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Dentigerous cysts (DCs) are one of the most common

lesions of the jaws.1,2 The typical radiographic appear-

ance is of a well-circumscribed, unilocular, usually

symmetric radiolucency around the crown of an

impacted tooth,1 but some are multilocular and have a

scalloping margin or discontinuity.3 Histologically, the

cyst is lined by nonkeratinized stratified squamous

epithelium and the connective tissue is usually flat, but

it often becomes highly irregular with inflammation.1

Odontogenic keratocysts (OKCs) are thought to arise

from the dental lamina or its remnants.4 The micro-

scopic findings of OKCs show a thin band-like lining

of stratified squamous epithelium; a spinous cell layer

about 5 to 8 cells in thickness and a corrugated kera-

tinized lining; and a thin, inflammation-free connective

tissue capsule.4 The radiographic features are solitary

unilocular or multilocular well-circumscribed radiolu-

cent lesions surrounded by a thin radiopaque border

with a smooth or loculated periphery.5 Most reports

have found that the recurrence rate of OKC is higher

than the recurrence rates of other odontogenic cysts.6,7

In so-called envelopmental keratocysts andfollicular

keratocysts,4 the radiographic images occasionally

resemble those of DCs. Biopsies are often undertaken

to distinguish between DCs and OKCs in cases of large

cysts. Determining whether DCs and OKCs have clin-

ical and radiologic features that could help radiologists

distinguish between them would be an aid in future

treatment. Thus, the purpose of this study is to deter-

mine the radiologic features of DCs and OKCs.

MATERIAL AND METHODSThe materials consisted of panoramic radiographs of

the DCs or OKCs provided by the Department of Oral

and Maxillofacial Surgery II, Okayama University

Dental Hospital, from 1990 to 1997. All cases were

diagnosed histologically, were associated with a

mandibular third molar, and had an adjacent second

molar that had erupted normally.The DC group consisted of 44 patients having a total

of 45 cysts of the unilocular type. The OKC group

consisted of 15 patients (2 cases were basal cell nevus

syndrome) having a total of 16 cysts, 13 unilocular and

3 multilocular.

The DCs and OKCs were evaluated by (1)

comparing age, sex, and clinical symptoms, (2) evalu-

ating panoramic radiographs, and (3) analyzing the

findings statistically.

A radiologic analysis of dentigerous cysts and odontogenic

keratocysts associated with a mandibular third molar

Goichi Tsukamoto, DDS, PhD,a Akira Sasaki, DDS, PhD,b Takehisa Akiyama, DDS,c

Tohru Ishikawa, DDS,d Koji Kishimoto, DDS, PhD,a Akiyoshi Nishiyama, DDS,a and

Tomohiro Matsumura, DDS, PhD,e

Okayama, JapanOKAYAMA UNIVERSITY

Objective. The purpose of this study was to discriminate radiographically between dentigerous cysts (DCs) and odontogenickeratocysts (OKCs) associated with a mandibular third molar.Study design. The material consisted of panoramic radiographs of dentigerous cysts (44 patients, 45 cysts) and odontogenickeratocysts (15 patients, 16 cysts), all of which were related to a mandibular third molar. The radiographic images were

analyzed with reference to the patients ages and symptoms.Results. The mean age of patients in the OKC group was less than that of patients in the DC group. The mean area of the cystsin the OKC group was larger than that of those in the DC group. The mean distance from the second to the third molar in theDC group was greater than that in the OKC group. Although there was a significant correlation between the area and distancein the DC and OKC groups, the patients ages did not significantly correlate to the area and distance of either cyst.Conclusions. The OKCs had a tendency toward rapid growth in the patients youth but short movement of a third molarcompared with the DCs. The DCs and OKCs do not appear to develop gradually from the period when follicles or dental

lamina were formed but arise at various periods randomly.(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:743-7)

aAssistant Professor, Department of Oral and Maxillofacial Surgery

II, Okayama University Dental School.bLecturer, Department of Oral and Maxillofacial Surgery II,

Okayama University Dental School.cJunior Resident, Department of Oral and Maxillofacial Surgery II,

Okayama University Dental School.dGraduate Student, Department of Oral and Maxillofacial Surgery II,

Okayama University Dental School.eProfessor and Chairman, Department of Oral and Maxillofacial

Surgery II, Okayama University Dental School.

Received for publication May 15, 2000; returned for revision Jul 6,

2000; accepted for publication Nov 14, 2000.

Copyright 2001 by Mosby, Inc.

