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ORIGINAL ARTICLE
Year : 2014  |  Volume : 2  |  Issue : 3  |  Page : 77-81

Dentigerous cysts of the jaws: Clinical and radiological findings of 18 cases


Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Ondokuzmayis University, Atakum, Samsun, Turkey

Date of Web Publication14-Nov-2014

Correspondence Address:
Erzurumlu Zerrin
Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Ondokuzmayis University, Atakum, 55139 Samsun
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-3841.144673

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  Abstract 

Aims: The purpose of this study was to investigate the demographic, clinicopathologic and imaging features of dentigerous cysts (DCs) and to review the literature. Materials and Methods: In this study, between 2010 and 2012, we analyzed 18 DCs of 18 patients (9 female, 9 male) whose ages ranged from 13 to 61. Results: Of the 18 DCs, 33% were found in the maxilla and 67% in the mandible. The most common site for DC was the mandibular molar region, and the most frequently involved tooth was the mandibular third molar. About 67% of the cases were found in the right side and 33% in the left side of the jaws. In the 67% of cases, displacement was observed in the involved tooth and/or adjacent teeth. 44% of the DCs partially surrounded the crown (lateral variety) and 56% surrounded the crown of the tooth (central variety). About 39% of cases had symptoms such as pain, swelling and drainage. 6% of the cases were infected, and resorption in the involved tooth was detected. 6% of the cases, DC caused devitalization of the adjacent tooth. Conclusions: The results of this study showed that DCs occurred most frequently in the posterior region of the mandible and related to third molar tooth. The cysts had a tendency to displace associated and/or adjacent teeth. Panoramic radiography is important in finding out these cysts. Computed tomography is recommended for differential diagnosis, expansion and association with neighboring anatomical structures.

Keywords: Dentigerous cyst, jaws, imaging


How to cite this article:
Zerrin E, Husniye DK, Peruze C. Dentigerous cysts of the jaws: Clinical and radiological findings of 18 cases . J Oral Maxillofac Radiol 2014;2:77-81

How to cite this URL:
Zerrin E, Husniye DK, Peruze C. Dentigerous cysts of the jaws: Clinical and radiological findings of 18 cases . J Oral Maxillofac Radiol [serial online] 2014 [cited 2019 Jun 20];2:77-81. Available from: http://www.joomr.org/text.asp?2014/2/3/77/144673


  Introduction Top


Dentigerous cyst (DC) is a developmental jaw cyst associated with a crown of unerupted/impacted tooth. DC is usually seen as a unilocular, well-defined radiolucent area clinging to the tooth in the cemento-enamel junction. [1] The borders may be scalloped and positioned centrally or laterally on dental crowns. [2],[3] DC has a tendency to teeth displacement and resorption. [1] DC may resemble odontogenic keratocyst (OKC), unicystic ameloblastoma (UA), and ameloblastic fibroma on plain radiography. [1],[4],[5] Computed tomography (CT) provide important information for the differential diagnosis.

In this study, clinical and radiological features of 18 cases of DC from 18 patients were investigated and compared with the similar studies in the literature.


  Materials and Methods Top


Eighteen DC cases of 18 patients who applied to our clinic between the years 2010 and 2012 and who had histopathological diagnosis were examined retrospectively. The patients' clinical information, plain graphies, CT examinations, operation notes and histopathological assessment results were recorded on a table [Table 1] and [Table 2].
Table 1: Panoramic radiography findings 1

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Table 2: Panoramic radiography findings 2

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Follicular space and the sizes of the cysts were measured in the panoramic radiograph. For follicular space, the distance from a dental crown to the cyst wall was measured, and for cyst size, the measurement was made at where the cyst was the widest. Nine of 18 patients had both panoramic graphy and CT examinations. In CT, the cyst size was measured at where the cyst was the widest on the axial scan [Figure 1] and [Figure 2].
Figure 1: Panoramic and computed tomography (CT) images of case 3. (a) Dentigerous cyst (central variety) related to left mandibular canine. (b) CT axial and coronal scans showing cystic area around the unerupted tooth

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Figure 2: Panoramic and computed tomography (CT) images of case 18. (a) Panoramic radiograph showing large, well defined border, dentigerous cyst (lateral variety) related to mandibular right third molar tooth. According to the left, right mandibular canal displaced inferiorly. (b) CT axial and coronal scans showing bucco-lingual expansion and the cortical thinning in corpus and ramus of the right mandible

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  Results Top


The ages of 18 patients who were found to have DC were between 13 and 61, and the average of their ages was 32 (±15). Nine patients (50%) were female, and 9 (50%) were male. Male/female ratio was 1:1. Of the 18 cysts, 12 (67%) were in the mandible and 6 (33%) were in the maxilla. 11 (61%) DCs were detected incidentally during routine examination. In the symptomatic cases (n = 7), 5 (71%) had swelling, 4 (57%) had pain and 2 (29%) had pus drainage [Figure 3].
Figure 3: The ratio of symptoms

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Eighty three percentage of DCs were smooth whereas 17% had scalloped borders on panoramic radiography. Cyst was centrally and laterally positioned in 10 (56%) and 8 (44%) of the cases respectively. Jaw expansion was observed in 4 (22%) of the cases. Resorption in ivolved/adjacent tooth in 4 (22%) patients and displacement of involved/adjacent tooth in 67% of the cases were observed [Table 1].

