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Differential Diagnosis

of
Pericoronal
Radiolucencies

Pratima kolekar

Format
Introduction
Classification
Differential Diagnosis
Radiographic Techniques
Conclusion

Specific Learning Objective


To know the classification of pericoronal
radiolucencies.
To know the differences between each of
the pericoronal radiolucencies.
Advice of relevant radiographs to achieve a
diagnosis.

Introduction

Pericoronal radiolucencies comprise those


lesions which cause radiolucency in the
coronal region of the tooth or teeth.

The teeth are usually not erupted or may be


clinically as covered by the cystic fluid
under the overlying mucosa.

Classification
1.
2.
3.
4.
5.

Dentigerous cyst
Odontogenic keratocyst
Paradental cyst
Eruption Cyst
AOT

DENTIGEROUS CYST:
(Synonym - Follicular cyst)

Definition:
It can be defined as an odontogenic cyst that
surrounds the crown of an impacted tooth.
It is estimated that about 10% of impacted teeth have formed a
dentigerous cyst.
Pathogenesis:
It is uncertain but apparently it develops by accumulation of
fluid between the reduced enamel epithelium and enamel
surface resulting in a cyst in which crown is located within the
lumen.

Clinical features:
10- 50yrs (Peak 2nd decade)
Male predilection.
Commonly involve:
Mandibular molars, Maxillary Canines, Maxillary Molars,
Supernumerary teeth.

The cyst is always associated with crown of an


impacted, embedded or unerupted tooth.
Most of them are Solitary. Bilateral or multiple
are in association
with
Cleidocranial
dysplasia and Maroteaux-lamy syndrome.

Expansion of bone with subsequent facial


asymmetry

Displacement of teeth, Root resorption of


adjacent teeth and
pain are subsequent sequelae (steps) of
continuous enlargement.

Displacement of third molar such that it comes


to lie compressed against the inferior border of
the mandible.

In case of a cyst associated with a maxillary


cuspid, expansion of anterior maxilla often
occurs and resemble acute sinusitis or
cellulitis.

Cuspid into the maxillary antrum

A dentigerous cyst that is expanding distally


from the involved third molar

RADIOGRAPHIC FEATURES:
Location:

Epicenter above the crown of the


involved tooth

Attached

at

Cemento

enamel

junction

Well corticated Margins

Little

tendency

towards

scalloping

Unicystic, some are multilocular

Periphery and shape

Dentigerous cysts typically have


well-defined cortex with a curved

or circular outline.
If infection is present, the cortex
may be missing.

Internal structure

The

internal

aspect

is

completely radiolucent except


for the crown of the involved
tooth.

The circumferential

dentigerous

cyst appears to erupt through the


cyst as through the hole in a
doughnut

The

lateral

dentigerous

cyst

occurs on one side of the involved


tooth.

Differential diagnosis:
Ameloblastoma

o soap bubble appearance


o Causes root resorption.

Calcifying Odontogenic Cyst

o Common in maxilla, cortical plate perforation

Adenomatoid odontontogenic tumor

o Anterior maxillary teeth, root divergence


o Cystic lining does not arise from CEJ

Odontogenic Keratocyst

o Mandibular ramus third molar region.


o Delayed Expansion so diagnosed very late.

Potential complications:
o Epidermoid carcinoma

Mucoepidermoid carcinoma

Mural Ameloblastoma

Management:
-Small lesions can be surgically removed.
-Large cysts are often treated by surgical drainage or
marsupialization.

ODONTOGENIC KERATOCYST:
Definition:

A cyst derived from the remnants


of the dental lamina, with a
biologic behavior similar to a
benign neoplasm, with a distinctive
lining of 6-10 cells in thickness &
exhibits a basal cell layer of
palisaded cells & a surface of
corrugated parakeratin.

It is named keratocyst because


cyst epithelium produces so
much keratin that it fills the cystic
lumen.

Keratocystic odontogenic Tumor


Oral Oncology (2007) 43, 619
620

Pathogenesis:
Epithelium

lining the OKC has innate growth potential, as in

a benign tumor. This difference in the mechanism of growth


gives OKCs a different radiographic appearance.
Islands

of epithelium in the connective tissue may give rise

to satellite microcysts.

CLINICAL FEATURES:
-They

occur in a wide age range, but most

develop during the second and third decades,


-Slight male predilection.
-Common site :
Mandibular ramus third molar region

-Asymptomatic, although mild swelling may


occur.
-No obvious swelling seen in these cases.
-Rarely paresthesia is noted.

-Pain may occur with


secondary infection.
-Aspiration may reveal
a thick, yellow, cheesy
material (keratin)
-High

propensity

recurrence.

for

RADIOGRAPHIC FEATURES:
Location
-Posterior

body of the mandible (90%

occur posterior to the canines) and


ramus (more than 50%).
-The epicenter is located superior to
the inferior alveolar nerve canal.

Periphery and shape:


-Well

corticated border unless they

have become secondarily infected.


-Smooth round or oval shape identical
to that of other cysts, or it may have
a scalloped outline.
Internal structure:
-Radiolucent.
-Some cases curved internal septa multilocular appearance.

Effects on surrounding structures


-Propensity to grow along the internal aspect
of the jaws, causing minimal expansion.
-This occurs throughout the mandible except
for the upper ramus and coronoid process,
where considerable expansion may occur.

-OKCs can displace and resorb teeth but to a


slightly lesser degree than dentigerous cysts.

-The inferior alveolar nerve canal may be


displaced, inferiorly.

-In the maxilla this cyst can invaginate and


occupy the entire maxillary antrum.

Management:
Surgical excision is the
treatment of choice.
Marsupialization
Enucleation and primary
closure
Enucleation and packing
open

Differential diagnosis:

Dentigerous cyst

Ameloblastoma

Residual cyst

Traumatic bone cyst

More scalloped and very thin


borders, covers more than one
tooth.
Is anterior in location.

Paradental Cyst

Associated with partially impacted


3rd molars
Result of inflammation of the
gingiva over an erupting molar
0.5 to 4% of cysts.
Clinical Features
The involved region shows a
slightly erupting third molar,
where a part of cusp can be seen.
Probe can usually pass through
the distal extent of the third molar
into the cystic lumen.
Cystic lumen is not totally covered
as in other cysts.

Paradental Cyst

Radiology

radiolucency seen in
the distal aspect of the
tooth with a well
defined cystic lining.
Cyst usually covers a
part of the crown
portion
and
not
Differential Diagnosis
necessarily starts from
1. Dentigerous Cyst
the CEJ.
2. Residual Cyst especially
after extraction of third
molar.
Treatment
3. Radicular cyst
Enucleation
4. Lateral Periodontal Cyst

ERUPTION CYST
It is a form of dentigerous cyst associated
with erupting deciduous /permanent teeth
in children.
Clinical features:

These cysts are found in children of


different ages and occasionally in adults if
there is delayed eruption.
Deciduous and permanent teeth are
involved frequently anterior to permanent
first molar.
It appears as a circumscribed fluctuant
often translucent swelling of the alveolar
ridge over the site of eruption of the teeth.
When the cystic cavity contains blood the
swelling appears purple or deep blue hence
it is called Eruption
hematoma.

Radiographic features:

It may show soft tissue shadow and usually there is no bone involvement.

In some cases saucer shape excavation of bone projecting into cavity.

Treatment:
No treatment is necessary as the cyst often ruptures spontaneously. Surgically,
exposing the crown of tooth may aid the eruption process.

Thank You

Quiz on 22/09/2014

TopicsPeriapical
Radiolucencies
Pericoronal
Radiolucencies

10 MCQs