DENTIGEROUS CYST - a case presentation with review

a case report on dentigerous cyst in anterior maxilla with review

1. DENTIGEROUS CYST IN ANTERIOR MAXILLA: A RARE ENTITY - CASE SERIES Presenting by : Anitha Chesetti Oral Medicine And Radiology GSL Dental College And Hospital

2. CASE- 1

3. OP No : 2212030009 Age : 26 years Name : P Suresh Gender : M ale Address : Yanam

4. Chief complaint: Complaints of swelling in upper front tooth region since 1 month History of Present Illness: The present complaint started 1 month ago as a small swelling in the upper front tooth region which gradually progressed to present size, with no associated pain and secondary changes. Patient gives history of same swelling in the upper front tooth region 1 year ago and visited nearby dentist and he was advised biopsy and underwent biopsy (Biopsy report revealed benign cystic lesion) & swelling has not subsided. Patient again visited a nearby hospital 1 month ago, advised root canal treatment and patient didn’t undergo treatment, swelling has not subsided and he further visited GSL dental hospital for further treatment.

5. Past Medical History: No relevant past medical history Past dental history : 1 st dental visit 1 and half year ago – swelling in upper front tooth region Family History : No relevant family history

6. Appetite : Normal Bowel and bladder : Normal Micturition : Normal Oral Hygiene Habits: Brushes once daily with tooth brush and tooth paste Deleterious habits : No H/O Sleep : Normal Personal history ; Marital status: Married

7. Mental Status: Coherent, Conscious and Cooperative on dental chair General Appraisal: Gait :  Normal Gait Posture : Erect Built : Moderately built Nourishment : Moderately nourished GENERAL PHYSICAL EXAMINATION :

8. Hair: Skin: Face: Eyes/Eyebrows: Ears: Nose: Lips: Nails: No Abnormality Detected Peripheral signs Anemia Cyanosis: Clubbing: Icterus: Not Detected

9. Vital signs Pulse rate : 68 beats/min B.P : 120/70 mmHg Respiratory rate : 18 breaths / min Temperature : 98.3 ⁰ F Height : 5’6” Weight : 53kgs

10. EXTRA ORAL EXAMINATION Head : No abnormality detected Face : No abnormality detected Jaws : No abnormality detected TMJ : No clicking sounds, No crepitus No deviation Well coordinated & synchronous bilateral movements Muscles of Mastication : No abnormality detected Salivary Glands : No abnormality detected Regional Lymph Nodes : No regional lymph nodes were palpable  

11. INTRAORAL EXAMINATION SOFT TISSUE EXAMINATION Lips , Alveolar & Buccal Mucosa : No Abnormality Detected Labial Mucosa : NODULAR GROWTH ON LABIAL FRENUM Palate : No Abnormality Detected Tongue : No Abnormality Detected Floor Of The Mouth : No Abnormality Detected Gingiva & Coral pink in color, firm in consistency Periodontium : Calculus + stains +

12. HARD TISSUE EXAMINATION Dental caries : 36,37,38,46,47,48 Filled teeth : Nil Attrition : 31,32,41,42,43 Abrasion : Nil Erosion : Nil Mobility : Nil Fractures : Nil Root stumps :  16 Occlusion : No Derranged occlusion

13. ON INSPECTION: 1. SOFT TISSUE A solitary dome shaped swelling of size measuring approximately 0.5x1 cm is seen in the upper front tooth region extending mediolaterally 0.5cm from labial frenum on both sides. Superoinferiorly from the depth of labial sulcus to marginal gingiva of 11,21 Overlying mucosa is smooth with a bluish hue and surrounding mucosa is normal 2. HARD TISSUE Teeth at the site of lesion were present and intact EXAMINATION OF THE SPECIAL LESION

14. ON PALPATION: 1. SOFT TISSUE All inspectory findings irt number, site, size, shape and extent were confirmed On palpation, swelling is soft in consistency , non-tender, non compressible, non reducible, non pulsatile and no discharge on provocation 2. HARD TISSUE Teeth associated with lesion were not mobile

