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J Oral Maxillofac Surg 61:728-730, 2003

Interesting Eruption of 4 Teeth Associated With a Large Dentigerous Cyst in Mandible by Only Marsupialization
mit Ertas, PhD, DDS,* and M. Selim Yavuz, DDS U
The dentigerous cyst has always associated with an impacted, embedded, or unerupted tooth.1-6 Most patients with a dentigerous cyst are younger than 20 years.2 The risk of cyst formation around the crowns of unerupted mandibular rst premolars, maxillary incisors, or mandibular second molars is signicant.7 If enlargement of the jaw occurs, it is progressive and generally painless. It may cause displacement of adjacent teeth and resorption of teeth roots. Marsupialization may be advisable to allow eruption of a cystassociated impacted or unerupted tooth, if sufcient space exists.5 Two principal methods of treating a dentigerous cyst are removal and marsupialization. Excision is indicated when there is no likelihood of damaging anatomic structures such as apices of vital teeth, maxillary sinus, or the inferior alveolar nerve. Marsupialization can maintain the impacted tooth in its cavity and promote its eruption.8 Marsupialization is especially useful for dentigerous cyst with teeth displacement. This report describes the case of a 9-year-old girl with a large dentigerous cyst associated with mandibular lateral incisor, canine, and rst and second premolar teeth. The cyst was marsupialized with the patient under general anesthesia, and the patient was checked biweekly. The impacted teeth erupted without orthodontic traction and therapy.

Report of a Case
A 9-year-old girl was referred to the oral and maxillofacial surgery clinic of Ataturk University Faculty of Dentistry with the complaint of mild swelling overlying the left side of the mandible. Extraoral examination revealed hard bony expansion overlying the mandible. The oral soft tissues were within normal limits, and inferior alveolar nerve function was intact. Radiographic examination showed a large expansile radiolucent region from the mandibular left second molar tooth to the mandibular right canine tooth germ. The mandibular left lateral incisor, canine, and rst and second premolar teeth were displaced to the inferior border (Fig 1).

Received from the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ataturk University, Erzurum, Turkey. *Assistant Professor. Assistant Professor. Address correspondence and reprint requests to Dr Ertas: Oral and Maxillofacial Surgery, Faculty of Dentistry, Ataturk University, 25240 Erzurum, Turkey; e-mail:
2003 American Association of Oral and Maxillofacial Surgeons

0278-2391/03/6106-0018$30.00/0 doi:10.1053/joms.2003.50145

FIGURE 1. Panoramic radiograph showing the large dentigerous cyst and displaced teeth.



FIGURE 2. Histopathologic view of the lesion (hematocylin and eosin stain, original magnication 200).

FIGURE 4. Six months after marsupialization, teeth reached half-way to the ideal position.

The mandibular deciduous lateral incisor had been extracted because of infection 2 years earlier. The response of all teeth to electric pulp test was within normal limits. A needle aspiration biopsy was performed on the initial visit to establish whether the lesion was solid or cystic. Findings of that examination suggested that the lesion was a dentigerous cyst. Because natural eruption of these teeth was possible, it was decided to perform marsupialization. Under general anesthesia, the mandibular left deciduous canine and molar teeth were extracted. After a buccal mucoperiosteal ap had been elevated, the cyst membrane was fenestrated. A specimen was sent for microscopic examination. Histopathologic examination revealed a diagnosis of dentigerous cyst (Fig 2). The cyst membrane was sutured to oral mucosa to create a window. Then, a gauze iodoform pack was inserted into the cyst cavity to keep it open. The packing was replaced biweekly. The patient was examined radiographically bimonthly. It was observed on the radiograph that the impacted teeth slowly moved toward the alveolar crest without orthodontic traction. After 2 months, the teeth were erupting slowly (Fig 3). After 6 months, the teeth reached half-way to the desired position (Fig 4). After 11 months, the teeth reached the alveolar mucosa (Fig 5), and after 16 months, all teeth had erupted without orthodontic traction (Fig 6). We have followed the patient for 30 months (Fig 7); during this period, there has been no recurrence of the cyst.

