|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
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
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.
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.
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.
Authors are grateful to the child and his parents who were always ready to cooperate and used to come for regular visits.
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