Normal eruption of impacted teeth associated with a dentigerous cyst managed by simple extraction and decompression

Ritesh Rambharos Kalaskar; Ashita R Kalaskar

doi:10.4103/0976-433X.149598

CASE REPORT

Year : 2015 | Volume : 6 | Issue : 1 | Page : 65-68

Normal eruption of impacted teeth associated with a dentigerous cyst managed by simple extraction and decompression

Ritesh Rambharos Kalaskar¹, Ashita R Kalaskar²
¹ Department of Pedodontics, Government Dental College and Hospital, Nagpur, Maharashtra, India
² Department of Oral Diagnosis and Radiology, VSPM Dental College and Research Center, Nagpur, Maharashtra, India

Date of Web Publication

19-Jan-2015

Correspondence Address:
Ritesh Rambharos Kalaskar
Department of Pedodontics, Government Dental College and Hospital, Nagpur, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0976-433X.149598

Abstract

Dentigerous cyst is an epithelial-lined cavity that encloses the crown of an unerupted tooth at the cementoenamel junction, can be either developmental or inflammatory in origin. The purpose of this paper was to report of an asymptomatic dentigerous cyst of inflammatory origin in a 7.5-year-old child who was managed by conservative means of a simple extraction, followed by decompression under local anesthesia. After 16 months of follow-up, the cyst was completely ossified, and the displaced premolars were normally erupted in the oral cavity. Similarly, we also noticed rapid root maturation of the cyst involved premolars than the contralateral premolars.

Keywords: Decompression, dentigerous cyst, extraction, impacted tooth, inflammatory mandibular premolar

How to cite this article:
Kalaskar RR, Kalaskar AR. Normal eruption of impacted teeth associated with a dentigerous cyst managed by simple extraction and decompression. SRM J Res Dent Sci 2015;6:65-8

How to cite this URL:
Kalaskar RR, Kalaskar AR. Normal eruption of impacted teeth associated with a dentigerous cyst managed by simple extraction and decompression. SRM J Res Dent Sci [serial online] 2015 [cited 2023 Mar 24];6:65-8. Available from: https://www.srmjrds.in/text.asp?2015/6/1/65/149598

Introduction

Inflammatory dentigerous cyst (IDC) is a relatively uncommon type of odontogenic cyst usually associated with the carious or traumatic nonvital primary teeth. ^[1] This cyst is mostly asymptomatic in nature and is discovered on routine radiographic examination. Radiographically, the cysts appear as a well-defined round or ovoid unilocular radiolucency with sclerotic border surrounding the crown of an involved unerupted permanent tooth. ^[2] This cyst gradually increases in size and may cause bone destruction, displacement, and resorption of the adjacent teeth as well as the obliteration of the maxillary antrum and nasal cavity. Due to the multipotentional nature of the cystic epithelium, several entities may also be associated with the wall of a dentigerous cyst such as odontogenic keratocyst, ameloblastoma, cystic ameloblastoma, and mucoepidermoid carcinoma. Therefore, these entities should be considered in the differential diagnosis. ^[3] Pathogenesis of a dentigerous cyst is still controversial; either developmental of inflammatory in origin. ^[4]

Inflammatory dentigerous cyst can be treated either by enucleation or marsupialization. The latter approach is preferred for larger cysts in pediatric patients because it facilitates eruption of the unerupted involved permanent teeth. ^[5],[6] The paper describes the management of an IDC that was treated by marsupialization that allowed complete normal eruption of the involved unerupted permanent tooth.

Case report

A 7.5-year-old girl with noncontributory medical history reported to the Department of Pediatric Dentistry with a complaint of pain and swelling in relation to the mandibular left posterior region since 1 week. On extraoral examination, a buccal bulge was present in the mandibular left posterior region which was tender and hard on palpation. Intraoral examination revealed the presence of grossly carious mandibular primary left and right second molar [Figure 1]. A panoramic radiograph was advised which revealed a well-defined radiolucency of 3 cm × 3 cm in diameter in relation to the roots of mandibular primary first and second molar. The radiolucency also involved unerupted mandibular left premolars. Mandibular left second premolar was displaced towards the lower border of mandible [Figure 2]. Mandibular left first and second premolars were in the 6 ^th stage of Nolla's tooth development, which was coinciding with dental and chronological age of the patient [Figure 2]. Based on clinical and radiological findings, a provisional diagnosis of IDC was made. Marsupilization of the lesion was planned to save the unerupted premolars. Routine blood examinations were advised before marsupilization which were within normal limits.

