|Year : 2012 | Volume
| Issue : 4 | Page : 264-267
Dentigerous cyst with an ectopically erupted supernumerary tooth in maxillary sinus
Ramesh Srinivasan1, Usha Giridhar Varadarajan2
1 Department of Oral and Maxillofacial Surgery, ESI Hospital, Coimbatore, India
2 Department of Oral and Maxillofacial Surgery, Best Dental Science College, Madurai, Tamil Nadu, India
|Date of Web Publication||12-Jul-2013|
Usha Giridhar Varadarajan
C-72/44 Santhanam Road, TVS Nagar, Madurai - 625 003
An ectopically erupted tooth in the maxillary sinus presents itself as a confounding problem, which may lead tomaxillary sinusitis. A case of a cyst associated with an ectopic supernumerary tooth in the left maxillary sinus cavity is presented, which is of interest as it has been very rarely documented. Investigations like computed tomography and orthopantamograph were carried out to confirm the extent of the lesion, and the management of the cyst was done by a high vestibular approach. The tooth was removed, cyst was enucleated, wound was closed, Specimen was sent for histopathological examination, and biopsy report confirmed the same. A detailed discussion has been done in relation to the case presented.
Keywords: Antral wash, dentigerous cyst, ectopic, enucleation, maxillary sinus, odontogenic cyst, orthopantomogram, supernumerary tooth
|How to cite this article:|
Srinivasan R, Varadarajan UG. Dentigerous cyst with an ectopically erupted supernumerary tooth in maxillary sinus. SRM J Res Dent Sci 2012;3:264-7
|How to cite this URL:|
Srinivasan R, Varadarajan UG. Dentigerous cyst with an ectopically erupted supernumerary tooth in maxillary sinus. SRM J Res Dent Sci [serial online] 2012 [cited 2020 May 28];3:264-7. Available from: http://www.srmjrds.in/text.asp?2012/3/4/264/114974
| Introduction|| |
Dentigerous cysts (DC) are the most frequent type of developmental odontogenic cysts derived from the epithelial remnants of the tooth-forming organ. DC is the second most common cyst, with periapical cyst being found more commonly. DC is defined as a cyst that originates by separation of follicle from around the crown of an unerupted tooth or impacted tooth, caused by accumulation of fluid between the reduced enamel epithelium and the enamel surface resulting in a cyst, in which the crown is located within the lumen. It may also be associated with crown of impacted, embedded, or unerupted teeth, supernumerary or an ectopically erupted tooth. DC may be found enclosing complex compound odontoma or a supernumerary tooth, found mostly in the second and third decades with slight male predilection. Most common sites of this cyst are the mandibular and maxillary third molar and maxillary canine areas. Most of the DCs are solitary and bilateral, and multiple cysts may be found with number of syndromes including cleidocranial dysplasia and Maroteaux-Lamy syndrome. These cysts can potentially expand and cause facial asymmetry, extreme displacement of teeth, and severe root resorption of adjacent teeth. Clinically, cyst presents as a slowly enlarging, bony hard swelling of the jaw with expansion of the cortical plates of bone. Massive facial swelling, derangement of occlusion, and development of facial asymmetry might be seen in extremely large lesion. Expansion and severe thinning of the bone may produce fluctuations in the area. On aspiration, straw colored fluid may be found. Radiographically, DC reveals a well-defined, unilocular rounded radiolucent area enclosing the crown of an impacted tooth and often resorption of roots of adjacent teeth. Histological findings are the presence of a cystic cavity lined by thin, non-keratinized epithelium of 2-3 cell layer thickness. Diagnosis of a DC can be made by careful clinical, radiological, and histological investigations. 
According to Thoma, DCs could be classified into three types: Central variety, in which crown enveloped symmetrically; lateral type, which is commonly seen when impacted mandibular molars are partially erupted and its superior aspect being exposed; and, circumferential type, where tooth appears to be enveloped by the cyst and the tooth has to erupt through the cyst. Mourshed classified DC as Class I DC associated with completely unerupted teeth. Class II: Associated with partially erupted teeth.  A large DC can cause displacement of adjacent teeth. 
DC occurs more commonly in men, in white population, and within an age group between third and fourth decades with prevalence of mandibular cyst twice more common than maxillary cyst. It is often painless, unless infected, and mostly silent, until they have enlarged sufficiently to produce expansion of the jaw. 
Rarely a tooth or root may be present in the sinus cavity associated with DC around. The cyst can lead to maxillary sinusitis. An extensive DC may surround the tooth or antro-oral fistula may develop. ,,
However, it can be large and cause symptoms related to expansion and impingement on contiguous structures. Pain and swelling may be the major complaints of patients. It can originate from any tooth including supernumerary tooth. Patients with DCs over maxillary sinus might present nasal symptoms such as sinusitis. In addition, ophthalmological symptoms might be present such as proptosis, diplopia, ptosis, epiphora, but visual acuity is rarely affected. 
A case of an upper third molar tooth located in the maxillary sinus just below the orbit with the entire sinus presumed to be occupied by an infected DC has been reported. Further follow-up for a period of 1 year showed no evidence of sinus infection or cyst recurrence. 
| Case Report|| |
A 50-year-old female patient presented with a complaint of epistaxis from left nostril for the past 3 months. The patient was referred by an ear, nose, and throat (ENT) surgeon suspecting a dental cause. The patient was advised orthopantomogram (OPG) and computed tomography (CT). The coronal section of CT scan showed a well-defined oval shaped radio opacity in left maxillary antrum, occupying more than 2/3 rd of the antrum, enclosing a supernumerary tooth, above the roots of left upper premolar and molar teeth. On clinical examination, all permanent teeth were present and there were no intra oral abnormalities. Direct nasal examination was done with endoscope by an ENT surgeon and there was a bulge near lateral nasal wall near the inferior meatus. The OPG and scan were checked [Figure 1] and [Figure 2].