15. SUMMARY OF CLINICAL FINDINGS

16. DIAGNOSIS PROVISIONAL DIAGNOSIS Benign non-odontogenic cyst DIFFERENTIAL DIAGNOSIS Hemangioma A V malformation Nasolabial cyst irt 11, 21 OTHER DIAGNOSIS: Chronic generalized gingivitis Rootstump irt 16 Dental caries irt 36,37,38,46,47,48 Localised attrition irt 31 32 33 41 42 43

17. INVESTIGATIONS IOPA IRT 11 21 MAXILLARY OCCLUSAL RADIOGRAPH

18. OPG

19. Dentigerous cyst irt 11, 21 DIFFERENTIAL DIAGNOSIS Adenamatoid odontogenic tumour CEOC RADIOLOGICAL DIAGNOSIS

20. TREATMENT PLAN Cyst enucleation along with extraction of supernumerary tooth Endodontic treatment irt 11 12 13 21 22 23

21. HISTOPATHOLOGICAL REPORT Odontogenic cystic lining epithelium exhibiting 1-2 layers thickness. Epithelial connective tissue junction is flat with absence of rete ridges Few goblet cells were seen Underlying connective tissue shows dense collagen bundles with minimal inflammatory cell infiltrate Few dilated blood capillaries are also seen

22. FINAL DIAGNOSIS Dentigerous cyst irt 11,21 POST OPERATIVE FOLLOW UP 1 WEEK FOLLOWUP 1 MONTH FOLLOWUP

23. POST OPERATIVE OPG

24. CASE- 2

25. OP No : 2104100002 Age : 73 years Name : B Satya Prasad Gender : M ale Address : Rajahmundry

26. CHIEF COMPLAINT : Complaints of pain and swelling in his upper front teeth region since 2 months HISTORY OF PRESENT ILLNESS: The present complaint started 2 months ago as mild, intermittent throbbing pain in his upper front teeth region associated with a swelling of peanut size gradually progressed to present size that subsided on its own There was no associated discharge/bleeding/paresthesia/ulceration with the swelling There were 3-4 episodes of swelling associated with pain in past 2 months and subsided on its own Patient had visited a near by dentist with same chief complaint 10days ago and was advised to get further investigations to proceed with the treatment procedures

27. Past Medical History: Known diabetic and is on medication since 3 years Past dental history : 1 st dental visit- 3 years ago – underwent extraction in upper front tooth region Family History : No relevant family history

28. Appetite : Normal Bowel and bladder : Normal Micturition : Normal Oral Hygiene Habits: Brushes once daily with tooth brush and tooth paste Deleterious habits : No H/O Sleep : Normal Personal history ; Marital status: Married

29. Mental Status: Coherent, Conscious and Cooperative on dental chair General Appraisal: Gait :  Normal Gait Posture : Erect Built : Moderately built Nourishment : Moderately nourished GENERAL PHYSICAL EXAMINATION :

30. Hair: Skin: Face: Eyes/Eyebrows: Ears: Nose: Lips: Nails: No Abnormality Detected Peripheral signs Anemia Cyanosis: Clubbing: Icterus: Not Detected

31. Vital signs Pulse rate : 74 beats/min B.P : 140/70 mmHg Respiratory rate : 17 breaths / min Temperature : 98.6 ⁰ F Height : 5’10” Weight : 54kgs

32. EXTRA ORAL EXAMINATION Head : No abnormality detected Face : No abnormality detected Jaws : No abnormality detected TMJ : No clicking sounds, No crepitus No deviation Well coordinated & synchronous bilateral movements Muscles of Mastication : No abnormality detected Salivary Glands : No abnormality detected Regional Lymph Nodes : No regional lymph nodes were palpable  