1079-2104/2001/$35.00 + 0 7/16/114157

doi:10.1067/moe.2001.114157

743


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Age, sex, and clinical symptomsThe age at the patients first visit to our hospital, the

sex, and the presence of inflammatory symptoms (pain,

swelling, pus discharge, and so forth) were compared

between the DC and OKC groups.

Panoramic radiographic evaluationOur panoramic radiographic evaluation checked the

following:

1. The peripheral shape of each cyst. The shapes of

the cysts were divided into a smooth periphery

type and a scalloped periphery type (Fig 1).

2. The relationship of the cyst and the third molar.

The lesions were divided into symmetrical (contain-

ing all the area of the crown or tooth) and asym-

metrical positions around the third molar.3. The area of the cyst. Outlines of the cysts were

traced, and their areas were measured, with an NIH

image analyzer downloaded from the Web

(http://rsbweb.nih.gov/nih-image/).

4. The distance from the mandibular third molar to

the adjacent second molar. The distances between

the top of the medial contour of the third molars

crown and the top of the distal contour of the

second molars crown were measured.

Statistical analysisThe findings were analyzed with the help of the

Student ttest, Fisher exact probability, and Pearson cor-

relation coefficient. Probability values


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Of the 45 DCs, 38 (84%) had a smooth periphery and

7 (16%) had a scalloped periphery. The smooth/scal-

loped ratio was 5.4:1. In the 16 OKCs, there were 2

(18%) smooth and 14 (82%) scalloped. The ratio was

1:7.0. There was a significant difference in the ratio of

peripheral shapetype between the 2 cyst groups (P =

.0000005; Table I).

Thirty-three cases (73%) were of the symmetrically

positioned type, and 12 cases (27%) were of the asym-

metrically positioned type in the DC group. The ratiowas 2.8:1. Ten cases (63%) were symmetrical, and 6

cases (37%) were asymmetrical in the OKC group. The

ratio was 1.7:1. There was no significant difference in

the symmetrical/asymmetrical ratio between the DC

and the OKC group (P = .30; Table I).

The area of the DC group was 6.9 5.6 cm2; in the

OKC group, the area was 15.9 9.3 cm2. The area of

the OKC group was significantly larger than that of the

DC group (P = .00002; Fig 3). The distance from the

mandibular third molar in the cyst to the adjacent

second molar in the DC group was 21.0 4.9 mm; it

was 15.7 9.6 mm in the OKC group. The DC distance

was significantly greater than that of the OKC (P =

.006; Fig 4).

There was no significant correlation between the

patients ages and the area of the cysts/distances from

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Tsukamoto et al 745Volume 91, Number 6

Fig 2. Age and sex distribution in DC and OKC groups. DC:46.4 17.1 (mean SD); n = 44. OKC: 21.9 7.0; n = 15.

Black circles, male; open circles, female (P = .00001).

Fig 3. Area of cysts. DC: 6.9 5.6 cm2

(mean SD); n = 45.OKC: 15.9 9.3 cm2; n = 16 (P = .00002).

Fig 4. Distance from third molar in cyst to adjacent second

molar. DC: 21.0 4.9 mm (mean SD); n = 45. OKC: 15.7

9.6 mm; n = 16 (P = .006).

Table I. Case distribution of radiographic images

Smooth Scalloped

DC 38 (84%) 7 (16%)P < .0001

OKC 2 (18%) 14 (82%)

Symmetry Asymmetry

DC 33 (73%) 12 (27%)NS

OKC 10 (63%) 6 (37%)

NS, Not significant.

P: Fisher exact probability.


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the second to third molar in the 2 cyst groups (Table II).

Between the area of cysts and the distances from the

second to the third molars there was a significant corre-

lation found in both cyst groups (Table II).

In the mean area of the DC group, the smooth periph-

eral type was 5.8 3.3 cm2

and the scalloped periph-eral type was 13.3 10.4 cm2. The scalloped type was

significantly larger than the smooth type (P = .0007).

In the OKC group, the former was 9.5 0.0057 cm2

and the latter was 16.9 9.6 cm2. There was no signif-

icant difference between them (P = .31; Fig 5).

DISCUSSIONIn the present study, the mean age of patients in the

OKC group was approximately 20 years younger than

that of patients in the DC group. Kramer et al4 reported

that OKCs occurred with a peak frequency in the

second and third decades and a second peak frequency

in the fifth decade. Main8 reported that the mean age of

patients with DCs associated with the appearance of

mandibular third molars was approximately 46 years

old. There has been no report that has compared themean age between OKCs and DCs with respect to a

mandibular third molar. The percentages of men

affected were higher in both cyst groups, as Kramer et

al4 had reported.

