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Surgical management of infected dentigerous cyst: a case report

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Author: Dr. Neelam Mittal, Dr. Jyoti Jain.
F.O.D.S, I.M.S, B.H.U, Varanasi-221005, U.P.

Dentigerous cyst is a developmental odontogenic cyst which originates through alterations of the reduced enamel epithelium in an unerupted tooth after the crown has been fully formed. About 95% of dentigerous cysts involve the permanent dentition. Dentigerous cysts around supernumerary teeth account for 5% of all dentigerous cysts, most developing around a mesiodens in the anterior maxilla and palate.1
Supernumerary teeth are present in 0.8% of primary dentitions and in 2.1% of permanent dentitions. One of the rare problems associated with supernumerary teeth is the formation of dentigerous cyst.2 The usual age of clinical presentation of dentigerous cyst due to supernumerary tooth is in the first 4 decades. The highest incidence of dentigerous cysts occurs during the second and third decades.
Dentigerous cysts are usually associated with unerupted teeth of the permanent dentition. When observed with erupted and complete dentition the diagnosis is a surprise. We report a rare case of mid palatal swelling due to a dentigerous cyst associated with an impacted supernumerary teeth in an adult.

Case report
A 14 year old male, reported with a chief complaint of swelling in the face and palate since 6 months. The swelling which was initially about the size of a peanut gradually increased to attain the present size. There was no history of trauma and it was not associated with any pain, just a local discomfort. On clinical examination showed a large swelling in the left side of anterior hard palate (fig: 1). The swelling was localized, fluctuant and tender on palpation. Radiographic examination   revealed large unilocular periapical radiolucency extending from the apices of tooth 21, 22 and 23 and  associated with unerupted supernumerary tooth which caused displacement of the root of the lateral incisor and canine distally (fig:2). A provisional diagnosis of mid palatine cyst was made. The differential diagnosis included neurofibroma, maxillary tori, tumor arising from minor salivary gland and dentigerous cyst arising from supernumerary teeth.  Vitality test was done for all the maxillary teeth with electric pulp tester which elicits non vital response.
The therapeutic approach included conventional root canal treatment of the non-vital permanent tooth 21,22 and 23 after this  the surgical intervention under local anesthesia was  done to resolve the symptoms (fig:3).
Histopathological examination revealed the presence of a cystic lumen lined by 2–3 cell thick non-keratinized stratified squamous epithelium resembling reduced enamel epithelium. The retepeg formation is generally absent in dentigerous cyst but its presence showed that the cyst was secondarily infected and presence of inflammatory cell infiltrate of connective tissue is a very common finding of dentigerous cyst. All these finding confirmed the diagnosis of a dentigerous cyst (fig: 4).

Large-swelling Large-unilocular

Fig 1: Large swelling in the left side of anterior hard palate

Fig 2: Large unilocular periapical radiolucency associated with unerupted supernumerary tooth

Root-canal Histopathological

Fig 3:Root canal treatment

Fig 4: Histopathological view

Next to the radicular cyst, the dentigerous cyst is the second most common type of odontogenic cyst and is always associated with the crown of an impacted, embedded, or otherwise unerupted tooth. 3 A cystic swelling of the hard palate may be the result of different kinds of cysts: Odontogenic, Non Odontogenic or Bone cysts.
Dentigerous cyst is associated with mesiodens usually located in anterior maxilla or palate but in this case it was caused by a maxillary impacted supernumerary tooth, leading to the swelling in the mid palatal region. Hence it should be carefully differentiated from other mid palatal swellings.
Radiographic appearance of dentigerous cyst is that of a well-defined pericoronal radiolucent lesion, which may be unilocular or multilocular in appearance.4 In addition to its potential for bone destruction and because of the multipotential nature of this epithelium derived from the dental lamina, several entities may arise in or be associated with the wall of a dentigerous cyst.
Treatment of dentigerous cyst depends on size, location, disfigurement & often requires variable bone removal to ensure total removal of the cyst, especially in cases of large ones.5 Thus treatment for dentigerous cysts is surgical removal.6 Because of the potential for occurrence of an odontogenic keratocyst or the development of an ameloblastoma or mucoepidermoid carcinoma, all such lesions, when removed, should be submitted for histopathologic evaluation.7

A rare case of dentigerous cyst arising from impacted supernumerary tooth and presenting as a midpalatal swelling was described. It should be carefully distinguished from other mid palatal swellings.

  1. Von Arx T: Anterior maxillary supernumerary teeth- A clinical and radiographic study; Australian Dental Journal 1992; 37(3): 189-195.
  2. Lustmann J, Bodner L: Dentigerous cysts associated with supernumerary teeth; Int J Oral Maxillofac Surg 1988; 17:100 - 102.
  3. Regezi JA, Sciubba JJ. Oral Pathology: Clinical- Pathologic Correlations. Philadelphia:Saunders,1989; p 306.
  4. Asaumi JI, Shibata Y, Yanagi Y, et al: Radiographic examination of mesiodens and their associated complications; Dentomaxillofacial Radiolology 2004; 33(2): 125-127.
  5. Primosch RE: Anterior supernumerary teeth: assessment and surgical intervention in children; Pediatric Dentistry 1981; 3: 204-21.
  6. Kessler HP, Kraut RA: Dentigerous cyst associated with an impacted mesiodens; General Dentistry 1989; 37(1):47-49.
  7. Gardner DG, Corio RL: Plexiform unicystic ameloblastoma - A variant of ameloblastoma with a low recurrence rate after enucleation. Cancer 1984; 53(8): 1730-1735.

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