Journal of International Dental And Medical Research ISSN 1309-100X Dentigerous Cyst

http://www.ektodermaldisplazi.com/journal.htm Kamil Serkan Agacayak et al

DENTIGEROUS CYST WITH AN IMPACTED CANINE: CASE REPORT

Kamil Serkan Agacayak1, Ibrahim Kose1, Nedim Gunes1, Emrullah Bahsi2,

Ferhan Yaman1*, Serhat Atilgan1
1. Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Dicle University. Diyarbakir / TURKEY.
2. Department of Operative Dentistry Faculty of Dentistry, Dicle University. Diyarbakir / TURKEY.

Abstract

Dentigerous cysts are the second most common developmental odontogenic cysts after
radicular cyst. They usually present in the second or third decades of life and these cysts are rarely
seen during child hood. Their frequency in the general population has been estimated at 1.44 cysts
for every 100 unerupted teeth. According to frequency of impaction, the maxillary permanent canine
ranks second only to the third molar, with a prevalence of approximately 2% in the general
population. Impacted canines are positioned palatally 85% of the time. The frequency of impaction
is three times greater in females than males.
In many instances the cyst may be asymptomatic till it attains a large size. It usually presents as
a slowly enlarging, sometimes painful swelling; particularly if infected. At radiography, dentigerous
cysts appear as well-defined, round or ovoid, corticated, lucent lesions around the crowns of
unerupted teeth. The radiographic appearance of such dentigerous cysts is comparable with that of
cystic, unilocular odontogenic keratocysts. Treatment includes extraction of the associated tooth
and enucleation of the cyst. In this study we present dentigerous cyst that caused by impacted
canine.
Case report (J Int Dent Med Res 2011; 4: (1), pp. 21-24)

Keywords: Dentigerous cyst, unerupted teeth, impacted canine.

Received date: 25 January 2011 Accept date: 16 February 2011

Introduction associated with the crown of an unerupted tooth.

Histologically, the dentigerous cyst displays a
After radicular cysts, the second most thin fibrous cyst wall with a myxomatous
common are dentigerous cysts of odontogenic appearance. The epithelial lining consists of 2-4
origin and account for about 16.6% of all such layers of fat or cuboidal cells, which in fact is the
jaw lesions1,2. reduced enamel epithelium and is
They are usually asymptomatic but can characteristically non-keratinized.
become extremely large and cause cortical Nests, islands or strands of odontogenic
expansion and erosion. In 75% of the cases, they epithelium are often seen in the fibrous capsule.
are located in the mandible. The mandibular third Localized proliferation of epithelial lining may
molar and maxillary canine are involved most occur in response to inflammation. Several
frequently1,2. treatment options existed, including removal of
Radiographically, the dentigerous cyst the cyst via enucleation; marsupialization of the
appears as a unilocular radiolucency of variable cyst to the oral mucosa, with placement of a wire
size with well-defined sclerotic borders, to allow for drainage and decompression of the
cyst; decompression of the cyst via fenestration.
*Corresponding author: The aim of this study is illustrates a
Dr. Ferhan Yaman simplified surgical treatment for large dentigerous
Dicle University Faculty of Dentistry cysts with impacted tooth. The procedure can be
Department of Oral and Maxillofacial Surgery
21280 Diyarbakir,Turkey
performed in the office and provides the best
chance to preserve.
E-mail: dtferhan@hotmail.com

Volume ∙ 4 ∙ Number ∙ 1 ∙ 2011 Page 21

 Journal of International Dental And Medical Research ISSN 1309-100X Dentigerous Cyst
http://www.ektodermaldisplazi.com/journal.htm Kamil Serkan Agacayak et al

Case Report enucleation of the pathology with a provisional

diagnosis of dentigerous cyst arising from the
A19 year-old female patient referred to impacted canine. On incision and reflection of the
our clinic with a complaint of swelling in the mucosa, a thinned maxillary cortex was evident
anterior maxilla. The patient’s medical history with areas of perforation. The bone cavity was
was insignificant. No other abnormality was lined by a thick epithelium that was easily
detected on complete systemic examination. enucleated (Figure 2).
The patient reported that she had first Impacted canine was removed along with
noticed the swelling one year ago. Oral and the left lateral incisor and left first premolar that
radiologic examination showed the absence of lacked sufficient bone support. The mucosa was
left maxillary canine tooth. Panoramic radiograph then sutured. Post operative healing was
showed that maxillary permanent canine was a uneventful. Biopsy specimen was sent for
radiolucency with a well-defined border which histopathological examination. The lesion was
measured 2.0cm x 2.0cm, surrounding the left reported as dentigerous cyst (Figure 3).
maxillary impacted canine. (Figure 1).

Figure 1. Preoperative panoramic view. Figure 3. Histological view.

The patient was follow up for six months.

In routine controls there was no problem and was
also no evidence of recurrence of the cyst (Fig-4).

Figure 2. Surgical specimen.

