Case Report
Conservative Treatment of Dentigerous Cysts: Two Case Reports
Arife Kapdan11*, Özgül Cartı2, Burak Buldur1 and Çiğdem Çukurcu1
1Department of Pediatric Dentistry, Faculty of Dentistry, Cumhuriyet University, Sivas, Turkey
2Bursa Duaçınarı Oral And Dental Health Center, Bursa, Turkey
*Corresponding author: Arife KAPDAN, Department of Pediatric Dentistry, Faculty of Dentistry, University of Cumhuriyet, Sivas, Turkey
Published: 15 Aug, 2017
Cite this article as: Kapdan A, Carti Ö, Buldur B, Çukurcu
Ç. Conservative Treatment of
Dentigerous Cysts: Two Case Reports.
J Dent Oral Biol. 2017; 2(11): 1071.
Abstract
The purpose of this case reports are to report two dentigerous cysts and spontenous eruption of
teeth after marsupyalization on a 9 and 12 years old boys. The children were referred to Cumhuriyet
University Department of Pediatric Dentistry with the complaint of a swelling on the jaws. After
intra oral and radiographical examination, dentigerous cysts were diagnosed. In cases of this type
of dental cysts it is possible to achieve spontaneus eruption of the involved permanent teeth into
the dental arch even if they are badly dislocated. Simultaneous with eruption of the permanent
teeth, ossification of bone defect can take place. In these case reports after 25 months of follow up
spontaenous eruptions of permanent teeth were noticed.
Keywords: Dentigerous cyst; Odontogenic infections; Marsupyalization
Introduction
A dentigerous cyst is the most prevalent type of developmental odontogenic cyst [1]. It is
associated with the crown of an unerupted tooth [2]. Its pathogenesis is unknown, but it can be
explained by the accumulation of liquid between the remnants of the reduced enamel epithelium
of the tooth-forming organ and the unerupted tooth crown after its complete development [3,4].
Dentigerous cysts are the second most common odontogenic cyst after the radicular cyst accounting
for 24% of all the true cysts of the jaws [5]. In children the frequency of odontogenic cysts is relatively
low. Shear has estimated that about 9% of dentigerous cysts occur in the first decade of life [6]. It is
more frequent in the second and third decades of life, with a male predilection and mandibula is the
most affected region [7,8]. Patients with dentigerous cysts have no painful symptoms unless there is
acute inflammatory exacerbation, thus explaining the fact that these lesions are often detected only
during routine radiographic examination [9].
Dentigerous cysts are generally discovered when radiographs are taken to investigate a failure of
tooth eruption, missing tooth, or malalignment. There is usually no pain or discomfort associated
with the cyst unless there is acute inflammatory exacerbation. Radiographs show a unilocular,
radiolucent lesion characterized by a well-defined sclerotic margins and associated with crown of
the unerupted tooth. While the normal follicular space is 3mm to 4 mm, a dentigerous cyst can be
suspected when the space is more than 5 mm [10]. Histologically, dentigerous cysts consist of a
fibrous wall containing variable amounts of myxoid tissue and odontogenic remnants. The cyst is
lined with nonkeratinized stratified squamous epithelium consisting of mucosebaceous, ciliated and,
rarely, sebaceous cells. The epithealial-connective tissue interface is typically flattened, but becomes
highly irregular when associated with inflammation [11]. Enucleation and marsupialization are the
best options to treat a dentigerous cyst [12,13]. The first is the process in which the cyst is completely
removed without rupture; this is generally indicated for small cysts. For large lesions, this procedure
can cause fracture of the mandible, tooth devitalization, or removal of impacted teeth associated
with the lesions that do not need to be removed. Marsupialization consists of a surgical cavity on the
wall of the cyst, emptying its content and maintaining the continuity between the cyst and the oral
cavity, maxillary sinus, or nasal cavity, but it is not indicated for infected lesions [14]. This technique
is indicated for large cysts, unerupted teeth associated with cysts in pediatric patients, or in patients
with systemic diseases, generally the elderly. It permits decompression of the cyst, reducing the
extent of the bone defect [15]. The treatment of impacted teeth is a challenge to orthodontists, and
the treatment of choice is surgical exposure of the tooth and consequent orthodontic traction,which
generally causes a cyst cavity reduction and preserves the unerupted tooth [16,17]. Spontaneous
eruption, without orthodontic intervention, can occur after the extraction of deciduous teeth and
cyst marsupialization [18]. The purpose of these case reports was to
present the management of dentigerous cysts in two children and
spontenous eruption of teeth after marsupyalization.
