosed      using radiographic    evidence   only    but     must   be     based    on    both   macroscopic     and    microscopic     examination    of  the  specimen   because   various  other  lesions (such as unicystic ameloblastoma and odontogenic keratocyst) can occur in the position(2,3) .

The frequency of dentigerous cyst formation has been estimated to constitute  1.44  per 100 unerupted teeth (4) .  Furthermore, the risk for individual teeth to develop dentigerous cyst varies considerably. In case  of  mandibular   third   molars,  the  frequency  of  impaction  is roughly  the  same  as  that  of cyst formation, whereas maxillary third molars  have  a  much  higher    frequency  of    impaction   than  cyst involvement, suggestion  that  this tooth has a much lower relative risk of  developing a dentigerous cyst  than  its  mandibular counterpart(5) . Similarly  the  risk  of cyst formation around the crowns of unerupted mandibular  first premolars, maxillary incisors, or mandibular second molars  is very  high, although  the  frequency of failure of eruption of these teeth is extremely low (6) .

The aim  of  the  present  study  is  to find the incidence, clinico- pathological  variation  of  dentigerous  cyst  in  a  review  of  series of dentigerous  cyst  from  1990-2000  such  information  are valuable to clinician   as  it  help  in  the  formulation  of a  working diagnosis and timing management decisions and approach to treatment.

Material and Methods

         All cases of  dentigerous  cyst  over  the  period  between 1990- 2000 were recorded from the laboratory of Oral Pathology Departement, College of Dentistry, University of Baghdad.

         The  clinico-pathological  details  were  taken  from the archives file   of   the  Department  of  Oral   Pathology. All  cases   diagnosed histologically  as  dentigerous cyst were analyzed according to the age, sex,  duration ,  site  distribution,  clinical  presentation,  radiographic appearance  and  histopathologic    details   based  on  the   individual pathologic   report   of   each  case. These   files  more   checked   for adequacy  of  information  given  by  surgeon  regarding  the  cases  at question.

Results

       From the total 2410 oral biopsy, 235 cases were diagnosed as jaw bone  cyst,  thirty-seven  cases  were  diagnosed  as  dentigerous   cyst, accounting (15.7%)  of  all   jaw  bone  cyst   and (1.5%)   over  all oral surgical biopsies.

        The  age   of  the patients ranged from 5 to 50 years, with a peak incidence  in  the  second  decade of life, and the mean age was (22.2) years. The  males  were affected more than the females with a ratio of (1.5:1). ( Table 1)  .

         Regarding  the site, (20  cases 54%)  occurred in the maxilla and (17 cases 46%)  in  the  mandible. In  four  cases  the  specific   region was  not  recorded. However,  for   the  maxilla, the   most   common affected  site  was  canine  region (15 cases = 40.5%).  While  for   the mandible the most common affected site was molar region (7 cases = 18.9%),   followed  by  canine   region (4 cases = 10.8%)( table 2).

       The  duration  of the  symptoms  ranged  from   one  month to 4 years (median = 11 months). The  initial   presenting symptom (for all 37 patients)  was intra-oral  alveolar  swelling, associated   with pain in only  3 cases,  parasthesia  was noted in only one case. Moreover, one case was recorded as a recurrent case after 12 years.

        The  dentigerous  cyst  appears as  circumscribed    radiolucency associated  with   impacted  tooth (Figure 1).

Fig1: Radiographic picture of Dentigerous cyst

 

The   majority  of  the   cysts  show unilocular  radiolucency  (24 cases 80%)  whereas  6  cases  appear  as multilocular. In  the  remainder  7  cases,   the   locularity    were   not recorded by the surgeon, in addition, 8 cases showed root  resorption of   the  adjacent    tooth. Moreover,  odontom  was  associated   with dentigerous  cyst  in  only  one  case, and   in  two  cases, the  cyst was associated with supernumerary tooth in the upper incisor area.

All  of   the   pathologic   reports  describe  a similar   histological picture (Figure 2).

