International Journal of Oral & Maxillofacial Pathology.

2011;2(2):20-23 ISSN 2231 – 2250

Available online at http://www.journalgateway.com or www.ijomp.org

Case Report
Dentigerous Cyst in Maxillary Sinus: A Rare Occurrence
Girish G, Mahesh Kumar R, Umashankar DN, Rashi Sharma, Veeresh M, Ambika Bhandari

Abstract
An ectopically erupted tooth associated with a dentigerous cyst in the maxillary sinus presents
itself as a confounding problem which may lead to maxillary sinusitis. One such case of a
dentigerous cyst associated with an ectopic maxillary 3rd molar tooth in the right maxillary sinus
cavity is presented which is of interest because of its presence within the maxillary sinus which
has been very rarely documented. Investigations like computed tomography were carried out to
confirm the extent of the lesion and the management of the cyst was done by the Caldwell-Luc
procedure which is still popular to this day. The theoretical aspects of such dentigerous cysts are
also reviewed here.

Key words: Dentigerous Cyst;Odontogenic;Jaw Cyst;Ectopic Tooth Eruption;Molar

Third;Maxillary Sinus.

Girish G, Mahesh Kumar R, Umashankar DN, Rashi Sharma, Veeresh M, Ambika Bhandari. Dentigerous
Cyst in Maxillary Sinus: A Rare Occurrence. International Journal of Oral & Maxillofacial Pathology;
2011:2(2):20-23. ©International Journal of Oral and Maxillofacial Pathology. Published by Publishing
Division, Celesta Software Private Limited. All Rights Reserved.

Received on: 25/05/2011 Accepted on: 29/06/2011

Introduction (OPG) and Computed Tomography (CT)

Dentigerous cysts are the most frequent were advised which revealed the presence
type of developmental odontogenic cysts of an ectopically erupted tooth within the
derived from the epithelial remnants of the sinus cavity under OPG and the axial
tooth-forming organ.1 It is defined as a cyst sections of CT at the level of the maxillary
that originates by separation of follicle from sinus show a definite hyper dense area
around the crown of an unerupted tooth. surrounded by an isodense area with a
Most often the involved tooth is the breach at the posterior wall of the sinus
mandibular third molar.2 It may also be cavity suggestive of a tooth surrounded by
associated with an impacted, supernumerary soft tissue (Fig 1). This was indicative of an
or an ectopically erupted (eruption of a tooth infected dentigerous cyst in right maxillary
in sites other than the natural position) tooth. sinus.
Most common ectopically erupted teeth
observed are third molars. Rarely a tooth or The condition was then treated by removal
root may be present within the sinus cavity.3 of the tooth with cyst enucleation by
Such a tooth may be associated with Caldwell luc procedure under general
dentigerous cyst around it.4 An ectopically anesthesia. A transvestibular incision was
erupted tooth associated with a dentigerous placed extending from first molar to a
cyst in the maxillary sinus presents itself as vertical releasing incision between the lateral
a confounding problem which may lead to and central incisor. A bony window was
maxillary sinusitis. This article describes a created and the tooth was removed with
case of dentigerous cyst arising from an enucleation of cystic lining (Fig 2a & b). The
ectopically erupted right maxillary third molar cavity was irrigated and packed with gauze.
present in the maxillary sinus causing Haemostasis was achieved and wound was
sinusitis. closed with sutures. The gauze pack was
removed after 72 hrs via an oral antrostomy.
Case report The patient was asymptomatic till the follow
A 19 year-old male reported with chief up period of three weeks.
complaint of purulent discharge from the
right nostril and also salty discharge from Histopathology of the soft tissue revealed a
behind the second maxillary molar since six cystic lesion lined by flattened cells of
months. Despite being treated with stratified squamous epithelium and at places
antibiotics by medical practitioners the covered by granulation tissue and infiltration
discharge persisted. On clinical examination by mononuclear cells. These features were
the right third molar was missing and suggestive of an infected dentigerous cyst
tenderness was elicited over the right (Fig 2c).
maxillary sinus. An Orthopantomograph

©2011 International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved
21 Dentigerous Cyst in Maxillary Sinus: A et al ISSN 2231 - 2250

Figure 1: An orthopantomograph shows a tooth within the right maxillary sinus (a) and a CT scan
shows hyperdense area within the sinus cavity attached to the posterior wall (b).

b c
a

Figure 2: Bony window created in anterior wall of right maxillary sinus via Caldwell-Luc approach
(a). The macroscopic examination included the enucleated cyst fragments along with the tooth (b)
and the Histopathology revealed odontogenic epithelial lining of about 4-5 cell layers thick with a
fibrous connective tissue wall showing few inflammatory cells and areas of hemorrhage (c).

