Dentigerous Cysts in Four Quadrants: A Rare and First Reported Case
A 24-year-old male reported to the Department of Oral and Maxillofacial surgery in Mayya Multispecialty Hospital, Bangalore, India, complaining of asymptomatic facial swelling of 1 year. An intraoral clinical examination revealed a non-tender bilaterally palpable swelling. The swelling extended from the first premolar to third molar region on the right, and from the first premolar region to the retromolar trigone on the left [Figures and ]. The swelling obliterated the buccal vestibule bilaterally and there was associated mobility of the first and second molars on both sides of mandible. The overlying mucosa appeared normal in color, non-tender, hard in consistency, and smooth on palpation. The third molars were unerupted in all the four quadrants. There was no history of paresthesia in lower lip region. All the sensations were found to be normal in lower lip area on clinical evaluation. Vitality was found to be present in first and second molars, premolars, and anterior teeth after thermal stimulation test using hot gutta percha application on teeth.\nA radiographic investigation by CT scan revealed a unilocular well-defined corticated hypodense lesion involving impacted mandibular third molars bilaterally []. The dimensions of the hypodensities were 31 and 42 mm anteroposteriorly on the right and left, respectively. There were also associated supernumerary teeth on both sides. The supernumerary teeth were small in size than third molars with single conical root and were placed coronally in close relation to third molars on both sides. The hypodensities were associated with radicular resorption of the first and second molars. Radiographs also revealed the inferior displacement of the mandibular canal. Incidentally another bilateral hypodense lesion associated with the crowns of maxillary third molars was observed. CT-Scan revealed a well-defined and corticated margin was observed surrounding the unilocular hypodensity. In maxilla, CT-scan revealed the dimensions of hypodensities around the crowns of third molars to be 15 and 18 mm in diameter on the right and left side, respectively [Figures and ]. There was no root resorption of adjacent teeth observed in maxilla. In all four quadrants the hypodense lesions were attached to the cementoenamel junction of the third molars at an acute angle which is one of the classical radiographic finding in cases of dentigerous cyst. Coronal sections and three-dimensional CT revealed bilateral lingual and buccal cortical perforations in mandible []. On aspiration a straw-colored fluid was obtained from each of these cystic lesions which is diagnostic of a dentigerous cyst [].\nAfter clinical and radiological examination a provisional diagnosis of dentigerous cyst was made. Multiple incisional biopsies were taken and histopathological examination revealed a cystic lumen lined by two to three-layer thick non-keratinized stratified squamous epithelium that resembled reduced enamel epithelium. The connective tissue wall was composed of a fibrous capsule which confirmed the diagnosis of dentigerous cyst [Figures and ].\nUnder general anesthesia the cystic lesions in all four quadrants were enucleated along with impacted third molars and supernumerary teeth. Also in both quadrants of mandible extraction of the first and second molars were carried out as they were mobile. The resultant cavities [] in the mandible after enucleation were packed with bismuth, iodoform, paraffin paste, and healing was by secondary intention []. Follow-up dressing was done after 24 hours postoperatively for the first 2 weeks and then follow-up of intraoral wound irrigation and dressing was carried out once a week for next 2 months for healing of the bony defects in mandible intraorally. Postoperative follow-up orthopantomographs (OPGs) were taken at regular monthly intervals. Six months postoperatively the dimensions of the cystic cavity were reduced both clinically and radiographically [Figures and ]. The patient is still under routine follow-up and will be closely monitored for long-term outcome.