Fig 2: Histopathological picture of Dentigerous cyst

 

The lesions  consist  of  a fibrous connective tissue wall which is  loosely  arranged. The  epithelium  lining   consist  of  two to three layers  of  cubiodal  epithelial cell. Four cases and due to infection the fibrous  wall  become more collagenized, with a variable infiltration of chronic    inflammatory  cell. In some  areas  hyperplastic   squamous epithelial  lining  was  seen  especially   in  older   patients. Moreover, characteristic   ameloblastoma was seen in the wall of dentigerous cyst in a 25 years old female with about one year duration.

Table (1): Age&sex distribution of 37 cases of dentigerous cyst

Age group (years)

Number

Male

Female

Male:Female ratio

0-10

9(24.3%)

6(16.2%)

3(8.1%)

2:1

11-20

11(29.7%)

6(16.2%)

5(13.5%)

1.2:1

21-30

7(18.9%)

4(10.8%)

3(8.1%)

1.3:1

31-40

3(8.1%)

2(5.4%)

1(2.7%)

2:1

41-50

7(18.9%)

4(10.8%)

4(10.8%)

1.3:1

Total

37(100%)

22(59%)

15(41%)

1.5:1

Table (2): Site distribution of 37 cases of dentigerous cyst

Jaw

Incisor

Canine

Premolar

Molar

Unknown

Total

Maxilla

2(5.4%)

15(40.5%)

1(2.7%)

0

2(5.4%)

20(54%)

Mandible

1(2.7%)

4(10.8%)

3(8.1%)

7(18.9%)

2(5.4%)

17(46%)

Total

3(8.1%)

19(51%)

4(10.8%)

7(18.9%)

4(10.8%)

37(100%)

        

Discussion

         The developmental odontogenic cysts occur rarely in the jaw bones as compared to inflammatory cysts. However, the present study , revealed that the dentigerous cyst is one of the most common jaw bone cyst (15.7%), this finding is in agreement with that conducted by Mourshed(4) and Daley et al., (7) .

         The lesion occurs most often in the second and third decades of life (8). This is in harmony with this result in which the majority of patients were young, 27 out of 37 patients being under the age of 30 years (72.7%). However, Brown (9) reported in a study conducted on 81 diagnosed dentigerous cysts a higher prevalence in the fifth decade of life.

         The present investigation showed that males were affected more than the females. A similar result was reported by Browne (9) . The reason for this sex difference is unknown. However, Daley and Wysocki(8) suggested that it may be related to smaller jaw size in female patients and a grater tendency for prophylactic extraction of third molar.

          Regarding  the  site,  dentigerous   cyst   in  our   study    occurs

predominantly   or   exclusively  in   the  maxillary   cuspid  area. This finding     confirmed    by  previous    studies (6,10,11) . However, Main (2) , Angela  and Mario (5)  reported  that  the common site for dentigerous cyst was in the mandibular third molar area.

          The   dentigerous   cyst   is     frequently    well    circumscribed unilocular   radiolucency  which is often associated with an unerupted tooth (4,12) . The cyst appears to have a greater tendency than other   jaw bone  cyst    to   induce    root    resorption    of    adjacent    teeth. By comparison,  root  resorption  due to  keratocyst  appears   to be very rare(6,11) . This finding is  supported by this series, in which the majority of  the  cases (80%) appear  as  unilocular   radiolucency  and (21.6%) showed  root  resorption of adjacent teeth. Moreover, Stanley et al., (13) suggest   that  a   pericoronal   radiolucency   larger   than    4mm    in greatest  with as  assessed on a panoramic radiograph is considered as small  dentigerous  cyst, to  differentiate  between  the  normal  dental follicles and a pathological change.

          Clinically, dentigerous  cyst  occur  most often as painless intra-oral  alveolar  swelling(5) ,sometime  the cyst  associated  with  pain(2)   . Our finding  is the same, in  which  the majority of cases were seen in advanced stages. Pain was reported less frequently; tooth mobility and displacement  were occasionally observed. Recurrence of dentigerous cyst is rare (14) . In our  study   only  one  case  was  recurred  within  a period of 12 years after treatment.

