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CASE REPORT
Year : 2020  |  Volume : 38  |  Issue : 4  |  Page : 425-429
 

Multidisciplinary management of delayed eruption of permanent mandibular first molar associated with dentigerous cyst


1 Department of Paediatric and Preventive Dentistry, Yenepoya Dental College, Karnataka, India
2 Department of Orthodontics, Yenepoya Dental College, Karnataka, India
3 Department of Oral & Maxillofacial Surgery, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission11-Sep-2020
Date of Decision21-Nov-2020
Date of Acceptance01-Dec-2020
Date of Web Publication5-Jan-2021

Correspondence Address:
Dr. Sharan S Sargod
Department of Paediatric and Preventive Dentistry, Yenepoya Dental College, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_391_20

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   Abstract 


The absence of a tooth in the oral cavity may be the result of some obstruction with the process of tooth eruption. Physical obstruction can result from many different causes, such as supernumerary teeth, mucosal barrier, scar tissue, and cysts or tumors. Their removal will usually permit the affected tooth to erupt. This case report describes the delayed eruption of the permanent mandibular first molar in a 9-year-old boy due to the dentigerous cyst associated with it. The management was done through a multidisciplinary approach. Surgical removal of cystic sac through marsupialization along with the removal of the barrier was done. As a consequence of delayed eruption of the permanent first molar, the opposing tooth had supraerupted, which was intruded using mini-implants. Following this, the tooth erupted satisfactorily into the oral cavity to establish class I molar relation.


Keywords: Delayed eruption, dentigerous cyst, intrusion using mini-implants, marsupialization, supraeruption


How to cite this article:
Sargod SS, Shetty N, Shabbir A, Poojary D, Ajay Rao H T. Multidisciplinary management of delayed eruption of permanent mandibular first molar associated with dentigerous cyst. J Indian Soc Pedod Prev Dent 2020;38:425-9

How to cite this URL:
Sargod SS, Shetty N, Shabbir A, Poojary D, Ajay Rao H T. Multidisciplinary management of delayed eruption of permanent mandibular first molar associated with dentigerous cyst. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2021 Apr 23];38:425-9. Available from: https://www.jisppd.com/text.asp?2020/38/4/425/306221





   Introduction Top


Tooth eruption has been defined as the movement of a tooth from its site of development within the alveolar process to its functional position in the oral cavity.[1] It is a localized process in the jaws that exhibits precise timing and bilateral symmetry.[2] The delayed eruption may result from some interference with the process of tooth eruption.

The eruption failure may result from a variety of causes, systemic and local. Systemic causes of delayed tooth eruption include premature birth, low birth weight, genetic abnormalities such as amelogenesis imperfecta and regional odontodysplasia, vitamin D-resistant rickets, cerebral palsy, nutritional deficiency, and certain congenital syndromes. Most commonly, local factors causing mechanical obstruction to tooth movement into the oral cavity are responsible for the failure of tooth eruption. Local factors include dental infection, trauma, insufficient space in the dental arch, cysts or tumors, etc.

Dentigerous cyst is the second most common odontogenic cyst. It presents as an asymptomatic, unilocular, radiolucency involving the crown of an impacted tooth or partially erupted tooth or less frequently, with an odontoma, a developing tooth, or a deciduous tooth. The large majority are discovered accidentally when radiographs are taken to investigate absence, wrong tooth position, or delay in the chronology of eruption. The incidence of dentigerous cysts has been estimated at 1.44 cysts for every 100 unerupted teeth comprising the second most common (14%–24%) of all odontogenic cysts.[3],[4] They are associated with impacted teeth, mandibular third molars being the most commonly affected, followed by permanent maxillary canine and permanent maxillary third molar. Such a cyst with a permanent first molar is uncommon and comprises about 1.1% of all dentigerous cysts.[5] Enucleation and marsupialization are forms of treatment most commonly used.

