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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2009  |  Volume : 27  |  Issue : 1  |  Page : 52-57
 

Save-a-tooth: Conservative surgical management of dentigerous cyst


Department of Pediatric and Preventive Dentistry, PMNM Dental College and Hospital, Bagalkot, India

Correspondence Address:
P Shivaprakash
Department of Pediatric and Preventive Dentistry, PMNM Dental College and Hospital, Bagalkot, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.50820

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   Abstract 

Dentigerous cysts are the most common bony lesions of the jaws in children. It is one of the most prevalent types of odontogenic cysts associated with an erupted or developing tooth, particularly the mandibular third molars; the other teeth that are commonly affected are, in order of frequency, the maxillary canines, the maxillary third molars, and rarely the central incisors. Radiographically, the cyst appears as ovoid well-demarcated unilocular radiolucency with a sclerotic border. Careful evaluation of the history and the clinical and radiographical findings help clinicians to currently diagnose the condition, identify the etiological factors, and administer the appropriate treatment.


Keywords: Dentigerous cyst, enucleation, marsupilization, unerupted


How to cite this article:
Shivaprakash P, Rizwanulla T, Baweja D K, Noorani H H. Save-a-tooth: Conservative surgical management of dentigerous cyst. J Indian Soc Pedod Prev Dent 2009;27:52-7

How to cite this URL:
Shivaprakash P, Rizwanulla T, Baweja D K, Noorani H H. Save-a-tooth: Conservative surgical management of dentigerous cyst. J Indian Soc Pedod Prev Dent [serial online] 2009 [cited 2019 Jul 23];27:52-7. Available from: http://www.jisppd.com/text.asp?2009/27/1/52/50820



   Introduction Top


Dentigerous simply means containing teeth. [6] It is the second most common of the developmental odontogenic cysts of the jaw and accounts for approximately 20-24% of all epithelium-lined jaw cysts. [2],[7] It develops around the crown of an unerupted tooth by expansion of follicle when fluid collects or a space occurs between the reduced enamel epithelium and the enamel of an impacted tooth. [7] The teeth most often involved are mandibular third molars, maxillary canines, and mandibular premolars. The expansion of dentigerous cyst is related to a secondary increase in cyst fluid osmolality as a result of passage of inflammatory cells and desquamated epithelial cells into the cyst lumen. In rare cases, the dentigerous cyst develops as a result of the intrafollicular spread of periapical inflammation from an overlying primary tooth. [1]

The following case reports describe the conservative surgical treatment approaches for the management of dentigerous cyst.


   Case Reports Top


Case 1

A 10.7-year-old girl reported to the Department of Pediatric and Preventive Dentistry, PMNM Dental College and Hospital, with a chief complaint of decayed tooth in the lower right and left back regions of the mouth since one year. On general examination, the patient was apparently healthy. There was no significant past medical history. Intraoral examination revealed bilateral expansion of the alveolus around the primary second molars (tooth no. 75 and 85). The bilateral swellings were well defined, firm in consistency, painless on palpation, measured about 2 x 2 cm, and there was no bruit on pulsation [Figure 1A] and [Figure 1B]. The tooth no. 75 was grossly decayed and nonvital, only root pieces were evident clinically with relation to tooth no. 85.

Radiographic examination of the left lower back region showed a large, circular, well-defined, and a unilocular radiolucent area surrounding the crown of the mandibular left second premolar [Figure 2A]. The apices of the primary left second molar appeared to project into the lumen of the cystic cavity and were not resorbed abnormally, suggesting the possibility - albeit low - of unicystic ameloblastoma.

Radiographic examination of the lower right back region showed a large, circular, well-defined, and a unilocular radiolucent area surrounding the crown of the mandibular right second premolar [Figure 2B]. The roots of primary second molar were almost resorbed and tooth structure was completely mutilated leaving behind few root pieces.

Occlusal radiographs revealed buccal expansion of cortical plate with respect to tooth no. 75 and 85 [Figure 3A] and [Figure 3B].

Treatment approach of tooth no. 75

Prior to the surgery, routine blood and urine examinations were advised; the results were within normal limits. Surgical enucleation of the cyst was chosen as the treatment of choice. The treatment consisted of raising the flap and extraction of the primary second molar along with total enucleation of the dentigerous cyst. The surgery was done using local anesthesia (inferior alveolar, long buccal, and lingual nerve block) and under antibiotic cover. The cyst was attached to the cementoenamel junction of the extracted molar [Figure 4A],[Figure 5A], and [Figure 6]. The cavity was packed with sterile iodoform gauze to achieve hemostasis. The iodoform gauze was removed on the next day and the sutures were removed after one week. The specimen was sent for histopathological examination. Histological examination showed a thin fibrous cystic wall lined by 2-3 layers thick nonkeratinized stratified squamous epithelium, with islands of odontogenic epithelium. The connective tissue showed a slight inflammatory cell infiltrate, which confirmed the diagnosis of dentigerous cyst [Figure 7].

The patient was asked to report back after two weeks for further clinical and radiographic follow up. After one month, bone neoformation was observed in the same region [Figure 8].

Treatment approach of tooth no. 85

Swelling associated with tooth no. 85 was also surgically treated two weeks after the enucleation of cyst associated with tooth no. 75.

Routine blood and urine examinations were advised prior to surgery; the results were within normal limits. The root pieces were extracted under local anesthesia and antibiotic cover. Marsupilization was suggested as the treatment of choice [Figure 4B] and [Figure 5B]. Histological examination was not done because the cyst lining under the second primary molar could not be excised. Antibiotics were advised for two days to prevent postoperative infection and the operative site was irrigated with saline and packed with Coe-pack.