33. SOFT TISSUE EXAMINATION Lips, Labial Mucosa & Buccal Mucosa : No abnormality detected Vestibule : No abnormality detected Palate : A DIFFUSE SWELLING IS PRESENT Tongue : No abnormality detected Floor Of The Mouth : No abnormality detected Gingiva :  pale pink in color, soft and edematous in consistency, Stains +, Calculus ++ Periodontium : Mobility (grade III)- 41,42,(grade-II) - 22,24 (grade I) - 17, 15, 14, 13, 21, 22, 23, 24 INTRA ORAL EXAMINATION:

34. HARD TISSUE EXAMINATION Missing Teeth : 11 Dental caries :   36 Filled teeth : 17, 24, 27 Attrition : Generalized attrition Abrasion : N il Erosion : N il Mobility : N il Fractures : N il Root stumps : N il Occlusion : No deranged occlusion

35. EXAMINATION OF THE SPECIAL LESION : INSPECTION: 1. SOFT TISSUE A solitary diffuse swelling of size approximately 1x1cm is present on the palatal region. Extending antero-posteriorly from incisive papilla region to posteriorly 2mm in front of palatal rugae Mediolaterally towards right side 1mm away from mid-palatal raphe to 2mm away from marginal palatal gingiva of 13 Overlying mucosa is edematous and erythematous, surrounding mucosa is normal 2. HARD TISSUE Tooth at the site of lesion was absent

36. PALPATION : 1. SOFT TISSUE All inspectory findings regarding site, size, shape and extent are confirmed On palpation, swelling is non-tender, soft in consistency, non compressible, non reducible and non pulsatile There was no discharge on provocation 2. HARD TISSUE Tooth at the site of lesion was absent

37. SUMMARY OF CLINICAL FINDINGS

38. PROVISIONAL DIAGNOSIS: Benign odontogenic cyst in upper front tooth region irt 11 12 DIFFERENTIAL DIAGNOSIS: Dentigerous cyst Adenomatoid odontogenic tumor OTHER DIAGNOSIS: Chronic generalized periodontitis Partially edentulous irt 11 Dental caries irt 36

39. INVESTIGATIONS IOPAR IRT 11 21 12 22 MAXILLARY OCCLUSALRADIOGRAPH

40. OPG

41. AXIAL SECTION SAGGITAL SECTION CORONAL SECTION CBCT

42. TREATMENT PLAN: Advised cyst enucleation with Extraction Of s upernumerary Tooth Irt 11 HISTOPATHOLOGY GROSSING OF THE SPECIMEN HISTOLOGY SLIDE BIOPSY SITE

43. HISTOPATHOLOGY REPORT The underlying connective tissue shows dense collagen fibres with minimal inflammatory cell infiltrate consisting of lymphocytes. Areas of dystrophic calcifications were also noticed FINAL DIAGNOSIS : Dentigerous Cyst

44. FOLLOW UP AFTER 7 DAYS FOLLOW UP AFTER 15 DAYS POST OPERATIVE FOLLOW UP

45. POST OPERATIVE FOLLOW UP FOLLOW UP AFTER 1 MONTH

46. DISCUSSION Cyst is defined ‘a pathological cavity having fluid, semifluid or gaseous contents and which is not created by the accumulation of pus’ (Kramer (1974) ) O dontogenic cysts - arising from the odontogenic epithelium and Non odontogenic ( F issural cysts) - arising from the oral epithelium trapped between fusing processes during embryogenesis Dentigenous cyst ( follicular, pericoronal ) – “An odontogenic cyst that surrounds the crown of an impacted tooth; caused by fluid accumulation between the reduced enamel epithelium and the enamel surface, resulting in a cyst in which the crown is located within the lumen” Rajendran, A., & Sundaram, S. (2014).  Shafer’s textbook of oral pathology . Elsevier Health Sciences Apac .