DCs and OKCs are not inflammatory lesions, but the

present study showed that radiographs were taken more

frequently for inflammatory symptoms than for any

other reasons in both cyst groups. Therefore, it is

unlikely that these symptoms would affect some of the

findings with respect to both age and lesion size.

The mean area of the OKC group was about 2 times

larger than that of the DC group. With respect to the

differences in the patients ages and the areas of thecysts, an OKC appears to arise at a younger age and

grow more rapidly than a DC.

In the DC group, the scalloped periphery type had a

significantly larger area than the smooth one. As a cyst

enlarges, its smooth periphery may change to a scal-

loped one. As a result, this tendency will make it diffi-

cult to discriminate between DCs and OKCs as Scholl

et al9 reported.

The symmetrical/asymmetrical ratio in the present

study did not differ between DCs and OKCs. Main8

also classified his 30 cases of dentigerous cysts as 13

central cysts (symmetrical type) and 17 lateral cysts

(asymmetrical type).

The distance an impacted mandibular third molar has

moved as a result of the cyst has not been discussed in

other articles, but we felt it was important to define it

for the present study because the distance is 0 mm in

the case of a normally erupting third molar. There was

a significant correlation between the area and the

distance in both cyst groups, but the mean distance

from the second to the third molar was significantly

greater in the DC group than in the OKC group despite

the mean area of the latter group being twice as large

as that of the former group. These findings may

suggest that a third molar erupts into OKCs later or thatthe cyst develops to a large size rapidlybefore the

third molar is sufficiently moved by the pressure of the

cyst. With respect to these results, a cyst is more likely

to be an OKC rather than a DC if the patient is younger,

the cyst has a larger area, and the third molar is not far

from an adjacent second molar.

There were no significant correlations between the

ages and the areas in the DC and OKC groups. Main8

also reported no correlation between them in DCs asso-

746 Tsukamoto et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGYJune 2001

Fig 5. Relationship between area of cysts and peripheral

types. DC: smooth peripheral type, 5.8 3.3 cm2 (mean

SD); n = 38. Scalloped peripheral type, 13.3 10.4 cm2; n =

7 (P = .0007). OKC: smooth peripheral type, 9.5 0.0057

cm2, n = 2; scalloped peripheral type, 16.9 9.6 cm2, n = 14.

NS, Not significant (P = .31).Black circles, dentigerous cysts;

open circles, odontogenic keratocysts.

Table II. Correlation between age and area, age anddistance, and area and distance

Age-area Age-distance Area-distance

DC

r .066 .219 .306

P .67 .15 .040*

OKC

r .210 .186 .505

P .45 .48 .045*

*Significant correlation.


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ciated with mandibular third molars. These findings

suggest that both cysts do not develop gradually during

the period when follicles or dental lamina are formed,

but they arise at various periods randomly during the

course of a patients life.

REFERENCES

1. Shafer WG, Hine MK, Levy BM. A textbook of oral pathology.4th ed. Philadelphia: WB Saunders; 1983. p. 260-5.

2. Regezi JA, Sciubba J. Oral pathology: clinical-pathologic corre-lations. 2nd ed. Philadelphia: WB Saunders; 1993. p. 326-32.

3. Langlais RP, Langland OE, Nortje CJ, editors. Diagnosticimaging of the jaws. Malvern (PA): Williams & Wilkins; 1995.p. 286-93, 327-35.

4. Kramer IRH, Pindborg JJ, Shear M, editors. Histological typingof odontogenic tumors. 2nd ed. Berlin: Springer Verlag; 1992. p.35-6.

5. Steven BB. Odontogenic keratocysts: review of the literatureand report of a case. J Periodontol 1997;68:306-11.

6. Shear M. Developmental odontogenic cysts. An update. J OralPathol Med 1994;23:1-11.

7. Ahlfors E, Larsson A, Sjgren S. The odontogenic keratocyst: Abenign cystic tumor? J Oral Maxillofac Surg 1984;42:10-9.

8. Main DMG. Follicular cysts of mandibular third molar teeth:radiological evaluation of enlargement. Dentomaxillofac Radiol

1989;18:156-9.9. Scholl RJ, Kellett HM, Neumann DP, Lurie AG. Cysts and cystic

lesions of the mandible: clinical and radiologic-histopathologicreview. Radiographics 1999;19:1107-24.

Reprint requests:

Goichi Tsukamoto, DDS, PhDDepartment of Oral and Maxillofacial Surgery IIOkayama University Dental School2-5-1 Shikata-cho, Okayama [email protected]

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Tsukamoto et al 747Volume 91, Number 6

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