|Year : 2013 | Volume
| Issue : 1 | Page : 21-24
Cystic lesion creating radiographic dilemma: An unusual case report
Neeraj K Dhiman1, Akhilesh Chandra2, Chandresh Jaiswara1, Richik Tripathi1
1 Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
2 Department of Oral and Maxillofacial Pathology, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
|Date of Web Publication||3-May-2013|
2/29 Rashmi Khand, Sharda Nagar, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Dentigerous cyst is caused by fluid accumulation between the epithelium and the crown of an unerupted tooth. It grows by expansion of the follicle and is attached to the neck of the tooth. The radicular cysts are inflammatory jaw cysts at the apices of teeth with infected and necrotic pulps. These arise from the epithelial residues in the periodontal ligament as a result of inflammation, usually following death of the pulp. We present a case of a cystic lesion creating dilemma between radicular and dentigerous cyst.
Keywords: Dentigerous cyst, orthopantomograph, radicular cyst
|How to cite this article:|
Dhiman NK, Chandra A, Jaiswara C, Tripathi R. Cystic lesion creating radiographic dilemma: An unusual case report. J Oral Maxillofac Radiol 2013;1:21-4
|How to cite this URL:|
Dhiman NK, Chandra A, Jaiswara C, Tripathi R. Cystic lesion creating radiographic dilemma: An unusual case report. J Oral Maxillofac Radiol [serial online] 2013 [cited 2021 Apr 13];1:21-4. Available from: https://www.joomr.org/text.asp?2013/1/1/21/111348
| Introduction|| |
Dentigerous cyst (DC) is the most prevalent type of odontogenic cysts and is associated with crown of an unerupted tooth and accounts for more than 24% of jaw cysts. The cyst mainly involves crown of impacted mandibular third molar, followed by maxillary canines, mandibular premolars, rarely supernumerary teeth, and central incisors. 
DCs are usually discovered on routine radiographic examination or when films are taken to determine the reason for failure of a tooth to erupt. They are always radiolucent and usually unilocular, although large lesions occasionally show a scalloping multilocular pattern. 
By definition, this lesion is attached to the cervix of an impacted tooth and results from proliferation of reduced enamel epithelium after the enamel formation.  There is fluid accumulation between the fully formed tooth crown and the reduced enamel epithelium. It is considered a developmental abnormality arising from the reduced enamel epithelium around the crown of an unerupted tooth but it rarely involves unerupted deciduous teeth. ,
Here, we discuss a case of DC arising from impacted right maxillary canine which was not visible on orthopantomograph (OPG) creating a diagnostic dialemma.
| Case Report|| |
A 18-year-old female patient presented with a progressively increasing swelling in the right maxillary region for approximately last 6 months. The extraoral swelling was extending from lateral side of the nose to the lower eyelid and below to the angle of the mouth [Figure 1].
The swelling was smooth, diffuse, fluctuant, non-tender, and measuring about 5 × 3.5 cm 2 . Intra-oral examination revealed the presence of retained 53 and the absence of 13 and a swelling with buccal cortical plate expansion in relation to 11 to 18 regions obliterating the labial vestibule in this area. There was no swelling on the palatal aspect.
Radiographic examination showed a unilocular radiolucent area extending from 11 to 18 regions and superiorly up to floor of the orbit. There was resorption of root of 53 and the roots of 12 and 14 were deviated. The 13 was missing and it was not visible on OPG although there was no history of extraction of this tooth [Figure 2]. The CT scan was advised but the patient was not willing due to her economical condition. Therefore, the provisional diagnosis of radicular cyst in relation to 53 was made on the basis of available radiograph.
|Figure 2: Orthopantomograph showing a large unilocular radiolucent area without any tooth or, tooth-like structure|
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The aspiration test was positive showing 2 ml of straw colored fluid. Other routine laboratory parameters were normal.
The lesion was enucleated and packed with gauze piece. During its removal, the cystic lining was found to be attached to the neck of a tooth [Figure 3] and after its removal the cavity was communicating with maxillary sinus. Therefore, 53 was not extracted to avoid another dependent opening.
The histopathological examination revealed a cystic cavity lined by thin, non-keratinized stratified squamous epithelium resembling reduced enamel epithelium. The cyst wall consisted of uninflamed fibromyxomatous connective tissue. [Figure 4] These findings were consistent with a diagnosis of a dentigerous cyst.
|Figure 4: H and E section showing a cystic lining of thin, non-keratinized stratifi ed squamous epithelium (× 40)|
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| Discussion|| |
Odontogenic developmental cysts arise from dental organ. The follicular cysts arise in any region of the alveolus and develop once the tooth has started to form. The tooth or its crown become part of the cyst wall and may penetrate into the cystic cavity and therefore also termed as dentigerous cyst. 
