|Year : 2016 | Volume
| Issue : 1 | Page : 63-66
Inflammatory dentigerous cyst mimicking a periapical cyst
Priya Gupta1, Manveen Kaur Jawanda1, Ravi Narula2, Jasheena Singh3
1 Department of Oral and Maxillofacial Pathology, Luxmi Bai Institute of Dental Sciences and Hospital, Patiala, Punjab, India
2 Department of Oral and Maxillofacial Surgery, Guru Nanak Dev Dental College, Sunam, Punjab, India
3 Department of Pedodontics, Maharana Pratap College of Dentistry and Research Centre, Gwalior, Madhya Pradesh, India
|Date of Web Publication||12-Feb-2016|
Dr. Priya Gupta
577/4A Ekta Vihar, Anand Nagar B, Patiala - 147 001, Punjab
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Odontogenic cysts are the most common form of cystic lesions that affect the maxillofacial region. The low frequency of dentigerous cysts in children has been reported in dental literature. Dentigerous cysts arise as a result of cystic change in the remains of the enamel organ after the process of enamel formation is complete. They enclose the crown of an unerupted tooth and are attached to the cementoenamel junction. Although most dentigerous cysts are considered developmental cysts, some cases seem to have an inflammatory origin. The purpose of this report is to present a case of an 8-year-old male patient with a dentigerous cyst of inflammatory origin.
Keywords: Dentigerous, developmental, inflammatory, odontogenic, periapical
|How to cite this article:|
Gupta P, Jawanda MK, Narula R, Singh J. Inflammatory dentigerous cyst mimicking a periapical cyst. J Int Clin Dent Res Organ 2016;8:63-6
|How to cite this URL:|
Gupta P, Jawanda MK, Narula R, Singh J. Inflammatory dentigerous cyst mimicking a periapical cyst. J Int Clin Dent Res Organ [serial online] 2016 [cited 2019 Aug 26];8:63-6. Available from: http://www.jicdro.org/text.asp?2016/8/1/63/176258
| Introduction|| |
Odontogenic cysts are the most common form of cystic lesions that affect the maxillofacial region.  In children, the frequency of odontogenic cysts is relatively low. Shear has estimated that about 9% of dentigerous and 1% of radicular cysts occur in the first decade of life, while according to Donath, about 4% of dentigerous and less than 1% of radicular cysts appear during this first decade life. , Radicular cysts involving the primary dentition are extremely rare. 
Although most dentigerous cysts are considered developmental cysts, some cases seem to have an inflammatory origin.
The purpose of this article is to report an additional case of inflammatory dentigerous cyst, possibly associated with the inflammation of the overlying deciduous tooth.
| Case Report|| |
An 8-year-old boy reported with a chief complaint of swelling on the left side of middle third of face for the past 2.5-month duration, which gradually progressed to attain its present size. Swelling was associated with pain in the lower left back tooth region. Medical and family histories were noncontributory.
On extraoral examination, a small diffuse painless bony hard swelling was seen in the left cheek region. Intraoral examination revealed a carious mandibular left second deciduous molar. Based on these findings, a clinical provisional diagnosis of radicular cyst was made.
A panoramic radiograph revealed a unilocular radiolucent lesion with well-defined sclerotic margins in relation to carious mandibular left second deciduous molar associated with the crown of an underlying erupting second permanent premolar extending posteriorly till the unerupted permanent second molar. The first premolar was dislocated medially [Figure 1].
Based on the patient's history and the results of the clinical and radiographic examination, the lesion was differentially diagnosed as radicular cyst or dentigerous cyst [Figure 2].
An incisional biopsy along with the extraction of tooth no. 75 was done under local anesthesia. Remaining cystic lining was marsupialized with the crown of underlying permanent second premolar and the excised tissue was sent to the oral pathology department for the histopathological examination. Surgical exploration confirmed the nonassociation of cyst to the carious deciduous molar and lining was found to be attached to the crown of successive permanent second premolar. Two soft-tissue bits of whitish brown colored cystic lining measuring 1.5 cm × 1.0 cm were received [Figure 3]. Histopathological examination showed a cystic capsule densely infiltrated with chronic inflammatory cells. The deeper cystic capsule was made up of condensed collagen and exhibited few chronic inflammatory cells. In uninflammed areas, the cystic cavity was lined by nonkeratinized stratified squamous epithelium that was two to three cell layers in thickness, resembling reduced enamel epithelium [Figure 4]. Areas of inflammation showed marked hyperplasia in the cystic epithelium exhibiting "arcades" similar to the histopathological picture of "radicular cyst" [Figure 5].
