Mandible & maxilla
Cysts of the jaw
Dentigerous cyst
Last author update: 1 October 2013
Last staff update: 17 April 2023 (update in progress)
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PubMed Search: Dentigerous cyst [title]
Table of Contents
Definition / general | Terminology | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Radiology description | Prognostic factors | Case reports | Treatment | Radiology images | Clinical images | Gross description | Gross images | Microscopic (histologic) description | Microscopic (histologic) images | Differential diagnosis | Additional referencesCite this page: Morrison A. Dentigerous cyst. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/mandiblemaxilladentigerous.html. Accessed June 2nd, 2023.
Definition / general
- Developmental odontogenic cyst that originates by separation of dental follicle from around the crown of an unerupted tooth
- Diagnosis requires correlation with radiographs or knowledge of radiographic findings
Terminology
- Dentigerous cyst also called follicular cyst
- Ameloblasts: specialized epithelial cells that form tooth enamel
- Reduced enamel epithelium:
- Enamel is normally composed of two cell layers: inner layer of reduced or atrophied ameloblasts and external layer, probably stratum intermedium cells
- Reduced enamel epithelium is normally found overlying an unerupted, otherwise developed tooth
- Deciduous tooth: also called baby tooth or primary tooth; falls out during childhood
- Succedaneous tooth: permanent tooth; also called adult tooth; replaces deciduous teeth; lasts throughout life under most normal circumstances
- Eruption cyst: soft tissue counterpart to dentigerous cyst; involves an erupting tooth
Epidemiology
- Second most common odontogenic cyst
- Most common developmental odontogenic cyst
- Multiple simultaneous dentigerous cysts uncommon
- Represents 20% of epithelium lined jaw cysts (J Investig Clin Dent 2013 Jun 14 [Epub ahead of print])
- Usually seen in teenagers / young adults, although can occur over a wide age range
Sites
- By definition, a dentigerous cyst occurs in association with an unerupted tooth
- Most commonly around permanent mandibular third molars (wisdom teeth)
- Somewhat less common around permanent maxillary third molars, maxillary cuspids and mandibular second premolars but any tooth may be involved
- Rarely involves supernumerary teeth and odontomas (Contemp Clin Dent 2011;2:215)
- Distinctly rare to occur around unerupted primary teeth
Pathophysiology
- Develops from accumulation of fluid (including glycosaminoglycans) between reduced enamel epithelium of dental follicle and crown of unerupted tooth
- Vast majority are developmental odontogenic cysts; may have inflammatory pathogenesis:
- Inflammation progressing from root apex of carious or necrotic deciduous tooth brings about development of dentigerous cyst around underlying, unerupted permanent tooth
- Impossible to histologically distinguish inflamed developmental odontogenic dentigerous cyst from those induced by inflammation
Etiology
- In normal tooth development, tooth enamel is produced by the enamel organ, an ectodermally derived specialized epithelium
- After enamel formation is complete, the enamel organ epithelium atrophies
- This reduced enamel epithelium eventually merges with the overlying mucosal epithelium to form the initial gingival crevicular epithelium of the newly erupted tooth
- Dentigerous cysts form when fluid accumulates between the reduced enamel epithelium and the crown of the unerupted tooth
Clinical features
- May be small / asymptomatic, identified on routine radiographs taken for unrelated reasons or for imaging to investigate delayed tooth eruption
- Can grow large enough to produce a painless bony expansion, can displace the involved tooth, cause resorption of adjacent teeth
- If secondarily infected, may be associated with pain
Diagnosis
- Radiographic findings, in combination with clinical information, can support a histomorphologic diagnosis
Radiology description
- Most commonly a well defined, unilocular radiolucency on X-ray
- Often has sclerotic rim
- Can cause resorption of adjacent teeth
- Three different radiographic relationships between involved tooth and cyst described:
- Central variety:
- Most common radiographic relationship
- Cyst develops around and surrounds the entire crown of tooth, thus tooth appears to be erupting into the cyst (see Clinical images)
- Lateral variety:
- Cyst develops at lateral tooth root and only partially surrounds crown (see Clinical images)
- Circumferential:
- Cyst develops around crown and extends down the root(s), thus roots also appear within the cyst
- Central variety:
- More aggressive odontogenic lesions such as odontogenic keratocyst, ameloblastoma, and other odontogenic tumors can have identical radiographic features
- Bilateral dentigerous cysts are uncommon
- Radiographic differential diagnosis for bilateral or multifocal 'cystic' lesions around impacted / partially impacted posterior teeth in a young person may include:
- Odontogenic keratocyst (keratocystic odontogenic tumor)
- Cherubism
- Bilateral buccal bifurcation cysts
- Enlarged dental follicles
- Multiple hyperplastic calcifying follicles
- Mucolipidosis Type III, or pseudo-Hurler polydystrophy
- Maroteaux-Lamy syndrome, also known as mucopolysaccharidosis type VI
- Amelogenesis imperfecta
- Tuberous sclerosis or cleidocranial dysplasia
- The radiographic distinction between an enlarged dental follicle and a small dentigerous cyst can be arbitrary
- Generally, a pericoronal radiolucency that is larger than 3 to 4 mm in diameter is considered suggestive of cyst formation
Prognostic factors
- Excellent prognosis, almost never recurs with complete enucleation, however follow up radiographic studies recommended
- Recurrence may indicate incomplete excision or possibly incorrect original diagnosis