The patient was recalled after one week, no postoperative complications had developed following marsupilization. After one month follow-up the affected second premolar had erupted almost completely.

Case 2

A 10.2-year-old boy reported to the department with the chief complaint of a painless swelling in the left mandibular vestibule [Figure 9]. Physical examination revealed a hard submucosal mass in relation to the second deciduous molar which had been endodontically treated two-years back. A panoramic radiograph showed a well-defined osteolytic lesion measuring 2 cm in diameter and including the crown of the unerupted mandibular premolar [Figure 10] and [Figure 11]. An initial sign of root resorption of the deciduous second molar was evident. Marsupilization was considered as the treatment of choice, extraction of the primary second molar was done under local anesthesia and a wide opening of the cavity was made. The cyst was deroofed and the lining was sutured to adjacent oral mucosa so as to establish a communication of cyst to oral cavity [Figure 12]. A gauze pack with petroleum jelly was inserted into the cyst cavity and secured with a suture. After one week of surgery, the gauze pack and sutures were removed.

The patient was on regular follow up for one month, the eruption of second premolar was clinically and radiographically appreciated and no complications developed following marsupilization even after five months of follow up [Figure 13] and [Figure 14].


   Discussion Top


The association between an infected primary tooth and the development of a dentigerous cyst involving the pre-erupted permanent tooth has long been discussed.

The key to the formation of a dentigerous cyst appears to be the accumulation of fluid either between the reduced enamel epithelium and the enamel or between the layers of the enamel organ. This fluid accumulation might be a result of pressure exerted by a potentially erupting tooth on the follicle which obstructs the venous outflow and induces serum transduction across the capillary wall. [3]

Murakami et al , [2] suggest that an intrafollicular spread of periapical inflammation from a primary tooth also may result in the development of a dentigerous cyst. These cysts can be referred to as inflammatory dentigerous cysts.

The nature of the causative tooth influences the type of surgical treatment required for the dentigerous cyst. If the cyst is associated with supernumerary or wisdom tooth complete enucleation of the cyst along with extraction of tooth may be the first treatment choice. However, when preservation of the teeth is desirable and in a young patient where the lesion is isolated, then marsupilization is the treatment of choice. [7]

On occasions, some untreated dentigerous cysts rarely develop into an odontogenic tumor (e.g. ameloblastoma) or a malignancy (e.g. oral squamous cell carcinoma). In such cases the treatment of choice is surgical enucleation. [9]

Treatment of dentigerous cyst depends on size, location, and disfigurement, and often requires variable bone removal to ensure total removal of the cyst, especially in cases of large ones. This may even require Weber-Ferguson incision as stated by Shah NJ. Nowadays, Scott-Brown has stated that marsupilization of the cyst lining is the treatment of choice for dentigerous cyst in children in order to give a chance to the unerupted tooth to erupt. [6]


   Conclusions Top


These case reports illustrate the conservative surgical treatment modalities for dentigerous cyst in adolescents in the mixed dentition stage. Children have a much greater capacity to regenerate the bony structures than do adults, and the teeth with open apices have a greater eruptive potential. [5] These factors should make one consider dentigerous cysts in children as distinct entities from those in adults, with a much better prognosis for the teeth involved. These techniques require close observation on the part of both the patient and the treating doctor. The result of these techniques can be elimination of the pathology and maintenance of dentition with minimal surgical interventions.

This saves a tooth in occlusion and prevents a young patient from psychological and mental trauma because of the loss of tooth.

 
   References Top

1.Clauser C, Zuccati G, Barone R. Simplified surgical-orthodontic treatment of a dentigerous cyst. J Clin Orthod 1994;28:103-6.  Back to cited text no. 1    
2.Murakami, et al. Eruption of an impacted second premolar after marsupilization of a large dentigerous cyst: Case report. Pediatr Dent 1995;17:372-4.  Back to cited text no. 2    
3.Benn A, Altini M. Dentigerous cyst of inflammatory origin: A clinicopathologic study. Oral Surg Oral Med Oral Pathol 1996;81:203.  Back to cited text no. 3    
4.Ziccardi VB, Eggleston TE. Schnider RE. Using fenestration technique to treat a large dentigerous cyst. J Am Dent Assoc 1997;128:201-5.  Back to cited text no. 4    
5.Martin-Peretz D, Varela-Moralis M. Conservative treatment of dentigerous cysts in children: A case report of 4 cases. J Oral Maxillofac surg 2001;59:331-4.   Back to cited text no. 5    
6.Isser KD, Das S. Dentigerous cyst in a young boy. Indian J Otolaryngol 2002;54:44-5.  Back to cited text no. 6    
7.Jena AK, Duggal R, Roychoudary A, Prakash H. Orthodontic assisted tooth eruption in a dentigerous cyst: A case report. J Clin Pediatr Dent 2004:29:33-5.  Back to cited text no. 7    
8.Desai RS, Vanaki SS, Puranik RS,Tegginamani AS. Dentigerous cyst associated with permanent centaral incisor: A rare entity. J Indian Soc Pedod Prev Dent 2005:23:49-50.  Back to cited text no. 8    
9.Kalaskar RR, Tiku A, Damle SG. Dentigerous cyst of anterior maxilla in a young child: A case report. J Indian Soc Pedod Prev Dent 2007;25:187-90.  Back to cited text no. 9  [PUBMED]  Medknow Journal


    Figures

  [Figure 1A], [Figure 1B], [Figure 2A], [Figure 2B], [Figure 3A], [Figure 3B], [Figure 4A], [Figure 4B], [Figure 5A], [Figure 5B], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]


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    Abstract
    Introduction
    Case Reports
    Discussion
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