Figure 1: Intraoral photograph showing carious 85

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Figure 2: Panoramic radiograph showing well-defined osteolytic lesion surrounding the crown of 35

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Under local anesthesia (Dentocaine 2% Pharma Health Care Product, Mumbai), extraction of mandibular primary left first and second molar was done which led to opening of the cystic cavity and draining of thick brown-colored fluid. During this process, enough soft tissue was removed from the superior portion of the cyst for histopathological analysis. Cortical plates were compressed, and a sterile iodoform gauge was placed in the cystic cavity for continuous drainage. The iodoform gauge was changed after every 2 days for a period of one. After 1 week, the edges of the extraction wounds had epithelialized. Histopathological examination showed dentigerous cyst lined by stratified squamous epithelium having features of inflammation including numerous proliferating blood vessels and mixed inflammatory cells [Figure 3]. The patient was recalled after every 3 months for follow-up examinations. Nine-month follow-up clinical and radiographic examinations showed erupted premolars and almost complete bone healing [Figure 4] and [Figure 5]. After 13 months of follow-up, the radiolucent lesion was completely resolved, and the premolars had erupted completely. The apex of the involved second premolar was almost closed [Figure 6]. Whereas, the mandible right premolars showed only 1/3 of root formation [Figure 6].

Figure 3: Histopathological image of the lesion showing more colonized fibrous wall with chronic inflammatory cells and thicker epithelial lining

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Figure 4: Clinical picture after 12 months of decompression

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Figure 5: A 12-month follow-up panoramic radiograph showed reduced size of the osteolytic lesion

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Figure 6: An 18-month follow-up panoramic radiograph showing complete ossification of the lesion and premolars in occlusion

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Discussion

Dentigerous cyst can be either developmental or inflammatory in origin. Developmental type mostly affects impacted mature tooth, usually the mandible's third molar. ^[7] IDC develops as a result of intrafollicular spread of periapical inflammation from an overlying nonvital primary tooth. This cyst usually involves the unerupted immature premolars, because the follicle of the premolars is more closely associated with the roots of primary mandible's molars, facilitating easy spread of inflammation. ^[8] They are mostly observed in the first and early part of the second decade. ^[9] It is known that almost every child had one or more decayed primary molars, but only a few proportions of them progress to develop into an IDC. This could be attributed to the fact that:

Either the cyst is under-reported or under-recognized,
Might resolve after removal or exfoliation of the involved primary tooth,
Resolve after pathologic resorption of the entire root, 4. Primary molar roots are not closely associated with its successors.

These cysts have also been reported to occur even after pulp treatment. Asiαn-Gonzαlez et al.^[10] reported with an IDC in a formocresol pulpotomized primary molar. It seems that even early endodontic treatment cannot prevent the development of these cysts.

Odontogenic keratocyst, unicystic ameloblastoma, radicular cyst are considered in the differential diagnosis of IDC. IDC is usually observed in the first decade of life, whereas all the above-mentioned lesions are observed in the second and third decade. Second, leaking out of cystic fluid during an extraction of a primary tooth confirms the clinical impression of the cyst. Radiograph alone cannot differentiate the above-mentioned lesions so a histopathological examination should be performed wherever possible. In the present case, content of the cystic cavity and histopathological examination confirmed the diagnosis of IDC.

Inflammatory dentigerous cyst can be either treated with marsupialization or enucleation. Marsupialization is preferred by many authors due to many advantages such as : C0 onservative technique, prevent loss and facilitate eruption of permanent teeth, stimulate rapid bone formation, and prevent damage to anatomic structures such as maxillary sinus and inferior alveolar nerve. Study conducted by Qian et al. suggested that IDC associated mandibular premolars can erupt spontaneously after marsupialization. ^[11] A recent case report in a 10-year-old child in which permanent teeth in relation to IDC were saved by marsupialization. ^[12] However, marsupialization leaves the pathologic tissue in situ that increases the risk of recurrence and a possibility of an aggressive lesion in the residual tissue. ^[11]

It is a well-known fact that there is a close relationship between the eruption and level of root formation. ^[12] A permanent tooth breaks through the alveolar bone when approximately two-third of the root formation has taken place and continues to erupt within the oral cavity till a stage of wide open apex. ^[12],[13] But this might not be true for the tooth associated with an IDC. Such teeth on the contrary show rapid eruption and rapid root maturation. In the present case, eruption of the cyst associated premolar was faster than the noncyst associated contralateral premolars. It is suggested that marsupialization decreases the intracystic pressure that speed up the eruption rate and rapid bone formation. ^[14]

In the case of mature root, the tooth may not erupt to the normal position because the tooth has lost the ability to erupt and may be hopelessly displaced. ^[7],[8],[15] Such cases usually required orthodontic traction to facilitate eruption. There are no data available with respect to the optimum timing to initiate orthodontic traction of the cyst associated premolars. However, we suggest that a complete resolution of the radiolucent lesion is the optimum timing to initiate orthodontic traction if required.

Conclusion

Inflammatory dentigerous cysts can be treated successfully by extraction of the nonvital and decompression of the cystic cavity. Although cyst associated premolar show rapid eruption, the chance of mesial and distal drifting of the adjacent tooth is also increased; hence, space maintainer should be planned. Due to multipotential nature of this cystic epithelium, the patient must be followed up until eruption of the involved permanent teeth and bony consolidation of the cyst.

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