Dentigerous Cyst.ppt

Dentigerous cyst is a type of odontogenic cysts and generally occurs in the ages of twenties or thirties. Dentigerous cyst always includes a tooth which cannot complete the eruption process and occurs around the crown by the fluid accumulation between the layers of enamel organ. In rare cases, dentigerous cyst occurs in the first decade of life and develops in an immature permanent tooth as a result of a chronic inflammation of overlying nonvital primary tooth.These cyst often show no symptoms, and they are generally detected by a radiographic examination to find the reason for the delayed eruption.

1. DENTIGEROUS
CYST
Presentedby
Dr. Rahul Srivastava
Professor
Rama Dental CollegeHospital
& ResearchCentre, Kanpur

2. DentigerousCyst(DC)
Thetermdentigerousmeans“containingtooth,”
andthisisthecharacteristicdescriptionofthe
cyst.Adentigerouscystsurroundsthecrownof
anuneruptedtooth,expandsthefollicleandis
characteristicallyattachedtothecemento-
enameljunctionoftheuneruptedtooth.

3. Itiscausedbyalterationofreducedenamel
epitheliumafterthecompletionofamelogenesis,
whichresultsinfluidaccumulation between
epitheliumandtoothcrown.

4. Etiology of DentigerousCyst
Thepathogenesisofdentigerouscystisstill
controversial.
Threefeasiblemechanismshavebeenproposedfor
histogenesisofthecystbyBennandAltini:
A-Theyproposedthatdevelopmentaldentigerous
cystmightformadentalfollicleandmightbecome
secondarilyinflamd,asourceofinflammationbeing
anon-vitaltooth.

5. B-Thesecondmechanism theyproposedwas
formationofaradicularcystatanapexofanon-
vitaldeciduoustoothfollowedbyeruptionofits
permanentsucessorintotheradicularcystresulting
inadentigerouscystofextrafollicularorigin.
C-Follicleofpermanent successormightget
secondarily infectedfrom eitherperiapical
inflammationofanon-vitalpredecessororother
sourceleadingtoadentigerouscystformation.

6. Clinical features
Dentigerouscystsaccountsforoneofthemost
commonodontogeniccysts,frequentlyseenwith
embeddeduneruptedteeth,supernumerary teeth,
andodontomes.
Occurrenceofdentigerouscystswithdeciduous
teethisararephenomenon.

7. Theyaremorefrequentinthesecondandthird
decadesoflife,withamalepreferenceandthe
mandiblebeingthemostinfluencedregion.
Malesaremoreaffectedwithanincidencerate
of1.6:1.
Thesecystscanleadtocorticalboneexpansion,
swelling,toothmobilityanddisplacement.

8. Cysticinvolvementofanuneruptedmandibular
thirdmolarmayresultina‘hollowing-out’ofthe
entireramusextendinguptothecoronoidprocess
andcondyleaswellasinexpansionofthecortical
plateduetothepressureexertedbythelesion.
Cystassociatedwithamaxillarycuspid,
expansionoftheanteriormaxillaoftenoccursand
maysuperficiallyresembleanacutesinusitisor
cellulitis.

9. Dentigerouscystoccuringinassociationwith
supernumerary toothandmesiodenshasbeen
occasionallyseen.
About5%ofalldentigerouscystsareattributed
bythedentigerouscystswithsupernumerary teeth.
Theyusuallyoccurinthemaxillaryanteriorregion
inassociationwithmesiodens.

10. Dentigerouscystsusuallyaresolitary,however,
bilateralandmultiplecystsmaybeseenwith
syndromessuchas:
Gardner's syndrome.
Mucopolysaccharidosis.
Maroteaux-Lamysyndrome.
Basal cell nevus syndrome.
Cleidocranialdysplasia.

11. Enamelhypoplasiaseenwhenadentigerous
cystcommencesatanearlystageofdevelopment
oftheinvolvedtoothwhereasincaseswherethe
cystoriginatingafterthecompletionoftooth
development, enamel hypoplasia isnota
significantfactor.

12. Radiographic Features:
Whileanormalfollicularspaceis3–4mm,a
dentigerouscystcanbesuspectedwhenthespace
ismorethan5mm.
Radiographically,thedentigerouscystusually
occursasawell-definedunilocularradiolucency,
oftenwithascleroticborder.

