Dentigerous cysts of anterior maxilla in a young child: A case report

RR Kalaskar, A Tiku, SG Damle

Department of Pediatric Dentistry, Nair Hospital Dental College, Mumbai, India
Correspondence Address:
R R Kalaskar
Department of Pediatric Dentistry, Nair Hospital Dental College, Mumbai
India

Abstract
Dentigerous cysts are the most common bony lesions of the jaws in children. It is one of the most
prevalent types of odontogenic cysts associated with an erupted or developing tooth, particularly
the mandibular third molars; the other teeth that are commonly affected are, in order of
frequency, the maxillary canines, the maxillary third molars and, rarely, the central incisor.
Radiographically, the cyst appears as ovoid well-demarcated unilocular radiolucency with a
sclerotic border. The present case report describes the surgical enucleation of a dentigerous cyst
involving the permanent maxillary right central incisor; the surgery was followed by oral
rehabilitation. Careful evaluation of the history and the clinical and radiographical findings help
clinicians to correctly diagnose the condition, identify the etiological factors, and administer the
appropriate treatment.

Keywords: Dentigerous cyst, enucleation, marsupialization, maxillary right central incisor,

unerupted
How to cite this article:
Kalaskar R R, Tiku A, Damle S G. Dentigerous cysts of anterior maxilla in a young child: A case
report. J Indian Soc Pedod Prev Dent 2007;25:187-90
How to cite this URL:
Kalaskar R R, Tiku A, Damle S G. Dentigerous cysts of anterior maxilla in a young child: A case
report. J Indian Soc Pedod Prev Dent [serial online] 2007 [cited 2015 Oct 25];25:187-90.
Available from: http://www.jisppd.com/text.asp?2007/25/4/187/37016
Dentigerous cysts are the most common of the developmental odontogenic cysts of the jaws and
account for approximately 20-24% of all the epithelium-lined jaw cysts. It develops around the
crown of an unerupted tooth by expansion of follicle when fluid collects or a space occurs
between the reduced enamel epithelium and the enamel of an impacted tooth. [1] Dentigerous
cysts are always associated with an unerupted or developing tooth bud and are found most

frequently around the crown of the mandibular third molars followed, in order of frequency, by
the maxillary canines, maxillary third molars and, rarely, the maxillary right central incisor. [2]
These cysts are often asymptomatic unless there is an acute inflammatory exacerbation and,
therefore, these lesions are usually diagnosed during routine radiographic examination. [1]
Swelling, teeth displacement, tooth mobility, and sensitivity may be present if the cyst reaches a
size larger than 2 cm in diameter. [3] Radiograph of the dentigerous cyst shows a well-defined
unilocular radiolucency, often with a sclerotic border, surrounding the crown of an unerupted
tooth. [2] Histologically, the dentigerous cyst consists of a fibrous wall lined by nonkeratinized
stratified squamous epithelium consisting of myxoid tissue, odontogenic remnants and, rarely,
sebaceous cells. [4] Complications associated with dentigerous cysts include pathologic bone
fracture, loss of the permanent tooth, bone deformation, and development of squamous cell
carcinoma, mucoepidermoid carcinoma, and ameloblastoma. [5] The treatment indicated for
dentigerous cysts are surgical removal of the cyst, avoiding damage to the involved permanent
tooth; enucleation of the cyst, along with removal of the involved tooth; or the use of a
marsupialization technique, which removes the cyst while preserving the developing tooth. [6] The
present case report describes the management of dentigerous cysts in children.
Case Report
A 7-year-old boy reported to the Department of Pediatric Dentistry, Nair Hospital Dental
College, Mumbai, with a chief complaint of a painless swelling in the maxillary right anterior
region since 4 months. On general examination, the patient was apparently healthy. There was no
significant past medical history. Intraoral examination revealed a bony swelling which caused a
bulging of the cortical bone, extending from the buccal vestibule of the maxillary left deciduous
central incisor to the maxillary right first deciduous molar. The swelling was well defined, firm
in consistency, painless on palpation, and measured about 3 3 cm. There was no bruit or
pulsation. The buccal cortical plate showed slight expansion and the overlying mucosa was
slightly inflamed. There were no signs of any acute periodontal condition or carious lesions. The
primary maxillary right central incisor was discolored and was associated with an intraoral sinus.
There was history of trauma 1 year back while playing in school. The teeth on the affected side
were mobile (51, 52, 53, 54, 61) although not sensitive to percussion.
The occlusal radiological examination showed a thin sclerotic border surrounding the welldefined unilocular radiolucent area that was associated with the root of a nonvital primary
maxillary right central incisor and an unerupted permanent maxillary right central incisor [Figure
- 1]. The permanent maxillary right central and lateral incisors were superiorly and laterally
displaced. There was irregular root resorption of the primary maxillary right lateral incisor and a
widened pulpal canal of the primary maxillary right central incisor [Figure - 1]. The contents of
the swelling were aspirated and sent for investigations; the result of which was consistent with
the diagnosis of a cystic lesion. After clinical and radiological examination, a provisional
diagnosis of dentigerous cyst was made; however, large periapical cyst, odontogenic keratocyst,
central giant-cell granuloma, adenomatoid odontogenic tumor, and ameloblastic fibroma were
also considered in the differential diagnoses. Prior to surgery, routine blood and urine
examination were advised; the results were within normal limits. Surgical enucleation of the cyst
was chosen as the treatment of choice. The treatment consisted of extraction of the maxillary