Figure 1
Figure 2
Figure 2
A) Intraoral view of anterior cross bite at santral incisors. B) Panoramic radiograph after marsupalization (After 15 months).
Figure 3
Case Presentation
Case presentation 1
A 9 years old boy was referred to Cumhuriyet University
Department of Pediatric Dentistry with the complaint of a swelling
on left side of his mandibula. Intraoral examination revealed
swelling, which produced bulging of the cortical bone of firm
consistency and on the buccal surface of the mandibula, the bone
was thin and anterior cross bite at santral incisors (Figure 1A and
2A). Radiographic examination showed a unilocular, radiolucent
area associated with primary left canine and primary second molar
and crowns of permanent canine and premolars (Figure 1B). The
patient didn't complain of pain and there wasn't any inflammation
symptom around the lesion. The patient's mandibular decidious
canine and second molar teeth was extracted, so the cyst cavity
was opened and the drainage was achieved. After marsupyalization
spontenous eruption of the permanent canine and premolars were
expected (Figure 2B). The malocclusion was corrected with cross
bite appliance. Patient was recalled for 6 months intervals. After 25
months the patient's mandibular canine and premolars eruption was
determined spontaneously (Figure 3).
Case presentation 2
A 12 year old boy was referred to Cumhuriyet University
Faculty of Dentistry, Department of Paediatric Dentistry with the
complaint of a swelling on right side of his maxilla since 3 months.
On general examination, the patient was apparently healthy. There
was no significant past medical history. Intraoral examination
revealed red swelling, which produced bulging of the cortical
bone of firm consistency. The swelling was well defined, firm in
consistency, painless on palpation. There was no bruit or pulsation.
There were no signs of any acute periodontal condition or carious
lesions. Radiographic examination showed a thin sclerotic border
surrounding the well-defined unilocular radiolucent area that was
associated with the root of primary maxillary right canine and an
unerupted permanent maxillary right canine (Figure 4). There was
irregular root resorption of the primary maxillary right canine. After
clinical and radiological examination the diagnosis of dentigerous
cyst was made. Surgical marsupialization of the cyst was chosen as
the treatment of choice. The treatment consisted of extraction of
the maxillary right primary canine and marsupialization of the cyst
cavity. The surgery was done using local anestesia. Maxillary right
primary canine was extracted. This opened the cyst, and its liquid
content leaked out. After marsupilazation spontenous eruption of
the permanenet canine was expected. After 6 months follow up visit
showed that the radiographic radioluceny had decreased and canine
was erupting without ortodontic traction or any other therapy. After
25 months the patient’s maxillary canine eruption was determined
spontaneously (Figure 5).
Figure 4
Figure 4
Initial panoramic radiograph shows the cystic lesion involving the
maxillary right primary canine and the permanent canine.
Figure 5
Figure 5
A) Intraoral view of the canine eruption. B) Spontaneous eruption of the maksillar right canine after 25 months.