13. Astheepithelialliningisderivedfromthe
reducedenamelepithelium,thisradiolucency,
typicallyandcharactersticallysurroundsthecrown
ofthetooth.
Alargedentigerouscystmaysometimesresemble
amultilocularprocess,asbonetrabeculaemaybe
seenwithintheradiolucency.
However,mostlydentigerouscystsaregrosslyand
histopathologically unilocular processes and
probablyarenevertrulymultilocularlesions.

14. A B C
Adentigerouscyst(a)unilocularandcrownside
type;(b)multiloculartype;(c)whole-toothtype.

15. Threetypesofdentigerouscysthavebeen
describedradiographically:
(a)Thecentralvarietyinwhichthetoothcrownis
enclosedbytheradiolucency,andthecrown
protrudesintothecysticlumen.
(a)Thelateralvarietyinwhichthecystoccurs
laterallyalongthetoothroot,thus,partially
surroundingthecrown.

16. (c)Thecircumferentialvarietyexistswhenthecyst
notonlysurroundsthecrown,butalsoextends
downalongtherootsurface,thus,givingthe
impressionofthetoothwithinthecyst.

17. CTisusefultoevaluatelargelesionsandcan
showtheorigin,size,andinternalcontentsof
thecystandevaluatetheintegrityofthecortical
plateanditsrelationshiptotheadjacent
anatomicstructures.
Significantcorticalexpansionorthinningofthe
buccalandlingualcorticalplatesmaybeseen
withlargerlesions.

18. MRIplaysakeyroleinthediagnosticprocessby
providingnewinformationwhichenabledusto
determineaconsistentpresumptivediagnosisand
consequentlyamorecoherentsurgicalapproach.
TheT1-weightedimageofthelesionshowedan
intermediatesignal,thusnotbeingusefulfor
determinationofthecontentofthelesion.

19. Nevertheless,T2-weighted image enabledto
observeanintensebrightnessinsidethelesion,
which contributed significantly to the
interpretationofaprobablecysticlesionrather
thantumoural.

20. CBCTissimilartopanoramic radiography,
however, thisexam providesmoreprecise
informationonthesize,position,andrelationship
ofthelesiontothesurroundingstructures.In
classicalhelicalcomputed tomography, the
contentofaDCtypicallyappearsaslowdensity
onCBCT(liquid-like).

21. Dentigerouscyst Aspirate:
AspirateisClear,pale,strawcoloredfluidwhich
contains“Cholesterolcrystals”andtheprotein
contentisinexcessof4.0gmper100ml.
HistologicFeatures
Composedofathinconnectivetissuewallwitha
thinlayerofstratifiedsquamousepitheliumlining
thelumen.
Retepegformationisgenerallyabsentexceptin
casesthataresecondarilyinfected.

22. Theconnectivetissuewallisfrequentlyquite
thickenedandcomposed ofaveryloosefibrous
connectivetissueorofasparselycollagenized
myxomatous tissue.
Anadditionalfinding,especiallyincystswhich
exhibitinflammation,isthepresenceofRushton
bodieswithintheliningepithelium.

23. Differential diagnosis :
Hyperplasticfollicle.
Odontogenickeratocyst.
Ameloblasticfibroma.
Cystic ameloblastoma.
Treatment
Various treatment plans proposed for dentigerous
cysts are:
(a) Surgically removing the cyst. Consideration
should be taken not to damage the associated
permanent tooth.

24. (b)Cystenucleationalongwithextractionofthe
involvedtooth.
(c)Marsupializationtechnique-involvesremovalof
thecyst,however,thedevelopingtoothispreserved.
Theoffendingtoothplayaamajorroleindeciding
thetypeofsurgicalinterventionrequiredforthe
dentigerouscyst.

25. Isolatedlesionsinyoung patients,where
preservation of the teeth is desirable,
marsupialization istherecommended treatment
option.
Potential Complications
Thedevelopmentofanameloblastoma eitherfrom
theliningepitheliumorfromrestsofodontogenic
epitheliuminthewallofthecyst.

26. Thedevelopmentofepidermoidcarcinomafromthe
sametwosourcesofepithelium.
Thedevelopmentofamucoepidermoid carcinoma,
basicallyamalignantsalivaryglandtumor,fromthe
liningepitheliumofthedentigerouscystwhich
containsmucussecretingcells,oratleastcellswith
thispotential,mostcommonlyseenindentigerous
cystsassociatedwithimpactedmandibular third
molars.

27. References
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28. BoyczukMP,BergerJR,LazowSK.Identifyinga
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29. BennA,AltiniM.Dentigerouscystsofinflammatory
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30. TerauchietalAnAnalysisofDentigerousCysts
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