- Tooth sparing marsupialization procedures may have higher risk of cyst recurrence / persistence
- Rarely, second neoplasms can arise from dentigerous cysts, most commonly:
- Ameloblastoma
- Squamous cell carcinoma
- Intraosseous mucoepidermoid carcinoma
Case reports
- 20 year old woman with florid cemento-osseous dysplasia in association with dentigerous cyst (J Oral Maxillofac Pathol 2010;14:63)
- 25 year old woman with an adenomatoid odontogenic tumor associated with dentigerous cyst of the maxillary antrum (J Oral Maxillofac Pathol 2010;14:24)
- 28 year old woman with adenomatoid odontogenic tumor with dentigerous cyst (Contemp Clin Dent 2012;3:S244)
- Extra-orally draining infected dentigerous cyst associated with a supernumerary fourth molar in ascending ramus (Dent Update 2013;40:343)
Treatment
- Varies based on age, maturity, anatomic position and relative importance of tooth involved, size of cyst, presence of additional neoplasms; also patient preference, including cosmetic and functional considerations
- Enucleation of entire cyst with extraction of the associated tooth is most common approach
- Marsupialization:
- Removal of the cyst sparing the permanent tooth (J Appl Oral Sci 2012;20:282)
- Requires close follow up to monitor for recurrence
Radiology images
Images hosted on other servers:
Central variety
Lateral variety
Multiple radiopaque masses with thin radiolucent rim
Expansion and thinning of the bony sinus wall
Unerupted maxillary canine
Lesion extension
Lesion pushing inferior wall of sinus
Orthopantomograph
Clinical images
Images hosted on other servers:
Swelling of right maxilla and left mandibular region
Swelling of right cheek
Intraoral involvement of maxillary right quadrant
Surgical exposure of lesional site
Gross description
- Relationship of tooth and cyst usually disrupted during surgery
- If cyst contains any nodularity, these areas should be sampled to rule out neoplastic change
Gross images
Images hosted on other servers:
Hard and soft tissues with impacted lateral incisor
Enucleated specimen with embedded canine
Cystic lesion
Tan-colored thickenings in wall of cystic lesion
Maxillary right quadrant
Mandibular left quadrant
Wisdom tooth with preserved dentiginous cyst orientation
Dentigerous cyst remnants with tooth
Extracted tooth and pathologic lining
Microscopic (histologic) description
- Microscopic features are influenced by presence of inflammation
- Inflamed Dentigerous Cyst:
- Fibrous connective tissue
- Hyperplastic non-keratinized epithelium, sometimes elongated interconnecting rete ridges
- Chronic inflammatory cells
- Cholesterol clefts, possibly formation of cholesterol granuloma
- Rushton bodies
- Scattered mucous, or ciliated or sebaceous cells uncommon but possible
- Occasional dystrophic calcifications
- Odontogenic epithelial rests, small, inactive appearing
- Non-inflamed Dentigerous Cyst:
- Fibrous to fibromyxoid connective tissue
- No rete ridges, flat interface
- Lining epithelium, 2 - 4 layers of cuboidal epithelium, devoid of superficial keratinization
- Occasional mucous cells; rare ciliated cells
- Occasional dystrophic calcifications
- Odontogenic epithelial rests, small, inactive appearing
- Some lesions submitted as dentigerous cysts are partially lined with a thin, fragmented layer of eosinophilic columnar cells / low cuboidal epithelium representing the postfunctional ameloblastic layer of the reduced enamel epithelium
- Many of these lesions probably do not technically represent true cysts but just hyperplastic connective tissue dental follicles
Microscopic (histologic) images
Contributed by Kelly Magliocca, D.D.S., M.P.H.
Dentigerous cyst
Images hosted on other servers:
Cystic lumen
Reduced enamel epithelium
Dentigerous cysts
Differential diagnosis
- Most significant and most common lesions to distinguish from dentigerous cyst:
- Cystic ameloblastoma
- Columnar basal cells with hyperchromatic nuclei
- Usually but not always exhibit reverse polarization of nuclei (away from basement membrane)
- Odontogenic keratocyst / keratocystic odontogenic tumor
- Uniform epithelium
- 4 - 8 cell layers in thickness
- Hyperchromatic basilar palisading of cuboidal to columnar cells
- Characteristic wavy / corrugated surface parakaratosis
- +/- keratin flakes within cyst lumen
- Differential greatly influenced by
- Radiographic features (relationship or lack thereof with impacted tooth / teeth, lytic vs. opaque imaging characteristics, size of lesion, number of radiographic lesions, precise tooth involved)
- Amount and features of epithelium available for evaluation
- Degree of inflammation
- Clinical history of new diagnosis vs recurrent disease also essential
- Radiographic features unknown / unavailable, markedly inflamed squamous epithelial lining
- Radicular / periapical cyst
- Paradental cyst
- Terminology used inconsistently
- For some, this term is used to characterize a dentigerous cyst suspected to be induced by inflammation rather than a developmental odontogenic cyst
- Others use the term paradental cyst synonymously with buccal bifurcation cyst
- Odontogenic keratocyst / keratocystic odontogenic tumor, markedly inflamed
- Dental follicle, inflamed
- Eruption cyst
- Plexiform variant ameloblastoma, inflamed
- Unicystic ameloblastoma, inflamed
- Radiographic features unknown / unavailable, limited cystic epithelium present for evaluation (ie: incisional biopsy of cystic lesion), however, basal palisading of the squamous epithelium present:
- Calcifying odontogenic cyst / Gorlin cyst
- Ameloblastoma with cystic features
- Unicystic ameloblastoma
- Odontogenic keratocyst / keratocystic odontogenic tumor
- Dentigerous cyst (uncommon to have basal palisading and if present, is focal)
- Odontogenic cyst or cystic odontogenic tumor, NOS
- Cystic ameloblastoma
Additional references