One of the complications of delayed eruption of the tooth is the supraeruption of the opposing tooth. Supraeruption is the tooth's physiological movement, which is missing an opposing partner in the dental occlusion. Due to the lack of opposing force and the natural eruptive potential of the tooth, there is a tendency for the tooth to erupt outside the line of occlusion. Supraeruption occurs when a tooth pushes out of the bone beyond the other teeth in that jaw. This leads to an uneven bite and misalignment of the neighboring teeth.

Supraeruption is commonly treated by directing the tooth back to the intended position using orthodontic techniques or cutting the interfering portion of the tooth and installing a crown. The intrusion of a supraerupted maxillary molar using traditional orthodontic methods is a real challenge.

To intrude supraerupted maxillary molars, orthodontic anchorage could be prepared by incorporating multi-unit teeth, adding extraoral headgear wear, or using newly adopted mini-implants as bony anchorage.[6] Recent reports have demonstrated the clinical efficiency of mini-implants in providing sufficient anchorage against orthodontic forces.[6] The advantages of using mini-implant as orthodontic anchorage include ease of application, minimal patient compliance needed, and the ability to load immediately after initial wound healing.[7],[8] The surgical procedure for inserting or removing the miniscrew is simple, with minimal unfavorable complications.[6]

This case report describes a case of delayed eruption/impaction of a mandibular first permanent molar associated with a dentigerous cyst managed by a multidisciplinary approach.


   Case Report Top


A 9-year-old male patient reported to the private clinic with a chief complaint of an unerupted mandibular right first permanent molar.

The medical and dental history was noncontributory, and the dental age correlated with the patient's chronological age with no other relevant findings. On clinical examination, 46 (mandibular right first permanent molar) was unerupted with firm gingiva and bone covering, which was slightly enlarged. On palpation, there was no tenderness or discomfort. However, a hard bony expansion on the buccal side was felt. The antagonist that is 16 had supraerupted and was almost touching the gingiva. An intraoral periapical radiograph revealed an unerupted fully developed first permanent molar which was slightly mesially angulated, and it appeared that the lower right deciduous second molar was hindering the eruption. 45 was erupting normally with Nolla's stage 8 tooth development. Cone-beam computed tomography showed an unerupted fully developed first permanent molar with complete root development [Figure 1]. The intrafollicular space was increased, making it appear encapsulated in the follicular sac measuring 3.28 mm on the mesial and 2.0 mm on the distal aspect of 46. About 3 mm alveolar bone was covering the crown. Based on the clinical and radiographic examination, a provisional diagnosis of dentigerous cyst was made.
Figure 1: Cone-beam computed tomography image

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Considering the age of the patient and close proximity of 46 to the mandibular canal and lower border of the mandible, surgical removal of cystic sac only through marsupialization was done with the help of an oral surgeon. Only the cystic sac was removed along with the bone covering it. Iodoform gauze dressing was inserted within the lesion cavity and sutures were placed. One week postoperatively, the sutures and the pack of gauze were removed gently. No pus discharge was noticed. The cavity was irrigated with normal saline and a new smaller medication gauze was applied. The healing was uneventful with regular change of dressings. Three weeks postoperatively, the pack of gauze was removed. The patient was instructed to rinse the area twice daily with betadine solution, followed by saltwater gargle and was recalled periodically for follow-up. After 4 weeks, the tooth showed signs of eruption into the oral cavity. The histopathological report confirmed the diagnosis of a dentigerous cyst.

Due to delayed eruption of 46, 16 had supraerupted. This hindered the further eruption of 46 into the occlusal plane. The patient was referred to an orthodontist. It was decided to intrude 16 using mini-implants and elastics/E chain.