The differential diagnosis of dentigerous cyst includes OKC, radicular cyst, unicystic ameloblastoma, odontogenic fibroma, and odontogenic myxoma, the origin of which are inflammatory and other types of odontogenic developmental cysts of the jaw bones. 
Radicular cyst arising from deciduous teeth may mimic dentigerous cysts radiologically.  Both the radicular and dentigerous cyst are very common jaw lesions. , The DC is the second most common odontogenic cyst, after radicular cyst which is found most commonly. It presents mostly in the second or third decade of life. 
Most radicular cysts develop slowly and generally do not become very large cavities. Patients do not experience pain unless acute inflammatory exacerbation is present and the affected tooth does not respond to electrical pulp testing. Tooth mobility may occur in large cysts.  In our case, the lesion was quite large and 53 was non-vital with grade I mobility.
Radiographically, the radicular cyst generally appears as round or ovoid radiolucent area surrounded by a radiopaque margin which extends from the lamina dura of the involved tooth. In infected or rapidly enlarging cysts, the radiopaque margin may not be present. Root resorption is not often seen but it may occur. 
Histologically, the cysts are lined by non-keratinized stratified squamous epithelium approximately 6-20 cell layer thick. The proliferating epithelium may exhibit arcading pattern in early stages. The connective tissue capsule is delicate with dense inflammatory cell infiltration and it may also show cleft like spaces filled with cholesterol that are seen as spindle shaped spaces. 
Many clinicians are of the opinion that a great majority of radicular cysts heal after conventional root-canal therapy.  However, some authors advise that small cyst (<3 cm) are usually enucleated, whereas large cysts (>3 cm) are often marsupiliazed. ,
The DCs are mostly asymptomatic and may be found on routine dental radiographic check-up. They may also cause symptoms like pain or swelling with the enlargement of the cyst size. Several researchers reported the pathologic fracture of the mandible caused by the huge of DC. , The outgrowth of the cyst may also cause the resorption of adjacent tooth. 
Radiographically, the typical DC showed a well-defined radiolucency with sclerotic border associated with the crown of an unerupted tooth. Since the epithelial lining is derived from the reduced enamel epithelium, this radiolucency typically and preferentially surrounds the crown of the tooth. 
A large dentigerous cyst may give the impression of a multilocular process because of the persistence of bone trabeculae within the radiolucency. However, dentigerous cysts are grossly and histopathologically unilocular processes and probably are never truly multilocular lesions ,
Three varieties of the cyst-to-crown relationships can be seen on radiographic examination. They are central variety in which the radiolucency surrounds, just the crown of the tooth, with the crown projecting into the cyst lumen. In the lateral variety, the cyst develops laterally along the tooth root and partially surrounds the crown; the circumferential variant exists when the cyst surrounds the crown but also extends down along the root surface, as if the entire tooth is located within the cyst. ,
Radiographic findings are not diagnostic for dentigerous cysts because unicystic ameloblastomas, odontogenic keratocysts and many other odontogenic, and non-odontogenic tumors have radiographic features essentially identical to those of a dentigerous cyst. These are ruled out after negative biopsy and histologic examination. 
In this case, the there was a large radiolucent lesion but 13 was missing and it was not visible on radiograph therefore questioning the presence of dentigerous cyst or any other odontogenic lesion.
The treatment choice for dentigerous and inflammatory follicular cysts is marsupialization, but most reports agree that enucleation of the cyst followed by extraction of involved tooth is recommended.  In our case the cyst was enucleated and the cystic lining was removed with the tooth.
It is possible for the lining of a dentigerous cyst to undergo neoplastic transformation to an ameloblastoma and this has been reported.  Squamous cell carcinoma may also arise in the lining of a dentigerous cyst. The frequency of such neoplastic transformation is very low. 
In our case, the cystic lining typically resembled reduced enamel epithelium and no neoplastic changes have been demonstrated in any part of it.
| Conclusion|| |
This case report cautions the dental professionals to be aware of, specifically radiologists, because the lesions may mimic and push in a wrong direction of diagnosis. So, all the possible examinations including computed tomography must be considered to get an accurate diagnosis and to determine the best treatment for the patient.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]