          The histological  features  of our dentigerous cyst are similar to those    seen      elsewhere (12) . Kim and Ellis (15) , showed     that     the dentigerous   cyst   may be  lined  by  stratified  squamous epithelium, especially   in   older   patient. In  their  study, Stanley et al., (16) found

that   all   follicles   of   patients   older  than 26 years   were  lined  by squamous   epithelium    rather  than  cubiodal  to  columnar  cell   or reduced enamel epithelium. This confirm by our finding in which the lining  epithelium  show  squamous  metaplasia  in  the  older patient. Furthermore, the   dentigerous   cyst   may   give   rise   to a  variety of tumors,       notably         ameloblastoma,    squamous cell carcinoma, mucoepidermoid carcinoma, and rarely other tumors (14,17,18,19) . In   our study, only  one  case  shows  ameloblastic  characteristic  in the lining epithelium  of  the  cyst. Therefore, every  case   mimic   radiographic appearance of  a dentigerous  cyst should be confirmed pathologically in order to exclude any other aggressive lesions.

References

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2- Main DMG. Epithelial jaw cysts: A clinicopathological reappraisal. Br J Oral Surg.1970; 8: 114-25.

3-Tie-Jun Li,  Yun-Tang Wu,   Shi-Feng  Yu,  Guang-Yan  Yu. Unicystic Ameloblastoma: A Clinicopathologic Study of 33 Chinese Patients. American Journal of Surgical Pathology 2000; 24(10): 1385-1392

4- Mourshed F. A roentgeographic study of dentigerous cysts: incidence in a population sample. Oral Surg Oral Med Oral Pathol  1964; 18: 47-53.

5- Angela Benn, Mario Altini. Dentigerous cysts of inflammatory origin: A clinicopathologic study. Oral Surg Oral Med Oral Pathol  1996; 81: 203- 209.

6- Shear M. Cysts of the jaws: recent Advances. J Oral Pathol 1985; 14: 43-59

7- Daley TD, Wysocki GP, Pringle GA.  The relative incidence of odontogenic tumors: Oral and jaw cysts in a Canadian population.

Oral Surg Oral Med Oral Pathol 1994; 77: 276-80.

8- Daley TD, Wysocki GP. The small dentigerous cysts: A diagnostic dilemma. Oral Surg Oral Med Oral Pathol 1995; 79: 77- 81.

9- Brown RM.  Metaplasia and degeneration in odontogenic cysts in man. J Oral Pathol Med 1972; 145-58.

10- Brown RM. The pathogenesis of odontogenic cysts: a review. J Oral Pathol  1975; 4: 31

11- Struthers PJ, Shear M. Root resorption produced by the enlargement of ameloblastomas and cyst of the jaws. Int J Oral maxillofac Surg 1976; 5: 128.

12- Shafer WG, Hine MK, Levy BM. A text book of oral pathology. 4th ed. Philadelphia: WB Saunders, 1983; 260- 5.

13- Stanley HR, Alattar  M, Collett WK, Stringfellow HR Tr, Spiegel EH. Pathological sequelae of “neglected” impacted third molars. J Oral Pathol Med 1988; 17: 113- 17.

14- Ismail  IM, AL-Talabani NG. Calcifying epithelial odontogenic tumor associated with dentigerous cysts. Int J Oral maxillofac Surg 1986; 15: 108- 11.

15- Kim J, Allis  GL. Dental follicular tissue: misinterpretation as odontogenic tumor. J Oral maxillofac Surg 1993; 51: 762- 7.

16- Stanley  HR, Krogh  H, Pannkuk  E.  Age changes in the epithelial component of follicles (dental sac) associated with impacted third molars.

Oral Surg Oral Med Oral Pathol  1965; 19: 128- 39.

17- Holmlund  HA, Anneroth  G, Lundquish  G, Nordnram  A. Ameloblastoma originating from odontogenic cysts. J Oral Pathol Med 1991;

   20:318- 21.

18- Maxymiw  WF, Wood  RE. Carcinoma arising in a dentigerous cysts: a case report and review of the literature. J Oral maxillofac Surg 1991; 49: 639-

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19- Waldron  CA, Koh  ML. Central mucoepidermoid carcinoma of the jaws: report of four cases with analysis of the literature and discussion of the relationship to mucoepidermoid, sialodontogenic, and glandular odontogenic cysts. J Oral maxillofac Surg 1990; 48: 871- 7.

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