Two orthodontic mini-implants 1.5 mm × 8 mm were placed, one on the buccal attached gingiva between 15 and 16 and one on the palatal surface between 16 and 17 [Figure 2]. Elastics were placed from the buccal to the palatal surface through mesiobuccal to distopalatal cusp, changing them once in 3–4 weeks [Figure 3]. There was a significant intrusion of 16 though not to the level of the upper occlusal plane, the 46 erupted significantly up to the cervical 1/3rd and established class 1 molar relation [Figure 4]a and [Figure 4]b. An orthopantamograph after 4 years of follow-up revealed good bone healing and eruption of 46 into normal position [Figure 5].
Figure 2: Intrusion using mini-implants and E chain

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Figure 3: E chain from mesiobuccal to distopalatal cusp

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Figure 4: (a and b) Erupting 46

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Figure 5: Follow-up after 4 years

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   Discussion Top


The eruption is the axial movement of a tooth from its nonfunctional position in the bone to functional occlusion. The normal eruption of deciduous and permanent teeth into the oral cavity occurs over a broad chronologic age range.[9] Often, delay in eruption might be the primary manifestation of some systemic or local pathology. Physical obstruction is a common local cause of delayed eruption of at least one tooth. These obstructions can result from many different reasons, such as supernumerary teeth, scar tissue, mucosal barrier, and cysts or tumors. Their removal will usually permit the affected tooth to erupt.

Dentigerous cysts most commonly occur in the second or third decade of life. However, the frequency in children is relatively low, and 4%–9% of these cysts occur in the first 10 years after birth.[10] In the present case, the cyst was associated with the mandibular first permanent molar tooth crown in a 9-year-old child.

The dentigerous cyst is normally detected by chance because it is asymptomatic. Therefore, they are generally detected due to a delay in the eruption of the tooth involved. Although a dentigerous cyst is not a very common reason for delayed/failure of eruption, it can still occur in rare cases.

Treatment for the failure of eruption of permanent molars depends on several factors, the most important being the age. Different treatment options of delayed eruption include observation, surgical exposure of tooth, and luxation or removal of any obstruction, the application of orthodontic traction, and lastly extraction. The usual treatment with a favorable prognosis is exposure and luxation.[11]

In this case for the treatment of the dentigerous cyst, the available options were a) enucleation of the cyst along with the tooth and hope and allow 47 to occupy the space of 46 and b) marsupialization of the cystic sac only to remove the barrier for the eruption of 46. The treatment of choice is dependent on the size and localization of the lesion, the bone integrity of the cystic wall, and its proximity to vital structures.[12]

Marsupialization, along with the removal of the barrier, was considered in this case because of the age of the patient and close proximity of 46 to the mandibular canal and lower border of the mandible and also considering the first molar being the key for occlusion.

Uniqueness, in this case, is that it is very rare to find dentigerous cyst associated with the first permanent molar (1.1%)[5] and no active appliance was used to help the eruption of impacted tooth, only the barrier that is bone and cystic sac was removed. Although the root growth was completed, the exact mechanism involved in the eruption of this tooth is unknown.

Furthermore, the erupting tooth showed signs of enamel hypoplasia which was not observed in any other erupted teeth [Figure 4]b. The reasons for hypoplasia are not known; however, it is speculated that unerupted tooth enveloped by a dentigerous cyst may or may not show enamel hypoplasia depending on the time of commencement of a dentigerous cyst. Enamel hypoplasia is seen when a dentigerous cyst commences at an early stage of development of the involved tooth, whereas in cases where the cyst originating after the completion of tooth development, enamel hypoplasia is not a significant factor.[13]

In this case, the maxillary first permanent molar supraerupted due to a delay in the eruption of the mandibular first permanent molar. The overeruption of maxillary molars usually results from missing antagonistic teeth. The intrusion of an overerupted maxillary molar using traditional orthodontic treatment is a real challenge. The use of conventional methods to intrude molars can lead to undesirable extrusion of the anchor teeth. Different techniques have been described in the literature such as loops, transpalatal arch, extraoral devices, and lately, the use of mini-screws.[14]

Most types of orthodontic tooth movement can be achieved using micro-implants without loss of anchorage or reliance on patients' compliance for wearing elastics and extra-oral appliances. The new generation of micro-implants is small enough to be placed between the roots of adjacent teeth, in inter radicular bone, the palate, the retromolar area, the inferior surface of the zygomatic arch, and in the anterior nasal spine or chin.[15]