Routine blood investigations were done. Under general anesthesia [Figure 3], high vestibular incision was placed from canine to 2 nd molar tooth in left maxillary region, mucoperiosteum raised, a bony window was created and the cyst wall visualized, enucleation of the contents done and cyst wall and the supernumerary tooth was removed. Antral wash was also given. Hemostasis was achieved and the wound was closed in layers with 3-0 vicryl. Histopathology of the specimen revealed a DC with no evidence of malignancy.
| Discussion|| |
Tooth development results from an interaction between oral epithelium and underlying mesenchymal tissue. This process begins in 6 th week in utero with the formation of maxillary and mandibular dental lamina in the region of future alveolar process. This ectodermal derivative undergoes proliferation to form the dentition, each mature tooth consisting of a crown and a root. Abnormal tissue interactions during development may potentially result in ectopic tooth development and/or eruption. Ectopic eruption of a tooth into a region other than the oral cavity is rare, although there have been reports of tooth in nasal septum, mandibular condyle, coronoid process, and palate. Occasionally, the tooth may erupt into maxillary antrum and present with local sinonasal symptoms attributed to chronic sinusitis. Etiologies of ectopic teeth in maxillary sinus include trauma/iatrogenic activity, pathological process, developmental anomalies, and idiopathic etiology. ,
Ectopic teeth in paranasal sinuses can present with a variety of clinical manifestations. Literature review showed that patients with such teeth may present with recurrent or chronic sinusitis, sepsis, nasolacrimal duct obstruction, ostiomeatal complex obstruction, headaches, and facial numbness. The diagnosis of this condition can be done radiographically with OPG, sinus X-ray, and CT scans taken in axial and coronal sections. ,
DC is the second most common odontogenic cyst, with periapical cyst being the most common cyst. DCs present mostly in the second or third decade of life in the mandibular or maxillary third molar or maxillary canine regions. It can originate from any tooth, including the supernumerary tooth. The DCs are mostly asymptomatic and may be found on routine dental radiographic check-up. They may also cause symptoms like pain or swelling with enlargement of the cyst size. The direct complication associated with a DC includes pathologic fracture of the jaw caused by the huge size of DC. The outgrowth of the cyst may also cause the resorption of adjacent tooth roots.
The differential diagnoses of DC includes envelopmental type odontogenic keratocyst (OKC), adenomatoid odontogenic tumor (AOT), calcifying epithelial odontogenic cyst (COC), calcifying epithelial odontogenic tumor (CEOT), and unicystic ameloblastoma (UAs). 
In addition to the histopathological differences between OKC and DC, other differences can also include the development and the recurrence tendency of these cysts. About 40% of OKC contain impacted tooth. The OKC is more aggressive with higher recurrence risk than DC and may be associated with nevoid basal cell carcinoma syndrome.
BMP-4 may be a useful biochemical marker to differentiate OKC and DC. BMP-4 is expressed more intensely in OKC as compared with DC, and is more intensely expressed in the recurred cases. The AOT and COC generally are more frequently seen in maxillary anterior area with some degree of calcification within the cyst cavity, which may be observed radiography. Histopathologically, the COC presents with keratinized epithelial cell so-called ghost cells in the cavity. The AOT is different from the DC, in which epithelial cells are syncytially arranged in rosettes or in a duct-like pattern. The CEOT may be differentiated from DC by its honeycomb-pattern radiolucency with foci of radiopacity in radiographs. Microscopically, it shows large polygonal epithelial cells with variation in size and shape with amyloid materials, which contained concentric calcified deposits (Liesegang rings). Although the unicystic ameloblastoma is rare, its clinical expression and microscopic feature can be deceptive and may be confused with DC. The UA is more locally aggressive than DC. The best treatment of the UAs is radical though enucleation is sufficient.
The potential complications of DC cyst include transformation into ameloblastoma or squamous cell carcinoma, but they are rare. In cases where mucous cells are present in the epithelium, the intraosseous mucoepidermoid carcinoma may develop. Enucleation of the cyst contents with extraction of the associated tooth is sufficient for DC. For extremely large lesions or in cases when the involved tooth is desired to keep in the arch, marsupialization may be done. With decompression, the involved tooth may erupt spontaneously and may be brought orthodontically into occlusion. When other odontogenic tumors are highly suspected, radical removal of the lesions or removal of the cyst with surrounding bony structures is suggested. 
| Summary|| |
Ectopic eruption of a tooth into the dental environment is common, whereas ectopic eruption in non-dental environment is not so common. One such site for ectopic eruption of a tooth in a non-dental location is maxillary sinus. The patients may present with swelling, pain, facial asymmetry, epistaxis, or symptoms of maxillary sinusitis. In a case of suspected cyst with supernumerary tooth or ectopically erupted in sinus, a panoramic radiograph is sufficient for evaluation, although CT may be useful for evaluating the extent of bony involvement. The treatment of an ectopically erupted tooth with cyst in the maxillary sinus is usually removal to avoid future complications. Close observation and follow-up with periodic radiograph is required.
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[Figure 1], [Figure 2], [Figure 3]