Dentigerous cysts are always associated with an embedded or unerupted tooth.1-5,9,10 Benn and Altini7 reported that 2 types of dentigerous cysts occur. The rst is developmental in origin and occurs in mature teeth usually as a result of impaction. These cysts usually occur in the late second and third decades, are discovered on routine radiography, and predominantly involve mandibular third molars.7 The second type is inammatory in origin and occurs in immature teeth as a result of inammation from a nonvital deciduous tooth follicle. These are diagnosed in the rst and early part of the second decade either on routine radiographic examination or when the patient complains of swelling and pain.9 We believe that our case might be classied as the second type of dentigerous cyst. Because of age and clinical behavior, there is a relationship between our case and the second type of dentigerous cyst. Furthermore, in

FIGURE 3. Two months after marsupialization, teeth erected slowly.

FIGURE 5. Eleven months after marsupialization, teeth reached the alveolar mucosa.



the medical history of the patient, it was noted that the deciduous lateral incisor tooth was extracted 2 years earlier. This clinical feature is typical for the second type of dentigerous cyst. Treatment of dentigerous cysts is often enucleation. However, cysts causing tooth displacement and involving loss of bone should be treated with marsupialization or decompression.2,11 In this method, new bone formation is stimulated because marsupialization decreases intracystic pressure.2,12 The major disadvantage of marsupialization is that pathologic tissue is left in situ, without a thorough histologic examination.2,12 Although the tissue taken in the window can be submitted for pathologic examination, there is a possibility of a more aggressive lesion in the residual tissue.12 It is known that although a dentigerous cyst inhibits eruption of the cyst-associated permanent tooth, maturation of tooth roots continues.4 Miyawaki et al5 reported that an impacted tooth is able to erupt more rapidly if marsupialization is performed at a time when the tooth has the ability to erupt. There is a close correlation between eruption and the development of teeth roots.2,5 Speed of eruption and rate of angulation of the cyst-involved permanent teeth were faster than those of the teeth on the noncyst side.5 Takagi and Koyama2 reported that marsupialization is useful for promoting eruption of teeth associated with dentigerous cysts. Orthodontic traction of impacted teeth with matured root has often been performed after marsupialization of a large cyst.4,10 However, in our case, all teeth erupted with only marsupialization without orthodontic traction. The major disadvantage of marsupialization is that pathlogic tissue is left in situ, without thorough histologic examination.2,12 Although the tissue taken in

FIGURE 7. Thirty months after marsupialization, there has been no recurrence of the dentigerous cyst.

the window can be submitted for pathologic examination, there is the possibility of a more aggressive lesion in the residual tissue.12 Although marsupialization has these disadvantages, we treated our case with only marsupialization because the patient was very young, the cyst was very large, the cyst had led to the displacement of 4 permanent teeth, and mandibular development had not been completed. We believe that the eruption of teeth is dependent on early age of the patient and incomplete root formation.

, Bocutog : A misdiagnosed giant dentigerous cyst 1. Kaya O lu O involving the maxillary antrum and affecting the orbit. Case report. Aust Dent J 39:165, 1994 2. 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 56:237, 1999 3. Graydon S: Two dentigerous cysts in the mandible of one patient: Case report. Aust Dent J 41:291, 1996 4. Golden AL, Foote J, Lally E, et al: Dentigerous cyst of the maxillary sinus causing elevation of the orbital oor. Oral Surg 52:133, 1981 5. Miyawaki S, Hyomoto M, Tsubauchi J, et al: Eruption speed and rate of angulation change of a cyst-associated mandibular second premolar after marsupialization of a dentigerous cyst. Am J Orthod Dentofac Orthop 116:578, 1999 6. Lustig JP, Schwartz-Arad D, Shopina A: Odontogenic cysts related to pulpatomized deciduous molars clinical features and treatment outcome. Oral Surg Oral Pathol 87:499, 1999 7. Benn A, Altini M: Dentigerous cysts of inammatory origin: A clinicopathologic study. Oral Surg Oral Pathol 81:203, 1996 8. Moro Antonio JM, Puente M: Surgical-orthodontic treatment of an impacted canine with a dentigerous cyst. J Clin Orthod 35:491, 2001 9. Mintz S, Alard M, Nour R: Extraoral removal of mandibular odontogenic dentigerous cysts: A report of 2 cases. J Oral Maxillofac Surg 59:1094, 2001 10. Thoma KH: Oral Surgery II (ed 5). St Louis, MO, Mosby Co, 1969, pp 891904 11. Wong M: Surgical fenestration of large periapical lesions. J Endod 17:517, 1991 12. Peterson LJ, Ellis E III, Hupp JR, et al: Contemporary Oral and Maxillofacial Surgery (ed 3). St Louis, MO, Mosby, 1998, p 540

FIGURE 6. Sixteen months after marsupialization, teeth completely erupted.