Orthodontic correction through mini-implant supported intrusion should currently be considered state of the art because it can deliver predictable results without relying heavily on patient compliance. Compared to traditional orthodontics, the molar intrusion facilitated with the mini-implants causes minimum extrusion of the adjacent teeth. The incorporation of mini-implants can achieve a significant amount of maxillary molar intrusion and is an excellent alternative to the traditional method.[6]


   Conclusion Top


This case report demonstrates that the first permanent molars associated with a dentigerous cyst under a favorable position can be managed using conservative marsupialization to favor the eruption into the oral cavity. The associated consequences like supraeruption can also be managed with mini-implants, which can provide orthodontic anchorage predictably without the need for complicated oral appliances regardless of the condition of the dentition.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to thank Dr. Ashwath Kumar, Bhuvina Multispeciality Dental Clinic, Mangalore.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Massler M, Schour I. Studies in tooth development: Theories of eruption. Am J Ortho Oral Surg 1941;27:552-76.  Back to cited text no. 1
    
2.
O'Connell AC, Torske KR. Primary failure of tooth eruption: A unique case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:714-20.  Back to cited text no. 2
    
3.
McDonald JS, Dean JA. Tumours of the oral soft tissues and cysts and tumours of bone. In: McDonald and Avery's Dentistry for the Child and Adolescent. 10th ed. St. Louis, MO, USA: Elsevier; 2016. p. 603-26.  Back to cited text no. 3
    
4.
Scully C. Oral and Maxillofacial Medicine. 3rd ed. Edinburg, UK: Elsevier; 2013.  Back to cited text no. 4
    
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Shear M. Cysts of the Oral and Maxillofacial Region. 4th ed. Blackwell: Johannesburg, South Africa; 2006.  Back to cited text no. 5
    
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Yao CC, Lee JJ, Chen HY, Chang ZC, Chang HF, Chen YJ, et al. Maxillary molar intrusion with fixed appliances and mini-implant anchorage studied in three dimensions. Angle Orthod 2005;75:754-60.  Back to cited text no. 6
    
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Park HS, Bae SM, Kyung HM, Sung JH. Micro-implant anchorage for treatment of skeletal Class I bialveolar protrusion. J Clin Orthod 2001;35:417-22.  Back to cited text no. 7
    
8.
Bae SM, Park HS, Kyung HM, Kwon OW, Sung JH. Clinical application of micro-implant anchorage. J Clin Orthod 2002;36:298-302.  Back to cited text no. 8
    
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Suri L, Gagari E, Vastardis H. Delayed tooth eruption: Pathogenesis, diagnosis, and treatment. A literature review. Am J Orthod Dentofacial Orthop 2004;126:432-45.  Back to cited text no. 9
    
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Demiriz L, Misir AF, Gorur DI. Dentigerous cyst in a young child. Eur J Dent 2015;9:599-602.  Back to cited text no. 10
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Arathi R, Suprabha BS, Pai SM. Permanent molars: Delayed development and eruption. J Indian Soc Pedod Prev Dent 2006;24:15-17.  Back to cited text no. 11
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Hegde RJ, Khare SS, Devrukhkar VN. Dentigerous cyst in a young child: Clinical insight and A case report. J Indian Soc Pedod Prev Dent 2013;31:209-11.  Back to cited text no. 12
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13.
Al-Talabani NG, Smith CJ. Experimental dentigerous cysts and enamel hypoplasia: Their possible significance in explaining the pathogenesis of human dentigerous cysts. J Oral Pathol 1980;9:82-91.  Back to cited text no. 13
    
14.
Sugii MM, Barreto BD, Vieira-Júnior WF, IzolaSimone KR, Bacchi A, Caldas RA. Extruded upper first molar intrusion: Comparison between unilateral and bilateral miniscrew anchorage. Dental Press J Orthod 2018;23:63-70.  Back to cited text no. 14
    
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Park HS, Kyung HM, Sung JH. A simple method of molar uprighting with micro-implant anchorage. J Clin Orthod 2002;36:592-6.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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