CHAPTER I

INTRODUCTION
1.1. Background
Dentigerous cysts are the most common benign odontogenic cysts of
developmental type that are usually single in occurrence. (Naclrio et al., 2003)
he dentigerous cyst initially is al!ays associated !ith the cro!n of an impacted,
embedded, or unerupted tooth. "t develops around the cro!n of the unerupted
tooth by the e#pansion of the follicle !hen fluid collects or space occurs bet!een
the reduced enamel epithelium and the enamel of an impacted tooth. Dentigerous
cysts occur predominantly in the third molar region of the mandible, follo!ed in
fre$uency by ma#illary canine, ma#illary third molar, and rarely in relation to
ma#illary central incisor. (%ramod, 20&&) Dentigerous cyst develops by
accumulation of fluid bet!een reduced enamel epithelium and enamel or !ithin
the enamel organ. %ressure e#erted by an erupted tooth on an impacted follicle
obstructs the venous outflo!. his leads to rapid transudation of serum across the
capillary !alls. "ncrease in the hidrostatitc pressure of the pooling fluid occurs,
leading to separation of follicle from the cro!n !ith or !ithout reduced enamel
epithelium. 'n intrafollicular spread of periapical inflammation from a deciduous
tooth may also result in the development of dentigerous cyst. (Devi et al, 20&0)
he dentigerous cyst is a congenital anomaly !hich appears at early stages of
organogenesis. he cystic structure is generally developed together !ith
heterotopic polydontia. ((apf ) Nuss, 200*+ ,ro!n et al., 200-)
1.2 Issue
' .* year old female patient came to the dental clinic complaining of s!elling
in the left upper /a! that has been going on for 2 years. he s!elling slo!ly
enlarges and lately the teeth in that region !as prominent and dislocating. "n
addition, she also gets pain. 0he has been given antibiotics and anti1inflammatory
but it didn2t !or3 and the s!elling has never become smaller.
&
1.3 Proble !"a"een"s
&.3.& 4o! is the histopathology, pathology, imunopathology and
pathobiology of non1infectious oral disease5
&.3.2 4o! is the clinical features of dentigerous cyst5
&.3.3 4o! is the roentgenology of dentigerous cyst5
&.3.. 4o! is the histopathology of dentigerous cyst5
&.3.* 4o! is the pathogenesis of dentigerous cyst5
1.#. Pur$ose
'fter completing this modul, the fourth semester students at dentistry of
'irlangga 6niversity are able to e#plain the histopathology, pathology, pathology,
imunopatologi, clinical features, roentgenology, and the epidemiology of non1
infectious oral disease.
1.%. Bene&'"s
&.*.& 0tudents can e#plain about histopathology, pathology, imunopathology
and pathobiology of non1infectious oral disease
&.*.2 0tudents get understand about the clinical features of dentigerous cyst
&.*.3 0tudents learn the radiography appearance of dentigerous cyst
&.*.. 0tudents 3no! the histopathology of dentigerous cyst
&.*.* 0tudents get understand about the pathogenesis of dentigerous cyst
CHAPTER II
2
(ITERATURE RE)IE*
2.1. Non+In&ec"'ous Oral D'sease
2.1.1 Descr'$"'on o& Non+In&ec"'ous Oral D'sease
Non1infectious diseases are diseases that are not caused by pathogens
and are not transmitted from one person to another. 0ome of non1infectious
diseases are cancer, asthma and heart diseases. Non1infectious diseases are
caused by the environment, genetic disorder, nutritional deficiencies or
lifestyles. (7iloro, 200.)
8ommonly 3no!n as non1communicable diseases, abbreviated as
N8Ds, non1infectious diseases are those that are caused by factors such as
genetics, environment, and lifestyle, and not by disease1causing organisms.
Non1infectious diseases do not pass on from one person to another.
(8ardesa, 2009)
2.1.2 Odon"ogen'c C,s"
8ysts of the /a! are classified into several categories depending on
histogenesis and aetiology. hose that arise from odontogenic epithelium are
called odontogenic, those that have their source in other epiyhelial structures
are 3no!n as non1odontogenic. 'mong the odontogenic cysts,
developmental and inflammatory types can be distinguished. ,y definition,
cysts are linedd by epithelium. here are, ho!ever also cavities in the /a!
lac3ing such as epithelium. here are also discussed under this heading.
(8ardesa, 2009)
8ysts of the /a! can be classified as:
a. ;dontogenic (arising from tooth1forming tissues)
b. Non1odontogenic (developmental or fissural)
he odontogenic cyst are derived from epithelium associated !ith the
developent of dental apparatus. he type of epithelium can vary !ith most
lesions having stratified s$uamous but some developmental or fissural cysts
in the ma#illa may have respiratory epithelium. (0araf, 2009)
3
0everal types of odontogenic cysts may occur, dependent chiefly upon
the stage of odontogenesis during !hich they originate. <arious
investigators have attept to devise classification and system of nomenclature
of the lesions. 0ome of these classifications have not been entirely
satisfactory because they generally failed to recogni=e the mode of origin
and development of the cysts and did not unite the vie!s of the oral surgeon,
the radiologist and the pathologist. (0hafer, 200>)
2.2. Den"'gerous C,s"
2.2.1. Descr'$"'on o& Den"'gerous C,s"
Dentigerous cyst is lined by cells that derived from enamel epithelium
and contains cro!n of an unerupted tooth. (0araf, 2009) 7ost commonly
mandibular third molars. ;ther common associated are !ith ma#illary third
molars, ma#illary canines, and mandibular second premolars. (7iloro, 200.)
