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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 9  |  Issue : 3  |  Page : 148-151

Conservative management of a dentigerous cyst by marsupialization treatment: Clinical insight and a case report


1 Department of Dental Surgery, North DMC Medical College and Hindu Rao Hospital, New Delhi, India
2 Department of Oral Medicine, Diagnosis and Radiology, Himachal Institute of Dental Sciences, Paonta Sahib, Himachal Pradesh, India

Date of Web Publication27-Sep-2018

Correspondence Address:
Nidhi Chhabra
Department of Dental Surgery, North DMC Medical College and Hindu Rao Hospital, New Delhi
India
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DOI: 10.4103/srmjrds.srmjrds_58_17

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  Abstract 

The progression of inflammation from a nonvital deciduous predecessor tooth around an unerupted permanent tooth is one of the possible etiologic factors for the development of a dentigerous cyst. The article reports the management of an inflammatory dentigerous cyst in an 11-year-old male patient, associated with the germ of an unerupted permanent maxillary canine. The patient was treated by extraction of the left first and second deciduous molars under local anesthesia and marsupialization of the cystic cavity. The patient was followed for 18 months, and eruptions of the permanent canine, first and second premolars, and gradual reduction of the radiolucent area were observed periodically. In conclusion, with proper case selection, marsupialization might be a good treatment option for the conservative management of dentigerous cysts.

Keywords: Conservative management, dentigerous cyst, marsupialization


How to cite this article:
Chhabra N, Chhabra A, Mehta R. Conservative management of a dentigerous cyst by marsupialization treatment: Clinical insight and a case report. SRM J Res Dent Sci 2018;9:148-51

How to cite this URL:
Chhabra N, Chhabra A, Mehta R. Conservative management of a dentigerous cyst by marsupialization treatment: Clinical insight and a case report. SRM J Res Dent Sci [serial online] 2018 [cited 2018 Dec 18];9:148-51. Available from: http://www.srmjrds.in/text.asp?2018/9/3/148/242455


  Introduction Top


Dentigerous cysts are the odontogenic cysts which enclose the crown and are attached to the neck of an unerupted tooth.[1],[2],[3] An inflammatory dentigerous cyst arises due to the progressing periapical inflammation from the root apex of the deciduous tooth around an unerupted permanent tooth. It usually occurs between 6 and 12 years of age and is ten folds more likely to occur in the lower jaw than the upper jaw.[4] The incidence of inflammatory dentigerous cysts is twice as high in male patients as compared to female counterparts.[4] In most of the cases, the dentigerous cyst is an asymptomatic entity, unless there is acute inflammatory exacerbation. If the cyst reaches a large size (>2 cm in diameter), swelling, mild sensitivity, tooth mobility, and displacement may be observed.[5]

A final diagnosis is based on clinical, radiographic, and histopathologic evaluation criteria. Radiographically, it is a unilocular radiolucent lesion with well-defined margins that appear enclosing the crown of an unerupted/impacted tooth. In case of infection, the dentigerous cyst might become symptomatic and present ill-defined margins on radiographic examination. The histopathologic examination reveals a nonkeratinized stratified squamous epithelium delimiting the cystic lumen.[1],[2],[3],[4]

The two main established treatment modalities of treating a dentigerous cyst are enucleation and marsupialization. Enucleation of the cyst together with the removal of the involved tooth rarely results in lesion recurrence. Excision is indicated when there is no likelihood of damaging anatomic structures, such as apices of vital teeth, the maxillary sinus, or inferior alveolar nerve. However, it is a very radical approach.[2] Management of dentigerous cysts in primary dentition necessitates special consideration due to the preservation of developing permanent tooth buds. More conservative management consists of cyst marsupialization, which maintains the impacted tooth in the cystic cavity and promotes its eruption.[6] This article reports the spontaneous eruption of a canine after marsupialization of an infected dentigerous cyst and extraction of the deciduous teeth.


