ABSTRACT. Dentigerous cyst is the most common cyst found in oral cavity. It is always better

to be conservative in managing this problem in children because dentition is yet to complete in

them. The case here describes the technique of marsupialization in which extraction of the

grossly carious deciduous 1st molar was done and window was created through the extracted

socket to decompress the lesion.

KeyWords. Dentigerous cyst, Marsupialization, deciduous dentition

INTRODUCTION

Dentigerous cysts are the most common developmental odontogenic cysts. Studies reveal that

dentigerous cyst constitute more than a quarter of all jaw cysts. They are usually derived from

the epithelial remnants of tooth forming organs1. They develop around the crown of an unerupted

tooth by expansion of the follicle when fluid collects or a space is created between the reduced

enamel epithelium and the enamel of an impacted tooth. It predominates during the 2nd – 3rd

decades of life2. Most commonly dentigerous cyst involves mandibular 3rd molar followed by

maxillary canine. These patients usually complain of painless slow growing swelling involving

the affected area which is very firm on palpation indicating cortical expansion. The classic

treatment for dentigerous cysts is enucleation and extraction of the involved tooth3. It is always

better to be conservative in managing this problem in children because dentition is yet to

complete in them. Children have a great regenerative potential and tooth with incomplete root

development maintain the eruptive strength4. In such circumstances, therefore, marsupialization

or decompression should be tried as a major therapy.5,6

CASE REPORT

This work was conducted in accordance with bioethical concerns. Written informed consents

were obtained from the child’s parents for all examinations and for the treatment modality

adopted.

A boy aged 10 years was referred to the department of Pedodontics who was accompanied by his

parents who complained about facial asymmetry and presence of decayed teeth. No history of

systemic pathologies or previous trauma in the affected area was reported. The boy presented an

important facial asymmetry with slight expansion of paranasal region and upper lip on the right

side. Intraoral exam revealed compressible and painless expansion of buccal cortical plates of the

alveolar ridge extending from deciduous canine to 1st deciduous molar on right side of maxilla.

(Figure1) Dentition was mixed, carious lesion was present with respect to maxillary 1st

deciduous molar on right side. The radiographic findings (OPG) revealed a radiolucent area,

measuring approximately 18 mm in its largest diameter, with sclerotic margins pushing the

premolars and canines. (Fig2) Premolars were completely overlapping each other.

Carious deciduous 1st molar was extracted and aspiration of the lesion fluid was done which

revealed a serous and bloody liquid content. (Fig 3a) The clinical diagnosis of dentigerous cyst

was concluded allowing the beginning of an initial treatment with marsupialization in the case of

the cyst that involved the maxillary teeth. The cyst cavity was packed with sterile iodoform

gauze to achieve hemostasis and to prevent hematoma formation. (Fig3b) The iodoform gauze

was changed on every third day. After 1 month the OPG was repeated and it was clearly visible

that the premolars started migrating mesially and the canine moved distally (Fig4). Follow up

radiographs were repeated after 3 months, 6 months and after 1year. (Fig 5a,b) Ist premolars

started erupting on both sides (fig 6). After 1 year of clinical and radiographic follow-up, there

were no signs of recurrence of the lesion. To relieve the crowding, the patient was referred to the

department of orthodontics for further treatment.

Discussion

Benn and Altini7 discussed the genesis of the dentigerous cysts and proposed two different

processes for cystic degeneration of the reduced epithelium of enamel organ of an included

tooth. The first phenomenon is usually associated to the compression promoted by tooth eruption

at the pericoronary follicle, which induces fluid accumulation between this tissue and tooth

crown. The other mechanism is associated to an apical inflammation in the primary predecessor

whose cytokines, stimulates cystic degeneration of the permanent tooth follicle. The case

described at this paper was probably associated with inflammatory processes caused by caries in

the primary dentition. Biopsy is an essential and fundamental diagnostic element for the

treatment7 since dentigerous cyst shares features with many other lesions such as

ameloblastomas, odontogenic keratocyst, adenomatoid odontogenic tumor, which can

simultaneously occur with this cyst8. For the treatment purpose many different surgical

therapeutic modalities have been applied to treat dentigerous cysts. Among them,

Marsupialization is more conservative method than enucleation of the entire cyst in cases of

large lesions and when the permanent teeth involved have eruptive potential8. This should be

considered as the first line of management in children with dentigerous cyst. The main

advantages of marsupialization or decompression for the treatment of dentigerous cyst are the

stimulus for bone formation after the decrease of cystic pressure. The communication with oral

secretions increases the inflammatory process and both macrophages and lymphocytes from

inflammation release growth factors that enhance bone formation9-11. Another Major advantage

of this procedure is loss of viable permanent tooth buds can be prevented11. The patients should

be followed up carefully by performing radiological imaging every 6 months in order to keep an

eye on potential recurrence. The lack of patient's cooperation in cleaning the pathological cavity

and the need for periodic follow-up visits represent few disadvantages.

In this case, only marsupialization led to successful eruption of the permanent tooth along with

complete ossification of the bony defects in 15 months. The patient comes from a nearby area

and is being supervised regularly. There is no sign or symptom of developing ameloblastoma or

other malignancy in the area since the last 2 years. The successful preservation and eruption of

the affected teeth in this present investigation may be attributed to the active growth potential

and remodeling of bone in children unlike in adults where jaw growth is completed.

Conclusion

Treatment of dentigerous cyst through conservative therapy is preferable in children.

Marsupialization and decompression are very low invasive techniques that could easily be

conducted by any dentist familiar with basic surgical procedures, in order to treat the pathology

and to preserve the teeth involved.

Acknowledgement

Authors are grateful to the child and his parents who were always ready to cooperate and used to

come for regular visits.

References.

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Pics..

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