Discussion
Dentigerous cyst is the most common type of developmental
odontogenic cyst [1]. Dentigerous cysts are usually associated with
an embedded or unerupted tooth [19,20]. Even though it has no
symptoms, sometimes it can cause maxillary expansion and facial
asymmetry [21,22]. Asymptomatic intraoral swelling and a large
radiolucent area with well-defined limits that involve permanent
teeth as observed on radiographic examination and can cause
their dislocation near the base of the mandible [3,12]. Although
evidence in the literature suggests that dentigerous cysts occur more
frequently during the second decade of life these lesions can also be
found in children adolescents [23,24]. The incidence of dentigerous
cysts is twice as high male patients compared female counterparts
[25,26]. Our patients had the clinical and radiographic features
of a dentigerous cyst. Several treatment options include complete
enucleation and marsupialization. If the cyst is associated with a
supernumerary tooth, complete enucleation of the cyst along with
extraction of the tooth may be the first choice [27,28]. If preservation
of the displaced teeth is desirable, and in a young patient where the
lesion is isolated, marsupialization is a rather conservative treatment
option [11,29-31]. Marsupialization is the conversion of a cyst into
a pouch by suturing the cyst lining to the oral mucosa. This method
has fewer complications than enucleation regarding the preservation
of important anatomical structures and developing permanent
tooth germs. It is believed that new bone formation is stimulated
because marsupialization decreases intracystic pressure [32,33] The
disadvantage of marsupialization is the pathologic tissue left in situ
[32,33]. Although the tissue taken from the window can be submitted
for pathologic examination, there is a possibility of a more aggressive
lesion in the residual tissue [32]. In our cases,we chose conservative
treatment based on the age of the patients and the strategic value of
the associated teeth.
All our cases regardless of the dimension of the cyst were treated
with extraction of the primary teeth. The leaking out of the cyst's fluid
during an extraction of a primary tooth or during a decompression,
respecitvely, confirms the clinical impression of the cyst. Children
have greater capacity to regenerate destructed bone. Therefore,
conservative treatment for spontaneous eruption of these teeth is
carried out well. Teeth with open apices have more eruptive potential
and fewer associated pathologic lesions within the dentigerous cyst.
In all our patients, the bone defect ossified without complications.
None of the patients showed signs of persistence or recurrence of the
cyst. These results suggest that it is worth starting the treatment by
marsupialization the cyst even when the permanent teeth are severely
displaced.
Conclusions
These case reports show the necessity for early diagnosis and treatment of impacted teeth associated with a dentigerous cyst. Marsupialization might be the first treatment option for conservative management of dentigerous cysts in children. This study showed that by extracting the decidious tooth, opening the cyst and ensuring continious drainage, it is possible to achieve spontaneous eruption of the involved permanent teeth into the dental arch even if they are badly dislocated. Simultaneously with eruption of the permanent teeth, ossification of bone defect can take place.
References
- Berti-Sde A, Pompermayer AB, Couto-Souza PH, Tanaka OM, Westphalen VP, Westphalen FH. Spontaneous eruption of a canine after marsupialization of an infected dentigerous cyst. Am J Orthod Dentofacial Orthop. 2010;137(5):690-3.
- Hu YH, Chang YL, Tsai A. Conservative treatment of dentigerous cyst associated with primary teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(6):e5-7.
- Muramaki A, Kawabata K, Suzuki A, Muramaki S, Ooshima T. Eruption of impacted second premolar after marsupialization of a large dentigerous cyst: case report. Paediatr Dent. 1995;17(5):372-4.
- Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 2nd ed. Philadelphia: Saunders; 2002.
- Daley TD, Wysocki GP, Pringle GA. Relative incidence of odontogenic tumors and oral and jaw cysts in a Canadian population. Oral Surg Oral Med Oral Pathol. 1994;77(3):276-80.
- Shear M, Gordon R. Cysts of the oral regions. 3rd ed. Oxford: John Wright, 1992.
- Aguilo L, Gandia JL. Dentigerous cyst of mandibular second premolar in a five-year-old girl, related to a non-vital primary molar removed one year earlier: a case report. J Clin Paediatr Dent. 1998;22(2):155-8.
- Benn A, Altini M. Dentigerous cysts of inflammatory origin. A clinicopathologic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;81(2):203-9.
- Daley TD, Wysocki GP. The small dentigerous cyst. A diagnostic dilemma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79(1):77-81.
