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CASE REPORT

Dentigerous Cyst Associted With Supernumerary Tooth In Anterior Maxilla: A Case Report
Satya Narain,1 Anubha Gulati2
ABOUT THE AUTHORS 1. Dr Satya Narain Associate Professor, Oral And Maxillofacial Surgery, Dr H.S. Judge Institute Of Dental Sciences And Hospital, Panjab University Chandigarh. 2. Dr Anubha Gulati Associate Professor, Oral Pathology, Dr H.S. Judge Institute Of Dental Sciences And Hospital, Panjab University Chandigarh.

Abstract
Dentigerous cyst is a developmental odontogenic cyst which originates through alterations of the reduced enamel epithelium in a unerupted tooth or a developing tooth bud. These cysts rarely associate with supernumerary teeth. The purpose of this article is to describe a rare case of dentigerous cyst associated with supernumerary tooth in anterior maxilla in a child. This case report is different from previously reported cases as the supernumerary tooth is located between maxillary central and lateral tooth and not with a mesiodens. Key words: Dentigerous cyst, Supernumerary tooth, anterior maxilla.

Introduction
The dentigerous cyst is defined as a cyst that originates by the separation of the follicle from around the crown of unerrupted tooth. This is the most common type of developmental odontogenic cyst. The pathogenesis of this cyst is uncertain, but apparently it develops by accumulation of fluid between the reduced enamel epithelium and the tooth crown. It occurs most commonly in the second and third decade of life and typically involves the mandibular third molar, the maxillary canines and the mandibular premolars. Dentigerous cyst around supernumerary teeth accounts for 5% of all dentigerous cysts and mostly involves a mesiodens in the anterior maxilla [1]. In the present case the supernumerary tooth was located between maxillary central and lateral incisor. CASE REPORT: A 9 year old male child presented with a painless hard tissue swelling on right side of anterior palate. Duration of swelling was three months. There was no change in swelling since the patient initially noticed it. On examination there was slight enlargement of right side of anterior hard palate which was hardly perceptible and was nontender with overlying mucosa normal. Buccal side of involved region was normal(Figure 1, 2).Patient was in mixed dentition stage, right permanent lateral incisor was missing clinically while its contra lateral counterpart had erupted in mouth. OPG X-ray revealed a supernumerary tooth between maxillary right central and lateral incisor (Figure3). On maxillary occlusal view X-ray there was a radiolucent lesion surrounding a radiopaque distorted tooth like structure in right anterior palate (Figure 4). These radiographic appearances suggested a diagnosis of supernumerary tooth causing dentigerous cyst. CT scan (in axial, coronal and sagittal planes) was performed. The lesion in alveolar process of maxilla was found to be nonenhancing.The contents were of fluid attenuation and showed the supernumerary tooth (Figure 5, 6, 7). Lesion was enucleated along with the supernumerary tooth under local anesthesia. Supernumerary tooth had a distorted morphology with a dilacerated root (Figure 8, 9). Histopathological examination revealed a cystic lumen lined with stratified squamous epithelium over a connective tissue stroma (Figure10).Correlation of clinical, radiological and histological findings confirmed the diagnosis of dentigerous cyst . IJCDS MARCH, 2012 3(1) 2012
Int. Journal of Clinical Dental Science

Corresponding Author:

Dr Satya Narain Associate Professor, Oral And Maxillofacial Surgery, Dr H.S. Judge Institute Of Dental Sciences And Hospital, Panjab University Chandigarh.
drsatya.maxfac@hotmail.com

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Figure 1, 2. Intraoral view showing slight enlargement right side of palate, buccal side appear normal, right permanent lateral incisor is missing.

Figure 3. OPG X-ray showing a supernumerary tooth, no radiolucency is visible around it.

Figure 4.occlusal x-ray revealed radiolucent lesion surrounding a supernumerary tooth.

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IJCDS MARCH, 2012 3(1) 2012 Int. Journal of Clinical Dental Science

Figure 5, 6, 7. CT Axial, sagittal and coronal view depicting the extent of lesion.

Figure 8, 9. Intraoperative view and surgical specimen.

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Figure10. Histophotomicrograph of lesion showing stratified epithelial lining the cystic lumen, connective tissue stroma is also seen. (Haematoxylin and eosin stain original magnification 40 X).