Figure 4. Postoperative panoramic view.
In the left lower canine region a softly
palpable, remarkable swelling was evident. The
overlying mucosa was of normal color and Discussion
appearance. Extra oral examination revealed that
there is no hard bony expansion over laying the Teeth may be impacted or erupt
maxilla. The oral soft tissues were within normal ectopically for a variety of reasons. Hereditary
limits, and inferior alveolar nevre function was factors, lack of space, persistence of primary
normal. Fine needle aspiration biopsy showed a canines, a true ectopic path of eruption, reduced
serious cyst liquid with colestine crystals. root length and aplasia of lateral incisors are a
The patient was further prepared for few of the factors cited3.

Volume ∙ 4 ∙ Number ∙ 1 ∙ 2011 Page 22

 Journal of International Dental And Medical Research ISSN 1309-100X Dentigerous Cyst
http://www.ektodermaldisplazi.com/journal.htm Kamil Serkan Agacayak et al

Failure of eruption of the mandibular syndrome was detected in our cases.

canine is an unusual event4. Mandibular canine It’s known that panoramic radiography
impaction is regarded as a much rarer has a limited value for evaluating the margins
phenomenon, and there are limited numbers of and extension of the lesion. CT examination aid
studies revealing its frequency of occurrence5. in delineating the extent of the lesion. The
Grover and Lorton found only 11 indications for CT examination of dentigerous
impacted canines (0.22%) in the mandible in cysts are not so familiar. Conventional X-ray
5000 individuals6. Chu et al. reported five methods /extraoral and intraoral/ give enough
mandibular impacted canine (0.07%) teeth in information for occasional findings- asymptomatic
7486 patients7. A study by Rohrer examining and without clinical signs dentigerous cysts. CT
3,000 patients radiographically found 62 imaging displays bony details and gives exact
impacted maxillary canines (2.06%) and only information about the size, origin, content and
three impacted mandibular canines (0.1%), a relationships of the lesion involving the maxilla9,18.
20:1 ratio.8 An another study by Aydin et al. The epithelial cells lining the lumen of
involving 4500 Turkish patients, the incidence of dentigerous cysts are able to undergo
mandibular canine impaction was 0.44% 5. metaplastic change to other epithelial cell types.
Dentigerous cysts enclos the crown of an The cyst's lining may contain areas of
unerrupted tooth, attaching to the neck of the orthokeratinization, ciliated cells or mucin-
tooth and grows by expansion of its follicle. It is secreting cells18. Because of this inherent ability
classified as a developmental cyst by the World for metaplastic change, some dentigerous cysts
Health Organization9. In 75% of cases they are appear to progress to more aggressive lesions
located in the mandible. The mandibular third such as an odontogenic keratocyst,
molar and maxillary canine are involved most ameloblastoma, mucoepidermoid carcinoma or
frequently.10 The first is developmental in origin squamous cell carcinoma19. We performed long
and occurs in mature teeth usually as a result of term follow up of our cases (approximately one
impaction. The incidence of cysts and tumours year and still goes on) and no dysplastic changes
around impacted third molars is 3.1% 11. were observed.
According to the literatures two types of The histopathologic findings of dentigerous
dentigerous cysts occur. These cysts usually cysts vary depending on whether the cyst is
occur in the late second and third decades, are inflamed. In the noninflamed variant, the fibrous
discovered on routine radiography, and connective tissue wall is loosely arranged
predominantly involve mandibular third molars with small islands of inactive odontogenic
12,13
. epithelial rests18. In our cases histological
The second type is inflammatory in origin sections of specimens were similar, showing cyst
and occurs in immature teeth as a result of walls composed of fibrous tissue and lined by
inflammation from a nonvital deciduous tooth stratified squamous, non-keratinized epithelium.
follicle12. These are diagnosed in the first and Treatment of dentigerous cysts depends
early part of the second decade either on routine on size, location, and disfigurement, and often
radiographic examination or when the patient requres variable bone removal to ensure total
complains of swelling and pain14. Our cases removal of the cyst, especilly in cases of large
classified as the first type of dentigerous cyst. ones20. However, cysts causing tooth
Dentigerous cysts are usually single displacement and involving loss of bone should
lesions. Bilateral and multiple cysts have been be treated with marsupialization or
reported in patients with syndromes such as decompression21.
basal cell nevus syndrome, In this method, new bone formation is
mucopolysaccharidosis, and cleido cranial stimulated because marsupialization decreases
dysplasia15,16. intracystic pressure. The major disadvantage of
Bilateral mandibular dentigerous cysts marsupialization is that pathologic tissue is left in
have also been reported after prolonged situ, without a thorough histologic examination.
concurrent use of cyclosporine A and calcium Although the tissue taken in the window can be
channel blockers. Gingival hyperplasia and submitted for pathologic examination, there is a
impaired dentition are the most common features possibility of a more aggressive lesion in the
shared by most of these syndromes2. No residual tissue22. We preferred enucleation of the