Loss of lamina dura was observed in 9 (50%) of the cases. In the panoramic radiography, minimum follicular space was found to be 3 mm (case 16), maximum follicular space was found to be 24.6 mm (case 18) and average follicular space was found to be 11.5 (± 7) mm, while minimum cyst size was found to be 9.3 mm (case 11), maximum cyst size was found to be 54.3 mm (case 18) and average cyst size was found to be 23.5 (± 1) mm [Table 2].

Of the DCs cases in the maxilla, 3 (50%) were anterior, and 3 (50%) were in the posterior area. Of the DC cysts, cases in the mandible 4 (33%) were anterior, and 8 (67%) were in the posterior are [Table 2]. The rate of anterior/posterior in the maxilla was found to be 1/1, whereas the rate of anterior/posterior in the mandibular was found to be 2/3.

Eight (44%) of 18 DCs were associated with mandibular third molar tooth, this was followed by mandibular canine 4 (22.2%), maxillary canine 3 (16.7%), maxillary third molar 2 (11.1%) and maxillary first premolar tooth 1 (5.6%) [Figure 4].
Figure 4: The association of dentigerous cysts with teeth

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When the relation between 18 DCs and anatomical structures examined, displacement of the mandibular canal was observed in 5 (42%) of 12 mandible DC cases and displacement of maxillary sinus occurred on 2 (33%) of 6 maxillar DC cases [Table 2].

Of the 9 cases who had panoramic radiography and CT examinations, 6 (67%) had smooth borders, and 3 (33%) had scalloped borders. Panoramic radiography showed expansion in 2 (22%) of the 9 DC cases, while CT showed expansion at the jaw in 8 (89%). Of the 8 cases who were found to have expansion, 4 (50%) had buccal expansion, 3 (37.5%) had buccal-lingual expansion, and 1 (12.5%) had palatal expansion.


  Discussion Top


Dentigerous cyst are the second most common odontogenic cysts of the jaws. [1] DCs is more common in second and third decades. [5],[6],[7],[8],[9],[10],[11] The average age of our study was 32. Although DC was reported to occur more frequently in men than in women, the ratio of W/M was found to be 1/1 in our study. [5],[6],[7],[8],[9],[10],[11]

Dentigerous cysts are mostly asymptomatic, and they are seen by chance in radiographs that are taken for other reasons. [4],[5],[12],[13] 61% of the cases in our study were asymptomatic. Tsukamoto et al. [11] have reported that 58% of the DCs they examined were symptomatic while 42% were asymptomatic. Sanatkhani et al. [14] reported that 15% of the DCs they examined had pain while 80% had swelling.

Dentigerous cysts are mostly seen in panoramic radiographies as unilocular, well-defined radiolucent areas that show cortication. [4],[5],[13] If they are infected, they may be ill defined. [5] Often their borders are smooth; however, they may be scalloped in big cysts. [2],[5],[13],[14],[15] Motamedi and Talesh [12] reported that 92.5% of the cysts they examined were unilocular and smooth borders while 7.5% were scalloped borders. Tsukamoto et al. [11] examined DC cases with panoramic radiography, and they reported that 84% of the cases had smooth borders, while 16% had scalloped borders, and they found that the ratio of smooth/scalloped was 5.4:1. In our study, 83% of the DC cases in panoramic radiography had smooth borders, while 17% had scalloped borders, and the ratio of smooth/scalloped was found to be 4.8:1.

Dentigerous cysts were reported to be mostly in the form of central variety. [11],[16] In our study, 56% of DCs were centrally located while 44% were laterally located.

Dentigerous cysts are found to occur in the mandible more frequently than the maxilla (75%). [13] Lin et al. [9] reported that 63.9% of DCs were in the mandible and 36.1% were in the maxilla; Mourshed [17] reported that 73.9% were in the mandible and 26.1% were in the maxilla, Zhang et al. [7] reported that 82% were in the mandible and 18% were in the maxilla; Motamedi and Talesh [12] reported that 57.5% were in the mandible and 42.5% were in the maxilla and Avelar et al. [6] reported that 59% were in the mandible. In our study, the ratio of mandible/maxilla was found to be 2/1.