- Goaz PW, Stuart CW. Cysts of the jaws. In: Oral radiology, principles and interpretation. St. Louis: Mosby; 1994.
- Tüzüm MS. Marsupialization of a cyst lesion to allow tooth eruption: a case report. Quintessence Int. 1997;28(4):283-4.
- 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(6):728-30.
- Marchetti C, Bonetti GA, Pieri F, Checchi L. Orthodontic extraction: conservative treatment of impacted mandibular third molar associated with a dentigerous cyst. A case report. Quintessence Int. 2004;35(5):371-4.
- Peterson LJ, Ellis E, Hupp JR, Tucker MR. Contemporary oral and maxillofacial surgery. 4th ed. St Louis: Mosby; 2002.
- Nishide N, Hitomi G, Miyoshi N. Irrigational therapy of a dentigerous cyst in a geriatric patient: a case report. Spec Care Dentist. 2003;23(2):70-2.
- Jena AK, Duggal R, Roychoudhury A, Parkash H. Orthodontic assisted tooth eruption in a dentigerous cyst: a case report. J Clin Pediatr Dent. 2004;29(1):33-5.
- Martínez-Pérez D, Varela-Morales M. Conservative treatment of dentigerous cysts in children: a report of 4 cases. J Oral Maxillofac Surg. 2001;59(3):331-3.
- Delbem AC, Cunha RF, Afonso RL, Bianco KG, Idem AP. Dentigerous cysts in primary dentition: report of 2 cases. Pediatr Dent. 2006;28(3):269-72.
- Kaya O, BocutoÄŸlu O. A misdiagnosed giant dentigerous cyst involving the maxillary antrum and affecting the orbit. Case report. Aust Dent J. 1994;39(3):165-7.
- Lustig JP, Schwartz-Arad D, Shopina A. Odontogenic cysts related to pulpotomized deciduous molars clinical features and treatment outcome. Oral Surg Oral Med Oral Pathol. 1999;87(4):499-503.
- Muthray E, Desai J, Suleman Y, Meer S. Inflammatory dentigerous cyst in a 3 year old South African black male: A case report. SADJ. 2006;61(6):252, 254-5.
- Kozelj V, Sotosek B. Inflammatory dentigerous cysts of children treated by tooth extraction and decompression-report of four cases. Br Dent J. 1999;187(11):587-90.
- Arotiba JT, Lawoyin JO, Obiechina AE. Pattern of occurrence of odontogenic cysts in Nigerians. East Afr Med J. 1998;75(11):664-6.
- Ziccardi VB, Eggleston TI, Schneider RE. Using fenestration technique to treat a large dentigerous cyst. J Am Dent Assoc. 1997;128(2):201-5.
- Benn A, Altini M. Dentigerous cysts of inflammatory origin. A clinicopathologic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;81(2):203-9.
- Ustuner E, Fitoz S, Atasoy C, Erden I, Akyar S. Bilateral maxillary dentigerous cysts: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95(5):632-5.
- Düker J. Dentigerous cyst associated with an impacted mandibular third molar. Quintessence Int. 2005;36(6):487-9.
- Shun Y. Dentigerous cyst associated with an impacted anterior maxillary supernumerary tooth. J Dent Child (Chic). 2008;75(1):104-7.
- Motamedi MH, Talesh KT. Management of extensive dentigerous cysts. Br Dent J. 2005;198(4):203-6.
- 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(6):728-30.
- Koca H, Esin A, Aycan K. Outcome of dentigerous cysts treated with marsupialization. J Clin Pediatr Dent. 2009;34(2):165-8.
- Peterson LJ, Ellis E III, Hupp JR. Contemporary Oral and Maxillofacial Surgery. 3rd ed. St Louis: Mosby; 1998.
- Takagi S, Koyama S. Guided eruption of an impacted second premolar associated with a dentigerous cyst in the maxillary sinus of a 6-year-old child. J Oral Maxillofac Surg. 1998;56(2):237-9.