|Figure 4: microscopic picture showing a cystic cavity, lined by two to three layered thick, nonkeratinized, stratified squamous epithelium, resembling reduced enamel epithelium in uninflammed areas|
Figure 3: macroscopic picture of the soft-tissue specimen
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|Figure 5: microscopic picture showing marked hyperplasia in the cystic epithelium exhibiting "arcades" in areas of chronic inflammation|
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Histopathological diagnosis of inflammatory dentigerous cyst was given.
| Discussion|| |
A dentigerous cyst is defined as an epithelium lined pathological cavity arising from the enamel organ due to an alteration in the reduced enamel epithelium and enclosing the crown of an unerupted tooth at the cementoenamel junction. It is the second most common odontogenic cyst, after radicular cyst. , Most reports have shown a peak incidence of dentigerous cysts in the second and third decades of life, with a slightly higher predilection for males. 
Usually, the dentigerous cysts begin to form through an accumulation of fluid within the follicle enclosing the crown of the involved tooth between the enamel organ and subjacent tooth structures shortly after complete formation of the crown.  Although most dentigerous cysts are considered developmental cysts, some cases seem to have an inflammatory origin. Main termed such cysts as "inflammatory follicular cysts." 
Inflammation has been implicated as a stimulus for epithelial proliferation in the case of apical periodontal cysts.  There are reports on children with dentigerous cysts associated with carious primary teeth and the crowns of more or less dislocated permanent successors. ,, The mechanism of development of an inflammatory dentigerous cyst is unclear. One theory advocates that dentigerous cyst formation is due to inflammation of the periapical tissues originating from the overlying primary predecessor tooth (carious/traumatic), which would reach and stimulate the underlying developing permanent tooth germ thus causing accumulation of fluid. , In the present case, the inflammatory reaction associated with the apex of the carious primary second molar may have stimulated proliferation of the reduced enamel epithelium of the adjacent developing permanent second premolar, leading to cyst formation or the developing follicle of the permanent second premolar was closer to the inflammatory reaction at the apex of the degenerating primary molar. Another theory that has been proposed is that the crown of a permanent tooth may erupt into a radicular cyst of its deciduous predecessor that is extrafollicular in origin.  Attachment of the cyst wall to the neck of the associated tooth is an essential feature; and microscopically, the cyst lining should demonstrate a readily identifiable component of reduced enamel epithelium as seen in the present case before a diagnosis of dentigerous cyst is made. 
Based on radiographic appearance, dentigerous cysts are classified into three varieties as follows: Central type, when radiolucency encircles the crown of unerupted tooth; lateral type, which develops laterally along the tooth; and circumferential type, where cyst completely encircles the crown and root of the tooth. , Our case resembles lateral type of dentigerous cyst.
A radicular cyst associated with a deciduous tooth appears to be in a dentigerous relationship with the erupting underlying permanent tooth. In such a case, the erupting tooth may indent rather than penetrate the wall of the radicular cyst and this should be apparent histologically, if not radiographically [Figure 2]. Nevertheless, individual cases need to be assessed critically.  A comprehensive assessment regarding the position of the permanent tooth germ with radiographic and surgical evaluation followed by a confirmatory histopathological appraisal may aid in the correct diagnosis.
Histologically, typical noninflammatory dentigerous cysts are lined by thin, nonkeratinized, stratified squamous epithelium. However, many variations in the thickness of the lining epithelium may be noted depending on type and severity of inflammation, like the spiky rete ridge hyperplasia seen in the present case. , The histologic features of a classical dentigerous cyst are characteristic and present few diagnostic problems. The clinical appearance and radiological features of the present case gave an impression that it was a radicular cyst; however, its histopathological features proved otherwise. So, this proves the importance of microscopic examination of the entire specimen, when giving a diagnosis based on histopathological observations. 
