Dentigerous cyst

Dentigerous cyst can be defined as an odontogenic cyst that surrounds the

crown of an impacted tooth; caused by fluid accumulation between the
reduced enamel epithelium and the enamel surface, resulting in a cyst in
which the crown is located within the lumen.

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 Pathogenesis

Intrafollicular origin Extrafollicular origin

 Pathogenesis
• During eruption of tooth, this reduced enamel epithelium acquire squamoid
appearance.

• In case of impacted tooth this squamoid changes become more marked.

• The attachment of the reduced enamel epithelium to the tooth surface

become weaker as it changes to squamous type.

• The epithelial cells assumes characteristic layer of stratified squamous

epithelium.

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 Extrafollicular hypothesis

• Crown of a permanent tooth may erupt into a

radicular cyst of its deciduous predecessor

• Not very popular because

• Radicular cyst in deciduous teeth are very uncommon

• Erupting tooth may indent rather than penetrate the cyst

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 Pressure exerted by erupting tooth on impacted follicle

Obstruction of venous outflow

Rapid transudation of serum across the capillary walls Increased

hydrostatic pressure

Separation of REE from the crown (Main,

1970)

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 Expansion of cyst

 Glycosaminoglycans and growth :

•GAGs, predominantly hyaluronic acid and also appreciable
amounts of heparin and chondroitin-4-sulphate, are
present in the fluids and walls of dentigerous cysts.

• Release of GAGs from the walls and their diffusion into

the cyst fluid increases the osmolality of the cyst fluid and
hence raising the internal hydrostatic pressure of the cyst.
 Inflammation and growth:

• Many dentigerous cysts show evidence of a degree of acute and

chronic inflammation in their walls.

• The passage of desquamated epithelial cells and inflammatory

cells into the cyst cavity must contribute to the increase in
intracystic osmotic tension and further expansion of the cyst.
 Bone resorption and growth:

IL-1 released by the cyst leads to number of osteolytic cell

reactions:
 Stimulation of osteoclasts to resorb bone,

 Stimulates connective tissue cells to produce –

• prostaglandins, which is responsible for further osteoclast

activation.

• Collagenase which is involved in the destruction of bone matrix.

 Clinical features
• Frequency
• 16.6%

• Age
• Peak between 2nd-4th decade
• Most common jaw cyst in the first decade

• Sex
• Male predilection (1.6: 1)

• Race
• More common in whites
• Site
• Mandibular third molar
• Maxillary canine
• Mandibular premolars
• Maxillary third molars
• Others
Supernumerary teeth
• Mesiodens (maxillary)  90%
Clinical Presentation:

•Most dentigerous cysts are solitary

•The dentigerous cyst is potentially capable of becoming an aggressive

lesion.

• Expansion of bone with subsequent facial asymmetry, extreme

displacement of teeth
• severe root resorption of adjacent teeth and pain are all possible sequelae
brought about by continued enlargement of the cyst

• Cystic involvement of an unerupted mandibular third molar may result in a

‘hollowing-out’ of the entire ramus extending up to the coronoid process and
condyle as well as in expansion of the cortical plate due to the pressure
exerted by the lesion.

•Associated with this reaction may be displacement of the third molar to such
an extent that it sometimes comes to lie compressed against the inferior border
of the mandible.

• In the case of a cyst associated with a maxillary cuspid, expansion of the

anterior maxilla often occurs and may superficially resemble an acute sinusitis
or cellulitis
 Swelling

• There is usually no pain or discomfort associated with the cyst unless it

becomes secondarily infected.

 Multiple and bilateral cysts are found in association with syndromes –

 Cleidocranial dysplasia
 Maroteaux-Lamy Syndrome
 Radiographic features
 Well defined unilocular radiolucency associated with the crown of
unerupted teeth.
 Well defined sclerotic margins.
 Occasionally trabeculae seen.
 Tooth displacement.
Radiographic variant:

• Central - the crown is enveloped symmetrically. In these instances,

pressure is applied to the crown of the tooth and may push it away from its
direction of eruption. In this way, mandibular third molars may be found at
the lower border of the mandible or in the ascending ramus and a
maxillary canine may be forced into the maxillary sinus as far as the floor
of the orbit.

•Circumferential dentigerous cyst results when the follicle expands in a

manner in which the entire tooth appears to be enveloped by cyst.

• Lateral-which result from dilatation of the follicle on one aspect of the

crown. This type is commonly seen when an impacted mandibular third
molar is partially erupted so that its superior aspect is exposed.
 Central

Lateral

Circumferential
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 Histopathological features
•  Epithelial lining :

• Non-keratinized

• 2-4 cell layers of flat or cuboidal cells, some time superficial layer of epithelial lining
is low columnar and retains the morphology of the ameloblasts layer.

 Rete ridges absent unless secondarily infected.

• Some time mucous producing cells present in lining.

• The presence of mucous and ciliated cells is thought to result from metaplasia.

• Hyaline bodies sometime seen.

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Thin fibrous cyst wall derived from dental follicle :

 Young fibroblast, separated by stroma and ground substance.

 Nest, islands and strands of odontogenic epithelium also seen in

capsule.

The content of cystic lumen is usually thin watery yellow fluid and is
occasionally blood tinged.

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• Rushton bodies
• Found within
• The epithelium or its surface
• Connective tissue wall

• Appear as
• Irregular, eosinophilic, glassy
structures
• Often showing a granular
center

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• Nests, islands and strands of odontogenic epithelium in the connective tissue
capsule

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Potential Complications
 Several relatively serious potential complications exist stemming from the
dentigerous cyst, besides simply the possibility of recurrence following
incomplete surgical removal. These include

􀁏 The development of an ameloblastoma either from the lining epithelium or

from rests of odontogenic epithelium in the wall of the cyst.

􀁏 The development of epidermoid carcinoma from the same two sources of

epithelium.

􀁏 The development of a mucoepidermoid carcinoma, basically a malignant

salivary gland tumor, from the lining epithelium of the dentigerous cyst which
contains mucussecreting cells, or at least cells with this potential, most
commonly seen in dentigerous cysts associated with impacted mandibular third
molars
 Differential diagnosis

 Ameloblastoma and ameloblastic fibroma—they are multilocular and not

associated with crown of an unerupted tooth. They will grow laterally away
from the tooth in comparison to dentigerous cyst, which envelopes the tooth
symmetrically and it is more common in premolar and molar area. There is
internal structure present in ameloblastoma and in case of dentigerous cyst, it
is most unlikely.

 Adenomatoid odontogenic tumor—they are rare and occur in the maxillary

anterior region.

 Calcifying odontogenic cyst—it may occur as pericoronal radiolucency and

may contain evidences of calcification.

 Odontogenic keratocyst—it does not expand the bone as severely as

dentigerous cyst and also is less likely resorbs the tooth. It is usually attached
more apically than the dentigerous cyst.
 Treatment
 The treatment of the dentigerous cyst is usually dictated by the
size of the lesion. Smaller lesions can be surgically removed in
their entirety with little difficulty. The larger cysts which
involve serious loss of bone and thin the bone dangerously are
often treated by insertion of a surgical drain or
marsupialization.