47. Dentigerous cyst develops around the crown of an unerupted tooth by accumulation of fluid either between the reduced enamel epithelium and enamel 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. Two types of dentigerous cysts occur( Ben and Altini ) First type - Developmental in origin, Occurs in mature teeth Result of impaction Second type - Inflammatory in origin Occurs in immature teeth Result of inflammation from a non-vital deciduous tooth or some other source spreading to involve the tooth follicle Önay Ö, Süslü AE, Yılmaz T. Huge dentigerous cyst in the maxillary sinus: a rare case in childhood. Turkish archives of otorhinolaryngology. 2019 Mar;57(1):54.

48. Most common developmental odontogenic cysts - 24% of the jaw cysts Second most common odontogenic cysts of the jaws next to radicular cyst (54.2%) 2nd and 3rd decades of life with Male prediliction Mandible – 70% and Maxilla – 30% Associated with the mandibular 3 rd molar (45.7%), followed by maxillary canines and mandibular premolars , maxillary third molars, maxillary incisors (1.5%) and supernumerary teeth(5-6%) and mesiodens Guruprasad Y, Chauhan DS, Kura U. Infected dentigerous cyst of maxillary sinus arising from an ectopic third molar. Journal of clinical imaging science. 2013;3( Suppl 1).

49. Mourshed stated that only 1.44% of impacted teeth undergo dentigerous cyst transformation So dentigerous cysts involving the permanent central incisor are rare( 44 Cases) Clinically, it is often asymptomatic; it is discovered as incidental radiographic finding or when acute inflammation, or swelling develops but have the potential to become extremely large and cause cortical expansion and erosion Expansion of the bone, facial asymmetry, extreme displacement of teeth, severe root resorption of adjacent teeth and pain are all possible sequelae of continuous enlargement of the cyst Arakeri G, Rai KK, Shivakumar HR, Khaji SI. A massive dentigerous cyst of the mandible in a young patient: a case report. Plastic and Aesthetic Research. 2015 Sep 15;2:294-8.

50. Cystic involvement of an unerupted mandibular third molar - ‘hollowing-out’ of the entire ramus extending up to the coronoid process and condyle as well as in expansion of the cortical plate due to the pressure exerted by the lesion and sometimes comes to lie compressed against the inferior border of the mandible. Cyst associated with a maxillary cuspid - expansion of the anterior maxilla and resemble an acute sinusitis or cellulitis Nagarajan N, Jayachandran S, Jayaram V, Nisha A. Dentigerous Cyst in the Maxillary Anterior Region of a Pediatric Patient. Annals of the National Academy of Medical Sciences (India). 2021 Jan;57(01):58-61.

51. Radiographically, If the follicular space on radiograph is more than 5 mm, an odontogenic cyst can be suspected It usually occurs as a well‑defined unilocular radiolucency, often with a sclerotic border around the impacted crown of the tooth The cyst to crown relationship in a dentigerous cyst can show different variations (T homa-Robinson-Bernier) C entral variety - The cyst surrounds the crown of the tooth with the crown projecting into the cyst(mandibular 3 rd molar, maxillary canine) L ateral variety - When the cyst grows laterally along the root surface surrounding the crown partially (mandibular 3 rd molar) Circumferential variety - a considerable amount of root appears to lie within the cyst along with the crown that is surrounded by the cyst Nagarajan N, Jayachandran S, Jayaram V, Nisha A. Dentigerous Cyst in the Maxillary Anterior Region of a Pediatric Patient. Annals of the National Academy of Medical Sciences (India). 2021 Jan;57(01):58-61.

52. The content of the cyst lumen is usually a thin, watery yellow fluid, occasionally blood tinged. Histologically, the dentigerous cyst is usually composed of a thin fibrous connective tissue wall lined by nonkeratinized stratified squamous epithelium consisting of myxoid tissue, odontogenic remnants and rarely sebaceous cells. Rete peg formation is generally absent except in cases that are secondarily infected. Rohilla M, Marwah N, Tyagi R. Anterior maxillary dentigerous cyst. International journal of clinical pediatric dentistry. 2009 Jan;2(1):42.