  Case Report Top


An 11-year-old boy reported with the chief complaint of swelling in the left upper back tooth region. Clinical history revealed that the swelling started as a small nodule that increased to the present size over a period of 3 months. Painful symptomatology, paresthesia, or any pus discharge were not reported by the patient. Extraoral examination revealed hard firm, nontender swelling present on the left cheek region of the mandible [Figure 1]a.
Figure 1: (a) Extraoral view showing swelling on the left cheek region of the mandible. (b) Intraoral view showing swelling in the left maxillary primary molar area. (c) Clinical appearance of the carious involvement of deciduous left maxillary first and second molars. (d) Initial periapical radiograph suggesting the presence of a dentigerous cyst associated with the crown of the unerupted permanent left maxillary canine

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Intraoral examination revealed a diffuse swelling of firm consistency, causing obliteration of the labial vestibule in 63, 64, and 65 tooth area [Figure 1]b. The deciduous left maxillary first and second molars were found to be cariously involved [Figure 1]c. Overlying mucosa was stretched. On palpation, the expansion of the cortical bone was found. The swelling was nontender, fluctuant, noncompressible, and nonreducible. Radiographic examination showed a unilocular radiolucent lesion 1.8 cm in diameter, having well-defined margins and extending from the mesial root of the deciduous left first molar to the distal aspect of the root of the left lateral incisor and surrounding the crown of the permanent left maxillary canine [Figure 1]d. Histopathologic examination of the aspiration biopsy showed a cystic lesion, and presumptive diagnosis of the dentigerous cyst was made.

A complete medical history and blood investigation were carried out to exclude any systemic contraindication of surgery. Marsupialization was chosen as the treatment of choice to spare the unerupted permanent tooth buds. Under local anesthesia, the patient was treated by extraction of the left deciduous first and second deciduous molars and marsupialization of the cystic cavity. The procedure involved reflection of the flap along with the thinned-out bone [Figure 2]a. The contents of the cyst were evacuated, and irrigation was done to remove any residual fragments and debris [Figure 2]b. The cavity was packed with the iodoform gauze [Figure 2]c. The removed surgical specimen on histopathological examination confirmed the diagnosis of the dentigerous cyst [Figure 2]d.
Figure 2: (a) Intraoral photograph following extraction of the left maxillary first and second deciduous molars and after marsupializing the cystic cavity. (b) Evacuation of the cystic contents followed by irrigation to remove any residual fragments and debris. (c) Cavity packed with the iodoform gauze. (d) Histological evaluation showing a compatible dentigerous cyst image

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A removable acrylic template was fabricated over the defected area to facilitate unhampered healing [Figure 3]a. The patient was recalled after 7 days for the change of dressing to allow decompression and eruption of the teeth. The patient was recalled periodically for clinical and radiographic examinations every 6 months, and reduction of the radiolucent area was observed during the course of time [Figure 3]b. A 13-month follow-up visit showed the eruption of first and second premolars [Figure 3]c. After a period of 18 months, permanent canine eruption was noted, without orthodontic traction or any other therapy [Figure 3]d.
Figure 3: (a) Intraoral view of the removable acrylic template, fabricated to facilitate unhampered healing. (b) Periapical radiograph depicting reduction of the radiolucent area. (c) Intraoral photograph at 13 months follow-up, showing the eruption of left maxillary permanent first and second premolars. (d) Follow-up visit at 18 months, showing eruption of permanent canine, without orthodontic traction or any other therapy

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  Discussion Top


Dentigerous cysts are the odontogenic cysts that are usually associated with an embedded or unerupted tooth.[7],[8],[9] There are different theories that describe the etiology of the dentigerous cyst. The first theory advocates that it evolves from the fluid accumulation between the reduced enamel epithelium and the crown of the permanent tooth germ.[3],[10] These developmental dentigerous cysts typically occur in the late second and third decades, are discovered on routine radiography, and predominantly involve mandibular third molars.[11] The second theory suggests that, along with its eruption path, the immature permanent tooth encounters a radicular cyst originating from its primary predecessor. This is the least accepted hypothesis because radicular cysts rarely develop in association with the primary teeth. According to the third theory, the dentigerous cyst is inflammatory in origin and occurs in immature permanent tooth as a result of inflammation from a nonvital deciduous predecessor tooth.[4],[11] The inflammatory dentigerous cyst is diagnosed in the first and early part of the second decade either on routine radiographic examination or when the patient complains of swelling and pain.[12] The dentigerous cyst in our case report was of inflammatory origin.

The dentigerous cyst can attain a considerable size with minimal or no symptoms and often block the eruption of teeth, displace teeth, destroy the bone, and encroach on vital structures such as maxillary sinus or alveolar nerve and may occasionally lead to pathologic fracture.[13] Moreover, the epithelial cells lining the lumen of the dentigerous cyst unlike that of other odontogenic cysts possess an unusual ability to undergo neoplastic transformation to nonodontogenic malignances like squamous-cell carcinoma and mucoepidermoid carcinoma and odontogenic tumors like ameloblastoma and adenomatoid odontogenic tumor.[14] Thus, an early detection and removal of the dentigerous cyst is important.