In differential diagnosis, an odontogenic keratocyst and a unicystic ameloblastoma must be considered. Although they both occur in the molar region of the lower jaw during the second and third decade of life as same as dentigerous cyst but the radiography does not show radiolucency associated with the roots of a nonvital primary tooth and the crown of an unerupted permanent tooth. 
In summary, dentigerous cyst development associated with an unerupted permanent tooth is not uncommon. On rare occasions, some untreated dentigerous cysts have the potential to develop odontogenic tumors such as ameloblastoma and malignancies such as oral squamous cell carcinoma and mucoepidermoid carcinoma.  This warrants the early detection of the cyst, so that early treatment strategies should be started to prevent the condition or to decrease the morbidity associated with the same.
| Conclusion|| |
The case presented here adds to the existing few cases of inflammatory dentigerous cyst reported in dental literature in English. A combination of clinical, radiographic, and histopathological examination is necessary for arriving at the final diagnosis.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Koseoglu BG, Atalay B, Erdem MA. Odontogenic cysts: A clinical study of 90 cases. J Oral Sci 2004;46:253-7.
Shear M. Cysts of the Oral and Maxillo-Facial Regions. 4 th
ed. Blackwell, Munksgaard: Oxford; 2007. p. 69-70.
Donath K. Odontogenic and nonodontogenic jaw cysts. Dtsch Zahnarztl Z 1985;40:502-9.
Kozelj V, Sotosek B. Inflammatory dentigerous cysts of children treated by tooth extraction and decompression-report of four cases. Br Dent J 1999;187:587-90.
Sunumu O. Nonsyndromic bilateral mandibular dentigerous cysts: Report of a rare case. Turkiye Klinikleri J Dental Sci 2007;13:129-34.
Cawson R, Binnie W, Speight P, Barret A, Wright J, editors. Lucas′s Pathology of Tumors of the Oral Tissues 5 th
ed. London: Churchill Livingstone; 1999. p. 127.
Vosough Hosseini S, Moradzadeh M, Lotfi M, Ala Aghbali A, Fattahi S. Dentigerous cyst associated with a mesiodens: A case report. J Dent Res Dent Clin Dent Prospects 2011;5:76-8.
Juntavee A. Management of delayed eruption of mandibular canine associated with dentigerous cyst. A clinical report. Khon Kaen Dent J 1999;2:101-7.
Main DM. Epithelial jaw cysts: 10 years of the WHO classification. J Oral Path 1985;14:1-7.
Croll TP. The collimation and film speed mystery in dental radiology: What does it take for a dcntisl to change? Quintessence Int 1990;21:429-34.
Azaz B, Shteyer A. Dentigerous cyst associated with second mandibular bicuspids in children: Report of five cases. ASDC J Dent Child 1973;40:29-31.
Shaw W, Smith M, Hill F. Inflammatory follicular cysts. ASDC J Dent Child 1980;47:97-101.
Benn A, Ackermann GL, Altini M. The role of deciduous teeth in the pathogenesis of odontogenic cysts. J Dent Res 1990;69:1092.
Benn A, Altini M. Dentigerous cyst of inflammatory origin, a clinicopathogenic study. Oral Surg Oral med Oral path Oral Radiol Endod.1996;81:203-9.
Lakkam B, Prabhawati, Majage B. Dentigerous (Follicular) cyst - a case report. IJCD 2010;1;23-8.
Srinivasan B. Textbook of oral and Maxillofacial Surgery. 2 nd
ed. Reed Elsevier India Private Limited; 2003. p. 213.
Sharma M, Pardhe ND, Gupta N, Mittal M, Gaikwad A, Pathak M. Inflammatory dentigerous cyst: A rare entity. J Res Adv Dent 2014;3:2s:4-7.
Shafer WG, Hine MK, Levy BM. A Textbook of Oral Pathology. Philadelphia: WB Saunders Company; 1993. p. 154-8.
Neville B, Damm DD, Allen CM, Bouquot J. Oral and Maxillofacial Pathology. St. Louis: WB Sounders Company; 2002. p. 471-3.
Manveen JK, Subramanyam RV, Simmerpreet SV, Ramandeep NS. Calcifying cystic odontogenic tumor mimicking as a residual cyst. J Clin Diagn Res 2010:2979-83.
Slootweg PJ. Carcinoma arising from reduced enamel epithelium. J Oral Pathol 1987;16:479-82.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]