Dentigerous cysts are mostly associated with mandibular third molar tooth. [5],[13],[16] Lin et al. [9] reported the rate of third molar tooth being associated with DC as 45.3%, Zhang et al. [7] as 77% and Jones et al. [10] as 73.2%. In our study, this rate was found to be 44.4%. DCs is secondarily reported to be associated with maxillary canine tooth. [4],[5],[10],[18] Regezi and Sciubba [4] stated that the most frequently seen impacted teeth were the third molar and maxillary canine teeth, and thus DCs occurred most frequently in these teeth. Lin et al. [9] reported that supernumerary teeth were the ones that DCs occurred second most frequently while Zhang et al. [7] reported that maxillary third molar teeth were the ones that DCs occurred second most frequently. In our study, mandibular canine teeth (22.2%) were the teeth that DCs were second most frequently associated with [Figure 4].

Dentigerous cysts can cause displacement and root resorption in the involved/adjacent teeth. [1],[13],[14],[15] In our study, displacement was seen in 67% of the involved/adjacent teeth. The rate of root resorption was found to be 40% by Sanatkhani et al., [14] 55% by Struthers and Shear [19] and 17% by our study.

Dentigerous cysts can also cause buccal and lingual expansion in the jaw. [4],[12],[13],[14] Hydraulic expansion and cortication can be seen well in CT and cone beam CT (CBCT). [13] They rarely reach very big sizes. [5] In our study, CTs showed jaw expansion in 8 (89%) of 9 DCs. Panoramic radiography showed expansion in 2 (22%) of these 9 DCs. In contrast enhanced CT (CECT), soft tissue window, contrast enhancement is seen in the cyst wall. If the cyst is not infected, there is no enhancement within the lesion to suggest a solid neoplasm. [13] In our study, cyst wall contrast was seen in 5 of the 9 cases.

Dentigerous cysts can cause displacement in the maxillary sinus, mandibular canal and nasal fossa. [1],[14],[13],[20] In panoramic radiography, displacement was seen in neighboring anatomical structures of the 7 (38.9%) out of 18 DCs.

In its histopathology, DC epithelium consists of 2-4 layers of smooth nonkeratinized cells and the interface of epithelium and connective tissue is smooth. There may be mucous, ciliated columnar and fat cells in DC epithelium. [5]

Differential diagnosis is made with hyperplastic follicles, UA, OKC, ameloblastic fibroma and eruption cyst. [13] Some radiographic criteria have been suggested for the differential diagnosis of DC and hyperplastic follicles. While a normal follicular space is 2-3 mm, a DC can be suspected when the space is more than 5 mm. [1] Cemento-enamel composition of the borders is interpreted in favor of DC. DCs can be mistaken for OKC in plain graphies. Especially when DCs reach big sizes, differential diagnosis of DC and OKC becomes difficult. [11],[21] In their study, they compared DC and OKC, Tsukamoto, et al. [11] stated that the distance between the affected third molar tooth and an adjacent second molar was found to be less in OKCs when compared with DCs. OKCs are not always pericoronal. They cause less expansion and less root resorption. [14],[13]

The characteristics of UA are the destruction of the anterior border of the ramus in plain graphy, whereas they are the presence of contrast enhanced nodules within the cyst in CECT scans. In addition, knife-edge root resorption can be seen in ameloblastoma. [13]

Ameloblastic fibromas occur in younger ages. They grow slowly, and they may reach big sizes. They are expansive unilocular or multilocular radiolucencies that are well-defined, corticated border and mostly they do not have tooth structure or calcification within the lesion. In many cases, they are associated with the crown of an unerupted tooth. They cause typical neoplastic expansion, they have an acute angle with the normal cortex. Big lesions can cause perforation in buccal and lingual cortices, and it can be seen in CT/CBCT. [13]

Eruption cyst is pathologically the same with DC. It is a soft tissue cyst in an erupting tooth. Clinically, it is a blueish swelling that is expanded to the oral cavity. [13]

The treatment for DCs is either enucleation or marsupialization. Recurrence is rare. DC epithelium can rarely turn into ameloblastoma, squamous cell carcinoma or mucoepidermoid carcinoma. [5]


  Conclusion Top


This study showed that DCs occurred most frequently in the posterior region of the mandible and related to third molar tooth. The cysts had a tendency to displace associated and/or adjacent teeth. Panoramic radiography is important in finding out these cysts. CT is recommended for differential diagnosis, expansion and association with neighboring anatomical structures.


  Acknowledgment Top


This study was presented as a poster presentation in 19 th International Congress of Dento-Maxillo-Facial Radiology. June 22-27 2013, Bergen, Norway.

 
  References Top

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Regezi JA, Sciubba J. Oral Pathology: Clinical-Pathologic Correlations. 2 nd ed. Philadelphia: WB Saunders; 1993. p. 326-32.  Back to cited text no. 4
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]


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