Motamedi and Talesh stated that the choice of the therapeutic approach for treating a dentigerous cyst should be based on the size and location of the cyst, patient age, affected dentition, and relationship with the surrounding vital structures.[13] Marsupialization being a conservative intervention is the treatment of choice to preserve the developing permanent tooth buds associated with the cystic lesion and is especially indicated for the growing children and adolescents. Marsupialization involves the creation of a surgical window in the cyst lining and evacuation of the cystic lesion contents while maintaining the continuity between the cyst and the oral cavity. This procedure stimulates a new bone formation by relieving the intracystic pressure and allows the spontaneous eruption of the unerupted/impacted tooth.[2],[4],[13] Miyawaki et al. reported that an impacted tooth can erupt faster if marsupialization is performed at a time when the tooth can erupt.[8] In the case reported here, marsupialization was the treatment of choice because the patient was a young child, and the cystic lesion occupied a large maxillary area.

Orthodontic traction of the impacted tooth with matured roots has often been performed after marsupialization of a large cyst.[15] In the present case, however, all teeth erupted with marsupialization only without orthodontic traction.


  Conclusion Top


Since the dentigerous cysts are usually asymptomatic and can attain a considerable size with minimal or no symptoms, early clinical and radiographic detection is important so that initial treatment strategies will prevent or decrease the morbidity associated with the same. The successful outcomes attained in this case report show that, with proper case selection, marsupialization might be a good treatment option for conservative management of dentigerous cysts.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Neville BW, Damm DD, Allen CM, Bouquot JE. Odontogenic cysts and tumors. In: Neville BW. Oral and Maxillofacial Pathology. 2nd ed. Philadelphia, PA: W.B. Saunders; 2002. p. 589-642.  Back to cited text no. 1
    
2.
Martínez-Pérez D, Varela-Morales M. Conservative treatment of dentigerous cysts in children: A report of 4 cases. J Oral Maxillofac Surg 2001;59:331-3.  Back to cited text no. 2
    
3.
Ertas U, Yavuz MS. Interesting eruption of 4 teeth associated with a large dentigerous cyst in mandible by only marsupialization. J Oral Maxillofac Surg 2003;61:728-30.  Back to cited text no. 3
    
4.
Kozelj V, Sotosek B. Inflammatory dentigerous cysts of children treated by tooth extraction and decompression – report of four cases. Br Dent J 1999;187:587-90.  Back to cited text no. 4
    
5.
Delbem AC, Cunha RF, Afonso RL, Bianco KG, Idem AP. Dentigerous cysts in primary dentition: Report of 2 cases. Pediatr Dent 2006;28:269-72.  Back to cited text no. 5
    
6.
Desai RS, Vanaki SS, Puranik RS, Tegginamani AS. Dentigerous cyst associated with permanent central incisor: A rare entity. J Indian Soc Pedod Prev Dent 2005;23:49-50.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Smith G. Two dentigerous cysts in the mandible of one patient. Case report. Aust Dent J 1996;41:291-3.  Back to cited text no. 7
    
8.
Miyawaki S, Hyomoto M, Tsubouchi J, Kirita T, Sugimura M. Eruption speed and rate of angulation change of a cyst-associated mandibular second premolar after marsupialization of a dentigerous cyst. Am J Orthod Dentofacial Orthop 1999;116:578-84.  Back to cited text no. 8
    
9.
Thoma KH. Oral Surgery. 5th ed. St. Louis, Mo.: Mosby Co.; 1969. p. 891-904.  Back to cited text no. 9
    
10.
Harris M, Toller P. The pathogenesis of dental cysts. Br Med Bull 1975;31:159-63.  Back to cited text no. 10
    
11.
Benn A, Altini M. Dentigerous cysts of inflammatory origin. A clinicopathologic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:203-9.  Back to cited text no. 11
    
12.
Mintz S, Allard M, Nour R. Extraoral removal of mandibular odontogenic dentigerous cysts: A report of 2 cases. J Oral Maxillofac Surg 2001;59:1094-6.  Back to cited text no. 12
    
13.
Motamedi MH, Talesh KT. Management of extensive dentigerous cysts. Br Dent J 2005;198:203-6.  Back to cited text no. 13
    
14.
Slootweg PJ. Carcinoma arising from reduced enamel epithelium. J Oral Pathol 1987;16:479-82.  Back to cited text no. 14
    
15.
Moro Antonio JM, Puente M. Surgical-orthodontic treatment of an impacted canine with a dentigerous cyst. J Clin Orthod 2001;35:491-3.  Back to cited text no. 15
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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