DISCUSSION: A cystic swelling of hard palate may be the result of different kind of cysts: odontogenic, nonodontogenic or bone cysts. In our patient the cystic swelling was because of dentigerous cyst associated with a supernumerary tooth. Differential diagnosis of sharply marginated radiolucent lesions of the maxilla include radicular cyst, dentigerous cyst, keratocyst, fissural cyst, simple bone cyst, aneurismal bone cyst or even tumor such as ameloblastoma. The characteristic feature of the lesion involving an unerupted tooth crown in the anterior region of the maxilla along with the radiographical and histological examination confirmed the diagnosis of dentigerous cyst in the present case. The etiology of supernumerary teeth is unknown[2].One school of thought is of the view that they develop from a third tooth bud arising from dental lamina near the permanent tooth bud or probably from splitting of permanent bud itself. This view is supported by the fact that a supernumerary tooth usually closely resembles the teeth of group to which it belong. Incidence of supernumerary teeth in the primary dentition is 0.2-0.8%, with an unknown male: female ratio. The incidence of the condition in the permanent dentition is 1.5-3.5%, with a male: female ratio of 2:1 [3]. Some studies have reported that dentigerous cyst formation arising from supernumerary teeth account for 5.29-7% of cases [4, 5]. Sheng et al (2004) in a study of 166 supernumerary teeth reported cystic change in 35% cases (6).According to Asaumi et al dentigerous cyst formation arising from supernumerary teeth comprises 11% of the cases (7).Hurlen and Humerfelt suggested that dentigerous cysts associated with the supernumerary teeth occur in 7% of cases [8]. Supernumerary tooth may cause problems such as failure of eruption of tooth, displacement of a permanent tooth, crowding, and development of pathologies. Removal of the supernumerary tooth is recommended where central incisor eruption is delayed, altered or displacement of incisor is present, associated pathology is present [9]. Surgical removal of the cyst has been considered as the preferred choice of treatment. Marsupialisation has been recommended for dentigerous cysts in children
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to allow the eruption of unerupted tooth; and should be preferred for large cysts where enucleation and tooth removal might result in damage to nerve and blood vessels supplying adjacent teeth [10]. In present case surgical removal of the impacted supernumerary tooth and enucleation of associated cyst was performed. Histological evaluation has been recommended, owing to its potential to develop in to an ameloblastoma or mucoepidermoid carcinoma [11]. CONCLUSION: In summary when supernumerary tooth is evident, its effects on adjacent dentition and formation of dentigerous cyst should be carefully evaluated. Early diagnosis can prevent associated complications. REFERENCES: 1. Dinkar AD, Dawasaz AA, Shenoy S. Dentigerous cyst associated with multiple mesiodens: A case report. J Indian Soc Pedod Prev Dent 2007; 25; 56-59. 2. Grover SB, Singh P, Venkatachalam VP, Nekha N. Mesiodens presenting as a dentigerous cyst: case report. Ind J Radiol Imag 2005 15:1:69-72. 3. Primosch RE. Anterior supernumerary teeth: assessment and surgical intervention in children. Pediatric dentistry 1981; 3:204-215. 4. Hyun HK, lee SH, Kim JW. Clinical characteristics and complications associated with mesiodentes. J Oral Maxillofac Surg 2009; 67:2639-43. 5. Kessler HP, Kraut RA. Dentigerous cyst associated with an impacted mesiodens. Gen Dent 1989; 37: 47-49. 6. Wenjie sheng, Peicheng Xu, Yimin Sheng, Zheng Cha.Cystic change of embedded supernumerary teeth.Int Chin J Dent 2004: 4:78-79. 7. Asaumi JI, Shibata Y ,Yanagi Y,et al. Radiograghic examination of mesiodens and their associated complications. Dentomaxillofacial Radiol 2004; 33; 125-27.

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8. Hurlen B, Humerfelt D. Characteristics of premaxillary hyperdontia. A radiographic study. Acta Odontol Scand 1985; 43; 75-81. 9. Garvey MT, Barry HJ, Black M. Supernumerary teeth: an overview of classification, diagnosis and Management. Journal of Canadian Dental Association 1999; 65(11): 612-616. 10. Kojima Y, Seo R, Maki K, Kimura M. A case of dentigerous cyst in a thirteen- year old girl. Pediatric Oral Maxillofac Surg 2005; 15:26-32.

11. Hyomoto M, Kawakami M, Inove M, Kirita T. Clinical conditions for eruption of maxillary canines and mandibular premolars associated with dentigerous cysts. Am J Orthod Dentofacial Orthop 2003; 124: 515-520. 12. Manganaro AM, Cross SE, Startzell JM. Carcinoma arising in a dentigerous cyst with neck metastasis. Head Neck 1997:19:436.

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