he cyst, !hich encloses the cro!n of an unerupted tooth, is attached to its
nec3 or at amelodentinal /unction. he dentigerous cyst besides associated
!ith cro!n of unerupted impacted teeth can also occur in association !ith
supernumerary teeth, odontomas and rarely deciduous teeth. hese form the
second most common cyst after radicular cyst of odontogenic origin (0araf,
2009)
Dentigerous cyst are usually seen as single lesions !hile bilateral and
multiple cyst, that are rarely seem, are associated !ith syndromes. he
bilateral dentigerous cyst have also been reportred to occur after prolonged
use of cyclosporine and calcium channel bloc3er. 'll these rare bilateral or
multiple dentigerous cyst have been mostly reported to occur in mandible.
?are case report of bilateral ma#illary cyst associated !ith cuspids has been
reported in a non syndromic patient. (0araf, 2009)
.
@ig 2.2. ?emnants of teeth !ith calcification (8) (bluish1purple), loose connective tissue
(8) and capillaries (arro!s), fibrous capsule (@8) and muscle bundles (7) (outer
side). 7alformed tooth germ (stars), calcification (8), capillaries (arro!s) and
connective tissue (8), A&00, 4BC. ('lcigir ) <ural, 20&2)
0ometimes, macroscopic e#amination of the cystic lining, may e#hibit
mural thic3enings !hich on histological e#amination may e#hibit
ameloblastic changes. he cystic lining is of reduced enamel ephitelium,
consist of 2 to * cell layers of flat or cuboidal cells and is attached to the
tooth at the cementoenamel /unction. he ephitelial lining is not 3eratini=ed,
rarely a dentigerous cyst may form 3eratin by metaplasia. %resence of
sebaceous glands, mucus of ciliated cells in the ephitelial lining, is also
considered to form as a result of metaplasia. (?a/esh et al., 20&.)
@ig 2.3. 7icrophotographs sho!ing (a) !all of dentigerous cyst lined by stratified
s$uamous epithelium (sho!n by arro! 4 and C, A&00), (b) other area of cyst
having features of inflammation including numerous proliferating blood vessels
and mi#ed inflammatory cells. (Dumar et al., 20&2)
;dontogenic cysts contain cholesterol crystals. hese crystals are
seen in dentigerous cyst, odontogenic3eratocyst and radicular cyst. he
presence of cholesterol crystals in radicular cyst fluid has in the past been
recogni=ed as a characteristic feature, although this is no longer accepted as
a pathognomonic feature. (hen such cyst fluid is e#amined macroscopically
!ith transmitted light, cholesterol crystals sho!s a shimmering appearance
*
to the gold or stra! colored fluid. "f an unstained smear of cystic fluid is
e#amined using a light microscope, cholesterol crystals are seen to have a
typical rhomboid shape. "n paraffin sections processed for routine
hemato#ylin and eosin staining, these crystals are dissolved by fat solvents
used in dehydration and infiltration, leaving needleshaped clefts 3no!n as
Echolesterol cleftsF !ithin the cyst !alls and cavities. Notably, once
cholesterol crystals have been deposited in the cyst !all, they behave as
foreign bodies and e#press a foreign body giant cell reaction. 8holesterol
clefts in histological sections are seen surrounded by multinucleated foreign
body type giant cells. "t is important to note that cholesterol crystals are
fre$uently seen in atherosclerotic pla$ues and this may have implications
for the origin of such crystals in odontogenic lesions. (?a/esh et al., 20&.)
he cyst contents consist of clear yello!ish fluid, in !hich cholesterol
crystals may be present, or purulent material, if infection has occurred.
4yaline bodies also may be seen !ithin the epithelium, and clefts from
cholesterol crystals may be found in the connective tissue capsule. Cphitelial
discontinuities may be present because of intense inflammatory infiltrate in
the ad/acent capsule or because of partia adherence to enamel. (7ali3, 200G)
he stroma is usually uninflammed, although inflammation is seen !hen
cyst becomes infected. "nflamed dentigerous cyst !alls occasionally contain
cholesterol clefts and haemosiderin pigments. (Hee et al., 20&0)
@ig 2... %hotomicrographs sho!ing histopathological features of the cholesterol
granuloma+ large number of !hite spindle1shaped clefts representing cholesterol
9
clefts, !ith lymphocytes(arro!s) infiltration. No epithelial cells are seen.
(4emato#ylin and eosin stain, I&00). (Hee et al., 20&0)
he anterior part, ho!ever, !as completely occupied by cholesterol
granulomatous tissue !ith heavy lymphocyte infiltration bet!een the
cholesterol clefts !ithin a fibrous connective tissue stroma. No presence of
epithelial cells !as evident. he presence of hemosiderin in the anterior part
may be an evidence of previous hemorrhage. he final diagnosis of the
resected lesion !as a dentigerous cyst !ith cholesterol granuloma occupying
its anterior part. (Hee et al., 20&0)
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