Discussion distribution ratio being 1.84:1

The Dentigerous cyst arises from the
enamel organ after amelogenesis is
completed. Many different factors are
involved in the development of these cysts.
There are two different views which are the
congenital anomaly view and the stimulatory
view by inflammation.5 The dentigerous cyst
is formed due to fluid accumulation leading
to separation of enamel epithelium of the
unerupted tooth from the surface. Due to the
increase of osmolality inside the cyst caused
by albumin, immunoglobulin and squamous
debris, fluid flows into the cyst and causes
increased pressure that leads to
engorgement of the cyst. Followed by the
growth of the cells covering the inner cavity
of the cyst, collagenase and osteoclast
activating factor are secreted by the
epithelium and the cyst grows.5 It encloses
the crown of an unerupted tooth and is
attached to the cementoenamel junction.
Dentigerous cysts take up about 24% of all
jaw cysts.5 It usually occurs in 2nd and 3rd
decades of life.6 There is a male
preponderance for white patients. The sex
(male:female).6 A substantial majority of
dentigerous cyst involved the mandibular
third molar. The maxillary permanent canine
is next in order of frequency of involvement,
followed by mandibular premolars and
maxillary third molars. The maxillary third
molar is involved in third decade of life.
Eliasson et al. reported a 1% occurrence of
these cysts in an impacted upper third molar
tooth.5 Prevalence of mandibular cyst is
twice more common than maxillary cyst.7
Dentigerous cyst associated with an
ectopically erupted tooth within the maxillary
sinus is a very rare occurrence.
Generally these cysts are painless and
remain dormant; though they may cause
some expansion of cortical bone.1 If
dentigerous cyst gets infected it shows
inflammatory symptoms such as facial
swelling, sensory changes. The formation of
fistula can occur especially when present in
maxillary sinus presents itself as sinusitis
with purulent discharge.8
22 Girish G et al
Dentigerous cysts are often found during
routine dental radiographs taken for a
missing tooth or because teeth are tilted or
otherwise out of alignment.9 It presents itself
as well-defined unilocular radiolucency with
sclerotic border associated with the crown of
an unerupted tooth. Occasionally,
trabeculations may be seen giving an
impression of multilocularity. Three
radiologic variants of dentigerous cysts are
observed. They are central variety, lateral
variety and circumferential variety.6 In the
case presented here was classified as a
central variety.
The histopathological findings of dentigerous
cysts are generally nonkeratinizing stratified
squamous epithelium consisting of 2-4 cell
layers. Mucous cells take up 25-50% of all
cells that cover the inner wall of the cyst.
Other cells such as ciliated cells, cuboidal
cells, columnar cells, hyaline bodies or
sebaceous elements are rarely detected and
invasion of inflammatory cells can be found.5
In our experience, the inner wall of the cyst
was covered with stratified squamous
epithelium and cuboidal cells, ciliated
columnar cells and goblet cells. On rare
occasions, squamous cell carcinoma,
mucoepidermoid carcinoma or
ameloblastoma can develop in dentigerous
cysts.
Computerized Tomography is very useful in
diagnosis of maxillary sinus pathologies.
However, routine CT imaging is reserved for
large lesions in particular those involving the
maxilla, in which case nasal cavity, orbital,
or pterygomaxillary space extension may
have occurred.7 In our case, CT images
allowed better depiction of the involved
structures and all of the paranasal sinuses.
There are mainly two treatment options for
dentigerous cyst, either by enucleation or
marsupialisation. In adults the impacted
teeth normally have a slim chance to erupt
therefore enucleation is a better treatment.7
As in our case the dentigerous cyst is
associated with a tooth in maxillary sinus the
treatment plan will deviate from a typical
case. To avoid formation of an oroantral
fistula marsupialisation was not performed
so the treatment of choice was enucleation
and removal of tooth via Caldwell-luc
approach.10 The Caldwell-Luc operation,
originally described in the late 1800s, is an
approach to the maxillary sinus through the
labio-gingival sulcus and canine fossa.
Caldwell-Luc and inferior antrostomy
ISSN 2231 - 2250
approaches are reserved for rare
circumstances like this. The prognosis is
excellent and recurrence is rarely observed
after enucleation. The sequel of these cysts
and ectopic teeth vary from obstruction of
the sinus to blindness.
Conclusion
Our patient presented with a history of
purulent discharge from the right nostril
since six months. After radiologic and
tomographic evaluation a diagnosis of
dentigerous cyst associated with an ectopic
maxillary third molar within the maxillary
sinus cavity was established. The possibility
of dentigerous cysts may always be
considered in cases with maxillary sinus
haziness on radiological findings.
Enucleation of the cyst along with removal of
the tooth was carried out via Caldwell-luc
procedure. Histopathological examination of
the cyst ruled out any associated
malignancies. The benefits of surgery should
always outweigh the risks, a ratio that is only
elucidated via a thorough workup and
evaluation. The recovery has been
uneventful.
Author Affiliations
1. Dr. Girish G, Senior Lecturer, 2. Dr. Mahesh
Kumar R, Reader, 3. Dr. Umashankar D N,
Reader, 4. Dr. Rashi Sharma, Senior Lecturer, 5.
Dr. Veeresh M, Professor, 6. Dr. Ambika
Bhandari, Post Graduate Student, Department of
Oral & Maxillofacial Surgery, Krishnadevaraya
Dental College and Hospital, Bangalore, India.
Acknowledgement
We would like to thank all the staff members of
Department of Oral Surgery and Oral Pathology,
Krishnadevaraya Dental College and Hospital,
Bangalore, for their support.
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Removal of extensive maxillary
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7. Kumar RM, Umashankar DN, Dr. Mahesh Kumar R,
Nandakumar H, Bawle MR, Sudhakar. Reader,
Inflammatory variant of Dentigerous Department of Oral & Maxillofacial Surgery,
Krishnadevaraya Dental College and
Cyst in Maxillary Sinus - A Case Report. Hospital,
Int J Oral Maxillofac Pathol Bangalore, India.
2010;1(1):17-9. Phone: 09845417365
Email: mahu017@gmail.com

Source of Support: Nil, Conflict of Interest: None Declared.