53. Differential diagnosis 1.Unicystic Ameloblastoma - They will grow laterally away from the tooth in comparison to dentigerous cyst, which envelop the tooth symmetrically and is more common in the premolar-molar area 2.Adenomatoid odontogenic tumor- rare and usually occur in the maxillary anterior region, Cystic lining is not attached to CEJ, it involves the uneruptedtooth 3.Calcifying odontogenic Cyst - it may occur as a pericoronal radiolucency and may contain evidences of calcification, Cystic lining is not attached to CEJ, it involves the unerupted tooth 4.Odontogenic keratocyst - does not expand the bone to the same extent, is less likely to resorb teeth and may attach further apically on the root instead at the cementoenamel junction 5 . Hyper plastic follicle - if the follicular space is more than 5 mm, a dentigerous cyst is suspected

54. These are usually solitary however bilateral and multiple cysts - syndromes such as basal cell nevus syndrome, mucopolysaccharidosis, Gardner’s syndrome, cleidocranial dysplasia, bifid rib syndrome and prolonged concurrent use of cyclosporine & calcium channel blockers Various treatment plans proposed for dentigerous cysts are: (a) Cyst enucleation along with extraction of the involved tooth. (b) Marsupialization technique ‑ involves removal of the cyst, however, the developing tooth is preserved. Potential Complications : untreated Dentigerous cyst may transform into tumours like mural ameloblastoma, and has the potential of developing into malignancies like squamous cell carcinoma and mucoepidermoid carcinoma Nagarajan N, Jayachandran S, Jayaram V, Nisha A. Dentigerous Cyst in the Maxillary Anterior Region of a Pediatric Patient. Annals of the National Academy of Medical Sciences (India). 2021 Jan;57(01):58-61.

55. Dentigerous cyst is a common developmental odontogenic cyst, mostly seen in relation with impacted mandibular third molars and maxillary canines Usually, they are asymptomatic and this delays the diagnosis Prompt diagnosis and treatment is mandatory to prevent dreadful complications A dentigerous cyst associated with an anterior tooth will result in failure or eruption of the tooth and therefore lead to esthetic and orthodontic problems CONCLUSION

56. REFERENCES Shear, M., & Speight, P. (2008).  Cysts of the oral and maxillofacial regions  (4th ed.). Wiley-Blackwell. Rajendran, A., & Sundaram, S. (2014).  Shafer’s textbook of oral pathology . Elsevier Health Sciences Apac . Nagarajan N, Jayachandran S, Jayaram V, Nisha A. Dentigerous Cyst in the Maxillary Anterior Region of a Pediatric Patient. Annals of the National Academy of Medical Sciences (India). 2021 Jan;57(01):58-61. Rohilla M, Marwah N, Tyagi R. Anterior maxillary dentigerous cyst. International journal of clinical pediatric dentistry. 2009 Jan;2(1):42. Cura N, Hanttash A, Inceoglu B, Orhan K, Oncul AM. Dentigerous cysts in four quadrants of a nonsyndromic patient: case report and literature review. Oral Radiology. 2015 Jan;31:49-58. Arakeri G, Rai KK, Shivakumar HR, Khaji SI. A massive dentigerous cyst of the mandible in a young patient: a case report. Plastic and Aesthetic Research. 2015 Sep 15;2:294-8. Guruprasad Y, Chauhan DS, Kura U. Infected dentigerous cyst of maxillary sinus arising from an ectopic third molar. Journal of clinical imaging science. 2013;3( Suppl 1). Önay Ö, Süslü AE, Yılmaz T. Huge dentigerous cyst in the maxillary sinus: a rare case in childhood. Turkish archives of otorhinolaryngology.2019Mar;57(1):54 9. Wood NK, goaz PW. Differential diagnosis of oral and maxillofacial lesions. 5th ed. St. Louis, MO: mosby ; 1997 10.White SC, pharoah MJ. White and pharoah’s oral radiology: principles and interpretation. 8th ed. London, england : mosby ; 2018.