Distinguishing dilated follicles from

dentigerous cysts
Some unerupted teeth have a slightly dilated follicle in the
pre-eruptive phase. This does not signify a cyst, nor even
necessarily a potential cyst unless the pericoronal width
is at least 3–4mm. Daley and Wysocki (1995) have
pointed out that it can be difficult to distinguish between
a small dentigerous cyst and a large dental follicle despite
the availability of both radiographical and histological
information. Their comparative study of 1662 dentigerous
cysts and 824 dental follicles showed considerable
overlap in age distribution and site predilection, and they
concluded that distinguishing reliably between a small
dentigerous cyst and a large dental follicle may only be
resolved by identifying a cyst cavity at the surgical
operation.
The approach taken by Damante and Fleury
(2001) was to verify the relationship between the radiographically measured width of the
pericoronal space
and the microscopic features of the follicle, in order to
contribute to the differential diagnosis of small dentigerous
and paradental cysts. Their sample comprised 130
unerupted teeth and 35 partially erupted teeth. These
were radiographed and then extracted. The widths of the
pericoronal spaces were measured radiographically. The
results of the radiographic analysis were compared with
those of the histopathological examination of the dental
follicle. The widths of the pericoronal spaces ranged from
0.1 to 5.6 mm. The most frequently observed lining of the
follicles was a reduced enamel epithelium in 68.4% of
unerupted teeth, and a hyperplastic stratified squamous
epithelium in association with the partially erupted teeth
in 68.5%. Inflammation was present in 36.1% of the
unerupted teeth and in 82.8% of the partially erupted
group. There was a statistically significant association
between the presence of stratified squamous epithelium
and pericoronal space enlargement for unerupted teeth
(P 0.05).
A trend was noted in the association between inflammation
and enlargements of the pericoronal spaces in partially
erupted teeth and possibly in unerupted teeth, but
there was no measurable statistical significance.

Surgically, the authors detected no bone cavitation or

luminal cystic contents in pericoronal spaces smaller than
5.6 mm. They suggested that the first radiographic diagnosis
for a pericoronal space enlargement, in most of the
routine clinical cases, should be of ‘inflammation of the
follicle’. A differential diagnosis of ‘dentigerous cyst’ or
‘paradental cyst’ might be considered. The final differential
diagnosis between a small dentigerous or a paradental
cyst and a pericoronal follicle depended on clinical
 and/or surgical findings, such as the presence of bone
cavitation and cystic content.

Pathogenesis
There can be little doubt that dentigerous cysts develop
around the crown of unerupted teeth, whatever causes
failure of eruption of the latter

Cytokeratins,
Numerous immunohistochemical studies have been
undertaken in the past few years, using a range of
antibodies, to compare the cytokeratin content of
dentigerous cyst epithelium with that of the OKC and
radicular cyst. Other studies compared the content in
these cyst linings of epidermal growth factor (EGF) and
transforming growth factor (TGF), elafin, bone morphogenic
protein-4 (BMP-4), epithelial membrane antigen
(EMA), carcinoembryonic antigen (CEA) and rat liver
antigen (RLA). The observations in these studies will not
be repeated here as they have been described in detail in
Chapter 3, and summarised in Table 3.7. Many of these
investigations were carried out to facilitate the diagnoses
of the different cysts, particularly the OKC.
More specifically, Hormia et al. (1987) addressed themselves
to the question of whether dentigerous cysts arose
between the reduced enamel epithelium and the enamel,
or by a split in the enamel organ itself. They proposed
that their results suggested that two histogenetic entities
could occur that could not be distinguished by routine histological
examination. They also pointed out that their
results indicated that dentigerous, but not other cyst
types, may share with some cases of ameloblastoma, the
expression of cytokeratin polypeptide No. 18. They speculated
that cytokeratin 18-positive cells could have a specific
histogenetic origin and could consequently have
distinct functional characteristics. Another possibility,
they suggested, was that the expression of cytokeratin
polypeptide No. 18 in dentigerous cysts was a sign of
oncofetal transformation in these lesions