Volume ∙ 4 ∙ Number ∙ 1 ∙ 2011 Page 23

 Journal of International Dental And Medical Research ISSN 1309-100X Dentigerous Cyst
http://www.ektodermaldisplazi.com/journal.htm Kamil Serkan Agacayak et al

cyst. Because the cyst is not as large as for using 9. Jacoby H. The etiology of maxillary canine impactions. Am J
Orthod 1983; 84,125-132 .
the method of marsupialization. 10. Johnson L.M., Sapp J.P., Mc Intire D.N. Squamous cell
carcinoma arising in a dentigerous cyst. J Oral Maxillofac Surg
Conclusions 1994; 52,987-90.
11. Kaya O., Bocutoglu O. A misdiagnosed giant dentigerous cyst
involving the maxillary antrum and affecting the orbit. Case report.
These cysts are usually slow-growing Aust Dent J 1994; 39,165.
12. Kramer L.R, Pindborg J.J., Shear M. International histological
lesions and may attain a considerable size with classification of tumors. 2nd edn 1992; 34-36
minimal or no symptoms. Ameloblastoma, 13. Ko K.S.C., Dover D.G., Jordan R.C.K. Bilateral dentigerous
mucoepidermoid carcinoma, and squamous cell cysts -report of an unusual case and review of the literature:
Clinical Practice 1999; 68,49-51.
carcinoma have also been reported to arise from 14. Miyawaki S., Hyomoto M., Tsubauchi J. Eruption speed and
the lining epithelium of dentigerous cysts, rate of angulation change of a cyst-associated mandibular second
premolar after marsupialization of a dentigerous cyst. Am J
indicating the pluripotentiality of their cells. Early Orthod Dentofac Orthop 1999; 116,578.
detection and removal of such cysts 15. Mintz S., Alard M., Nour R. Extraoral removal of mandibular
is therefore important to reduce potential odontogenic dentigerous cysts: A report of 2 cases. J Oral
Maxillofac Surg 2001; 59,1094.
morbidity. 16. Norris L., Piccoli P., Papageorge M.B. Multiple dentigerous
As it is common to find an unerupted cysts of the maxilla and the mandible: report of a case. J Oral
tooth as the only initial presenting symptom of a Maxillofac Surg 1987; 45,694-7.
17. Peterson LJ, Ellis E, Hupp JR, Tucker MR. Contemporary Oral
dentigerous cyst, it is important to undertake and Maxillofacial Surgery 4th edn: 2003; p116
radiographic examinations of all such teeth that 18. Rohrer A. Displaced and impacted canines. Int J Orthod Oral
Surg 1929; 15,1003.
are well past their expected eruption date. 19. Shivaprakash P., Rizwanulla T., Baweja D.K., Noorani H.H.
Despite the rarity of bilateral occurrence, Save a tooth: Conservative surgical management of dentigerous
once a dentigerous cyst has been identifed, cysts; J Indian Soc Pedod Prevent Dent 2009: 1,27, 52-5.
20. Ustuner E., Fitoz S., Atasoy Ç.,Erden İ., Akyar S. Bilateral
attempts must be made to rule out the presence maxillary dentigerous cysts: A case report Oral Surg Oral Med
of any co-existent lesions in other parts of the Oral Pathol Oral Radiol Endod 2003; 95,632-5.
jaws. 21. Vincent B.Z., Todd I.E., Ronald E.S. Using fenestration
technique to treat a large dentigerous cysts J Am Dent Assoc
1997; 128,201-205.
Declaration of Interest 22. Wong M. Surgical fenestration of large periapical lesions. J
Endod 1991; 17,517.
The authors report no conflict of interest
and the article is not funded or supported by any
research grant.

References

1. Aydin U., Yilmaz H.H., Yildirim D. Incidence of canine impaction

and ransmigration in a patient population. Dentomaxillofac Radiol
2004; 33,164-9.
2. Baykul T., AA. Saglam, U.Aydin, Basak K. Incidence of cystic
changes in radiographically normal impacted lower third molar.
Oral surg Oral Med Oral Pathol Oral Radiol Endod 2005; 99,5.
542-5.
3. Camilleri S, Scerri E. Transmigration of mandibular canines-A
review of the literature and a report of five cases. Angle Orthod
2003; 73,753-762.
4. Chu F.C.S., Li T.K.L., Lui V.K.B., Newsome P.R.H., Chow R.L.K.,
Cheung L.K. Prevalence of impacted teeth and associated
pathologies - a radiographic study of the Hong Kong Chinese
population. Hong Kong Med J 2003; 9,158-163.
5. Ertaş Ü., Yavuz M. S. Interesting eruption of 4 teeth associated
with a large dentigerous cyst in mandible by only marsupialization
J Oral Maxillofac Surg 2003; 61,728-730.
6. Grover P.S, Lorton L. The incidence of unerupted permanent
teeth and related clinical cases. Oral Surg Oral Med Oral Pathol
1985; 59,420-425.
7. Guven G.O., Keskin A., Akal U. K. The incidence of cysts and
tumors around impacted third molars. Int J Oral Maxillofac Surg
2000; 29,131-135.
8. Mihailova H., Nikolov V., Slavkov S. Diagnostic imaging of
dentigerous cysts of the mandible. Journal of IMAB - Annual
Proceeding (Scientific Papers), book 2008; 2 ,8-12.

Volume ∙ 4 ∙ Number ∙ 1 ∙ 2011 Page 24