right deciduous central incisor, maxillary right deciduous lateral incisor, maxillary right
deciduous canine, maxillary left deciduous central incisor, and permanent maxillary right canine,
along with total enucleation of the dentigerous cyst. The surgery was done using local anesthesia
(Dentocaine 2% Pharma Health Care Product, Mumbai) and under antibiotic cover. The cyst was
attached to the cementoenamel junction of maxillary right permanent central incisor [Figure - 2],
[Figure - 3]. The cyst cavity was packed with sterile iodoform gauze to achieve hemostasis and
to prevent hematoma formation [Figure - 4]. The iodoform gauze was removed on the next day
and the sutures were removed after one week. The specimen was sent for histopathological
examination. The histological examination showed a thin fibrous cystic wall lined by a 2 to 3
layer thick nonkeratinized stratified squamous epithelium, with islands of odontogenic
epithelium. The connective tissue showed a slight inflammatory cell infiltrate, which confirmed
the diagnosis of dentigerous cyst [Figure - 5]. After 15 days, a removable partial denture was
delivered, which served as a functional space maintainer, improved esthetics and phonetics, and
also as a guidance for the eruption of the permanent maxillary left central incisor. The patient
was asked to return for clinical and radiographic follow-up once a month. After 6 months, bone
neoformation was observed in the same region [Figure - 6] and the permanent maxillary left
central incisor was seen erupting in its proper place [Figure - 7]. A follow-up after every 6
months and careful monitoring of the permanent right lateral incisor and permanent left central
incisor is required.
Discussion
A dentigerous cyst can be defined as a cyst that encloses the crown of an unerupted tooth,
expands the follicle and is attached to the cementoenamel junction of the unerupted tooth. [7]
Dentigerous cysts account for more than 24% of jaw cysts. The substantial majority of
dentigerous cysts involve the mandibular third molar and the maxillary permanent canine,
followed by the mandibular premolars, maxillary third molars and rarely the central incisors. [8]
Studies have shown that the incidence rate of dentigerous cysts involving the maxillary central
incisor was 1.5% as compared to 45.7% involving the mandibular third molar. [8] Mourshed [9]
stated that 1.44% of impacted teeth undergo dentigerous cyst transformation, so dentigerous
cysts involving the permanent central incisor are rare. Daley et al . [10] reported an incidence rate
of 0.1-0.6%, whereas Shear found the incidence to be 1.5%. [8] Dentigerous cysts most commonly
occur in the 2 nd and 3 rd decades of life. These lesions can also be found in children and
adolescents and show a male predilection. [8] In the present case report, the dentigerous cyst was
associated with the permanent maxillary right central incisor in a 7-year-old male child.
The exact histogenesis of the dentigerous cyst is not known. It is stated that the dentigerous cyst
develops around the crown of an unerupted tooth by accumulation of fluid either between the
reduced enamel epithelium and enamel or in between the layers of the enamel organ. 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. [11] Toller [12] stated that the likely origin of the dentigerous cyst is the
breakdown of proliferating cells of the follicle after impeded eruption. These breakdown
products result in increased osmotic tension and hence cyst formation. Bloch suggested that the
origin of the dentigerous cyst is from the overlying necrotic deciduous tooth. The resultant

periapical inflammation will spread to involve the follicle of the unerupted permanent successor;
an inflammatory exudate ensues and results in dentigerous cyst formation. [13] In the present case,
the most likely explanation is that the cyst originated from the discolored primary maxillary right
central incisor. Most of the authors have reported the presence of carious or discolored deciduous
teeth in relation to the development of dentigerous cysts. [9],[10] This suggests that the periapical
inflammatory exudates from the deciduous teeth might be one of the risk factor for the
occurrence of dentigerous cysts.
A large periapical cyst, odontogenic keratocyst, central giant-cell granuloma, and unicystic
ameloblastoma can mimic a dentigerous cyst. Odontogenic keratocyst and unicystic
ameloblastoma most frequently occur in the molar region of the lower jaws in the 2 nd and 3 rd
decades of life. A radiograph will not differentiate between a radiolucency associated with the
root of a nonvital primary teeth and the crown of unerupted teeth. [13] Unlike other odontogenic
cysts, the epithelial cells lining the lumen of the dentigerous cyst possesses an unusual ability to
undergo metaplastic transition. On occasion, some untreated dentigerous cysts rarely develop
into an odontogenic tumor (e.g., ameloblastoma) or a malignancy (e.g., oral squamous cell
carcinoma). [14] Marsupialization and surgical enucleation of the cyst may be the treatment of
choice. In the present case surgical enucleation of the cyst was done.
The present case occurring in a 7-year-old boy, supports the age and sex predilection mentioned
by other authors. [11],[13] Though dentigerous cysts are most common in the mandibular jaw, in the
present case the maxillary jaw was involved. A dentigerous cyst associated with an anterior tooth
will result in failure of eruption of the tooth and therefore lead to esthetic and orthodontic
problems. Absence of a central incisor can have an impact on the psychology of child. Further
esthetic management has to be considered to prevent any psychological trauma to the child. In
the present case, esthetic management was done by providing the patient with a removable
partial denture, which also serves as a functional space maintainer and facilitates the eruption of
the permanent maxillary left central incisor.
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