The dentigerous cyst as a potential ameloblastoma

Numbers of workers have claimed that many ameloblastomas
arise in dentigerous cysts but the present author
has seen no evidence to support such a contention.
Indeed, the fact that dentigerous cysts are rarer in South
African blacks, compared with whites, whereas
ameloblastomas are very much more common in blacks
(Meerkotter, 1969; Shear and Singh, 1978) provides contrary
evidence. While ameloblastomas, being of odontogenic
epithelial origin, may theoretically arise from
dentigerous cyst lining as well as any other odontogenic
 epithelium, the belief that it commonly arises in this situation
and that the dentigerous cyst should therefore be
regarded as pre-ameloblastomatous, should be viewed
with caution. Much of the confusion has probably arisen
for three reasons. First, an ameloblastoma, like an OKC,
may involve an unerupted tooth, particularly a third
molar at the angle of the mandible, and this may be incorrectly
interpreted as a dentigerous cyst on radiographs
(Fig. 4.14). When subsequently the lesion is removed and
diagnosed histologically as an ameloblastoma, the erroneous
conclusion may be reached that the ameloblastoma
developed from the dentigerous cyst.
The second possible reason for believing that many
ameloblastomas develop from dentigerous cysts is that
biopsies of ameloblastomas may be taken of an expanded
locule lined apparently by a thin layer of epithelium. If
the surgeon’s provisional diagnosis is dentigerous cyst
because of the radiological picture, the pathologist may
well regard such histological features as consistent with
this diagnosis. When the tumour is removed entirely and
a diagnosis of ameloblastoma is made, once again this
may be misinterpreted as having developed from a
dentigerous cyst.
Third, as Lucas (1954) has pointed out, apparently isolated
islets or follicles of epithelium are sometimes found in the cyst wall some distance from the
epithelial lining.
These have been interpreted as ameloblastoma although
they bear only a superficial resemblance to the tumour.
It is likely that in the past, cases of unicystic ameloblastoma
may have been misdiagnosed as dentigerous cysts.
This lesion has now been well documented in the literature
as a benign cystic neoplasm, and is not explored
further in this book

Treatment
Much of the literature on the treatment of dentigerous
cysts has dealt with the procedures followed in handling
these lesions in children. The emphasis is on conservative
surgical treatment, combined with orthodontics, in order
to retain the involved teeth and to ensure eruption into
normal occlusion. Hyomoto et al. (2003) performed a retrospective
investigation into the eruption of teeth associated
with dentigerous cysts involving 47 mandibular
premolars and 11 maxillary canines in pre-adolescent
children. In one group, 81% of the mandibular premolars
and 36% of the maxillary canines erupted successfully
about 100days after marsupialisation without
traction. In the second group, the teeth had either undergone
orthodontic traction, or the cysts had been removed
entirely together with the associated tooth. The authors
suggested that a period of 100 days after marsupialisation
was the critical time for deciding whether to extract or to
 use traction. The eruption potential, they contended, was
closely related to root formation, so that teeth with
incomplete root formation had good potential to erupt,
whereas those with fully formed roots could not. They
recommended that on the basis of their study, position

angulation and root maturity of the cyst-related teeth

should be considered in the treatment plan.
Other research papers and case reports supporting
similar treatment approaches are those of Miyawaki et al.
(1999), Counts et al. (2001), Bodner (2002), Jones et al.
(2003), Jena et al. (2004) and Marchetti et al. (2004).
Motamedi and Talesh (2005) have detailed their experience
in treating 40 large dentigerous cysts involving
three or more teeth, referred to them over an 11-year
period. Their view was that dentigerous cysts were usually
easy to treat when small, but that the more extensive cysts
were more difficult to manage.
Their treatment approaches were based on patient age,
cyst site and size, involvement of vital structures by the
cyst, and the potential for normal eruption into occlusion
of the impacted tooth involved. Aspiration with a 16 or
18 gauge needle was performed to confirm that they
were dealing with cysts and not tumours, and these
were followed by incisional biopsies to make definitive
histological diagnoses.
Cyst enucleation along with extraction of the
impaction(s) was indicated in 34 patients. In these
patients the impacted teeth were deemed unlikely to be
useful, or lacked space for eruption. Cyst enucleation with
preservation of the impacted tooth was indicated in six
patients: five by enucleation of the cyst while preserving
the associated maxillary or canine teeth, while one was
treated by decompression. These teeth erupted normally
when root formation was incomplete. Orthodontics was
used in cases requiring aided eruption or alignment.
Decompression was used in only one case where there was
an extensive cyst in an 11year old girl involving the
mandibular body and angle, and impinged on the inferior
alveolar nerve and term germs.