Authors : Dr. Parag Kerkar, Dr. Rashu Mittal, Dr. Payal Katakwar.
The article reviews a case of palatally placed lateral incisor and a dentigerous cyst associated with a palatal supernumery tooth .since the size of the cyst was huge a Marsupilization approach was done first .after a period of 6 months a surgical approach to enucleate was done to remove the palatally impacted supernumery tooth and the cyst linin.
The dentigerous cyst is the second most common cyst of the jaws comprising 14–20 per cent of all jaw cysts, and they are more frequent in males and more common in the mandible. 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. Dentigerous cysts 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 pattern1.
|Intra oral Photograph showing the palatal swelling||IOPA showing the supernumery tooth and the radiolucent|
Third molars followed by maxillary canines (the most commonly impacted teeth) and occasionally supernumerary teeth or odontomas are involved in cyst formation. Their pathogenesis remains unknown. Proliferation of the epithelium in a fluid-filled sac may be induced by osmotic pressure during the extended period of time the tooth is impacted. Were the tooth to erupt, the dentigerous cyst would burst and cease to be a pathologic entity, as is usually the case in small eruption cysts. Small cysts are also easy to treat surgically.
However, dentigerous cysts occasionally become extensive since lesions are asymptomatic even when reaching considerable size and then treatment is more difficult as associated teeth are often impacted and displaced a considerable distance due to cyst pressure; surgery may require removal of several teeth or tooth buds or endanger vitality of adjacent teeth2. Nevertheless, because of the many damaging sequelae, dentigerous cysts must be surgically eliminated. Methods employed for elimination have included decompression, marsupialisation, and enucleation.
Chief complaint: 32 year male pt came with a palatally placed supernumery tooth with a difficulty in speaking clearly and a swelling in relation to the palate since the past few months.
On examination extra orally there was no evidence of any swelling or signs of inflamation intraorally there was a distinct palatal swelling on the right side of the palate extending from the right central incisor till the second molar. The swelling was distinctly soft and fluctuant. Signs of inflamation such as acute sever pain or pus discharge was absent .pain on percussion in relation to the upper teeth was absent .permanent lateral incisor was palatally placed while deciduous lateral incisor was over retained
|Axial view showing the extent of the lesion||Saggital view showing the superioinferior extent of the lesion||OPG showing the palatally placed tooth and the cyst extent and the supernumery tooth|
Medical history: no relevant medical history
Provisional diagnosis: cyst, abscess or odontogenic tumor
Radiographic assessment: IOPA showed a palatally placed lateral incisor and a supernumerary tooth in the hard palate there was a distinct radiolucency whose margins couldn’t be traced
OPG confirmed the palatally placed lateral incisor and the presence of the supernumerary tooth in the palate and the radiolucency extending from the right central incisor till the second molar on the same side with distinct displacement of the maxillary sinus and nasal fossa.
CT scans: coronal section shoed the lesion involving the right maxillary sinus and the right nasal aperture extending till the orbital floor but not involving it
Axial view confirmed the involvement of the maxillary sinus and the nasal aperture on the right side posteriorly. It extended till the posterior surface of the maxilla but not perforating it
Vitality test confirmed the vitality of al, the teeth Aspiration test showed a straw colored fluid.
Histopathology confirmed cholesterol crystals.
Final diagnosis: dentigerous cyst
Treatment plan: Due to the sheer size of the lesion and the extent and the proximity to the floor of the orbit it was decided to marsupelize the cyst and enucleate it 6 months hence when sufficient amount of bone is deposited around the lesion. As planned Marsupilization was done through the Caldwell luc incision3.
|Access opening into the cyst space||Marsupilization done through the Caldwell luc approach||Partial suturing done|
The pt was inject with lignocain with 1:80000 adrenaline. An incision was taken above the attached mucosa just below the depth of the sulcus (The Caldwell luc incision) .A mucoperiosteal flap is raised to visualize the bone below. A small window is prepared in the paper thin bony wall to drain out the straw colored cystic fluid4. The cyst cavity is emptied and irrigated with a butadiene solution. a roller gauze soaked in betadine ointment is packed layer by layer and a small piece is left outside for retrieval at a later date. such dressings are repeated initially three times weekly followed by twice weekly after two months. The patient was thus kept under constant observation for any signs of infection.
After 6 months OPG confirmed the deposition of bone and through the same incision the cyst lining was removed by initially separating the cyst lining from the bony wall and then slowly packing the area with a gauze and sliding it forward to separate the entire cyst lining from the bone5. The supernumerary tooth and the palatally placed permanent lateral incisor were now removed and the wound closed with a black silk suture
Dentigerous Cyst (follicular cyst) A cyst that occurs around the crown of an unerupted tooth is called a dentigerous cyst or follicular cyst7. They are thought to arise as a result of the accumulation of tissue fluid between the crown of the tooth and the adjacent reduced enamel epithelium that lines the dental follicle. Why this occurs is unknown. Dentigerous cysts are developmental in origin (not inflammatory) and may have little or no inflammation in the cyst wall. The lining epithelium is stratified squamous type6. The size ranges from small (barely larger than a normal follicle) to huge. The wall of the cyst is attached to the neck of the tooth from which it arose. Figure 10 shows the relation of the cyst to the tooth. This cyst may be multilocular but far more often is unilocular. Since it produces no calcified product, it is purely radiolucent. Another cyst, the keratocyst, and a tumor, the cystic ameloblastoma, may radiographically mimic a dentigerous cyst. The risk of developing a dentigerous cyst has been cited as a reason to have all unerupted teeth removed. But the risk is low, probably less than 1%
|6 months post op showing bone deposition||Enucleation procedure carried out||Specimen out|
More References are available on request.